Abstract
Background
Type III female genital mutilation (FGM) is corrected by the scar tissue removal of the vaginal opening, known as deinfibulation.
Objectives
To determine the current evidence on whether deinfibulation leads to improved obstetric, neonatal, gynecologic, and sexual health outcomes.
Search Strategy
The following databases were searched from inception to May 18, 2023: CINAHL Plus (EBSCOhost), MEDLINE (Ovid), PsycINFO (EBSCOhost), SCOPUS, and Web of Science.
Selection Criteria
Two review authors independently screened the titles and abstracts, extracted data, and performed the risk of bias assessment.
Data Collection and Analysis
Meta‐analysis was conducted with RevMan, and the quality of evidence was assessed using the GRADE approach.
Main Results
Eight studies with serious risk of bias involving 3166 women were included. Very low‐certainty evidence indicates that deinfibulation for women with type III FGM reduced the odds of an emergency cesarean birth (odds ratio [OR] 0.16, 95% confidence interval [CI] 0.06–0.42) and genital tract lacerations (OR 0.48, 95% CI 0.29–0.79) when compared to women with type III FGM without deinfibulation. Reduced odds of an emergency cesarean birth apply when compared to women without FGM (OR 0.59, 95% CI 0.37–0.93). Antepartum deinfibulation, compared to intrapartum deinfibulation, may lead to a reduction in the duration of labor, with little or no difference in the risk of prolonged labor (low‐certainty evidence). Antepartum deinfibulation may increase the likelihood of postpartum hemorrhage and cesarean births in pregnant women with type III FGM (low‐certainty evidence). We found no studies for inclusion on gynecologic, urologic, and sexual health outcomes for this update.
Conclusions
The evidence of deinfibulation for women with type III FGM is available only for obstetrics outcomes. Larger observational studies in settings where type III FGM is predominantly practiced are required to improve the certainty of the evidence in these findings.
Keywords: deinfibulation, infibulation, type III FGM, type III FGM/C
1. INTRODUCTION
Female genital mutilation (FGM) is a harmful practice that involves removing or altering parts of the external female genitalia for non‐therapeutic reasons. 1 According to estimates, approximately 230 million girls and women are living with FGM, and more than 3 million girls are at risk each year. 2 There are four types of FGM, with type III FGM (infibulation) defined as the narrowing of the vaginal orifice through the creation of a covering seal by cutting and appositioning the labia minora or labia majora, with or without excision of the clitoris. 3 Type III FGM is the second most common form after type II, with a prevalence in the range of 18%–37%. 4 , 5
Type III FGM causes immediate and long‐term complications, such as hemorrhage, infection, acute urine retention, shock, and death. 6 Immediate complications occur in 23% of girls who undergo FGM. Several long‐term complications of type III FGM have been reported, including obstetric, neonatal, gynecologic, and sexual health challenges. Obstetric consequences of infibulation include genital tract laceration, anal sphincter rupture, postpartum hemorrhage, episiotomy, prolonged labor, obstructed labor, and cesarean birth. 4 , 6 , 7 , 8 Neonatal complications reported with type III FGM are birth asphyxia and stillbirth. 4 Gynecologic consequences include dysmenorrhea, clitoridal cysts, bacterial vaginosis and hematocolpos, and infertility. 6 , 9 , 10 Sexual health consequences include dyspareunia, reduced sexual desire and arousal, and reduced frequency of orgasm or an outright anorgasm. 11 , 12 Unfortunately, sexual health dysfunctions are often unreported. 13 Type III FGM is more associated with infections such as HIV, chlamydia trachomatis, and herpes simplex virus (HSV) 2 than other types of FGM. 5 , 14 The mental health consequences of type III FGM include anxiety, depression, and post‐traumatic stress disorder (PTSD). 14
Because type III FGM involves extensive alteration of the female genitalia, it can be partially through deinfibulation. This process involves making a midline incision along the scar tissue that closes the vaginal opening. A finger is placed beneath the scar to protect the urethra during the incision, after which the vestibule (including the urethra, vagina, and clitoris) is exposed and examined. 15 A postoperative examination of the surgical site is conducted approximately 7 days after the procedure and any spontaneous adhesion is also addressed. 15 Deinfibulation may be performed at the onset of labor just before a vaginal birth 16 or during the second trimester of pregnancy, allowing adequate time for healing before the onset of labor. 17 The procedure can also be performed as an elective gynecologic procedure to relieve or prevent painful menstruation, difficulty with urinating, dyspareunia, and apareunia. 18
There is conflicting evidence of the benefits of deinfibulation on obstetric, gynecologic, urologic, and sexual health outcomes. Case reports indicate that deinfibulation resolved dyspareunia, improved sexual function, incontinence, and pregnancy outcomes. 9 , 10 One study reported that labor outcomes after deinfibulation were the same as those of women with type III FGM, except for blood loss and instrumental delivery. 19 In addition, deinfibulation has been reported to improve the physiologic, urogynecologic, and sexual functions in women. 9 , 10 , 15 It decreases dyspareunia, improves sexual functioning, and allows sexual intercourse with vaginal penetration. 10 , 15 , 20 Deinfibulation also restores micturition and menstrual outflow, alleviating genitourinary complications, as well as improving the overall psychological health of women. 15
Intrapartum deinfibulation procedures can avert the need for cesarean birth and reduces labor duration, episiotomy, and blood loss. 20 After deinfibulation, there is no difference in Apgar score and birth weight when compared with women without type III FGM. 20 There are currently no recommendations regarding the preferred timing of deinfibulation.
This review is an update of earlier systematic reviews published in 2016 on the effectiveness of deinfibulation for the prevention or treatment of complications in women living with type III FGM and antepartum versus intrapartum deinfibulation for women with type III FGM. 21 , 22 The reviews did not identify any randomized trials for inclusion, and data from observational studies provided low‐quality evidence that deinfibulation improves birth outcomes in women with type III FGM, with no evidence of deinfibulation effectiveness on gynecologic and sexual health outcomes [21 22]. In addition, the comparison of antepartum and intrapartum deinfibulation found low‐certainty evidence on the appropriate timing of deinfibulation in pregnant women with no difference in obstetric, neonatal, and gynecologic outcomes between antepartum and intrapartum deinfibulation. 22
The objectives of this systematic review were to determine the current evidence on deinfibulation and the effects of antepartum or intrapartum deinfibulation on obstetric, neonatal, gynecologic, and sexual health outcomes in women living with type III FGM.
