Review Obstetric management of women with female genital mutilation

Transcription

1 /toag Obstetric management of women with female genital mutilation Authors Mumtaz Rashid / Mohammed H Rashid Key content: Female genital mutilation is the partial or total removal of the female genitalia for non-medical reasons. The practice is illegal in the United Kingdom. It is estimated that one woman dies every 10 minutes from the sequelae of the procedure. Healthcare professionals require adequate training in the clinical management of women with this condition and they also need to demonstrate great cultural sensitivity. In types III and IV the narrowed vaginal opening is likely to cause obstetric problems. Defibulation prepregnancy is the most desirable option, failing which it may be carried out antenatally or during early labour (less desirable options). Learning objectives: To know about the practice of female genital mutilation, different types of mutilation procedures and associated medical complications. To learn about the obstetric complications and childbirth experience of women with the condition in the developed world. To understand how delivery of obstetric services in the UK for women with genital mutilation could be improved. To understand the ethical and child protection issues associated with the practice. Ethical issues: Female genital mutilation is a violation of universal human rights. The procedure is regarded as a form of child abuse but not given the same recognition on the grounds that it is carried out with the best intentions for the future welfare of the child. Is it right to impose a Western concept of justice, which outlaws female genital mutilation, on a society where the practice is widely accepted? Keywords defibulation / female genital mutilation / infibulation Please cite this article as: Rashid M, Rashid MH. Obstetric management of women with female genital mutilation. The Obstetrician & Gynaecologist. Author details Mumtaz Rashid FRCOG Consultant Obstetrician and Gynaecologist James Paget University Hospital NHS Healthcare Trust Gorleston, Great Yarmouth, Norfolk, NR31 6LA, UK mumtaz.rashid@jpaget.nhs.uk (corresponding author) Mohammed H Rashid BSc (Hons) Medical Student Imperial College School of Medicine London, SW7 2AZ, UK 95

2 The Obstetrician & Gynaecologist Figure 1 Normal female genitalia. Illustration by Douglas Middleton, James Paget University Hospital Introduction Female genital mutilation is defined as the partial or total removal of the female external genitalia for non-medical reasons. 1 It is not known precisely when and where it was first practised, but it is thought to have originated in ancient Egypt. 2 The custom is practised by people of all faiths, including Christians, Muslims, Jews and animists. 3 It is prevalent primarily across 28 African countries from Gambia to Somalia and includes some parts of the Middle East and Asia. Some 138 million girls have undergone the procedure, with a further 2 million (6 000/day) at risk each year. 1 Because of migration and the movements of refugees, the issue of female genital mutilation is now a global concern. The practice is increasingly seen in European countries, Canada, Australia and the USA. The World Health Organization (WHO) has outlawed it on the grounds that it is a violation of human rights. 4 The practice has been banned in many countries around the world but not eradicated. 5 The procedure and reasons for practice Mutilations are usually performed by traditional birth attendants without the use of anaesthetics or antiseptics while the girl is physically restrained. The raw edges are sewn together, usually by thorns, sometimes with sutures, and the girl s legs are tied together from the thighs to the ankles to encourage scar healing. Paste mixtures of herbs, ash or other substances are rubbed onto the wound to stop the bleeding. The age at which mutilation is carried out varies from a few days after birth to 7 years. The reasons cited 6 for female genital mutilation include: controlling female sexuality; hygiene and cleanliness; guaranteeing female virginity until marriage; a belief by both men and women that a narrow opening heightens male sexual pleasure; enhancing fertility; traditional and cultural practice; 7 and, wrongly, the belief that it is a religious obligation. 8 The procedure is seen by parents as a positive action that guarantees their daughters initiation into womanhood and future security. The event culminates in a colourful community celebration with feasting and dancing where the girls are showered with gifts by their parents and relatives. Anatomy of the female external genitalia The vulva is comprised of the labia majora, labia minora and the clitoris, which is covered by a prepuce (Figure 1). The highly sensitive glans part of the clitoris, a specialised female sexual organ, is visible externally. The rest of the organ is embedded behind the symphysis pubis. The glans clitoris, with its abundant neurovascular supply, constitutes the primary female erogenous zone, from which all orgasms are thought to originate. Classification of female genital mutilation The WHO classifies female genital mutilation into four distinct types (Box 1). 