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ISSN: 2161-0711
Journal of Community Medicine & Health Education

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Impacts of Female Genital Mutilation on Women's Reproductive Health

Khaled Kasim*, Samy Shaaban, Abed El-Aziz El Sadak and Haytham Hassan

Department of Public Health and Community Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Corresponding Author:
Dr. Khaled Kasim
Department of Public Health and Community Medicine
Faculty of Medicine, Al-Azhar University
Nasr city, Cairo, Egypt
E-mail: [email protected]

Received Date: March 21, 2012; Accepted Date: April 05, 2012; Published Date: April 07, 2012

Citation: Kasim K, Shaaban S, El Sadak AE, Hassan H (2012) Impacts of Female Genital Mutilation on Women’s Reproductive Health. J Community Med Health Edu 2:137. doi: 10.4172/jcmhe.1000137

Copyright: © 2012 Kasim K, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Female genital mutilation is common practice in Egypt with its drawback effects. Studies concerned with the impacts of that practice on women’s health in general and reproductive health in particular are sparse. Objective: To assess the impact of female genital mutilation (FGM) on some reproductive health factors among Egyptian women. Material and Methods: A case-control study was conducted in Alexandria governorate, Egypt. The study recruited 200 circumcised (case group) and 200 uncircumcised (control group) women attending maternity health care centers in the studied area. Interview questionnaires were used to collect data from the studied women. The questionnaire included sociodemographic and reproductive data related to FGM. Chi square tests were used to compare between the two groups with p value ≤ 0.05 as a significant difference. A multivariate logistic regression was also used to assess the effect of FGM on the studied reproductive health factors. Results: The study revealed statistically significant associations between FGM and adverse reproductive health. The risk of dyspareunia was high among circumcised women with an adjusted odds ratio (OR) of 3.9 (95% CI = 2.5- 6.1). There have also been significant high risks of recurrent vaginal infection (OR = 3.3; 95% 1.6-7.5), infertility (OR = 2.9; 95% CI = 1.5-5.9), and post partum hemorrhage (OR = 3.2; 95% CI = 1.2-8.3) among circumcised women. Conclusions: Women with FGM are significantly more likely to have adverse reproductive health than women without FGM. This finding is highly relevant for preventive work against this ancient practice.

Keywords

Case-control study; Epidemiology; Female genital mutilation; Reproductive health.

Introduction

Female Genital Mutilation (FGM), also known as female circumcision or female genital cutting, has been practiced for centuries. Egyptian mummies were found to have been circumcised as far back as 200 B.C [1]. The practice of FGM is most prevalent in the African countries including Egypt [2].

The findings of demographic and health survey (DHS) declared nine out of 10 women in Egypt, Eritrea, Mali and northern Sudan have undergone some form of female circumcision [3]. The recent 2008 Demographic Health Survey in Egypt (EDHS) reported a high prevalence rate (91%) among women aged 15-49 years [4]. There are many reasons for perpetuation of this practice; the most common are cultural and religious beliefs. An overwhelming factor for its justification is the cultural influence and traditions, social acceptance within the community, and ensuring chastity and fidelity by attenuating sexual desire [2]. The Egyptian demographic and health survey has shown that a mother’s level of education, residency and economic status are important variables. For example, urban women are less likely to be circumcised than rural. Also, the likelihood of circumcision drops by educational level and wealth quintile [4].

Although several studies have been conducted in Egypt to determine the prevalence of FGM in different localities and to identify of the underlying factors that support and motivate that practice [5- 10], there has been a literature shortage in those studies addressed the risk of FGM on women’s health in general and reproductive health in particular. Nowadays, the concerted efforts to eliminate FGM in Egypt have informed the need for this study to assess the impact of FGM on some elements of women’s reproductive health in a sample of circumcised and uncircumcised women in Egyptian community.

Materials and Methods

This primary health care based case-control study was conducted in Alexandria governorate, Egypt to assess the impact of FGM on some elements of women’s reproductive health. The study recruited 400 women attending maternal clinics at rural and urban primary health care centers in Alexandria governorate during the period from June through December 2011. Of the studied women, 200 were circumcised forming the case group and 200 were uncircumcised forming the control group. The study sample is sufficient to detect 1.5 folds increase in the risk of the studied factors with study power of more than 80%. Using pre-designed questionnaire, sociodemographic and reproductive health related data were collected from the studied women by the help of trained health care nurses at the studied clinics. Sociodemographic data were classified during the study analysis as follow: age (< 20, 20-40, and > 40 years), marital status (single, married, divorced, and widow), education (illiterate, less than university, and university and higher), occupation (housewife, unskilled and professional work), residence (urban vs rural). Factors related to women’s reproductive health were also collected and included the presence or absence of dyspareunia, pleasure feeling with sexual relationship (satisfaction), recurrent vaginal infection, recurrent urinary tract infection, infertility, obstructed labor and post partum hemorrhage. Dyspareunia and sexual satisfaction were assessed by using related questions extracted from the female sexual function index (FSFI) [10]. The FSFI, a 19-item questionnaire, was designed and validated for assessment of female sexual function and quality of life in epidemiological studies. For satisfaction, each of the studied 3 FSFI questions is measured in 3 choices on a modified Likert-type scale graded from 0 to 2; the grade of the unstisfaction = 0, indifference = 1, and satisfaction = 2. Satisfaction is considered as (Yes) when the total scores ≥ 4 and is considered as (No) when the total score < 4. Dyspareunia is considered when the studied subject reported the presence of any level of pain during or following vaginal penetration. Obstructed labor is considered when the subject reported a previous caesarean section, tears, forceps and/or ventuose delivery.