2. METHODS
This systematic review followed the Cochrane Handbook for Systematic Reviews of Interventions 23 and has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) statement. 24 The review protocols were registered a priori with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023429858; CRD42023431334).
2.1. Eligibility criteria
Included studies were of female participants living with type III FGM. The intervention of interest was deinfibulation with a comparison group of no deinfibulation. For the analysis on timing of deinfibulation, included studies compared deinfibulation during pregnancy (antepartum) to deinfibulation during labor and childbirth (intrapartum). The prespecified outcome measures included obstetric, gynecologic, and sexual health outcomes. The obstetric outcomes included cesarean birth, postpartum hemorrhage, episiotomy, prolonged labor, obstetric tears and/or lacerations, instrumental delivery, difficult labor/dystocia, and extended maternal hospital stay. Neonatal outcomes were infant resuscitation at delivery, stillbirth, and early neonatal death.
The gynecologic outcomes were vulvar and clitoral pain, vaginal discharge, vaginal itching, dysmenorrhea, irregular menses and difficulty in passing menstrual blood, chronic pelvic pain, and bacterial vaginosis. The sexual health outcomes were dyspareunia, reduced sexual satisfaction, reduced sexual desire and arousal, reduced lubrication during sexual intercourse, and reduced frequency of orgasm or anorgasmia. Quality of life was also included as an outcome.
2.2. Information sources
We searched CINAHL Plus (EBSCOhost), MEDLINE (Ovid), PsycINFO (EBSCOhost), SCOPUS, and Web of Science from inception to May 18, 2023.
2.3. Search strategy
We used a combination of keywords and Medical Subject Headings (MeSH) terms, including or related to deinfibulation and FGM, to identify studies examining the impact of predefined health outcomes (Appendix S1). We applied no language restrictions and used Google Translate (Google, Mountain View, CA, USA) to translate any non‐English papers during the initial screening of studies for eligibility. We did not restrict our analysis to randomized trials. The reference lists of retrieved studies were reviewed for additional relevant studies.
2.4. Study selection
Two review authors independently screened the title and abstract of results of the literature search for potentially relevant studies and obtained the full reports of potentially relevant studies for further assessment. They independently applied the inclusion criteria to the full‐text reports using an eligibility form and ensured each study was included in the review only once. We resolved disagreements in assessment through discussion and consensus agreement within the review team. The excluded studies and the reasons for their exclusion are presented in Appendix S2.
2.5. Data extraction
We used Covidence Systematic Review Manager for the review, including the data extraction. 25 We extracted data related to population, type, and severity of complications and associated physical morbidities, intervention, timing of deinfibulation, and outcome measures. Two authors independently extracted data using a custom‐made data extraction form in Covidence. We resolved disagreements through discussion between all review authors. We contacted study authors for clarification and disaggregated data when the data presentation was unclear.
For each outcome, we extracted the number of participants included in the study as well as the number analyzed in each group. For dichotomous outcomes, we recorded the number of participants experiencing the event and the number assessed in each group.
2.6. Assessment of risk of bias
The Cochrane Risk of Bias in Non‐randomized Studies‐Interventions (ROBINS‐I) tool 26 was used to assess the risk of bias in included studies. Two review authors independently assessed the risk of bias of each included study using a “Risk of bias” form. We assessed if the study authors employed methods to control for selection bias at the design stage (e.g., matching or restriction to subgroups) and in their methods of analysis (e.g., the use of stratification or regression modeling). In the case of differing opinions regarding the risk of bias assessment by two study authors, a third author (BO) was consulted and consensus was reached.
2.7. Data synthesis
We entered data into RevMan 5.4 (The Nordic Cochrane Center, Copenhagen, Denmark). The software was used to combine data using a random‐effect meta‐analysis, where it was reasonable to assume the studies estimated the same underlying treatment effect. We used a random‐effect meta‐analysis to pool data from included studies to produce an overall summary or average treatment effect because they are all observational studies.
The results of dichotomous data are presented as odds ratios (ORs) with 95% confidence intervals (CIs). Forest plots are presented to summarize the findings from the included studies.
2.8. Assessment of heterogeneity
We assessed statistical heterogeneity in each meta‐analysis using the I 2 statistics. We regarded heterogeneity as substantial if an I 2 was greater than 50%. A subgroup analysis was not conducted because none of the included studies reported criteria prespecified in the protocol in a manner to allow its conduct. We did not conduct a sensitivity analysis because there were no marked differences in the quality of the included studies.
2.9. Assessment of quality of evidence
We assessed the quality of the evidence using the GRADE approach 27 with GRADEpro. 28 We appraised the quality of evidence for each outcome against five criteria: risk of bias (an appraisal of the overall risk of bias for trials contributing to the outcome), consistency (an evaluation of explained and unexplained heterogeneity), directness (an appraisal of how directly the included trials address the review question), precision (an assessment of the statistical precision of the result), and publication bias (an assessment of the risk of publication bias). Certainty of evidence started at very low quality and was upgraded to low or moderate when there was greater consistency and directness in the evidence.
3. RESULTS
3.1. Study selection
The search output identified 1166 studies, and we found three additional unpublished studies from the reference list of eligible studies. After the removal of duplicates, we identified 834 unique citations. Based on titles and abstracts, 772 studies were excluded. The PRISMA flow diagram (Figure 1) was used to report the search and selection of studies. We reviewed the full text of 62 studies, after which eight studies met the inclusion criteria for this review. Table 1 summarizes the characteristics of the included studies. We included seven cohort studies and one case–control study involving 3166 women, with most studies having serious risk of bias. 20 , 29 , 30 , 31 , 32 , 33 , 34 , 35 The excluded studies, and the reasons for their exclusion, are included in Appendix S2.
FIGURE 1.
The PRISMA flow diagram.
TABLE 1.
