Deinfibulation for preventing or treating complications. introitus of women living with type III female genital mutilation (FGM).

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1 DOI: /ijgo SYSTEMATIC REVIEW AND META- ANALYSIS Deinfibulation for preventing or treating complications in women living with type III female genital mutilation: A systematic review and meta- analysis Babasola O. Okusanya 1 * Olabisi Oduwole 2,3 Nuria Nwachuku 2,4 Martin M. Meremikwu 2,3,4 1 Experimental and Maternal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria 2 Institute of Tropical Diseases Research and Prevention, University of Calabar Teaching Hospital, Calabar, Nigeria 3 Cochrane Nigeria, Institute of Tropical Diseases Research and Prevention, University of Calabar Teaching Hospital, Calabar, Nigeria 4 College of Medical Sciences, University of Calabar, Calabar, Nigeria *Correspondence Babasola O. Okusanya, Experimental and Maternal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria. babakusanya@yahoo.co.uk Funding Information WHO, Department of Reproductive Health and Research Abstract Background: Deinfibulation is a surgical procedure carried out to re-open the vaginal introitus of women living with type III female genital mutilation (FGM). Objectives: To assess the impact of deinfibulation on gynecologic or obstetric outcomes by comparing women who were deinfibulated with women with type III FGM or women without FGM. Search strategy: Major databases including CENTRAL, MEDLINE, and Scopus were searched until August Selection criteria: We included nonrandomized studies that compared obstetric outcomes of women with deinfibulation, type III FGM (not deinfibulated during labor), and no FGM. Data collection and analysis: Quality of evidence was determined following the GRADE methodology. Summary measures were calculated using odds ratios at 95% confidence intervals. Results: We found no randomized controlled trials. We included four case control studies. The quality of evidence was very low. Compared with women with type III FGM at delivery, deinfibulated women had a significant reduction in the risk of having a cesarean delivery or postpartum hemorrhage. Compared with women without FGM, deinfibulated women had a similar risk of episiotomy, cesarean delivery, vaginal lacerations, postpartum hemorrhage, and blood loss at vaginal delivery. The length of second stage of labor, mean maternal hospital stay, and Apgar scores less than 7 were also comparable. Conclusions: Low-quality evidence suggests deinfibulation improves birth outcomes for women with type III FGM. PROSPERO registration: CRD KEYWORDS Deinfibulation; Female genital mutilation; Infibulation; Obstetric complications 1 INTRODUCTION Type III female genital mutilation (FGM), known as infibulation, is the narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora, with or without excision of the clitoris. 1 Infibulation constitutes the most severe form of FGM, which may lead to several health complications including severe pain, excessive bleeding, local infections, death, acute urine retention, 2017 International Federation of Gynecology and Obstetrics. The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication. Int J Gynecol Obstet 2017; 136 (Suppl. 1): wileyonlinelibrary.com/journal/ijgo 13

2 14 Okusanya ET AL. and genital tissue swelling following the infibulation; scarring, keloids, and vaginal obstruction are complications in the longer term. 2 These conditions can lead to reduced quality of life and loss of life years. 2,3 Long-term obstetric complications of FGM include higher risk of prolonged labor, episiotomy, cesarean delivery, postpartum hemorrhage, and prolonged maternal hospitalization. 4 The management of these complications may likely further stress the already weak health systems in many countries of Sub-Saharan Africa where FGM is prevalent. The surgical correction of infibulation, also referred to as anterior episiotomy, is called deinfibulation. The procedure consists of cutting open the narrowed vaginal opening in a woman who has been infibulated, which is often necessary for improving health and well-being as well as to allow intercourse or to facilitate childbirth. 5 Equivocal research findings 3,4,6,7 on the effectiveness of deinfibulation to prevent complications of type III FGM has made the present review important to optimize the health of women living with FGM. The objective of this review was to assess the current evidence on the effectiveness of deinfibulation for treating and preventing the complications of type III FGM. We used the methodology outlined in the Cochrane Handbook of Systematic reviews 8 to conduct this systematic review. 