Abstract
Purpose
Female Genital Mutilation/Cutting (FGM/C) is a surgical intervention that is still performed in large numbers worldwide and has severe effects in terms of both obstetric and sexual consequences. Due to the increase in immigration, it has become more frequent in many countries. This study aims to compare the labor performance, complications, and postpartum sexual function of Type 3 Female Genital Mutilation/Cutting (FGM/C) pregnant women undergoing deinfibulation with Type 3 FGM/C patients without deinfibulation.
Methods
This is a prospective study of pregnant women with Type 3 FGM/C and puerperium patients at Nyala Turkish Training and Research Hospital in Sudan over 4 years, from September 2018 to September 2022. Type 3 FGM/C patients who underwent deinfibulation were compared with those who did not, considering age, parity, and obstetric and neonatal outcomes and the Female Sexual Function Index (FSFI) scores at 3 months.
Results
In our homogeneous Type 3 FGM/C group mainly consisting of primiparous women, it was found that more episiotomy procedures were performed. The second stage of labor was significantly prolonged, and perineal damage was greater in the group without deinfibulation. In addition, postpartum hemorrhage and hospitalization of mother and baby were longer in the group without deinfibulation. In the second part of our study, we compared the FSFI scores between the deinfibulation group and the episiotomy subgroup. The results indicated that the deinfibulation group exhibited higher scores across all FSFI domains.
Conclusion
Type 3 FGM/C is definitely associated with poor obstetric and sexual outcomes. It is essential to include partners in family discussions and to protect the perineum by performing deinfibulation and episiotomy at appropriate times and in the correct manner during labor.
What does this study adds to the clinical work
The contribution of the deinfibulation procedure, which is recognized for its obstetric benefits, should also be communicated to families and spouses in terms of its long-term impact on sexual performance. By sharing this information, the devastating effects of Female Genital Mutilation/Cutting (FGM/C) can be mitigated, both obstetrically and sexually.
Keywords: Female Genital Mutilation/Cutting; Deinfibulation; FSFI; Sexual functions; Obstetric outcome, Episiotomy
Introduction
Female Genital Mutilation/Cutting (FGM/C) is a non-medical surgical intervention traditionally practiced predominantly in Africa [1]. According to the World Health Organization (WHO), FGM/C is defined as the partial or total removal of the female external genitalia without a medical reason. According to WHO, there are four types: Type 3 is also known as infibulation. It is defined as cutting of the labia majora and/or labia minora followed by suturing to narrow the vaginal opening (with or without excision of the clitoris) [2]. To avoid confusion with male circumcision and to emphasize that it is not as harmless as it is, the terminology was revised, and the word cutting was added [3]. Women who have been subjected to Type 3 FGM/C face sexual dysfunction and severe obstetric complications, such as postpartum hemorrhage (PPH), perineal trauma, genital fistulae, obstructed labor, emergency cesarean section, and serious complications affecting the fetus that can lead to death [4].
Deinfibulation is a surgical procedure performed in women living with Type 3 FGM/C to uncover the vaginal introitus and urethral meatus and, if not traumatized, the clitoris [5] (Fig. 1A, B). The cut edges are then sutured to reconstruct the labia minora. Defibulation is a technically simple procedure that can be conducted under local, local regional, or general anesthesia. Since there is no clear consensus, it can be performed before pregnancy as well as during pregnancy or labor [5].
Fig. 1.
a The appearance of Type 3 Female Genital Mutilation/Cutting during examination.b The appearance during the examination of a patient with Type 3 Female Genital Mutilation/Cutting after undergoing deinfibulation
FGM/C has still not been wholly eradicated from certain societies. This has a deep cultural background and many social balances [6]. However, if patients are informed in detail, especially with their spouses, and the subsequent consequences are explained, they can view deinfibulation positively. In addition, patients and their partners can easily accept this procedure if they are informed about maternal health and the health of the baby before and during labor [4, 7, 8].
This study aims to compare Type 3 FGM/C pregnant women who underwent deinfibulation with those who did not, considering labor performance, complications, and postpartum sexual function.
