- Email: [email protected]
cutting: An audit of two Australian hospitals
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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Maternity care of women affected by female genital mutilation/ cutting: An audit of two Australian hospitals Heidi K. Shukrallac,* , Paul McGurgana,b a b c
Osborne Park Hospital, Department of Obstetrics and Gynaecology, Osborne Place, Stirling, Perth, WA 6021, Australia King Edward Memorial Hospital, 374 Bagot Road, Subiaco, Perth, WA 6008, Australia Therapeutic Goods Administration, 136 Narrabundah Lane, Symonston, ACT 2609 Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 March 2019 Received in revised form 23 July 2019 Accepted 23 July 2019 Available online xxx
Background: Pregnant women affected by female genital mutilation/cutting are at risk of adverse maternal outcomes compared to unaffected women, and sometimes require procedures to facilitate giving birth that midwives and doctors do not routinely perform. These women require culturally sensitive care. Current health professional literature provides evidence that midwives and doctors need further knowledge and training in this area. Aims: This audit aimed to describe the demographic characteristics of pregnant women with female genital mutilation/cutting giving birth at two Perth maternity units, in addition to assessing health provider compliance with the local female genital mutilation/cutting Clinical Guideline. Materials and methods: The clinical database used by public maternity units in Western Australia was used to identify affected women who gave birth during 2014 at King Edward Memorial Hospital or Osborne Park Hospital. Demographic characteristics and information about antenatal care and maternal outcomes were collected. Results: 53 women fulfilled the audit criteria. Prevalence of pregnant women with female genital mutilation/cutting varied from 0.33% to 2.18% between the two units. Compliance with the Female Genital Mutilation/Cutting Clinical Guideline was generally suboptimal. While no woman was deinfibulated antenatally, 26% of women required intrapartum deinfibulation to give birth. Conclusions: Women with female genital mutilation/cutting make up more than 2% of the antenatal population in some Perth metropolitan maternity units. Health care provider knowledge of, and compliance with, the Female Genital Mutilation/Cutting Clinical Guideline was poor in the two units studied. It appears that healthcare professionals need more education and training to provide affected women with the best care. Crown Copyright © 2019 Published by Elsevier Ltd on behalf of Australian College of Midwives. All rights reserved.
Keywords: Female circumcision Infibulation Pregnancy Female genitalia
Statement of significance
Problem or issue Pregnant women with female genital mutilation/cutting (FGM/ C) are at increased risk of adverse maternity outcomes.
* Corresponding author at: Therapeutic Goods Administration, 136 Narrabundah Lane, Symonston, ACT 2609 Australia E-mail address: [email protected] (H.K. Shukralla).
What is already known Healthcare professionals lack knowledge and awareness about FGM/C. Limited data exists about the prevalence and birth outcomes of women with FGM/C in Australia. What this paper adds Evidence that healthcare professionals’ compliance with a local FGM/C clinical guideline is poor, and demographic data about pregnant women affected by FGM/C in Perth, Western Australia.
http://dx.doi.org/10.1016/j.wombi.2019.07.008 1871-5192/Crown Copyright © 2019 Published by Elsevier Ltd on behalf of Australian College of Midwives. All rights reserved.
Please cite this article in press as: H.K. Shukralla, P. McGurgan, Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.008
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1. Introduction Terminology: in some contexts, the term “mutilation” is thought to be judgemental, and can result in feelings of stigma in affected women. Some groups and organisations prefer to use “cutting” instead – in this article, the term “female genital mutilation/cutting” or “FGM/C” is used to acknowledge both perspectives.1 Female genital mutilation/cutting (FGM/C) currently affects more than 200 million girls and women worldwide, with a further 3 million girls and women at risk of being subjected to the procedure.2 FGM/C, which the World Health Organisation (WHO) defines as “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons”2 is unanimously harmful, and can lead to many short and long term negative medical and psychosocial sequalae. It is practiced in approximately 30 countries in Africa, in addition to India, Indonesia, Israel, Malaysia and the Middle East,3 and is illegal in Australia.4 The rise in international migration and the resulting diaspora communities settling in countries such as Australia means that increasing numbers of women and girls with FGM/C reside and access healthcare in Australia. Accordingly, health care providers need to be trained to provide care to these women and girls in a culturally sensitive manner. In 2016, the WHO developed the Guideline on the Management of Health Complications from FGM – the first principle of the guideline being “Girls and women living with FGM have experienced a harmful practice and should be provided quality health care.”2 Prevalence data from Australia is scarce. A recent report estimates that 53 000 women and girls born elsewhere but now living in Australia have undergone FGM/C.1 Migration to Australia from Sub-Saharan Africa, a region where prevalence rates of FGM/C are generally above 70%, has increased dramatically in the last decade.5 In the same time period, Western Australia (WA) has settled over 173 000 migrants from Africa, indicating that the population of women with FGM/C is likely to be increasing.6 Recent studies describe health caregivers’ lack of awareness and knowledge regarding FGM/C,7–10 including a number from the Australian health professional literature.11–16
Of particular relevance to midwives and obstetricians is the potential for women with FGM/C to suffer complications during childbirth. A multi-country WHO study examined 28 000 women with FGM/C and found that women with FGM/C are significantly more likely to have adverse obstetric and neonatal outcomes.17 Relative risks for caesarean section, post-partum haemorrhage, and stillbirth or early neonatal death increase with each successive type of FGM/C from one to three.17 The purpose of this descriptive study is to provide epidemiological information regarding pregnant women with FGM/C at two maternity hospitals in WA and assess health providers’ compliance with the local FGM/C guideline. 2. Participants, ethics and methods A retrospective chart audit was conducted of all women with FGM/C and singleton pregnancies who gave birth in 2014 at either King Edward Memorial Hospital (KEMH) or Osborne Park Hospital (OPH). KEMH is WA’s public tertiary women’s and newborns hospital, providing comprehensive specialist maternal and neonatal care to approximately 6000 women and their babies per year from across the state. It is one of a small number of hospitals in Australia that has developed a clinical guideline for the care of women with FGM/C.18 The clinical practice guideline, reproduced in Fig. 1, was developed in 2008, and provides guidance to practitioners caring for pregnant women affected by FGM/C in the antenatal, intrapartum and postpartum periods. OPH is a smaller public hospital in Perth’s northern suburbs, providing maternity care to approximately 1600 women with low to moderate risk pregnancies and their babies per year, with a limited number of specialist services available. OPH was included in this audit as its catchment area contains large numbers of culturally and linguistically diverse people and the service provides care in accordance with KEMH guidelines. The 2016 Census found that in the City of Stirling, in which OPH is situated, over one third of the population were born overseas, and about a quarter of the population spoke a language other than English at home.19 Neither site has a specialist clinic for women affected by FGM/C. The maternity care of all pregnant women affected by FGM/C in this
Fig. 1. KEMH FGC/M clinical practice guideline.
