Volume 26, Number 1, March 2000
Severity of Genital Cutting Is Linked to Complications Experienced Later in Life
More than nine in 10 women attending selected rural health clinics in Burkina Faso and urban and rural clinics in Mali have experienced some form of genital cutting. According to observational data collected at the clinics, clitoridectomy was the most common form of genital cutting among the women in Burkina Faso, while excision was the type most frequently observed among those in Mali.1 Compared with women who had undergone excision, women who had been infibulated were more likely to have gynecologic or obstetric complications later in life, and those who had undergone clitoridectomy were less likely to experience such difficulties.
Women receiving any service that included a pelvic examination at selected health clinics in Mali and Burkina Faso were invited to participate in a study of complications associated with female genital cutting. Of 1,920 women approached in Burkina Faso and 5,337 in Mali, none refused. Clinic staff trained in female anatomy, the identification and classification of genital cutting, and the possible gynecologic and obstetric consequences of such cutting reported the presence and type of genital cutting (based on World Health Organization guidelines) and any related complications observed during pelvic examinations. The women also provided a birth history and information about their social and demographic characteristics.
The studies in the two countries were conducted separately; thus, the methodology and the samples differed somewhat. The study in Burkina Faso was carried out at 21 rural clinics between April and July 1998; the data from Mali, on the other hand, were collected at four rural and four urban clinics as part of a broader study on female genital cutting conducted between July and September 1998. Clinic staff in Burkina Faso recorded information about signs of genital infection and asked if women had experienced stillbirths, while those in Mali did not. Participants in Burkina Faso were women aged 15-55; as there were no age limits in the Mali study, some data were collected from girls younger than 14, seven of whom were visiting the clinic with immediate complications of genital cutting.
Approximately two-thirds of the women in each sample were between ages 15 and 29 (66% in Burkina Faso, 71% in Mali). All of the women in Burkina Faso and 21% of those in Mali lived in rural areas. The great majority of women in both countries (88-89%) were in a monogamous or polygamous marriage, and more than half were illiterate. About half of the women in each sample were visiting a clinic for prenatal care (57% in Burkina Faso, 49% in Mali); other common reasons for visiting the clinics included delivery, family planning and gynecologic or postnatal care.
Genital cutting was almost universal among the women attending these clinics. Ninety-three percent of those in Burkina Faso and 94% of those in Mali had experienced some type of cutting. In Mali, genital cutting was more common among women in rural areas than among those in urban areas (98% vs. 93%). In Burkina Faso, women aged 35 or older were more likely than those aged 15-24 to have undergone cutting (97% vs. 90%). No difference between age-groups was evident in Mali.
The prevalence of different types of genital cutting varied substantially between the women in the two studies. Clitoridectomy--the partial or total removal of the prepuce or clitoris or both--was the most prevalent type of cutting in Burkina Faso (56%), but had been performed on only 21% of cut women in Mali. In contrast, the proportion of women who had undergone excision--the removal of the clitoris and all or part of the labia minora--was almost twice as great in Mali as in Burkina Faso (74% vs. 39%). Five percent of the women examined in each country had experienced infibulation, a practice in which the vaginal opening is sewn almost completely closed after partial or total removal of the external genitalia.
When the prevalence of types of cutting among women aged 15-24 was compared with that among women aged 35 or older, no differences were found in Burkina Faso. In Mali, the differences were slight: Women in the older age-group were slightly more likely than the younger women to have experienced excision (80% vs. 75%) and slightly less likely to have undergone clitoridectomy (17% vs. 19%) or infibulation (3% vs. 6%).
Fourteen percent of all cut women in Burkina Faso and 5% of those in Mali had at least one gynecologic complication. Among cut women with at least one such complication in Burkina Faso, the most common complications reported were keloid scars (62%) and vaginal narrowing (20%). In Mali, the most common gynecologic complications observed were hemorrhage (52%) and vaginal narrowing (13%).
In a logistic regression analysis, the likelihood that a woman had symptoms of a gynecologic complication was related to the type of cutting she had experienced. Compared with women who had undergone excision, those who had had a clitoridectomy were 29-39% less likely to experience a complication, while infibulated women were 2.4-2.5 times as likely to do so.
In Burkina Faso, cut women were more than twice as likely as other women to report having experienced obstetric complications in prior deliveries (odds ratio, 2.2) and cut Muslim women were less likely to experience complications of cutting than were other women (odds ratios of 0.7 for observed gynecologic complications and 0.7 for reported previous obstetric complications). In Mali, urban women were more likely than rural women to have complications (odds ratios of 1.9 for gynecologic complications and 2.7 for obstetric complications).
Information about obstetric complications differed between the studies. In Mali, complications experienced by the 1,468 women who came to a clinic to give birth were noted by staff. Some 24% experienced difficulties, including 12% who had episiotomies, 6% who had perineal tears, 3% who hemorrhaged and 3% who required a cesarean section. In Burkina Faso, where women were asked about problems they had had with past deliveries, 51% reported a complication--34% an episiotomy, 9% obstructed labor, 5% perineal tears, 1% a cesarean section and 2% other difficulties.
Obstetric complications were associated with the presence of any cutting as well as with types of cutting. Women who had never been cut were less likely than cut women to experience an obstetric complication (odds ratios of 0.3 in Burkina Faso and 0.2 in Mali). Among cut women in Burkina Faso, those who had experienced excision or infibulation were more likely to experience an obstetric complication than were women who had had a clitoridectomy (odds ratios of 1.3 and 2.3, respectively). In Mali, women who had undergone excision were more likely than women who had had a clitoridectomy to have such complications (odds ratio, 1.8).
In Burkina Faso, where providers recorded information about symptoms of possible genital infection, logistic regression analysis showed that cut women were more likely than other women to have vaginal discharge or other symptoms that might signal a genital infection (1.7), but there were no differences in this category according to types of cutting.
The researchers caution that these studies had a number of limitations. It is not known, for example, whether women attending the health clinics were representative of all local women, particularly in rural areas in Mali, where rates of clinic use are low. Data collection on gynecologic complications was limited to women who had experienced genital cutting, which made it impossible to compare cut and uncut women. The training of clinic staff also varied, which the investigators suggest may explain the differences in the prevalence of complications found in rural and urban clinics in Mali. Finally, neither study collected information on other potentially negative consequences of genital cutting, such as effects on a woman's sex life. Nonetheless, the researchers note that "little empirical evidence exists of the relationship between cutting and [gynecologic and obstetric] complications" and conclude that their study provides data on female genital cutting through direct observation that may be of "greater validity than women's self-reports."--M. Moore
1. Jones H et al., Female genital cutting practices in Burkina Faso and Mali and their negative health outcomes, Studies in Family Planning, 1999, 30(3):219-230.