77, 95% CI 0.52 to 7.10).20 Similarly, the case–control study from Egypt could not establish a difference opposite between FGM/C type II and type I with respect to tubal factor infertility (AOR=1.9, 95% CI 0.8 to 4.2).40 The available evidence did not allow us to conclude whether women were more likely to be infertile if they were cut by a traditional than a medical circumciser (AOR=2.1, 95% CI 0.8 to 5.7).40 Ten cross-sectional studies examined infertility in women with and without FGM/C. The association between FGM/C and infertility varied, both in unadjusted analyses (effect estimates ranged from

0.34 to 3.67) and adjusted analyses (AORs from 0.99 to 2.76). Specifically, the results of the two clinical studies of moderate to high methodological quality did not establish a greater risk with FGM/C (OR=1.3, 95% CI 0.7, 2.7; OR=1.05, 95% CI 0.65 to 1.67. Of eight adjusted estimates, two reached significance. These are not shown here because the CIs were not

provided in the publications).46 54 Obstetric outcomes Obstetric events (prolonged labour, tears/lacerations, caesarean section, episiotomy, instrumental delivery, haemorrhage, difficult labour) were reported in 26 comparative studies (2.97 million women).19 24–29 33–36 38 42 43 48 51 53 56 59 61 66–69 71 72 Seven of these were prospective.24 28 29 43 53 69 70 Eight studies reported adjusted data, with the number and types of confounders varying greatly across studies (detailed in the study under review).28 36 42 43 48 66 68 69 Data on prolonged labour were reported in six studies.28 29 36 48

53 68 The meta-analysis of adjusted estimates from four studies showed a significantly greater risk of prolonged labour with FGM/C (AOR=1.49, 95% CI 1.01 to 2.19; GRADE: low; figure 4).28 36 48 68 There was one prospective study, of low to moderate methodological quality, that reported an adjusted estimate for prolonged labour, the result of which was concordant with the meta-analysis (AOR=2.40, 95% CI 1.40 to 2.80).28 Regarding obstetric tears/lacerations, the meta-analysis of four studies which presented adjusted data showed an AOR of 1.39 (95% CI 0.99 to 1.95; GRADE: very low; figure 4).42 48 66 68 No prospective studies presented Carfilzomib adjusted estimates for obstetric tears. There were 15 studies with data on caesarean section.24 25 28 29 33 42 48 56 59 66–71 Five studies reported adjusted estimates, the pooled estimate of which resulted in an AOR of 1.32 (95% CI 0.97 to 1.80; GRADE: very low). Restricting the meta-analysis to the two prospective studies established a significant difference between groups (AOR=1.60, 95% CI 1.33 to 1.91; GRADE: low), indicating a greater risk of caesarean section among women with FGM/C (figure 4).28 69 As with the other obstetric outcomes, the study-level results were inconsistent regarding episiotomy.