Female genital mutilation
by Jennifer Louisa Williams and Krystn Cohen-Dodge
© 1993 Midwifery Today, Inc. All rights reserved. http://www.midwiferytoday.com/articles/unveiling.asp
[Editor's note: This article first appeared in Midwifery Today Issue 25, Spring 1993.]
Midwifery has kept me constantly on the go for the past six years, ever since the first birth when I walked in and caught the baby before the primary midwife arrived. It's been like that ever since.
One day the phone rang at my house. "Do you know anything about female circumcision?" asked Lisa, a midwife friend. No, I thought, but I had a feeling I was about to learn.
It was early November. A woman named Amal was due December 5. She was an Islamic from Sudan who had been ritually circumcised as a little girl. She spoke almost no English. Her husband was a student. They lived with their two children in a tiny one bedroom apartment.
I went to see Amal the first time with Beth, a CNM who provides my medical backup. An Iraqi woman, Medeha, served as our interpreter. An Egyptian woman, also Amal, was there. So was my friend, Lisa. We all spent some time talking and getting to know each other.
All of the family's belongings were packed and ready to go, as they had planned to birth in the Sudan. But because of Amal's pregnancy, they had been refused admittance. Her religious and cultural beliefs allowed her only female attendants and she wanted to birth at home, as she would have done in the Sudan.
We began by doing a prenatal. I listened to the heart tones and palpated the baby. We determined that the baby was very small, convincing me that she needed to go to term. We did some heavy-duty nutritional counseling for her last month of pregnancy, not knowing how much she actually understood. She seemed to have little money and little knowledge of what a good prenatal diet was. (She was very enamored of "The Great American Diet" —hamburgers, Pepsi and Wonder Bread, just like on TV.)
When it was time to examine her genitals, I could sense her discomfort and was reticent to intrude upon her modesty. It was very difficult for her to expose herself to white American women. We were strangers who might be judgmental of her, her culture and her body.
Outwardly, I tried to maintain a clinical detachment to help me cope with seeing the mutilation for the first time, but inwardly, I was shocked.
From her navel to the small opening in her vagina, all I could see was smooth black skin with lines of obvious scarring. There was no pubic hair.
Her perineum, such as it was, was badly scarred with two deep mediolateral episiotomies, and a midline episiotomy that extended deep into her rectum. The scar tissue looked like railroad tracks. As I was learning about her body, I discovered that her clitoris and inner labia had been cut off, the fleshy inner parts scraped out. Her labia majora had been sliced open on both sides and then sewn together so as to fuse across what had been her clitoral, urethral and vaginal area. These fused labia created a tough, somewhat thick layer of skin, a "one-piece" look, with a pocket in front of her urethra. Urine couldn't escape, except to dribble down and out the hole. We surmised that this major genital mutilation must cause a tremendous amount of both urinary tract and vaginal infections.
When I reached out to touch her she flinched, and I sensed that she was as emotionally scarred from this brutal ordeal as she was physically. Through her interpreter, and by gesturing, she expressed to us that menstruation, urination and especially sexual intercourse were anguishingly painful to her.
She had undergone two mutilations, one as a child, and one on her wedding night. She also carried four tribal mutilation scars on her face. She had not had pain relief of any kind for any of this, including the episiotomies. She was in extraordinary pain after each of her births, unable to eat or drink anything except some milk for two weeks because she hurt so much.
I was able to do a vaginal exam once I got my fingers behind the flap of skin. I didn't want to inflict more pain on her, but I needed to know if she had a normal vagina behind that flap. I found a very ample pelvis, and a soft two-centimeters cervix. The baby's small head presented. This flap had been cut open for her other births and would need to be cut for this one, too. Amal explained that she wanted not to be sewn so tightly this time so she could urinate and menstruate freely. This would also help her in future births.
Amal had received care from a team of obstetricians through her fifth month. One of them was a woman, but because of her rotating schedule she could not guarantee Amal that she would be present at the baby's birth. From the chart we could tell that they were also perplexed by the circumcision. She had two early ultrasounds. Nothing seemed amiss. She had apparently had a healthy pregnancy.
I spent the following week discussing Amal's situation with my assistant and my midwife friends. From them I received the support I needed to help this woman. I talked with Beth and my backup doctor, drew diagrams, and discussed it all thoroughly. Because we were unable to visualize her previous genitalia, the doctor cautioned me about cutting into Amal's clitoral artery.
Beth and I felt fairly certain after examining Amal that a cut up the labia to expose her urethra and cautious perineal guarding, would get us by without a lower episiotomy, even though she had obviously had large ones in the past.
I consulted several other midwives with impeccable reputations to see if anyone had ever had experience with a birth like this. No one had seen this exact situation before. I knew I would have to trust my heart when the time came.
I finally decided that I would cut the labial fusion open and make sure it didn't extend. We would diligently guard the perineum during the birth and, only if absolutely necessary, would do a small midline. Given correct support, I felt she could birth over an intact perineum.