Characteristics of included studies.
| Albert et al. (2015) 36 | |
| Methods | Retrospective cohort study |
| Participants | 63 women identified as having type III FGM between 2008 and 2012 |
| Interventions | Antepartum deinfibulation versus intrapartum deinfibulation |
| Outcomes | Blood loss; prolonged labor; Apgar scores; episiotomy; perineal tears |
| Identification |
Country: United Kingdom Author's name: Juliet Albert Email: juliet.albert@nhs.net |
| Bikoo et al. (2006) 30 | |
| Methods | Prospective cohort study |
| Participants | 26 pregnant women with type III FGM |
| Interventions | Deinfibulation versus none |
| Outcomes | Vaginal delivery, intact perineum, vaginal delivery and tear, vaginal delivery and episiotomy, ventouse and episiotomy, lower segment cesarean birth |
| Identification |
Country: United Kingdom Author's name: Matigaye Bikoo Email: sarah.creighton@uclh.nhs.uk |
| Paliwal et al. (2014) 31 | |
| Methods | Retrospective cohort (audit) study |
| Participants | All women with type III FGM who delivered in Heartlands Hospital between January 2008 and December 2009 |
| Interventions | Definbulation |
| Outcomes | Cesarean birth, birth weight, blood loss, episiotomy, Apgar score, prolonged second stage of labor, PPH, second‐, third‐, and fourth‐degree tears |
| Identification |
Country: United Kingdom Author's name: Kate Jolly Email: c.b.jolly@bham.ac.uk |
| Raouf et al. (2011) 32 | |
| Methods | Retrospective cohort study |
| Participants | The first 250 women who had consecutive type III FGM who were seen in the clinic since its establishment in 2002 |
| Interventions | Deinfibulation |
| Outcomes | Mode of delivery, rates of episiotomy, perineal tears, blood loss, and Apgar scores |
| Identification |
Country: United Kingdom Author's name: Sanaria A. Raouf Email: sanariaraouf@hotmail.com |
| Rouzi et al. (2001) 33 | |
| Methods | Retrospective cohort study |
| Participants | Sudanese and Somalian women with type III FGM who gave birth between January 1996 and December 1999 to ascertain whether intrapartum deinfibulation was required |
| Interventions | Deinfibulation |
| Outcomes | Duration of labor, mean blood loss, episiotomy, genital tract laceration, emergency cesarean birth, maternal stay, and mean Apgar score |
| Identification |
Country: Saudi Arabia Author's name: Abdulrahim Rouzi Email: aarouzi@gmail.com |
| Rouzi et al. (2012) 21 | |
| Methods | Case‐control study |
| Participants | Women from Sudan, Egypt, Somalia, Eritrea, and Yemen who delivered at the hospital between November 1, 2000, and September 30, 2011 |
| Interventions | Definbulation |
| Outcomes | Number of episiotomies, duration of first stage (h) and second stage (min), blood loss (PPH), Apgar score, birth weight |
| Identification |
Country: Saudi Arabia Author's name: Abdulrahim Rouzi Email: aarouzi@gmail.com |
| Taraldsen et al. (2021) 34 | |
| Methods | Historical cohort study |
| Participants | 886 women with type III FGM |
| Interventions | Deinfibulation |
| Outcomes |
Obstetric outcome: cesarean birth Perinatal outcome: birth asphyxia |
| Identification |
Country: Norway Author's name: Solvi Taraldsen Email: sotara@ous-hf.no |
| Taraldsen et al. (2022) 35 | |
| Methods | Historical cohort study |
| Participants | Nulliparous Somali‐born women who gave birth in South‐East Norway during 1990–2014 and all nulliparous women with a vaginal birth from the medical birth registry of Norway in the same time period |
| Interventions | Deinfibulation |
| Outcomes | OASI, blood loss, Apgar <7 at 5 min, severe birth asphyxia, perinatal death |
| Identification |
Country: Norway Author's name: Solvi Taraldsen Email: solvi.taraldsen@yahoo.com |
Abbreviations: FGM, female genital mutilation; OASI, obstetric anal sphincter injury; PPH, postpartum hemorrhage.
3.2. Study characteristics
All included studies were conducted in the last three decades at either a secondary care health facility, including specialized hospitals for the care of FGM, or in a university teaching hospital. The included studies involved pregnant women with type III FGM (infibulation) who either had deinfibulation in a previous pregnancy or who underwent deinfibulation during pregnancy 29 , 30 , 31 , 33 , 34 , 35 or labor [20, 29–35]. Women who had deinfibulation were compared with women with type III FGM who labored and delivered without deinfibulation, and women who had not undergone FGM.
3.3. Risk of bias of included studies
As shown in Figure 2, seven of the eight included studies were assessed as having an overall “serious risk” of bias due to serious risk of bias in the domains “Bias due to confounding” and “Bias in selection of participants”. 20 , 29 , 30 , 31 , 32 , 33 , 34 One study was assessed as having an overall “moderate risk of bias”. 35
FIGURE 2.
Risk of bias of included studies.
3.4. Synthesis of results
We present the results on the effects of deinfibulation first and then the analyses from studies that compared deinfibulation during pregnancy (antepartum) to deinfibulation during labor and childbirth (intrapartum).
3.4.1. Effects of deinfibulation
For our first comparison, deinfibulation had been performed either during a previous pregnancy or before the current pregnancy, 31 , 34 as well as during the antenatal or intrapartum period. 30 , 31 , 34 Antenatal deinfibulation was carried out at 20–34 weeks of gestation [31]. The second comparison included five studies [20, 29, 32–34] with a total of 671 participants who had never undergone FGM. These studies compared pregnancy outcomes between women who underwent deinfibulation and those who had never experienced FGM. 20 , 29 , 32 , 33 , 34 Participants in these studies were predominantly of African origin, particularly Somalian. 20 , 29 , 32 , 33 , 34
3.5. Comparison 1: Deinfibulation compared to no deinfibulation in women with type III FGM
Three retrospective cohort studies with serious risk of bias, involving 1067 women, evaluated obstetric outcomes in women living with type III FGM with or without deinfibulation. 30 , 31 , 34 Obstetric outcomes assessed included cesarean birth, postpartum hemorrhage, episiotomy, prolonged labor (second stage), obstetric tears/lacerations, and Apgar scores at 1 minute.
Very low‐certainty evidence indicates that for women with type III FGM, deinfibulation reduced the need for emergency cesarean birth (OR 0.16, 95% CI 0.06–0.42; one study, 250 participants) (Figure 3).
FIGURE 3.
Deinfibulation compared to no deinfibulation in women with type III FGM; cesarean birth.
