Safi Abdulahi's protruding belly leads the way to the fourth floor of the hulking Hennepin County Medical Center building. The big-eyed 20-year-old shuffles down an echoing hallway, draped in vibrant dresses with a hijab hugging her round cheeks. She passes a framed photo of a sleeping ivory-pale baby and duplicate English and Spanish posters shouting the benefits of breastfeeding. She stops at a corner area labeled in large letters, "BIRTH CENTER."
Minutes later, Abdulahi lies on a sterile bed in the doctor's office. A lady spreads cold jelly over her seven-month-pregnant belly. A machine shows a blurry picture of her son curled up inside her. The baby's heart is beating just fine, the woman tells her.
For a moment, Abdulahi's mind is at ease. Then just as quickly she is preoccupied with questions about the delivery. Will it hurt badly? Will there be medicine to ease the pain? She doesn't ask how the birth, or her body, will be affected by what was done to her as a child.
Suffer in Silence
Abdulahi lay on the kitchen floor of her home in Ethiopia, waiting, as her mom handed money over to a stranger. She had never met the old woman now hovering over her armed with a pair of scissors and a razor. Then everything went blurry. All she'd remember was the piercing pain. Sections of her vagina were cut away, the whole of it sewn nearly entirely shut.
The next time she was cut was just after her wedding day. Abdulahi's new husband surveyed her body to confirm she was pure and untouched. Then she headed to a doctor to open the sutures slightly so she could consummate the marriage.
Now, relaxing on a couch in her south Minneapolis apartment, Abdulahi says she plans to have doctors open her up once more — this time to give birth. The beaming mother-to-be says she wants the doctors to "open everything, bigger!"
But at nearly eight months pregnant, Abdulahi hasn't yet talked with her doctor about if and when this procedure would be done, and whether her vagina would be sewn again after giving birth.
Back home in Ethiopia, Abdulahi underwent the most severe form of female genital cutting — infibulation, or "fir-oo-ni" as the Twin Cities' African immigrant community calls it. Though the media and some experts refer to the procedure as "female genital mutilation," healthcare professionals who work with African immigrants prefer "female genital cutting," a less offensive term to infibulated women. The procedure, practiced in nearly 30 African countries and a few places in Asia and the Middle East, involves removing all external genitalia, sometimes the clitoris, and then sewing the two sides of the vulva together so the woman is left with a hole about the width of a pencil for urinating and menstruating.
Most of these women come from war-torn areas; some have seen their friends and families brutally murdered, yet still vividly remember the day they were cut. They remember their childhood friends who didn't make it out alive.
Abdulahi's 17-year-old neighbor in Ethiopia was one of those friends. Her head sinks to her chest as she remembers how the girl wanted to have only sunnah like the "lucky" girls whose clitorises are removed or only nicked with a small razor. But her friend's mother forced her to have the full circumcision. The procedure went wrong. The teenage girl bled to death.
Female genital cutting is usually performed when the girl is younger than high school age.
Abdulahi has asked her own mother why she made her undergo the worst form of FGC. "Why did you do this one?'" she's pleaded. That's what she had done to her, Abdulahi's mother says, so she wanted her daughter to have the same.
The mother and daughter are close, and live together along with Abdulahi's husband in a small, two-bedroom apartment.
Even late in her third trimester, Abdulahi cooks and helps care for her aging mother, whose body is partially paralyzed from polio. The women go on walks together around nearby parks, one of Abdulahi's favorite pastimes since she dropped out of school last winter. She's become a bit stir crazy in the confined apartment and likes to get out whenever she can. "Right now, I just stay home. I just clean, I just cook something. That's it."
She expects her mother, not husband, to be in the delivery room when she has the baby. "I'm so shy!" Abdulahi says at the thought of him seeing her give birth.
She, like many Ethiopian women, is very close with her mother. Matriarchs have a lot of say in their daughters' life choices — including the style and severity of the genital cutting they undergo. Traditionally, being cut makes a woman more desirable and gives her the best chance of finding a good husband in countries where the practice is popular. It's a tradition that's passed on from generation to generation.
