International Journal of Gynecology and Obstetrics 125 (2014) 125–128

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

Female genital mutilation and efforts to achieve Millennium Development Goals 3, 4, and 5 in southeast Nigeria Lucky O. Lawani a,⁎, Azubuike K. Onyebuchi a, Chukwuemeka A. Iyoke b, Nwabunike E. Okeke c a b c

Department of Obstetrics and Gynecology, Federal Teaching Hospital, Abakaliki, Nigeria Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria Mile Four Catholic Hospital, Abakaliki, Nigeria

a r t i c l e

i n f o

Article history: Received 4 August 2013 Received in revised form 1 November 2013 Accepted 3 February 2014 Keywords: Cultural practice Female genital mutilation Genital Harmful Millennium Development Goal Mutilation Obstetrics

a b s t r a c t Objective: To determine the prevalence of female genital mutilation (FGM), the common forms of FGM, reasons for the practice, associated obstetric outcomes, and how these have affected efforts to achieve Millennium Development Goals (MDGs) 3, 4, and 5 in southeast Nigeria. Methods: A prospective descriptive study of parturients in southeast Nigeria was conducted from January to December 2012. All primigravid women attending delivery services at 2 health institutions during the study period were recruited, examined, and classified using the 2008 WHO classification for FGM. Results: The mean age of the 516 participants was 27.24 ± 4.80 years and most (66.3%) had undergone FGM. Type II FGM was the most common form, accounting for 59.6% of cases. Most FGM procedures were performed in infancy (97.1%) and for cultural reasons (60.8%). Women who had undergone FGM had significantly higher risk for episiotomy, perineal tear, hemorrhage, cesarean delivery, neonatal resuscitation, fresh stillbirth/early neonatal death, and longer hospitalization, with higher risk ratios associated with higher degrees of FGM. Conclusion: FGM is still a common practice in southeast Nigeria, where its association with adverse reproductive outcomes militates against efforts to achieve MDGs 3, 4, and 5. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction In Sub-Saharan Africa, hundreds of thousands of women and children develop complications and die from harmful cultural practices and pregnancy-related conditions. This region has also continued to record the worst maternal and perinatal indices in the world. With the target date of 2015 fast approaching, it is obvious that many lowresource countries such as Nigeria—which account for approximately 10% of the world’s population—are still not on track to achieve the targets of Millennium Development Goals (MDGs) 3, 4, and 5: to promote gender equality, to reduce child mortality by two-thirds, and to reduce maternal mortality by three-quarters, respectively, by 2015 [1]. These setbacks can be attributed to numerous factors, among which are harmful cultural practices such as female genital mutilation (FGM). Female genital mutilation remains a pressing issue that has been recognized as a violation of human and child rights. It has been reported that approximately 3 million women and girls are subjected to FGM every year, while between 100 and 140 million have already undergone the procedure—most of whom live in 28 countries in Africa and western Asia [2–4]. There is reliable evidence about the harmful effects of FGM, especially on reproductive outcomes. It is, therefore, important to review its impact on obstetric outcomes in a country like Nigeria ⁎ Corresponding author at: Department of Obstetrics and Gynecology, Federal Teaching Hospital, PMB 102, Abakaliki, Ebonyi 234, Nigeria. Tel.: +234 8036691209. E-mail address: [email protected] (L.O. Lawani).

in which there is a very high maternal mortality ratio (700–1500 per 100 000 live births) [2,5–7]. This high mortality ratio has also been associated with 20 times more morbidity for every death [7]. WHO has reported that “the lifetime risk of maternal death ranges from 1 in 35 in Ghana to 1 in 12 in Burkina Faso and estimated perinatal mortality rates range from 44 per 1000 births in Sudan to 88 per 1000 births in Nigeria” [8]. This shows that the practice of FGM poses a great risk to women at various stages of their reproductive lives—increasing morbidity and mortality during childbirth, with attendant poor obstetric outcomes for mother and infant, and threatening the MDG objectives of improving the living conditions of people (especially children and women) around the world. The aim of the present study was to determine the prevalence of FGM in southeast Nigeria and to ascertain the reasons for the practice, the various forms of FGM predominantly practiced, and the effects of the different types of FGM on a range of maternal and neonatal outcomes during and immediately after delivery, in addition to assessing how this has affected efforts to achieve MDGs 3, 4, and 5. 2. Materials and methods A prospective descriptive study was conducted involving primigravid women managed between January 1 and December 31, 2012, at 2 specialist obstetric centers in Abakaliki, Ebonyi, southeast Nigeria: Federal Medical Center (now Federal Teaching Hospital Abakaliki) and Mile Four Clinic. These centers provide obstetric services to more than 4800

