Midwifery Care for FGM Survivors

Introduction

Female genital mutilation (FGM) is the process in which a female’s genitals are cut with no medical reason (WHO, 2008). This practice is seen in different countries such as Africa, South Asia, and Middle East Asia. In Africa, Nigeria and Somalia are the two places in which the cases of FGM are common. IN the UK, FGM is considered as one of the malpractice s which is strictly banned by the UK government through developing relevant acts such as Female Genital Mutilation Act 2003 and Prohibition of Female Genital Mutilation (Scotland) Act 2005. Under these acts, it would be considered as the offence if there is any arrangement of FGM for British citizen outside the country (Odukogbe et al. 2017). Different aspects are associated with the FGM such as psychosocial, cultural and psychological. Women, who have undergone FGM, suffer from mental health consequences, are more likely to either suffer from vaginal tearing or need an emergency C-section and require a deinfibulation in labour (deBeche-Adams et al. 2010); these issues will be elaborated in the context of current research. In this paper, midwifery care for women who have undergone FGM at different points in their pregnancy will be examined, focusing on antenatal care and looking at the most up-to-date guidelines on FGM. Finally, the paper will conclude with evidence-based analysis of methods of improvement.

Background

The evidence suggests that specialised midwifery care is needed for women with female genital mutilation (FGM) due to the necessity for tailored treatment at every stage of the pregnancy (WHO, 2008). There are four types of FGM: (1) full or partial removal of the clitoris; (2): full or partial removal of the clitoris and labia minora; (3): complete removal of the external genitalia (infibulation) as well as narrowing the vaginal orifice in order to allow the menstruation and urination; (4): any other non-medical practice such as piercing, pricking, and enlarging of the labia (WHO 2008). While all types of FGM could lead to a physical, psychological and psychosocial effect on the woman(Behrendt and Moritz, 2005). The midwifery care specifically focuses on Type 3, otherwise known as infibulation, which leads to the most of the consequences such as psychological harm (Behrendt and Moritz, 2005) and physical complications (Rashid and Rashid, 2007). According to Gale and Rymer (2016), morbidity and mortality of foetus and the mother are significantly increased as a result of FGM. There are a variety of devastating negative effects of FGM on the women who undergo the procedure. The Review: Obstetric Management of Women with Female Genital Mutilation (Rashid and Rashid, 2007) discusses, drawing from a variety of sources the negative effects of FGM on a woman; these include:

Keloid formation which occurs due to a wound healing in an incomplete manner which leads to ‘deposition of excess connective tissue and vulval granulation’ (Rashid and Rashid, 2007)

Rectovaginal fistulae which are defined as ‘abnormal epithelial-lined connections between the rectum and the vagina’(Depeche-Adams and Bohl, 2010) (after prolonged delivery) (Rushwan, 2000)

The Royal College of Obstetricians and Gynecologists released a NICE accredited guide in 2015 that explained the steps they recommend during each of these stages. Based on the research conducted by the researchers in Royal College, women with FGM are highly prone to health complications (Royal College of Obstetricians and Gynaecologists, 2015). Women with FGM have more blood supply into their external and internal genital organs which make the Vul-Val areas mi more vascular than the normal individuals. Based on the guidelines set by the National Health Service (NHS), midwives and the NHS staffs need to make a proper check-up of female genital organs before delivery, medication and treatment process of pregnant women having FGM. Based on the researchers set by World Health Organization (WHO), women with FGM have a severe risk of the Urinary Tract Infection which leads to cause more complication in the delivery process of the pregnant women. Midwifery care for women who have undergone FGM can be separated into three separate sections and they are antenatal screening, labour and postnatal care as detailed within The Royal College of Obstetricians and Gynecologists guide. This paper will only focus on antenatal screening and care.

