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26 Raffaldi IGarazzino SBallardini G, et al. Vitamin D status in internationally adopted

children: the experience in Northwest Italy. Minerva Pediatr 2017. doi:

10.23736/S0026-4946.17.04883-6. https://www.minervamedica.it/it/riviste/minerva-

pediatrica/articolo.php?cod=R15Y9999N00A17091501.

27 Chiappini EVierucci FGhetti F, et al. Vitamin D status and predictors of hypovi-

taminosis D in internationally adopted children. PLoS One 2016;11:e0158469.

28 Saggese GVierucci FProdam F, et al. Vitamin D in pediatric age: consensus of the

Italian Pediatric Society and the Italian Society of Preventive and Social Pediatrics,

jointly with the Italian Federation of Pediatricians. Ital J Ped 2018;44:51.

29 Holick MFBinkley NCBischoff-Ferrari HA, et al. Guidelines for preventing and

treating vitamin D deficiency and insufficiency revisited. J Clin Endocrinol Metab

2012;97:1153–8.

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for calcium and vitamin D from the Institute of Medicine: what clinicians need to

know. J Clin Endocrinol Metab 2011;96:53–8.

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atric population. J Pediatr Gastroenterol Nutr 2013;56:692–701.

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to age and sex. Caspian J Intern Med 2012;3:535–40.

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Africans in America study. Osteoporos Int 2015;26:2607–15.

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migrants in accessing health care services: a systematic review. Eur J Public Health

2017;27:480.

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health in Europe: moving from emergency response to integrated and individual-

ized health care provision for migrants and refugees. IJERPH 2018;15:1100–6.

36 Gulland A. Migrants’ access to healthcare is restricted across Europe, charity warns.

BMJ. 2015;350:h2681.

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The European Journal of Public Health, Vol. 30, No. 3, 556–561

� The Author(s) 2019. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckz193 Advance Access published on 23 October 2019

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Healthcare access for asylum seekers and refugees in England: a mixed methods study exploring service users’ and health care professionals’ awareness

Louise J. Tomkow 1, Cara Pippa Kang2, Rebecca L. Farrington2, Ruth E. Wiggans3, Rebecca J. Wilson4, Piyush Pushkar5, Maya C. Tickell-Painter6, Alice R. Lee4, Emily R. Whitehouse7, Nadia G. Mahmood8, Katie M. Lawton3, Ellen C. Lee9

1 Humanitarianism and Conflict Response Institute, School of Arts Languages and Culture, University of Manchester, Manchester, UK

2 Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK 3 Wythenshawe Hospital, Manchester Foundation Trust, Manchester, UK 4 Royal Manchester Children’s Hospital, Manchester Foundation Trust, Manchester, UK 5 School of Social Science, University of Manchester, Manchester, UK 6 Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK 7 Preston Royal Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK 8 Royal Blackburn Teaching Hospital, East Lancashire Hospital Trust, Lancashire, UK 9 School of Health and Related Research, University of Sheffield, Sheffield, UK

Correspondence: Louise J. Tomkow, Humanitarianism and Conflict Response Institute, School of Arts Languages and Culture and Faculty of Biology, Medicine and Health, Division of Medical Education, University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester M15 6JA, UK, Tel: þ44 (0) 16 12 75 0245, e-mail: louise_tomkow@hotmail.com

Background: With the aim of decreasing immigration, the British government extended charging for healthcare in England for certain migrants in 2017. There is concern these policies amplify the barriers to healthcare already faced by asylum seekers and refugees (ASRs). Awareness has been shown to be fundamental to access. This article jointly explores (i) health care professionals’ (HCPs) awareness of migrants’ eligibility for healthcare, and (ii) ASRs’ awareness of health services. Methods: Mixed methods were used. Quantitative survey data explored HCPs’ awareness of migrants’ eligibility to healthcare after the extension of charging regulations. Qualitative data from semi-structured interviews with ASRs were analyzed thematically using Saurman’s domains of awareness as a framework. Results: In total 514 HCPs responded to the survey. Significant gaps in HCPs’ awareness of definitions, entitlements and charging regulations were identified. 80% of HCP respondents were not confident defining the immigration categories upon which eligibility for care rests. Only a small minority (6%) reported both awareness and understanding of the charging regulations. In parallel, the 18 ASRs interviewed had poor awareness of their eligibility for free National Health Service care and suitability for particular services. This was compounded by language difficulties, social isolation, frequent asylum dispersal accommodation moves, and poverty. Conclusion: This study identifies significant confusion amongst both HCP and ASR concerning eligibility and healthcare access. The consequent negative impact on health is concerning given the contemporary political climate, where eligibility for healthcare depends on immigration status. .........................................................................................................

