Clinical indications for cesarean delivery among women living with female genital mutilation

Abstract Objective To compare primary indications for cesarean delivery among patients with different female genital mutilation (FGM) status. Methods The present secondary analysis included data from women who underwent trial of labor resulting in cesarean delivery at 28 obstetric centers in six African countries between November 1, 2001, and March 31, 2003. Associations between cesarean delivery indications and FGM status were assessed using descriptive statistics and multivariable multinomial logistic regression. Results Data from 1659 women (480 patients with no type of FGM and 1179 patients with FGM [any type]) were included; cesarean delivery indications were collapsed into five categories (fetal indications, maternal factors, stage 1 arrest, stage 2 arrest, and other). The incidence of a clear medical indication for cesarean delivery did not differ between the groups (P=0.320). Among patients without a clear indication for cesarean delivery, women with FGM were more likely to have undergone cesarean delivery for maternal factors (adjusted relative risk ratio [aRRR] 3.92, 95% confidence interval [CI] 1.3–11.71), stage 1 arrest (aRRR 7.74, 95% CI 1.33–45.07), stage 2 arrest (aRRR 6.63, 95% CI 3.74–11.73), or other factors (aRRR 2.41, 95% CI 1.04–5.60) rather than fetal factors compared with women who had no type of FGM. Conclusion Among women with unclear medical indications, FGM was associated with cesarean delivery being performed for maternal factors or arrest disorders.


| INTRODUCTION
Female genital mutilation (FGM) includes procedures involving partial or total removal of the external female genitalia for non-therapeutic reasons. 1  outcomes. 1 Evidence-based guidance to minimize the health consequences of FGM is essential for healthcare providers. 5 The impact of FGM on obstetric outcomes has been investigated. 2,[6][7][8][9][10] Compared with women without FGM, evidence suggests that women living with FGM have an increased risk of cesarean delivery, postpartum hemorrhage, episiotomy, extended maternal hospital admission, infant resuscitation, and inpatient perinatal death. 8,[11][12][13] The mechanisms of association between FGM and an increased risk for cesarean delivery are unknown, but it has been suggested that this is due to varying amounts of scar tissue. 2,8 Scar tissue can restrict the vaginal opening but can also cause extensive vaginal and vulvar stenosis, resulting in differing degrees of obstructed labor. 2,6,8 Scarring can result from FGM itself, or from prior difficult deliveries.
FGM has been reported to be associated with difficult deliveries and fetal distress, which can also contribute to increased rates of cesarean delivery. 2,14 It is also possible that FGM can limit the ability of providers to conduct pelvic exams to assess the safety and feasibility of alternatives to cesarean delivery, such as operative vaginal delivery (forceps or vacuum) or assisted vaginal delivery of a breech fetus. If providers are unable or unwilling to attempt operative vaginal deliveries or breech vaginal deliveries in women with FGM, this could contribute to increased cesarean delivery rates. 2 It is also possible that providers could have a lower threshold for performing a cesarean delivery in women with FGM owing to concerns about increased risks of complications and lack of evidence to inform clinical decision making. Although several theories exist regarding potential reasons for increased cesarean delivery rates, the indications for cesarean delivery in this population have not been well described or studied previously.
An improved understanding of the reasons for cesarean delivery could help guide obstetric care for women living with FGM, and potentially reduce unnecessary cesarean deliveries. The aim of the present study was to assess whether a clear medical indication was given for cesarean delivery, and to analyze the clinical indications for cesarean delivery based on FGM status. It was hypothesized that any type of FGM would be associated with an increased risk of an unclear medical indication for cesarean delivery.

