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Female Genital Mutilation in Sierra Leone: Forms, Reliability of Reported Status, and Accuracy of Related Demographic and Health Survey Questions

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      Abstract

      Objective. To determine forms of female genital mutilation (FGM), assess consistency between self-reported and observed FGM status, and assess the accuracy of Demographic and Health Surveys (DHS) FGM questions in Sierra Leone. Methods. This cross-sectional study, conducted between October 2010 and April 2012, enrolled 558 females aged 12–47 from eleven antenatal clinics in northeast Sierra Leone. Data on demography, FGM status, and self-reported anatomical descriptions were collected. Genital inspection confirmed the occurrence and extent of cutting. Results. All participants reported FGM status; 4 refused genital inspection. Using the WHO classification of FGM, 31.7% had type Ib; 64.1% type IIb; and 4.2% type IIc. There was a high level of agreement between reported and observed FGM prevalence (81.2% and 81.4%, resp.). There was no correlation between DHS FGM responses and anatomic extent of cutting, as 2.7% reported pricking; 87.1% flesh removal; and 1.1% that genitalia was sewn closed. Conclusion. Types I and II are the main forms of FGM, with labia majora alterations in almost 5% of cases. Self-reports on FGM status could serve as a proxy measurement for FGM prevalence but not for FGM type. The DHS FGM questions are inaccurate for determining cutting extent.

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      Most cited references 66

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      Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.

      Reliable evidence about the effect of female genital mutilation (FGM) on obstetric outcome is scarce. This study examines the effect of different types of FGM on obstetric outcome. 28 393 women attending for singleton delivery between November, 2001, and March, 2003, at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal, and Sudan were examined before delivery to ascertain whether or not they had undergone FGM, and were classified according to the WHO system: FGM I, removal of the prepuce or clitoris, or both; FGM II, removal of clitoris and labia minora; and FGM III, removal of part or all of the external genitalia with stitching or narrowing of the vaginal opening. Prospective information on demographic, health, and reproductive factors was gathered. Participants and their infants were followed up until maternal discharge from hospital. Compared with women without FGM, the adjusted relative risks of certain obstetric complications were, in women with FGM I, II, and III, respectively: caesarean section 1.03 (95% CI 0.88-1.21), 1.29 (1.09-1.52), 1.31 (1.01-1.70); postpartum haemorrhage 1.03 (0.87-1.21), 1.21 (1.01-1.43), 1.69 (1.34-2.12); extended maternal hospital stay 1.15 (0.97-1.35), 1.51 (1.29-1.76), 1.98 (1.54-2.54); infant resuscitation 1.11 (0.95-1.28), 1.28 (1.10-1.49), 1.66 (1.31-2.10), stillbirth or early neonatal death 1.15 (0.94-1.41), 1.32 (1.08-1.62), 1.55 (1.12-2.16), and low birthweight 0.94 (0.82-1.07), 1.03 (0.89-1.18), 0.91 (0.74-1.11). Parity did not significantly affect these relative risks. FGM is estimated to lead to an extra one to two perinatal deaths per 100 deliveries. Women with FGM are significantly more likely than those without FGM to have adverse obstetric outcomes. Risks seem to be greater with more extensive FGM.
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        Posttraumatic stress disorder and memory problems after female genital mutilation.

        This pilot study investigated the mental health status of women after genital mutilation. Although experts have assumed that circumcised women are more prone to developing psychiatric illnesses than the general population, there has been little research to confirm this claim. It was predicted that female genital mutilation is associated with a high rate of posttraumatic stress disorder (PTSD). The psychological impact of female genital mutilation was assessed in 23 circumcised Senegalese women in Dakar. Twenty-four uncircumcised Senegalese women served as comparison subjects. A neuropsychiatric interview and further questionnaires were used to assess traumatization and psychiatric illnesses. The circumcised women showed a significantly higher prevalence of PTSD (30.4%) and other psychiatric syndromes (47.9%) than the uncircumcised women. PTSD was accompanied by memory problems. Within the circumcised group, a mental health problem exists that may furnish the first evidence of the severe psychological consequences of female genital mutilation.
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          The long-term reproductive health consequences of female genital cutting in rural Gambia: a community-based survey.

          This paper examines the association between traditional practices of female genital cutting (FGC) and adult women's reproductive morbidity in rural Gambia. In 1999, we conducted a cross-sectional community survey of 1348 women aged 15-54 years, to estimate the prevalence of reproductive morbidity on the basis of women's reports, a gynaecological examination and laboratory analysis of specimens. Descriptive statistics and logistic regression were used to compare the prevalence of each morbidity between cut and uncut women adjusting for possible confounders. A total of 1157 women consented to gynaecological examination and 58% had signs of genital cutting. There was a high level of agreement between reported circumcision status and that found on examination (97% agreement). The majority of operations consisted of clitoridectomy and excision of the labia minora (WHO classification type II) and were performed between the ages of 4 and 7 years. The practice of genital cutting was highly associated with ethnic group for two of the three main ethnic groups, making the effects of ethnic group and cutting difficult to distinguish. Women who had undergone FGC had a significantly higher prevalence of bacterial vaginosis (BV) [adjusted odds ratio (OR)=1.66; 95% confidence interval (CI) 1.25-2.18] and a substantially higher prevalence of herpes simplex virus 2 (HSV2) [adjusted OR=4.71; 95% CI 3.46-6.42]. The higher prevalence of HSV2 suggests that cut women may be at increased risk of HIV infection. Commonly cited negative consequences of FGC such as damage to the perineum or anus, vulval tumours (such as Bartholin's cysts and excessive keloid formation), painful sex, infertility, prolapse and other reproductive tract infections (RTIs) were not significantly more common in cut women. The relationship between FGC and long-term reproductive morbidity remains unclear, especially in settings where type II cutting predominates. Efforts to eradicate the practice should incorporate a human rights approach rather than rely solely on the damaging health consequences.
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            Author and article information

            Affiliations
            1Division of Global Health, Department of Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden
            2Department of Community Health, College of Medicine and Allied Health Sciences, University of Sierra Leone, Sierra Leone
            3Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 117, 221 00 Lund, Sweden
            4Geneva Foundation for Medical Education and Research, 1290 Versoix, Switzerland
            Author notes
            *Owolabi Bjälkander: owolabi.bjalkander@ 123456ki.se

            Academic Editor: Birgitta Essen

            Journal
            Obstet Gynecol Int
            Obstet Gynecol Int
            OGI
            Obstetrics and Gynecology International
            Hindawi Publishing Corporation
            1687-9589
            1687-9597
            2013
            24 September 2013
            : 2013
            3800578
            10.1155/2013/680926
            Copyright © 2013 Owolabi Bjälkander et al.

            This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Categories
            Research Article

            Obstetrics & Gynecology

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