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Introduction

A sylum seekers and refugees (ASRs) often have diverse and add- itional health needs to the general population.

1–3 The health of

ASR has been shown to deteriorate following arrival to the UK, owing to separation, social marginalization and barriers to accessing healthcare.4–8 Access to health care throughout European countries is increasingly being used as part of immigration control. Health coverage for undocumented migrants varies between European countries: Spain provides the widest coverage and Germany the least.

9 In 2012 the British government introduced ‘Hostile

Environment’ policies, restricting the welfare and healthcare entitle- ments of those classified as irregular migrants.10,11 This includes people with refused asylum applications. In 2017, existing National Health Service (NHS) charging regulations were extended in England. General practice (GP) consultations remain free, but charges apply to non-urgent secondary care and community services allied to primary care, such as mental health services, drug and alcohol treatment services and community midwifery services. Those ineligible for free care must pay upfront.

12 . This policy has

been widely criticised on ethical, practical, fiscal and public health grounds.13–17

Research both before and after the 2017 extension of charging demonstrates multiple barriers for ASR accessing safe and effective healthcare in England, including language, cost and concerns over being reported to immigration authorities.18 Furthermore, a recent study exploring access to primary care suggested ASRs’ awareness of the NHS was particularly problematic.

19 Similar results are seen in

other European countries. 9

In parallel, there are concerns about gaps in health care professionals’ (HCPs) knowledge about vulnerable migrant groups’ entitlements and needs.20 We identified no existing research exploring this, either in the UK or the rest of Europe. UK HCPs are provided with no formal training regarding the new charging regulations. NHS England guidance states individuals are not required to declare their immigration status on registering with a GP, yet 13% of migrants were refused GP registration due to their immigration status in 2017.21

Awareness, shown to be a fundamental component of access, is ‘content and context specific’.

22 No identified studies have explored

HCPs’ and ASRs’ awareness of healthcare access and eligibility in the UK’s contemporary hostile political climate. Using mixed method- ology, this article addresses this gap in the literature with (i) quan- titative survey data to investigate HCPs’ awareness of migrants’ eligibility for NHS care, and (ii) qualitative interview data to explore asylum applicants’ awareness of NHS services.

Methods

Quantitative research design

An online survey was distributed to HCP’s in England. Peer- reviewed multiple-choice questions focussed on respondents’ under- standing and experience of migrants’ health. A 10-question pilot survey exploring awareness was circulated to HCPs before the extension of the NHS charging regulations; the results of this pilot survey are described elsewhere and are not included in this ana- lysis.

23,24 A 17-question substantive survey was disseminated follow-

ing regulation changes. This substantive survey also explored awareness, but focussed on the recent regulatory changes. This art- icle analyses the responses to five survey questions on awareness from the substantive survey, the first four of which were present in both pilot and substantive surveys (figure 1).

Quantitative sampling and data collection

Opportunistic snowball sampling was used to maximize sample size. An email containing a hyperlink to the survey was distributed to HCPs through hospital staffing lists, speciality trainees, locum

agencies and professional contacts of the authors. Anonymous responses were collected over 5 weeks in early 2018.

Quantitative data analysis

When assessing HCPs awareness of migrants’ health entitlements, participants could select combinations of answers (figure 1). All wrong answers were grouped together and considered ‘incorrect’. Descriptive statistical methods were used to illustrate the proportion of correct and incorrect answers.

