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FGM And Fistula: The Double Tragedies of Women’s Reproductive Health

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To save a girl’s purity before marriage and curb her sexual desire, people in many African countries have practiced female genital mutilation for ages. Today, even with law banning the practice, many still practice this age-long tradition ignorant of its tragic effects on the woman’s health. VICTOR OKEKE writes on this.

“‘Let’s go to the bush and fetch firewood’ — I will remember my mother’s words forever, I was only five years old. Who would have thought that they portend such pain, and this walk will be different from all previous ones. In the forest we were waiting for a woman to undergo the operation. There were two other girls about my age. I remember that everything happened quite quickly. I was simply taken to the bushes, where, without any preliminary procedures, she pierced my clitoris with a needle and just cut it off with an ordinary blade. There were no painkillers other than folk remedies, such as menthol and donkey urine. And there was unbearable pain that lasted for weeks… Mama did not say a word to me, she did not explain anything even after everything healed,” Sarjo Bah, 37.

The above narration by Sarjo Bah as captured by Asha Miles for Bird in Flight is the story of the one-quarter of Nigerian women out of the estimated 115–130 million circumcised in the world.

Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.

The practice is mostly carried out by traditional circumcisers, who often play other central roles in communities, such as attending childbirths. Increasingly, however, FGM is being performed by health care providers.

Medical experts say that the procedure has no health benefits for girls and women rather it presents the risks of severe bleeding, problems in urinating, and later, potential childbirth complications and newborn deaths.

It is mostly carried out on young girls sometime between infancy and age 15 years. In Africa an estimated 92 million girls from 10 years of age and above have undergone FGM.

FGM is recognized internationally and by Nigerian law as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.

According to Dr Obiajulu Nnamuchi of the University of Nigeria Faculty of Law in an article in the Quinnipiac Health Law Journal, “while several human rights are claimed to be imperiled by FGM, there are two that are particularly critical: lack of informed consent and the resulting adverse health consequence.”

FGM is condemned by most governments because of its potentially devastating consequences, both during or directly following the procedure and subsequently, for women’s sexual and reproductive health.

Due to several contributing factors, FGM is commonly found in many of the contexts where obstetric fistula is also prevalent. FGM can lead to serious difficulties during childbirth. With significant risks of hemorrhage (bleeding) for the mother, FGM can also lead to the increased risk of death or the need for resuscitation of the newborn.

“When I got married, my husband and I did not get intimate on our wedding night. As it turned out, I was not only circumcised, but also sewn up. It was necessary to pass all this nightmare anew, to go to the sorcerer after the procedure of ‘embedding’. Needless to say, after all this, to experience any kind of sexual pleasure is very difficult for me. In addition, I needed a Caesarean section to give birth to my Child,” Fatou Bah, 31, a victim of FGM said.

According to studies conducted by the United Nations Population Fund (UNFPA) and partners evidence shows that while some types of FGM do not contribute to the development of obstetric fistula, the radical form, also called infibulation (the stitching up of the vagina), may prolong the expulsion phase during delivery, especially if significant scarring is present.

However, there is insufficient evidence to conclusively show that it contributes to obstructed labour or obstetric fistula. But it known is that a woman with radical FGM is at increased risk of traumatic fistula from having her genitalia cut open during labour, to allow the birth of the baby.

Fistula in itself is one of the most devastating injuries of child birth.  It occurs mainly as a result of prolonged obstructed labour, without timely medical intervention – such as a caesarean section. The sustained pressure of the baby’s head on the mother’s pelvic bone causes damage of soft tissues creating a hole – or fistula – between the vagina and the bladder and/or rectum.

This means that, the wall of the birth canal gets compressed by the baby’s head during an obstructed labour. The pressure causes blood to stop flowing, and the tissue dies. The vagina then leaks urine and/or faeces.

The result is continuous leaking of urine and feaces.  When this occurs, a woman has no control of this unnatural phenomenon and if not assisted may suffer isolation, social stigma, neglect and humiliation.

However, obstetric fistula is preventable and can largely be avoided by delaying the age of first pregnancy, the cessation of harmful traditional practices like FGM; and timely access to obstetric care.

According to EngenderHealth Nigeria Country Project Manager for the USAID-funded Fistula Care Plus (FC+) project, Chief Iyeme Efem, fistula is one of the most devastating consequences of neglected childbirth.

Through the Fistula Care Plus project, the largest U.S. government-funded effort to-date dedicated to treating and preventing fistula, EngenderHealth works to restore dignity to women with fistula and to prevent other women from developing the condition.

The Fistula Care project covers the costs of treatment, equipment, and supplies. It also supports training for providers in fistula repair, nursing, counseling, and quality improvement.

According to Dr Abiodun Amodu, a ‎Clinical Associate with ‎EngenderHealth Nigeria, FGM is one of the direct non-obstetrical causes of fistula.