Materials and methods
This prospective study included women with Type 3 Female Genital Mutilation/Cutting (FGM/C) who were treated during pregnancy and the puerperium at the Turkish Training and Research Hospital in Nyala, Sudan, from September 2018 to September 2022. A follow-up was carried out over a period of 4 years. The aim is to compare the labor performance, complications, and postpartum sexual function of Type 3 FGM/C pregnant women who underwent deinfibulation with Type 3 FGM/C patients. FGM/C is defined as all procedures involving partial or complete removal of the external female genitalia. The diagnosis was made by an experienced obstetrician and gynecologist following WHO guidelines.
The sample size was determined to be 138 women, using G*Power software with a power of 80%, an error level of 5% (a = 0.5), and an effect size of 0.05. The inclusion criteria were women who were older than 18 years of age, legally married, diagnosed with Type 3 FGM/C, vertex, term, singleton pregnancy and normal vaginal delivery. Multiple pregnancies, smokers, pregnant women with fetuses presenting other than vertex, pregnant women with amniotic fluid abnormalities, pregnant women with previous or current cesarean delivery, pregnant women with fetuses with congenital anomalies, pregnant women with diagnosed systemic diseases (diabetes mellitus, gestational hypertension, pre-eclampsia, eclampsia, etc.), pregnant women at risk of mother-to-baby infection [HIV (human immunodeficiency virus), HSV-2 (herpes simplex virus type 2), etc. were excluded from the study.
In the second stage of the study, participants were asked whether they had maintained a regular sexual life for at least 1 month after 6 weeks postpartum, had no chronic hormonal or metabolic diseases, and their partners did not experience sexual dysfunction. If these criteria were met, the questionnaire was administered between 3 and 6 months postpartum. After applying these criteria, we divided the patient population into two groups: Type 3 FGM/C patients who underwent deinfibulation and those who did not.
Antenatal follow-up and delivery of all women were performed at Nyala-Turkey Training and Research Hospital in Sudan. The diagnosis of FGM/C was defined by examination of the external genitalia by an obstetrician and gynecologist. Intrapartum management was performed according to the intrapartum management guidelines of the Turkish Ministry of Health. Delivery and its details were carefully recorded [9]. Detailed information about the deinfibulation procedure was provided when the pregnant women were admitted to our clinic for delivery. In case of medical need during labor, the right mediolateral episiotomy procedure was performed by the specialist with the decision of the gynecologist and obstetrician. However, for those who agreed to intrapartum deinfibulation after consent was obtained, in women living with Type III FGM/C, a surgical procedure was performed to expose the vaginal introitus and urethral meatus and, if not traumatized, the clitoris. Deinfibulation was performed under local or local regional anesthesia. The procedure was performed at the beginning of the second stage of labor. First, the bladder was emptied with a catheter. Then, while there was no active pushing, the obliterated area was incised to create a smooth and symmetrical wound edge. The cut edges were repaired to reconstruct the labia minora after the baby and placenta were delivered, together with the episiotomy and other injuries.
Pregnant women with Type 3 FGM/C who underwent deinfibulation were compared with a Type 3 FGM/C women who did not accept deinfibulation in terms of age, parity, gestational age, obstetric and neonatal outcomes, and postpartum Arab female sexual function index (FSFI) scores [10, 11]. A follow-up was conducted through a 4-year timeframe.
The FSFI is a multidimensional, reliable, and validated self-assessment questionnaire consisting of 19 items and six domains that assess the main dimensions of sexual function in women over the past four weeks. The assessment domains assessed by the FSFI are sexual arousal, lubrication, orgasm, desire, pain, and satisfaction. Although the questionnaire was in Arabic, it was also explained one by one in Turkish and the local language with an Arabic interpreter, and responses were obtained.
Obstetric outcomes included mode of delivery, duration of labor for normal delivery, estimated blood loss after normal delivery, length of hospital stay after normal delivery, perineal trauma, and fetal outcomes. Fetal outcomes recorded included birth weight, length of hospital stay, and fetal death. Postpartum hemorrhage (PPH) is defined as blood loss > 500 ml during labor. Minor postpartum hemorrhage is defined as blood loss between 500 and 1000 ml, and major postpartum hemorrhage is defined as blood loss > 1000 ml. Perineal injuries were classified as follows: A first-degree vaginal tear was defined as damage to the superficial vaginal epithelium; a second-degree tear was defined as a tear involving the vaginal epithelium and deeper muscles but excluding the anal sphincters. A third-degree perineal tear was defined as a partial or complete anal sphincter rupture without involvement of the anal mucosa, and a fourth-degree tear was defined as a rupture of the anal sphincter and mucosa.