Although trained to do an episiotomy, I had never in six years found one necessary. I had a hard time thinking about cutting someone on purpose, even if it was the only way the baby could come out. We wanted some more experience.
First, Jennifer and I got out all the textbooks. Then we got out the chickens. We meticulously prepared our sterile field on my kitchen table, placing the chickens, dripping with Betadine, on Chux pads. (A man came to fix my stove, working on it while we were injecting Xylocaine and performing episiotomies on chicken breasts. He finally said, "Uh, it's none of my business, but what are you ladies doing?" I told him we were just cutting up chickens, only we liked to sew them back up. He didn't ask any more questions—and he never came back.) The crucial element would be knowing when to cut her—this thought kept playing through my mind.
Finally, I felt that the midwife part of me was as prepared as it was going to be. However, I was five months pregnant myself. The pregnant woman part of me, the part that cried at diaper commercials, felt emotionally unprepared. I knew this family would be leaving soon after the birth to go back to the Sudan where their six-year-old daughter would undergo the same ritual circumcision. I secretly prayed that this baby would be a boy. If I didn't help her, I felt the hospital would misuse its Western technological power to the fullest extent on a woman like Amal. And worse, she would be made a spectacle. I was finally able to be at peace about the decision to do this birth.
Lisa called at 6 am on Amal's due date to tell me Amal had gone into labor. Amal's contractions were about five minutes apart and at first Lisa thought she was going fast. By the time I got there, things had quieted down and she was a good four centimeters dilated and 70 percent effaced with the head at -1. She was having contractions every four to six minutes. I was welcomed by Amal herself. She was pacing but could still get us juice. Medeha and the Egyptian Amal were already there.
When Jennifer arrived, we set up two trays. The first was our birth tray, with the normal birthing supplies. The second was the episiotomy and suturing tray. We kept everything scrupulously sterile.
As the morning grew late, Islamic women from many countries moved in and out of the tiny apartment to see if they could help. The strong cultural and language barriers faded away as we became a group of women with a single goal, steeped in the ancient tradition and ritual of birth.
We were eating food prepared by several of the women when Amal's voice changed. It was time. Her water had broken on the toilet. She wanted the baby now!
We switched into high gear, preparing quickly for a more "medical" birth than usual. At 2:15 pm Amal had an anterior lip and was pleading to push. She thought that if I cut her now, she could go ahead and have the baby. She urged me to cut her. I tried to explain that it wasn't time yet…hold off a little longer…just a little longer. We breathed with her. Labor was intense. Medeha beseeched her to say "Allah" when the pain got too great. All her noises and her gestures were familiar to us now. We had no difficulty understanding her.
By 2:30 the baby's head had moved completely down. This small baby was going to be born in just a few quick pushes. When I saw a quarter's worth of head, I grabbed the syringe of Xylocaine. I was having a lot of trouble positioning her, getting the right angle. To numb her, I placed two fingers behind the flap of fused labia and injected straight up the middle from bottom to top as far as the needle would go, and infused on the way out. I then went for the scissors. I asked her to please wait to push, and began the upward episiotomy. I was shocked at the strength, resistance and stubbornness of those tissues, mostly scars. Several snips at the bottom were needed to start, although I had intended to make only one solid cut. Once I had a good bite, I clipped easily—four centimeters, just enough for me to see the urethral opening underneath, and provide a passage for the baby's head. Lisa was sitting up on the bed with Amal, and Jennifer and I were on the floor, with Amal scooted up to the edge of the bed. Lisa applied pressure constantly and strongly to the apex of the incision with a 4 x 4 gauze pad to keep it from extending. Jennifer and I worked on getting the perineum to stretch. All the women urged her to push slowly and gently. For a moment I thought she might need a midline episiotomy, but just as I started to do it, she stretched, the baby's head popped out, and then the whole body! She loudly announced her presence. Our fear of needing to resuscitate her was drowned out by her squalling. We lifted her in an arc to her mother. I quickly noted the bleeding—minimal—while Jennifer assessed the baby: Excellent! I could see no tear, and the baby, although petite, was a perfect 10-10.
We all took a breath, and stepped out of the circle as mother and baby greeted each other. Emotions were running high all around, and the women friends were all teary, especially the Egyptian Amal who was four months pregnant with her first baby. None of the feared complications had materialized.
She was one of the healthiest babies we had ever seen, an exquisite chocolate brown, with huge brown eyes and curly black hair. We quickly prepared for the placenta. Amal wanted it out, worked to push it out, and delivered it quickly—not the healthiest placenta we had ever seen.
After she had some time with the baby, we came back in, and showed Amal her bottom with a hand mirror. Her face told us she was astonished at the small incision. She said again that she wanted to be left open as much as possible. We decided to secure the apex of the incision, and just try to give enough stitches in the sides to encourage them to grow back into themselves and not fuse back together.
