Strength of recommendation: Conditional (very-low-certainty evidence)
Women and girls living with FGM are more likely to have a mental health disorder, such as
anxiety, depression and/or post-traumatic stress disorder (PTSD), compared with women and
girls who have not undergone FGM.
- Summary of the evidence -
The evidence review for this recommendation, which updated a previous review,
considered whether the timing of deinfibulation, i.e. antepartum versus intrapartum, made
any difference in terms of obstetric or newborn outcomes among women living with Type
III FGM. Four studies were identified in the systematic
review. These included a retrospective cohort study conducted in Norway by Taraldsen et al., and three studies conducted in the United Kingdom: one prospective cohort study
by Bikoo et al., one non-randomized controlled study by Paliwal et al. using hospital-based
controls drawn from medical records at the hospitals, and one retrospective cohort study
by Albert et al. in which antepartum and intrapartum deinfibulation were directly compared. The study participants were predominantly African women who had migrated to Norway
or the United Kingdom. No RCTs were identified and the certainty of the evidence from all four
of the studies for all outcomes was considered very low.
Evidence from these studies suggested that antepartum deinfibulation may lead to a shorter
duration of labour, compared with intrapartum deinfibulation. However, the effects of
antepartum deinfibulation vary, and it is possible that antepartum deinfibulation makes little
or no difference to the risk of prolonged labour. One study by Paliwal et al. (n = 253 women
with Type III FGM) found that antepartum deinfibulation was associated with higher rates
of postpartum haemorrhage and caesarean births in pregnant women with Type III FGM,
compared with intrapartum deinfibulation. It is therefore, unclear whether antepartum
deinfibulation compared with intrapartum deinfibulation increases or decreases the likelihood
of perineal tears, rate of episiotomies, birth asphyxia and perinatal deaths.
Another study, by Albert et al. (n = 59), showed no significant difference in the odds of
prolonged labour among women who received antepartum versus intrapartum deinfibulation. All four of the studies (n = 632) found that the odds of perineal tears did not significantly
vary based on the timing of deinfibulation. Evidence from two of these studies,
by Albert et al. and Taraldsen et al. (n = 597), also found that the likelihood of postpartum
haemorrhage was significantly higher in pregnant women who were deinfibulated during pregnancy compared with those deinfibulated during labour. Two studies, by Albert
et al. and Paliwal et al. (n = 77), found no overall difference in the likelihood of requiring
an episiotomy between women in the antepartum deinfibulation group and those in the
intrapartum deinfibulation group. Finally, three studies, by Bikoo et al., Paliwal et al.
and Taraldsen et al. (n = 912), found that the odds of caesarean delivery were significantly
higher among women who had received antepartum deinfibulation compared with
intrapartum deinfibulation.
Similarly, three studies (n = 288) found no overall difference in the likelihood of birth
asphyxia (Apgar scores of < 7 at 1 minute and 5 minutes) between women in the antepartum
deinfibulation group and those in the intrapartum deinfibulation group. Evidence
from one study by Taraldsen et al. (n = 869) found no difference between the antepartum
deinfibulation and intrapartum deinfibulation groups with regard to the risk of perinatal
death. One study by Albert et al. found no statistically significant difference between the
groups on the need for blood transfusion, antibiotics and/or syntocinon.
- Rationale -
The GDG noted that contextual and health systems factors influence decision-making about
the timing of deinfibulation, for women who request it during pregnancy. In most settings with
a high prevalence of FGM, many pregnant women don’t attend ANC until late in pregnancy,
and in some settings, the rates of facility-based births attended by skilled health personnel are
low and the competence of health workers to offer and perform deinfibulation varies. Given
the very low certainty of the available evidence and after assessing the benefits and harms,
values and preferences, equity, acceptability, feasibility and resource needs, the GDG decided
to retain the existing recommendation on the timing of deinfibulation without recommending
a preferred timing. In making this decision, GDG members considered the following contextual
factors that may influence the decision on the timing of deinfibulation.
1. Preference of the woman: Women should be consulted on their preferences. For
example, if a woman prefers to avoid an additional intrapartum procedure, or if she
suffers from urinary complications, she is likely to prefer antepartum deinfibulation
since this allows adequate healing time before childbirth to prevent additional
complications.
2. Access to health facilities and commodities: In settings where women may encounter
unintended delays in physically reaching health facilities (e.g. challenges with related
costs) and where there may be issues with the availability of health commodities
(e.g. type of analgesia to conduct the procedure), antepartum deinfibulation may be
preferred to ensure the procedure is done, in case there are delays in reaching the
facility at the time of labour/delivery.
3. Place of delivery: Given that deinfibulation should be carried out by a trained health
worker at a health facility, antepartum deinfibulation may be prioritized in contexts
where home births are common. The same applies to settings where the health facility
has a high patient load.
4. Health worker’s skill level: Anatomical conditions like tissue oedema and distortion
during labour, as well as the size of the opening of the infibulation – including whether
a vaginal exam is possible or not – may pose difficulties for less-experienced health
workers performing intrapartum deinfibulation. In this case, antepartum deinfibulation
would likely be preferable.
In settings with experienced, well trained providers, intrapartum deinfibulation is an
acceptable procedure. The GDG noted that during intrapartum deinfibulation, it may be
clinically useful to conduct the intervention during the first stage of labour as opposed to
later for better neonatal outcomes and better monitoring of labour. The GDG also noted the
advantages of antepartum deinfibulation: less oedematous tissue than during labour, more
time to heal prior to giving birth, and more time for women to adjust to the changes in the
functioning and appearance of their genitals.
- Implementation remarks -
Given that both antepartum and intrapartum deinfibulation appear to be comparable in terms
of obstetric and neonatal outcomes, the decision about the timing of the procedure should
be based on the contextual factors outlined above. The GDG noted a lack of clarity on the
responsibility for various tasks along the continuum of care among health workers caring for
women living with FGM in many settings, which may represent a barrier to identifying women
who need deinfibulation to prevent FGM-related obstetric and neonatal risks. In this regard,
the GDG emphasized the importance of establishing a clear referral pathway for pregnant
women living with Type III FGM, and encouraged efforts to define the roles and responsibilities
of different health workers within the client continuum of care from antenatal care to the
postpartum period, including local requirements regarding which types of health workers can
perform the deinfibulation procedure.
- Research gaps -
Many research gaps remain with regard to women’s preferences around the timing of
deinfibulation, health system readiness to carry out deinfibulation during the antepartum
period, and feasibility of antepartum deinfibulation. Current research provides conflicting
evidence around clinical outcomes, demonstrating the need for additional studies that
prioritize women’s preferences while considering contextual factors, with the aim of informing
recommendations on the timing of deinfibulation.
- Summary of the evidence -
A systematic review was conducted to explore the outcomes of counselling before undergoing
deinfibulation as compared with no counselling, with or without inclusion of a male partner
or family member during counselling. No studies were
identified to assess the outcomes of interest, which were increased uptake of deinfibulation
and reduced rate of requests for reinfibulation.
Evidence on the values and preferences of women who underwent deinfibulation suggests
that some women may report initial discomfort with the post-operative appearance of
deinfibulated labia. Therefore, in addition to obtaining preoperative consent, when counselling
women with a history of FGM, health workers should always provide balanced, unbiased
information on expected benefits and potential risks associated with a procedure in a clear
preoperative briefing. In the context of deinfibulation, this briefing should include information
regarding the anatomical and physiological changes that can be expected after deinfibulation
(e.g. faster micturition, increased vaginal discharge).
- Rationale -
Counselling and consent prior to any medical procedure is a clinical best practice and an
important aspect of person-centred care, which is a cornerstone of good clinical care. As
explained in WHO’s clinical handbook on the care of girls and women living with FGM,
it is important to recognize that women often feel conflicted in how they manage their
sociocultural values and the expectations of their families. Without counselling, some women
may request reinfibulation because of fear of repercussions if they go against their family’s
wishes, especially if they are dependent on their family for social or financial support. Clear
and respectful communication while ensuring confidentiality is essential in enabling women to
make decisions.
- Implementation remarks -
The GDG emphasized the importance of informed decision-making prior to the deinfibulation
procedure, regardless of whether it is during the antepartum or intrapartum period. They
noted that in many settings this decision-making might include the involvement of a male
partner or another person, such as a woman’s mother or mother in-law. The GDG also noted
the potential for unintended negative consequences if the involvement of a partner or family
member is not arranged sensitively and with a woman’s consent. For girls living with Type III FGM, no paediatric evidence currently exists on the benefits of
deinfibulation. However, expert opinion suggests that deinfibulation would prevent urological
and gynaecological complications regardless of the presence of symptoms. Health workers
can wait for girls to reach the age of assent and until their genitals have estrogenized
before suggesting deinfibulation, unless a girl is experiencing urological or gynaecological
complications.
- Research gaps-
Given the importance of pre-operative counselling prior to any surgical procedure and the
need to ensure that counselling considers contextual factors, potential risks or unintended
outcomes, and individual concerns, additional research should aim to identify effective
communication and counselling models. These efforts should inform decision-making in
contexts where decisions might be influenced by partners and family members, and where
sociocultural beliefs around FGM and body image present barriers to deinfibulation. Greater
understanding and acknowledgement of women’s preferences and concerns related to body
image would contribute to improvements in provider–client interactions, improved uptake of
deinfibulation, and reduced requests for reinfibulation.
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