Recommendation 4: Deinfibulation is recommended for women and girls with Type III FGM.

Strength of recommendation: Conditional (low-certainty evidence) 

Deinfibulation is a surgical procedure carried out to reopen the vaginal introitus in women living with Type III FGM. In order to achieve this, a trained health worker performs an incision of the midline scar tissue that covers the vaginal introitus up to the external urethral meatus, and the clitoral glans (if present/intact). The cut edges are then sutured, which allows the vaginal introitus to remain open. This procedure is performed to improve the health and well-being of women living with Type III FGM, as well as to allow intercourse and/or to facilitate childbirth.

- Summary of the evidence -

The evidence review for this recommendation considered the effects of deinfibulation on obstetric, neonatal, gynaecological and sexual health outcomes, including the quality of life among women living with Type III FGM. To meet the criteria for this review, in addition to the intervention group (deinfibulation in women with Type III FGM), the studies had to include one or both of the following two comparison groups: (i) women with Type III FGM without deinfibulation and (ii) women who had never had any type of FGM (i.e. non-infibulated). One prospective cohort study conducted in the United Kingdom, five retrospective cohort studies conducted in Norway, Saudi Arabia and the United Kingdom and one case–control study from Saudi Arabia with participants from Egypt, Ethiopia, Somalia, Sudan and Yemen were included, with a total of 3103 women participants. All the studies were conducted within the last three decades at either a secondary-level health facility, including specialized hospitals for the care of women and girls with FGM, or at a tertiary-level university teaching hospital. The included studies involved pregnant women with Type III FGM (infibulation) who had either had deinfibulation in a previous pregnancy or were scheduled for deinfibulation during pregnancy or labour. For all the studies considered, the certainty of the evidence was assessed as very low. For the first comparison, i.e. deinfibulation versus no deinfibulation in women with Type III FGM, one study by Raouf et al. (n = 250) found that deinfibulation reduced the need for performing an emergency caesarean section (84). Two studies by Paliwal et al. and Taraldsen et al. (2022) (n = 877) found that deinfibulation did not significantly reduce the odds of postpartum haemorrhage, prolonged second stage of labour, or the need for neonatal resuscitation for newborns. The two studies by Paliwal et al. and Raouf et al. (n = 503) informed the estimate on risk of neonatal resuscitation for newborns with low Apgar score at 1 minute with no significant association found. All three studies (n = 1067) found that deinfibulation did not significantly reduce the odds of episiotomy but did reduce the odds of genital tract lacerations. For the second comparison, i.e. deinfibulation in women with Type III FGM compared with women without FGM, three studies, by Bikoo et al., Rouzi et al. and Taraldsen et al. (2021) (n = 1009), found that deinfibulation reduced the odds of emergency caesarean section. One study by Rouzi (n = 776) found that deinfibulation did not reduce the odds of having postpartum haemorrhage. All four of those studies (n = 1784) found that deinfibulation did not significantly reduce the odds of having an episiotomy compared with women without FGM. The study by Taraldsen et al. (2022) (n = 708) found no difference between the two groups in terms of odds of a prolonged second stage of labour, and two studies by Bikoo et al. and Rouzi et al. (n = 300) found no difference in terms of odds of obstetric tears/lacerations. One qualitative study by Turkmani et al., which was included in a mixed-methods synthesis of evidence from humanitarian settings,14 was conducted among refugees and migrants in Australia and found that the acceptability of deinfibulation and other clinical management interventions hinges on health workers’ capabilities and their ability to communicate with women about what changes to expect following the procedure. Participants noted that they were often unprepared for and unhappy with the appearance of their genitals following deinfibulation if the health worker had not adequately briefed them ahead of time or offered psychological support.

- Rationale -

 Given the specific health risks of Type III FGM to a woman’s or a girl’s physical, sexual and mental health, there was consensus among GDG members that the benefits of deinfibulation outweigh any harms even though the certainty of the evidence from most of the studies presented was very low. However, given that the capacity to conduct deinfibulation remains low in most settings with a high prevalence of FGM, the GDG decided to issue a conditional recommendation. To perform a caesarean section and to repair third- and fourth-degree lacerations both require significantly higher levels of surgical skill than are required to perform deinfibulation and may result in longer-term adverse outcomes and higher health-care costs (e.g. care and management of urinary incontinence due to pelvic floor instability, which can result from perineal lacerations).

There was consensus among the GDG members that reinfibulation should not be performed as it is considered a form of FGM medicalization (34) and could result in further clinical complications. Deinfibulation can restore some physiological functions. Additionally, depending on the subtype of Type III FGM and whether the clitoral glans and inner or outer labia are affected, the physiological anatomy can potentially be restored. In this regard, deinfibulation could be considered a necessary part of upholding a woman’s right to health and ensuring that she has access to services needed to fulfil this right. The GDG noted the lack of evidence on health outcomes of deinfibulation among non-pregnant girls or women, since all identified studies related to pregnant women with Type III FGM

- Implementation remarks -

 The GDG noted that the lack of health worker training on deinfibulation may prevent them from performing this procedure, even when it has been requested. Likewise, qualitative research shows that when women are not adequately informed about the anatomical changes to expect after deinfibulation, this leaves them unable to make an informed decision about whether to undergo deinfibulation, and it can increase their fear of the procedure. The GDG noted that adequate health worker training is a crucial and urgently needed step as part of the implementation of this recommendation. This also involves, where relevant, adequate training of cultural translators who can help health workers by explaining the procedure and the importance of not undergoing reinfibulation, so that women are fully informed and supported in their decision-making. The GDG noted that in most settings with a high prevalence of FGM, deinfibulation skills are often lacking; and while in some settings, deinfibulation is conducted as part of the duty of care, in other settings, routine caesarean sections end up being performed to avoid deinfibulation and to avoid requests for reinfibulation. It is important, therefore, for health workers to receive adequate training on how to perform the procedure correctly and also how to discuss it clearly and sensitively with their clients and patients so that they understand that deinifibulation is associated with better health outcomes and why they should avoid reinfibulation. Implementation of this recommendation has significant resource implications since it will require improving the skills of health workers to perform the deinfibulation procedure. While primary care health workers can be trained to perform deinfibulation, in many settings it would only be available at secondary- or tertiary-level facilities.

- Research gaps -

The lack of training among health workers on how to correctly perform the deinfibulation procedure and how to counsel women during the decision-making process is an important barrier to the implementation of this recommendation. Therefore, more evaluations are needed on training models to build the capacity of health workers providing care to women with Type III FGM. Understanding women’s perspectives about deinfibulation and their concerns about body image following the procedure, as well as the perspectives of their partners, would enable health workers to better address these concerns, support women in their decision-making and prevent repeated reinfibulation requests.