Role of the funding source.

Role of the funding source.
Norad and the WHO commissioned the study and the latter contributed some funding ($10 000). The commissioners of the systematic review had no role in the study design, data collection, data analysis, data interpretation or writing of the report. RCB had final responsibility for the decision to submit for publication.
Our search strategy identified 5109 unique publications, the titles and abstracts of which were screened for inclusion. The full text of 12 publications could not be located, while 431 articles were retrieved, of which 185 met the inclusion criteria (figure 2).
PRISMA flow diagram for selection of literature.
The 185 included studies were of varying publication types, published between 1927 and 2011, and from 42 different countries (see online supplementary appendix 1). There were 13 studies from the Middle East, 43 from a Western country, and 129 from Africa. Twenty different African countries were represented. The FGM/C participants in studies from a Western country originated in the majority of cases from Somalia, and in the remaining cases they originated from another African country where FGM/C is commonly practised. Overall, the 185 studies involved 3.17 million female participants, from infants to women in their 70s, with a mean age of approximately 30. With respect to the FGM/C characteristics, the majority of women had genital alteration that involved the cutting and removal of portions of the external female genitalia, without stitching, corresponding to either type I or type II. The procedure had in the absolute majority of cases been undertaken in early childhood, usually before the age of 10, by a traditional circumciser. A total of 75 different outcomes were extracted.
In this overview, we present key physical health complications of FGM/C in a life course perspective. Except for some immediate outcomes, these key outcomes derive from comparative studies, that is, women with FGM/C are compared to women without FGM/C with respect to an outcome in a cohort, case–control or cross-sectional study (table 1). We prioritise the presentation of studies with clinically measured and adjusted outcome data, but note also the best available evidence for additional key outcomes, largely immediate complications. Table 1 shows the 57 studies with the best available evidence regarding the physical health sequelae of FGM/C (comparative cohort, case–control, cross-sectional studies).19–72 About 40% of the outcomes were self-reported primarily by adult women, although the great majority of the obstetric and some genitourinary outcomes were clinically measured. The meta-analytical results that are based on unadjusted estimates are presented in figure 3, and those based on adjusted estimates are shown in figure 4.
Summary of included comparative studies (N=57)
Meta-analyses of urinary tract infection, dyspareunia, sexually transmitted infections, episiotomy (unadjusted effect estimates).
Meta-analyses of bacterial vaginosis, HIV, prolonged labour, obstetric tears, caesarean section, instrumental delivery, obstetric haemorrhage, difficult delivery (adjusted effect estimates).
Immediate complications.
In most cases of FGM/C, a girl’s clitoris and labia are cut away, often with a crude unsterile instrument and without anaesthetics by a traditional practitioner who has little knowledge of female anatomy.2 Thus, it is reasonable to assume that physiological harms such as bleeding ensue during the cutting process and the short-term postprocedure period. We identified no studies that analysed the potential statistical differences in the risk of direct, procedure-related complications between types of FGM/C. However, 56 observational studies reported on eight main types of immediate medical harms (bleeding, shock, genital tissue swelling, fever, infections and problems with urination and wound healing) on 133 515 females of various ages and types of FGM/C. The rate of immediate complications varied greatly across the studies. There were strong indications of under-reporting of immediate complications from the procedure, with some studies reporting that 90% of the girls undergoing FGM/C experienced no bleeding at all.30 , 64 However, representative studies (ie, where the participants can be assumed to represent the larger population) of moderate and high methodological quality indicated that the most common immediate complications were: excessive bleeding (median 32%, range 5–62%), urine retention (median 31%, range 8–53%), genital tissue swelling (median 15%, range 2–27%), problems with wound healing (13%) and pain (11%).30 , 73 , 74 Girls generally suffered more than one immediate complication. We identified three clinical reports on deaths directly attributed to FGM/C.75–77 Fourteen studies reported the number of events for different types of FGM/C separately, allowing us to estimate differences in risk across exposure groups.30 , 45 , 64 , 65 , 78–87 Our results indicated that there might be a greater risk of immediate harms with FGM/C type III relative to types I–II. We found few, and small, differences in risk of immediate complications with FGM/C types I–II compared to type IV (generally ‘nick’).

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