Groups like UNICEF and the World Health Organization have made strides in educating communities about health risks and the long-held misconception that cutting is in the Quran, but experts agree that cultural habits are the hardest to break. Many don't see the tradition ending soon. With the practice still widely popular, more immigrants will be coming into Minnesota cut.
FGC is illegal in the U.S. But because of the Twin Cities' large Somali immigrant population, the nonprofit Population Reference Bureau has ranked it one of the top three metropolitan areas in the U.S. where women and girls are at risk for having undergone FGC or having it done to them in the future. More than 37,000 Twin Cities women were at risk in 2013, and that number rises to over 44,000 throughout the state.
An influx of immigrant women who have been cut, compounded by a lack of consensus on FGC in the medical community, could create an even larger gap between health providers and their new patients. And that gap is already wide enough as it is.
On a warm spring day, Abdulahi and about a dozen other pregnant African immigrant women lie on yoga mats, adjusting their hijabs and flowing dresses to get comfortable. They prop their legs up on chairs in a 45-degree angle, squirming and chatting with the women next them. After the yoga class is done, they wade into the middle of the room where couches and chairs form a square for a weekly talk with Shamsa Idle.
Idle is the doula of all doulas in the Twin Cities. Soon-to-be moms around the area typically hear about her through word of mouth and come find her at Everyday Miracles, a nonprofit center in northeast Minneapolis that provides pregnancy services and doula support for expecting mothers.
As a doula, Idle shepherds pregnant immigrants through prenatal care, a concept foreign to many of the women. Healthcare and birth practices in countries like Somalia and Ethiopia are vastly different from the Western world. Next to no preventative health care is practiced in their home countries. When they get pregnant in the U.S. they're often puzzled by all the doctors visits and ultrasounds.
Since Somali is Abdulahi's native language, she struggles to understand what her physicians tell her at monthly check-ins. She's polite and agreeable and nods along, though later admits she doesn't exactly know what was said.
She and others come to Idle to decode their hospital experiences. Idle is their most critical advocate at the hospital because she's fluent in Somali and English, and both cultures. Without her, many immigrant women are lost in a sea of English medical jargon.
More than any doctor, Idle understands what these women are going through. She's a Somali immigrant, a mother of six grown children, and was also cut as a girl.
She was 7 years old and two women held down her legs and began to cut. She says she called out "Mama! Mama! Help!" Her mother had to put cotton balls in her ears so she wouldn't hear the screams.
Back in Somalia, Idle was a distinguished nurse and midwife. After receiving a scholarship to learn about infant nutrition in Rome for a stint, she returned to Somalia and helped educate families about nutrition and healthy eating habits. Civil war in the 1990s eventually forced her and her family out of their home, and eventually to America. Once here, Idle was driven to continue helping families in her immigrant community.
The former nurse is content being a family educator at Minneapolis non-profit Way To Grow and a doula at Everyday Miracles in her free time. She doesn't want to go to nursing school in the U.S. because she insists nurses do more work than doctors, and get paid a lot less. Idle's tone quickly shifts from spunky to annoyed, and sometimes angry, whenever she talks about doctors. Many of them don't listen to or understand these women's needs, she says. They might be reluctant to cut open an infibulated vagina during delivery and instead push for a C-section. That's where she comes in.
"It happened last week. The mom [was] in labor and she was pushing and I know when you cut it helps, too. And the doctor, finally, said that."
Idle's Everyday Miracles classes hum with chatter and side-conversations until she asks what worries them about giving birth. "The pain!" some chime in. Others mention epidurals – they're cautious of what the drugs may do to them and their babies.
Cesarean sections, in particular, are on every woman's mind. They've heard from family and friends that U.S. hospitals make sewn women have C-sections. They've heard they won't be able to have as many kids if they have one. That's a terrifying thought for a community of women who believe they should have all the children Allah will gift them.
