Our analysis retrospectively assessed the number of women from a country where FGM/C is practiced giving birth in our region. In 10-year period 539 women from high-risk countries delivered at our center and among them, 17 (3.2%) cases of FGM/C were documented. This was significantly less than what was expected based on prevalence estimates (n = 208; 38,6%). Our results suggest most FGM/C cases are not diagnosed and/or documented. Lack of awareness and incorrect documentation have been described in other studies undertaken in Europe and worldwide [36,37,38,39,40].
A recent study from Switzerland looked at female patients from one of the 30 countries in which FGM/C is practiced hospitalized from 2016 to 2018. FGM/C was coded in 2.3% of cases. However, using indirect estimation methods an FGM/C prevalence of 57% was expected. Thus, in about 96% of patients estimated to be affected by FGM/C, the condition was not adequately identified, documented, and/or coded , which is consistent with our findings. Knowledge gaps among health workers regarding the prevalence, diagnosis, and management of FGM/C, especially in high-income countries are well documented [36, 37, 42,43,44,45,46,47,48].
Although the lack of awareness among health workers seems to play a major role in under-recording of FGM/C, other factors may be responsible for a drastic difference in estimated and actual numbers of detected FGM/C cases. Firstly, the extrapolation from the estimated FGM/C prevalence published by UNICEF does probably not reflect the reality in the population of migrant women living in Austria. Support for the FGM/C practice among migrants from FGM/C practicing countries coming to regions with low or no FGM/C prevalence may decrease, especially after residing in a country where FGM/C is illegal for a longer period of time. Furthermore, migrants who are not supportive of the practice may be more likely to migrate to a non-practicing country [41, 49, 50]. Studies suggest that immigrants tend to be younger and more educated, thus more likely to understand the consequences of FGM/C . This selective migration likely contributes to the difference between expected and actual detected numbers of FGM/C.
Secondly, the appearance after FGM/C varies greatly with parity, age, and type of practice. FGM/C might be clinically difficult to recognize even when health workers are aware of the risk .
Increase in the number of deliveries between 1.7.2015–31.12.2020 when compared to the time period between 1.1.2010–30.6.2015 was documented by women from 5 out of 10 countries with the highest FGM/C prevalence rates. These are Somalia (with FGM/C prevalence of 98%), Sudan (87%), Sierra Leone (86%), Eritrea (83%), and Gambia (76%). Given the high prevalence of FGM/C among women coming from these countries, obstetric personnel should be especially vigilant for possible female genital mutilation among this collective.
Although no significant increase in overall deliveries by women coming from FGM/C practicing countries could be demonstrated, it can be expected that the number of births by women with FGM/C will increase across Europe and thus also in Austria and Graz. This assumption is confirmed by a demographic forecast which predicts that the EU28 countries will welcome about 1.3 million migrant women from FGM/C practicing countries between 2016 and 2030. About one-third of these migrant women are expected to have already been affected by FGM/C prior to immigration .
Expected increases may expose healthcare professionals to health risks of FGM/C, defined by WHO . Poor communication between affected women and healthcare workers, cultural differences, language barrier, lack of training and fear of consultation need to be addressed.
Language barriers make it difficult for women to understand treatment protocols and health information or making shared decisions . Our data reveals that in 17% (n = 146) of 856 deliveries an existing language barrier was explicitly noted. The WHO guidelines for treating women with FGM/C state that in case of a language barrier an official interpreter should be consulted . Interpreters should be qualified and preferably female, not a family member or a friend of the affected person, and, in the best case scenario, familiar with FGM/C . In everyday practice and especially in a busy labor ward situation, however, this is often not practicable. This illustrates once more the need for specialized consultation-hours where best possible counseling and treatment can be offered beforehand. There, affected women can receive interdisciplinary care with psychologists, interpreters and trained health professionals working together.
