Female genital mutilation and obstetric sequelae in the Upper East Region of Ghana

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Large-scale evidence regarding the social, psychosexual and medical consequences of Female Genital Mutilation (FGM) is lacking despite the numerous resolutions and recommendations that have been made, aimed at the elimination of FGM. The available evidence suggests that women with FGM may be more likely to suffer adverse obstetric outcomes than women without FGM. The hypothesis posed for this work was to examine the risk of adverse obstetric outcomes for each type of FGM (FGM type I, FGM type II, FGM type III and FGM type IV) compared with that in women without FGM, adjusting for study centre and other potential confounding factors. The study was a multi-centered prospective cohort study, based at the maternity units and obstetric departments of the Bolgatanga, Bawku and Navrongo Hospitals. Based on a pilot study, it was estimated that approximately 6,000 women would be required in order to detect a two-fold increase in the risk of outcomes such as stillbirth and early neonatal death, in women with each type of FGM, compared to women without FGM. A total of 6,413 consenting women with singleton pregnancies presenting for delivery were consecutively recruited into the study from December 2001 to June 2003. Subjects were followed through labour and delivery, and obstetric outcome, including duration of labour, instrumental delivery, episiotomies, perineal tears, post-partum haemorrhage and maternal deaths were recorded. The newborn infant was examined and vital status, APGAR score, birth weight, and other anthropometric data were also recorded. Subjects were followed up at the two-week and at the six-week post-partum period to ascertain the presence of complications such as genital wound infections and fistulas. After the data had been carefully checked, cleaned and edited, they were analyzed using STATA (version 8.2) and Statistical Package for Social Science (SPSS) (version 11). The results were presented in frequencies, cross-tabulations and univariate and multivariate analyses by logistic regression adjusting for confounding. Overall, the FGM prevalence was 38%, made up of 7% of FGM type I, 30% of FGM type II and 1% of FGM type III. Bawku had the highest FGM prevalence of 82% and accounted for 84% of all the cases of FGM Type III that were seen. FGM was significantly associated with prolonged labour (odds ratio: 1.47, p = 0.000, CI = 1.23 - 1.75). FGM had a direct relationship with post-delivery fistulas. The association between FGM type I and FGM type II was however not significant but FGM type III with odds ratio of 33.08, p-value = 0.000, CI of 5.95 to 184.09 was strongly associated with post delivery fistulas. FGM type II and type III were significantly associated with post-delivery genital wound infection. FGM type III with odds ratio of 38.03, p-value of 0.003, CI of 3.36 to 430.85 was strongly associated with post-delivery genital wound infection. FGM Type III with odds ratio of 453.16 and a p-value of 0.000 was strongly associated with third degree tears. FGM type III with odds ratio of 2.7 and a p-value of 0.003, CI of 1.39 to 5.24 was significantly associated with low APGAR score. FGM type I and FGM type II did not demonstrate any association with C-section; FGM type III (odds ratio3.12, z-statistic 3.76, pO.000, C11.75 - 5.86) however was significantly associated with C-section. FGM had only a mild association with Post-Partum Haemorrhage. FGM had no direct relationship with Cephalo Pelvic Disproportion, maternal death, extended stay in hospital after delivery, low birth weight and stillbirth. Location of residence, age, number of births, level of education and household wealth all interact. The increased risk of adverse obstetric outcomes with FGM observed in the study occurs against the background of increased maternal morbidity and mortality. This means that FGM is likely to be responsible for substantial numbers of additional causes of adverse obstetric outcomes. Adverse obstetric and perinatal outcomes can therefore be added to the known harmful immediate and long-term effects of FGM.
A thesis submitted to the Department of Theoretical and Applied Biology, Faculty of Biosciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana for the degree of Doctor of Philosophy (Reproductive Biology), 2005