1 Types II and III are shown in Figures 2 and 3. In practice these subtypes often overlap and women can have a combination of injuries. Mortality It is impossible to know the exact mortality rate as deaths are generally concealed from the authorities and, in many countries, statistical data is not systematically collected. Immediate mortality as high as 15% has been reported, with further deaths resulting from AIDS, hepatitis and childbirth later in life. 10 It is estimated that teenagers die each year during childbirth from complications of genital mutilation. The overall mortality from the sequelae of female genital mutilation is quoted as the death of one woman every 10 minutes. 11 Box 1 WHO classification of female genital mutilation 1 Type I: Type II: Type III: Type IV: excision of the prepuce with or without excision of part or all of the clitoris excision of the clitoris with partial or total excision of the labia minora excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation) unclassified includes applying corrosive substances for narrowing the vagina, pricking, piercing, incising, stretching, scraping or other harming procedures performed on the clitoris and/or labia Female genital mutilation in the United Kingdom The practice is illegal in the United Kingdom under the Female Genital Mutilation Act The Act also makes it an offence for any person to carry out female genital mutilation abroad or to aid, abet, counsel or procure the carrying out of female genital mutilation abroad. The definition of abroad includes countries where the procedure is legal. The offence carries a maximum penalty of 96

3 14 years imprisonment. To date there have been no prosecutions under the Act. Despite legislation and awareness being raised in communities that practise female genital mutilation, there is evidence that girls who grow up in the UK are still at risk. It is estimated to affect the lives of women living in the UK and a further girls are at risk. 6 Most of the women at risk come from Eritrea, Ethiopia, Somalia, Sudan and Egypt. There are private doctors, nurses and midwives in the UK who carry out the procedure on a highly confidential basis. These professionals are often from the same communities where female genital mutilation is practised and are sympathetic to their needs. There are also traditional circumcisers within the communities concerned who perform female genital mutilation. In all instances parents and communities protect the names of both the health professionals and the circumcisers. As the campaign against female genital mutilation in the West deepens, parents are bringing down the age of mutilation and are increasingly taking girls abroad for the procedure. Legislating against it may have contributed to the practice going underground in the UK and has failed to eradicate it. Obstetricians and midwives in the UK are increasingly facing the challenge of obstetric management of such women and may not have adequate experience or training. 13 Complications It is rare for women to survive the mutilation procedure without complications and it leaves permanent physical and psychological scars. Although all types of female genital mutilation give rise to future health problems, types III and IV are the most likely to cause major complications. 14 Acute complications include haemorrhage, shock and death; infection, such as tetanus and septicaemia; retention of urine from pain and direct mechanical obstruction; injury to the urethra, vagina, perineum or rectum; and urinary or faecal incontinence. 7,15 Long-term complications (which can include keloid formation, see Figure 4) are shown in Box 2. Obstetric problems In general, in types III and IV the narrowed vaginal opening is likely to cause obstetric problems. These include: 19,20 prolonged and obstructed labour (Figure 5) an increase in the number of episiotomies and perineal tears a high caesarean section rate caused by the difficulty in fetal monitoring and lack of adequately trained obstetric staff an increased incidence of postpartum haemorrhage an increased incidence of postnatal wound infection maternal death from obstructed labour and postpartum haemorrhage increased stillbirth and early neonatal death rates increased neonatal morbidity from hypoxia and brain damage. A WHO collaborative study 21 published in 2006 looked into female genital mutilation and obstetric outcomes in Africa. It found a causal relationship between obstetric complications and the type of Figure 2 Example of a type II FGM. Courtesy of RAINBO organisation 9 Figure 3 Example of a type III FGM. Courtesy of RAINBO organisation 9 Figure 4 Keloidal scar tissue. Courtesy of RAINBO organisation 9 97

