FGM/C: education matters
By Jamie Norris on 23 November 2018 Midwives Magazine FGM - Female Genital Mutilation
Midwives have the skills and knowledge to educate women and their families on the adverse consequences and illegality of FGM, writes Jamie Morris.
Female genital mutilation/cutting (FGM/C) is a growing concern within midwifery practice because of complications that arise in childbirth for women who have undergone the procedure and their newborns.
FGM/C is the cultural practice of partially or totally removing healthy external female genitals for non-medical reasons (WHO, 2017). There are no health benefits – only negative physical, emotional and psychological effects to the women and girls undergoing this practice, which is most prevalent in certain areas of Africa, Asia and the Middle East (WHO et al, 2008).
Background
The term FGM/C is recommended by WHO (2017) to highlight the brutality of the practice that is forced on women and girls, and the violation of their human rights. It estimates that there are at least 200 million women and girls who have been subjected to FGM/C worldwide (WHO, 2017). Unicef (2016) shows how there has been a slow decline of the practice over the past three decades in the FGM countries: from 51% of girls aged 15 to 19 who had undergone FGM/C to 37% today. However, it is difficult to obtain an accurate figure because of the remoteness of some villages in countries where FGM/C continues and the illegality of the practice in most countries (WHO, 2017).
Global migration has caused a significant rise in FGM/C among childbearing women in the UK, and midwives are vital in identifying and supporting women who have undergone the practice because of the negative effects it has on pregnancy and childbirth (RCM et al, 2013).
In England and Wales, births to women who were born outside the UK continued to rise: 28.4% in 2017, compared with 11.6% in 1990 (Office for National Statistics, 2018). FGM/C is therefore being observed more frequently, which has led to more guidance and mandatory reporting policies for healthcare professionals (Department of Health and Social Care, 2017). A study by City, University of London estimates prevalence rates of FGM/C in England and Wales at 7.7 per 1000 women (Macfarlane and Dorkenoo, 2015). And the RCM (2016) reports that 1242 new cases of FGM/C in England were recorded in just one quarter of 2016. The impact of worldwide concern and UK legislation surrounding FGM/C has led to an increase in awareness and education among midwives (Unicef, 2016).
What is FGM/C?
FGM/C is also known as cutting, genital cutting, female genital surgery, female cutting and female circumcision (see FGM/C classification panel on page 64). Jacoby and Smith (2013) recommend avoiding the term ‘mutilation’ when addressing women who have undergone FGM/C and suggest the terms ‘cutting’ or ‘circumcision’. Whichever term is used, knowledge of the reasons FGM/C is performed, and how women can be ostracised from their communities if they have not undergone it is vital to provide empathic support (El-Shawarby and Rymer, 2008). The procedure of FGM/C is commonly undertaken by traditional circumcisers called ‘cutters’, women living within the villages with no medical training. The equipment used is often unsterile and anaesthesia is not provided, which adds to the pain and traumatic experience (UNFPA, 2017), and supports the WHO’s insistence on the term FGM/C.
Addressing the aftershock
Understanding FGM/C is essential for midwives so that accurate identification, documentation and management can be undertaken
To counteract the effects of FGM/C on childbirth, deinfibulation is a practice undertaken by medically trained personnel and specialist midwives to open the vaginal seal created after type 3 FGM/C, infibulation (Albert et al, 2015). This procedure is offered to pregnant women antenatally and in labour to allow passage of the fetus in childbirth to try and limit the effects of FGM/C on both mother and child (WHO, 2016). Reinfibulation after deinfibulation has been performed is an illegal practice in the UK.
Understanding FGM/C is essential for midwives so that accurate identification, documentation and management can be undertaken. It also provides midwives with confidence to care for women who have undergone FGM/C, according to one small US quantitative study of 11 participants (Jacoby and Smith, 2013).
A larger quantitative study, which covered 56 hospitals in Belgium with 820 participants, also found that midwives desire more education and training on FGM/C, and guidelines and policies concerning the management, reporting, recording and safeguarding of FGM/C requires more dissemination (Cappon et al, 2015).
| FGM/C Classification | |
| Type 1 Clitoridectomy | The partial or total removal of the clitoris. This sometimes entails only the prepuce, but this is quite rare. |
| Type 2 Excision | Includes clitoridectomy as well as the labia minora and can also consist of excision of the labia majora. |
| Type 3 Infibulation | The vaginal opening is narrowed by making a seal, which involves cutting, repositioning and stitching the labia minora or labia majora, with or without clitoridectomy. |
| Type 4 Other | Any procedure for non-medical reasons, such as piercing, pricking, incising, scraping and cauterising of the genital area. |
Obstetric outcomes
The physical and psychological effects of FGM/C on a woman’s general health can lead to additional implications in pregnancy and childbirth. FGM/C causes a narrowing of the vaginal opening, which can lead to fistulas, vulva abscesses and menstrual problems that can develop into dysmenorrhea (Daley, 2004).