In women with type III FGM, very low‐certainty evidence indicates deinfibulation did not reduce the odds of postpartum hemorrhage (OR 0.53, 95% CI 0.23–1.22; two studies, 877 participants) (Figure 4), episiotomy (OR 0.66, 95% CI 0.21–2.05; three studies, 1067 participants) (Figure 5), and prolonged second stage of labor (OR 1.02, 95% CI 0.52–1.99; two studies, 877 participants) (Figure 6).
FIGURE 4.
Deinfibulation compared to no deinfibulation in women with type III FGM; postpartum hemorrhage.
FIGURE 5.
Deinfibulation compared to no deinfibulation in women with type III FGM; episiotomy.
FIGURE 6.
Deinfibulation compared to no deinfibulation in women with type III FGM; prolonged labor (second stage).
In addition, in women with type III FGM, very low‐certainty evidence indicates deinfibulation reduced the odds of genital tract lacerations (OR 0.48, 95% CI 0.29–0.79; three studies, 1067 participants) (Figure 7), while it did not reduce the odds of neonatal resuscitation for low Apgar score at 1 minute of life (OR 0.56, 95% CI 0.18–1.68; two studies, 877 participants) (Figure 8). The summary of findings for this comparison can be found in Table 2.
FIGURE 7.
Deinfibulation compared to no deinfibulation in women with type III FGM; genital tract laceration.
FIGURE 8.
Deinfibulation compared to no deinfibulation in women with type III FGM; neonatal resuscitation.
TABLE 2.
Summary of findings for deinfibulation compared to no deinfibulation in women with type III FGM. a
| Certainty assessment | No. of patients | Effect | Certainty | Importance | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No. of studies | Study design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | Deinfibulation | No deinfibulation | Relative (95% CI) | Absolute (95% CI) | ||
| Cesarean birth | ||||||||||||
| 1 | Observational studies | Very serious b | Serious c | Not serious | Serious d | All plausible residual confounding would reduce the demonstrated effect | 45/230 (19.6) | 12/20 (60.0) | OR 0.16 (0.06–0.42) | 406 fewer per 1000 (from 517 fewer to 213 fewer) |
⨁◯◯◯ Very low |
IMPORTANT |
| Postpartum hemorrhage | ||||||||||||
| 2 | Observational studies | Very serious b | Serious e | Not serious | Serious d | All plausible residual confounding would reduce the demonstrated effect | 178/774 (23.0) | 33/103 (32.0) | OR 0.53 (0.23–1.22) | 120 fewer per 1000 (from 223 fewer to 45 more) |
⨁◯◯◯ Very low |
IMPORTANT |
| Episiotomy | ||||||||||||
| 3 | Observational studies | Very serious b | Very serious e | Not serious | Serious d | All plausible residual confounding would reduce the demonstrated effect | 434/956 (45.4) | 68/111 (61.3) | OR 0.66 (0.21–2.05) | 102 fewer per 1000 (from 363 fewer to 152 more) |
⨁◯◯◯ Very low |
IMPORTANT |
| Prolonged labor (second stage) | ||||||||||||
| 2 | Observational studies | Very serious b | Not serious | Not serious | Extremely serious d | All plausible residual confounding would reduce the demonstrated effect | 76/774 (9.8) | 11/103 (10.7) | OR 1.02 (0.52–1.99) | 2 more per 1000 (from 48 fewer to 85 more) |
⨁◯◯◯ Very low |
IMPORTANT |
| Genital tract laceration | ||||||||||||
| 3 | Observational studies | Very serious b | Serious f | Not serious | Serious g | All plausible residual confounding would reduce the demonstrated effect | 174/956 (18.2) | 26/111 (23.4) | OR 0.48 (0.29–0.79) | 106 fewer per 1000 (from 153 fewer to 40 fewer) |
⨁◯◯◯ Very low |
IMPORTANT |
| Neonatal resuscitation at 1 min of life | ||||||||||||
| 2 | Observational studies | Very serious b | Serious f | Not serious | Serious d | All plausible residual confounding would reduce the demonstrated effect | 29/465 (6.2) | 4/38 (10.5) | OR 0.56 (0.18–1.68) | 43 fewer per 1000 (from 85 fewer to 60 more) |
⨁◯◯◯ Very low |
IMPORTANT |
Abbreviations: CI, confidence interval; FGM, female genital mutilation; OR, odds ratio.
Values are given as number (percentage) unless otherwise indicated.
A retrospective cohort study conducted by review of medical records. The study has residual confounding scar tissue.
Only a study, making it impossible to assess.
Few events with a wide CI.
There is statistical heterogeneity; I 2 > 50%.
Despite the absence of statistical heterogeneity, there is clinical heterogeneity of studies that provided data for this outcome.
Much high proportion of events occurred in intervention arm of included studies than in control arm.
3.6. Comparison 2: Deinfibulation in women with type III FGM compared to women without FGM
Five studies with serious risk of bias, involving 2660 participants, provided data for this comparison. 20 , 29 , 32 , 33 , 34 Obstetric outcomes assessed included cesarean birth, postpartum hemorrhage, episiotomy, prolonged labor (second stage), and obstetric tears/lacerations.
Compared to women who had not experienced FGM, women who underwent deinfibulation for type III FGM had lower odds of emergency cesarean birth, although the certainty of evidence is very low (OR 0.59, 95% CI 0.37–0.93; three studies, 1009 participants) (Figure 9).
FIGURE 9.
Deinfibulation in women with type III FGM compared with women without FGM.
Moreover, very low‐certainty evidence indicates that women with type III FGM who underwent deinfibulation did not have reduced odds of having postpartum hemorrhage compared to women who had not experienced FGM (OR 2.52, 95% CI 0.49–13.07; one study, 776 participants) (Figure 9, Figure 10), episiotomy (OR 1.10, 95% CI 0.46–2.66; four studies, 1784 participants) (Figure 11).
FIGURE 10.
Deinfibulation in women with type III FGM compared with women without FGM; postpartum hemorrhage.
FIGURE 11.
Deinfibulation in women with type III FGM compared with women without FGM; episiotomy.
