48 The result from the most comprehensive model in this study (ie, Oligomycin A Sigma adjusting for the highest number of confounders) showed an AOR of 1.18 (95% CI 0.76 to 1.84). No prospective studies presented adjusted estimates for episiotomy, but we aggregated the unadjusted results

from five prospective studies (n=32 088 women), finding an increased risk with FGM/C (RR=1.38; 95% CI 1.14 to 1.67; GRADE: very low; figure 3).24 29 53 69 70 There were nine studies with data on instrumental delivery.24 25 29 42 53 66–68 70 Two (registry based) studies reported adjusted data.42 68 The meta-analysis for primiparous women suggested a greater risk of instrumental delivery with FGM/C (AOR=1.56, 95% CI 1.32 to 1.86; GRADE: very low), which could not be firmly established for multiparous women (AOR=1.34, 95% CI 0.80 to 2.26; GRADE: very low; figure 4). We also included nine studies with data on obstetric or postpartum haemorrhage.28 29 38 42 56 66 68–70 Five studies reported adjusted results, which we combined in a meta-analysis. The result indicated a greater risk with

FGM/C (AOR=1.50, 95% CI 1.22 to 1.84; GRADE: very low). However, the pooled adjusted estimate based on the two prospective studies that reported adjusted data for haemorrhage failed to establish a convincing difference relative to FGM/C (AOR=1.91, 95% CI 0.89 to 4.08; GRADE: very low; figure 4).28 69 Lastly, we included six comparative studies with data on difficult delivery.28 42 43 56 66 The pooled result based on adjusted estimates from the two studies that could be combined resulted

in an AOR of 1.88 (95% CI 1.06 to 3.35; GRADE: low; figure 4).28 66 A third study compared women without FGM/C with women who had FGM/C type I. The AORs were 0.17 (95% CI=0.06 to 0.52) and 0.32 (95% CI=0.19 to 0.54), which favoured not having FGM/C.43 There was one prospective study with data on difficult delivery.28 The estimate showed a greater risk with FGM/C (AOR=2.30, 95% CI 1.3 to 2.5). Discussion This systematic review provides clear evidence that FGM/C entails harms to women’s physical health throughout their life, from the moment of cutting as an infant or child, to sexuality and childbirth in adulthood. Predictably, the most common direct, procedure-related Dacomitinib complication includes haemorrhage, most likely resulting from laceration of the internal pudendal artery or the clitoral artery. It is difficult to determine the number of females who die from procedure-related complications. Only a few studies reported death, but highly publicised fatalities from FGM/C heighten the awareness of the possible harms posed by the procedure, such as three recent cases in Egypt and Kenya.88–90 We found several long-term consequences of FGM/C, including increased risks of urinary tract infections, bacterial vaginosis, dyspareunia and obstetric complications. Studies have been published since we conducted our search, and they corroborate our findings.