Qualitative research design and methods

Qualitative sample recruitment

ASRs were recruited through Voluntary Community Organizations (VCO) at their free community drop-ins which provide non- medical support in 2018. VCO staff facilitated enrolment. Criterion-based sampling was used to identify ASR who had accessed health services in the preceding 2 years. Participants were provided with oral and written information about the research and written informed consent was obtained prior to interview. Independent professional interpreters, using confidentiality agree- ments, were offered for all contacts.

Qualitative data collection

Semi-structured interviews explored participants’ experiences of accessing healthcare in early 2018. The research team developed an interview guide collaboratively. Audio-recorded interviews were conducted in private at VCO premises and transcribed by university-approved professional services.

Ethical considerations

Ethical approval was obtained from the University of Manchester. Many participants had experienced traumatic events. Avoiding dis- tress and re-traumatization was prioritized using an interviewer with 10 years of experience working with ASR. Participants were given options to withdraw and data was pseudoanonymized. Pseudonyms are used in this article. Participants received travel expenses and a £20 voucher for participation.

Qualitative data analysis

The first phase of qualitative analysis focussed on access to health- care more broadly; methods and findings are described by the same research group elsewhere.

19 From this first phase of analysis, aware-

ness emerged as a dominant finding in need of further exploration. Saurman suggests that awareness functions across multiple domains22 (figure 2). These themes were used as the theoretical framework; thematic analysis was used to re-code the qualitative data into the six domains of awareness. Transcripts were re-analyzed individually by two researchers, before undertaking collaborative review with a third researcher, to ensure consistency.

Results

Quantitative survey results

A total of 514 HCPs completed the survey. The majority of respond- ents were doctors (58%). 30% were nurses and 12% were allied health professionals. Results are displayed in table 1. Respondents’ awareness of the definitions, entitlements and charging regulations affecting migrants was poor. Only 20% of HCPs were confident in defining migrants’ immigration categories. 57% had some idea and 23% were not sure.

All migrants were eligible for free GP and emergency care during the survey distribution. Only 26% of HCPs correctly identified that all migrants were entitled to free GP services. 45% answered incor- rectly and 29% reported being unsure. 64% correctly identified that

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all migrants were entitled to free emergency care. 17% answered incorrectly and 19% were unsure.

Since the extension of the charging regulations in 2017, certain groups of migrants, including some refused asylum seekers,12 are charged ‘prospectively’ for non-emergency hospital care. The survey was distributed following this policy change and only 39% of HCP respondents correctly identified the groups eligible for free care; 27% answered incorrectly and 34% were not sure. Only a small minority (6%) reported understanding the charging regulations. 52% were aware of, but did not understand, them. 42% reported having no awareness of the regulations.

Qualitative interview results

The sample of 18 participants comprised seven males and eleven females aged 18–47 years. Six were refugees, eight were asylum seekers and four were ‘refused’ asylum seekers. Participants had resided in the UK between 4 months and 5 years. The sample reflected the current countries of origin of asylum seekers in the UK.25 Issues of awareness were identified for all of Saurman’s themes (figure 2); however, findings of the thematic analysis mostly centred around three domains. In order to provide a focussed in- sight into the most salient findings, this article describes data from these three dominant themes: (i) ‘whom the service is for’; (ii) ‘where and how to use it’; and (iii) ‘why the service would need to be used’.22

Whom the service is for

There was confusion amongst the ASRs interviewed about which services they were entitled to access for free. Some were unaware they were entitled to free primary care:

When you are out the system, you are a destitute asylum seeker . . . they take us out the system, and they stop the benefits, they stop housing, they stop college . . . they take everything, even the NHS is stopped, you cannot go to your own GP—Pascal

These misconceptions about eligibility meant that some were not registered with a GP:

I’m out the system, because first thing he ask you your address. I don’t have address, I’m homeless. Any form you have you have to write your address, your postcode, your door number, what can I put in this section? When I fill any form without address it doesn’t accept that . . . They didn’t give me appointment because I didn’t fill the form, they asked me. . .you don’t have address . . . You need it to register.—Samir

A number of participants were charged for services, some in- appropriately. One described receiving multiple letters demanding payment for medications prescribed by the GP, which should have been free. This had a negative impact on her mental health:

When I received the first letter, second letter, it made me very, very depression, but when I go to the NHS meeting, who helped the refugee and asylum seekers, so they give me awareness of this one.—Hania

