Table 4.3 reports the results of a small-scale study conducted by Poulin in France in respect of the obstetrical consequences of FGM. From these estimates, one may judge type I to have far fewer risks than types II and III (Poulain 2007). These results are a statistical indication used in epidemiological studies to measure the relationship between exposure to a risk factor (e.g. FGM) and the occurrence of morbidity (e.g. obstetrical complications). It is widely viewed as a measure of risk.
For instance, suggesting that a circumcised woman faces a double risk of experienc- ing episiotomy when compared to non-circumcised women is tantamount to saying that the risk related to FGM is equal to two. The figures in brackets represent
reliability indicators. This means that the authors estimated there is a 95% chance of the true value of the relative risk being between the two value limits or bands.
As one can see, the table does not include the situation that would obstetrically result if a patient had undergone type IV FGM. As a result of lack of data in this area, and given the relatively insignificant nature of FGM types such as a nick, it is reasonable to believe that a nick would have no direct medical or obstetrical effects for the patient.
Table 4.4 shows how hemorrhages due to childbirth depend on the type of FGM undertaken. The amount of bleeding is measured in milliliters and this is estimated using data collected by Poulain (2007).
When Poulain (2007) was conducting her study, she recorded 1185 (4.2%) as stillborn children. Of those children, 448 (38%) were macerated stillborn and 737 (62%) fresh stillborn. There was no significant difference between women who had had their first child and those who had already given birth before; and both catego- ries presented roughly the same obstetrical complication risks following FGM.
The presence of a type of FGM increased significantly the number of incidents requiring an episiotomy. The duration of child release from the wound was esti- mated to be fewer than 10 min and this was often the case among circumcised women giving birth, despite the high rate of preventative episiotomies. This phe- nomenon can be accounted for by the sceleral nature of the vulva following circum- cision. The prolonged vulvae retention of the foetus among circumcised women giving birth results in foetal distress. The difference in children born to uncircum- cised women was significant. It can therefore be concluded that such a study is valid, as it clearly shows the existence of obstetric and neonatal complications caused by FGM. The neonatal status of eight newborns depended on them being resuscitated;
two newborns from non-circumcised women were recorded against six newborns from circumcised mothers. The eight newborns presented from birth scored between three and seven on the Apgar scale. The pediatrician was called for nine deliveries by non-circumcised mothers and 23 deliveries by circumcised women. None of the clinical and maternity units interviewed had, at the time, either a protocol or policy guidelines for the delivery of circumcised mothers (Poulain 2007).
Table 4.3 Poulain’s obstetrical consequences of FGM Caesarean section Relative risk
No FGM 1.0
Type I FGM 1.03 (0.88–1.21) Type II FGM 1.29 (1.09–1.52) Type III 1.31 (1.01–1.70)
Table 4.4 Haemorrhages in childbirth by FGM
type Haemorages > 500 ml Relative risk
No FGM 1.00
Type I 1.03 (0.87–1.21)
Type II 1.21 (1.01–1.43)
Type III 1.69 (1.34–2.12)
Poulain [ibid] has suggested as part of her clinical studies that types II FGM and I did not increase the rate in pre-maturity or stillbirth. However, both types increased the duration of the baby’s expulsion from the womb. Besides, type I slightly increased the rate in episiotomy with respect to circumcised mothers, while type II required more elaborate episiotomy. Generally speaking, the deliveries of circum- cised mothers have required almost three times more episiotomies than the deliver- ies of non-circumcised mothers.
As far as perineal tears are, concerned, non-circumcised women were more likely to have their perinea left intact after childbirth. The Apgar score of newborns was often below ten in mothers who had undergone FGM. Such a score was also below ten among women who had experienced type II FGM; equally remarkable is the fact that types II and I had a relatively small impact on the weight of the newborn.
The WHO (2006) study represents a cohort study designed to determine the extent to which FGM complications at childbirth. The WHO work, constitutes a prima facie plausible study based on observations and evaluation of real patients (i.e. birth-giving mothers). That study follows the IMRAD approach (introduction, materials, results, analysis and discussions), which is indicative of the scientific reli- ability of the study. Among the factors explored are the rate of caesarean sections, the rate of haemorrhages following delivery, extended hospitalization time, weight of the newborn, the rate of newborns requiring neonatal resuscitation and the rate of prenatal deaths among circumcised women, as opposed to mothers who had not experienced FGM. Indicators are well described and midwives assessed expectant mothers (Poulain 2007).
As far as the target population is concerned, participants were recruited accord- ing to the unique stage of their pregnancy and were asked if they had undergone prenatal consultation to determine the type of their FGM. The only criterion for exclusion, as discussed in the study, related to a planned caesarean section. The study was multicentric and carried out in six countries, in which over 120 ethnic groups were interviewed. The fact that the study was carried out in 28 clinical cen- tres is important and ensures further reliability of the results achieved.
Poulain has demonstrated the health effects posed by some types of FGM on the mothers. She began by discussing a small-scale study by the authors, which was supplemented and contrasted with the findings commissioned by the WHO. The key difference between the findings of Poulain (Poulain 2007) combined with those of the WHO (2006) constitutes a randomized comparative data, which remains reliable today. However, the WHO’s (2006) study does not state how the risks are distributed among circumcised and uncircumcised mothers. Moreover, the WHO’s (2006) study does not clearly contemplate the possibility that complications at birth may be caused by more than one factor (i.e. FGM). Despite these shortcomings, it is accepted beyond doubt that the type of FGM is certainly one of the contributory factors. The challenging question is how to reduce the risks posed by this practice (Poulain 2007).
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