Please cite this article in press as: H.K. Shukralla, P. McGurgan, Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.008
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H.K. Shukralla, P. McGurgan / Women and Birth xxx (2019) xxx–xxx Table 1 Classification of types of FGM/C1 Type 1 Type 2 Type 3
Type 4
Partial or total removal of the clitoris (clitoridectomy) and/or the prepuce Partial or total removal of the clitoris and labia minora, with or without excision of the labia majora (excision) Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation) All other procedures to the female genitalia for non-medical purposes, for example: pricking, pulling, piercing, incising, scraping and cauterization.
study was assessed for compliance with each section of the FGM/C clinical guideline.20 The study was approved as an audit by KEMH’s Governance, Evidence, Knowledge, Outcomes (GEKO) committee as well as by the Sir Charles Gardiner Hospital Human Research Ethics Committee. All data was accessed retrospectively and de-identified prior to analysis. StorkTM is the clinical data recording system used by midwives in public hospitals in WA to record information regarding a woman’s pregnancy and birth, with FGM/C status also being recorded. This database is regularly validated and has been previously used in epidemiological studies.21 Eligible women were identified by searching the database for women with a history of FGM/C who gave birth at either hospital during 2014. Medical record review was then undertaken for each of the women identified and selected demographic, obstetric and intrapartum information extracted using an audit proforma. The relevant pieces of information extracted were decided by the obstetric consultant supervising the audit. All analysis was performed in Microsoft Excel. The women’s type of FGM/C was classified according to the WHO guidelines2 and is described in Table 1. 3. Results 3.1. Demographics and FGM/C prevalence and types In the audit period, between January 1st and December 31st 2014, there were a total of 1517 births at OPH, with 33 births (2.18%)
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by women with FGM/C. At KEMH, there were 5977 births in total, with 20 births (0.33%) by women with FGM/C. All of these fifty three cases were audited. A similar number of women had undergone FGM/C types one (30%), two (32%) and three (34%), with only two women (4%) with type four. The majority of women were born in Africa (97%), with one woman born in Malaysia, and one woman born in New Zealand. The median age was 28 years. Twenty six percent (n = 14) of women with FGM/C were recorded as having poor English fluency – of these women, 10 (72%) used an interpreter, 2 (14%) declined an interpreter and the remaining 2 woman’s’ notes did not document whether an interpreter was used or declined. The demographic characteristics of women documented as having FGM/C are summarised in Table 2. 3.2. Antenatal and intrapartum management Review of the medical records of the 53 women identified by the database as being affected by FGM/C demonstrated that 47 women had documented discussions of whether they had undergone FGM/C. It is notable that four (17%) of the women of those questioned regarding their FGM/C history were initially unsure of their FGM/C status. Twenty three percent (n = 12) of women underwent an inspection of their genitalia in the antepartum period, and were then seen by a senior doctor (for the purposes of this audit, a senior doctor was defined as a registrar or a consultant) for a labour, birth and postpartum management plan. Eleven percent (n = 6) of women had a documented discussion regarding the maternal consequences of FGM/C, and 17% (n = 9) of women had a documented discussion describing that FGM/C is illegal in Australia. Only two women (4%) with FGM/C across both hospital sites were referred to the social work department. Compliance with the KEMH FGM guideline is shown in Table 3. Deinfibulation is a surgical procedure undertaken to restore a vaginal introitus that has been closed through type 3 FGM/C.4 An anterior episiotomy is a form of deinfibulation carried out at the time of childbirth to facilitate giving birth. In this audit, no antenatal deinfibulations were carried out; however 9 women
Table 2 Demographic characteristics of women with FGM/C. FGM/C type 1 (n = 16)
FGM/C type 2 (n = 17)
FGM/C type 3 (n = 18)
FGM/C type 4 (n = 2)
Age group 15–19 20–24 25–29 30–34 35–39
n 0 4 8 3 1
(%) (7) (15) (6) (2)
n 2 3 5 3 4
n 3 0 5 8 2
(9) (15) (4)
n (%) 0 0 2 (4) 0 0
Total 5 (10) 7 (13) 20 (37) 14 (27) 7 (13)
Region of birth East Africa Western/Southern Africa North Africa and Middle East Malaysia New Zealand
n 9 1 4 1 1
(%) (17) (2) (7) (2) (2)
n (%) 12 (23) 2 (4) 3 (6) 0 0
n (%) 14 (26) 0 4 (7) 0 0
n (%) 0 0 2 (4) 0 0
35 (66) 3 (6) 13 (24) 1 (2) 1 (2)
Parity 0 1 2 3 4 or more
n 5 8 0 1 2
(%) (9) (15)
n 6 7 2 1 1
n 6 4 7 1 0
(%) (11) (8) (13) (2)
n (%) 0 1 (2) 1 (2) 0 0
17 (31) 20 (37) 10 (19) 3 (6) 3 (6)
Level of spoken English Good Poor
n (%) 14 (26) 2 (4)
n (%) 11 (21) 7 (13)
n (%) 1 (2) 1 (2)
39 (73) 14 (27)
(2) (4)
(%) (4) (6) (9) (6) (7)
(%) (11) (13) (4) (2) (2)
n (%) 13 (24) 4 (8)
(%) (6)
Please cite this article in press as: H.K. Shukralla, P. McGurgan, Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.008
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Table 3 Compliance with FGM/C guideline by hospital site.
