Female genital mutilation (FGM) encompasses a range of procedures that damage and change women’s external genitalia. More than 200 million girls and women have been subjected to FGM, and an estimated three million girls are at risk every year. FGM has significant effects on women’s health, especially during pregnancy and delivery. There is very little information available for health care providers to help provide evidence based care for women living with FGM, and minimize obstetric risks. We looked at how episiotomy, an incision to extend the vaginal opening during birth, varied by FGM status. We also looked at whether type of episiotomy improved maternal health outcomes. We found that women living with FGM were more likely to have the most extensive types of episiotomies performed. Our findings suggest that anterior episiotomy, to release scar tissue, may reduce some obstetrical risk among women with the most extensive type of FGM. We need more information to help women and providers decide when is the best time to provide defibulation during pregnancy.

The impact of FGM on obstetric outcomes has been investigated in several studies [2–4]. Compared to women without FGM, women with FGM have an increased risk of episiotomy, caesarean delivery, haemorrhage, extended maternal hospital stay, infant resuscitation, and inpatient perinatal death [3]. The risk of adverse obstetric outcomes varies by FGM type, with the most extensive forms of FGM being associated with the greatest risk [3, 5]. Women with Type 3 FGM have been shown to have increased risk of episiotomy, caesarean delivery, postpartum haemorrhage and stillbirth [3]. There is an urgent need for evidence on how to minimize the negative perinatal consequences for women living with FGM [6, 7]. The majority of existing recommendations for obstetric practice in this population are based on expert opinion [6]. New guidelines from the WHO examine the evidence for optimizing the health care management of women living with FGM [8]. Topics included reflect a broad range of health care needs including: female sexual health, mental health, information & education needs for women and providers, as well as defibulation. Improved data to guide defibulation practices was identified as a research priority by the WHO.

The scar tissue from FGM, in particular with Type 3, narrows the vaginal introitus, and is thought to increase the risk for obstructed labour and extensive perineal lacerations [9, 10]. Prolonged labour is a risk factor for postpartum haemorrhage [11]. Anterior episiotomy (or defibulation) to release the scar tissue is commonly performed, but when a circumcised woman presents in labour, the optimal type of episiotomy and time to perform it is not known. Performing the procedure early in labour requires anesthesia, and may increase risk of intrapartum bleeding, as the incision would be irritated by subsequent cervical exams. [9] Delaying the procedure until immediately prior to delivery may increase the risk of postpartum haemorrhage due to obstructed labour.

Episiotomy is the surgical enlargement of the vaginal opening due to a perineal incision [5, 12]. Seven different types of episiotomies are reported in the literature, although only anterior, mediolateral and midline posterior are commonly used [13]. Among women without FGM, anterior, mediolateral and midline posterior episiotomies are typically performed. A posterior lateral episiotomy may also be referred to as a “J-shaped” episiotomy [13]. Anterior episiotomy, or defibulation, is the opening of the scar associated with FGM, most commonly used with women living with FGM Type 3 [13]. It is frequently performed during labour, to allow for cervical exams and to prevent obstructed labour [14, 15]. Anterior episiotomy may be performed alone, or in combination with midline posterior or posterior lateral episiotomies. A provider may choose to only perform a midline posterior or posterior lateral episiotomy as well, to avoid incising the scar tissue anteriorly. The decision of what type of episiotomy to perform is typically based on provider training and preference. Episiotomy is not without risks: it is associated with increased risk of pain, perineal trauma (extensive lacerations), need for suturing, and healing complications [12]. It is likely that the more extensive the episiotomy performed, the greater the risk of maternal harm.

There is scant evidence to guide episiotomy practice among women living with FGM [6, 16]. All existing guidelines are based on expert opinion with respect to episiotomy practice and FGM. The Royal College of Obstetricians and Gynaecologists recommends that intrapartum episiotomy in women with FGM be performed if inelastic scar tissue prevents progress. In general, existing guidelines advise a low threshold for performing episiotomy, despite the absence of studies on the real benefits of episiotomy with each type of FGM [6, 17]. No evidence exists to guide the type or timing of episiotomy to perform.

The objective of this study is to investigate the association between type of episiotomy and obstetric outcomes among women with living with FGM Type 3. We examine whether episiotomy improves maternal outcomes including anal sphincter tears, intrapartum blood loss requiring intervention, and postpartum haemorrhage.

The WHO previously conducted an international, multicentre study examining obstetric outcomes in women by FGM status. The cohort contained women without FGM, as well as women with FGM, categorized by the WHO classification system. Previous papers have reported on the risks of different obstetric outcomes for both the woman and the neonate, as well as estimated costs to the health system [3, 18]. In this sub analysis, we focus on the association between type of episiotomy and maternal outcomes in women with FGM Type 3.

Women who presented for singleton delivery at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan between November 2001 and March 2003 were screened for study eligibility. Women with multiple gestations, or presenting for elective caesarean delivery or in advanced labour (unable to complete a pelvic exam prior to delivery) were excluded from the study, along with women who were unwilling or unable to give informed consent. Women and their infants were then followed until time of maternal discharge from the hospital. All participants provided informed consent prior to enrolment. Institutional review boards at all participating hospitals and the World Health Organization (WHO) Secretariat Committee on Research Involving Human Subjects gave ethics approval.

We used descriptive statistics and bivariate measures of association to describe the study population and the population of women by type of FGM. Bivariate and multivariable logistic regression models were used to examine the association of type of episiotomy and maternal outcomes (anal sphincter tears, intrapartum blood loss requiring intervention, and postpartum haemorrhage) among women with type 3 FGM.

Women with FGM Type 3 had significantly narrower introituses when compared with women without FGM or with other types of FGM (mean of 2.37 fingers compared with 2.56 and 2.45, p < 0.001). Width of pelvic introitus was associated with episiotomy performed among women with FGM Type 3; women with more narrow introituses were significantly more likely to have an episiotomy. The analysis sample was limited to the 6,187 women who had FGM Type 3 with data on episiotomy status.

The objective of our study was to investigate the association between type of episiotomy and obstetric outcomes including anal sphincter tears, and intrapartum blood loss requiring an intervention, and postpartum hemorrhage among women with living with FGM Type 3. We found that all types of episiotomies are protective against these outcomes. Given the risks associated with episiotomy however, the smallest episiotomy needed should be utilized. Currently women living with FGM Type 3 are significantly more likely to have the most extensive type of episiotomy, with both an anterior and posterior incision. There is not strong data to support this clinical practice.

More data are needed to guide the medical care of women living with FGM. Evidence to inform when (antenatal or during labour) anterior episiotomy or deinfibulation is performed is urgently needed. Research to identify when episiotomy should be performed and for which women living with FGM is needed. Anterior episiotomy, or defibulation in pregnancy, at the first and at the second stage of labour, should be prospectively compared for blood loss, rate of episiotomy, perineal tear, demand for reinfibulation, and acceptance and satisfaction with deinfibulation for women. Provider training to improve the obstetrical care of women with FGM is also needed.