What are the Complications Associated with Female Genital Mutilation Among Postnatal Women in Chuko Primary Hospital, Sidama Regional State, Ethiopia?

Objectives: - To assess female genital mutilation associated birth complications among postnatal women in Method: An institutional-based cross-sectional study was conducted in Chuko Primary Hospital, Sidama Regional State, Southern Ethiopia from May 1 to June 15, 2020. Two hundred fty postnatal women were involved in the study. A systematic random sampling technique was used. The data was collected using pretested and structured interviewers administered questionnaire adapted from a validated questionnaire, content validity was checked by experts, and reliability of the scaled tools was tested by Cronbach's alpha test (0.70). Before analysis data was entered and checked using Epi data and exported into Statistical Package for Social Sciences version 25.00. Bivariate analysis was carried out between the dependent and independent to identify candidate variables for multivariable logistic regression. Multivariable logistic regression analysis was made to obtain the odds ratio and the condence interval of statistical associations between Female Genital Mutilation associational Birth complications. Result: Two hundred fty postnatal women were included in the study. The prevalence of FGM was 76.8% with 95% CI: [71.6- 81.6]. Episiotomy (AOR= 7.25[95% CI: 2.27, 23.2] and prolonged labour (AOR= 2.16[95% CI: 0.03, 0.82] were signicantly associated with Female Genital Mutilation. Conclusion and recommendations: The prevalence of female genital mutilation among postnatal women in Chuko Primary Hospital was high. Family members, health and social care professionals have crucial roles in determining FGM and associated birth complication of women. Therefore, Stakeholders who are working on the improvement of maternal and neonatal health during delivery should try to reduce FGM by intervening at the individual level, family and community level to lessen the problem to some extent. Further researches in more detail to fully understand the problems and the ndings will be used as inputs for concerned bodies.

According to WHO de nition female genital mutilation is any surgical modi cation of the female genitalia, comprising all procedures involving partial or total removal of the external female genitalia or another injury to the female genital organs for cultural or nontherapeutic reasons (2).
WHO interagency group has classi ed female genital cutting into four types: Type 1 -Clitoridectomy: partial or total removal of the clitoris; Type 2 -Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora; Type 3 -In bulation: narrowing of the vaginal opening through the creation of a covering seal.; and Type 4 -Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g.
Female genital mutilation is commonly referred to as female circumcision and one of the deeply rooted, harmful traditional practices. Common resin for FGM is social acceptance, religion, hygiene, preservation of virginity, marriageability, and enhancing of male sexual pleasure (5). Even though it is taken as a cultural entity, it is a form of violence against girls and women re ecting discrimination against these vulnerable sections of the society(6).
According to WHO report 2011 showed there were an estimated 130-140 million girls and women who have been subjected to the operation and 3 million girls are at risk of undergoing the practice every year (7).
In Africa, about 101 million girls age 10 years and above are estimated to have undergone female genital Mutilation in northeast Africa, where the practice ranges from 80 to 97%, while in East Africa it is markedly lower and ranges from 18 to 32% (8). FGM is practiced in many countries in Africa including Ethiopia, the Middle East, and around the world.
The deliveries of women who had undergone genital mutilation were signi cantly more likely to be complicated by cesarean section, postpartum hemorrhage, and prolonged maternal hospitalization. Women who had undergone the most serious form of genital mutilation (type III) had a 30% higher risk for delivery by cesarean section. Similarly, women with type III mutilation(severe FGM) had a 70% more likely to suffer hemorrhage after birth. The rates of infant resuscitation and perinatal death were higher among infants born to women who had undergone genital mutilation than among those born to mothers who had not, and the severity of the adverse outcomes increased with the severity of female genital mutilation (11).
Its common birth complications are: mechanical obstruction caused by the scarring covering the urethra and vagina, bleeding, perineal tear, unnecessary operative delivery, fetal distress, wound infection, and stula (9,12).
The researchers also found there was an increased need to resuscitate babies whose mother had experienced FGM, and the death rate among babies during and immediately after birth is also higher (7). In all, the study estimated that in the African context an additional one to two babies dies per 100 deliveries as a result of the practice (11).
FGM physically removing and damaging normal female genital tissue, and interferes with the natural functions of girls and women's bodies, Psychologically, the trauma leaves a scar that seldom, if not never, heals (9).
Females' genital mutilation is one of the harmful traditional practices affecting the health of women and children. It has a long-term physiological, sexual, and psychological effect on women. Females' genital mutilation still remains to be a serious problem for a large proportion of women in some parts of Africa (13).
In Ethiopia, there are some reasonable interventions and strategies that are ongoing to eliminate FGM, but the magnitude of FGM is very high in many Regions and districts including the SNNPR district, still, there is a gap of information and little researches were done to identify the one women on postnatal care service provision. Therefore, this study aimed To assess Female Genital Mutilation associational Birth complications among postnatal women in Chuko Primary Hospital, Sidama regional state, Ethiopia. The study would provide helpful information on female genital mutilation and birth complications among women on postnatal care. Besides, it may help to reduce morbidity and mortality associated with FGM. It may also provide helpful information to modify and design clinical interventions for women undergone FGM during labor and delivery service providers. Additionally, it may give a baseline of data for interested researchers, policymakers, and scienti c knowledge.

