Type 3 Female Genital Mutilation and Obstetric Outcomes

by Marina Koch

The full extent to which female genital mutilation (FGM) affects the mental and physical health of the person it is practiced on is still unknown, and under researched. In the past 30 years, however, there have been a growing number of studies done on the repercussions of FGM, in part due to the recognition of FGM as a human rights violation (WHO, 2024). In 1995, female genital mutilation was categorized into four distinct types (UNICEF, 2024); type one, the cutting of the clitoral glans, type two, which removes the labia minora and often majora in addition to the clitoral glans (WHO 2024), type 3, covered in this paper, and type four, a catchall category for all other kinds of non-medical mutilation of the female genitalia. The third and most extensive method is type 3; infibulation (WHO, 2024). As with every type of FGM, there is a wide range of extremity under the umbrella term of infibulation (Bailey et. al, 2021) but it is classified as the removal or alteration of the labia minora, often the clitoris as well, followed by the stitching together of the labia majora, creating a narrower vaginal opening. Infibulation has been performed on an estimated 8 million women alive today (about 10% of the 3 million at risk of any type of FGM every year (WHO 2024)), mainly in north-eastern Africa. The percentage of women between the ages of 14 and 49 that go through FGM (including all types, but infibulation is most common in the following countries) in Ethiopia is 65%, 83% in Eritrea, 87% in Egypt and Sudan, and 98% in Somalia (National FGM Centre, n.d.). Infibulation can restrict the flow of urine and menstrual blood, and increase the risk of complications during labor, with infibulated women being twice as likely to require an extended hospital stay after giving birth (Larsen et. al, 2006). Birth after type 3 FGM presents the possibility of increased risk of hemorrhages, tears, and caesareans, which can be influenced by the extent of the mutilation and scarring, what type of episiotomy, if any, is performed, and the timing of deinfibulation.

Infibulation, like all forms of FGM, is practiced for a variety of reasons, but historically the most common have been for marriageability, rape prevention, suppression of female libido, and pregnancy prevention (Mackie, 1996). The practice of infibulation is likely to have originated on the west coast of the Red Sea, as the type of FGM performed in the surrounding countries tends to decrease in severity the farther west one looks. For example, the rates of FGM are still very high in western Africa (prevalence in Sierra Leone is approximately 90%, 91% in Mali, and 97% in Guinea), but infibulation is not practiced there; the considerably less severe type one and type two being most common (National FGM Centre, n.d.). FGM is likely to have persisted for thousands of years, its origins still murky. Female Egyptian mummies were found to be infibulated, prompting the commonly held belief that the practice began near Egypt, and spread in part due to traveling Arabian traders (Chatterjee, 2018).

Though FGM became the cultural norm in the communities in which it is practiced - an essential rite of passage for all young women - it is believed to have originated to control slave populations. There are differing theories as to why enslaved women seemed to be the first ones subjected to this practice, but most agree that the mutilation was done to ensure virginity and protect against rape and conception. Some have argued that because an infibulated slave was one less likely to get pregnant (Chatterjee, 2018) and had “proof” of virginity (Hicks, 1996) she was therefore worth more as a manual laborer or prostitute. The advent and dispersal of Islam brought a higher demand for non-Muslim slaves, prompting slave traders to travel across the continent looking for non-Islamic women to enslave and infibulate (Chatterjee, 2018). As slavery and Islam spread, so did female genital mutilation. This may be why many believe it to be the Prophet’s wish that every woman is circumcised, despite it not being mentioned in the Quran (WHO 2024). In cultures that perform type 3 FGM, an infibulated woman is a clean, chaste, loyal, fertile, wife-to-be.

Most women, once infibulated (usually at a very young age - before 5 years, and almost always before 15 (Farouki et. al, 2022)), must be deinfibulated (cut back open) in order to have sex and give birth. Although there is currently no official recommendation on the best time to deinfibulate pregnant women (Bailey et. al, 2021), it is preferable to perform deinfibulation either preconception or after 13 weeks. Most miscarriages happen during the first trimester of pregnancy, and providers do not want patients to attribute spontaneous abortion to deinfibulation (Brady et. al, 2019, WHO 2018). Depending on the size of the altered vaginal opening, antenatal deinfibulation may be helpful in the context of vaginal exams. Antenatal deinfibulation can also cause unnecessary trauma, as it is yet another invasive vaginal procedure, and so some choose to wait until active labor to avoid being reminded of the original mutilation (Moxey & Jones, 2016). Although current data does not reflect that the timing of deinfibulation before birth makes a huge difference (obstetrically speaking – psychologically it certainly could), not being deinfibulated at all, or waiting until the baby is crowning to deinfibulate, could have devastating effects on the mother (Bailey et. al, 2021). When looking at the deliveries of multiparous women, infibulation status was a significant indicator of risk of emergency c-section; multiparous women who had been deinfibulated prior to childbirth were much less likely to need an emergency cesarean section (Raouf, 2011). In the largest study ever done of birth after FGM, featuring 28,393 women, it was found that having type 3 FGM (versus no FGM) increased the risk of c-section by 30% (Larsen et. al, 2006). This finding was supported by a later study looking at multiparous women with non-reversed type 3 FGM, who had c-sections 53.8% of the time, while the hospital average for multiparous women was 25% (Raouf, 2011). In this case, not receiving deinfibulation antenatally more than doubled the likelihood of a c-section.