2 MATERIALS AND METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, ClinicalTrials.gov, ICTR, PsycINFO, SCOPUS, CINAHL Plus (EBSCOhost), Web of Science, SCOPUS, PILOT, African Index Medicus, LILACS, (EBSCOhost), POPLINE, WHOLIS via LILACS, ERIC (EBSCOhost), and NYAM Library from inception up to August 3, We used a combination of key words and Medical Subject Headings (MeSH terms) to identify studies examining the impact of deinfibulation on predefined health outcomes. We applied no language restrictions and used Google translator (Google, Mountain View, CA, USA) to translate any non-english papers during initial screening of studies for eligibility. All study methodologies were included: we did not restrict our analysis to randomized trials. The reference lists of retrieved studies were reviewed for additional relevant studies. The PRISMA guidelines and flow diagram 9 were used to report the search and selection of studies. We prespecified outcomes based on common clinical complications derived from a scoping review of the literature on FGM (see Stein et al. 10 ). For gynecologic outcomes, women who had been deinfibulated were compared with infibulated women or women who had not undergone FGM. Gynecologic outcomes assessed included: chronic vulvar/clitoral pain, dyspareunia, genital infections, male pain during intercourse, wound infection, patient satisfaction with deinfibulation, infertility, and sexual satisfaction. For obstetric outcomes, women who had been deinfibulated were compared with women who remained infibulated during labor, or who had not undergone FGM. Obstetric outcomes included episiotomy and cesarean delivery rates, estimated blood loss, postpartum hemorrhage after vaginal delivery, genital lacerations, neonatal Apgar scores, maternal hospital stay (in days), and hospital readmission rate. Two team members (BO and NN) independently assessed all potential studies from the literature search for inclusion. The titles and abstracts were examined to remove irrelevant reports. Multiple reports of the same study were linked together. We retrieved the full text of any potentially relevant reports and examined them for compliance with our eligibility criteria as published in the review protocol. The protocol for this review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD Two team members (BO and OO) extracted data from eligible studies using a predefined data extraction form. Two investigators evaluated the quality of the evidence for each outcome using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. 11 The quality of the evidence in the results of the present systematic review was assessed as high, moderate, low, or very low. The effects and quality of evidence were summarized in GRADE evidence tables available from the corresponding author upon request. Two team members (BO and OO) independently assessed risk of bias for each study using the criteria outlined in the risk of bias in nonrandomized studies of interventions (ROBINS-I) by Sterne et al. 12 In case of differing opinions between the two study authors, a third author (MMM) was consulted, and consensus reached. We entered data into RevMan 5.3 (The Nordic Cochrane Center, Copenhagen, Denmark). The software was used to combine data using fixed effect meta-analysis where it was reasonable to assume the studies estimated the same underlying treatment effect as was for postpartum hemorrhage after vaginal birth. If there was clinical heterogeneity sufficient to expect that the underlying treatment effects differed between studies, or if substantial statistical heterogeneity was detected, random effects meta-analysis was used to produce an overall summary or average treatment effect as in the meta-analysis for episiotomy. The results of dichotomous data were presented as summary odds ratio (OR) with 95% confidence intervals (CI), while the mean difference was used for continuous data if outcomes were measured in the same way between studies. We used the standardized mean difference to combine studies that measured the same outcome as in the Cochrane Handbook of Systematic Reviews. 8 We assessed statistical heterogeneity in each meta-analysis using the I 2 square statistics. We regarded heterogeneity as substantial if an I 2 was greater than 50%. 8 Subgroup analysis was not conducted because none of the included studies reported criteria prespecified in the protocol in a manner to allow its conduct. 3 RESULTS The search output identified 3724 studies. A search of the reference lists of eligible studies identified two additional studies. Following removal of duplicates, we identified 2844 unique citations. Based on titles and abstracts, 2826 studies were screened out. Detailed selection of studies is shown in Figure 1. We reviewed the full text of 18 studies, after which only four studies met the inclusion criteria for this review. See characteristics of included studies (Table 1). We included four case control studies involving 1551 women Two of the included studies 13,15 were of serious risk of bias, while the remaining two 14,16 had moderate risk. All studies were conducted in the last 16 years at either a secondary