0020-7292/$ – see front matter © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.11.008

126

L.O. Lawani et al. / International Journal of Gynecology and Obstetrics 125 (2014) 125–128

women annually. The study was initiated after obtaining ethical clearance from the ethical and research committees of both institutions. Written consent was obtained from all participants. Primigravid women who presented for maternity services at the study centers were recruited, evaluated, and followed-up for the duration of labor, delivery, and hospital stay. Sociodemographic data, obstetric history, reasons for FGM, mode of delivery, and obstetric and neonatal outcomes were recorded. Participants were examined by trained medical doctors (resident doctors of the rank of registrar and above) and experienced midwives to ascertain whether they had undergone FGM. They were then classified using the 2008 WHO classification [9]. Data were collated and analyzed using Epi Info version 7.0 (Centers for Disease Control and Prevention, Atlanta, GA, USA), and conclusions were drawn by means of simple percentages and inferential statistics using risk ratios (RRs), odds ratios (ORs), and 95% confidence intervals (CIs). P b 0.05 was considered to be statistically significant. 3. Results The sociodemographic characteristics of the 516 participants are shown in Table 1. The mean age of the participants was 27.24 ± 4.80 years. The prenatal booking status of participants showed that 483 (93.6%) were booked in the 2 study facilities, 30 (5.8%) were unbooked, and 3 (0.6%) booked elsewhere but delivered at the study centers (Table 1). Mean gestational age at booking was 22 ± 6 weeks, and mean number of prenatal visits was 6 ± 3. In total, 342 (66.3%) participants had undergone FGM, with type II FGM the most common form experienced (59.6% of cases) (Table 2). The main reason reported for FGM was culture/tradition (60.8%), and most women reported having undergone the procedure in infancy (97.1%) (Table 2). The most common complication among women who had undergone FGM was hemorrhage (80.1%) (Table 3). Overall, 364 (70.5%) participants delivered vaginally, while 152 (29.5%) delivered via emergency cesarean (Table 4). Of the women who delivered vaginally, 167 (45.9%) had not undergone FGM, while 197 (54.1%) had (Table 4). Mean birth weight was 3178.88 ± 498.77 g. Table 5 and Fig. 1 show obstetric and perinatal outcomes and complications associated with FGM. Women who had undergone FGM were at higher risk of episiotomy, with higher RRs associated with higher degrees of FGM (P = 0.001) (Table 5). Perineal tears were also more common among participants who had undergone FGM compared with those who had not, and the RR was also higher with higher degrees of FGM (Table 5). Postpartum hemorrhage (PPH; estimated blood loss ≥500 mL or blood loss that was large enough to compromise the hemodynamic status of the parturient) occurred in 48 (13.2%) women who

Table 1 Sociodemographic characteristics of participants (n = 516). Characteristics Age, y ≤20 21–30 31–40 41–50 Educational status None Primary Secondary Tertiary Booking status Booked Unbooked Booked elsewhere Residence Urban Rural

No. (%) 30 (5.8) 285 (55.2) 197 (38.2) 4 (0.8) 19 (3.7) 97 (18.8) 205 (39.7) 195 (37.8) 483 (93.6) 30 (5.8) 3 (0.6) 360 (69.8) 156 (30.2)

Table 2 FGM status, type of FGM, and reasons for the procedure. Variables FGM status FGM No FGM Total Type of FGM Type I Type II Type III Total Reasons for performing FGM Culture/tradition Unaware of the reasons To prevent promiscuity To improve perinatal outcome Beautification Religious grounds Total Time FGM was performed Infancy Puberty Time of marriage During childbirth After childbirth Total

No. (%) 342 (66.3) 174 (33.7) 516 (100.0) 96 (28.1) 204 (59.6) 42 (12.3) 342 (100.0) 208 (60.8) 84 (24.6) 37 (10.8) 7 (2.0) 3 (0.9) 3 (0.9) 342 (100.0) 332 (97.1) 6 (1.7) 1 (0.3) 1 (0.3) 2 (0.6) 342 (100.0)

Abbreviation: FGM, female genital mutilation.