Some ASRs were not aware of their entitlement to free interpret- ation services:

After two and a half years, I find they give interpreters as well. Before I am thinking maybe if I ask them for an interpreter, they must charge me for the interpreter.—Hania

Where the service is and how to use it

Many participants faced difficulties navigating and negotiating the NHS, making comparisons with healthcare in home countries:

I thought it was like in [country of origin], you know, that when you go in to the GP you do get an appointment straight away . . . I didn’t know that I had to register.—Haya I had the . . . knowledge about [country of origin], I didn’t know here. It is quite different to [that] system . . . I don’t know what services the GP offers—Halina

Some participants did not know the imperative or process to book appointments to see clinicians. This impaired access and caused treatment delays:

In our country, we don’t ring them and ask for an appointment, we just walk in and that’s it. But here, we didn’t know how the

Figure 1 Survey questions

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system works . . . we don’t know what to do . . . it was really hard.—Zarah

It’s almost seven months since I registered with the GP and I didn’t even meet the doctor up to now, in six months. I still feel painful in my body . . . six months without anything—Majeed

A number of participants were not aware of how to access an emergency ambulance. One participant with chronic lung disease described:

Even if I’m not breathing well . . . I stay at home because, like, I don’t have medicine and no one can take me and I don’t know how to get that ambulance—Majeed

Participants described confusion about the location of NHS serv- ices. This was augmented by language difficulties, frequent changes of asylum dispersal accommodation and poverty, making transpor- tation problematic:

I think the direction, that’s my problem; if you have an appoint- ment that make me confused the direction. I don’t know anyone here, as you know, it’s difficult for me. I don’t have an Internet to go there, and the bus pass also, the ticket, you don’t have the ticket to go there.—Omari

Few participants received information about how to access healthcare from providers.

I’ve just got that general information from people, so no one has sat specifically and explained, no.—Majeed

Some participants felt they were well informed about how to ac- cess NHS services. This knowledge was gained formally, through social services or VCOs, and informally, through word of mouth. Those with a support network of friends or support workers appeared to have better knowledge of how to use healthcare services:

[The housing officer] told us, showed us, in fact . . . she had a paper and one of the responsibilities to say that in the first day when you enter the house.—Tareq

They give me this paper and the manager of my room where I live I ask him, he show me hospital, he show me [supermarket], how I can buy the food. He show me park.—Isaac

I was connected with the charities . . . they offer me a place to sleep . . . they connected me with the hospital—Tareq

Why the service would be used

There was confusion about which healthcare services should be used for which conditions, leading to delays in safe and appropriate care:

I have a problem with my teeth [but] I don’t know where I need to go.—Aziz

Really, to be honest, I don’t know really how is working [the difference between hospital and GP].—Pascal

I went to the GP, I asked for emergency appointment because I have really emergency thing, but they said we can’t do that be- cause we are crowded with the people in the queue . . . when I’m going outside, one of the people stopped me and he said you don’t go by yourself. . . he said, look, I can see you are at the point that you drag your legs, so you need to call the emergency and the ambulance will come and take you—Tareq

Discussion

The survey identified significant deficiencies in HCPs’ awareness of migrants’ entitlements to NHS care. Only 20% of HCP who responded to the survey described being confident in defining dif- ferent migrant groups. A small minority of respondents (6%) under- stood the NHS charging regulations and there was poor awareness about which migrant groups are entitled to free NHS care. Worryingly, 36% of respondents did not know that all migrants are eligible for free emergency NHS care, irrespective of their im- migration status. These results illustrate an impaired awareness amongst HCPs about migrants’ eligibility for NHS care.

In parallel there are significant gaps in ASRs’ knowledge and understanding of the NHS. Thematic analysis, using Saurman’s’ domains of awareness, highlights three findings. First, ASR have a poor knowledge of their eligibility for free NHS care; second, some NHS services are difficult to navigate and negotiate for ASRs; third, there is a lack of awareness amongst ASR interviewed about why particular services should be accessed. As reported elsewhere, the issue of awareness appeared to be compounded by language diffi- culties, social isolation, insecure accommodation, and poverty.