General Objective
To assess the prevalence of female genital mutilation associational birth complications among postnatal women in Chuko Primary Hospital, Sidama Regional State, Ethiopia, from May 1-June 15, 2020 G.C

Speci c Objectives
To determine the prevalence of female genital mutilation among postnatal women in Chuko Primary Hospital, Sidama Regional State, Ethiopia.
To identify the association of female genital mutilation and birth complications among postnatal women in Chuko Primary Hospital, Sidama Regional State, Ethiopia

Study Setting and Design
An institution-based cross-sectional study was conducted from 1/January --15/ February /2020 in chuko primary hospital, Sidama regional state, Ethiopia. Chuko twon is located in Sidama reginal state,southern Ethiopia.The town is located 295 Km from Addis Ababa the capital city of Ethiopia and 76 km from Hawassa the capital city of the Sidama

Source population and Study population
The source population was all reproductive-age women living in catchment areas of Chuko Primary Hospital and all women coming for the delivery service to Chuko Primary Hospital was study population. Inclusion and exclusion criteria: All women coming to Chuko Primary Hospital for the delivery services were include in the study while those who were unable to listen, speak, or critically ill were excluded from the study.

Sample size determination and Sampling Technique
The sample size was calculated by using a single population proportion sample size calculation formula, then the nal sample size was 250. The prevalence of female genital mutilation (p = 82%) was taken from an institution-based study conducted in Hadiya Zone, Southern Ethiopia [10]. Then the study participant was systematically selected from the delivery registration logbook of the Hospital. The rst postnatal woman was selected based on the lottery method and the rest were selected every six intervals.

Data collection procedure and instrument
Data were collected using the interviewer-administered structured questionnaires by reviewing different published literature and guidelines. The data were collected by two midwife nurses, and the principal investigator supervised the whole data collection process. All data collectors took a one-day intensive training before data collection about the objectives of the study, the issues of verbal assent, and the rights of the respondents.

Data Quality assurance
Data collectors were trained on how to collect and handle data. The questionnaire prepared in English was translated into Amharic and was translated back to English to assess consistency and the Amharic version was used while carrying out the interview. Questionnaires were pretested on 5% of the postnatal women in Kebado Primary Hospital.
Some modi cations and updating of tools were done based on the result of the pretest. Reviewing the lled questionnaires at the end of data collection every day for completeness, consistency, and taking corrective measures were contentiously managed during the data collection periods.