Descriptive analyses of the studied factors were compared between cases and controls by χ2 tests. P values ≤ 0.05 were used as indictors of statistically significant differences. Logistic regression analyses were used to estimate odds ratios (OR) and their 95% confidence intervals (CIs) for the association of FGM with the studied reproductive health factors while controlling for the confounding sociodemographic factors. All the analyses were done by using the SAS software package [11].

Approval from health care administrators and the local authorities of Alexandria governorate was taken to attend the studied health care unites and centers. Ethical consideration was considered to avoid physical or emotional harm, particularly in single female, and to ensure confidentiality and privacy of the collected data and obtaining free written informed consent.

Results

A total of 200 circumcised and 200 uncircumcised women were included in this study. Table 1 compares the distribution of sociodemographic factors among the studied women with FGM (cases) and those without FGM (controls). Cases and controls were comparable with regard to their age and occupation. For marital status, however, a significant difference was observed between cases and controls (p = 0.001), where the percent of divorce was more among cases. The studied cases were less educated and more rural residence compared to the studied controls with statistically significant differences.

Characteristics Case group
N= 200
Control group
N= 200
P value
No % No %
Age (years):
<20
20 – 40
> 40
10
172
18
5.2
85.8
9.0
15
170
15
7.4
85.3
7.3
0.80
Marital status:
Single
Married
Divorced
16
167
17
8.0
83.5
8.5
15
179
6
7.2
89.5
3.3
0.01
Educational level:
Illiterate
Less than University
University and higher
53
117
30
26.4
58.8
14.8
29
117
54
14.2
56.3
29.5
< 0.0001
Occupation:
House wives
Students
unskilled workers
Employee
96
20
48
36
48.0
10.0
24.0
18.0
86
16
54
44
43.0
8.0
27.0
22.0
0.20
Residence
Urban
Rural
92
108
46.2
53.8
146
54
73.2
26.8
0.001

Table 1: Comparison of sociodemographic characteristics between women with FGM (case group) and women without FGM (control group).

Table 2 presents the distribution of the studied reproductive factors among the studied cases and controls. Avoiding physical or emotional harm to single women, no reproductive data were collected from them. Accordingly, single women were excluded from study analyses in that and subsequent table.There have been significant differences between cases and controls regarding all the studied reproductive health factors. Dyspareunia and lack of sexual satisfaction were more among cases compared to controls with statistically significant differences. Also, recurrent vaginal and urinary infection, infertility, obstructed labour and post partum haemorrhage were more among cases.

 Reproductive health elements Case group
N= 184
Control group
N= 185
P value
No % No %
Dyspareunia
Yes
No
130
54
70.7
29.3
70
115
37.8
62.2
<.0001
Pleasure feeling with sexual relationship
Yes
No
100
84
54.3
45.7
140
45
75.7
24.3
0.0001
Recurrent vaginal infections
Yes
No
32
152
17.4
82.6
11
174
5.9
94.1
0.001
Recurrent Urinary tract infection
Yes
No
52
132
28.3
71.7
20
165
10.8
89.2
<.0001
Infertility
Yes
No
34
150
18.4
81.6
13
172
7.0
93.0
0.002
Prolonged labor
Yes
No
65
119
35.3
64.7
31
154
16.8
83.2
0.0001
Post partum hemorrhage
Yes
No
18
166
9.8
91.2
6
179
3.2
96.8
0.02

Table 2: Distribution of the studied women according to long term impact of FGM on the studied reproductive health factors*.

Table 3 presents the association of FGM with the studied reproductive health factors. The risk of dyspareunia is found to increase significantly four folds in circumcised compared with uncircumcised women with an adjusted OR of 3.9 (95% CI = 2.5-6.1). Also, a significant increased risk of lack of sexual satisfaction was observed among circumcised women. The adjusted OR was 2.6 (95% CI = 1.6- 4.01). For other studied reproductive health factors, there have also been increased risks of recurrent vaginal infectios (OR = 3.3; 95% CI = 1.6-7.5), recurrent urinary infection (OR = 3.2; 95% CI = 1.8-5.7), infertility (OR = 2.9; 95% CI = 1.5-5.9), obstructed labour (OR = 2.7; 95% CI = 1.6-4.4) and post partum haemorrhage (OR = 3.2; 95% CI = 1.2-8.3) among the studied circumcised women.