Problems with infertility and the formation of scar tissue can cause difficulties in pregnancy and labour, explains Rushwan (2013). These issues can cause obstructed labour, postpartum haemorrhage (PPH) and affect the management of the pregnancy, as well as result in issues for the neonate if not managed appropriately (Rushwan, 2013).
A systematic review and meta-analysis undertaken to identify the link between FGM/C and obstetric outcomes recognised that FGM/C has a negative effect on pregnancy and childbirth (Berg and Underland, 2013). It was determined that PPH and obstetric complications were increased for women who had FGM/C. The low methodological quality of the evidence was established; however, there was a marked association between FGM/C and the obstetric implications were clear (Berg and Underland, 2013). It is crucial for midwives to be aware of this when caring for women with FGM/C.
FGM/C and women
FGM/C clinics are a relatively new intervention to provide specialised care: they can offer psychological assessment and treatment, antenatal support and education about the dangers of FGM/C (Holmes et al, 2017).
However, all midwives – regardless of whether they are in a specialised clinic – should be educating women on FGM/C in the UK (RCOG, 2015). Women who have been subjected to FGM/C and reside within the UK may have more complex needs than solely FGM/C (NICE, 2010). Midwives need to be aware of this and assess women holistically using a woman-centred approach to identify needs. The midwife needs to consider language barriers because the women may speak little or no English and interpreter services may be required (NICE, 2010). The midwife should demonstrate sensitivity and empathy and understand that the FGM/C experience may be very traumatic to disclose (Oginni, 2017).
Women may also be reluctant to discuss FGM/C because of embarrassment and stigma (Abdullahi et al, 2009) or if other people are present, such as their partner or family members. Midwives should also be aware that the use of interpreters may become problematic, with the woman not wishing to discuss her experience through them. Hadziabdic et al (2011) explain that interpreters are important for effective communication, although they can cause problems in disclosure of sensitive issues. It is also important that family members are not used in place of professional interpreters, because of confidentiality and ethical issues (NMC, 2015).
Legislation and guidelines for FGM/C
FGM/C has been illegal in the UK since 1985. The original Prohibition of Female Circumcision Act was replaced in 2003 by the Female Genital Mutilation Act, which has also been amended by the Serious Crime Act 2015 (Crown Prosecution Service, 2017). No person has been convicted to date under this legislation (Symon, 2015a).
Berer (2015) argues that the terminology of the legislation can make it difficult to prosecute individuals, and Griffith (2013) acknowledges a poor understanding of the law and general lack of reporting of FGM/C. The overall lack of understanding and appropriate training of FGM/C could be fuelling the shortage of criminal convictions, says one study (Jackson, 2016). It further mentions the importance of education within the communities that practise FGM/C and the role of healthcare professionals in disclosing suspected FGM/C.
All healthcare professionals, as well as teachers and social workers, have a legal duty to report to the police any suspected FGM/C in those girls under the age of 18 (HMSO, 2015). Mandatory reporting allows for essential monitoring of any FGM/C incidents in England and Wales, but this duty may also deter women from seeking advice and support due to more stringent policies (Symon, 2015b).
Eliminating the practice
Midwives may be the first healthcare professionals with whom women have contact and can build a trusting relationship (Gardner, 2012). The Department of Health (2014) provides guidelines on professional responsibilities for each profession with a duty to report FGM/C, including midwives, although this may jeopardise the trust that has been built (Gardner, 2012). Clarke (2015) concurs with the importance of collaborative working to enhance knowledge and assist with the elimination of FGM/C. Guidance on mandatory reporting has been made available (Home Office, 2016) to provide midwives and other professionals with detailed information on suspected FGM/C, how to report and legal duties to act.
Legislation and guidelines are in place to provide information on the management of FGM/C in the UK (Home Office, 2016; Welsh Government, 2016; NMC, 2015; RCOG, 2015; NICE, 2010). These give clear guidance on multidisciplinary working, safeguarding and mandatory reporting of FGM/C. To tackle the perceived lack of guidance and knowledge, online training is available for all NHS staff (E-learning for Healthcare, 2018) and, although not standardised, the NMC (2009) recommends FGM/C is included within midwifery education. With midwives working towards the same standards and guidance, care of women with FGM/C will be knowledgeable and consistent throughout the UK.
The challenge to eradicate FGM/C requires education of the communities that support the custom. The midwife has a role to provide support, and it is imperative that they possess the knowledge and skills to educate women and their families on the negatives of FGM/C and its illegality in the UK. With standardised training on FGM/C and strict adherence to guidelines and policies, midwives are in a strong position to support women to end the practice of FGM/C.
FGM/C: Obstetric consequences
FGM/C leads to an increased risk of complications including:
- Difficult delivery
- Excessive bleeding
- CS
- Newborn death.
It can also cause:
- Fear of childbirth
- Difficulty in intrapartum monitoring (including application of fetal scalp electrodes and fetal blood sampling)
- Difficulty in catheterisation during labour
- Wound infection
- Retention of lochia.
(WHO, 2017; RCOG, 2015)
Jamie Morris is a midwife at Aneurin Bevan University Health Board
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