Total
Asked about FGM/C antenatally Referred to social work department Genitalia inspected in antepartum period to assess introitus Reviewed by a senior doctor for a management plan Maternal consequences of FGM/C discussed Made aware FGM/C is illegal in Australia
KEMH
OPH
20
33
n
%
n
%
17 0 3 3 0 0
85 0 15 15 0 0
30 2 9 9 6 9
91 6 27 27 18 27
(23%) had been deinfibulated during a previous pregnancy. Of these 9 women, 5 women did not require any further genital surgery to facilitate giving birth, compared to 4 women who required a repeat anterior episiotomy to give birth. Of these 53 women audited in 2014, 8 women (15%) underwent a Caesarean section. 31 (59%) women had a vaginal birth – of these women, 9 remained deinfibulated from an earlier birth. The remaining 14 women (26%) required intrapartum anterior episiotomy to facilitate birth. However, taking into account the women who had previously required deinfibulation, regardless of whether it was required in the audited pregnancy, a total of 43% of women had required deinfibulation or anterior episiotomy to facilitate giving birth (Fig. 2). Five women developed post-partum issues: postpartum haemorrhage (n = 1), vulval haematoma (n = 1), urinary retention (n = 1), urinary incontinence (n = 1) and hypertension (n = 1). 4. Discussion This audit highlights substantial gaps between what local guidelines recommend and what care is being documented as being provided according to the clinical notes – the implication being that suggestion that care for these women is unlikely to be consistent with recommended best practice. The prevalence of women with FGM/C giving birth varied from 0.33% at KEMH to 2.18% at OPH. This variance likely reflects the different case mix each hospital receives, as well as the different geographical location and socioeconomic areas each hospital
services. Two other recent studies of maternity outcomes in women with FGM/C have reported similar prevalence rates. An Australian study published in 2016 investigated 196 women with FGM/C who gave birth at a Sydney hospital between 2006 and 2012, and reported a prevalence of 2–3%.22 The demographic characteristics of the Sydney study group were similar to the women in this study in terms of age and countries of birth. A study from the United Kingdom (UK) published in 2013 examined 197 women who gave birth at a London hospital over a 6 month period in 2009, and reported a prevalence of 2% – other demographic characteristics were not reported.23 Ninety six percent of women in this study were born in Africa, with one notable exception – one woman was born in New Zealand. In the pregnancy and birth database used in this study, data is not collected as to the geographical location where the FGM/C was performed. It is important to note that evidence of FGM/C being performed in the community tends to be anecdotal as the procedures are shrouded in secrecy. Surveyed Australian paediatricians, as well as obstetricians and gynaecologists, have reported anecdotal evidence of FGM/C being performed currently in Australia.15,16 Health providers caring for a woman with FGM/C throughout pregnancy can play a key role in beginning a dialogue about FGM/C provided they are adequately trained to discuss the issue in a culturally respectful and sensitive manner. Many studies have shown that healthcare providers feel they lack the requisite knowledge and skills to appropriately discuss this issue with women.7,8,10–13,16,22–24 We can postulate that this lack of confidence on the health providers’ part is the reason there were so few documented conversations regarding the maternal consequences of FGM/C – none at one site and only 18% at the other site. A recent article has described the rationale for a national, comprehensive, multidisciplinary, evidence based policy response to address the physical and psychological impact of FGM/C on affected women and girls.8 The majority of efforts to address FGM/C have focussed primarily on prevention, with less attention to treating associated complications, caring for women with this condition and engaging health care providers as key stakeholders.9 Documented compliance with the KEMH FGM/C Clinical Guideline was found to be poor in our study, likely reflecting a lack of staff awareness of the guideline, and education and training on FGM/C. Similarly, a UK study audited the maternal care of
Fig. 2. Flowchart illustrating birth outcomes for women with FGM/C.
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women with FGM/C against the Royal College of Obstetricians and Gynaecologists (RCOG) Green Top Guideline and also found compliance to be poor.23 Since then, the UK has implemented an FGM e-learning module for health professionals, as well as creating an FGM Enhanced Dataset, which requires the submission of data about women and girls to the National Health Service (NHS).25 The Western Australian Women’s and Newborns Health Service has an excellent FGM eLearning package available online for midwives, nurses and doctors,26 but completion is not mandatory. The Royal Australian College of Obstetricians and Gynaecologists also provides a continual professional development (CPD) module on FGM/C for obstetricians, gynaecologists and midwives in Australia.27 The availability of these evidence based elearning packages may prove to be useful for education for midwifery and medical staff in Australia. Most (89%) women were asked about a history of FGM/C, but it is vital that all women, regardless of cultural background are asked about genital surgery or FGM/C, as detailed in the Clinical Practice Guideline. Caregivers are generally not given any guidance or training on how to ask such questions in a sensitive and inclusive manner, which may explain why some caregivers avoid asking. It is notable that 17% of women with FGM/C, when asked about their status, were unsure or denied a history of FGM/C, underpinning the importance of health care providers asking the question in a nonjudgemental and sensitive manner. Encouraging the use of interpreters is also fundamental.14 Although 14% of clinical notes documented those women had refused an interpreter it is notable that this means only 72% had an interpreter present to discuss the sensitive issues around the topic of FGM/C. Only 23% of women with disclosed FGM/C were examined before labour or referred to senior doctors. As per the Clinical Practice Guideline, disclosure of a history of FGM/C should result in an antenatal examination (specifically, an inspection of the genitalia) so that there is adequate time to discuss a plan for labour, if the FGM/C is likely to obstruct birth. Referral to the social work department was particularly inadequate – this not only potentially deprives these women of extra social supports, but also denies these women another opportunity to discuss the legalities of FGM/C in the Australian context. The clinical guideline requires referral to the social work department for discussion of the legalities as social workers are usually more familiar with the legal context of FGM/C in Australia and may have more time available to discuss these matters with affected women. This audit identified 43% of women with FGM/C required deinfibulation or anterior episiotomy to assist birth. Surveyed Australian midwives have reported performing such procedures without feeling adequately trained or competent to do so.13 The 2016 Australian study reported that almost all women with type 3 FGM/C required deinfibulation to allow birth,22 indicating that deinfibulation of FGM/C is a procedure that midwives and doctors should be competent at performing. This finding also suggests that some of these women may have benefited from antenatal deinfibulation, which is available at both hospital sites. Evidence has shown that expertise in providing care to women with FGM/C can dramatically increase when health providers have formal education and training provided.7,14,22 The recently developed WHO guidelines on the treatment of complications of FGM/C explicitly describe the responsibilities of health care providers in providing accurate and clear information to women – however the results from this audit clearly show that health care providers are unable to do so due to a lack of knowledge. 4.1. Strengths and limitations The main strength of this audit is that it is the first available data on the number of women with FGM/C giving birth in WA. In addition to providing much needed demographic data, this audit
