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Rapport fra Kunnskapssenteret nr 8 - 2014 - Systematisk oversikt

Immediate health consequences of female genital mutilation/cutting (FGM/C)

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Berg RC, Underland V. Rapport fra Kunnskapssenteret nr 8 - 2014. ISBN 978-82-8121-856-7 ISSN 1890-1298

3-page executive summary

Background

Female genital mutilation/cutting (FGM/C) has been performed in various forms for millennia and involves a range of practices. In 1997, WHO, UNICEF and UNFPA issued the following definition of FGM/C: “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.” Further, to clarify understanding of both the prevalence and consequences of FGM/C, WHO classified the procedure into four categories: type I (clitoridectomy), type II (excision), type III (infibulation), and type IV (other). According to a recent UNICEF report, there is wide variation in FGM/C prevalence across and within the countries where the practice is concentrated, which include 27 African countries, Yemen, and Iraq. Although trend analyses document an overall decline in prevalence of the practice across generations, UNICEF estimates that FGM/C has been performed on more than 125 million girls and women alive today in the 29 countries where the practice is concentrated.

The practice is generally performed on pre-pubescent girls, often without anaesthetics, thus, it is reasonable to assume that it is a traumatic event that may cause both short-term and long-term harm. With regards to long-term harm, in previous systematic reviews we established that women with FGM/C were more likely than women without FGM/C to experience attenuation of sexual functioning, obstetric complications, and possibly psychological disturbances. In the present systematic review we addressed harm occurring during the cutting or alteration modification process and the short-term period.

Objective

The main objective of this systematic review was to summarize the empirical quantitative research describing the immediate (acute) consequences of FGM/C on girls and women. The overall aim of the systematic review is to support well-informed decisions in health promotion and health care, and improve quality of services related to the consequences of FGM/C. 

Method

We conducted this systematic review of the immediate consequences of FGM/C in accordance with the NOKC Handbook for Summarizing Evidence and the Cochrane Handbook for Systematic Reviews of Interventions. Our main literature search strategy was searches in 15 international electronic databases. Studies eligible for inclusion were systematic reviews, cohort studies, case control studies, cross-sectional studies, case series, and case reports. The population of interest was girls and women who have been subjected to any type of FGM/C. Thus, the event or intervention was FGM/C, and the comparison was no- or an alternative type of FGM/C. In the present report, we summarized the immediate (acute) consequences of FGM/C, including but not limited to outcomes such as bleeding, pain, infection, swelling, and fever.

Two reviewers assessed studies for inclusion, considered the methodological quality of the studies, and extracted data from the included sources. Pre-designed forms (inclusion, checklists, data recording) were used to guide the reviewers’ assessment and enable consistency. Each step was done independently and then jointly by the two reviewers. We prioritized presenting results from those studies with highest internal validity (studies which compared groups of girls/women), summarizing the study level results in texts and tables and calculating effect estimates. There were no studies that analyzed whether there were statistical differences in the frequency of immediate outcomes between groups of girls/women. Thus, all presented effect estimates are unadjusted. We concluded that the included studies were not reasonable resistant to biases and relatively homogeneous in this respect. It was therefore not warranted to combine outcome data across studies in meta-analyses. However, we show the forest plots with no pooled effect estimate, in order to illustrate the direction of effect across studies.

Results

We included 56 primary (observational) studies that reported on immediate outcomes of FGM/C. There were 14 comparative cross-sectional studies in which two or more groups of girls/women with different types of FGM/C were compared with regards to one or more acute complication, and 42 non-comparative studies (single group cross-sectional studies, case series, case reports). The methodological study quality was low in about half (55%) of the 56 included studies, but among the 14 comparative studies, the majority (79%) had moderate methodological study quality. Overall, the 56 studies included 133,515 females of various ages and types of FGM/C. Across the studies, the most frequently measured outcomes were bleeding/ hemorrhage, infections, problems with urination, and swelling. Three quarters of the studies included outcomes that were self reported or where mothers reported on circumstances surrounding the FGM/C procedure of their daughters.

 

There are three main findings:

  • The most common immediate FGM/C complications were: pain, excessive bleeding, swelling, problems with wound healing, urine retention.
  • The girls and women undergoing FGM/C often suffered more than one immediate complication.
  • There were few differences in risk of immediate complications among different types of FGM/C, but there might be a greater risk of immediate complications for women with FGM/C type III compared to types I-II.

Discussion

There was evidence of under-reporting of complications. However, the findings show that girls and women who undergo any form of FGM/C suffer a range of, and typically several, complications during the FGM/C procedure and the short-term period. The most common physical complications caused by the removal of, or damage to, healthy female genital tissue in the short-term include pain, excessive bleeding, swelling, problems with wound healing, and urine retention. Each of these complications occurred in more than one of every ten girls and women who undergo FGM/C. Further, the female participants in these studies had FGM/C types I through IV, thus immediate complications such as bleeding and swelling occur in settings with all forms of FGM/C. Even FGM/C type I and type IV 'nick', the forms of FGM/C with least anatomical extent, presented acute complications, thus there is no evidence to support a shifting to a form with less anatomical extent, such as type I, on the rationalization that it involves limited immediate harm. In fact, the evidence base from the comparative studies shows that there were few differences in risk of immediate complications between girls and women who undergo different types of FGM/C. We found no health benefits of the practice. The results should be viewed in light of long-term complications, such as obstetric and gynecological problems, and protection of human rights. As a whole, the findings explicate the avoidance of unnecessary harm for many girls and women in the short- and long-term with the abandonment of FGM/C.

Conclusion

The evidence base, which covers over half a century of research from more than twenty countries in Africa and beyond, shows that the FGM/C procedure unequivocally causes immediate health complications. Although the exact frequency of complications is unclear – there is evidence of under-reporting of complications – and caution is required in interpreting the findings, it is highly unlikely that further research would find that there are no short-term complications associated with the FGM/C procedure. The results document the importance of continuing to raise awareness that ending FGM/C will avoid multiple short-term problems suffered by girls and women when they undergo FGM/C as well as preserve their human rights.


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Immediate health consequences of female genital mutilation/cutting (FGM/C)
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