delivered vaginally, and the RR was higher with higher degrees of FGM (P = 0.02) (Table 5). Neonatal resuscitation (for Apgar score b7) was more common in the FGM group, and the RR was higher with higher degrees of FGM (P = 0.001) (Table 5). The incidence of fresh stillbirth/early neonatal death was also significantly higher in the FGM group (P = 0.003) (Table 5). Mean duration of hospital stay was 5.16 ± 1.02 days in the FGM group, compared with 2.16 ± 1.07 days among women who had not undergone FGM (OR 2.39 [95% CI, 1.05–3.51]; P = 0.03). 4. Discussion The present results indicate that FGM is still a common finding among women of reproductive age in southeast Nigeria, consistent with findings by WHO in 6 African countries [10]. This would explain its significant effect on obstetric and perinatal outcomes. In our locality (and as shown by the present results), FGM is often performed in infancy, before an individual has had any formal education and when they often have no input into whether they should consent to the procedure; furthermore, even the women who were of age were culturally bound to undergo the procedure for the sake of tradition. Other participants underwent FGM at puberty, at the time of marriage, during childbirth, or after childbirth—depending on variations in culture and customs. Recent surveys in some low-resource countries, especially in Sub-Saharan Africa, found that 90% of girls in Egypt who had undergone FGM were between 5 and 14 years of age at the time; 50% of those in Ethiopia, Mali, and Mauritania were under 5 years of age; and 76% of those in Yemen were 2 weeks old or younger [3]. In some communities, women who were about to be married or who were pregnant with/had Table 3 Immediate and late complications associated with FGM (n = 342). Complications

No. (%)

Hemorrhage Sepsis Gynatresia Dyspareunia Tetanus Total

274 (80.1) 51 (14.9) 7 (2.0) 7 (2.0) 3 (0.9) 342 (100.0)

Abbreviation: FGM, female genital mutilation.

L.O. Lawani et al. / International Journal of Gynecology and Obstetrics 125 (2014) 125–128

127

Table 4 Mode of delivery and indications for cesarean (n = 516). Variables

No. (%)

Mode of delivery Vaginal (n = 364) No FGM Type I Type II Type III Cesarean (n = 152) No FGM Type I Type II Type III Indications for cesarean delivery No FGM (n = 7) Prolonged second stage of labor Prepartum hemorrhage Cephalopelvic disproportion Previous cesarean Fetal distress FGM (n = 145) Prolonged second stage of labor Prepartum hemorrhage Cephalopelvic disproportion Previous cesarean Fetal distress

167 (45.9) 72 (19.8) 118 (32.4) 7 (1.9) 7 (4.6) 24 (15.8) 86 (56.6) 35 (23.0)

0 (0.0) 1 (14.3) 1 (14.3) 1 (14.3) 4 (57.1) 14 (9.6) 9 (6.2) 39 (26.9) 3 (2.1) 80 (55.2)

Abbreviation: FGM, female genital mutilation.

just given birth to their first child were also made to undergo the practice [2]. The FGM prevalence rate of 66.3% in the present study was higher than the 45.9% reported in Benin City (southern Nigeria) in 2003 [11], indicating that it is still a common cultural practice in southeast Nigeria. Type II FGM was the most common form in the present sample, representing 59.6% of all forms of FGM; this is much higher than the 11.5%–24% previously reported in Benin City [8,11].

Table 5 Obstetric and perinatal complications associated with FGM. Obstetric and perinatal outcomes Episiotomy (n = 166) No FGM Type I Type II Type III Perineal tear (n = 45) No FGM Type I Type II Type III Postpartum hemorrhage (n = 48) No FGM Type I Type II Type III Cesarean delivery (n = 152) No FGM Type I Type II Type III Neonatal resuscitation (n = 48) No FGM Type I Type II Type III Fresh stillbirth or early neonatal death (n = 16) No FGM Type I Type II Type III

No. (%)

Risk ratio (95% confidence interval)

20 (12.0) 36 (21.7) 68 (41.0) 42 (25.3)

1.00 1.80 (1.09–2.96) 3.40 (2.17–5.33) 2.10 (1.29–3.42)

2 (4.4) 8 (17.8) 15 (33.3) 20 (44.4)

1.00 4.00 (1.00–17.81) 7.50 (1.82–30.92) 10.00 (2.48–40.29)

8 (16.7) 5 (10.4) 16 (33.3) 19 (39.6)

1.00 1.13 (0.38–3.37) 1.71 (0.75–3.47) 9.89 (4.63–20.93)

7 (4.6) 24 (15.8) 86 (56.6) 35 (23.0)

1.00 3.43 (1.52–7.72) 12.29 (5.88–25.67) 5.00 (2.29–10.90)

6 (12.5) 9 (18.7) 12 (25.0) 21 (43.8)

1.00 1.50 (0.58–3.89) 2.00 (0.82–4.89) 3.50 (1.55–7.90)

1 (6.2) 2 (12.5) 4 (25.0) 9 (56.3)

1.00 2.00 (0.20–19.92) 4.00 (0.50–31.98) 9.00 (1.29–63.03)

Abbreviation: FGM, female genital mutilation.