Data analysis procedures
Data were entered with Epi data version 3.1 and exported to SPSS version 23 for analysis. Data explorations were done to examine different characteristics of the data. After cleaning data, descriptive statistics like frequencies were computed for the categorical variables while measures of central tendency and dispersion were summarized for continuous data. Bivariable logistic regression was carried out to select a candidate for multivariable logistic regression analysis with a p-value < 0.25 at 95% con dence. Then, candidate variables were entered into a multiple logistic regression model using the backward elimination method. The degree of association was assessed using odds ratio and statistical signi cance was declared at 95% of con dence level and p-value of less than 0.05. Hosmer & Lemeshow's test as well as its signi cance status was checked to assess the tness of the model.  Table 1].

Obstetrics Characteristics of the Study Populations
From two hundred fty postnatal women, one half (50.8%) of the respondents were gravida II-IV,followed by gravida I(35.2%) of the respondent. One hundred seventy-one (68.4%) of the women's had 1-3 four alive children [ Table 1].

Maternal and Newborn Related Birth Complications
This study revealed that the prevalence of birth complications among the study participants was (71.9%) 95% CI: asphyxia (34%) of the child complication followed by low birth weight (13.6%) [ Table 1].

Prevalence Of Female Genital Mutilations
One hundred ninety-two (76.8%) 95% CI: [71.6-81.6] of the respondents were circumcised and (68.4%) of the circumcision was performed by a traditional birth attendant (TBA). One hundred forty-seven (76.2%)of the respondents were circumcised at the age of fewer than 10 years old [ Fig. 1].

FGM Associated Birth Complications among Postnatal Women
Among all variables, episiotomy, prolonged labor, and asphyxia have shown a signi cant association with FGM related birth complication in bivariate logistic regression (LR) analysis had p-value < 0.25. After adjusting for other confounders, in multivariate logistic regression analysis; episiotomy, prolonged labor were found to be signi cantly associated with FGM related birth complication (P-value < 0.05). Having female genital mutilation (FGM) increases the risk of episiotomy seven times (AOR = 7.25(95% CI: 2.27, 23.2) more likely compared with counterparts. On the other hand, having female genital mutilation (FGM) increases the risk of prolonged labor two times (AOR = 2.16(95% CI: 0.03, 0.82) more likely compared with counterparts [ Table 2].

5: Discussion
The study assessed the prevalence of female genital mutilation and associated birth complications among postnatal women in chuko primary hospital, Sidama regional state, Ethiopia. The overall prevalence of female genital mutilation among postnatal women was (76.8%),95% CI: [71.6-81.6]. This result was found to be in line with the prevalence among Postnatal women in the Hadiya zone (82.2%), the pooled prevalence in Ethiopia (87.5%), and Hossana (92.2%) (15)(16)(17). On the other hand, the study ndings in Sierra-Leone 2013(63%), Kersa district of Ethiopia ((38.5%) were less than the ndings of this study (18,19). The possible explanation for this difference might be due to the difference in Socio-demographic characteristics of study participants and sample size.
This study also revealed that episiotomy and prolonged labor had a signi cant association with female genital increases the probability to develop prolonged labor among women. This nding was in line with the study conducted in the Hadiya zone (17). The possible explanation for this difference might be the difference in socio-demographic characteristics of study participants and sample size.
The overall prevalence of the FGM and associated birth complications among postnatal women in Chuko Primary Hospital was high. Family members, Health and social care professionals have crucial roles in determining the FGM of women. Therefore, Stakeholders who are working on the improvement of maternal and neonatal health during delivery should try to reduce FGM by intervening at the individual level, at the family or community level, and at levels beyond the community to lessen the problem to some extent. Researchers should do similar researches in more detail to fully understand the problems and the ndings will be used as inputs for concerned bodies.

Availability of Data and Materials
The datasets generated and/or analyzed during the current study are not publicly available as consent for the sharing of this data was not sought from the participants as there was no data sharing requirement at the time.

Competing interests
The authors declare that they have no competing Interests Ethical Approval and Consent to Participants Primary l hospital and the study was carried out after obtaining permission from hospital authorities. The whole objective of the study was brie y explained to the maternity head as well as those assigned in the Labour and delivery department.