| MATERIALS AND METHODS
The present study was a secondary analysis of a WHO multicenter prospective cohort study 8  Previous studies 8,15 have reported different maternal and neonatal obstetric outcomes and estimated healthcare system costs. The focus of the present sub-analysis was associations between clinical indications for cesarean delivery and FGM status.
Indications for cesarean deliveries were organized into five categories; maternal factors, fetal indications, labor arrest stage 1, labor arrest stage 2, and other. Arrest stage 1 was defined as arrest of cervical dilation prior to achieving full dilation and arrest stage 2 was defined as failure of vaginal delivery after reaching 10-cm dilation. Indications were then coded by whether the reason given for the cesarean delivery was a commonly report reason for a surgical delivery. 16 If the reviewing obstetricians (M.I.R. and J.A.) understood the indication given, and the reason was an established indication for operative delivery, 16,17 it was coded as "a clear medical indication" for cesarean delivery. Otherwise, the cesarean delivery was coded as an "unclear indication." The classification of indications into the developed categories was reviewed by an independent group of obstetricians not affiliated with the present study.
Box 1 WHO classification of female genital mutilation. Type I: Partial or total removal of the clitoris a and/or the prepuce (clitoridectomy) Type Ia: Removal of the clitoral hood or prepuce only.
Type Ib: Removal of the clitoris a with the prepuce.
Type II: Partial or total removal of the clitoris a and the labia minora, with or without excision of the labia majora (excision) Type IIa: Removal of the labia minora only.
Type IIb: Partial or total removal of the clitoris a and the labia minora.
Type IIc: Partial or total removal of the clitoris a , the labia minora, and the labia majora.
Type III: Narrowing of the vaginal orifice with creation of a covering seal by cutting and apposition the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation) Type IIIa: Removal and apposition of the labia minora.
Type IIIb: Removal and apposition of the labia majora.

Type IV: Unclassified
All other harmful procedures to the female genitalia for nonmedical purposes, for example, pricking, piercing, incising, scraping, and cauterization. a When total removal of the clitoris is reported, it refers to the total removal of the glans of the clitoris.
Descriptive statistics and multinomial logistic regression were used to explore associations between FGM status and indications for cesarean delivery; the data were stratified by whether a clear medical indication for cesarean delivery was provided. Women with any type of FGM were compared with women without FGM using multivariable multinomial logistic regression stratified by whether or not the cesarean delivery was classified as medically necessary. Model covariates included parity, age, urban location, socioeconomic status, and education. Owing to the data being clustered in the six countries, robust standard errors were used to account for clustering. 18 Statistical analyses were conducted using Stata version 14 (Stata Corp LP, College Station, TX, USA) and variables were compared using the χ 2 test and the Student t test, as appropriate.

| RESULTS
The present study included 1659 women, including 480 who had not undergone FGM, and 1179 who had any type of FGM (Table 1). There were a further three patients living with FGM who underwent cesarean delivery but cesarean-indication data were not available for these patients. The level of education and the country of residence differed significantly when stratified by FGM status.
The frequency of verbatim indications given by healthcare providers for cesarean deliveries, how these indications were classified, and whether these were classified as clear medical indications were collated ( Table 2). Indication data were missing for 3 (0.2%) patients. The results of the bivariate and multivariable models were similar so only the multivariable model was included in the present manuscript.

| DISCUSSION
Many studies have described increased cesarean delivery rates among women living with FGM; however, little evidence exists to explain the mechanisms that contribute to these increases. The findings of the present study suggest that among women with an unclear medical indication for cesarean delivery, women living with FGM are significantly more likely to have a cesarean delivery owing to a maternal factor or arrest disorder.
There were limitations to the present study that should be considered when interpreting the findings. The study did not include women who had scheduled cesarean deliveries, only those who had a trial of T A B L E 2 (Continued) T A B L E 2 Indications for cesarean delivery.   demonstrated that some women with FGM delay seeking medical attention until labor is well advanced out of a concern they will be forced to have a cesarean delivery. The present study did not control for the duration of pregnancy among patients who presented for prenatal care or the timing of defibulation, which could also impact the cesarean delivery rate.

Category of indication and specific indication for cesarean delivery
Cesarean delivery is a life-saving intervention for women and neonates when performed for medically indicated reasons. 21 However, it is a major surgery that can be associated with significant morbidity and even mortality. 22 The overall rate of cesarean delivery in the parent study population was low, 6%, 8  The elimination of FGM is a key focus of the sustainable development goal to achieve gender equality and empower for all women and girls. 25 Ending FGM will take a systematic and intense effort at multiple levels and it is essential that effective policies and interventions to eliminate FGM are identified and implemented. Equally important is the need for health evidence and training to minimize the negative health outcomes for girls and women living with FGM. 5  Scant data exist to guide the medical care of these patients. 5 Evidence is needed to guide the medical care of women living with FGM, in particular training for healthcare providers in the specific healthcare needs of this population. Data to help guide patients and healthcare providers in both accepting and offering defibulation could help mitigate the obstetric consequences of FGM.

AUTHOR CONTRIBUTIONS
MIR contributed to the conception of the study and the categorization schema, performed data cleaning, and contributed to writing the manuscript. LS contributed to the conception of the study and writing the manuscript. JA contributed to the development of the categorization schema and writing the manuscript. MJH performed data cleaning, designed and performed the analyses, and contributed to writing the manuscript.