Female genital mutilation (FGM) is described by the World Health Organization (WHO, 2016) as the partial or total removal of the external genitalia as well as other non-medical injury to this region. FGM is physically and emotionally painful, and can cause an increased risk of both short and long term complications, including excessive bleeding, infections, psychological consequences, painful urination, menstrual and obstetric difficulties, HIV and death. FGM is performed for a range of cultural, religious and social reasons (Molloy, 2014). In countries such as Kenya and Sierra Leone, FGM may be performed as a rite of passage into womanhood, while in Egypt or Sudan FGM can be performed to preserve a girls' virginity (Boseley, 2014). FGM was made illegal in the UK by the Female Circumcision Act 1985, which was followed by the Female Genital Mutilation Act 2003, which made it illegal to arrange for FGM to be performed on UK citizens or residents while they are in another country, whether or not FGM is legal in the destination country.
FGM has been classified by WHO (2016) into four main categories:
The most common form of FGM is Type I (Royal College of Obstetricians and Gynaecologists (RCOG), 2015); however Type III is the most harmful, and involves narrowing the vaginal opening through a covering seal that is formed by cutting and repositioning the labia (Byrne, 2014). It has been estimated that women with Type III have a 70% greater chance of a postpartum haemorrhage than women who have Type I or Type II (Johansen and Bathija, 2008).
There has been an increase in the prevalence of FGM in the UK as a result of increasing numbers of refugees migrating from areas such as Sub-Saharan Africa, Asia and the Middle East (Kern, 2013). This highlights the need for further guidance for midwives and health professionals. This literature review will highlight the issues faced when providing care for women who suffer with FGM, and ways to improve care.
Methodology
The methodology was designed to collate and analyse data from health and social care databases. The databases used for the literature searches were British Nursing Index, Wiley Online Library, Library Search and CINHAL. McMasters' critiquing framework as adapted by Letts et al (2007) was used to complete a critical appraisal of qualitative research articles. The keywords used were ‘female genital mutilation’, ‘female genital cutting’, ‘female circumcision’, ‘midwives’, ‘training’, ‘obstetric’, ‘healthcare’ and ‘awareness’. It was noted that using ‘FGM’ and ‘awareness’ or ‘midwives’ together in an advanced search generated more articles on raising awareness in general and lacked focus on raising awareness for midwives in the health sector. This literature review focused on qualitative results as this enabled an understanding on the underlying reasons, opinions and motivations, as well as helping to provide insight into the issues for further research. The literature was restricted to a 10-year period from 2007 to 2017 in order to provide up-to-date evidence. This search generated 55 sources on raising awareness surrounding FGM. Inclusion criteria were: sources focused on female genital mutilation, in English, published within the years 2007–2017 and restricted to the UK. Publications that were before 2007 and sources that were not focused on raising awareness of FGM for midwives in the UK were excluded. This left seven main sources.
Theme 1: cultural differences
Cultural sensitivity
Cultural sensitivity is the process of being conscious of and sensitive to the existence of cultural similarities and differences (Kubokawa and Ottaway, 2009). Bagness (2015) suggests that midwives in the UK need to develop cultural sensitivity towards women who have undergone FGM. Turner (2007) recommends that cultural sensitivity should be implemented with respect for the woman's beliefs and practices, and additionally suggests that this should include sensitivity during vaginal examinations. In these circumstances, women who may not have experienced examinations previously need a full explanation of the process in an supportive environment (Fisher et al, 2009). As well as this, the multi-agency practice guideline on FGM (HM Government, 2016) states that the memory of FGM can cause anxiety and depression, which may require psychological support.
Cultural differences
Chang (2007) identifies that cultural sensitivity begins with an understanding that there are differences and similarities between cultures in society. In the context of FGM, Zhu (2011) suggests that emphasising that FGM is right or wrong may be challenging when communicating with women who have undergone FGM. In their study, Terry and Harris (2013) found that some women still considered FGM as a positive procedure that they were willing to continue, as this was the norm within their society. This belief can cause issues for midwives who are unfamiliar with this concept, and can create a hostile environment as a result (Terry and Harris, 2013). Moloney and Gair (2015) suggest that instead of blaming midwives for a lack of sensitivity to cultural differences, it is important that midwifery training programmes incorporate the need for both empathy and sympathy when discussing FGM. A study by Ellison (2013); however, found that midwives were failing women, not because they were culturally insensitive, but because they were uneasy about discussing issues with which they felt unfamiliar or uncomfortable. This behaviour contradicts the six C's, which aim to encourage a caring and compassionate attitude.