Very low‐certainty evidence indicates that deinfibulation in women with type III FGM did not reduce the odds of prolonged labor (second stage) (OR 0.64, 95% CI 0.29–1.43; one study, 708 participants) (Figure 12) and obstetric tears/lacerations (OR 0.75, 95% CI 0.38–1.48; two studies, 300 participants) (Figure 13) compared with women who had not experienced FGM. Table 3 shows the summary of findings of this comparison.
FIGURE 12.
Deinfibulation in women with type III FGM compared with women without FGM; prolonged labor (second stage).
FIGURE 13.
Deinfibulation in women with type III FGM compared with women without FGM; obstetric tears/lacerations.
TABLE 3.
Summary of findings of women with type III FGM with deinfibulation versus women without FGM.
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | No. of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
|---|---|---|---|---|---|---|
| Risk with women with no FGM | Risk with deinfibulation in women with type III FGM | |||||
| Cesarean birth | 347 per 1000 | 239 per 1000 (165–331) | OR 0.59 (0.37–0.93) | 1009 (3 observational studies) |
⨁◯◯◯ |
|
| Postpartum hemorrhage | 5 per 1000 | 13 per 1000 (3–63) | OR 2.52 (0.49–13.07) | 776 (1 observational study) |
⨁◯◯◯ |
|
| Episiotomy | 366 per 1000 | 388 per 1000 (210–605) | OR 1.10 (0.46–2.66) | 1784 (4 observational studies) |
⨁◯◯◯ |
|
| Prolonged labor (second stage) | 174 per 1000 | 119 per 1000 (58–231) | OR 0.64 (0.29–1.43) | 708 (1 observational study) |
⨁◯◯◯ |
|
| Genital tract laceration | 145 per 1000 | 113 per 1000 (61–201) | OR 0.75 (0.38–1.48) | 300 (2 observational studies) |
⨁◯◯◯ |
|
Note: GRADE Working Group grades of evidence: High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
Abbreviations: CI, confidence interval; FGM, female genital mutilation; OR, odds ratio.
The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
There is the possibility of residual effects of FGM scar tissue. This is a cohort study conducted with residual confounding.
Despite the absence of statistical heterogeneity, there is clinical heterogeneity of studies that provided data for this outcome.
Much higher proportion of events occurred in intervention arm of included studies than in control arm.
Few events, with wide CI.
There is statistical heterogeneity; I 2 > 50%.
Wide CI.
There are few events.
The included studies did not report outcome data in a usable format for instrumental delivery, difficult labor/dystocia, extended maternal hospital stay, stillbirth, and early neonatal death. In addition, the included studies reported no gynecologic, urologic, or sexual health outcomes.
3.7. Timing of deinfibulation
3.7.1. Comparison 3: Antepartum versus intrapartum deinfibulation in women with type III FGM
This comparison included five studies [29, 30, 33–35]. Data for Taraldsen et al. 33 , 34 were combined for this comparison (Table 4).
TABLE 4.
GRADE evidence profile for antepartum deinfibulation versus intrapartum deinfibulation.
| Certainty assessment | No. of patients | Effect | Certainty | Importance | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No. of studies | Study design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | Antepartum deinfibulation | Intrapartum deinfibulation | Relative (95% CI) | Absolute (95% CI) | ||
| Prolonged labor | ||||||||||||
| 1 | Observational studies | Serious a | Not serious | Not serious | Serious b | None | 9/42 (21.4) | 5/16 (31.3) | OR 0.60 (0.17–2.18) | 98 fewer per 1000 (from 241 fewer to 185 more) |
⨁◯◯◯ Very low |
CRITICAL |
| Perineal tears | ||||||||||||
| 4 | Observational studies | Serious a | Not serious | Not serious | Very serious c | None | 52/264 (19.7) | 39/368 (10.6) | OR 1.52 (0.94–2.45) | 47 more per 1000 (from 6 fewer to 119 more) |
⨁◯◯◯ Very low |
CRITICAL |
| Postpartum hemorrhage | ||||||||||||
| 2 | Observational studies | Serious a | Not serious | Not serious | Serious b | None | 76/248 (30.6) | 72/349 (20.6) | OR 1.51 (1.03–2.22) | 76 more per 1000 (from 5 more to 160 more) |
⨁◯◯◯ Very low |
CRITICAL |
| Episiotomies | ||||||||||||
| 2 | Observational studies | Serious a | Serious d | Not serious | Very serious c | None | 30/48 (62.5) | 19/29 (65.5) | OR 0.94 (0.34–2.58) | 14 fewer per 1000 (from 263 fewer to 175 more) |
⨁◯◯◯ Very low |
CRITICAL |
| Cesarean births | ||||||||||||
| 3 | Observational studies | Serious a | Not serious | Not serious | Serious b | None | 104/322 (32.3) | 131/590 (22.2) | OR 1.66 (1.22–2.25) | 99 more per 1000 (from 36 more to 169 more) |
⨁◯◯◯ Very low |
CRITICAL |
| Birth asphyxia | ||||||||||||
| 3 | Observational studies | Serious a | Not serious | Not serious | Very serious e | None | Not pooled | Not pooled | No overall difference in the likelihood of birth asphyxia (Apgar <7) at 1 and 5 min of life. Also, no difference at 1 min of life (Apgar <5) |
⨁◯◯◯ Very low |
CRITICAL | |
| Perinatal death | ||||||||||||
| 1 | Observational studies | Serious a | Not serious | Not serious | Very serious e | None | 3/303 (1.0) | 9/566 (1.6) | OR 0.62 (0.17–2.30) | 6 fewer per 1000 (from 13 fewer to 20 more) |
⨁◯◯◯ Very low |
CRITICAL |
Note: GRADE Working Group grades of evidence: High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
Abbreviations: CI, confidence interval; OR, odds ratio.
Downgraded by 1 for study design limitations: selection of cases and controls in included studies makes them prone to selection bias and bias due to confounding.
Downgraded by 1 for serious imprecision: the 95% CI is wide and includes benefit and appreciable harm.
Downgraded by 2 for very serious imprecision: optimal information size not achieved and the 95% CI is wide and includes benefit and appreciable harm.
Downgraded by 1 for serious inconsistency: high level of heterogeneity observed (I 2 = 74%).
Downgraded by 2 for very serious imprecision: optimal information size not achieved and the 95% CI is wide and includes benefit and appreciable harm to the estimate.
