Approximately 63 million girls are likely to be circumcised by 2050 [1], making it a global concern. All surgeries that entail partial or total removal of the external female genitalia for cultural reasons are included in this practise [2]. Female genital mutilation (FGM) is common in 30 African countries, with an estimated three million girls at risk of FGM each year [1, 3]. FGM is prevalent not just in Africa, but also in Asia and other European nations where migrants from FGM-practicing communities reside [2]. FGM is a societal phenomenon in some regions of Africa, linked to social mores and religion, and justified by the preservation of virginity, which is a requirement for marriage, initiation ceremonies, identity, conjugal fidelity, honour, purity, and increased fertility [2, 4, 5]. Many contextual factors, such as highly unequal cultures in which gender prescriptions demand girls' virginity before marriage, have been proven to reinforce FGM. The gender perspective of FGM is also rooted in the socio-cultural norm that emphasises the need for men to control women’s sexuality, prevent promiscuity, ensure premarital virginity, marital fidelity and male sexual satisfaction. This is often being widely considered as a result of patriarchal oppression and the subjugation of women [6].
The World Health Organization (WHO) classifies FGM into four categories: Types 1 and 2, also known as clitoridectomy and excision, respectively, involve the partial or complete removal of the clitoris and labia, while Type 3 involves cutting and repositioning of the labia to create a partial cover and may involve stitching the tissues together (this is the most radical of all the procedures), and finally, Type 4 involves piercing or scraping of the genitalia [3]. According to the 2016 United Nations Children's Fund (UNICEF) report, around 90% of FGM cases include either Types 1 (mainly clitoridectomy), 2 (excision), or 4 (“nicking” without flesh removed), and about 10% (over 8 million women) have gone through Type 3 (infibulation) [1].
According to a 2016 UNICEF report, Types 1 (primarily clitoridectomy), 2 (excision), and 4 (“nicking” without flesh removed) account for around 90% of FGM incidences, while Type 3 (infibulation) accounts for about 10% (about 8 million women) [1]. Infibulation, the most severe form of FGM, is predominantly practised in Djibouti, Eritrea, Ethiopia, Somalia, and Sudan in the North-Eastern area of Africa. The tendency in West Africa (Guinea, Mali, Burkina Faso, and so on) is to remove flesh (clitoridectomy and/or excision) without sewing the labia minora and/or majora together. The high prevalence of infibulation in Africa's North-East area has a negative impact on birthing [2]. High maternal mortality and FGM prevalence have long been critical concerns of public health interest in many countries in sub-Saharan Africa (SSA) [7].
The majority of high-FGM-prevalent nations also have high maternal mortality ratios and high numbers of maternal fatalities, with SSA accounting for approximately 66% of maternal deaths in 2017 [7]. The increased prevalence of maternal mortality and FGM has the opportunity to decelerate the achievement of Sustainable Development Goals 3 and 5 by 2030.
FGM has been shown in numerous studies to be more of a disadvantage than a benefit to mutilated women. It has been linked to a variety of consequences, including extreme pain, haemorrhage, infection, cyst formation, keloids, sexual dysfunction, chronic pelvic infection, obstetric issues, and death [1,2,3, 8, 9]. FGM causes major difficulties during labour, including the need for a caesarean section, an episiotomy, and a protracted hospital stay, as well as post-partum bleeding and maternal fatalities [8,9,10,11]. Scar formation as a result of FGM is one of the ways in which the procedure exposes women to complications after childbirth [8]. These scars cause vaginal stenosis, in which the vaginal walls fail to gradually dilate, putting the baby's and mother's lives at danger of morbidity and mortality [8, 9].
Women who have experienced FGM are much more likely to encounter difficulties during childbirth and their newborns are more likely to die as a result of the procedure, according to studies on FGM and obstetric outcome in SSA [2, 10]. This is especially true for women who have had infibulation since they are more likely to experience protracted and obstructed labour, which can lead to foetal mortality and obstetric fistula [10].
Previous research on FGM and maternal healthcare utilization (antenatal care services) found that in a non-normative community, women who have experienced FGM may find it difficult to socialize with others [12]. It’s possible that this is linked to stigma and discrimination. According to Goffman [13], stigma is a social feature that transforms a person “from a whole and ordinary person to a tainted, devalued one.” As a result, physical differences caused by FGM may expose women who have already undergone it to stigma, relegating them to the status of ‘other’ in the greater social context, potentially preventing them from accessing public spaces. Women who have been subjected to FGM are also more likely to reject negative socio-cultural norms and practices that serve as a barrier to the utilization of maternal healthcare services, such as skilled birth attendance (SBA).
Given the difficulties associated with FGM and childbirth, circumcised women are undeniably at risk of morbidity and mortality during delivery, and this risk is exacerbated for the majority of circumcised women who deliver outside of a hospital or obstetric setting and are supervised by unskilled birth attendants [10]. Regardless, no research has been conducted to determine if women who have experienced FGM are more or less likely to use skilled birth attendants during delivery. This is significant because skilful delivery may safeguard women who have been subjected to FGM during childbirth and lower their odds of dying during the delivery process. In this regard, we examined the association between FGM and SBA in 10 countries in SSA, where data on FGM and other important variables considered in this study are available. This study is based on the hypothesis that women who have undergone FGM will be less likely to utilise the services of skilled birth attendants compared to those who have not undergone FGM.