Statistical analysis
Statistical analyses were performed using the Statistical Package for the Social Sciences 29.0 software for Windows (SPSS, Chicago, IL, USA). Descriptive statistics were stated as the mean, standard deviation, frequency, and percentage. Statistical analyses were performed using Student's t test for continuous variables and the Chi-square test for categorical variables. Mann–Whitney U test was used for continuous and unpaired nonparametric variables. The Kolmogorov–Smirnov test was used to assess continuous data for normality prior to significance testing. P < 0.05 was considered statistically significant.
Results
A total of 300 pregnant women who met the study criteria were included in the study. Each group consisted of 150 pregnant women diagnosed with Type 3 FGM/C (with and without deinfibulation). All patients were from the Nyala region of Sudan and were indigenous to this region. All patients were Muslim, were married, and did not use any contraception. There was no statistically significant difference between the groups in terms of age at onset, gestational age at delivery, and parity. Participant demographics are detailed in Table 1.
Table 1.
Demographics of women in the female genital mutilation/cutting Type 3 (FGM/C) groups with and without deinfibulation
| With deinfibulation | Without deinfibulation | p value | |
|---|---|---|---|
| n: 150 (%) | n: 150 (%) | ||
| Age (year ± SD) | 23.27 ± 2.96 | 22.78 ± 3.05 | 0.895 |
| Parity | 0.695 | ||
| 1 | 95 (63.3%) | 89 (59.3%) | |
| 2 | 17 (11.3%) | 15 (10%) | |
| 3 | 21 (14%) | 20 (13.3%) | |
| 4 and above | 17 (11.4%) | 26 (17.4%) | |
| Gestational age (weeks) | 0.78 | ||
| 37+0–37+6 | 13 (8.6%) | 14 (9.3%) | |
| 38+0–38+6 | 24 (16%) | 21 (14%) | |
| 39+0–39+6 | 61 (40.7%) | 58 (38.7%) | |
| 40+0–40+6 | 21 (14%) | 24 (16%) | |
| 41+0–41+6 | 31 (20.7%) | 33 (22%) |
SD standard deviation
In terms of the duration of labor, there was no significant difference in the first stage of labor. However, the second stage of labor was significantly longer in the non-deinfibulation group than in the deinfibulation group [66.1 ± 51.1 / 27.4 ± 33.9 (min) ± SD; p value 0.03]. In terms of postpartum hemorrhage, significantly more bleeding was encountered in the non-deinfibulation group. This was statistically significant in terms of minor PPH and major PPH. Additionally, a significantly higher number of patients in the non-deinfibulation group could not be discharged and remained in the hospital for more than 24 h or even more than 72 h after or more than 72 after 24 h of postpartum follow-up. Obstetric outcomes are summarized in Table 2.
Table 2.
Obstetric outcomes in female genital mutilation/cutting Type 3 (FGM/C) groups with and without deinfibulation
| Obstetric outcomes | With deinfibulation | Without deinfibulation | p value |
|---|---|---|---|
| n: 150 (%) | n: 150 (%) | ||
| Delivery time (min) ± SD | |||
| Duration of 1st stage | 320.1 ± 242.0 | 353.2 ± 254.4 | 0.23 |
| Duration of 2nd stage | 27.4 ± 33.9 | 66.1 ± 51.1 | 0.03 |
| Postpartum hemorrhage (n) | 7 (4.6%) | 22 (14.6%) | 0.002 |
| Minor (500 ml-1000 ml) | 4 (2.6%) | 9 (6%) | 0.01 |
| Major (1000 ml <) | 3 (2%) | 13 (8.6%) | 0.000 |
| Hospitalization for more than 24 h | 3 (2%) | 24 (16%) | 0.000 |
| Hospitalization for more than 72 h | 1 (0.6%) | 6 (4%) | 0.002 |
SD standard deviation
There was a statistically significant increase in the use of episiotomy among women who did not undergo deinfibulation. Episiotomy use was higher in primigravidae of both groups. When perineal trauma rates were analyzed, the non-deinfibulation group had a statistically significant higher rate in all perineal injuries. Data related to perineal trauma are summarized in Table 3.
Table 3.
