Advancing Sexual and Reproductive Health and Rights
 
International Perspectives on Sexual and Reproductive Health
Volume 36, Number 3, September 2010
DIGEST

Female Genital Mutilation Complications Lead to Lost Lives and High Costs

In an analysis using simulated cohorts of women aged 15–45 from six African nations, the estimated annual cost of treating obstetric complications associated with female genital mutilation was $3.7 million (in international dollars).1 Researchers calculated that the average 15-year-old who undergoes the most severe type of female genital mutilation loses nearly one-fourth of a year of life and generates $5.82 of associated medical costs over her lifetime; the averages for women who undergo any degree of female genital mutilation are 0.07 years lost and $1.71 in costs.

Currently, 100–140 million girls and women are living with female genital mutilation, defined as any procedure that involves the partial or total removal of female genitalia, or as injury to the genitals for nonmedical reasons. These women have an elevated risk of suffering serious health consequences, including pain, bleeding, infection, infertility, susceptibility to STIs, psychological trauma, obstetric complications and perinatal death. This analysis, which estimated the medical costs associated with obstetric complications related to female genital mutilation, was based on a 2006 World Health Organization (WHO) study in which some 28,000 women and their newborns were monitored for adverse health outcomes at obstetric centers in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. Female genital mutilation status was determined by direct examination of external genitalia, using WHO's four-category classification: type 1, excision of the prepuce (with or without partial or total excision of the clitoris); type 2, excision of the clitoris, with partial or total removal of the labia minora; type 3, partial or total excision of the external genitalia, and stitching or narrowing of the vaginal opening; and type 4, unclassified (e.g., piercing or incising the clitoris or labia; this type was excluded from the analysis).

For each of the six nations, data from the WHO study were used to create four simulated cohorts of 100,000 women: one in which no women had female genital mutilation, and three others in which all women had type 1 mutilation, all had type 2 mutilation or all had type 3 mutilation. A woman's risk of experiencing adverse outcomes depended on her mutilation status and her likelihood of receiving medical obstetric care; the survival and birth history of each woman from age 15 to 45 was constructed using the fertility and mortality rates for each country, as well as Demographic and Health Survey data on the proportion of births attended by a physician. Unit costs were calculated for care associated with cesarean section, postpartum hemorrhage, prolonged hospitalization, inpatient perinatal death, infant resuscitation and episiotomy; costs were calculated in international dollars, which adjust for the cost of living in each country. For each type of mutilation, the relative risk for each obstetric outcome was taken from the overall WHO estimates for the six countries. Because women who have undergone female genital mutilation have an increased risk of fatal hemorrhage during childbirth, years of life lost were calculated for each type of mutilation. To make savings from preventing female genital mutilation today equivalent to the present value of future savings, costs and life-years were discounted by 3% per year.

Compared with a hypothetical 15-year-old who underwent no female genital mutilation, one who experienced a type 3 procedure would lose 0.23 years of life and generate $5.82 of associated medical costs over her lifetime. The years of life lost and medical costs were lower for women who underwent types 1 or 2 (0.02 and 0.08 years, and $0.11 and $2.50, respectively); the weighted average for women who experienced any of the three major types was 0.07 years lost and $1.71. The consequences of the procedure varied across countries, depending on rates of fertility and medically attended deliveries. The estimated annual cost of female genital mutilation–related obstetric complications totaled $3.7 million for the 53 million women living in the six countries; national costs ranged from 0.1% to 1% of government health spending on women aged 15–45.

For the current population of 2.8 million 15-year-old females in these countries, the analysis estimated that obstetric hemorrhage associated with the female genital mutilation procedures performed in one year would cause a loss of nearly 130,000 life-years—equivalent to a half month per woman. Multivariate sensitivity analyses confirmed that female genital mutilation imposes an economic burden on these nations' health systems: The proportion of simulations in which female genital mutilation resulted in elevated costs, years of life lost or both was 77%, 85% and 93% for types 1, 2 and 3, respectively.

The researchers note that their study has a number of limitations. First, it did not address the medical complications of the initial procedure—pain, bleeding and infection—or any psychological or psychosexual consequences. Second, the data were collected from a small number of obstetric care centers in each country, and some of the estimated costs may have been paid by patients' families and not by the heath care system. Finally, costs did not include treatment of postdelivery complications for women who delivered at home, and some estimated costs were extrapolations and not specific to each country. Nonetheless, the researchers assert that female genital mutilation "is not only a severe form of discrimination against women, but also a violation of the rights of girls." They believe that "efforts to combat [female genital mutilation] have been traditionally underfunded, but … African health ministries that invest in curbing the practice … are likely to recover a large portion of the investment by saving money from prevented obstetric complications."—J. Thomas

REFERENCE

1. Adam T et al., Estimating the obstetric costs of female genital mutilation in six African countries, Bulletin of the World Health Organization, 2010, 88(4):281–288.