Editor's Choice


Female genital mutilation and another real world

Female genital mutilation (FGM) is an important worldwide issue in women's health. In this issue we publish the results of two novel studies on the sequelae of this procedure. For those not very familiar with the subject, I thought some background information would be useful. The 2008 World Health Organization (WHO) interagency statement Eliminating Female Genital Mutilation (whqlibdoc.who.int/publications/2008/9789241596442_eng.pdf) makes sombre reading. Between 100 and 140 million girls and women in the world are estimated to have undergone FGM, which is defined as ‘procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for nonmedical reasons’. Three million girls are estimated to be at risk of undergoing the procedures every year. The WHO is very clear on its stand concerning the ethics of FGM. Female genital mutilation is nearly always carried out on minors and is therefore a violation of the rights of the child as well as violating not only the person's rights to health and security, but also the physical integrity of the person, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life if the procedure results in death.

The majority of girls and women who have undergone FGM live in Africa. It is estimated that over 70 million girls and women aged 15–49 years in Africa and in Yemen have undergone the procedure. Approximately 60% of them live in sub-Saharan Africa, while 40% are in the Middle East and North Africa. The prevalence among women aged 15–49 years varies widely, from 98% in Somalia and more than 90% in Djibouti, Egypt, Guinea and Sierra, to a low of 1% in Cameroon, Uganda and Zambia (Figure 1) (http://www.childinfo.org/fgmc_progress.html).

Figure 1.

Percentage of women 15–49 years old who have been cut. Reprinted with permission from UNICEF, www.childinfo.org.

Overall the practice is declining in most countries, indicated by data that show fewer daughters are circumcised compared with mothers, but there appears to be considerable variation in this decline between countries. The ratio of the percentage of women 15–49 years old with at least one daughter circumcised to the percentage of women 15–49 years old who have undergone FGM can be used as a marker of decline in the practice. In countries with high FGM incidence (90% or more) this ratio varies from approximately 1:2 in Somalia to 1:4 in Egypt. The variation seems even greater in countries with lower FGM incidences, in the range 10–50%, where the ratio varies between 1:1 in Nigeria to 1:6 in Benin.

Comparative data concerning declines in rate should be interpreted with caution as there is variation between countries in the age at which the procedure is performed. The attitude of mothers towards the practice does not always affect whether their daughter is cut. Lack of support for the practice by mothers does not necessarily lead to a decline in incidence. Large differences exist between prevalence of FGM and support for the continuation of the practice, and some of the greatest disparities are seen in countries with the highest prevalence. For example, in Burkino Faso (percentage of adult women cut 72%) only 11% of women support the practice but 25% of their daughters have had FGM. In contrast, in Ethiopia and Guinea-Bissau the corresponding support for the practice/incidence of daughters cut percentages are closer at 31%/38% and 39%/34%, respectively (United Nations Children's Fund [UNICEF] global databases).

The WHO maintains that ‘female genital mutilation is a manifestation of gender inequality that is deeply entrenched in social, economic and political structures’ and UNICEF concludes that ‘analysis of international health data shows a close link between women's ability to exercise control over their lives and their belief that female genital mutilation should be ended’ (www.unicef-irc.org/publications/pdf/fgm_eng.pdf). Another manifestation of gender inequality is intimate partner violence (IPV). Several studies suggest that 50% of women in sub-Saharan Africa have been a victim of IPV. On page 1597 of this issue Salihu et al. report the results of a study examining the relationship between FGM and IPV in Mali, where it has been previously reported that over one-fifth of women have been exposed to sexual or physical violence by a partner. Mali is a country with a high incidence of FGM: according to UNICEF data the percentage of women 15–49 years old who have undergone FGM is 85%, and percentage of women 15–49 years old with at least one daughter circumcised is 68%. The authors used the Demographic and Health Survey (DHS) individual recode data. The DHS is an international project conducted in 90 countries throughout the world. Mali was chosen for the study because it was the only sub-Saharan African nation whose dataset included the modules for both female circumcision and domestic violence. The interview for the domestic violence module of the DHS was undertaken only when privacy could be achieved and maintained throughout the process. A total of 7875 women aged 15–49 years were studied in what is the only study to date to examine FGM and multiple forms of IPV. The raw demographic data are in themselves interesting to those who are not familiar with the sociosexual norms in some African countries, for example the age at first marriage was 14 or less in over a quarter of women and the marriage was polygamous in nearly 40% of women. The findings confirmed the suspicion that women with FGM were more likely to experience physical, sexual or emotional IPV, with odds ratios of 2.9, 3.2 and 2.3, respectively. The odds of experiencing IPV increased with the degree of FGM, with those women who had the most severe form of FGM having nearly a nine times risk of IPV in any form. In response to the high prevalence of FGM, the Malian government has instituted an executive order to raise awareness regarding its harmful effects; however, no advancements have been made to outlaw or restrict the practice of FGM. One barrier is the lack of public support for political or legal measures to abolish a highly respected tradition, which is confirmed by UNICEF data that indicate that approximately three-quarters of women aged 15–49 years in Mali appear to support FGM.

