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Is There a Relationship Between Female Genital Mutilation/Cutting and Fistula

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Is There a Relationship Between Female Genital Mutilation/Cutting and Fistula Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-025355 on 29 July 2019. Downloaded from Is there a relationship between female genital mutilation/cutting and fistula? A statistical analysis using cross-sectional data from Demographic and Health Surveys in 10 sub-Saharan Africa countries Dennis Juma Matanda,1 Pooja Sripad,2 Charity Ndwiga1 To cite: Matanda DJ, ABSTRACT Strengths and limitations of this study Sripad P, Ndwiga C. Is there a Objectives Literature on associations between female relationship between female genital mutilation/cutting (FGM/C) and fistula points to ► The study used nationally representative samples genital mutilation/cutting and a common belief that FGM/C predisposes women to fistula? A statistical analysis from 10 African countries to investigate associations developing fistula. This study explores this association using cross-sectional data between female genital mutilation/cutting (FGM/C) using nationally representative survey data. from Demographic and Health and fistula. Design A secondary statistical analysis of cross- Surveys in 10 sub-Saharan ► Demographic and Health Survey data is inherently sectional data from Demographic and Health Surveys was Africa countries. BMJ Open hierarchical rendering itself suitable for investigat- conducted to explore the association between FGM/C and 2019;9:e025355. doi:10.1136/ ing associations between FGM/C and fistula while bmjopen-2018-025355 fistula. considering other contextual and socioeconomic Setting Sub-Saharan Africa. ► Prepublication history and correlates. Participants Women aged 15–49 years in Burkina Faso additional material for this paper ► Questions asked during surveys about sensitive (n=17 087), Chad (n=17 719), Côte d’Ivoire (n=10 060), are available online. To view events such as fistula and FGM/C are not as ac- Ethiopia (n=14 070), Guinea (n=9142), Kenya (n=31 079), please visit the journal (http:// curate as the gold standard of a gynaecological dx. doi. org/ 10. 1136/ bmjopen- Mali (n=10 424), Nigeria (n=33 385), Senegal (n=15 688) examination. http://bmjopen.bmj.com/ 2018- 025355). and Sierra Leone (n=16 658). ► Due to sample size limitations, this study was not Main outcome measures Fistula symptoms. able to run country specific multivariate logis- Received 11 July 2018 Results Multivariate logit modelling using pooled data tic regression analyses for all the 10 countries. Revised 28 June 2019 from 10 countries showed that the odds of reporting fistula Accepted 10 July 2019 Multivariate logistic regression was nonetheless symptoms were 1.5 times (CI 1.06 to 2.21) higher for conducted on a pooled dataset for the 10 countries. women whose genitals were cut and sewn closed than ► This study analyses self-report data that is subject those who had undergone other types of FGM/C. Women to recall bias. who attended antenatal care (ANC) (adjusted odds ratio (AOR) 0.51, CI 0.36 to 0.71) and those who lived in urban on October 1, 2021 by guest. Protected copyright. areas (AOR 0.62, CI 0.44 to 0.89) were less likely to report female genital organs for non-medical fistula symptoms than those who did not attend ANC or reasons.1 The practice of FGM/C is catego- lived in rural areas. Conclusions Severe forms of FGM/C (infibulation) rised into four types: type I—total or partial removal of the clitoris and/or the prepuce © Author(s) (or their may predispose women to fistula. Contextual and employer(s)) 2019. Re-use socioeconomic factors may increase the likelihood of (clitoridectomy), type II—total or partial permitted under CC BY-NC. No fistula. Multisectoral interventions that concurrently removal of the clitoris and labia minora with commercial re-use. See rights address harmful traditional practices such as FGM/C and or without excision of the labia majora (exci- and permissions. Published by other contextual factors that drive the occurrence of fistula sion), type III—narrowing of the external BMJ. are warranted. Promotion of ANC utilisation could be a 1 genitalia and stitching together the edges Department of Reproductive starting point in the prevention of fistulas. Health, Population Council of the vulva (infibulation) and type IV—any Kenya, Nairobi, Kenya kind of non-therapeutic procedures to the 2Department of Reproductive female genitalia including pricking, piercing, Health, Population Council, New INTRODUCTION incising, scraping and cauterisation.2 York, New York, USA The WHO defines female genital mutila- The practice of FGM/C is globally Correspondence to tion/cutting (FGM/C) as all procedures that recognised as a human rights violation Dr Dennis Juma Matanda; involve partial or total removal of external