4 The Obstetrician & Gynaecologist Box 2 Long-term complications from female genital mutilation 16,17,18 Figure 5 Case of obstructed labour resulting in fetal death and both vesicovaginal fistula and rectovaginal fistula 3 days after the onset of labour. Courtesy of RAINBO organisation 9 Keloid formation from slow, incomplete wound healing leading to deposition of excess connective tissue and vulval granulation Paraclitoral cysts Sexual dysfunction and marital disharmony resulting from painful intercourse Anorgasmia from repeated difficulty in penetration and absence of the clitoris Recurrent urinary tract infection (from the collection and stagnation of urine in the vagina allowing bacteria to enter the urethra) Renal failure Haematocolpos from retention of menstrual flow Incontinence resulting from a damaged urethra Pelvic inflammatory disease and infertility as a result of chronic infections Vesicovaginal or rectovaginal fistulae (after prolonged delivery) Transmission of HIV and hepatitis from the use of non-sterile instruments Psychological disorders mutilation suffered the more severe the mutilation, the worse the complication. Childbirth experiences of women with female genital mutilation in the developed world Research on the childbirth experience and obstetric complications of women with female genital mutilation in the developed world is limited. Results from a small number of publications reveal an alarming degree of dissatisfaction with the obstetric care women received. 22,23 Most of the women reported harmful comments being made by their caregiver, being regarded with disgust, lack of respect for their cultural practice, being handled roughly during prenatal examinations and at delivery and not receiving any special care for the postpartum period. Women s preference for female birth companions was also ignored. These responses indicate that most health professionals are not adequately prepared to meet the challenges of female genital mutilation and the resulting obstetric complications. 24 Also, those seeing mutilated genitalia for the first time were shocked or horrified and many did not know that the procedure was illegal in the UK. 25 A recent study into the obstetric complications of women with female genital mutilation who were treated at a UK specialist clinic shows that many of the women required defibulation (removal of the mechanical barrier) before delivery, with a significant number declining antenatal defibulation and preferring to wait until the onset of labour. 26 This has implications for those midwives and obstetricians who are not, at present, trained in the management of these women in labour. Obstetric management Problems in obstetric management in the developed world arise mainly because of the unfamiliarity of the medical and nursing staff with the procedure, as well as the culture and traditions of the community. Junior medical and nursing staff are unlikely to have the required skills and experience. It is recommended that management includes the following: Psychological support Female genital mutilation is likely to leave women psychologically scarred and terrified of childbirth. The memory of the original mutilation may trigger the onset of anxiety and depression. Both the mother and her family will benefit from psychological support and professional counselling should be offered. It must be appreciated that women do not choose mutilation but are born into societies where it is the norm. Along with experiencing the physical and psychological trauma from the procedure they will have had the emotional turmoil of migration, separation from their family, often civil war and possibly even torture. There is no place for expressing disgust. Women must be treated with kindness and sympathy and in a non-judgemental way. Their privacy and confidentiality should be respected at all times. Culturally, these women may prefer a female companion (such as their mother, family member or a friend), rather than their husbands, during labour and birth. 27 Nursing staff should be aware of such preferences and be willing to accommodate them. Assessment at the first antenatal visit It is important that senior staff who are familiar with female genital mutilation are available at the first antenatal visit to assess the extent of damage and degree of the physical barrier. Women with a tight introitus are at a greater risk of major perineal damage. 28 As a general rule, if the urinary meatus can be observed, or if two fingers can be inserted into the vagina without discomfort, the mutilation is unlikely to cause major physical problems at delivery. Digital assessment is not always needed as 98

5 physical appearance may provide the reassurance that is needed. Advice on the importance of good nutrition The woman should be advised about the importance of good nutrition as women with female genital mutilation may try to limit the size of baby by cutting down on food, hoping that a smaller baby will result in an easier birth. Close monitoring of gestational size will be required, both clinically and by ultrasound. Monitoring urinary tract infections Women with female genital mutilation can experience difficulty in emptying the bladder as scar tissue can form a skin diaphragm over the urethra. They are also more prone to urinary tract infections. Urine should be tested routinely for infection. They are also more likely to acquire vaginal infection. Repeated infection is an indication for defibulation. Defibulation Antenatal defibulation is desirable to assist in the diagnosis and management of complications such as urinary tract infections, vaginal infection and threatened or incomplete miscarriage and to check for proteinuria to detect pre-eclampsia. Early defibulation has the advantage that the introitus