Antenatal screenings, which occur before birth, and when it comes to women with FGM the midwife should take special care to consider the perinatal mental health of the patient. This will involve processes like history taking, where the FGM will be disclosed and the stage ascertained. It is highly important that at this stage the woman feels comfortable enough with her midwife that she discloses this information. In these aspects the guidelines set by National Health Service, in case of natural birth, midwives play important roles in order to support the pregnant women physically and mentally. In case women with FGM, eh natural birth process is highly complicated and painful, which can lead to their health complication. In this process, midwives provide h emotional and psychological strength to would be a mother for assisting them to hold their hope during the labour pain. Based on the database published by World Health Organisation (WHO), it is seen that, in under developed countries such as Nigeria and Somalia, majority id eth women with FGM die during their childbirth due to lack of proper support and care from the midwives. Moreover, the majority of healthcare staffs and the midwives in these counties have limited knowledge and expertise, therefore cannot provide proper physical and emotional support to the pregnant mothers in order to improve their patients. Another method recommended in the guide is the practice of asking anyone regardless of their background if they have ever undergone FGM. This is to guarantee that any woman who has had FGM is provided with an opportunity to speak about it. In order to ensure all legal proceedings have been adhered to, the antenatal procedures require diligent record keeping within the clinical records, because, this will assist the midwives as well as health professionals to execute the actual health condition of women with FGM before their delivery. Based on the guidelines of National Institute of Clinical Excellence (NICE), antenatal procedures is important for the FGM women in order to make proper health assesses before the delivery process in order to ensure that both the baby and the mothers will be healthy and fit before the delivery. . All of this helps to ensure no woman slips through the net and has access to all of the support offered.

Methods

In this paper, a variety of resources were used, such as Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, SAGE and ScienceDirect which were the main search engines used for this task. Specific keywords searched for were, ‘female genital mutilation’ and‘midwifery’ or ‘midwife guidelines for female genital mutilation’. The Boolean operators chosen were ‘AND’ as there needed to be information both on midwifery guidelines and female genital mutilation. Some searches were limited to the keywords ‘impacts of female genital mutilation’ so a bigger picture could be built. Since a wider search was required to look at National Health guidelines and health trust, National Institute of Clinical Excellence (NICE) were used to find these and the search then resulted in existing midwifery guidelines. When looking for information regarding the background, the paper focused on words such as ‘Health consequences of female genital mutilation’ and ‘pregnancy and female genital mutilation’. Based on the report from UNICEF, nearly 29 countries from the Middle East and Africa have shown the increasing number if cassis of FGM. Egypt is reported to have the highest number of FGM cases which not only affect the health of women in these countries but also increases the overall mortality and morbidity cases in cases in this country. In Africa, Somalia has the highest percentage of the FGM (98%), which leads to the high number of infant mortality and antenatal death of mothers. Based on the report from the World Health Organisation, (WHO), FGM cases are also seen in many parts of UK in spite of UK government have made the laws and acts for banning it strictly. Statistics from NHS England show that 1015 cases of FGM have now been recorded in the UK. Moreover, the UNICEF database shows that 100,000 women in the UK have been reported to suffer from FGM in order to fulfil the cultural and religious aspects.