3.7.1.1. Prolonged labor
There was no statistically significant difference in the odds of prolonged labor (second stage of labor >120 minutes) between women with antepartum and intrapartum deinfibulation (OR 0.60, 95% CI 0.17–2.18; one study, 59 participants) (Figure 14).
FIGURE 14.
Antepartum deinfibulation versus intrapartum deinfibulation, prolonged labor.
3.7.1.2. Perineal lacerations
Similarly, the odds of perineal tears did not significantly vary based on the timing of deinfibulation (OR 1.52, 95% CI 0.94–2.45; four studies, 632 participants; I 2 = 14%) (Figure 15).
FIGURE 15.
Antepartum deinfibulation versus intrapartum deinfibulation, perineal tears.
3.7.1.3. Postpartum hemorrhage
The likelihood of postpartum hemorrhage was significantly higher in pregnant infibulated women who were deinfibulated during pregnancy compared to those deinfibulated during labor (OR 1.51, 95% CI 1.03–2.22; two studies, 597 participants; I 2 = 0%) (Figure 16).
FIGURE 16.
Antepartum deinfibulation versus intrapartum deinfibulation, postpartum hemorrhage.
3.7.1.4. Episiotomy
There was no overall difference in the likelihood of requiring an episiotomy between women in the antepartum deinfibulation group and those in the intrapartum deinfibulation group (OR 0.94, 95% CI 0.34 to 2.58; 2 studies; n = 77 participants; I 2 = 74%, Figure 17).
FIGURE 17.
Antepartum deinfibulation versus intrapartum deinfibulation, episiotomies.
3.7.1.5. Cesarean births
The odds of cesarean birth were significantly higher among women who received antepartum deinfibulation compared to intrapartum deinfibulation (OR 1.66, 95% CI 1.22–2.25; three studies, 912 participants; I 2 = 0%) (Figure 18). Albert et al. [35] excluded women with cesarean births from the secondary analyses.
FIGURE 18.
Antepartum deinfibulation versus intrapartum deinfibulation, cesarean births.
3.7.1.6. Birth asphyxia
There was no overall difference in the likelihood of birth asphyxia (Apgar scores <7) between women in the antepartum deinfibulation group and those in the intrapartum deinfibulation group at 1 minute and 5 minutes of life. Similarly, there was no difference in the odds of birth asphyxia (Apgar score <5 at 1 minute of life) (Figure 19).
FIGURE 19.
Antepartum deinfibulation versus intrapartum deinfibulation, birth asphyxia (<7 at 5 min).
3.7.1.7. Perinatal death
One study reported on perinatal death, and there was no difference between the antepartum deinfibulation and intrapartum deinfibulation groups (OR 0.62, 95% CI 0.17–2.30; one study, 869 participants) (Figure 20).
FIGURE 20.
Antepartum deinfibulation versus intrapartum deinfibulation, perinatal death.
3.8. Adverse events
3.8.1. Need for blood transfusion
Albert et al. 35 reported complications, including needing blood transfusion, antibiotics, and/or syntocinon. There was no statistically significant difference between the groups (19% vs 33%; P = 0.227).
4. DISCUSSION
We re‐evaluated the effectiveness of deinfibulation in women with type III FGM on obstetric, gynecologic, urologic, and sexual health outcomes for this review update. The main findings indicate that deinfibulation reduces the odds of emergency cesarean birth and genital tract lacerations in women with type III FGM compared with those who have not been deinfibulated. Deinfibulated women with type III FGM also had lower odds of cesarean birth compared with women with no FGM. Antepartum deinfibulation, compared with intrapartum deinfibulation, may shorten the duration of labor; however, results varied, and antepartum deinfibulation may make little or no difference to the risk of prolonged labor (low‐certainty evidence). Antepartum deinfibulation may also increase the likelihood of postpartum hemorrhage and cesarean birth among pregnant women with type III FGM (low‐certainty evidence). No studies assessing gynecologic or sexual health outcomes met the inclusion criteria for this update.
Despite the evidence presented in this review, high‐quality research is still needed to strengthen the findings. The eight included studies enrolled between 26 and 960 participants, with five studies involving more than 250 participants, most of whom were in the intervention arms. All studies were assessed as having a “serious risk” of bias, particularly related to confounding and selection of participant selection. Consequently, the certainty of evidence for cesarean birth and genital tract laceration was very low. Although these studies contributed data on the effects of deinfibulation, the methodological limitations substantially weaken confidence in the observed associations.
Since the publication of previous reviews on deinfibulation, it was expected that high‐quality intervention studies would provide additional evidence on health outcomes in women with type III FGM after deinfibulation. However, none were identified. A recent observational study of 345 women, published in 2022, had to be excluded because disaggregated data for women with type III FGM were not provided, and a request for these data received no response. 36 This highlights the limited uptake of the FGM research priorities included in the 2016 WHO FGM guidelines by the global research community. 37 , 38 , 39
The first multicenter cross‐sectional study on birth outcomes in women with FGM reported higher adverse maternal and fetal outcomes compared to women who had not experienced FGM. 8 However, subsequent evidence has been contradictory. One study conducted in Australia reported similar risks on obstetric outcomes in women with and without FGM, and even higher risk for first‐ and second‐degree perineal tears and cesarean birth among women without FGM. 40 Yet, another study involving 41% of women with type III FGM reported no difference in cesarean birth rate, with less likelihood of vacuum or forceps delivery, though women with type III FGM had more episiotomies. 41 The previous review for the 2016 guideline reported a significantly lower likelihood of cesarean birth and postpartum hemorrhage after vaginal birth compared with women with type III FGM without deinfibulation. 21 In this update, no difference was observed in the occurrence of postpartum hemorrhage, although emergency cesarean birth remained less likely after deinfibulation in women having a vaginal birth. Unlike the previous review, this update also found that deinfibulation in women with type III FGM reduces the likelihood of genital tract lacerations.
4.1. Strengths and limitations
For consistency, this updated review used the same search strategy, developed and administered by the same information scientist as the first review, covering five databases from the last search up to May 8, 2023. We included three studies that were not in the previous systematic review. Two review team members independently screened studies for eligibility in pairs, and two review authors independently performed data extraction and risk of bias assessment. We also evaluated the obstetric outcomes in deinfibulated women with type III FGM who had a vaginal birth, comparing their outcomes with two other groups of women. Despite these efforts, the review is limited by moderate‐ and low‐quality evidence reported for genital tract laceration and cesarean birth, respectively. Therefore, the conclusions of this review should be interpreted with caution.