18

Recent research shows that in comparison to host populations, migrants use emergency healthcare more frequently and for less serious ailments across Europe, however the reasons for this were unclear.

26 Barriers to vulnerable migrants’ healthcare access in the

UK have been described elsewhere. This mixed methods study adds to existing scholarship by jointly exploring the issues of ASRs’ and HCPs’ awareness of healthcare access in England. Awareness is a

Figure 2 Domains of awareness

Table 1 Survey responses

Question 1: how confident are you about the different definitions of ‘refu-

gee’, ‘asylum seeker’, ‘refused asylum seeker’ and ‘economic migrant’

Confident 102 20%

Some idea 294 57%

Not sure 116 23%

Total 512 100%

Question 2: which groups are entitled to free GP services?

Correctly identified all groups 131 26%

Answered incorrectly 233 45%

Reported being unsure 150 29%

Total 514 100%

Question 3: which groups are entitled to free emergency care?

Correctly identified all groups 328 64%

Answered incorrectly 89 17%

Reported being unsure 97 19%

Total 514 100%

Question 4: which groups are entitled to free non-emergency NHS care?

Correctly identified all groups 200 39%

Answered incorrectly 137 27%

Reported being unsure 177 34%

Total 514 100%

Question 5: are you aware of the new charging regulations for overseas

visitors using the NHS brought into effect from October 2017?

Yes; I understand the regulations 30 6%

Yes; but I do not understand the regulations 268 52%

No 216 42%

Total 514 100%

NHS, National Health Service.

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fundamental facet of access.18,21 Our analysis suggests impaired awareness of both ASRs and HCPs is a significant barrier to access- ing safe appropriate care, thus suggests how awareness can contrib- ute to differential patterns of healthcare utilization. These findings also add to a body of literature that problematizes the moral, public health and fiscal implications of a policy that charges vulnerable migrants for healthcare and positions HCPs as immigration offi- cers,

13–18,20 Moreover, by highlighting significant deficiencies in

HCP’s awareness of ASR’s eligibility for NHS care we identify prac- tical difficulties with the new regulations.

Limitations of the research include issues of sampling and exter- nal validity. The sampling method used in both qualitative and quantitative components was opportunistic, which leaves the study vulnerable to self-selection bias. Those who participated in the re- search may be more likely to have a pre-existing interest in the topic. Although this makes generalizations about the ASRs’ experiences from the qualitative data difficult, self-selection for the quantitative component makes HCPs high levels of uncertainty a more signifi- cant finding. Furthermore, the snowball sampling technique means that we were unable to calculate a reliable survey response rate. Questions remain about the relationship between the specialty and grade of the HCP and their likelihood of answering correctly. We only interviewed migrants who had applied for asylum. More research is needed to explore the extent to which these research findings translate to the refusal or delay of medical care into clinical practice, and to other migrant groups.

This research highlights the need to increase migrant populations’ awareness of how to navigate and negotiate the NHS. Health and immigration policy makers must develop and implement robust strategies to ensure new arrivals are provided with information about local health services in appropriate formats, considering lit- eracy in any language and enlisting people with lived experience for co-production. When provided with this information by VCOs or housing workers, ASRs’ access to safe appropriate care appeared to be enhanced. These examples of good practice can guide policy implementation.

Equitable access to healthcare for migrants in the current context of the UK’s hostile environment is an area in need of further re- search. Charging regulations have the potential to influence moral and ethical clinical decision-making.

15,17 Understanding and imple-

menting the regulations is complex, time consuming and requires considerable motivation.

17 This may cause dissonance in the clini-

cian’s ability to provide medically necessary care according to need.14,17 Delivering NHS services free at the point of use is a long- standing fundamental part of UK practitioners’ modus operandi. Many may feel uncomfortable with the racial profiling risk inherent to establishing who is entitled to which care.17 In short, the regu- lations are in tension with the General Medical Council’s recom- mendations for doctors in their guidance ‘Good Medical Practice’.27

This study has identified a gulf in awareness of ASR access to healthcare in England between both providers and receivers of healthcare, which conceivably harms both parties. Further research and policy work must investigate these potential harms; we urge policy makers to revisit this as a priority. Until such work has been done, this research shows that the charging regulations repre- sent a perilous addition to migrants’ already problematic access to healthcare.