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also assesses compliance of caregivers with the FGM/C clinical guideline, and provides some information regarding postnatal complications. The relatively small numbers of women with FGM/C (53 women) are a limitation, restricting statistical analysis. 5. Conclusion This audit reveals that documented compliance with the FGM/C clinical guideline is poor. It can be inferred that the care given to this vulnerable population of women could be improved. One strategy is to provide better teaching and training to Australian health care providers on how to provide optimal care to women with FGM/C. Conflict of interests None declared. Ethical statement On 24th November, 2015, the Human Research Ethics Committee Office at Sir Charles Gardiner Hospital, Perth, granted an ethics exemption for this audit. The reference number for this exemption is 10668. CRediT authorship contribution statement Heidi K. Shukralla: Formal analysis, Investigation, Resources, Writing - original draft, Visualization, Project administration. Paul McGurgan: Conceptualization, Methodology, Validation, Writing review & editing, Supervision. Acknowledgements We would like to thank Dr Carol Kaplanian for their support and assistance with this project. The authors alone is responsible for the content and writing of the paper. References 1. Australian Institute of Health and Welfare. Towards estimating the prevalence of female genital mutilation/cutting in Australia. Canberra: AIHW; 2019. 2. Organization. WH. WHO Guidelines on the Management of Health Complications from Female Genital Mutilation. Geneva; 2016. Report No.: 9789241549646. 3. Unicef. Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change. New York: Unicef; 2013. 4. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Female Genital Mutilation (FGM); 2017. 5. Shahid U, Rane A. African, male attitudes on female genital mutilation: an Australian survey. J Obstet Gynaecol 2017;37(8):1053–8. 6. Australian Government Department of Immigration and Citizenship. Settler arrivals 1998–99 to 2008–9 Australia, States and Territories. Canberra: Department of Immigration and Citizenship; 2009. 7. Abdulcadir J, Rodriguez MI, Say L. Research gaps in the care of women with female genital mutilation: an analysis. BJOG 2015;122(3):294–303. 8. Balfour J, Abdulcadir J, Say L, Hindin MJ. Interventions for healthcare providers to improve treatment and prevention of female genital mutilation: a systematic review. BMC Health Serv Res 2016;16(1):409. 9. Khosla R, Banerjee J, Chou D, Say L, Fried ST. Gender equality and human rights approaches to female genital mutilation: a review of international human rights norms and standards. Reprod Health 2017;14(1):59. 10. Zurynski Y, Sureshkumar P, Phu A, Elliott E. Female genital mutilation and cutting: a systematic literature review of health professionals’ knowledge, attitudes and clinical practice. BMC Int Health Hum Rights 2015;15:32. 11. Dawson A, Homer CS, Turkmani S, Black K, Varol N. A systematic review of doctors’ experiences and needs to support the care of women with female genital mutilation. Int J Gynaecol Obstet 2015;131(1):35–40. 12. Dawson A, Turkmani S, Fray S, Nanayakkara S, Varol N, Homer C. Evidence to inform education, training and supportive work environments for midwives involved in the care of women with female genital mutilation: a review of global experience. Midwifery 2015;31(1):229–38.
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H.K. Shukralla, P. McGurgan / Women and Birth xxx (2019) xxx–xxx 13. Dawson AJ, Turkmani S, Varol N, Nanayakkara S, Sullivan E, Homer CS. Midwives’ experiences of caring for women with female genital mutilation: insights and ways forward for practice in Australia. Women Birth 2015;28 (3):207–14. 14. Jordan L, Neophytou K, James C. Improving the health care of women and girls affected by female genital mutilation/cutting. Family Planning Victoria; 2014. 15. Moeed SM, Grover SR. Female genital mutilation/cutting (FGM/C): survey of RANZCOG fellows, diplomates & trainees and FGM/C prevention and education program workers in Australia and New Zealand. Aust N Z J Obstet Gynaecol 2012;52(6):523–7. 16. Sureshkumar P, Zurynski Y, Moloney S, Raman S, Varol N, Elliott EJ. Female genital mutilation: survey of paediatricians’ knowledge, attitudes and practice. Child Abuse Negl 2016;55:1–9. 17. Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006;367(9525):1835–41. 18. Varol N, Hall JJ, Black K, Turkmani S, Dawson A. Evidence-based policy responses to strengthen health, community and legislative systems that care for women in Australia with female genital mutilation/cutting. Reprod Health 2017;14(1):63. 19. Stirling Co. Community Profile Perth 2019. Available from: https://www. communityprofile.com.au/stirling.
20. Women and Newborn Health Service. Clinical practice guideline: female genital cutting/mutilation (FGM/C). Perth: Government of Western Australia, North Metropolitan Health Service; 2019. 21. Newnham JP, White SW, Meharry S, Lee HS, Pedretti MK, Arrese CA, et al. Reducing preterm birth by a statewide multifaceted program: an implementation study. Am J Obstet Gynecol 2017;216(5):434–42. 22. Varol N, Dawson A, Turkmani S, Hall JJ, Nanayakkara S, Jenkins G, et al. Obstetric outcomes for women with female genital mutilation at an Australian hospital, 2006-2012: a descriptive study. BMC Pregnancy Childbirth 2016;16(1):328. 23. Zenner N, Liao LM, Richens Y, Creighton SM. Quality of obstetric and midwifery care for pregnant women who have undergone female genital mutilation. J Obstet Gynaecol 2013;33(5):459–62. 24. Costello S. Female genital mutilation/cutting: risk management and strategies for social workers and health care professionals. Risk Manag Healthc Policy 2015;8:225–33. 25. Dixon S, Agha K, Ali F, El-Hindi L, Kelly B, Locock L, et al. Female genital mutilation in the UK—where are we, where do we go next? Involving communities in setting the research agenda. Res Involv Engagem 2018;4:29. 26. Government of Western Australia. Female genital mutilation (FGM) — a harmful cultural practice e-learning package. 2017. 27. Dawson A, Varol N. Continuing professional education on female genital mutilation for obstetricians, gynecologists, and midwives in Australia: educational program development. Reprod Health 2017;14(115).