4.2. Implications for practice and research
The Royal College of Obstetricians and Gynaecologists (RCOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommend that clinicians examine every woman's external genitalia during medical consultation to document the presence and type of FGM. 42 , 43 It is also recommended that physicians ask about gynecologic complications that precede the pregnancy in those living with type III FGM. Clinicians should be aware of the benefits of deinfibulation and the need to counsel and offer deinfibulation to women living with type III FGM and decline requests for reinfibulation. 43 The RCOG also recommends that deinfibulation should be performed on all women living with type III FGM, preferably before first sexual intercourse. 42 The SOGC recommends deinfibulation for gynecologic indications, such as vaginal obstruction, mass effect, or intercourse, and for obstetric indications where it is likely to improve birth outcomes. 43 It also recommends performing an episiotomy when deinfibulation is done intrapartum to prevent genital laceration. 43 This suggests that deinfibualation alone may not be sufficient to improve birth outcomes.
The evidence from this review alone makes it difficult to confidently recommend deinfibulation for improving obstetric outcomes of women with type III FGM due to limited evidence on its effectiveness for common outcomes such as postpartum hemorrhage and episiotomy, as well as on gynecologic and sexual health outcomes. The extent of damage to the external genitalia, obstruction of the vaginal introitus, and covering of the urethra are alterations that impede natural gynecologic, urologic, and sexual functioning, representing a violation of the right to health of those affected. Given that deinfibulation may be offered antenatally or intrapartum in populations with a high prevalence of FGM, genital examination should be carried out to document the presence and type of FGM. Women with type III FGM should be counseled about deinfibulation and allowed to undergo the procedure during pregnancy or labor.
5. CONCLUSIONS
This review highlights the lack of high‐quality studies on deinfibulation for women with type III FGM, as most included studies were retrospective observational designs. Future research should prospectively assess the effectiveness of deinfibulation on obstetric, gynecologic, urologic, and sexual health outcomes in this population. In addition, well‐conducted large‐scale observational studies are needed to capture outcomes beyond pregnancy, including the role of deinfibulation in preventing genital infections, dysmenorrhea, urologic complications, chronic pelvic pain, and dyspareunia in women and their male partners, alongside improvements in obstetric outcomes.
AUTHOR CONTRIBUTIONS
BO and EE: Review of study selection, review of the risk of bias assessment, review of data extraction, grading of evidence, and drafting of the manuscript. VA and EO: Study selection, data extraction, risk of bias assessment, and review of draft manuscript. NN, KI, CM, JM, and FI: Study selection, data extraction, and review of draft manuscript. MM: Review of the draft manuscript for scientific content and overall project supervision.
FUNDING INFORMATION
This work received funding from the Government of Norway and the UNDP‐UNFPA‐UNICEF‐WHO‐World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO).
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest.
Supporting information
Appendix S1.
Appendix S2.
Okusanya B, Esu E, Nwachuku N, et al. Deinfibulation for improving obstetric, neonatal, gynecologic, and sexual health outcomes in women and girls with type III female genital mutilation: A systematic review and meta‐analysis. Int J Gynecol Obstet. 2026;172(Suppl. 1):31‐47. doi: 10.1002/ijgo.70759
DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
REFERENCES
- 1. Terry L, Harris K. Female genital mutilation: a literature review. Nurs Stand. 2013;28(1):41‐47. [DOI] [PubMed] [Google Scholar]
- 2. United Nations Children's Fund . Female Genital Mutilation: A global concern. 2024. https://data.unicef.org/resources/female‐genital‐mutilation‐a‐global‐concern‐2024/
- 3. World Health Organization . WHO Guidelines on the Management of Health Complications from Female Genital Mutilation. World Health Organization; 2016. [PubMed] [Google Scholar]
- 4. Minsart AF, N'Guyen TS, Ali Hadji R, Caillet M. Maternal infibulation and obstetrical outcome in Djibouti. J Matern Fetal Neonatal Med. 2015;28(14):1741‐1746. [DOI] [PubMed] [Google Scholar]
- 5. Iavazzo C, Sardi TA, Gkegkes ID. Female genital mutilation and infections: a systematic review of the clinical evidence. Arch Gynecol Obstet. 2013;287(6):1137‐1149. [DOI] [PubMed] [Google Scholar]
- 6. Berg RC, Underland V, Odgaard‐Jensen J, Fretheim A, Vist GE. Effects of female genital cutting on physical health outcomes: a systematic review and meta‐analysis. BMJ Open. 2014;4(11):e006316. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Sylla F, Moreau C, Andro A. A systematic review and meta‐analysis of the consequences of female genital mutilation on maternal and perinatal health outcomes in European and African countries. BMJ Glob Health. 2020;5(12):e003307. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet. 2006;367(9525):1835‐1841. [DOI] [PubMed] [Google Scholar]
- 9. Abdulcadir J, Dällenbach P. Overactive bladder after female genital mutilation/cutting (FGM/C) type III. BMJ Case Rep. 2013;2013:bcr2012008155. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Chen G, Dharia SP, Steinkampf MP, Callison S. Infertility from female circumcision. Fertil Steril. 2004;81(6):1692‐1694. [DOI] [PubMed] [Google Scholar]
- 11. Gudeta TA, Regassa TM, Gamtessa LC. Female genital mutilation: prevalence, associated factors and health consequences among reproductive age group women in Keffa zone, southwest, Ethiopia. Reprod Health. 2022;19(1):60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Oyefara JL. Ritual female genital mutilation: a psychosocial analysis of a flourishing rather than a dying tradition in Oworonshoki community, Lagos, Nigeria. IFE Psycholog IA. 2014;22(2):72‐83. [Google Scholar]
