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The Daily Champion - August 7, 2006 Lagos - A recent research by the World Health Organisation (WHO) has, once again, debunked the claim that female genital mutilation (FGM), a harmful traditional practice that is still prevalent in many African countries, reduces promiscuity. It also confirms that circumcised complications and risks during childbirth. BONNY AMADI spoke with some of the experts who were part of the research. IMAGINE a situation where two pregnant women on their days of delivery were wheeled into the theatre, and one delivered safely without complication. But for the other woman, no matter how hard she pushed the baby couldn't come. Because she was circumcised when she was young, her vagina becoming inelastic, could not withstand further pressure and so experiences tears and bleeding. However, where this is happening in a rural clinic or clinic not equipped for such emergencies, the woman would just lament and labour to her untimely grave. However, where this is happening in a well equipped hospital, experts say that she would be given a life saving caesarean section in which process, the baby would be brought out dead or alive but in most cases the mother continues bleeding with many pints of blood. The woman having lost enough blood in the process could relapse into coma that even a life saving device may not resuscitate her. The result would then be that she would be wheeled out of the theatre dead. In which case the woman would be joining the league of other women that died as a result of complications during child birth, which recent research by World Health Organisation (WHO) attributed to Female Genital Mutilation (FGM). The research conducted in some African countries including Ghana, Kenya, Burkinafaso, Senegal, Sudan and Nigeria, revealed that women with FGM were more likely to have a caesarean section and post-pastum blood loss of 500 ml greater than women without FGM among other findings. The Nigerian research team involved two principal investigators, Prof Friday E. Okonofua and Dr Mairo Mandara. In the Nigerian centre they were charged by the World Health Organisation (WHO) to determine through verifiable evidence the effect of female genital mutilation (FGM) on obstetric outcome. Dr Mairo Mandara, Consultant to the David and Lucile Packard foundation, California, United States of America and Senior country advisor, population programme, speaking on the scope of FGM, said that over 100 million women across the world including Nigeria have female genital mutilation (FGM) circumcision performed on them. She defined FGM as all procedures that involve partial or total removal of the female external genitalia (clitoris) or injury to the female organs for cultural of any other non-medical reasons. She said that FGM which has five classifications from type 1-5 is still widely practised in Nigeria based on their research findings and those who practice it advance reasons such as, myths around the survival of a baby whose head touches the clitoris during childbirth, reducing sexual desire in females thus curtailing promiscuity, promoting virginity among all other reasons. She said "whatever the reasons, it is absolutely evident today that there is no single benefit derivable from the practice, instead it has very severe consequences". In the same vein, Prof. Friday Okonofua, Executive Director, International Federation of Gynaecology and Obstetrics who presented the result of their research findings recently in Lagos, said: "We found that female genital mutilation (FGM) increase the chances that a woman would have one or more caesarean section during child birth. So that means a woman that has FGM would be more likely to have more caesarean section as compared to a woman without FGM". About excessive bleeding during delivery, Prof Okonofua said, "the second finding is that a woman that has FGM is also more likely to bleed during delivery and therefore more likely to have post partum haemorrhage. As you know this kind of haemorrhage is the commonest cause of death in women during pregnancy. It simply means that circumcised women, because they are more likely to have post partum haemorrhage, may also be more likely to experience these complications during pregnancy. Okonofua also said that in their findings they discovered that women with FGM are more likely to stay longer in the hospital beyond three days after delivery, have still births or lose their baby to death within seven days after delivery as well as have babies with low birth weight. Speaking further on their findings, Prof Okonofua said, "also women who have FGM are found to be more likely to have what is called episiotomy, which is a perennial cut in the vagina as well as tears during delivery. This can also lead to more complications and can make an expectant mother have additional problems during the process of child birth. About the reasons given as to why people still circumcise their girl child even after repeated campaign that it is a deadly practice, Prof Okonofua said: "We have done a thorough study which shows that women who do not have FGM are not promiscuous, our study shows that circumcised and uncircumcised women have the same social feelings and they are also likely to have the same number of social partners, so female genital cutting does not reduce the sociality of women". Prof Okonofua does not agree that circumcision should be medicalise. He believes that medicalising circumscision would amount to legalizing murder", he said. "No! medicalising female genital mutilation will be illegal; the truth is that the World Health Organisation (WHO) had said that FGM should not be medicalised. "In fact at Nigerian Medical and Dental Council, we frown at any doctor who practices FGM, it is not to be medicalised. I am sure that the Midwifery and Nursing Association will also not accept a situation whereby doctors and nurses practice female circumcision. Clearly, there are no moves to medicalise female genital mutilation, because I am a senior officer of the Nigerian Medical Association as well as a senior officer of the society of gynaecology and obstetrics of Nigeria and there are simply no moves whatever to medicalise FGM. In fact it was stated to all doctors and midwives that FGM should not be practised as a medical procedure. So, it is not true that there are moves to medicalise the practice". Dr Mairo Mandara spoke further on the grave consequences of FGM. Speaking with passion, she said "when a woman becomes pregnant and she goes through labour, during labour, because the virgina is no longer elastic due to FGM, then it leads to tearing and therefore there is expected bleeding. "And if she is in a hospital, she needs to have what is called episiotomy, and this has been found to result in some cases, women with FGM having more of caesarean section during child delivery". Complementing what Prof Okonofua said Dr Mandara added: "It also leads to women with FGM having their babies being resuscitated, having tears around virgina" and the implication she said is disastrous. When these medical complications occur in well equipped hospitals, interventionist methods could easily be applied, but when it occurs in the rural settings or ill-equipped city hospitals, it becomes more complicated", said Mairo, adding "the implication for such practice in the rural areas is that a lot of medical centres in the rural areas are not equipped to deal with issues of caesarean section, so you find out that the baby may even die in the uterus because of lack of early intervention". To those who still believe that a woman should be