Perineal trauma in female genital mutilation/cutting Type 3 (FGM/C) groups with and without deinfibulation
| Perineal trauma | With deinfibulation | Without deinfibulation | p value |
|---|---|---|---|
| n: 150 (%) | n: 150 (%) | ||
| Episiotomya | 77 (51.3%) | 134 (89.3%) | 0.000 |
| Types of perineal trauma | |||
| First-degree tear | 13 (8.6%) | 42 (28%) | 0.001 |
| Second-degree tear | 8 (5.3%) | 22 (14.6%) | 0.002 |
| Third-degree tear | 0 (0.0%) | 7 (4.6%) | 0.001 |
| Fourth-degree tear | 0 (0.0%) | 2 (1.3%) | 0.002 |
| Clitoral tear | 0 (0.0%) | 8 (5.3%) | 0.000 |
| Urethral tear | 0 (0.0%) | 8 (5.3%) | 0.000 |
aEpisiotomies in the FGM/C Type 3 group with deinfibulation were anterior and/or postero-lateral, and only postero-lateral episiotomies were performed in the group without deinfibulation
In terms of neonatal outcome, two fetal deaths were observed in the non-deinfibulation group. The patients with fetal deaths were primigravida patients who neither accepted deinfibulation nor emergency cesarean section. The cause of neonatal death was the prolonged second stage of labor and the occurrence of acute fetal distress. Additionally, it was due to the family's refusal to accept a cesarean delivery despite being thoroughly informed. In addition, the number of patients whose neonatal intensive care unit stay exceeded 72 h was statistically significantly higher in the group of patients who did not undergo deinfibulation. No difference was observed in terms of the birth weight of the babies. Neonatal outcomes are summarized in Table 4.
Table 4.
Neonatal outcomes in female genital mutilation/cutting Type 3 (FGM/C) groups with and without deinfibulation
| Fetal outcomes | With deinfibulation | Without deinfibulation | p value |
|---|---|---|---|
| n: 150 (%) | n: 150 (%) | ||
| Fetal death | 0 (0.0%) | 2 (1.3%) | 0.003 |
|
Birth weight (g) ± SD |
3462 ± 423 | 3497 ± 498 | 0.65 |
| Hospitalization for more than 72 h | 2 (1.3) | 14 (9.3) | 0.001 |
Although the FSFI questionnaire was applied to all patients, to make the groups homogeneous, the patients from both groups who had an episiotomy were included in the questionnaire score evaluation, as the figure determined by power analysis allowed. Accordingly, the questionnaire scores of 77 patients with deinfibulation and 134 patients without deinfibulation were obtained 3 months later. All score parameters were statistically significantly higher in the deinfibulation group. The mean scores in all subheadings and the total score are summarized in Table 5.
Table 5.
The Arab female sexual function index (FSFI) (a self-reported 19-item questionnaire assessing the main domains of female sexual function) in female genital mutilation/cutting Type 3 (FGM/C) groups with and without deinfibulation
| FSFI parameters mean ± SD |
With deinfibulation n: 77 |
Without deinfibulation n: 134 |
p value |
|---|---|---|---|
| Sexual desire | 4.4 ± 0.41 | 2.1 ± 0.53 | 0.000 |
| Sexual arousal | 4.68 ± 0.98 | 1.9 ± 0.82 | 0.000 |
| Lubrication | 4.8 ± 0.35 | 2.6 ± 1.18 | 0.000 |
| Orgasm | 3.94 ± 0.91 | 2.7 ± 1.38 | 0.000 |
| Satisfaction | 4.98 ± 0.71 | 3.25 ± 0.95 | 0.000 |
| Pain | 4.6 ± 0.94 | 2.2 ± 1.65 | 0.000 |
| Full-scale score | 27.40 ± 3.12 | 14.75 ± 5.12 | 0.001 |
Discussion
Main findings
In our study, we compared obstetric and neonatal outcomes, as well as postpartum FSFI scores, between a group of patients with deinfibulation and a group without deinfibulation, both consisting of homogenous Type 3 FGM/C patients. Most women were primiparous. We found that more episiotomies were performed, the second stage of labor was significantly prolonged, and perineal damage was more in the group without deinfibulation. We also observed that postpartum hemorrhage and the duration of hospitalization of the mother and baby were longer in the group without deinfibulation. In the second part of our study, in which we evaluated the effect of deinfibulation on FSFI scores in the subgroup with episiotomy, we found higher scores in all categories for the group that underwent deinfibulation.
