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Midwifery matters - The challenges of FGM

Almost 4,000 females in Ireland have undergone genital mutilation, something midwives need to be aware of when delivering their care

There are ongoing concerns about the prevalence of female genital mutilation (FGM) in Europe. This issue includes women who have immigrated to Europe having undergone FGM in their home country and girls who are born or raised in Europe who are at risk of FGM by being brought to a country where it is routinely performed.

In many African countries, although illegal, FGM is still accepted practice in a bid to control female sexuality and preserve a cultural identity.1 There is increasing recognition that FGM may take place in Ireland or other European countries.

In the UK it was identified that females who experienced the procedure, either there or in other countries, were not receiving adequate protection from the state.1 Is has been recommended that FGM be classified as child abuse in the UK and that anyone presenting with FGM should be identified to the police as potential victims of a crime.

The WHO classifies the types of FGM as:

  • Type I – clitoridectomy: partial or total removal of the clitoris and/or prepuce
  • Type II – excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora
  • Type III – infibulation: narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris
  • Type IV: all other harmful procedures to the female genitalia for non-medical purposes (eg. pricking, piercing, incising, scraping and cauterisation).

In Ireland, it is estimated that 3,780 women have undergone FGM but it is unknown how many Irish-born females have experienced FGM.2 AKiDwA, in collaboration with the HSE and RSCI, produced guidelines for healthcare workers that require FGM be identified as a risk factor in the new national maternity chart. As such, midwives must be familiar with the challenges that women with FGM experience during pregnancy and childbirth.

It is optimal to obtain this information in early pregnancy, otherwise it may not become apparent until late pregnancy or established labour when the women is offered a vaginal examination. This may cause unnecessary stress for the woman and confusion for the maternity staff who may be unfamiliar with procedure.

The maternal consequences of female genital mutilation include:3

  • Fear of childbirth
  • Increased likelihood of Caesarean section
  • Increased likelihood of postpartum haemorrhage
  • Increased likelihood of episiotomy
  • Increased likelihood of severe vaginal lacerations (including fistula formation)
  • Extended hospital stay
  • Difficulty performing vaginal examinations in labour
  • Difficulty in applying fetal scalp electrodes
  • Difficulty in per forming fetal blood sampling
  • Difficulty in catheterising of the bladder.

To encourage disclosure of FGM from a pregnant women, it may be more useful to ask if she has been ‘closed’, ‘cut’ or ‘circumcised’.2 This must be made in a sensitive non-judgemental manner. If an interpreter is required, a female, non-family member should be used. Appropriate assessment should be made and if defibulation is required, it should be performed around 20 weeks gestation to ensure adequate healing before the birth.3 Pain relief is essential and traumatic flashbacks related to the original assault on the woman’s body can occur. Signs of FGM can be missed, particularly Type I.

In labour, an anterior midline incision at the introitus may be required for FGM type III. After the birth, it is important that re-infibulation does not take place, even if requested by the woman or her husband. They must be informed sensitively that this is illegal. Appropriate care should be provided by a clinician experienced with the management of FGM. Defibulation does not restore physical or emotional normality.

Any girls born to a woman with FGM are at high risk of having this mutilation performed on them. Mothers may experience pressure from family members to have FGM performed on their daughters.

Globally, FGM causes death, disability, physical and psychological harm for millions of women and girls each year.1 The UN describe it as ‘torture’ and the WHO as ‘gender-based violence’.

In some countries, it is performed in girls under five while in other countries it is performed between the age of five to 14. In Ireland, since 2012, it has been illegal to perform FGM or remove a girl from the State for FGM. If this is suspected, the Gardaí and social services should be informed.

Ireland’s first drop-in FGM clinic was set up by the Irish Family Planning Association in Dublin recently. It offers free, specialised medical care and counselling to females affected by FGM. A useful e-learning toolkit is available at: www.uefgm.org/Index.aspx?Language=EN

Rhona O’Connell is a midwifery lecturer at the School of Nursing and Midwifery, University College Cork


  1. RCM, RCN, RCOG, Equality Now, (UNITE). Tackling FGM in the UK: Intercollegiate Recommendations for identifying, recording, and reporting. London: Royal College of Midwives. 2013
  2. RCOG, AkiDwA, RSCI, HSE. Female Genital Mutilation Information for Health-Care Professionals Working in Ireland Dublin: AkiDwA. 2013
  3. RCOG. Female Genital Mutilation and its Management Green Top Guideline No 53 London: RCOG 2009
Midwifery matters - The challenges of FGM


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