3 Okusanya ET AL. 15 Iden fica on Screening Eligibility Records iden fied through database searching (n=3724) Records iden fied (13 databases) (n=3726) Records screened (n=2844) Full-text ar cles assessed for eligibility (n=18) Addi onal records iden fied through other sources (n=2) Duplicates removed (n=882) Records excluded based on tle and abstract screening (n=2826) 14 full-text ar cles excluded for reasons related to: Par cipants=2 There was a statistically significantly lower odds of cesarean delivery in deinfibulated women compared with women living with type III FGM with no deinfibulation (OR 0.19; 95% CI, ; 2 studies, 491 participants, very low quality evidence; Fig. 3). One study 15 indicated deinfibulation was associated with a statistically significant lower odds of postpartum hemorrhage compared with women living with type III FGM with no deinfibulation (OR 0.31; 95% CI, ; 1 study, 253 participants, very low quality evidence; Fig. 4). There was no statistically significant difference in the odds of prolonged second stage of labor between deinfibulated women and women living with type III FGM with no deinfibulation (OR 0.54; 95% CI, ; 1 study, 241 participants, very low quality evidence; Fig. 5). Two studies 15,16 showed no statistically significant difference in Apgar scores of less than 7 at 1 minute between women with deinfibulation and women living with type III FGM with no deinifibulation (OR 0.56; 95% CI, ; 2 studies, 499 participants, very low quality evidence; Fig. 6). Included care health facility, including specialized hospitals for the care of FGM, or in a university teaching hospital. The included studies reported no gynecological outcomes. Studies included in quan ta ve synthesis (meta-analysis) (n = 4) FIGURE 1 Flow diagram of identified studies. Interven on=3 Control=7 Outcome=2 The included studies involved pregnant women with type III FGM (infibulation) who had been scheduled for deinfibulation during pregnancy 15 or during labor Women who were deinfibulated were compared with: (1) women with type III FGM that labored and delivered without deinfibulation; and (2) women who had never undergone FGM (non-infibulated). For our first comparison, deinfibulation was performed in previous pregnancies or before the current pregnancy, 15 in the antenatal period, 15,16 or intrapartum period Antenatal deinfibulation was performed at weeks of gestation. 16 For our second comparison, we included two studies 13,14 involving 532 participants who had never undergone FGM. These studies compared pregnancy outcomes of women who underwent deinfibulation with those of women who had never undergone FGM. The age range of participants in three studies was years, and they were predominantly of African origin, particularly Somalian. 3.1 Comparison 1: Deinfibulation versus no deinfibulation among women living with type III FGM Two case control studies, one with serious risk of bias, involving 503 women evaluated obstetric outcomes in women living with type III FGM with or with no deinfibulation. 15,16 Obstetric outcomes assessed included: episiotomy, cesarean delivery, postpartum hemorrhage, prolonged second stage of labor, and APGAR scores. They indicated no statistically significant difference in episiotomy risk between deinfibulated women and women with type III FGM with no deinfibulation (OR 0.31; 95% CI, ; 2 studies, 431 participants, very low quality evidence; Fig. 2). 3.2 Comparison 2: Deinfibulation versus women with no FGM Two case control studies, 13,14 involving 1101 women evaluated obstetric outcomes in women living with type III FGM compared with women with no FGM. The studies indicated that the odds of having an episiotomy in women who underwent deinfibulation and women with no FGM were not statistically different (OR 0.79; 95% CI, ; 2 studies, 1050 participants, very low quality evidence; Fig. 7). Additionally, one study 13 showed no statistically significant difference in the odds of having a cesarean delivery in women with type III FGM who had deinfibulation compared with women with no FGM (OR 0.60; 95% CI, ; 1 study, 325 participants, very low quality evidence; Fig. 8). There was no statistically significant difference in the odds of vaginal lacerations following delivery in deinifibulated women compared with women with no FGM (OR 0.80; 95% CI, , 1 study, 274 participants, very low quality evidence; Fig. 9). In the case of mean blood loss at vaginal delivery, there was no statistically significant difference between deinfibulated women compared with women with no FGM (MD 9.50; 95% CI, to 34.47, 1 study, 274 participants; Fig. 10). Deinfibulation had no statistically significant effect on the duration of the second stage of labor in women with infibulation compared with women with no FGM (MD 0.18; 95% CI, 2.47 to 2.10; 2 studies, 1050 participants, very low quality evidence; Fig. 