Interpretation
The first study in the UK comparing the FGM/C patient group with the normal patient group in terms of obstetric outcomes was published in 2018 with a patient group of 121. The rate of episiotomy in the FGM/C group compared to normal pregnant women was found to be statistically significantly higher. The duration of the stages of labor was also compared in this study, but no statistically significant difference was found. They attributed the low rate of obstetric anal sphincter injury in both groups to an experienced and intuitive healthcare team and the correct use of episiotomy [12]. In a study conducted in Gambia in 2022, it was reported that episiotomy and/or perineal tears were observed in 80.2% of 126 Type 3 FGM/C patients. In the same study, the rate of postpartum hemorrhage was found to be 46% in the same group [13]. In a meta-analysis and systematic review conducted in 2024, postpartum hemorrhage, episiotomy, perineal injury, and prolongation of the second stage of labor were found to be approximately two-to-three times riskier with statistical significance in a comparison between the patient group with Type 3 FGM/C and the patient group without FGM/C. However, it was not found statistically significant in terms of obstetric anal sphincter injuries and cesarean section rates [14]. In another study in the same region in which patients with FGM/C were compared with patients without FGM/C, cesarean section rates, prolonged labor, postpartum hemorrhage, the possibility of the mother staying in the hospital for more than 48 h, high rates of episiotomy, and high rates of periclitoral injury were observed [4]. We have found that the higher risk of postpartum hemorrhage in the group without deinfibulation is related to the prolonged second stage of labor, leading to uterine atony and hemorrhage. In this patient group, liberal use of oxytocin, methylergonovine, and misoprostol should be considered postpartum.
While it has been found in the literature that poor obstetric outcomes were encountered in most of the studies comparing pregnant women with Type 3 FGM/C and women without Type 3 FGM/C, the comparison of obstetric and fetal outcomes of the groups with and without deinfibulation procedure in such a homogeneous patient group has found little place in the literature [14]. In a historical cohort study conducted in Norway, the application of deinfibulation was compared in terms of obstetric anal sphincter injury, and it was found to be beneficial with an OR of 0.48 in terms of sphincter injury when performed during labor compared to before [15]. In addition, in another study of the same group, the deinfibulation procedure performed before labor did not contribute positively to cesarean section rates [16]. In most studies, FGM/C was associated with perineal trauma, obstetric anal sphincter injury and maternal morbidity. However, these studies were conducted in hospitals with poor healthcare services or where healthcare workers were not competent in FGM/C [8, 17]. In addition, in a meta-analysis of 44 studies, there was no difference in episiotomy rates between FGM/C and control groups, whereas an increase in obstetric lacerations was observed in patients with FGM/C [8]. This shows that the correct and timely use of episiotomy and deinfibulation procedures is important, especially in patients with Type 3 FGM/C. In a study of 6000 patients with Type 3 FGM/C, it was found that the combined use of anterior and postero-lateral episiotomy decreased the amount of postpartum bleeding with perineal injuries. It was also observed that it did not affect the amount of intrapartum bleeding, which is the most feared thing [18].
In our study, the rate of episiotomy was higher in the group without deinfibulation. Although right mediolateral episiotomy alone decreased the rate of perineal injuries, it was statistically more common in the deinfibulation group. Type 4 and Type 3, the most severe level of perineal trauma, were not observed in the deinfibulation group. In addition, the absence of deinfibulation caused the second stage of labor to be prolonged, and therefore, postpartum hemorrhage was statistically higher, although not as much as the rates in the literature.
Hospitalization rates are higher in the patient group with Type 3 FGM/C compared to other female circumcisions [4, 19]. In our study, the rates of hospitalization for both 24 h and more than 72 h were statistically higher in the patient group without deinfibulation than in the group with deinfibulation. It was observed that both perineal injury and postpartum hemorrhage of the patients increased this situation. In terms of neonatal outcomes, stillbirth, need for intensive care, and increased length of hospitalization were found to be compatible with FGM/C in studies conducted in Africa. In fact, these risks are higher in Type 3 FGM/C [8, 19]. In our study, no fetal death was observed in the deinfibulation group. There were two fetal deaths in the non-deinfibulation group. This unfortunate result was encountered, because these patients did not allow emergency cesarean delivery. In addition, in terms of neonatal outcomes, the duration of hospitalization was statistically significantly longer in the non-deinfibulation group.