Reproductive health elements Cases
(n= 184)
Controls
(n=185)
OR** 95% CI
Dyspareunia
Yes
No
130
54
70
115
3.9
1.00
2.5 – 6.1
Ref.
Pleasure feeling with sexual relationship
Yes
No
100
84
140
45
1.00
2.6
Ref
1.6 – 4.01
Recurrent vaginal infections
Yes
No
32
152
11
174
3.3
1.00
1.6 – 7.5
Ref.
Recurrent Urinary tract infection
Yes
No
52
132
20
165
3.2
1.00
1.8 – 5.7
Ref.
Infertility
Yes
No
34
150
13
172
2.9
1.00
1.5 – 5.9
Ref.
Prolonged/obstructed labor
Yes
No
65
119
31
154
2.7
1.00
1.6 – 4.4
Ref.
Post partum hemorrhage
Yes
No
18
166
6
179
3.2
1.00
1.2 – 8.3
Ref.

Table 3: Adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) for the association of FGM with the studied women’s reproductive health factors*.

Discussion

This study revealed a significant association between FGM and adverse reproductive health, particularly those concerned with sexual life, infertility, urogenital infection and obstetric outcome. The study demonstrated significant positive associations between FGM and all the studied reproductive and sexual factors.

The rate of sexual complications among women with FGM has been reported high among an Egyptian study included 250 women, randomly selected from the patients of maternal and childhood centers in Ismailia. The rate of dyspareunia was 80.5% and lack of sexual desire was 45% among the studied women [10]. Similarly, Elnasher and Abdelhady [8] reported a significant high prevalence of sexual problems among circumcised newly married women. As consequences of circumcision, the rigid scar tissue may lead to narrowing of the vaginal opening and vaginal muscular spasm (vaginismus) and which make penetration painful and difficult, or sometimes impossible [12]. Moreover, the difficulty in penetration and painful intercourse may cause women to lack sexual satisfaction and even hate sex [13].

The finding of higher risk of primary infertility among circumcised women coincides with the results of a previous hospital based casecontrol study showed a significant positive association between the anatomical extent of FGM and primary infertility [14]. In another clinical case-control study compared 100 infertile cases (a mixed group of both primary and secondary infertility) and 90 fertile controls recruited from a hospital in Alexandria, Egypt [15], there has been a tendency that women having undergone excision (type II) to have a non significant higher risk of tubal factor infertility than those having undergone clitoridectomy (type I) with an odds ratio of 1.9 (95% CI = 0.8-4.2). Recurrent urogenital infections associated with FGM may spread to the inner reproductive organs causing pelvic inflammatory diseases (PID) and subsequent infertility [16].

The high risk of recurrent vaginal and urinary infections observed in this study among circumcised women is similar to the finding of DeSilva [16]; reported urinary tract infection with Escherichia coli was common among circumcised women. Rrepeated urinary tract and genital infection are the consequences of poor vaginal drainage, which results from a space formed behind the vulva skin. This then becomes an excellent reservoir for the growth of pathogenic organisms and leading to recurrent infections [17].

The adverse obstetric outcome investigated in this study showed a high risk of obstructed labour and postpartum haemorrhage among circumcised women. The adjusted OR was 2.7 (95% CI = 1.6-4.4) for prolonged and obstructed labour and 3.2 (95% CI = 1.2-8.3) for postpartum haemorrhage. Similar findings were also reported in WHO study carried out in six African countries, and showed that women who have had Female Genital Mutilation (FGM) are significantly more likely to experience difficulties during childbirth, including post partum hemorrhage and that their babies are more likely to die as a result of the practice [18]. Other reported obstetrical complications were delayed second-stage labor, episiotomy, perineal tearing, and distressed babies [8]. For the infibulated mother in labor with a narrow orifice, there is a great difficult for the obstetrician to do a proper vaginal examination, to monitor progress, or to apply fetal scalp electrodes [19].

Most of the previous studies in Egypt were stressed primarily on the prevalence of FGM in different localities, and identification of the underlying factors that support and motivate the practice [5- 10]. There have also been some articles reported obstetric, urinary and psychosexual complications of FGC. These studies, however, have focused on the rate of such complications [8,9,12,20] among circumcised women, or calculating the risk for only one studied factor [15,21]. This study has the advantage of probing the impact of FGM on several reproductive health factors at the same time, and assessing the adjusted risk for each studied factor in a well organized case-control study. Although the collected data of the studied factors were based on the use of self report-based assessment questionnaire that may have a bias, dyspareunia and sexual satisfaction were accurately assessed by using related questions extracted from the female sexual function index (FSFI) [10].

Conclusions

The present study confirms the negative impact of FGM on a woman’s reproductive health and psychosexual life. The study raveled significant adverse effect of FGM on all studied reproductive health factors. More research is needed to examine the full range of physical, sexual, and psychological impact of FGM.

Acknowledgements

The authors would like to thank all health care nurses in the studied primary health care centers and unites for their help in data collection and cooperation.

References

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