is then adequate for vaginal examination, it avoids the need for a suitably trained person to perform it at delivery and it prevents excessive blood loss at delivery, thereby protecting the staff and baby from exposure to possible HIV. In the infibulated type III mutilation, urine is always contaminated with vaginal secretion and can show false proteinuria. In the infibulated woman there is difficulty in performing vaginal examinations, application of fetal scalp electrodes and fetal blood sampling. Women should understand the consequences of withholding consent for defibulation during the antenatal period, such as the increased risk of caesarean section because of the inability to monitor the fetus in labour. The aim of surgery should be to restore normal anatomy as far as possible. 28,29 The procedure can be performed under local or spinal anaesthesia but general anaesthesia may be required where the woman is distressed by the idea of being awake. 30 Using a probe or dilator, the undersurface of the scar should be examined. The excision scar is incised exactly in midline until the urethral meatus is exposed and the raw edges on both sides are then oversewn with rapidly absorbable sutures (Figure 6). Defibulation should be offered and performed at one of following stages: (i) Early in pregnancy (before 20 weeks of gestation), according to the RCOG guidelines. 31 This will allow the scar to be fully healed before delivery and is the best time for defibulation short of removing the mechanical barrier before pregnancy begins. (ii) Between 34 and 38 weeks of gestation to ensure fetal viability in the event of triggering premature labour. (iii) During labour the least desirable option, as midwives or doctors appropriately trained to deliver women with type III mutilation may not be available. Defibulation should be performed in the first stage of labour under epidural or, if the woman presents in the second stage of labour or chooses to leave defibulation until this stage, a midline incision can be done during crowning of the fetal presenting part to expose the urethra, leaving the perineum intact. Since a full bladder adversely affects uterine activity, the first stage of labour can be prolonged because of the difficulties of catheterising the bladder in infibulated women. Adequate post-defibulation analgesia is important as the pain associated with the procedure can influence a woman s decision to breastfeed. 31 The woman should be informed that reinfibulation is prohibited by law in the UK. A skilled interpreter, not related to the woman, may be required at this stage. Often, when time is given for psychosexual counselling, women do not request reinfibulation. 1 It is important to remember that the woman has been familiar with her external genitalia for most of her life in the closed or covered form and may find it hard both psychologically and physically to accept a new shape and feeling. Acceptance of the different form requires sensitive counselling. A woman s concern regarding physical problems or sexual ramifications, together with the attitude of her husband, possibly including fear of divorce, must also be dealt with. Husbands should be supplied with the appropriate medical facts and advice so that the couple can reach a mutual understanding. A routine postnatal check-up should be arranged Figure 6 Defibulation procedure. Courtesy of RAINBO organisation 9 99

6 The Obstetrician & Gynaecologist at 6 weeks to inspect the perineum and discuss contraception. Improving delivery of obstetric services Although one woman dies every 10 minutes of female genital mutilation-related complications (almost half that from malaria, which causes some 1 million fatalities per year) this it is not even a recognised medical condition. Furthermore, none of the major obstetric, paediatric or midwifery textbooks describe female genital mutilation in any detail. The most important step in educating health carers is to include this in the international classification of diseases. Although it is included in the medical and midwifery teaching syllabuses of many UK health institutions, healthcare professionals lack adequate training in the clinical management. This needs to be addressed. There is a general perception among many women that carers in the UK are culturally insensitive and not familiar with providing care for women with female genital mutilation. They may have heard stories of other women having suffered embarrassment and humiliation when attending the antenatal clinic. Because of this, coupled with language barriers, which further hinder access to medical services, some women may not attend antenatally and may first present in labour. There is a need to assess the knowledge, attitudes, practice and belief of health workers with respect to female genital mutilation at all levels and to offer appropriate education where necessary. It is important that health professionals understand the customs and the medical and psychological problems faced by these women so that the correct treatment and advice is delivered. Services are likely to be well developed in areas with a large population of groups that practise female genital mutilation and where dedicated clinics operate. In