Sociocultural differences complicate healthcare for women with FGM/C further. Some girls and women feel shame and anger when they were labeled as “different” and “mutilated” by host country health workers and felt culturally misunderstood. This may lead to concealment and feeling extremely uncomfortable during medical examinations. Open communication and mutual understanding between those affected and the healthcare personnel treating them can subsequently be very difficult to achieve .
Awareness-raising and training of healthcare staff can improve documentation and identification of FGM/C. Following such efforts, including the awareness-raising and the implementation of training programs, 18 Belgian hospitals detected the number of documented FGM/C cases - compared to the median number in previous years – to increase by a factor of 2.5, resulting in a significant increase in the perceptiveness of the issue .
Appreciation and recognition of FGM/C is particularly important in obstetrics and perinatal care [9, 13,14,15]. Although previous studies showed that the risk of episiotomies is increased in women with FGM/C compared to women without FGM/C [9, 13, 14], the episiotomy rate was lower in our study population (12.3%) compared to the overall episiotomy rate in our region (18.6%) . The rate of cesarean deliveries in the overall cohort (36.4%) was slightly lower than that of the study population (40.1%), but not statistically significant. However, the rate of primary cesarean sections in the study population (22.3%) was significantly higher compared to overall rate of primary cesarean deliveries in our region (18.1%). A potentially increased risk of cesarean delivery among women with FGM/C is especially important due to a higher fertility rate in this collective. In our study population, the mean parity of 2.7 is significantly higher than the fertility rate of 1.44 per women in Austria . Thus, the decision whether to perform a cesarean section in primiparous women with FGM/C should be made with particular care, especially in view of the increased likelihood of subsequent pregnancies and the associated increased morbidity.
Finally, with an estimated number of 2.6 births per month by women who have undergone female genital mutilation and the assumption that approximately 50% of the children born are female, it can be estimated that every month at least one girl is born in our hospital who is at risk of becoming a victim of FGM/C in the future. To protect further generations from the performance of FGM/C, it is of great importance that the presence of FGM/C is detected by the health personnel. The parents of newborn daughters should be informed and counseled about the legal situation in Austria regarding FGM/C and the importance of physical integrity for healthy child development should be emphasized . These preventive measures should also be continued by the future pediatrician, which once again points to the importance of interdisciplinary collaboration in this special patient population . The WHO and other institutions provide educational resources which can be referenced for guidance [1, 4, 28].
To date, this retrospective data analysis is the first to address the issue of FGM/C in an Austrian hospital. Our study included a large sample size at an Austrian tertiary center and covered a long study period (2010–2020). The study period was chosen to allow a comparison of deliveries before the wave of refugees in 2015 (1.1.2010–30.6.2015) with the period after (1.7.2015–31.12.2020) and consequently analyze potential effects of the refugee crisis on the number of births by women from FGM/C practicing countries.
The retrospective design does not allow for verification of the documented data. Whether the presence of FGM/C was detected but not documented cannot be assured retrospectively. To produce the most accurate analysis, the country of origin was prioritized over the country of citizenship. This decision was made under the assumption that the prevalence figures of the country of birth were more accurate than those of the country of citizenship. In the estimation of FGM/C prevalence in our population we assumed that the prevalence figures published by UNICEF could be applied to migrant women living in Austria. However, studies suggest education, cultural adaptation, length of residence in a country where FGM/C is illegal and being part of a new generation or community reduce migrants’ support for the practice . Thus, the estimated prevalence of our study population does probably not accurately reflect reality, but rather represents a worst-case scenario.
Our results indicate an unmet need for specific obstetrical and gynecological care for women after FGM/C in our area. They highlight the lack of awareness by healthcare personnel and the need for specific training. Because this issue affects the whole family including the possible female newborn, an interdisciplinary approach with pediatricians, psychologists as well as social workers should be favored [1, 4, 57].
This underlines the suggestion of the European Institute for Gender Equality for counseling infrastructure (gynecologists, obstetricians, pediatricians, psychiatrists, psychologists, social workers, interpreters) in every Austrian state . Girls and women who have undergone female genital mutilation as well as their partners, children and relatives should have the opportunity to receive the best possible counseling.