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Background Approximately 200 million women and girls were reported to have undergone female genital mutilation worldwide in 2015.UNICEF’s data based on household survey estimates 15% of women from 15–49 years have undergone FGM from year 2004–2015. Despite this, reliable data on trend of prevalence of female genital mutilation and its associated birth outcomes have not been documented in Tanzania. This study aimed at determining the trends of female genital mutilation and associated maternal and neonatal adverse outcomes in northern Tanzania. Methods A cross-sectional study was conducted using maternally-linked data from Kilimanjaro Christian Medical birth registry involving 30,286 women who gave birth to singletons from 2004–2014. The prevalence of female genital mutilation was computed as proportion of women with female genital mutilation yearly over 10 years. Odds ratios with 95% confidence intervals for adverse birth outcomes associated with female genital mutilation were estimated using multivariable logistic regression model. Results Over the 10-year period, the prevalence of female genital mutilation averaged 15.4%. Female genital mutilation decreased from 23.6% in 2005 to 10.6% in 2014. Female genital mutilation was associated with increased odds for caesarean section (aOR1.26; 95% CI: 1.18–1.34), post-partum haemorrhage (aOR 1.31; 95% CI: 1.10–1.57) and long hospital stay (aOR 1.21; 95% CI: 1.14–1.29). Female genital mutilation also increased women’s likelihood of delivering an infant with low Apgar score at 5th minute (aOR 1.60; 95% CI: 1.37–1.89).FGM type III and IV had increased odds of caesarean section, episiotomy and prolonged duration of hospital stay as compared to FGM type I and II, although the association was statistically insignificant. Conclusion Female genital mutilation prevalence has declined over the study period. Our study has demonstrated that postpartum haemorrhage, delivery by caesarean section, long maternal hospital stays and low APGAR score are associated with FGM. Initiatives to mitigate FGM practice should be strengthened further to reduce/eliminate this practice. Moreover, surgical interventions to improve severe form FGM are welcomed to improve the aforementioned aspects of obstetric outcome in this locality.
This was a cross-sectional study which was designed to use maternally-linked data from Kilimanjaro Christian Medical birth registry for women who delivered singletons from 2004–2014 at Kilimanjaro Christian Medical Centre (KCMC). KCMC is a referral and teaching hospital with 1200 inpatients in 630 official beds located in Northern zone of Tanzania, Kilimanjaro region. It serves 4 regions of the Northern Zone-Tanzania including Kilimanjaro, Arusha, Tanga and Manyara. The population of Kilimanjaro region is estimated to be 1,640,087 and at least 6,804,733 in all the four regions [14]. The KCMC medical birth registry has been operating since 2000 with 70,000 deliveries recorded since its inception to December 2019. Maternity care cost at KCMC is provided in subsidised cost. Majority of client are not covered by health insurance pays privately or through a social welfare scheme. In this locality there is no specialised antenatal care for women with FGM. This study enrolled all women who delivered at KCMC hospital between 2004 and 2014. Inclusion criteria included singleton women aged 15–49 years. We excluded multiple gestations, missing records on FGM status, missing records on gestation age at delivery and those with missing records on the mode of delivery. The final sample size was 30,286 women “Fig 1”. Data extraction sheet was used to obtain information on socio-demographic characteristics, obstetric history, FGM status and immediate maternal and foetal complications from the medical birth registry database. The status on FGM was recorded from direct observation by the attending midwife and documented in the partograph during the routine examination in labour and delivery. Trained midwife nurses conduct interviews on a daily basis using a standardized questionnaire of the hospital. Mothers who were admitted were also asked to provide their antenatal cards from which relevant information was abstracted and then all this information is entered in the KCMC medical birth registry database. The primary outcome of interest included caesarean delivery, episiotomy, postpartum haemorrhage (PPH) and prolonged duration of hospital stay. In our study, the latter was defined as staying in hospital for more than 24hours after vaginal delivery and/or for more than 72hours after caesarean delivery. And PPH was defined as bleeding of approximately >500mls after vaginal delivery or/and >1000mls after caesarean section delivery. Other outcomes included, low APGAR score which was defined as a score of less than 7 in the fifth minute of a new born. And early neonatal death which was defined as death of a new born baby, within 24 hours of life. FGM was the main exposure variable in our study which is defined as partial or total removal of external genitalia or other injury to the female genital organs for non-medical reasons. Only women with documented FGM on the birth registry database were selected. According to WHO, FGM is classified in type I, II, III and IV. Type I consists of the removal of the prepuce, with or without the excision of the clitoris Type II consists of the removal of the clitoris with partial or total excision of the labia minora. Type III involves the removal of a part or the whole external genitalia, making a suture of the vaginal canal (also called ‘‘infibulation”). Type IV is unclassified and includes all the procedures modifying normal external genitalia anatomy (e.g., drilling, piercing, cutting, clitoris cauterization, vaginal orifice abrasion) [15]. Other covariates include socio-demographic characteristics such as maternal age, level of education, marital status, occupation, residence, tribe, residency, religion, gestation age at delivery, and parity. Other exposures included complications during pregnancy such as antepartum haemorrhage (APH), which is bleeding between 28 weeks of gestation to delivery. Preeclampsia, gestational diabetes mellitus (GDM), Diabetes type II in pregnancy, anaemia and body mass index (BMI). BMI was categorised into 4; underweight, normal weight, overweight and obese. Data was abstracted from Microsoft access and then sorting, cleaning and checking for consistency and duplicates followed by data analysis using STATA (Version 13.0). Descriptive statistics were summarized using frequency and proportions for categorical variables while mean and standard deviation (SD) were used for numerical. Trend in prevalence of FGM was computed as a proportion of female who underwent FGM practice during the study period. Chi-square test was used to determine the association between FGM and a set of medical conditions in a bivariate analysis. Both crude and adjusted odds ratios and 95% confidence interval for adverse birth outcomes associated with FGM with were estimated using multivariable logistic regression models. A p-value of <0.05 was considered statistically significant. Ethical approval no. 2323 was obtained from the Kilimanjaro Christian Medical University College Research Ethics Committee prior to starting data collection. Permission was sought from the department of Obstetrics and Gynaecology at KCMC Hospital. No informed consent was sought from clients as their consent to store their records in the birth registry allows the analysis and reporting of their anonymous records for research purposes. Access to this information was made available only to the researcher, the assistant and supervisors.
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