Traditionally, very elderly women who have no appreciation of the dangers of infection from unsterilised instruments used including knifes, scissors, razors and pieces of glass, perform the circumcision.

However, people are increasingly turning to healthcare providers to perform the procedure in the hope that it will reduce the risk of complications.

Recent analysis from WHO shows that more than 18 per cent of all girls and women who have been subjected to FGM in the countries from which data is available have had the procedure performed on them by a healthcare provider. There are large variations between countries regarding health provider involvement – less than one per cent in several countries to between nine per cent and 74 per cent in six countries.

“Medicalisation gives the misleading impression that the procedure is good for health or that it is harmless. As an unfortunate consequence of this, some providers may develop a professional and financial interest in continuing the practice.”

“It must be stated that the performance of FGM by healthcare providers is a harmful practice and a violation of human rights,” Dr Amodu said.

Indeed, several studies show increases in obstetric complications—mainly perineal lacerations and/or stillbirths–among women who have undergone genital cutting operations.

The WHO in 2006 completed a prospective study of delivery outcomes among 28,393 women with singleton pregnancies attending for delivery at 28 obstetric centers in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan according to the presence of absence and type of genital cutting present.

This study concluded that adverse outcomes increased according to the severity of the genital cutting with significant increases in the risk for cesarean section, postpartum hemorrhage, episiotomy, extended maternal hospital stay, and the need for infant resuscitation at delivery.

According to data from Dr Andrew Browning and Dr Jennifer Allsworth of the Department of Obstetrics and Gynaecology, Washington University School of Medicine in a 2010 study on “The Relationship Between Female Genital Cutting and Obstetric Fistulas” and published in the Journal of  Obstetrics and gynecology, “although there is no clear mechanical association between Type I and Type II female genital cutting and obstetric fistula formation from obstructed labour, it is very clear that obstetric fistulas are prevalent in culture-areas where genital cutting practices are also common.”

“Rather than being a cause of obstructed labour, we believe that female genital cutting is a marker for the presence of other important risk factors that combine to promote obstetric fistulas,” the researchers said.

Fistulas are found where the socio-economic status of women is low, where early marriage is common and pregnancy occurs before pelvic growth is complete, where women’s personal autonomy is highly restricted, where contraceptive choice is limited or non-existent and fertility is high, where women are largely uneducated and have little political power, where transportation is difficult and the medical infrastructure is inadequately developed so that timely access to emergency obstetric services is poor and those services are often of marginal quality.

Together, these factors combine to produce high levels of maternal mortality and obstetric morbidity, of which the obstetric fistula is a common and tragic component. It should not be surprising that female genital cutting is commonly found within this same social milieu.

Apart from these findings, fistula experts like Professor Orji Ernest, the Head, Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospital, Ile Ife and Dr Abiodun Amodu agree that infibulated women- type lll FGM- belong to a high-risk group for chronic infections of the pelvis. FGM and occlusion of the vagina and urinary canal increase the likelihood of infection, diminishing the effectiveness of natural mechanisms of protection.

At times, after FGM, the vaginal opening may be so small – conception may even occur without penetration – that in the event of a miscarriage the foetus may be retained inside. This can give rise to serious infection.

At the time of delivery, fear or obstruction (if the scar fails to dilate, for example) may cause delay and a prolonged second state of labour. In turn, fatigue from protracted labour may induce uterine inertia i.e. labour may be interrupted by exhaustion.

Obstructed labour may be dangerous to mother and child: the mother may suffer lacerations or tears and the formation of fistulae; the baby may suffer brain damage as the result of an insufficiency of oxygen (anoxia). Death for both is possible.

As a consequence of decircumcision a woman may suffer additional loss of blood, injury to surrounding parts, fistulae, uterine prolapse, and infection. Recircumcision, a common operation after decircumcision, is replete with all the hazards of initial FGM. Repetition of de- and recircumcision may weaken scar tissue exceedingly.

According to Dr Amodu, for a woman who has been infibulated, first coitus is invariably a difficult process; it may be very painful and require long and repeated efforts before penetration succeeds. Tissue may be torn or cut with some instruments with the danger of serious injury, infection, and, in extreme cases, death.

“Even later intercourse may be painful (dyspareunia). Dissatisfaction with vaginal intercourse may prompt anal penetration. Removal of sensitive organs at the time of FGM may destroy the woman’s capacity to experience orgasm.” he added.

Here, the testimony of one of the victims of FGM is apt, “I am sure that there is nothing good in the procedure of female circumcision. Loss of blood, infection, pain, and sometimes death. Today female circumcision is illegal, but the procedure continues to be conducted secretly. Sometimes there are rumors that someone here and there cut a baby in the toilet. I want it to stop.”

 




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