because of its negative impact on women’s matandajd@ gmail. com female genitalia, or any form of injury to health. It violates the UN Convention on Matanda DJ, et al. BMJ Open 2019;9:e025355. doi:10.1136/bmjopen-2018-025355 1 Open access the Elimination of all forms of Discrimination Against caesarean section, experience postpartum haemorrhage, BMJ Open: first published as 10.1136/bmjopen-2018-025355 on 29 July 2019. Downloaded from Women, UN Convention on the Rights of the Child and episiotomy, extended maternal hospital stay, resuscitation the Universal Declaration of Human Rights.3–5 In recog- of the infant and inpatient perinatal death—though it nition of the negative effects of FGM/C, the WHO has did not describe obstetric fistula outcomes.1 A meta-anal- published clinical guidelines on managing complications ysis on the obstetric consequences of FGM/C demon- resulting from FGM/C and strategies to stop healthcare strated that despite methodologically low quality studies, providers from performing FGM/C.6 7 Immediate conse- effect sizes of exposure to FGM/C show elevated associ- quences of FGM/C to the health and well-being of girls ated risk of childbirth complications including prolonged and women include severe pain, excessive bleeding, urine labour, obstetric lacerations, instrumental delivery, retention and genital tissue swelling.2 8–10 Documented obstetric haemorrhage and difficult delivery.11 Some long-term effects of FGM/C range from urinary tract studies have suggested that the pathway through which infections to obstetric complications such as perineal FGM/C is linked to fistula is through its association with tearing and obstructed/prolonged labour to surgical prolonged/obstructed labour, particularly types I, II and childbirth procedures such as caesarean section and III where FGM/C-induced scarring can cause obstructed episiotomy to elevated postpartum risks such as haem- labour.32 34–36 orrhage, extended maternal hospital stay and perinatal Despite the widespread belief that FGM/C predisposes death.2 11–14 FGM/C has also been linked to women’s women to the development of obstetric fistulas,37–39 there sexual functioning4 15 16 and long-lasting adverse effects is limited evidence showing a causal relationship between on women’s mental health.2 17–20 Analysis using nation- these two conditions.40 41 Studies conducted in Europe ally representative surveys showed that over 200 million that compared cut African immigrants to uncut Euro- girls and women in just 30 countries have been subject pean women delivering at the same health facility found to FGM/C. Over 70 million girls younger than 15 years no differences between the two groups regarding delivery have either been cut or are at risk of being cut.21 Global outcomes such as prolonged labour, need for forceps or estimates are likely higher because of under-reporting caesarean delivery, foetal distress, or perinatal deaths.34 41 and unavailable data from countries known to prac- It is important to note the large differences in availability tice FGM/C such as Indonesia, India, Pakistan, Oman, of and level of care between Africa and Europe and there- Malaysia, Iran and Colombia.21 fore data from deliveries in Europe cannot be extrapo- Fistula, a condition in which a hole between the vagina lated to deliveries in Africa. In Africa, studies have shown and the rectum or bladder causes a woman to continu- increases in obstetric complications among women who ously leak urine, faeces or both, is a distressing morbidity. have undergone FGM/C.14 42 A prospective analysis by the Fistulas can be caused by obstetric, traumatic or iatro- WHO of delivery outcomes among 28 393 women with genic complications.22 Globally, approximately one to singleton pregnancies in 28 obstetric centres in Burkina two million women are living with fistula with a majority Faso, Ghana, Kenya, Nigeria, Senegal and Sudan showed http://bmjopen.bmj.com/ residing in sub-Saharan Africa and South Asia.23 24 that adverse outcomes increased with increasing severity Using 19 surveys from countries in sub-Saharan Africa, of the genital cutting.1 Notwithstanding the existence of Maheu-Giroux et al, estimated a lifetime and point preva- independent literature on FGM/C1 43 and fistula,24 44 45 lence of fistula of three and one case per 1000 women of there is limited research on the association between the reproductive age.22 The common cause of fistula in sub-Sa- two conditions. This study contributes to the existing haran Africa is the obstetric complication of inadequately limited literature on associations between FGM/C and managed prolonged obstructed labour.25–27 Generally, fistula by conducting a statistical analysis using nationally women with fistula suffer extensive psychosocial conse- representative data in 10 sub-Saharan Africa countries to on October 1, 2021 by guest. Protected
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