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Women and Birth xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Maternity care of women affected by female genital mutilation/ cutting: An audit of two Australian hospitals Heidi K. Shukrallac,* , Paul McGurgana,b a b c
Osborne Park Hospital, Department of Obstetrics and Gynaecology, Osborne Place, Stirling, Perth, WA 6021, Australia King Edward Memorial Hospital, 374 Bagot Road, Subiaco, Perth, WA 6008, Australia Therapeutic Goods Administration, 136 Narrabundah Lane, Symonston, ACT 2609 Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 March 2019 Received in revised form 23 July 2019 Accepted 23 July 2019 Available online xxx
Background: Pregnant women affected by female genital mutilation/cutting are at risk of adverse maternal outcomes compared to unaffected women, and sometimes require procedures to facilitate giving birth that midwives and doctors do not routinely perform. These women require culturally sensitive care. Current health professional literature provides evidence that midwives and doctors need further knowledge and training in this area. Aims: This audit aimed to describe the demographic characteristics of pregnant women with female genital mutilation/cutting giving birth at two Perth maternity units, in addition to assessing health provider compliance with the local female genital mutilation/cutting Clinical Guideline. Materials and methods: The clinical database used by public maternity units in Western Australia was used to identify affected women who gave birth during 2014 at King Edward Memorial Hospital or Osborne Park Hospital. Demographic characteristics and information about antenatal care and maternal outcomes were collected. Results: 53 women fulfilled the audit criteria. Prevalence of pregnant women with female genital mutilation/cutting varied from 0.33% to 2.18% between the two units. Compliance with the Female Genital Mutilation/Cutting Clinical Guideline was generally suboptimal. While no woman was deinfibulated antenatally, 26% of women required intrapartum deinfibulation to give birth. Conclusions: Women with female genital mutilation/cutting make up more than 2% of the antenatal population in some Perth metropolitan maternity units. Health care provider knowledge of, and compliance with, the Female Genital Mutilation/Cutting Clinical Guideline was poor in the two units studied. It appears that healthcare professionals need more education and training to provide affected women with the best care. Crown Copyright © 2019 Published by Elsevier Ltd on behalf of Australian College of Midwives. All rights reserved.
Keywords: Female circumcision Infibulation Pregnancy Female genitalia
Statement of significance
Problem or issue Pregnant women with female genital mutilation/cutting (FGM/ C) are at increased risk of adverse maternity outcomes.
* Corresponding author at: Therapeutic Goods Administration, 136 Narrabundah Lane, Symonston, ACT 2609 Australia E-mail address: [email protected] (H.K. Shukralla).
What is already known Healthcare professionals lack knowledge and awareness about FGM/C. Limited data exists about the prevalence and birth outcomes of women with FGM/C in Australia. What this paper adds Evidence that healthcare professionals’ compliance with a local FGM/C clinical guideline is poor, and demographic data about pregnant women affected by FGM/C in Perth, Western Australia.
http://dx.doi.org/10.1016/j.wombi.2019.07.008 1871-5192/Crown Copyright © 2019 Published by Elsevier Ltd on behalf of Australian College of Midwives. All rights reserved.
Please cite this article in press as: H.K. Shukralla, P. McGurgan, Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.008
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1. Introduction Terminology: in some contexts, the term “mutilation” is thought to be judgemental, and can result in feelings of stigma in affected women. Some groups and organisations prefer to use “cutting” instead – in this article, the term “female genital mutilation/cutting” or “FGM/C” is used to acknowledge both perspectives.1 Female genital mutilation/cutting (FGM/C) currently affects more than 200 million girls and women worldwide, with a further 3 million girls and women at risk of being subjected to the procedure.2 FGM/C, which the World Health Organisation (WHO) defines as “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons”2 is unanimously harmful, and can lead to many short and long term negative medical and psychosocial sequalae. It is practiced in approximately 30 countries in Africa, in addition to India, Indonesia, Israel, Malaysia and the Middle East,3 and is illegal in Australia.4 The rise in international migration and the resulting diaspora communities settling in countries such as Australia means that increasing numbers of women and girls with FGM/C reside and access healthcare in Australia. Accordingly, health care providers need to be trained to provide care to these women and girls in a culturally sensitive manner. In 2016, the WHO developed the Guideline on the Management of Health Complications from FGM – the first principle of the guideline being “Girls and women living with FGM have experienced a harmful practice and should be provided quality health care.”2 Prevalence data from Australia is scarce. A recent report estimates that 53 000 women and girls born elsewhere but now living in Australia have undergone FGM/C.1 Migration to Australia from Sub-Saharan Africa, a region where prevalence rates of FGM/C are generally above 70%, has increased dramatically in the last decade.5 In the same time period, Western Australia (WA) has settled over 173 000 migrants from Africa, indicating that the population of women with FGM/C is likely to be increasing.6 Recent studies describe health caregivers’ lack of awareness and knowledge regarding FGM/C,7–10 including a number from the Australian health professional literature.11–16
Of particular relevance to midwives and obstetricians is the potential for women with FGM/C to suffer complications during childbirth. A multi-country WHO study examined 28 000 women with FGM/C and found that women with FGM/C are significantly more likely to have adverse obstetric and neonatal outcomes.17 Relative risks for caesarean section, post-partum haemorrhage, and stillbirth or early neonatal death increase with each successive type of FGM/C from one to three.17 The purpose of this descriptive study is to provide epidemiological information regarding pregnant women with FGM/C at two maternity hospitals in WA and assess health providers’ compliance with the local FGM/C guideline. 2. Participants, ethics and methods A retrospective chart audit was conducted of all women with FGM/C and singleton pregnancies who gave birth in 2014 at either King Edward Memorial Hospital (KEMH) or Osborne Park Hospital (OPH). KEMH is WA’s public tertiary women’s and newborns hospital, providing comprehensive specialist maternal and neonatal care to approximately 6000 women and their babies per year from across the state. It is one of a small number of hospitals in Australia that has developed a clinical guideline for the care of women with FGM/C.18 The clinical practice guideline, reproduced in Fig. 1, was developed in 2008, and provides guidance to practitioners caring for pregnant women affected by FGM/C in the antenatal, intrapartum and postpartum periods. OPH is a smaller public hospital in Perth’s northern suburbs, providing maternity care to approximately 1600 women with low to moderate risk pregnancies and their babies per year, with a limited number of specialist services available. OPH was included in this audit as its catchment area contains large numbers of culturally and linguistically diverse people and the service provides care in accordance with KEMH guidelines. The 2016 Census found that in the City of Stirling, in which OPH is situated, over one third of the population were born overseas, and about a quarter of the population spoke a language other than English at home.19 Neither site has a specialist clinic for women affected by FGM/C. The maternity care of all pregnant women affected by FGM/C in this
Fig. 1. KEMH FGC/M clinical practice guideline.