In Belgium, a cosmopolitan country with many immigrants, only 1% of gynecologists are aware of local guidelines on this issue [20]. In a university teaching hospital in the UK, half of the obstetricians did not know the classification of FGM/C and the other half considered FGM/C as an indication for cesarean section [21]. It is very important to know and recognize a clinical picture of Type 3 FGM/C and to inform the family in detail about the process and procedures. Being experienced in this subject and having a group that can convince the family about deinfibulation will lead to positive results in terms of obstetric and neonatal outcomes. In a study conducted in Spain, it was found that even making a complete diagnosis of FGM/C decreased the complication rate [22].
The second part of our study, FSFI scores, contains promising data for convincing the family for deinfibulation, which is missing in the literature. FSFI is a widely used test to detect female sexual dysfunction. In a meta-analysis and systematic review of FGM/C and FSFI scores, statistically significant results were obtained against FGM/C in terms of all headings and total scores in the evaluation of 6672 patients [23]. In addition, studies have shown that type-independent FSFI scores of patients who underwent FGM/C were found to be lower than those who did not [24, 25]. However, most of the studies are based on the comparison of FGM/C and normal patients. To the best of our knowledge, no study evaluating FSFI in the Type 3 FGM/C group, especially in terms of postpartum deinfibulation, has been found in the literature [10, 26].
This process of convincing and deinfibulation will have a significant impact not only on obstetric and neonatal outcomes but also on the patient's sexual life. The inclusion of husbands/partners in this process gains importance in this sense. In addition to convincing Africa, which has a rigid cultural structure, with obstetric and neonatal gains, we think that it will be effective to explain that couples will also be offered a healthy sexual experience. In the previous reviews, it was stated that self-report was used in some studies to identify FGM/C patients and that this was not objective. In addition, the active sexual life of some patient groups was not questioned [24]. However, in our study, these factors were taken into consideration in patient selection.
Many studies have found that there is a difference between patients with and without FGM/C in different areas of the six topics. However, a common score difference was generally observed in lubrication, orgasm, and satisfaction. FSFI total scores of patients with FGM/C were lower than 28.1 points regardless of type. However, Type 3 FGM/C is followed with lower scores compared to other Type 1 and Type 2 FGM/C types [24]. In our study, in all topics, the scores of the Type 3 FGM/C patient group without deinfibulation were found to be statistically significantly lower than of the group with deinfibulation. This rate was also reflected in total scores. The application of deinfibulation significantly increased the scores, and a catastrophic circumcision table such as Type 3 FGM brought the FSFI scores closer to the values accepted as the limit. In a study of 197 patients, Type 1 FGM/C total FSFI scores were 23.5 and Type 2 FGM/C score was 17.4 [27]. In our study, the group without deinfibulation showed poor scores of 14.75, and the group with deinfibulation showed better scores of 27.4.
Conclusion
Patients with Type 3 FGM/C are not limited to Africa; many cases are now seen worldwide due to migration and refugee movements. Healthcare professionals must be equipped to recognize and manage these cases. We recommend early and informed follow-up of Type 3 FGM/C in the antenatal period. It is crucial to include spouses/partners in discussions regarding family health information. Additionally, protecting the perineum during labor involves performing deinfibulation and episiotomy at the appropriate times and in proper ways. The benefits of the deinfibulation procedure, which is recognized for its obstetric advantages, should also be communicated to the family, particularly in relation to its positive impact on long-term sexual performance. By addressing these aspects, the devastating effects of female genital mutilation/cutting (FGM/C) can be mitigated both obstetrically and sexually.
Strengths and limitations
The strength of our study is that it compares homogeneous patient groups living in the same region and culture in Africa by evaluating them in the clinic of our accredited Western standard hospital. In addition, the follow-up of these obstetric patient groups and their effects on sexual functions have not been studied at the same time, and these data were also included in our study. The limitation of our study is the small number of women with Type 3 FGM/C in the FSFI scores categories and limited statistical analysis.
Author contribution
YKA: protocol/project development, data collection and management, data analysis, and manuscript writing and editing. EA: protocol/project development, data collection and management, data analysis, and manuscript writing/editing. SO: data management, data analysis, and manuscript editing. MFK: data management, data analysis, and manuscript writing. AGK: data analysis and manuscript writing. MBB: data analysis and manuscript editing. ET: data analysis and manuscript editing.
Funding
The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.