The C-section fear stems from the 1990s, when Somali, Liberian, Ethiopian, and other African immigrants started pouring into Minnesota. The health industry then wasn't as familiar with female genital cutting. Some health professionals would recommend a C-section rather than cutting the scar open. That's less likely now, especially in the Twin Cities, where midwives and hospitals are more familiar with FGC.
But the women still want Idle by their side, just in case. Idle pushes them to speak up for themselves, too. "You have your voice," she emphasizes to the mothers. "I teach them that so they know they have a right even to say."
To sew or not to sew
Like Abdulahi, some infibulated expecting mothers might not think to ask what will happen to their unique anatomies before and after they give birth. Even if they did, their doctor might not have an answer for them.
Clinicians should be offering to cut open, or defibulate, a sewn vagina before the woman gives birth, says Jessica Lane, community outreach coordinator for women's services at Park Nicollet. But Lane, who has spent years researching FGC and working with women affected by it, has found that many providers don't necessarily know how to do that.
Lane's research has found that only 12 percent of over 500 women-focused healthcare providers in the country felt comfortable performing defibulation. And though more than half of them had provided care to a patient who had undergone FGC, a majority couldn't correctly identify the different forms of it.
Lane says she knows a family practitioner for a local hospital who will get paged, even when she's not on-call, to do the cut because some of her co-workers don't feel comfortable doing it. "Obviously, there's gaps," she said.
Then there's the controversial question: Do you re-sew the woman's vagina after she gives birth? If so, how much?
Abdulahi isn't sure if or how much she'd like her vagina sewn up after she gives birth, but that might not be up to her anyway. There are no federal policies on whether re-sewing a vagina is considered female genital mutilation. A doctor can choose whether to perform the procedure and how far up to sew, leaving the woman's body at the mercy of her clinician.
Mary Malotky, an advanced practice nurse and midwife at Hennepin County Medical Center, says she knows some doctors don't believe in sewing the vagina and won't do it, but she maintains that's the woman's choice, not the doctor's.
If the woman does ask that it be sewn up, Malotky says HCMC will try to educate her on the health risks associated with infibulation and convince her to just close the opening slightly.
Recently, more African women and their families are opting to keep the vagina completely open, she says. But even then the woman may feel some discomfort with the new opening. It isn't a custom to repair the vagina in countries where FGC is popular, Malotky says, but for some women closing it is about feeling comfortable in their own skin.
At Everyday Miracles, a 40-year-old Somali woman pregnant with her seventh child, who chose to remain anonymous, said her midwives have sewn her after every child, not for cultural reasons, but because she's used to her body that way.
"I've had Somali women say 'This is my sexual identity, this is how I feel beautiful,'" Malotky says.
Kathrine Simon, owner of North Metro Midwives in Plymouth, Minn., will also sew at the mother's wishes. Her job isn't to take a stance on re-infibulation or judge her patients, she says.
"I don't go home with her," she says. "I don't know what happens there. They still have to deal with the decisions they make when they go home."
As far as health risks go, Simon says she's never had anyone come in with a vaginal infection whether they've been re-sewn or not. But if the woman does want it sewn mostly closed, the doctor would close it up just to the urethra to prevent any potential complications.
Although she advocates for her patients to keep their vaginas open after birth, Idle still believes the doctor should respect the woman and ask her opinion.
"Sometimes the doctor is really, really good and they ask ... 'Do you want to sew again?' But mostly they ask, 'Why would she want [that if] she'll have another baby?'"
Bridging the gap
After a long evening of yoga and chatting amongst themselves, the group of pregnant women at Everyday Miracles moves from the couches to a dinner table full of sweet Somali rice and goat meat.
The women closest to their due dates give Idle money for the food, and in return everyone prays for them to have safe, quick and natural births free of epidurals and C-sections.