I began to suture the apex and immediately found very rough going. Her outer skin was very tough and scarred. We numbed her as best we could, and before we were done we had used four syringes of Xylocaine. We were determined to give her more comfort than she'd had before. Using 3-0 Chromic gut, I began to suture from the top down. Going through the tissue was tough and her skin was very rough. After the three most difficult sutures of my entire career, the stitches were just not turning out as I desired. The scar tissue was very unyielding, and approximating the top and side proved more difficult than I expected. I consulted by phone with my backup doctor, who told me to continually use fresh sutures and fresh needles. She thought that just securing the apex and allowing the sides to heal apart would be enough. Tears welled in my eyes as I tried with all my physical strength to put in those sutures without hurting Amal. The first went in with great difficulty, the next, with new suture, was easier, and then the third was difficult again. I finally stopped and gave her written and verbal instructions on keeping it clean to help it heal. We helped her to the bathroom for the first time, and found that she was not too uncomfortable. After tucking her back in bed with her precious babe, we did a more thorough inspection of the placenta, which revealed a small, thinner than normal, oblong-shaped organ containing two large infarcts. She had very little bleeding, from the episiotomy site or from regular vaginal bleeding. Her total blood loss was less than 300 cc.
The newborn exam revealed a sweet five pound six ounce girl, 18 inches long. She had a 12 1/2 inch head circumference and all her reflexes and landmarks indicated that she was 40 weeks gestation.
Our instructions for newborn care were quite different from what Amal was used to, especially nursing. From almost the moment of birth, Amal had been digging in a bag near the bed for pacifiers. She later told us that she did not normally nurse until the milk came in. The baby was given sugar water and pacifiers at first. We did back hand-springs to get her to nurse, but we only had limited success. I told her that she needed to nurse a lot, every two hours, day and night, to make the baby bigger before she went back to Sudan. But their culture and the way they had raised their first two babies took precedence.
We showed her how to use ice on her perineum for swelling and pain, and gave her herbs for baths and Betadine for perineal washes. Amal had never had any comfort measures before. She told us that this was by far her easiest and least painful birth.
Amal had what is called pharaonic circumcision. According to Hanny Lightfoot-Klein in Prisoner of Ritual, An Odyssey into Female Genital Circumcision in Africa, a pharaonic consists of a clitoridectomy (removal of clitoris) and excision of the labia minora, as well as the inner layers of the labia majora. The raw edges are then held together with cat gut or thorns. The remaining skin of the labia majora will heal together and form a bridge of scar tissue over the vaginal opening. A small sliver of wood or straw is inserted into the vagina to prevent complete blockage and to leave a passage for urine and the menstrual flow. This fusion is called infibulation.
On her wedding night, a circumcised woman must be opened in order for intercourse to occur. Sometimes penetration is not achieved for days, weeks or even months. The groom tears the hole open or cuts her with his knife. Sometimes the couple goes to a doctor for surgery. When a child is born, the midwife must cut the woman's scar tissue open. Afterward, she sews the genitalia almost completely shut. The woman must again endure repeated attempts at intercourse until penetration is achieved. Sudanese women generally have large families.
According to Lightfoot-Klein, Sudanese believe that girls must be circumcised or they will be too sensitive sexually, that the operation will prevent malodorous discharges and make sex organs cleaner. In a society which highly values chastity, circumcision is supposed to keep girls virgins and protect against rape. Little girls are told that if they are not circumcised they will get dirt and worms in their vagina, and that men won't accept an uncut wife.
When the girl is told she is to be circumcised, she is treated like a bride, her hands are painted with henna, she is given gifts, and the midwife is considered the heroine. Most girls ask to be circumcised. They are usually not anesthetized (even in rich families) and are held down by three or four kinswomen for the procedure. The children are said to be "less hyperactive" afterward.
The grandmothers usually are the ones who get their granddaughters circumcised. They find the midwife and exert great pressure on the family, threatening to break all communication with the family if it is not done.
Although a ritual scratch will completely fulfill the religious requirements, most Sudanese think that the full pharaonic circumcision is necessary.
Ms. Lightfoot-Klein estimates that 94 million women in Africa have undergone ritual mutilation. A 1974 law forbids pharaonic circumcision but does permit clitoral excision. Because of the law, girls are not brought in for medical treatment when they hemorrhage or become infected.
If anything goes wrong, everything possible is done to protect the midwife. Sudanese doctors estimate that 10 to 30 percent of little girls die from female circumcision. There is a weak movement in the Sudan to end female circumcision, but cultural mores run highly in favor of it. Most people seem to think that it will take a new generation of women to end this practice.
Krystn Cohen-Dodge lives with her husband and three children in Indiana. She has been a direct-entry midwife for six years.
Jennifer Louisa Williams also lives in Indiana with her three daughters. She is an assistant midwife, freelance writer, and editor and publisher of Birth Root magazine.
More information about female genital mutilation (FGM) can be found at the World Health Organization Web site: http://www.who.int/mediacentre/factsheets/fs241/en/
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