11). One study 13 showed no significant difference in the odds of postpartum hemorrhage after vaginal birth (OR 2.52; 95% CI, ; 1 study, 776 participants, very low quality evidence; Fig. 12) in deinfibulated women compared with women with no FGM. Another study 14 indicated a non-statistically significant difference in the mean Apgar scores at 1 minute (MD 0.20; 95% CI, 0.50 to 0.10; 1 study, 274 participants, very low quality evidence; Fig. 13) and at 5 minutes of life (MD 0.10; 95% CI, 0.16 to 0.36; 1 study, 274 participants, very low quality evidence; Fig. 14) between the two groups. Likewise, there was no statistically significant difference in the mean maternal hospital stay (in days) in women who had deinfibulation and women with no

4 16 Okusanya ET AL. TABLE 1 Characteristics of included studies. Study ID Study design Sample size Population Setting Intervention(s) Comparison(s) Outcome(s) reported Paliwal et al Case control 253 All women with type III FGM that delivered in Heartland s Hospital between January 2008 and December 2009 African Women s Service of the Heartland s Hospital, Birmingham, UK Deinfibulation No deinfibulation Proportion of women managed according to locally agreed criteria for FGM. Perineal tears, number of episiotomies, blood loss/median (IQR), infant APGAR scores, number of second, third, and fourth degree tears, PPH, birth weight, prolonged second stage labor Rouzi et al Case control 388 Women from Sudan, Somalia, Ethiopia, Egypt, and Yemen who delivered at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from January 1, 2000 to November 30, 2011 King Abdulaziz University Hospital, Jeddah, Saudi Arabia Deinfibulation No deinfibulation Number of episiotomies, duration of first (h) and second (min) stage labor, blood loss (ml), Apgar score, birth weight Rouzi et al Case control 158 King Abdulaziz University Hospital, Jeddah, Saudi Arabia King Abdulaziz University Hospital, Jeddah, Saudi Arabia No deinfibulation First, second, and third stage labor (min), blood loss (ml), number of episiotomies, birth weight, APGAR Score (min), length of hospital stay (d) Raouf et al Case control 250 The first 250 women who had consecutive type III FGM that were seen in the clinic since its establishment in 2002 Heartland s Hospital, Birmingham, UK Deinfibulation No deinfibulation Intact perineum, number of first, second, third, and fourth degree tears, episiotomy, bilateral uretheral tear, perineal lacerations Risk of bias Serious Serious Moderate Moderate

5 Okusanya ET AL. 17 FIGURE 2 Deinfibulation versus no deinfibulation among women living with type III female genital mutilation: Episiotomy. [Colour figure can be viewed at FIGURE 3 Deinfibulation versus no deinfibulation among women living with type III female genital mutilation: Cesarean delivery. [Colour figure can be viewed at FIGURE 4 Deinfibulation versus no deinfibulation among women living with type III female genital mutilation: Postpartum hemorrhage. [Colour figure can be viewed at FIGURE 5 Deinfibulation versus no deinfibulation among women living with type III female genital mutilation: Prolonged second stage of labour. [Colour figure can be viewed at FGM (MD 0.30; 95% CI, 0.69 to 0.09; 1 study, 274 participants, very low quality evidence; Fig. 15). No adverse events were reported in the included studies. 4 DISCUSSION Type III FGM, also referred to as infibulation, may cause a number of short- and long-term morbidities that reduce the quality of life, and may even lead to the death of those who have undergone the procedure. Despite the associated complications, we noted that no randomized trials and very few nonrandomized studies of intervention have been conducted on the subject. Women who were deinfibulated were significantly less likely to have a cesarean delivery or experience postpartum hemorrhage after vaginal delivery compared with women with type III FGM without deinfibulation. When comparing women with deinfibulation to women without FGM, there were no significant differences in risk of episiotomy, vaginal laceration, second stage labor duration, and mean blood loss. While these results suggest that women with deinfibulation can achieve similar obstetric outcomes to women who never had type III FGM, additional high-quality research is needed to confirm these results. The included studies involved women, and were of moderate size. Half of the four studies included in the analysis were assessed as having serious overall risk of bias. The quality of evidence from the four studies included in this review was very low. Two (50%) were assessed to be of serious risk of bias in the domains of selection of study participants and measurement of intervention of ROBINS-I. 15,16 These two studies were also assessed to have serious overall risk of bias and they contributed data to the effective outcomes: cesarean delivery and postpartum hemorrhage after vaginal birth.

