New study outlines research priorities to improve the care of women with Female Genital Mutilation

Further evidence on how to improve the care of women living with Female Genital Mutilation (FGM) is urgently needed, suggests a new study, published today (17 December) in BJOG: An International Journal of Obstetrics and Gynaecology (BJOG).

FGM comprises all procedures involving partial or total removal of the external genitalia for non-therapeutic reasons. It violates the human rights of women and girls, has no health benefits and can have significant, negative, psychological and health outcomes.

Conducted by Geneva University Hospitals and the World Health Organization (WHO), this study highlights that international attention has focused on efforts to end these practices across the policy, community and health sectors. However, despite these efforts, more than 125 million girls and women have been subjected to FGM and at least three million girls are at risk every year.

The study reviews existing evidence and key knowledge gaps in the clinical care of women with FGM. It also identifies research priorities to improve the evidence necessary to establish further guidelines for the best multidisciplinary, high-quality care for women with FGM.

The study reviewed the available literature about the clinical care of women with FGM and identified four areas with significant evidence gaps, and controversy regarding optimal management. These include;

• Obstetric outcomes and post-partum care
• Defibulation (surgical opening of the labia) outside of pregnancy or labour
• Clitoral reconstruction
• Training, skills and confidence of healthcare providers

Previous studies conducted in Africa have suggested that FGM is associated with an increased risk of obstetric complications, such as caesarean section, post-partum haemorrhage, episiotomy and low birth weight. However, studies performed in Western settings suggest that a high standard of obstetric care can reduce such risks.

The study highlights that obstetric outcomes should be evaluated for age, socio-economic status, reproductive history, and health affecting a pregnancy, in addition to FGM type. Future research should also take into account the quality and utilisation of healthcare services.

Little evidence exists around long term post-partum complications, such as the prevalence of incontinence and the effectiveness of treatments such as pelvic floor exercises, state the authors.

Additionally, evidence around the ideal timing of defibulation during pregnancy and how to manage intrapartum defibulation, as well as the incidence of urinary tract and vaginal infections during pregnancy and the health consequences is urgently needed. The authors also highlight a lack of evidence around the impact of FGM on sexuality, including orgasm and the lack of studies on clitoral reconstruction.

With regards to the training skills and confidence of healthcare providers, currently, FGM is not included in the curricula of most medical, nurse, midwifery and public health training and recommendations about clinical management, refibulation and legislation on FGM are not well known, states the paper. Further training for healthcare professionals may improve counselling and care.

Future studies should focus on addressing existing research gaps such as obstetric outcomes, complications, sexuality and therapeutic surgeries, state the authors. They should also take into consideration the diversity of women with FGM, for example, the different types of FGM, origins, cultures, complications and migration.

The authors conclude that there is an urgent need for well-designed research to inform evidence-based guidelines and improve the healthcare of women and girls living with FGM.

Jasmine Abdulcadir, from Geneva University Hospitals and the World Health Organization, and co-author of the study said:

"As important as identifying effective policies and interventions to eliminate FGM is the need for evidence on how to minimise negative health outcomes for women and girls living with FGM".

"This includes improving the knowledge base about obstetrical and gynaecological consequences as well as strengthening healthcare professionals' training to deliver high quality, comprehensive and non-stigmatising evidence-based care for women living with FGM".

John Thorp, BJOG Editor-in-chief, added:

"Further progress is needed in eradicating FGM, as well as caring for the girls and women who have undergone it.

"Additional evidence in this area will help to improve the physical and psychological health of women living with FGM. Much has been achieved internationally but more can be done."