Please cite this article in press as: H.K. Shukralla, P. McGurgan, Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.008
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H.K. Shukralla, P. McGurgan / Women and Birth xxx (2019) xxx–xxx Table 1 Classification of types of FGM/C1 Type 1 Type 2 Type 3
Type 4
Partial or total removal of the clitoris (clitoridectomy) and/or the prepuce Partial or total removal of the clitoris and labia minora, with or without excision of the labia majora (excision) Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation) All other procedures to the female genitalia for non-medical purposes, for example: pricking, pulling, piercing, incising, scraping and cauterization.
study was assessed for compliance with each section of the FGM/C clinical guideline.20 The study was approved as an audit by KEMH’s Governance, Evidence, Knowledge, Outcomes (GEKO) committee as well as by the Sir Charles Gardiner Hospital Human Research Ethics Committee. All data was accessed retrospectively and de-identified prior to analysis. StorkTM is the clinical data recording system used by midwives in public hospitals in WA to record information regarding a woman’s pregnancy and birth, with FGM/C status also being recorded. This database is regularly validated and has been previously used in epidemiological studies.21 Eligible women were identified by searching the database for women with a history of FGM/C who gave birth at either hospital during 2014. Medical record review was then undertaken for each of the women identified and selected demographic, obstetric and intrapartum information extracted using an audit proforma. The relevant pieces of information extracted were decided by the obstetric consultant supervising the audit. All analysis was performed in Microsoft Excel. The women’s type of FGM/C was classified according to the WHO guidelines2 and is described in Table 1. 3. Results 3.1. Demographics and FGM/C prevalence and types In the audit period, between January 1st and December 31st 2014, there were a total of 1517 births at OPH, with 33 births (2.18%)
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by women with FGM/C. At KEMH, there were 5977 births in total, with 20 births (0.33%) by women with FGM/C. All of these fifty three cases were audited. A similar number of women had undergone FGM/C types one (30%), two (32%) and three (34%), with only two women (4%) with type four. The majority of women were born in Africa (97%), with one woman born in Malaysia, and one woman born in New Zealand. The median age was 28 years. Twenty six percent (n = 14) of women with FGM/C were recorded as having poor English fluency – of these women, 10 (72%) used an interpreter, 2 (14%) declined an interpreter and the remaining 2 woman’s’ notes did not document whether an interpreter was used or declined. The demographic characteristics of women documented as having FGM/C are summarised in Table 2. 3.2. Antenatal and intrapartum management Review of the medical records of the 53 women identified by the database as being affected by FGM/C demonstrated that 47 women had documented discussions of whether they had undergone FGM/C. It is notable that four (17%) of the women of those questioned regarding their FGM/C history were initially unsure of their FGM/C status. Twenty three percent (n = 12) of women underwent an inspection of their genitalia in the antepartum period, and were then seen by a senior doctor (for the purposes of this audit, a senior doctor was defined as a registrar or a consultant) for a labour, birth and postpartum management plan. Eleven percent (n = 6) of women had a documented discussion regarding the maternal consequences of FGM/C, and 17% (n = 9) of women had a documented discussion describing that FGM/C is illegal in Australia. Only two women (4%) with FGM/C across both hospital sites were referred to the social work department. Compliance with the KEMH FGM guideline is shown in Table 3. Deinfibulation is a surgical procedure undertaken to restore a vaginal introitus that has been closed through type 3 FGM/C.4 An anterior episiotomy is a form of deinfibulation carried out at the time of childbirth to facilitate giving birth. In this audit, no antenatal deinfibulations were carried out; however 9 women
Table 2 Demographic characteristics of women with FGM/C. FGM/C type 1 (n = 16)
FGM/C type 2 (n = 17)
FGM/C type 3 (n = 18)
FGM/C type 4 (n = 2)
Age group 15–19 20–24 25–29 30–34 35–39
n 0 4 8 3 1
(%) (7) (15) (6) (2)
n 2 3 5 3 4
n 3 0 5 8 2
(9) (15) (4)
n (%) 0 0 2 (4) 0 0
Total 5 (10) 7 (13) 20 (37) 14 (27) 7 (13)
Region of birth East Africa Western/Southern Africa North Africa and Middle East Malaysia New Zealand
n 9 1 4 1 1
(%) (17) (2) (7) (2) (2)
n (%) 12 (23) 2 (4) 3 (6) 0 0
n (%) 14 (26) 0 4 (7) 0 0
n (%) 0 0 2 (4) 0 0
35 (66) 3 (6) 13 (24) 1 (2) 1 (2)
Parity 0 1 2 3 4 or more
n 5 8 0 1 2
(%) (9) (15)
n 6 7 2 1 1
n 6 4 7 1 0
(%) (11) (8) (13) (2)
n (%) 0 1 (2) 1 (2) 0 0
17 (31) 20 (37) 10 (19) 3 (6) 3 (6)
Level of spoken English Good Poor
n (%) 14 (26) 2 (4)
n (%) 11 (21) 7 (13)
n (%) 1 (2) 1 (2)
39 (73) 14 (27)
(2) (4)
(%) (4) (6) (9) (6) (7)
(%) (11) (13) (4) (2) (2)
n (%) 13 (24) 4 (8)
(%) (6)
Please cite this article in press as: H.K. Shukralla, P. McGurgan, Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.008
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Table 3 Compliance with FGM/C guideline by hospital site.