The law
The Royal College of Midwives (RCM) (2012) report indicated indicated that just 21.2% of midwives were aware that it was illegal for midwives or doctors in the UK to re-suture following birth. In 2012, a doctor was suspended from the medical register for performing re-infibulation after childbirth (Symon, 2015). This case highlighted the complex issues surrounding the management of FGM and the importance of why midwives should understand the relevant laws and safeguarding regulations (Gardner, 2013). As well as this, in a survey of 1756 midwives, a majority were unaware of referral processes for women during the childbirth continuum, although this may not be representative of the wider population of midwives working in the UK (RCM, 2012).
Language barriers
Cambridge (2012) maintains that cultural differences, combined with language barriers may discourage some women from engaging with midwives during appointments. Hussein (2010) examined the perceptions and experiences of a group of eleven women from Bristol and found that while some participants received positive attitudes from midwives, others reported negative comments which left them feeling humiliated and reduced their confidence (Hussein, 2010). Although it was acknowledged that these findings may have only related to a small number of women living within a defined locality and may not be representative of women living elsewhere in the UK (Sauro, 2010), it does nevertheless raise interesting insights in terms of the experience of women from various communities.
Cultural terms of FGM
In an attempt to address the issue of cultural sensitivity and awareness, there are various terms that can be used to describe FGM (HM Government, 2016), but simple language and straightforward questions would appear to facilitate the woman's understanding. Seelinger and Reyes (2013) provide an example of the clear language that may be used and says it may be acceptable to ask, ‘Have you been cut down there?’. Gillespie (2012), however, also urges caution, staing that, for some women, terms such as ‘mutilation’ or ‘circumcision’ may cause offence and result in non-disclosure of information and an unreceptive relationship. Added to these challenges, there are additional concerns when a woman does not speak English and requires the use of an interpreter (RCOG, 2015). The multi agency practice guideline on FGM (HM Government, 2016) identifies that interpreters should be present at all antenatal appointments to help discuss FGM. This is important for the woman, as an interpreter will be able to facilitate a discussion about FGM using terms that are commonly used in the woman's own culture. This may also be problematic, however, as interpreters who are from the same community may be supportive of FGM which may result in non-disclosure from women (Dorkenoo, 2007). Additionally, the presence of a partner or family member at appointments may make conversations related to FGM difficult to discuss (Iavazzo et al, 2013).
Theme 2: midwifery education
Contemporary education within midwifery
Zurynski et al (2015) emphasises that FGM is not universally detailed in core midwifery textbooks or witnessed in clinical practice in many areas. This creates a barrier for student and qualified midwives in both education and clinical practice (Fransen, 2012; Albert, 2015). Zurynski (2015) encourages the importance of training midwives to identify the signs and symptoms of FGM and the complications that can arise during labour, such as haemorrhages and third and fourth degree tears (Rashid and Rashid, 2007). Women who have undergone Type III FGM are more likely to experience long term complications such as keloid scars which can create excess scar tissues (New Zealand FGM Programme, 2017). This can complicate vaginal examinations and can prolong and obstruct labour (Rashid and Rashid, 2007).
Training midwives to recognise FGM
Another key theme to emerge from the literature was the need for adequate midwifery training in the clinical management of women with FGM (Rashid and Rashid, 2007). In some areas of the UK, where there has been an increase in the rate of women with FGM, there has been a corresponding growth in specialist clinics and increased awareness and training for midwives (About FGM, 2011a). However, midwives working in areas where there are fewer women with FGM may lack knowledge about the practice and management of FGM (NHS Digital, 2014).
The RCM report (2012) suggests that midwives were often shocked and horrified at seeing women who had undergone FGM. The National Institute for Health and Care Excellence (NICE) (2008) suggests that if midwives were able to identify FGM early in the antenatal period it would be much easier to manage during the intrapartum period. RCOG guidelines (2015) suggest that this is only possible if midwives are aware of the clinical signs and symptoms of FGM. According to Bagness (2015), identifying FGM in practice can be challenging for midwives who are unfamiliar with the procedure. This is corroborated by Turner (2007), who states that recognising FGM is an important aspect of providing quality care for the women. The HM Multi-Agency Practice Guidelines (2016) recommend that midwives should be able to recognise FGM and refer women to an FGM specialist for support and a care plan, but the RCM (2012) identified that only 15.3% of midwives reported having a training session on FGM. There are certainly gaps in the research and data collection on FGM, stalling the eradication of FGM. The Royal College of Nursing (2015) suggests that training is required to recognise the types of FGM as well as the short and long term effects it can have on women. Training midwives on the management of defibulation is also important (About FGM, 2011b), particularly ensuring that midwives are aware that they should only perform defibulation and not re-infibulation (NICE, 2008). Statistical data from Purchase et al (2013) suggests that 31.1% of midwives were aware that defibulation during pregnancy is recommended at around 20 weeks’ gestation, meaning more than half were unaware of the appropriate time to defibulate. Although there is qualitative data from this literature, it is not possible to make a generalised comment on whether this is a true representative of midwives in the UK. Rashid and Rashid (2007) suggest that there needs to be more education on the types of FGM, which has been supported by the Department of Health's FGM safeguarding pathway (Department of Health, 2017). This will prompt health professionals to consider if a woman has been subjected to FGM, and provides clear instructions on what to do if they believe a woman is at risk.