- 13. Elneil S. Female sexual dysfunction in female genital mutilation. Trop Dr. 2016;46(1):2‐11. [DOI] [PubMed] [Google Scholar]
- 14. Klein E, Helzner E, Shayowitz M, Kohlhoff S, Smith‐Norowitz TA. Female genital mutilation: health consequences and complications‐a short literature review. Obstet Gynecol Int. 2018;2018:7365715. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Abdulcadir J, Marras S, Catania L, Abdulcadir O, Petignat P. Defibulation: a visual reference and learning tool. J Sex Med. 2018;15(4):601‐611. [DOI] [PubMed] [Google Scholar]
- 16. Bishai D, Bonnenfant YT, Darwish M, et al. Estimating the obstetric costs of female genital mutilation in six African countries. Bull World Health Organ. 2010;88(4):281‐288. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Johnson C, Nour NM. Surgical techniques: defibulation of type III female genital cutting. J Sex Med. 2007;4(6):1544‐1547. [DOI] [PubMed] [Google Scholar]
- 18. Nour NM, Michels KB, Bryant AE. Defibulation to treat female genital cutting: effect on symptoms and sexual function. Obstet Gynecol. 2006;108(1):55‐60. [DOI] [PubMed] [Google Scholar]
- 19. Rouzi AA, Berg RC, Al‐Wassia H, et al. Labour outcomes with defibulation at delivery in immigrant Somali and Sudanese women with type III female genital mutilation/cutting. Swiss Med Wkly. 2020;150:w20326. [DOI] [PubMed] [Google Scholar]
- 20. Rouzi AA, Al‐Sibiani SA, Al‐Mansouri NM, Al‐Sinani NS, Al‐Jahdali EA, Darhouse K. Defibulation during vaginal delivery for women with type III female genital mutilation. Obstet Gynecol. 2012;120(1):98‐103. [DOI] [PubMed] [Google Scholar]
- 21. Okusanya BO, Oduwole O, Nwachuku N, Meremikwu MM. Deinfibulation for preventing or treating complications in women living with type III female genital mutilation: a systematic review and meta‐analysis. Int J Gynaecol Obstet. 2017;136(Suppl 1):13‐20. [DOI] [PubMed] [Google Scholar]
- 22. Esu E, Udo A, Okusanya BO, Agamse D, Meremikwu MM. Antepartum or intrapartum deinfibulation for childbirth in women with type III female genital mutilation: a systematic review and meta‐analysis. Int J Gynaecol Obstet. 2017;136(Suppl 1):21‐29. [DOI] [PubMed] [Google Scholar]
- 23. Higgins JPT, Thomas J, Chandler J, et al., eds. Cochrane Handbook for Systematic Reviews of Interventions Version 6.3 (Updated February 2022). 2022.
- 24. Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA group: preferred reporting items for systematic reviews and meta‐analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Veritas Health Innovation . Covidence Systematic Review Software. Melbourne, Australia. www.covidence.org
- 26. Sterne JA, Hernan MA, Reeves BC, et al. ROBINS‐I: a tool for assessing risk of bias in non‐randomised studies of interventions. BMJ. 2016;355:i4919. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction‐GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383‐394. [DOI] [PubMed] [Google Scholar]
- 28. McMaster University and Evidence Prime . GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. 2025. gradepro.org
- 29. Bikoo M, Davies M, Richens Y, Creighton S. Female genital mutilation: a growing challenge for midwives in the UK. Br J Midwifery. 2006;14(7):403‐405. [Google Scholar]
- 30. Paliwal P, Ali S, Bradshaw S, Hughes A, Jolly K. Management of type III female genital mutilation in Birmingham, UK: a retrospective audit. Midwifery. 2014;30(3):282‐288. [DOI] [PubMed] [Google Scholar]
- 31. Raouf SA, Ball T, Hughes A, Holder R, Papaioannou S. Obstetric and neonatal outcomes for women with reversed and non‐reversed type III female genital mutilation. Int J Gynaecol Obstet. 2011;113(2):141‐143. [DOI] [PubMed] [Google Scholar]
- 32. Rouzi AA, Aljhadali EA, Amarin ZO, Abduljabbar HS. The use of intrapartum defibulation in women with female genital mutilation. BJOG. 2001;108(9):949‐951. [DOI] [PubMed] [Google Scholar]
- 33. Taraldsen S, Vangen S, Øian P, Sørbye IK. Female genital mutilation/cutting, timing of deinfibulation, and risk of cesarean section. Acta Obstet Gynecol Scand. 2021;100(4):587‐595. [DOI] [PubMed] [Google Scholar]
- 34. Taraldsen S, Vangen S, Øian P, Sørbye IK. Risk of obstetric anal sphincter injury associated with female genital mutilation/cutting and timing of deinfibulation. Acta Obstet Gynecol Scand. 2022;101(10):1163‐1173. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Albert J, Bailey E, Duaso M. Does the timing of deinfibulation for women with type 3 female genital mutilation affect labour outcomes? Br J Midwifery. 2015;23(6):430‐437. [Google Scholar]
- 36. Bonavina G, Kaltoud R, Ruffolo AF, Candiani M, Salvatore S. Female genital mutilation and cutting and obstetric outcomes. Obstet Gynecol. 2022;140(1):87‐90. [DOI] [PubMed] [Google Scholar]
- 37. Atkinson HG, Ottenheimer D, Mishori R. Public Health Research priorities to address female genital mutilation or cutting in the United States. Am J Public Health. 2019;109(11):1523‐1527. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38. Abdulcadir J, Rodriguez MI, Say L. Research gaps in the care of women with female genital mutilation: an analysis. BJOG. 2015;122(3):294‐303. [DOI] [PubMed] [Google Scholar]
- 39. WHO Guidelines Approved by the Guidelines Review Committee . WHO Guidelines on the Management of Health Complications from Female Genital Mutilation. World Health Organization Copyright © World Health Organization; 2016. [PubMed] [Google Scholar]
- 40. Varol N, Dawson A, Turkmani S, et al. Obstetric outcomes for women with female genital mutilation at an Australian hospital, 2006‐2012: a descriptive study. BMC Pregnancy Childbirth. 2016;16(1):328. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. Davis G, Jellins J. Female genital mutilation: obstetric outcomes in metropolitan Sydney. Aust N Z J Obstet Gynaecol. 2019;59(2):312‐316. [DOI] [PubMed] [Google Scholar]
- 42. Royal College of Obstetricians and Gynaecologists . Female Genital Mutilation and its Management. Green‐top Guideline No. 53. 2015.
- 43. Perron L, Senikas V, Burnett M, Davis V. Guideline No. 395‐Female Genital Cutting. J Obstet Gynaecol Can. 2020;42(2):204‐217.e202. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix S1.
Appendix S2.
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this study.