These weekly talks and gatherings led by Idle provide the women with a sense of comfort that can be rare for them to find with some of their doctors. Idle has even had women travel from St. Cloud, where a lot of Somali immigrants live, because they didn't feel comfortable going to their local hospitals where they fear doctors won't know how to care for infibulated women.
"Nowadays, [the doctors] learn a lot. But sometimes you see a new doctor or what you call a 'resident' and they have no idea," Idle says.
Regions Hospital, Allina Health, HCMC, and the University of Minnesota's Women's Health Specialists Clinic said all or most of their OBGYNs know how to defibulate women. They also all allow the patient to decide if she wants to be re-sewn after giving birth.
However, when first asked about its care practices for infibulated women, an HCMC spokeswoman said the hospital rarely sees these patients because there "aren't that many women coming from Somalia for their first pregnancy." And in regards to re-sewing patients, she said, "This isn't about respecting someone's culture – it's about being complicit in mutilating women."
Later, she recanted, noting that HCMC's Midwife Unit sees quite a few infibulated women and it does, in fact, repair vaginas and refers to the patients for how far to sew.
This kind of miscommunication emphasizes the gap in understanding female genital cutting, even within one hospital. Most providers in Lane's study said they want additional counseling and technical guidelines on the clinical and surgical management of FGC. A portion also said FGC is an important topic that isn't adequately addressed in clinical practice.
Lane's hoping that her study, which is still awaiting publication, will spur a discussion within the medical community about the issue and lead to more training on the topic for providers.
She also urges physicians to be nonjudgmental about female genital cutting when working with the African immigrant population. "If you've lived here your whole life and you haven't experienced a lot of what they've experienced, to you female genital cutting is this horrific thing. [But] I have friends that are Somali and their moms have stories of being raped in front of their husbands, watching daughters being raped, husbands killed. They've seen horrific things."
That's the philosophy the U of M's Women's Health Specialists Clinic follows. Patients all have different experiences and opinions regarding their infibulated genitals and the clinic doesn't try to tell them what they should do with their bodies after giving birth, says the clinic's medical director, Carrie Terrell. "We have a really open approach. We realize we are more progressive than some providers in the state."
Terrell, who's worked with the local African immigrant population for 16 years, is also an OBGYN assistant professor at the university's medical school. She says students who go through the clinic's OBGYN rotations have a good chance of learning about FGC because it sees a lot of Somali patients, though students aren't guaranteed to work with the population.
Her primary advice to new doctors working with an immigrant population? "Familiarize yourself with the culture and the techniques and opportunities that you can offer women."
Not like before
Abdulahi points at the words stitched across her baby boy's onesie as he lies belly-up on a blanket spread across the floor of their living room. "Se-ri-ous-ly cute," she recites, smiling.
The eight-pound baby took five hours to deliver, and wasn't easy – even with the epidural Abdulahi opted for. She's still surprised at her body's ability. "This head is big, how'd it come out?" Allah helped stretch her open for the birth, she says with surety. She wasn't cut to give birth, she says.
Abdulahi's midwife helped put her vagina back to her liking, though. The HCMC midwife sewed her up "not like before," but just slightly. She assumed everyone was sewed up a little after birth so she would be, too.
Shamsa Idle wasn't at the delivery, but Abdulahi's mother, mother-in-law, and female cousin were by her side, along with the health providers. There were a lot of ladies in the room, so many Abdulahi says she isn't sure who they were. One of them showed her how to change her son's diaper. She'd never changed one before.
Abdulahi brushes her fingers softly across her newborn's closed eyes, round cheeks and pursed lips while he falls asleep in her arms. "Please sleep," she quietly pleas.
Before giving birth, Abdulahi thought maybe she'd have seven kids. Exhausted, she's not so sure about that now. Her husband jokes that they'll have 17. Abdulahi quickly replies, "No."
"Whatever God gives to us ... that's the way," he says.
Abdulahi's cell phone rings, and an automated message plays in Somali on speaker. It's HCMC, confirming a follow-up appointment for the baby. She's not sure, but she thinks they want to weigh him.