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05_HB_Dakar_DEC1 Female Genital Mutilation and Obstetric Outcome: How to take the results to doctors and midwives Hermione Lovel UK Heli Bathija, WHO 6.

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Presentation on theme: "05_HB_Dakar_DEC1 Female Genital Mutilation and Obstetric Outcome: How to take the results to doctors and midwives Hermione Lovel UK Heli Bathija, WHO 6."— Presentation transcript:

1 05_HB_Dakar_DEC1 Female Genital Mutilation and Obstetric Outcome: How to take the results to doctors and midwives Hermione Lovel UK Heli Bathija, WHO 6 February, Washington DC

2 05_HB_Dakar_DEC2 Challenge: Each year 3 million girls are forced to undergo female genital mutilation, in many cases the medical profession is carrying out the procedure. However, in many other cases the doctors and nurses want to prevent complications but do not know how Challenge: Each year 3 million girls are forced to undergo female genital mutilation, in many cases the medical profession is carrying out the procedure. However, in many other cases the doctors and nurses want to prevent complications but do not know how

3 06_Women Health Ministers Dinner November 8 06_HB3 WHO overall Strategy on FGM To play an advocacy role by emphasizing the importance of action against harmful practices at international, regional and national levels. To initiate and to coordinate the research and development being undertaken by – international agencies, nongovernmental organizations and national authorities. To support national networks or organizations and groups involved in developing relevant policies, strategies and programmes. To support the training of health professionals in the prevention of female genital mutilation and the management of its health consequences.

4 06_Women Health Ministers Dinner November 8 06_HB4 To support the training of health professionals ( in all countries) in the prevention of female genital mutilation and the management of its health consequences. Issues – Medicalisation: increase in percentages of girls whose FGM is performed by medical personnel – Re-stitching: routine practice in many countries without any public discussion – Preventing complications at birth for the woman and the newborn: de-infibulation during pregnancy not practised

5 06_Women Health Ministers Dinner November 8 06_HB5 It is important to train students of medical professions 330 5th year medical students in Alexandria, Egypt (country with 97% FGM prevalence): – Awareness of the prevalence, practices and procedures low – Poorly informed about complications, ethical and legal aspects – 52% in favour of continuation of practice – 73% in favour of medicalization – 87% thought that the issue of FGM should be included in the curriculum Eastern Mediterranean Health Journal 2006, vol 12 (Suppl 2), S78-S92

6 05_HB_Dakar_DEC6 The medical personnel might know WHO classification of FGM… Type I : Excision of the prepuce and part or all of the clitoris Type II: Excision of the prepuce and clitoris together with partial or total excision of the labia minora Type III: Infubulation Excision of part or all of the external genitalia and stitching of the two cut sides together to varying degrees Type IV:Pricking, piercing, incision, stretching, scraping, or other harming procedures on clitoris or labia, or both …But they might not be aware of how the FGM is performed and what the complications might be

7 05_HB_Dakar_DEC7 FGM instruments the thorns used to clasp infibulation the herb, mal mal, that is used to "glue" infibulation

8 06_Women Health Ministers Dinner November 8 06_HB8 Physical consequences of FGM Severe pain is the most common immediate consequence of all forms of FGM. The degree of pain and trauma is such that a woman or girl is often left in a state of medical shock after the operation. Bleeding (Long-term anaemia also possible) Damage to adjacent tissue In extreme cases: death due to severe and uncontrolled bleeding or to infection. Urine retention Keloid scars, abscesses and painful cysts. Infertility

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10 05_HB_Dakar_DEC10 Aims of the study The primary aims of the study – To evaluate the relationship between different types of FGM and obstetric complications. – To estimate the incidence of obstetric complications among women with a history of FGM giving birth in hospital. The secondary aim of the study – To obtain clinical information relevant to the prevention and treatment of obstetric complications in women with FGM.