Total
Asked about FGM/C antenatally Referred to social work department Genitalia inspected in antepartum period to assess introitus Reviewed by a senior doctor for a management plan Maternal consequences of FGM/C discussed Made aware FGM/C is illegal in Australia
KEMH
OPH
20
33
n
%
n
%
17 0 3 3 0 0
85 0 15 15 0 0
30 2 9 9 6 9
91 6 27 27 18 27
(23%) had been deinfibulated during a previous pregnancy. Of these 9 women, 5 women did not require any further genital surgery to facilitate giving birth, compared to 4 women who required a repeat anterior episiotomy to give birth. Of these 53 women audited in 2014, 8 women (15%) underwent a Caesarean section. 31 (59%) women had a vaginal birth – of these women, 9 remained deinfibulated from an earlier birth. The remaining 14 women (26%) required intrapartum anterior episiotomy to facilitate birth. However, taking into account the women who had previously required deinfibulation, regardless of whether it was required in the audited pregnancy, a total of 43% of women had required deinfibulation or anterior episiotomy to facilitate giving birth (Fig. 2). Five women developed post-partum issues: postpartum haemorrhage (n = 1), vulval haematoma (n = 1), urinary retention (n = 1), urinary incontinence (n = 1) and hypertension (n = 1). 4. Discussion This audit highlights substantial gaps between what local guidelines recommend and what care is being documented as being provided according to the clinical notes – the implication being that suggestion that care for these women is unlikely to be consistent with recommended best practice. The prevalence of women with FGM/C giving birth varied from 0.33% at KEMH to 2.18% at OPH. This variance likely reflects the different case mix each hospital receives, as well as the different geographical location and socioeconomic areas each hospital
services. Two other recent studies of maternity outcomes in women with FGM/C have reported similar prevalence rates. An Australian study published in 2016 investigated 196 women with FGM/C who gave birth at a Sydney hospital between 2006 and 2012, and reported a prevalence of 2–3%.22 The demographic characteristics of the Sydney study group were similar to the women in this study in terms of age and countries of birth. A study from the United Kingdom (UK) published in 2013 examined 197 women who gave birth at a London hospital over a 6 month period in 2009, and reported a prevalence of 2% – other demographic characteristics were not reported.23 Ninety six percent of women in this study were born in Africa, with one notable exception – one woman was born in New Zealand. In the pregnancy and birth database used in this study, data is not collected as to the geographical location where the FGM/C was performed. It is important to note that evidence of FGM/C being performed in the community tends to be anecdotal as the procedures are shrouded in secrecy. Surveyed Australian paediatricians, as well as obstetricians and gynaecologists, have reported anecdotal evidence of FGM/C being performed currently in Australia.15,16 Health providers caring for a woman with FGM/C throughout pregnancy can play a key role in beginning a dialogue about FGM/C provided they are adequately trained to discuss the issue in a culturally respectful and sensitive manner. Many studies have shown that healthcare providers feel they lack the requisite knowledge and skills to appropriately discuss this issue with women.7,8,10–13,16,22–24 We can postulate that this lack of confidence on the health providers’ part is the reason there were so few documented conversations regarding the maternal consequences of FGM/C – none at one site and only 18% at the other site. A recent article has described the rationale for a national, comprehensive, multidisciplinary, evidence based policy response to address the physical and psychological impact of FGM/C on affected women and girls.8 The majority of efforts to address FGM/C have focussed primarily on prevention, with less attention to treating associated complications, caring for women with this condition and engaging health care providers as key stakeholders.9 Documented compliance with the KEMH FGM/C Clinical Guideline was found to be poor in our study, likely reflecting a lack of staff awareness of the guideline, and education and training on FGM/C. Similarly, a UK study audited the maternal care of
Fig. 2. Flowchart illustrating birth outcomes for women with FGM/C.
Please cite this article in press as: H.K. Shukralla, P. McGurgan, Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.008
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women with FGM/C against the Royal College of Obstetricians and Gynaecologists (RCOG) Green Top Guideline and also found compliance to be poor.23 Since then, the UK has implemented an FGM e-learning module for health professionals, as well as creating an FGM Enhanced Dataset, which requires the submission of data about women and girls to the National Health Service (NHS).25 The Western Australian Women’s and Newborns Health Service has an excellent FGM eLearning package available online for midwives, nurses and doctors,26 but completion is not mandatory. The Royal Australian College of Obstetricians and Gynaecologists also provides a continual professional development (CPD) module on FGM/C for obstetricians, gynaecologists and midwives in Australia.27 The availability of these evidence based elearning packages may prove to be useful for education for midwifery and medical staff in Australia. Most (89%) women were asked about a history of FGM/C, but it is vital that all women, regardless of cultural background are asked about genital surgery or FGM/C, as detailed in the Clinical Practice Guideline. Caregivers are generally not given any guidance or training on how to ask such questions in a sensitive and inclusive manner, which may explain why some caregivers avoid asking. It is notable that 17% of women with FGM/C, when asked about their status, were unsure or denied a history of FGM/C, underpinning the importance of health care providers asking the question in a nonjudgemental and sensitive manner. Encouraging the use of interpreters is also fundamental.14 Although 14% of clinical notes documented those women had refused an interpreter it is notable that this means only 72% had an interpreter present to discuss the sensitive issues around the topic of FGM/C. Only 23% of women with disclosed FGM/C were examined before labour or referred to senior doctors. As per the Clinical Practice Guideline, disclosure of a history of FGM/C should result in an antenatal examination (specifically, an inspection of the genitalia) so that there is adequate time to discuss a plan for labour, if the FGM/C is likely to obstruct birth. Referral to the social work department was particularly inadequate – this not only potentially deprives these women of extra social supports, but also denies these women another opportunity to discuss the legalities of FGM/C in the Australian context. The clinical guideline requires referral to the social work department for discussion of the legalities as social workers are usually more familiar with the legal context of FGM/C in Australia and may have more time available to discuss these matters with affected women. This audit identified 43% of women with FGM/C required deinfibulation or anterior episiotomy to assist birth. Surveyed Australian midwives have reported performing such procedures without feeling adequately trained or competent to do so.13 The 2016 Australian study reported that almost all women with type 3 FGM/C required deinfibulation to allow birth,22 indicating that deinfibulation of FGM/C is a procedure that midwives and doctors should be competent at performing. This finding also suggests that some of these women may have benefited from antenatal deinfibulation, which is available at both hospital sites. Evidence has shown that expertise in providing care to women with FGM/C can dramatically increase when health providers have formal education and training provided.7,14,22 The recently developed WHO guidelines on the treatment of complications of FGM/C explicitly describe the responsibilities of health care providers in providing accurate and clear information to women – however the results from this audit clearly show that health care providers are unable to do so due to a lack of knowledge. 4.1. Strengths and limitations The main strength of this audit is that it is the first available data on the number of women with FGM/C giving birth in WA. In addition to providing much needed demographic data, this audit