Funding

This article was developed during a doctoral research project, which was supported by the Economic and Social Research Council [Grant number 9801149].

Conflicts of interest: None declared.

Key points

• There are concerns that extending charging for migrants’ healthcare in England in 2017 adds further barriers to asylum seekers and refugees (ASRs) healthcare access.

• This mixed methods study explores both HCP and ASR awareness of migrants’ eligibility and access to healthcare in England.

• A lack of awareness in both providers and receivers of health- care is identified, with potential to harm both parties.

• We conclude the charging extensions represent a perilous add- ition to ASRs’ already problematic access to healthcare.

• We urge health policy makers to revisit the introduction of ‘Hostile Environment’ policies into healthcare as a priority.

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� The Author(s) 2019. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckz195 Advance Access published on 21 October 2019

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Prevalence and adverse obstetric outcomes of female genital mutilation among women in rural Northern Ghana

Engelbert A. Nonterah 1,2,3, Edmund W. Kanmiki 4, Isaiah A. Agorinya 1,5,6, Evelyn Sakeah1, Mariatu Tamimu7, Juliana Kagura 8, Michael B. Kaburise1,2, Emmanuel Y. Ayamba1, Esmond W. Nonterah 1, Denis A. Awuni1, Majeedallahi Al-Hassan2, Winfred Ofosu9, John K. Awoonor-Williams10, Abraham R. Oduro1

1 Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana 2 Navrongo War Memorial Hospital, Ghana Health Service, Navrongo, Ghana 3 Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht

University, Utrecht, The Netherlands 4 Regional Institute for Population Studies, University of Ghana, Legon, Accra, Ghana 5 Swiss Tropical and Public Health Institute, Basel, Switzerland 6 University of Basel, Basel, Switzerland 7 Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya 8 Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the

Witwatersrand, Johannesburg, South Africa 9 Upper East Regional Health Directorate, Ghana Health Service, PMB, Bolgatanga, Ghana

10 Policy Planning Monitoring and Evaluation Division, Ghana Health Service, Accra, Ghana

Correspondence: Engelbert A. Nonterah, Navrongo Health Research Centre, Ghana Health Service, P. O. Box 114, Navrongo, Ghana, Tel: þ233 (0) 505989986, Fax: +233 3821 22310, e-mail: drenanonterah@gmail.com

Background: Female genital mutilation (FGM) is commonly practiced in sub-Saharan Africa and results in adverse pregnancy outcomes among affected women. This paper assessed the prevalence and effects of FGM on preg- nancy outcomes in a rural Ghanaian setting. Methods: We analyzed 9306 delivery records between 2003 and 2013 from the Navrongo War Memorial Hospital. Multivariable logistic regression analyses were used to determine the effects of FGM on pregnancy outcomes such as stillbirth, birth weight, postpartum haemorrhage, caesarean and instrumental delivery. We also assessed differences in the duration of stay in the hospital by FGM status. Results: A greater proportion of mothers with FGM (24.7%) were older than 35 years compared with those without FGM (7.6%). FGM declined progressively from 28.4% in 2003 to 0.6% in 2013. Mothers with FGM were nearly twice as likely to have caesarean delivery (adjusted odds ratios ¼ 1.85 with 95%CI [1.72, 1.99]) and stillbirths (1.60 [1.21, 2.11]) compared with those without. Similarly, they had a 4-fold increased risk of post-partum haemorrhage (4.69 [3.74, 5.88]) and more than 2-fold risk lacerations/episiotomy (2.57 [1.86, 3.21]) during delivery. Average duration of stay in the hospital was higher for mothers with FGM from 2003 to 2007. Conclusions: Despite significant decline in prevalence of FGM, adverse obstetric outcomes are still high among affected women. Increased public health education of circumcised women on these outcomes would help improve institutional deliveries and heighten awareness and prompt clinical decisions among healthcare workers. Further scale-up of community level interventions are required to completely eliminate FGM. .........................................................................................................

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