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Obstetric events (prolonged labour, tears/lacerations, caesarean section, episiotomy, instrumental delivery, haemorrhage, difficult labour) were reported in 26 comparative studies (2.97 million women).19 , 24–29 , 33–36 , 38 , 42 , 43 , 48 , 51 , 53 , 56 , 59 , 61 , 66– , 69 , 71 , 72 Seven of these were prospective.24 , 28 , 29 , 43 , 53 , 69 , 70 Eight studies reported adjusted data, with the number and types of confounders varying greatly across studies (detailed in the study under review).28 , 36 , 42 , 43 , 48 , 66 , 68 , 69.
Data on prolonged labour were reported in six studies.28 , 29 , 36 , 48 , 53 , 68 The meta-analysis of adjusted estimates from four studies showed a significantly greater risk of prolonged labour with FGM/C (AOR=1.49, 95% CI 1.01 to 2.19; GRADE: low; figure 4).28 , 36 , 48 , 68 There was one prospective study, of low to moderate methodological quality, that reported an adjusted estimate for prolonged labour, the result of which was concordant with the meta-analysis (AOR=2.40, 95% CI 1.40 to 2.80).28 Regarding obstetric tears/lacerations, the meta-analysis of four studies which presented adjusted data showed an AOR of 1.39 (95% CI 0.99 to 1.95; GRADE: very low; figure 4).42 , 48 , 66 , 68 No prospective studies presented adjusted estimates for obstetric tears.
There were 15 studies with data on caesarean section.24 , 25 , 28 , 29 , 33 , 42 , 48 , 56 , 59 , 66–71 Five studies reported adjusted estimates, the pooled estimate of which resulted in an AOR of 1.32 (95% CI 0.97 to 1.80; GRADE: very low). Restricting the meta-analysis to the two prospective studies established a significant difference between groups (AOR=1.60, 95% CI 1.33 to 1.91; GRADE: low), indicating a greater risk of caesarean section among women with FGM/C (figure 4).28 , 69 As with the other obstetric outcomes, the study-level results were inconsistent regarding episiotomy. Eleven studies reported on episiotomy,19 , 24 , 29 , 33 , 38 , 48 , 53 , 56 , 66 , 69 , 70 but there was only one (retrospective) study with adjusted data.48 The result from the most comprehensive model in this study (ie, adjusting for the highest number of confounders) showed an AOR of 1.18 (95% CI 0.76 to 1.84). No prospective studies presented adjusted estimates for episiotomy, but we aggregated the unadjusted results from five prospective studies (n=32 088 women), finding an increased risk with FGM/C (RR=1.38; 95% CI 1.14 to 1.67; GRADE: very low; figure 3).24 , 29 , 53 , 69 , 70.
There were nine studies with data on instrumental delivery.24 , 25 , 29 , 42 , 53 , 66–68 , 70 Two (registry based) studies reported adjusted data.42 , 68 The meta-analysis for primiparous women suggested a greater risk of instrumental delivery with FGM/C (AOR=1.56, 95% CI 1.32 to 1.86; GRADE: very low), which could not be firmly established for multiparous women (AOR=1.34, 95% CI 0.80 to 2.26; GRADE: very low; figure 4). We also included nine studies with data on obstetric or postpartum haemorrhage.28 , 29 , 38 , 42 , 56 , 66 , 68–70 Five studies reported adjusted results, which we combined in a meta-analysis. The result indicated a greater risk with FGM/C (AOR=1.50, 95% CI 1.22 to 1.84; GRADE: very low). However, the pooled adjusted estimate based on the two prospective studies that reported adjusted data for haemorrhage failed to establish a convincing difference relative to FGM/C (AOR=1.91, 95% CI 0.89 to 4.08; GRADE: very low; figure 4).28 , 69 Lastly, we included six comparative studies with data on difficult delivery.28 , 42 , 43 , 56 , 66 The pooled result based on adjusted estimates from the two studies that could be combined resulted in an AOR of 1.88 (95% CI 1.06 to 3.35; GRADE: low; figure 4).28 , 66 A third study compared women without FGM/C with women who had FGM/C type I. The AORs were 0.17 (95% CI=0.06 to 0.52) and 0.32 (95% CI=0.19 to 0.54), which favoured not having FGM/C.43 There was one prospective study with data on difficult delivery.28 The estimate showed a greater risk with FGM/C (AOR=2.30, 95% CI 1.3 to 2.5).
This systematic review provides clear evidence that FGM/C entails harms to women’s physical health throughout their life, from the moment of cutting as an infant or child, to sexuality and childbirth in adulthood. Predictably, the most common direct, procedure-related complication includes haemorrhage, most likely resulting from laceration of the internal pudendal artery or the clitoral artery. It is difficult to determine the number of females who die from procedure-related complications. Only a few studies reported death, but highly publicised fatalities from FGM/C heighten the awareness of the possible harms posed by the procedure, such as three recent cases in Egypt and Kenya.88–90.
We found several long-term consequences of FGM/C, including increased risks of urinary tract infections, bacterial vaginosis, dyspareunia and obstetric complications. Studies have been published since we conducted our search, and they corroborate our findings.91–98 The identified risks from FGM/C are also supported by biological rationales for the associations. As explained by experts,21 , 54 , 92 any alteration of the natural anatomy of the vulva, such as removal of the protective labia minora, can lead to structural and physiological changes, including trauma to the urethra, adjacent tissues and nerves at the time of the procedure as well as formation of scars and flaps of skin during the healing process.

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