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also assesses compliance of caregivers with the FGM/C clinical guideline, and provides some information regarding postnatal complications. The relatively small numbers of women with FGM/C (53 women) are a limitation, restricting statistical analysis. 5. Conclusion This audit reveals that documented compliance with the FGM/C clinical guideline is poor. It can be inferred that the care given to this vulnerable population of women could be improved. One strategy is to provide better teaching and training to Australian health care providers on how to provide optimal care to women with FGM/C. Conflict of interests None declared. Ethical statement On 24th November, 2015, the Human Research Ethics Committee Office at Sir Charles Gardiner Hospital, Perth, granted an ethics exemption for this audit. The reference number for this exemption is 10668. CRediT authorship contribution statement Heidi K. Shukralla: Formal analysis, Investigation, Resources, Writing - original draft, Visualization, Project administration. Paul McGurgan: Conceptualization, Methodology, Validation, Writing review & editing, Supervision. Acknowledgements We would like to thank Dr Carol Kaplanian for their support and assistance with this project. The authors alone is responsible for the content and writing of the paper. References 1. Australian Institute of Health and Welfare. Towards estimating the prevalence of female genital mutilation/cutting in Australia. Canberra: AIHW; 2019. 2. Organization. WH. WHO Guidelines on the Management of Health Complications from Female Genital Mutilation. Geneva; 2016. Report No.: 9789241549646. 3. Unicef. Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change. New York: Unicef; 2013. 4. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Female Genital Mutilation (FGM); 2017. 5. Shahid U, Rane A. African, male attitudes on female genital mutilation: an Australian survey. J Obstet Gynaecol 2017;37(8):1053–8. 6. Australian Government Department of Immigration and Citizenship. Settler arrivals 1998–99 to 2008–9 Australia, States and Territories. Canberra: Department of Immigration and Citizenship; 2009. 7. Abdulcadir J, Rodriguez MI, Say L. Research gaps in the care of women with female genital mutilation: an analysis. BJOG 2015;122(3):294–303. 8. Balfour J, Abdulcadir J, Say L, Hindin MJ. Interventions for healthcare providers to improve treatment and prevention of female genital mutilation: a systematic review. BMC Health Serv Res 2016;16(1):409. 9. Khosla R, Banerjee J, Chou D, Say L, Fried ST. Gender equality and human rights approaches to female genital mutilation: a review of international human rights norms and standards. Reprod Health 2017;14(1):59. 10. Zurynski Y, Sureshkumar P, Phu A, Elliott E. Female genital mutilation and cutting: a systematic literature review of health professionals’ knowledge, attitudes and clinical practice. BMC Int Health Hum Rights 2015;15:32. 11. Dawson A, Homer CS, Turkmani S, Black K, Varol N. A systematic review of doctors’ experiences and needs to support the care of women with female genital mutilation. Int J Gynaecol Obstet 2015;131(1):35–40. 12. Dawson A, Turkmani S, Fray S, Nanayakkara S, Varol N, Homer C. Evidence to inform education, training and supportive work environments for midwives involved in the care of women with female genital mutilation: a review of global experience. Midwifery 2015;31(1):229–38.
Please cite this article in press as: H.K. Shukralla, P. McGurgan, Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.008
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H.K. Shukralla, P. McGurgan / Women and Birth xxx (2019) xxx–xxx 13. Dawson AJ, Turkmani S, Varol N, Nanayakkara S, Sullivan E, Homer CS. Midwives’ experiences of caring for women with female genital mutilation: insights and ways forward for practice in Australia. Women Birth 2015;28 (3):207–14. 14. Jordan L, Neophytou K, James C. Improving the health care of women and girls affected by female genital mutilation/cutting. Family Planning Victoria; 2014. 15. Moeed SM, Grover SR. Female genital mutilation/cutting (FGM/C): survey of RANZCOG fellows, diplomates & trainees and FGM/C prevention and education program workers in Australia and New Zealand. Aust N Z J Obstet Gynaecol 2012;52(6):523–7. 16. Sureshkumar P, Zurynski Y, Moloney S, Raman S, Varol N, Elliott EJ. Female genital mutilation: survey of paediatricians’ knowledge, attitudes and practice. Child Abuse Negl 2016;55:1–9. 17. Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006;367(9525):1835–41. 18. Varol N, Hall JJ, Black K, Turkmani S, Dawson A. Evidence-based policy responses to strengthen health, community and legislative systems that care for women in Australia with female genital mutilation/cutting. Reprod Health 2017;14(1):63. 19. Stirling Co. Community Profile Perth 2019. Available from: https://www. communityprofile.com.au/stirling.
20. Women and Newborn Health Service. Clinical practice guideline: female genital cutting/mutilation (FGM/C). Perth: Government of Western Australia, North Metropolitan Health Service; 2019. 21. Newnham JP, White SW, Meharry S, Lee HS, Pedretti MK, Arrese CA, et al. Reducing preterm birth by a statewide multifaceted program: an implementation study. Am J Obstet Gynecol 2017;216(5):434–42. 22. Varol N, Dawson A, Turkmani S, Hall JJ, Nanayakkara S, Jenkins G, et al. Obstetric outcomes for women with female genital mutilation at an Australian hospital, 2006-2012: a descriptive study. BMC Pregnancy Childbirth 2016;16(1):328. 23. Zenner N, Liao LM, Richens Y, Creighton SM. Quality of obstetric and midwifery care for pregnant women who have undergone female genital mutilation. J Obstet Gynaecol 2013;33(5):459–62. 24. Costello S. Female genital mutilation/cutting: risk management and strategies for social workers and health care professionals. Risk Manag Healthc Policy 2015;8:225–33. 25. Dixon S, Agha K, Ali F, El-Hindi L, Kelly B, Locock L, et al. Female genital mutilation in the UK—where are we, where do we go next? Involving communities in setting the research agenda. Res Involv Engagem 2018;4:29. 26. Government of Western Australia. Female genital mutilation (FGM) — a harmful cultural practice e-learning package. 2017. 27. Dawson A, Varol N. Continuing professional education on female genital mutilation for obstetricians, gynecologists, and midwives in Australia: educational program development. Reprod Health 2017;14(115).
Please cite this article in press as: H.K. Shukralla, P. McGurgan, Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.008