FGM Type 3 in Pregnancy
Key points
- Female Genital Mutilation (FGM) is commonly performed in parts of Africa, Asia and the Middle East; there are no identifiable health benefits associated with FGM.
- Good quality research evidence about the complications associated with FGM is sparse and there is none from the UK.
- The available evidence, largely from Africa, suggests there are substantial antenatal and delivery complications and poor fetal outcomes.
- The prevalence of FGM in pregnancy in the UK is currently based on unreliable estimates.
Surveillance Period
1st October 2016 – 31st January 2017
Background
Female Genital Mutilation/Cutting is defined by the WHO as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons[1].” There are four types of FGM of which type 3 (Infibulation) is the most extreme. Long term gynaecological complications include scarring, infections, menstrual complications and sexual dysfunction[2]. Psychological harm and post-traumatic stress disorder have also been described[3]. Despite widespread practice and misconceptions about FGM there are no identified health benefits associated with FGM[1][2].
Evidence about pregnancy related impacts is relatively sparse as illustrated by a recent systematic review and meta-analysis; none of the studies included were from the UK and were generally poor quality[4]. However, the findings indicate an increased risk of prolonged labour, lacerations, instrumental delivery, dystocia, and obstetric haemorrhage; whereas there was no significant association with caesarean section and episiotomy. Of note fetal outcomes were not assessed and it is not possible to directly relate these findings to the contemporary management of pregnancy and delivery in the UK.
Available data about FGM in the UK are sparse, as a consequence prevalence estimates are based on the analysis of maternal place of birth data derived from birth registrations and the application of estimates of FGM practices in different countries[5]. From this it is estimated that 1.2% of women giving birth in the UK have undergone FGM, of these it is estimated that 0.9% (9 in 1,000) have FGM type 3, but there is considerable uncertainty about the true prevalence. However, if this is an accurate estimate this would make the condition too frequent for a UKOSS study (frequency limit 1 in 2,000). For this reason we propose an initial study to estimate the prevalence to assess whether it would be possible to conduct a full UKOSS study of FGM.
Mandatory data collection of FGM is underway in England. However, this data collection requires submission of patient-identifiable data, a cause of concern for some clinicians[6]. With only 50% of eligible acute Trusts currently returning data centrally, under-ascertainment remains problematic.
Objective
To use the UK Obstetric Surveillance System (UKOSS) to estimate the prevalence of type 3 FGM in pregnancy in the UK to assess whether it would be feasible to conduct a full UKOSS study.
For this study only prevalence data will be collected for a four month period i.e. the number of cases of type 3 FGM. Full data collection will proceed only if the prevalence meets the UKOSS threshold for inclusion that is, it occurs less frequently than 1 in 2,000 women giving birth.
Research questions
- What is the prevalence of type 3 FGM in pregnancy in pregnant women in the UK?
- Is the prevalence such that it would be possible to conduct a full UKOSS study?
Case definition
Any pregnant woman in the UK who fulfils the following criteria:
- A woman identified on examination during pregnancy or at delivery who has been subject to infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora or majora with or without removal of the clitoris.
- Include also women whose infibulation has been reversed by de-infibulation prior to this pregnancy.
Funding
This study is funded by the National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford.
Ethics committee approval
This study has been approved by the North London REC1 (REC Ref. Number: 10/H0717/20).
Lead Investigator
Jenny Kurinczuk and Marian Knight, NPEU; Brenda Kelly, John Radcliffe Hospital, Oxford; Sarah Creighton, University College London Hospitals.
References
- a, b WHO. Female genital mutilation. Fact sheet No 241,Updated Feb 2014; Available from: www.who.int/mediacentre/factsheets/fs241/en/
- a, b Davies, S.C. Annual Report of the Chief Medical Officer, 2014, The Health of the 51%: Women. London: DH 2015.
- ^ Behrendt A, Moritz S. Post-traumatic stress disorder and memory problems after female genital mutilation. Am J Psychiatry. 2005; 162(5): 1000-1002.
- ^ Berg RC, Underland V. The obstetric consequences of female genital mutilation/cutting: a systematic review and meta-analysis. Obstet Gynecol Int. 2013;2013:496564. doi: 10.1155/2013/496564. Epub 2013 Jun 26.
- ^ Macfarlane, A. J. & Dorkenoo, E. (2015). Prevalence of Female Genital Mutilation in England and Wales: National and local estimates. London: City University London in association with Equality Now. Available at: http://openaccess.city.ac.uk/12382/
- ^ Bewley S, Kelly B, Darke K, Erskine K, Gerada C, Lohr P, de Zulueta P. Mandatory submission of patient identifiable information to third parties: FGM now, what next? BMJ. 2015 Sep 30;351:h5146. doi: 10.1136/bmj.h5146.