Literature

Based on the guidelines of National Health Service, midwives need to provide proper physical, emotional and psychological support to the pregnant women having FGM, in order to assist them to have successful pregnancy [NHS, 2019]. Midwives are responsible for consulting proper healthcare assessment for the pregnant women having FGM, in order to detect any kind of health hazards during to pregnancy. Through checking-up genital part of women, midwives make proper health records of the pregnant women in order to assist the health professional to use proper delivery methods in order to have a successful pregnancy and delivery process. The Obstetrician & Gynaecologist released a review on the Obstetric Management of Women with Female Genital Mutilation (Rashid and Rashid, 2007). The limitation of this study was that it was based in the US and therefore may not be entirely applicable to the UK [NHS, 2019]. However, it illustrates the point that midwives ‘assumptions can be harmful to a patient and therefore blanket procedures, such as making sure to ask all patients about FGM helps to eliminate this bias (Momoh, 2017). The Royal College of Midwives released a report entitled Female Genital Mutilation: Report of a survey on midwives’ views and knowledge which discussed some of the major concerns midwives have and why their knowledge of FGM is vital (The Royal College of Midwives, 2012). 70.5% of the midwives working in NHS hospitals and healthcare centres in the UK stated that they did understand the stance of the laws on FGM, however, some of the midwives stated that at some points they dealt with FGM patients with no prior training or guidelines at all. However, more than 15.3% of the midwives working on the NHS hospitals have stated that they did not have any kind of the FGM training and assessment process (UNICEF, 2019). Under the Prohibition of Female Circumcision Act 1985, midwives who are assigned to take care of the pregnant women having cut off their genital part, it is considered as illegal and unethical activities. This type of illegal approaches' is considered as the legal breach under the UK governmental rules and it can ban the license of the hospital as well as the midwives who are associated with their process. In this aspect, Moxey et al. (2016) mentioned that midwives who are associated with taking care of pregnant women having FGM need to highly train in handling FGM cases. In this training process, the midwives are trained about making proper health check-up of the pregnant women having FGM, checking up the condition of genital part of the women and current mental and emotional status of the women before their delivery. This report was an online survey and therefore there could be a bias in those who chose to complete the survey because there is huge bias in the FGM demographics, which leads to missing both qualitative and quantitative responses of the respondents (Varol et al. 2016). During this mixing of the qualitative and quantitative answer researchers need to face severe difficulties in order to get the expected research outcomes. There was a mixture of qualitative and quantitative answers dependent on the question which allowed for quantifiable answers but equally allowed for the midwives to express their thoughts and explain their own ideas.

The need to keep the procedures culturally aware is evidenced in the results of a study by the Northwick Park Hospital (Dawson et al. 2015). This study shows that how pregnant women in Somalia who have FGM, is reported to have received the proper emotional, medical and physical support from midwives. In Northwick Park Hospital, midwives play important roles in order to produce the proper support and care to the women with FGM who are pregnant. Rush wants a paper on the management of FGM details how keloid formation can occur after female genital mutilation. As stated by Moxey et al. (2016), Keloid is formed where the skin is damaged or burn. Keloid is considered as the scars and skin growth at the place in which the skin is the cut. In the case of the female with FGM have the high chances of having keloid in the cut skin within their vagina, which cause severe complication during their pregnancy and intercourse. According to Dawson et al. (2015), in the case of women having FGM has the highest level of chances information of keloid. It is due to increased vascularity that naturally occurs during pregnancy, which leads to the formation of keloid in the cut area. In this aspect, women who have FGM and are pregnancy have to face severe birth complications. In this aspects Moxey et al. (2016) mentioned that, in case of the normal delivery process, women with keloids and FGM have to face severe pain and chances of the blood flow from vagina a the time of birth. From eth UNICEF report it can be stated that in Somalia, more than 32% of the women are died during their delivery process due o the extensive bleeding through their vagina.

On the contrary Dawson et al. 2015 argued that most recent researchers have stated that, sometimes women who do not have any FGM in their early life, have the tendency of keloid formation in heir genital parts. The research described the reason behind this keloid formation is due to increased vascularise and hormonal disbalances. There are many women who gave face severe difficulties in their delivery process due to having keloid. In this aspect Moxey et al. (2016) stated that in the case of the women suffer from different biological disturbances but not the FGM, also can have chances of development of keloid in their genital parts. According to Momoh I2017), The report by the Royal College of Obstetricians and Gynecologists stated that Africa, where FGM is most commonly practised, lacks detailed information as the methodology of the studies is considered ‘patchy’ and since the region has many other factors that could cause maternal and perinatal morbidity it is hard to identify specific reasons and causes. However, a meta-analysis by Berg et. al (2014) showed that FGM led to increased ‘prolonged labour, postpartum haemorrhage and perinatal trauma’ all of which are issues a midwife should be aware of before dealing with a patient who has undergone FGM. Recent researches have shown that women having FGM in their early life have higher chances of suffering from prolonged labour and postpartum haemorrhage. This is because; in most of the cases women having FGM in tier early life have scars, infections and keloids in their cut area. During pregnancy due to the pressure from the baby inside the womb, there can occur bleeding from the cut genital parts. In this aspect, Abdulcadir et al. (2015) mention that in most of the cases general parts that are cut becomes infected which leads to release of heavy blood flow from the vagina during the childbirth.