areas with a small, scattered population, obstetricians and midwives may know little, if anything, about the practice and services may be inadequate or non-existent. Staff in these areas should seek advice and skill from dedicated centres. In their home countries, many women with type III genital mutilation have their infibulation reversed just before marriage to enable them to have intercourse. In the UK, these women face difficulty in obtaining this procedure through general practitioners who may be unfamiliar with the problems of this ethnic group. There is an urgent need to develop effective information, education and communication programmes for use at community levels. Specific antenatal educational programmes should be translated into appropriate languages for the affected communities to prepare women for childbirth and delivery. Female genital mutilation tends to be considered mainly as a feminist issue, although men perpetuate it. It is important, therefore, that men are included and involved in educational programmes. Ethical issues and child protection According to its proponents, female genital mutilation is a traditional or cultural practice and preventing mutilation of girls may be seen as an attack on the community and perceived as racist or culturally insensitive. This has been a barrier to both discussion and to finding a solution. In Great Britain it is regarded as a form of child abuse but it has not been given the same recognition as other forms of child abuse in that it is considered to have been done with the best intention for the future welfare of the child. However, the reality is that the child suffers serious and irreparable physical injury. Female genital mutilation may present as an issue in a variety of ways. These can include: When a woman who has had the procedure herself also approves of it for her daughter, who is then at risk. When a child has already undergone female genital mutilation: particular attention should be paid to the potential risk of harm to other female children in the family. When a family is preparing to have their child sent away to have the operation. If it becomes apparent that a girl is at risk, the family must be made aware of the health and legal issues. This may involve the services of counsellors, supportive local community groups or other professionals who have experience in dealing with female genital mutilation. It is important to ensure that the approach is sensitive to the beliefs and culture of the family while remembering that female genital mutilation is illegal in the UK and participation by any person, including a doctor, is a criminal offence. The aim should be to find effective mechanisms for ensuring the protection of the child in a way that promotes her overall welfare. Despite the health hazards associated with female genital mutilation, parents can genuinely believe that it is in their daughter s best interests to conform to their prevailing customs. Where a child has been identified as at risk of significant harm, it may not be appropriate to remove the child. If the parents cannot be persuaded that their daughter should not be subjected to female genital mutilation and the child appears to be in immediate danger, consideration should be given to seeking a prohibited steps order. Steps for 100

7 initiating child protection proceedings are set out in the Department of Health guidelines. 32 Conclusion There is a need for systematic research to establish the true magnitude of health effects and morbidity associated with female genital mutilation as well as the incidence of complications during pregnancy, childbirth and the postpartum period. Women often book late in pregnancy, present unbooked in labour or may decline antenatal defibulation until the onset of labour. This has implications for midwives and obstetricians not trained in the management of female genital mutilation. Defibulation prepregnancy is the most desirable option. Existing training materials for health professionals at all levels contain little information relating to the prevention of female genital mutilation or its management. Improved training is required for all health care professionals. Guidelines for safe practice, based on evidence-based research on all aspects of female genital mutilation, should be widely available to enable maternity services to provide the care these women require. Midwives need to be instructed in performing a defibulation procedure (anterior episiotomy). Legislation against female genital mutilation in this country has not made the practice disappear. Raising the profile of the issue among all health professionals who come into contact with children seems to be the best way forward. Public education, with effective use of the media to target communities concerned, should be used to raise awareness of the harmful effects and induce a change in public opinion. References 1 World Health Organization. Fact Sheet No 241. Female Genital Mutilation. WHO: Geneva; 2004 [ 2 Mawad NM, Hassanein OM. Female circumcision: three years experience of common complications in patients treated in Khartoum teaching hospitals. J Obstet Gynaecol 1994;14: Momoh C. 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