Fig. 1. Obstetric and perinatal complications associated with female genital mutilation (FGM).

This form of FGM is more severe than type I and is associated with greater morbidity—consistent with the present results. Female genital mutilation may be associated with life-threatening morbidity such as hemorrhage, genital tract laceration, and episiotomy— which were more common in the FGM group in the present study. Considering the fact that hemorrhage is a major cause of maternal mortality in Nigeria [7,12], its contribution in the present study may jeopardize efforts to reduce maternal mortality by three-quarters by 2015. In the present study, FGM was also associated with other immediate and late sequelae such as sepsis, gynatresia, dyspareunia, and tetanus. Sepsis and tetanus are life-threatening conditions that adversely affect infant and child mortality rates in most low-resource countries [7]. The present findings were similar to those reported from Port Harcourt, Nigeria, where other complications such as urinary tract infection, infertility, clitoral neuroma, and vesicovaginal fistula were also observed [13]. Culture and tradition have a major role in the practice of FGM; therefore, it was not surprising that 60.8% of the participants were circumcised for these reasons, consistent with previous reports [5,13]. When used as a way to prevent promiscuity of the girl child—as observed in the present study—FGM aggravates the issue of gender inequality, which MDG 3 aims to address. The belief of the people in the study region is that FGM improves perinatal outcome because it is thought that the fetus will die if the clitoris touches its head during childbirth, consistent with previous reports [5]. In the present study, the recorded birth weight was average, so birth weight was not a risk factor for any adverse reproductive outcomes, as was also reported in the WHO multicenter study [10]. Of the 364 women who delivered vaginally, more than half (54.1%) had undergone FGM; this could have been because the less severe forms of FGM (types I and II) comprised 87.7% of cases in the studied population and because only 2% of women who had undergone FGM experienced gynatresia. The presence of scar tissue, which is less elastic than normal perineal and vaginal tissue, might cause differing degrees of obstruction and lead to tearing or episiotomy [3,10]. Previous studies of FGM have reported adverse outcomes such as episiotomy [6], tearing [14–16], protracted labor [6,17], PPH [16,17], and low Apgar scores [15–17]— consistent with the present findings. Because episiotomy, genital tract laceration, and prolonged labor are often associated with PPH, they may increase maternal and perinatal morbidity and mortality. Of the women who delivered vaginally, the rate of PPH was higher among those who had undergone FGM than among those who had not. This is similar to the findings of the WHO multicenter study [10].

128

L.O. Lawani et al. / International Journal of Gynecology and Obstetrics 125 (2014) 125–128

The effect of FGM on MDG 4 is highlighted by the present finding that need for neonatal resuscitation was higher in cases involving FGM—probably because of asphyxia following prolonged labor, especially the second stage. The poor progress made so far in achieving MDG 4 in this region has been partly attributed to perinatal deaths in the form of fresh stillbirths and early neonatal deaths. This correlates with the finding of excessive perinatal mortality attributed to FGM— ranging from 11 to 17 per 1000 deliveries, in relation to a background perinatal mortality rate of 40–60 per 1000 deliveries [10]. It is important to note that, despite WHO recommendations against FGM and its medicalization, studies in Nigeria have reported that a large proportion (34.5%) of FGM procedures were conducted by medical doctors [18]. This situation is similar to that in some other African countries such as Egypt and Kenya [18–20]. Medicalization of FGM by doctors has contributed to continuation of the practice and should be discouraged to reduce the prevalence of or eliminate FGM. Female genital mutilation is still common in southeast Nigeria, and culture was identified as a major contributory factor to this harmful practice. As well as being a form of gender-based violence and inequality against women, FGM was found to be associated with significantly higher morbidity and mortality in the study setting. Therefore, in order to achieve the MDGs of ensuring gender equality, reducing perinatal mortality by two-thirds, and reducing maternal mortality by three-quarters by 2015, it is important that we tackle the practice of FGM. The findings from the present study can be harnessed in policy making so that the political and moral will to abolish FGM can be developed. Enacting legislation to prohibit FGM by both orthodox (medical practitioners) and non-orthodox practitioners (e.g. traditional birth attendants) and applying such laws to the letter in order to ensure that offenders are prosecuted, irrespective of who is involved, will go a long way to eliminating the practice. Public enlightenment campaigns targeted at individuals, families, and communities should be implemented to raise awareness among law makers, religious and civic community leaders, traditional and orthodox healthcare providers, and the general public about the health-related dangers of FGM and its transgression of human rights. Conflict of interest The authors have no conflicts of interest.