The adverse physical effects of FGM on the health of women and children in the long and short term are clear. The intervention itself is traumatic as girls are usually physically held down during the procedure (Chalmers and Hashi Birth 2000;27:227–34; Talle. In: Hernlund and Shell-Duncan, eds. Transcultural bodies: female genital cutting in global context. New Brunswick: Rutgers University Press, 2007:91–106.). Almost all experience pain and bleeding as a consequence of the procedure. Those who are infibulated often have their legs bound together for several days or weeks thereafter (Talle, In: Broch-Due, Rudie, Bleie, eds. Carved flesh, cast selves: gender symbols and social practices. Oxford, Berg, 1993:83–106.). Other short-term complications include shock, caused by pain and haemorrhage, urinary retention and infection, including HIV transmission, and death. Long-term physical effects include chronic vulval pain, development of dermoid cysts, abscesses and genital ulcers, keloid formation, chronic pelvic infections causing chronic back and pelvic pain. The obstetric complications associated with FGM are familiar to most obstetricians in the developed world, including vulval lacerations and postpartum haemorrhage. Worldwide, the risk of caesarean section and neonatal low Apgar scores and death has been reported to be higher (WHO Study Group on Female Genital Mutilation and Obstetric Outcome Lancet 2006;367:1835–41.).

The psychological consequences of FGM have been less well studied. Some have reported an increased fear of sexual intercourse, post-traumatic stress disorder, anxiety and depression. The second paper concerning FGM in this issue on page 1606 examines the effect of FGM on sexual quality of life in women attending the African Well Women's clinic and gynaecological clinic in an inner London teaching hospital using the Sexual Quality of Life–Female (SQOL-F) questionnaire, which had been previously validated for measuring sexual quality of life in women with female sexual dysfunction. It is accompanied by an independent mini-commentary by Emma Crosbie, one of our BJOG editors, about the considerable difficulty of conducting such studies. The study indicates that FGM was associated with a poorer sexual quality of life. I concur with Dr Crosbie's comment that the study is a ‘brave attempt to explore tough issues in the real world’. The paper concerning IPV and FGM also gives a thought provoking insight into another real world.

Predicting preterm delivery

The importance of being able to predict preterm delivery (PTD) and the difficulty in doing so is clear. It has long been established that a history of previous PTD and multiple gestation are the most important risk factors for subsequent PTD. However, much less is known about the recurrence risk for twin pregnancies following a preceding singleton preterm birth. On page 1624 Schaaf et al. report the findings of a study of 4071 nulliparous women in the Netherlands who had a singleton delivery followed by a subsequent twin delivery during 1999 to 2007. They found that the risk of subsequent twin preterm birth was considerably higher after previous singleton preterm delivery (57% versus 21%) and that the risk of subsequent twin preterm birth was higher the earlier the previous delivery gestation (Figure 2).

Figure 2.

Percentage risk of subsequent twin preterm delivery after previous (A) singleton delivery and (B) singleton preterm delivery.

The increased risk was greater after preceding spontaneous rather than iatro-genic singleton PTD. It is clear that women with a twin pregnancy who have had a previous PTD represent a very high risk group for PTD. The same cannot be said for women with low vitamin D levels. On page 1617 Thorp et al. report the findings of a nested case–control study of 131 cases (women with PTD <35 weeks) and 134 term control women, in whom serum 25-hydroxyvitamin D concen-trations were measured at 16–22 weeks of gestation. There was no relationship between vitamin D levels and preterm delivery. The studies that have examined the relationship between vitamin D and the development of pre-eclampsia or gestational diabetes and other adverse pregnancy outcomes have shown conflicting results. This is probably a result of the paucity of randomised trials, heterogeneity of populations studied and low sample size with poor adjustment for confounding among observational studies (Urrutia and Thorp Curr Opin Obstet Gynecol 2012;24:57–64). Having lived through the swings and roundabouts of the definition of iron deficiency and the need for iron supplementation in pregnancy over the last 30 years, it seems to me that we should focus on defining what is the optimal (in layman's terms ‘normal’) vitamin D level in pregnancy.