Recommendations

Overall, there is a clear need for education regarding FGM, as evidenced in the HM Government report. The most pressing part of this report was that 56.8% of the midwives requested further training from the Royal College of Midwives with 64.1% requesting e-learning modules. This shows an urgent need for education that focuses on areas that are lacking, such as the location of specialised resources for FGM patients, education on UK laws and the procedures surrounding FGM.

Hospital trusts sharing the different methods that have succeeded for them could also be a helpful strategy. From the above-mentioned discussion, it can be recommended that hospitals need to take proper strategies for appointing the health executing in each village and urban areas in the country. Through providing proper education and health literacy, healthcare executives will be able to make people understand about the harmful affected of FGM in their health and wellbeing of women. In order to improve the education and knowledge of different culture, it is important for healthcare authority to provide equal facilities and car to the community. Moreover, the healthcare executives and social workers need to develop positive perception and understanding into the people of the different community to make them realise that culture is associated with improving the ability and skill of people but not with posing harmful effect on the health and wellbeing of people.

It can be also recommended that the government need to make strict regulation against the FGM and implement bit in a proper manner. In the hospital and care centres, the knowledge needs to highly-trained in such manner that they can provide proper antenatal support to women having FGM.

Health and social care staffs need to be assigned to develop a positive culture and perception in the community, which will assist people to avoid the practice of FGM in society. In most of the ethnic community, FGM is considered as one of the most important religious rituals. In this aspect, social care staffs need to meet with this community people to change their perspectives about the malpractice of FGM and assist them, to get rid of this practice. Through providing training, awareness program and the health education courses for the community, the government can improve the overall perception of the proper regarding the care process.

Conclusion

In conclusion, the duty of care upon a midwife is important and a vital part of ensuring a mother has adequate antenatal, labour and post-natal care. Since a midwife is the first point of contact for a pregnant woman, regardless of the treatment plan that is chosen for the woman in question, the midwife is responsible for the safety and security of both the woman and child. Now that this has been established, it is essential to educate midwives in handling all of the specific issues relating to FGM and the many ways it may make labour different from a non-FGM patient’s labour. This is vital to create a safe, prepared environment for the woman to have her baby

Reference list:

HM Government, 2016. Multi-agency statutory guidance on female genital mutilation.

Macfarlane, A., Dorkenoo, E., 2015. Prevalence of female genital mutilation in England and Wales: national and local estimates. RCOG Press, London.

NHS Digital, 2018. Female Genital Mutilation (FGM) Enhanced Dataset.

Abdulcadir, J., Rodriguez, M.I. and Say L., 2015. Research gaps in the care of women with female genital mutilation: an analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 122(3), pp.294-303.

Momoh, C., 2017. Female genital mutilation. The Social Context of Birth (pp. 143-158). Routledge.

Moxey, J.M. and Jones, L.L., 2016. A qualitative study exploring how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England. BMJ Open, 6(1), p.e009846.

Dawson, A.J., Turkmani, S., Varol, N., Nanayakkara, S., Sullivan, E. and Homer, C.S.E., 2015. Midwives’ experiences of caring for women with female genital mutilation: insights and ways forward for practice in Australia. Women and Birth, 28(3), pp.207-214.

Varol, N., Dawson, A., Turkmani, S., Hall, J.J., Nanayakkara, S., Jenkins, G., Homer, C.S. and McGeechan, K., 2016. Obstetric outcomes for women with female genital mutilation at an Australian hospital, 2006–2012: a descriptive study. BMC pregnancy and childbirth, 16(1), p.328.