6 18 Okusanya ET AL. FIGURE 6 Deinfibulation versus no deinfibulation among women living with type III female genital mutilation: Apgar score less than 7 at 1 min of life. [Colour figure can be viewed at FIGURE 7 Deinfibulation versus women with no female genital mutilation : Episiotomy. [Colour figure can be viewed at FIGURE 8 Deinfibulation versus women with no female genital mutilation : Cesarean delivery. [Colour figure can be viewed at FIGURE 9 Deinfibulation versus women with no female genital mutilation : Vaginal lacerations. [Colour figure can be viewed at Although case reports and cross-sectional studies involving nonpregnant women reported improved gynecologic symptoms after deinfibulation, 6,7,17 a systematic review on the effects of FGM on health outcomes reported equivocal predisposition of women living with FGM to complications. 3 While FGM may increase the likelihood of bacterial vaginosis, menstrual problems (dysmenorrhea, difficulty in passing menstrual blood flow), dysuria, and dyspareunia, its effect on scarring, fistula, vaginal obstruction, and vaginal cysts was inconclusive. 3 The uncertainty surrounding gynecologic consequences of FGM casts some doubt on the conclusions of observational studies that deinfibulation is an effective intervention. We could not ascertain this as the included studies reported no gynecological outcomes. In contrast, a multicenter cross-sectional study on birth outcomes in women with FGM reported improved maternal and fetal outcomes. 4 This review has shown that deinfibulation is associated with a statistically significant reduction in the likelihood of having a cesarean delivery or postpartum hemorrhage. When compared with women who never had FGM, deinfibulation did not increase the likelihood of a prolonged second stage of labor, genital tract laceration, blood loss, lower Apgar scores, and prolonged maternal hospital stay. Women and girls living with type III FGM have similar risks of vaginal laceration, episiotomy, and postpartum hemorrhage following vaginal birth compared with women who never had FGM. These findings underscore the important potential benefits of deinfibulation for women and girls living with FGM. 4.1 Strengths and limitations In this review, we used a comprehensive search strategy developed and administered by an information specialist and had two team members independently screen identified studies for eligibility. Although we aimed to be comprehensive, we might have missed some studies because time did not permit hand-searching of the grey literature. Independent data extraction and risk of bias assessment of included studies was conducted by two review authors. The effectiveness of deinfibulation reported in

7 Okusanya ET AL. 19 FIGURE 10 Deinfibulation versus women with no female genital mutilation : Blood loss. [Colour figure can be viewed at FIGURE 11 Deinfibulation versus women with no female genital mutilation : Duration of second stage of labor. [Colour figure can be viewed at FIGURE 12 Deinfibulation versus women with no female genital mutilation : Postpartum hemorrhage after vaginal birth. [Colour figure can be viewed at FIGURE 13 Deinfibulation versus women with no female genital mutilation : Apgar score at 1 min. [Colour figure can be viewed at this review is limited by the very low quality of the evidence. Hence, the conclusion that deinfibulation may reduce cesarean delivery and postpartum hemorrhage rates should be taken with caution. 4.2 Practice recommendations The Royal College of Obstetricians and Gynaecologists (RCOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommend that clinicians examine every woman s external genitalia during medical consultation to document the presence and type of FGM. 18,19 Physicians are to also ask about gynecologic complications that precede the pregnancy in those living with type III FGM. Clinicians should be aware on the benefits of deinfibulation and the need to counsel and offer deinfibulation to women living with type III FGM and decline requests for reinfibulation. 19 The RCOG also recommends that deinfibulation should be performed on all women living with type III FGM, preferably before first sexual intercourse. 