circumcised, Dr Mairo has a word for them: "Most importantly there is no need to cut the female genitalia, ab initio. A lot of female genital cutting is done because it is cultural that women are not promiscuous. It doesn't stop promiscuity, that a woman have had FGM doesn't stop her from sleeping with a lot of men. But what it does is that it dehumanizes her, psychologically these girls when they have this female genital cutting at seven or nine years, they go through a lot of trauma". The process of circumcision which is barbaric, traumatic and dehumanizing compel women to endless tears due to the multiplying damaging effects as enumerated by Dr Mandara "because they are forcefully held down, the target part is cut, they have to bear pain and it mentally affects them for the rest of their lives. Women who have female genital cutting also have pain during sex, this causes mental disharmony because such women do not want to have conjugal relationships with their spouses because of the pain and the trauma. "And that may cause a lot of strain in the marriage and may even lead to divorce particularly in this part of the country. As that was not even enough, it could lead to vesico virginal fistula (VVF) or even set them on premature journey to early grave, she added. "It could also lead to infection, because these things are done by traditional birth attendants in unhygienic situations, so infections could set in and these infections could ascend to later years of development in the young girl, and in the end a young girl just at the age of seven years or even at the age of seven days had her genital cutting, could have an infection that will ascend to her uterus and make her infertile in future. Can you imagine what the women will go through in our own kind of culture because she is infertile. "But she became infertile not because of the sins she committed but because her parents decided to mutilate her as a baby". Commenting on why the various legislations to abolish female circumcisions has not produced the required result, Dr Mandara said "one of the big challenges in Nigeria as a country which doesn't have to deal only with FGM is the fact that legislations are not enforced, advocating the best approach to stop it, she said: "The scrapping of female genital mutilation and a lot of other harmful traditional practices against women has to do with behavioural change. People's behaviour have to change, their values have to change and that is based on information dissemination". Some legislations could even make the practice go underground as experienced in some parts of Africa. "In terms of laws and sanctions, it hasn't worked in other countries, in Egypt for example, when there were sanctions FGM went underground, people do them underground and they were not known. She emphasized on the role of religious bodies to stop the practice, saying that the other partners in this information dissemination are the religious leaders and community leaders, if religious and community leaders are committed to this campaign. They are the custodians of our culture and religion and if they speak against it in the pulpits and in the mosques, people will listen to them, and people will stop doing this. So the key partners in effecting behaviourial change of the communities are the traditional leaders and the faith-based groups. Speaking on the most shocking revelation in their research findings, Dr Mandara revealed, "actually as an obstetrician, what actually shocked me was that there was an increase in caesarean section rate, because caesarean rate is a big concern". How actually did they arrive at that findings? She has an answer, "there are so many things you have to segregate and even after going through all the rigors of scientific segregation of those findings, caesarean section came up tops, I was shocked. "For a country to have increase caesarean section rate is a huge amount of money, you are talking delivering a baby at the cost of N500 - N1000, to increase to something like N20,000, that is significant. Despite the prevalence of circumcision in Nigeria, yet in some parts of Nigeria it is not prevalent while in other parts it is as high as between 65-90 per cent, "I think it is basically culture-based. FGM is the product of the culture of the people. Different cultures approach differently while in some cultures it does not exist. "If you go to southern Kaduna and ask them about FGM, they will be shocked and will ask you to tell them about it, because it is simply non-existent there". Proving answer to the puzzle that if the head of the un-born child touches the mothers clitoris, it will die, she stated. "In some parts of Ekiti, I understand that they do circumcision to save the life of the unborn child, because the myth there is that if the head of the unborn child touches the clitoris it dies. "But as advocates what we need to teach those people is that the clitoris is not touching the head of the unborn child, and I am sure that if you can prove to the very reasonable people that what really kills these babies is not their head touching the clitoris it, is something else and you give them alternative, they will stop it. "What I don't like is being dogmatic about it and telling people that it is in-human and all that. We have to get out side our pride of knowledge based and see from their own end as well as reason from their own end, I am sure that the reasonable set of people among them will understand". "In some cultures you can't get a husband unless you have female genital mutilation done. So it is the culture. Actually religions all over the world has been found to be significantly affected because it is done by both Christians, Muslims and even people of no faith. "Why I mentioned religion is that religion can be used to stop it. It can be used as a tool to stop FGM. I truly believe that certainly in Nigeria even if you are going to do armed robbery, you still ask for God's blessing. As to the extent education has helped to reduce the practice she stated, "tertiary education had significantly reduced in a woman's intent whether or not have FGM on her own children. "In essence what I am saying is that cultural influence affects all women but it is less likely to affect women that have had tertiary education. Women that have tertiary education are less bound by culture and pressure to be able to push to have FGM on their daughter. Speaking on what becomes the faith of traditional birth attendants who earn their living through the preponderance of the practice, she said that they need to be refocused and given alternative means of livelihood, because the bottom line is poverty as it is a crucial issue; "if they earn N500-N1000 per circumcision unless you can give them an alternative means of income that will guarantee them the same income level, they will stick to it. "So these traditional birth attendants should be given other skills, to retrain them and give them micro credits so that can give good quality for themselves so that they can change a little extra which they cannot do as traditional birth attendants. "However, it differs from place to place so each state has to look at the circumstances it finds itself and therefore try to come up with acceptable strategy within their culture, to give these women alternative means of making a commensurable income with other skills." However, Dr Mrs Olusola Odujinrin of World Health Organisation added that women who after gaining the knowledge that FGM is detrimental to the women's life and still goes ahead to perform it on her children, should be sanctioned.

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