11 06_Women Health Ministers Dinner November 8 06_HB11 FGM prevalence in the participating countries Burkina Faso75% - 2003 Ghana5% - 2003 Kenya32% - 2003 Nigeria19% - 2003 Senegalabout 20% Sudan90% - 2000

12 05_HB_Dakar_DEC12 Methods Women – Singleton delivery at one of 28 obstetric centres in Burkina Faso (5), Ghana (3), Kenya (3), Nigeria (6), Senegal (8), Sudan (3) – Planned elective Caesarean sections excluded – Consenting women examined in early labour and FGM status determined before delivery (women in advanced labour with expected imminent delivery excluded)

13 05_HB_Dakar_DEC13 Methods Statistics – 28 509 women enrolled – 126 (0.4%) excluded for missing data on age, parity, education, height, residence (urban/rural) – Multivariate logistic regression, adjusted ORs Core factors: centre, age, parity, education, socio-economic status Additional factors (>5% impact on OR): height, residence, time to reach hospital, # ANC visits – Separate models for FGM I vs. no FGM, FGM II vs. no FGM, FGM III vs. no FGM

14 05_HB_Dakar_DEC14 CountryFGM 0FGM IFGM IIFGM IIITotal Burkina Faso20%23%45%13%4816 Ghana60%11%28%1%3094 Kenya40%21%29%10%4167 Nigeria12%63%24%1%5366 Senegal21%24%54%1%3449 Sudan18%5%5%73%7501 Total25%24%27%23%28393 Recruitment Distribution of FGM type, by country

15 05_HB_Dakar_DEC15 Birth complications of FGM From Caring for women with circumcision, av Nahid Toubia, MD. Rainbo, UK.

16 05_HB_Dakar_DEC16 Women with FGM run greater risks during childbirth…

17 05_HB_Dakar_DEC17 … and so do their babies

18 05_HB_Dakar_DEC18 Additional Results Patterns of risks similar in nulliparous and parous women Significantly higher rates of episiotomy and perineal tears in women with FGM, though substantial heterogeneity between centres Estimated 10 – 20 additional perinatal deaths per 1000 live births in the countries where study conducted Complication rates likely higher in women with limited access to obstetric services

19 05_HB_Dakar_DEC19 Implications First clear evidence of obstetric sequelae Previous data limited and equivocal, and focused more on immediate complications of procedure Clear evidence of harm for mothers and babies Adverse health effects of all FGM types – greatest risks with more extensive FGM Lack of effect on birth weight yet clear adverse effect on delivery process: supports hypothesis of mechanical problem (lack of elasticity of cut/excised tissues?)

20 06_Women Health Ministers Dinner November 8 06_HB20 "These results invite the authorities and health professionals to focus on women's rights and to ensure effective skilled attendance during deliveries at high risk." Dr Michel Akotionga, Principal Investigator, Burkina Faso "The results of this research provide empirical data … about FGM in general and especially in women with FGM going through labour, in our quest to eradicate the practice of FGM worldwide" Dr Kwasi Odoi-Agyarko, Executive Director, Rural Help Integrated Bolgatanga, Ghana Implications

21 06_Women Health Ministers Dinner November 8 06_HB21 Way forward Strengthening health systems capacity to deal with consequences of FGM: – Promotion of use of WHO guidelines – Developing new guidance documents based on the findings of the research – Electronic media: DVDs, internet (example the DVD by DFID for medical practitioners in UK)

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23 06_Women Health Ministers Dinner November 8 06_HB23 Way forward need to be working together: – WHO – World Medical Association (WMA) – International Federation of Obstetricians and Gynecologists (FIGO) – International Council of Midwives (ICM) – Partnership for Maternal, Newborn and Child Health – Pediatricians – Private sector – others

24 06_Women Health Ministers Dinner November 8 06_HB24 Next steps Meeting of a working group to develop two, three options for a workplan and resource mobilization Identifying focus countries Targeting information sharing through various tools Arranging training opportunities

25 06_Women Health Ministers Dinner November 8 06_HB25


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