Effect of type III female genital mutilation on obstetric outcomes: a systematic review and meta-analysis
Authors: Bonavina Giulia , SPINILLO Silvia Lina , Sotiriadis Alexandros , BULFONI Alessandro , KALTOUD Randa , salvatore stefano , Candiani Massimo , Cavoretto Paolo 
Published: November 2023

Background. Controversial evidence suggests a potential
association between female genital mutilation (FGM/C) and adverse
obstetric outcomes, with type III FGM/C (infibulation) carrying the
greatest risk. Objectives: To assess current rate of adverse
obstetric outcomes in women with type III female genital mutilation and
cutting (FGM/C; infibulation) delivering across different settings
worldwide. Search Strategy. Two authors searched relevant
literature in the PubMed, Scopus, Embase, and ClinicalTrials.gov
databases from inception to Jan 1, 2023, looking for articles reporting
outcomes of women with type III FGM/C compared with women with no FGM/C.
Selection criteria. Studies were selected if they included the
main outcome of postpartum haemorrhage (PPH) or secondary outcomes,
which included major conditions affecting maternal-neonatal health
during labour and delivery. Data Collection and Analysis:
DerSimonian-Laird random effects meta-analysis was performed and pooled
effect estimates with corresponding 95% confidence intervals were
computed. Heterogeneity was assessed using the I
statistic. Meta regression for relevant covariates was performed when
data on relevant confounders were available. The Newcastle-Ottawa scale
(NOS) was used to assess quality of observational studies. The level of
evidence was assessed with the GRADE method. Main Results: 14
observational studies including 15,320 type III FGM/C women and 59,347
controls were eligible. The risk for postpartum haemorrhage was
significantly increased in type III FGM/C, in the main analysis (OR
1.83, 95% CI 1.03 to 3.24, I =93%), in pooling of
data adjusted for confounders (aOR 1.76, CI 1.42 to 2.17, I
= 0%), and in sensitivity analysis of higher quality
studies with NOS≥7 (OR 2.76, CI 1.38 to 5.51, I =
95%). Meta-regression showed that nulliparity was significantly and
positively associated with postpartum haemorrhage. Similarly, analysis
of data adjusted for confounders showed an increased risk of episiotomy
in type III FGM/C (aOR 1.56, CI 1.03 to 2.35, I =
52%). Sensitivity analysis of studies with NOS≥7 revealed a significant
increase for episiotomy (OR 7.53, CI 1.19 to 47.54, I
= 96%), perineal tears (OR 4.24, CI 1.09 to 16.46, I
= 66%), prolonged second stage of labour (OR 5.19,
95% CI 1.00 to 26.85, I = 66%), and Apgar score
less than 7 (OR 4.19, CI 1.64 to 10.70, I = 0%). No
difference was found regarding obstetric anal sphincter injuries and
mode of delivery in these women. Deinfibulation achieved similar
obstetric and neonatal outcomes to women who never had type III FGM. The
overall quality of the studies was adequate (median NOS score: 7; IQR:
6-8), the level of evidence, according to the GRADE assessment, was low.
Conclusions. These results consistently show an increased risk
of adverse obstetric outcomes in women with FGM/C type III. Infibulation
substantially increases the risk for PPH, particularly in nulliparae.