NHS training: the cost and benefits
Kaplan-Markesan et al's (2009) study suggests that, although more is needed to increase midwives’ knowledge of FGM, there has been a significant rise in the detection of FGM in the UK. Rashid and Rashid (2007) nevertheless suggest that midwives who are unfamiliar with FGM and its different types typically come from areas with lower rates of FGM, as areas where the prevalence is high may have dedicated clinics catered to FGM survivors as well as specialist midwives who are able to facilitate training sessions. Beecham and Curtis (2015) state that training days can be costly for the NHS, and Barr (2017) suggests that training NHS staff can be timely and poorly facilitated. Training days on FGM are imperative and will be worth the costs to the NHS when all health professionals can successfully provide care for women with FGM. Health Education e-learning is a platform that can be accessed to provide training on issues such as domestic violence and female genital mutilation (e-Learning for Healthcare, 2017).
Wider collaboration to end FGM
As well as online training, recognising and celebrating the work of health professionals who support women with FGM helps raise awareness of FGM with midwives and other UK health professionals. The UK Government (2016) and UNICEF (2013) appreciate that eradicating FGM is a collective effort and they are working towards this through organising events such as the Girl Summit 2014, which aimed to end FGM within a generation, and the International Day of Zero Tolerance for Female Genital Mutilation on 6 February, which this year aimed to build ‘a solid and interactive bridge between Africa and the wold to accelerate ending FGM by 2030’ (United Nations, 2017). The elimination of FGM is only possible if effort is made through training by bringing communities across the world to work together.
Discussion
FGM is a controversial topic and midwives should approach discussions with cultural sensitivity (Nzemeke, 2013). By doing this, they are communicating effectively and respecting each woman's individuality (Cao and Lutz, 2013). Oguntoye et al (2009) highlighted the dissatisfaction women faced from midwives who were perceived to be insensitive. As a result, many women shy away from discussing their experience of FGM due to fear of stigmatisation (Odemerho and Baier, 2012). In addition, there is lack of training on the different types of FGM and the management of FGM during labour (Rashid and Rashid, 2007), and as many midwives in areas where the prevalence of FGM is low (Wigmore, 2015), they may be unable to manage and provide basic care for these women. It is therefore important that areas such as these communicate with midwives in areas with higher rates of FGM to gain new knowledge on ways to care for and manage women who attend their maternity services. Research by City University London (Wigmore, 2015) identified that there is no area in England and Wales where there is no FGM, and this means that the Governement should invest in countrywide training and resources, regardless of levels of FGM (Elison, 2013).
Research mainly focuses on explaining FGM and documenting women's experiences of FGM (Bagness, 2015). As much as women's views are important, it is also important to understand the attitudes, knowledge and feelings of midwives who are providing care for these women. The multi agency practice guideline on FGM (HM Government, 2016) offers to educate and inform health professionals on the signs and symptoms of FGM, and to provide support on the legal action to take when FGM has been identified.
Conclusion
Overall, further research is essential to identify midwives' knowledge of FGM in different areas of the UK, which would make it easier for the Government and local departments to collate goals and targets to end FGM. Research is also needed to identify issues relating to midwifery practice in terms of attitudes and cultural sensitivity. Guidelines for safe practice, based on evidence-based research, should be widely available to all health professionals. It is important that health professionals have a good understanding on how to safeguard women and their families, especially women who are bearing female infants. In future, it is important that all health professionals involved in the care of women with FGM continually increase their training, in order to develop a culturally sensitive attitude and to be able to manage complications that may arise from FGM during the childbirth continuum. The eradication of FGM is an ongoing process and it is imperative that midwives work together with other agencies to continuously encourage change in practice through training and the development of cultural sensitive attitudes throughout the child-birth continuum.