References [1] United Nations. The Millennium Development Goals Report 2006. https://www. un.org/zh/millenniumgoals/pdf/MDGReport2006.pdf. Published 2006. Accessed July 15, 2013. [2] World Health Organization. Female genital mutilation: a joint WHO/UNICEF/UNFPA statement. http://www.childinfo.org/files/fgmc_WHOUNICEFJointdeclaration1997. pdf. Published 1997. Accessed July 15, 2013. [3] Department of Reproductive Health and Research, World Health Organization. Progress in Sexual and Reproductive Health Research: Female genital mutilation—new knowledge spurs optimism. http://www.who.int/reproductivehealth/topics/fgm/ progress72_fgm.pdf. Published 2006. Accessed July 15, 2013. [4] UNICEF. Female Genital Mutilation/Cutting: A Statistical Exploration 2005. www. unicef.org/publications/files/FGM-C_final_10_October.pdf. Published 2005. Accessed July 15, 2013. [5] Nour NM. Female genital cutting: a persisting practice. Rev Obstet Gynecol 2008;1(3): 135–9. [6] Hakim LY. Impact of female genital mutilation on maternal and neonatal outcomes during parturition. East Afr Med J 2001;78(5):255–8. [7] Ojewumi TK, Ojewumi JS. Trends in Infant and Child Mortality in Nigeria: A WakeUp Call Assessment For Intervention Towards Achieving the 2015 MDGS. Sci J Sociol Anthropol 2012;2012(3). [8] World Health Organization. The World health report 2005: make every mother and child count. http://www.who.int/whr/2005/whr2005_en.pdf. Published 2005. Accessed July 15, 2013. [9] World Health Organization. Sexual and reproductive health. Classification of female genital mutilation. http://www.who.int/reproductivehealth/topics/fgm/overview/ en/. Accessed July 15, 2013. [10] WHO study group on female genital mutilation and obstetric outcome, Banks E, Meirik O, Farley T, Akande O, Bathija H, et al. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006;367(9525):1835–41. [11] Snow RC, Slanger TE, Okonofua FE, Oronsaye F, Wacker J. Female genital cutting in southern urban and peri-urban Nigeria: self-reported validity, social determinants and secular decline. Trop Med Int Health 2002;7(1):91–100. [12] Balachandran V. Maternal mortality in Kaduna. Niger Med J 1975;5(4):366–70. [13] Eke N, Nkanginieme KE. Female genital mutilation: A global bug that should not cross the millennium bridge. World J Surg 1999;23(10):1082–7. [14] Jones H, Diop N, Askew I, Kaboré I. Female genital cutting practices in Burkina Faso and Mali and their negative health outcomes. Stud Fam Plann 1999;30(3):219–30. [15] Larsen U, Okonofua FE. Female circumcision and obstetric complications. Int J Gynecol Obstet 2002;77(3):255–65. [16] De Silva S. Obstetric sequelae of female circumcision. Eur J Obstet Gynecol Reprod Biol 1989;32(3):233–40. [17] Shandall AA. Circumcision and infibulation of females: a general consideration of the problem and a clinical study of the complications in Sudanese women. Sudan Med J 1967;5(4):178–212. [18] Ugboma HA, Akani CI, Babatunde S. Prevalence and medicalization of female genital mutilation. Niger J Med 2004;13(3):250–3. [19] Refaat A. Medicalization of female genital cutting in Egypt. East Mediterr Health J 2009;15(6):1379–88. [20] Christoffersen-Deb A. "Taming tradition": medicalized female genital practices in western Kenya. Med Anthropol Q 2005;19(4):402–18.

Female genital mutilation and efforts to achieve Millennium Development Goals 3, 4, and 5 in southeast Nigeria.

To determine the prevalence of female genital mutilation (FGM), the common forms of FGM, reasons for the practice, associated obstetric outcomes, and ...
230KB Sizes 0 Downloads 3 Views