Not only does FGM contribute to higher rates of caesarean deliveries, it often necessitates more frequent and more extensive episiotomies as well. Technically, deinfibulation is an anterior episiotomy (Rodriguez et. al, 2016); the “opening” of the scar tissue that resulted from infibulation. Sometimes, women have been infibulated for so many decades that deinfibulation is not an option because of the way the area has "healed”; due to keloid scarring or the fusing of sewed labia to urethral tissue, it is impossible to carry out deinfibulation without further genital damage (Bailey et. al, 2021). This was the case for four of 32 women not deinfibulated before labor, in a study looking at the timing of deinfibulation. In these instances, a mediolateral episiotomy is planned for during parturition (Bailey et. al, 2021). Because women with type 3 FGM are much more likely to tear, they are more likely to receive episiotomies, both to widen the artificially small vaginal opening, and to protect against perineal damage. First-time mothers with type 3 FGM were 39% more likely to get an episiotomy than primiparous women without FGM, and infibulated multiparous women with were 47% more likely than multiparous women without FGM. FGM status also strongly influences the likelihood of receiving anterior and posterior lateral episiotomy, the most extensive type of episiotomy. In a group of 6,187 women with FGM, those with type 1, 2, and 4 FGM got an anterior and posterior lateral episiotomy 0.6% of the time, whereas 54% of the women with type 3 got them (Rodriguez et. al, 2016).

Deinfibulation status also contributed to postpartum blood loss and hemorrhage. In a group of 250 women with type 3 FGM, the average postpartum blood loss for those who had been deinfibulated was 300 mL. The women with intact infibulation lost an average of 375 mL (Raouf, 2011). WHO reported that those with type 3 FGM were 69% more likely to lose more than 500 mL of blood postpartum than women without FGM, and 48% more likely than women with type 2 (WHO, 2024). It's been suggested that women with FGM may experience more bleeding during and after birth due to the behavior of scar tissue (Berg & Underland, 2013). Because scar tissue is less prone to stretching, women with extreme scarification may experience prolonged labor (Berg & Underland, 2013), which increases the chance of postpartum hemorrhage (Bailey et. al, 2021). On average, women with FGM were twice as likely to have post-partum hemorrhage than those without (Berg & Underland, 2013).

The more severe the FGM, the more scar tissue, and the less elasticity; therefore, women with type 3 FGM, the most severe form, are at the highest risk for prolonged labor, both from the physical obstruction of the unnaturally small vaginal opening due to infibulation, and because of the decreased elasticity of scar tissue. Deinfibulation, which has been shown to decrease some of the obstetric risks resulting from type 3 FGM (Raouf, 2011), can pose its own risks in regard to dangerous amounts of blood loss (Rushwan, 2000). Like any type of FGM, infibulation, deinfibulation, and re-infibulation all pose the risk of hemorrhage, usually by accidental cutting of the clitoral artery (Rushwan, 2000). Obstructed labor could lead to hemorrhage, as could the deinfibulation performed to avoid obstructed labor. In addition, the risk of hemorrhage during genital modification goes up during pregnancy, partially due to the extra blood flowing through the pregnant woman’s body. Increased vascularity makes any procedure on reproductive organs more dangerous (Rushwan, 2000), as more blood can be lost in a shorter amount of time.

By scrutinizing the data on three common obstetric complications; caesarean sections, tearing, and postpartum hemorrhage, and their relationship to type 3 FGM, we can form a clearer image of the impact infibulation has on obstetric outcomes. Primiparous infibulated women are 40% more likely to have a c-section than women without FGM, 54% more likely to lose over 500 mL of blood while giving birth, and 97% more likely to stay in the hospital for more than three days (Larsen et. al, 2006). Half of all infibulated women receive extensive episiotomies, with healthcare providers having to cut above and below the tiny vaginal opening, a practice that helps prevent tears (Rodriguez et. al, 2016), but also contributes to how often infibulated women require extended postpartum time in the hospital (Larsen et. al, 2006). Far more research is required to grasp the full scope of how infibulation affects women’s physical, psychological, and social health, and up-to-date studies should be performed to provide access to current, accurate statistics on the risks involved in birth after infibulation. The largest study on obstetric outcomes for women with FGM was done 20 years ago (Larsen et. al, 2006). The more we know about infibulation, the better healthcare we can provide for the women who have undergone it. Bibliography

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