18 However, clinicians should give consideration to performing intrapartum deinfibulation in women living with type III FGM as this review has shown benefits in reduced cesarean delivery and postpartum hemorrhage, and similar obstetric complication rates following deinfibulation to those of women with unaltered genitalia. This systematic review has shown the lack of experimental studies on the effectiveness of deinfibulation to prevent and treat obstetric and gynecologic complications in girls and women living with type III FGM. The very low quality of evidence on obstetric outcomes equally requires well-conducted large population observational studies, and if ethically appropriate, randomized clinical trials to evaluate the effectiveness of deinfibulation on the complications of type III FGM in childbirth. Outside of pregnancy, suggested thematic areas for research include effectiveness on: genital infections; dysmenorrhea and chronic pelvic pain; dyspareunia in women and their male partners; and improved obstetric outcomes. Such studies should be large enough to detect the effectiveness of deinfibulation to prevent and treat complications in all women living with FGM, regardless of subtype. AUTHOR CONTRIBUTIONS BO wrote the draft of the background while OO, NN, and MM reviewed the draft. NN wrote the draft of the methods section and it was reviewed

8 20 Okusanya ET AL. FIGURE 14 Deinfibulation versus women with no female genital mutilation : Apgar score at 5 min. [Colour figure can be viewed at FIGURE 15 Deinfibulation versus women with no female genital mutilation : Maternal hospital stay. [Colour figure can be viewed at by OO and MM. BO, NN, and OO conducted eligibility screening while BO and OO performed the data extraction. The draft of the review was written by BO while OO, NN, and MM commented and edited the draft review. All review authors subsequently modified the review and agreed to the contents of the final version. ACKNOWLEDGMENTS This review was commissioned by the WHO, Department of Reproductive Health and Research. Michelle Hindin and Karin Stein provided editorial support. CONFLICT OF INTEREST The authors have no conflicts of interest. REFERENCES 1. Hearst AA, Molnar AM. Female genital cutting: An evidence-based approach to clinical management for the primary care physician. Mayo Clin Proc. 2013;88: Bishai D, Bonneenfant YT, Darwish M, et al. Estimating the obstetric costs of female genital mutilation in six African countries. Bull World Health Organ. 2010;88: Berg RC, Underland V, Odgaard-Jensen J, Fretheim A, Vist GE. Effects of female genital cutting on physical health outcomes: A systematic review and meta- analysis. BMJ Open. 2014;4:e WHO study group on female genital mutilation and obstetric outcome. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet. 2006;367: World Health Organization. WHO Guidelines on the Management of Health Complications From Female Genital Mutilation. Geneva: WHO; Accessed May 16, Abdulcadir J, Dallenbach P. Overactive bladder after female genital mutilation/cutting (FGM/C) type III. BMJ Case Rep. 2013;2013. pii: bcr Chen G, Dharia SP, Steinkampf MP, Callison S. Infertility from female circumcision. Fertil Steril. 2004;81: Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version The Cochrane Collaboration, Accessed August 11, Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analysis: The PRISMA Statement. PLoS Med. 2009;6: Stein K, Hindin MJ, Chou D, Say L. Prioritizing and synthesizing evidence to improve the health care of girls and women living with female genital mutilation: An overview of the process. Int J Gynecol Obstet. 2017;136:S1: Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336: Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: A tool for assessing risk of bias in non-randomized studies of interventions. BMJ. 2016;355:i Rouzi AA, Al-Sibiani SA, Al-Mansouri NM, Al-Sinani NS, Al-Jahdali EA, Darhouse K. Defibulation during vaginal delivery for women with type III female genital mutilation. Obstet Gynecol. 2012;120: Rouzi AA, Aljhadali EA, Amarin ZO, Abduljabbar HS. The use of intrapartum defibulation in women with female genital mutilation. BJOG. 2001;108: Paliwal P, Ali S, Bradshaw S, Hughes A, Jolly K. Management of type III female genital mutilation in Birmingham, UK: A retrospective audit. Midwifery. 2014;30: Raouf SA, Ball T, Hughes A, Holder R, Papaioannou S. Obstetric and neonatal outcomes for women with reversed and non- reversed type III female genital mutilation. Int J Gynecol Obstet. 2011;113: Akotionga M, Traore O, Lakoande J, Kone B. External genital excision sequelae at the Yalgado Ouedraogo national central hospital: Epidemiology and surgical treatment [in French]. Gynecol Obstet Fertil. 2001;29: Royal College of Obstetricians and Gynaecologists. Female Genital Mutilation and its Management. Green-top Guideline No. 53. July guidelines/gtg53/. Assessed July 17, Perron L, Senikas V, Burnett M, Davis V; Society of Obstetricians and Gynaecologists of Canada Clinical Practice Guidelines: Female genital cutting. J Obstet Gynaecol Can. 2013;35: