Genital cutting not tied to childbirth complication

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The practice of female genital cutting may not raise the risk of a severe childbirth complication common in the developing world, a new study suggests.

The study, of nearly 500 Ethiopian women, found no clear relationship between female genital cutting and the development of obstetric fistula—where a prolonged, difficult labor causes a hole to form between the uterus and bladder or, less often, the rectum.

It is estimated that more than 130 million women worldwide have undergone female genital cutting, also known as female “circumcision.”

The centuries-old practice, which involves removing part or all of a girl’s clitoris and labia, and sometimes narrowing the vaginal opening, remains a common practice in some countries, mainly in sub-Saharan Africa.

Studies in Africa have found that women who underwent genital cutting as girls have higher risks of certain childbirth complications, including stillbirth and severe vaginal tears. Similarly, some European studies of African immigrants have linked genital cutting to higher risks of vaginal tearing and emergency C-section.

But it has been unclear whether genital cutting raises the risk of obstetric fistula.

Obstetric fistula is now almost unheard of in wealthier countries, but it remains a serious problem in parts of the world with little access to emergency obstetric care. In these countries, women with obstructed labor can remain in labor for days, usually ending in a stillbirth.

Those who suffer fistulas are left with chronic incontinence; some are then abandoned by their families and ostracized by their communities.

The thinking has been that, if female genital cutting contributes to obstetric fistulas, then eradicating the practice will help prevent some cases of the childbirth complication.

But the current findings suggest that this would not be the case, according to the researchers, led by Andrew Browning of the Barhirdar Hamlin Fistula Centre in Ethiopia.

“Although the eradication of female genital cutting is desirable from the standpoints of both women’s health and human rights,” the researchers write in the journal Obstetrics & Gynecology, “the elimination of these traditional genital operations will not eliminate the obstetric fistula as a complication of childbirth.”

The findings are based on 492 women who underwent surgery to correct obstetric fistula at the Barhirdar center; 255 women had undergone genital cutting, while 237 had not.

Overall, Browning and his colleagues report, there were no differences between the two groups of women as far as the location or severity of the fistulas. They also had similar success with surgical repair; the fistula was closed in nearly all women in both groups.

Women with genital cutting did have slightly longer labors—3.1 days, on average, versus 2.8 days among the other women.

However, the researchers note, a look at the patients’ geographical locations suggested that the longer labor was attributable to their living in more-remote areas, farther from medical help.

Indeed, Browning’s team writes, rather than being a cause of obstetric fistula, genital cutting may be a marker of other factors that raise a woman’s risk of complications. Those factors include greater poverty, poor infrastructure, earlier marriage (young girls are at greater risk of obstructed labor) and little personal freedom for women.

The elimination of obstetric fistula, the researchers conclude, “will require the presence of a trained attendant during every labor and timely, universal access to competent emergency obstetric services worldwide.”

SOURCE: Obstetrics & Gynecology, March 2010.

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