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W.H.O. Responds on F.G.M

Early in our debate over female genital cutting, Richard Shweder of the University of Chicago critiqued a 2006 Lancet study by a group of researchers working with the World Health Organization. I invited those researchers from the W.H.O. study to respond.

They’ve prepared a response written by Hermione Lovel of Department of Health in Cambridge, England; Efua Dorkenoo of WHO; Zeinab Mohamed and Clare McGettigan of the University of Manchester, England, and E.O. Akande of W.H.O. and University College Hospital in Ibadan, Nigeria. The researchers addressed two questions raised by Lab readers:

1. Are there local organizations around the world discussing this topic? (Asked by Elizabeth Tierney.)

2. Is there any any collation of evidence on the positive and negative effects female genital mutilation (FGM)?

Here are the researchers’ answers:

1. There are many local organizations around the world discussing female genital mutilaltion (FGM). Your readers may be interested to know they exist in many countries in Africa where FGM is a traditional practice as well as in western countries where the practice has been reported in specific immigrant communities. To list just a few examples, they include the Inter-African Committee (IAC) which is the largest African women’s regional organization with national chapters in 28 African countries working to end FGM . Other well known groups working to stop FGM include Tostan in Senegal; BAFROW in the Gambia; the Babiker Badri Scientific Society in Sudan, Equality Now Kenya, Agency for Cultural Change UK, FORWARD UK, FORWARD Germany and RAINBO. Most of these are fully engaged in their work in local communities so do not devote their limited resources to web sites but some do have a web presence people. These include the large organizations such as the IAC, EQUALITY NOW and RAINBO. All have networks of grassroots organizations campaigning against FGM in Africa and parts of the Middle East. Most importantly the WHO Department of Reproductive Health and Research publishes factual education materials on FGM which can be downloaded here.

2. Aside from a number of research articles that have brought together what we know to date of the health complications, in 1995 a Manchester University team was commissioned to work with WHO to undertake a systematic literature search on primary evidence of health sequelae of FGM. This was produced in 2000 and is available here. The results of the review showed that FGM can be associated with a wide range of physical complications including factors affecting childbirth and gynaecological health. The complications noted were more pronounced with FGM Type III. What was not clear in the review was the frequency of the physical health complications related to the different types of FGM. Much of the evidence identified in the WHO review is in the form of case studies either clinical or anthropological. In addition, the classification of the FGM types in the studies reviewed were not clear as until 1995 there was no standard classification of FGM.

The review of the childbirth health sequelae was collated following a very thorough search developed by a team of medical librarians aiming to include the anthropological literature (precise search strategy published); it covered 3 generations of articles (this means that from the articles found in the first trawl each paper’s list of references is then used to identify further articles, and the same procedure then repeated). Then the most commonly cited journals were each hand searched to identify any other articles that the computer terms might not have identified, and also to track back to the issues not yet included on computerized databases. Thus we explored by hand (and found) articles including those dating back to the 1920s in the (then) Kenyan Medical Journal, now East African Medical Journal. Altogether 422 articles were identified, 129 had primary data with health outcomes. The project formed the background to some important studies since then. It is now being put into Cochrane format and should form the basis for regular future updates.

2.1. In order to validate the findings in the WHO review of the health complications, WHO undertook a follow up study to examine the childbirth sequelae of FGM. The results of this study were published in June 2006 in the Lancet. The study had a highly robust scientific design to ensure association with FGM could be assessed; and to investigate differences in childbirth complications between women with no FGM compared separately with FGM Type I, FGM Type II, and FGM Type III. Altogether over 28,000 singleton births in health units were studied across 6 countries (Sudan, Ghana, Burkina Faso, Kenya, Nigeria and Senegal). The results were controlled for factors such as parity, socioeconomic position, antenatal care etc that are known to affect childbirth outcomes. The study showed clear evidence of harm for mothers and babies; adverse health effects of all FGM types and the greatest risks with more extensive FGM. Women with FGM I had significantly higher risks of episiotomy and fresh stillbirth (borderline significant) and women with FGM II and III had significantly elevated risks of episiotomy, caesarean section, extended hospital stay, postpartum haemorrhage, infant resuscitation, fresh stillbirth and death of the infant in the period surrounding the birth.

It is estimated from this study that in the countries where the study was conducted there are 10 20 additional perinatal deaths due to FGM per 1000 live births. Complication rates are likely to be higher in women with limited access to obstetric services.

The exact reason for these harmful effects on childbirth is not known. Low birth weight tends to reflect problems during gestation, while fresh stillbirth of an otherwise normal baby tends to reflect problems during delivery. Thus the lack of effect of FGM on birth weight demonstrated in the study, accompanied by a clear adverse effect on the delivery process supports a hypothesis of mechanical problem at the perineum, maybe a lack of elasticity of cut/excised/sewn tissues?

2.2. Most importantly every indicator of childbirth harm identified from the case studies, case series or the small comparative investigations found in the systematic literature search was confirmed by this huge cohort study. This suggests other commonly reported clinical problems may also be confirmed including sequelae around psychological co-morbidity, and psychosexual sequelae if there were resources to investigate them further systematically and on a large scale.

In addition there are some sequelae that are so blindingly obvious they hardly need an expensive study to verify! For example, in FGM Type III the very small match-stick size introitus left for the passage of urine and menstrual fluid is known to be associated with occurrence of continuing problems with urinary infections and also ‘haematocolpos’, accumulation of menstrual fluid behind the bridge of scar tissue can occur. It is also known that ‘flashbacks’ to the acute pain and shock of assault by loved relatives at the time of the FGM can cause ongoing lifetime distress .

2.3. There have been other useful studies published recently. A study in West Africa where Type II FGM is practised found that women with FGM were more likely to have bacterial vaginosis and to have been infected with Herpes Simplex Virus-2. Both of these could have implications for increasing risk of HIV infection (Morison et al. 2001). There has been little formal investigation and documentation on the psychosexual and the mental health consequences of FGM but one controlled study which was undertaken in Senegal found that women who had been subjected to FGM were significantly more likely to suffer from post-traumatic stress disorder (PTSD) and other psychiatric syndromes when compared to women who had not been subjected to FGM (Behrendt et al 2005).

2.4. We hope this is a helpful overview of some careful published work on FGM, which affects 3 million girls each year. We hope we can encourage systematic approaches to further work on this important topic, including work by the excellent scientists and social scientists working within countries and within those communities where the practice occurs. WHO has recently revised the United Nations Joint Statement on FGM. The Statement will be released in 2008.

Dr Hermione Lovel, Efua Dorkenoo, OBE, Zeinab Mohamed, Dr Clare McGettigan , Professor EO Akande

References
Morison L, Scherf C, Ekpo G, Paine K, West B, Coleman R, Walraven G (2001) ‘The long-term reproductive health consequences of female genital cutting in rural Gambia: A community-based survey’ Trop Med Int Health (2001) 6(8), pp. 643-653.

Behrendt, A, Moritz, S.(2005). ‘ Posttraumatic Stress Disorder and Memory Problems After Female Genital Mutilation’, 5 AM J. PSYCHIATRY, 1000-02 (2005

SOURCE: The New York Times

AUTHOR: John Tierney

URL: Click here

DATE: 26/01/2008

 

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