Psychological and counselling interventions for female genital mutilation

Postpartum depressive symptoms in women with female genital mutilation in Somalia

OBJECTIVES

This study aimed to identify associated factors for postpartum depression (PPD) among women with female genital mutilation (FGM) in Somalia.

METHODS

This was a cross-sectional study conducted between February and May 2021 in Somalia Mogadishu-Turkey Recep Tayyip Erdogan Training and Research Hospital, Mogadishu, Somalia. Mothers with any known chronic disease, or psychiatric disorders and who refused to participate were excluded from the study. The cutoff point for depression was defined as ≥13 points according to the Edinburgh Postnatal Depression Scale.

RESULTS

Out of 446 postpartum mothers, 267 (59.9%) had increased depressive symptoms in the early postpartum period. PPD scale scores of mothers who were very poor were significantly higher depression scores than their counterparts (p = .002). Education level, place of residence, occupational status, number of children, type of FGM, and the presence of perineal tear did not differ significantly between depressed and non-depressed groups.

CONCLUSIONS

Women with FGM had increased depressive symptoms in the early postpartum period in Somalia. In addition, women who had lower income had higher PPD scores than their counterparts. Further studies are needed to develop a deeper understanding of the relationships between FGM and PPD and its causes.

What women want: A reflexive thematic analysis of the healthcare experiences of women with female genital mutilation/cutting in South Australia

BACKGROUND

Global migration has seen an increase in female genital mutilation/cutting (FGM/C) cases observed in countries where it is not part of the cultural norm. This shift has led to many healthcare professionals (HCPs) reporting a lack of knowledge and skills necessary to support the needs of women with FGM/C.

AIM

To explore the experiences and needs of women with FGM/C accessing women's health services in South Australia.

METHODS

Women with FGM/C were recruited through purposive and snowball sampling to participate in one-to-one semi-structured interviews. The voice recorded interviews were transcribed verbatim, coded, and analysed using Braun and Clarke's reflexive thematic analysis to determine themes.

FINDINGS

Ten migrant and refugee women living in South Australia, were interviewed. Four themes and 13-subthemes were identified. The main themes were, 1) the healthcare experience, 2) cultural values shape the healthcare experience, 3) speaking up about female genital cutting and 4) working together to improve healthcare experiences.

DISCUSSION

Women's cultural needs, not their health needs, play a fundamental role on how women experienced healthcare services. When women's cultural values and traditions are acknowledged by HCPs, they are more likely to trust and feel confident to engage with services and seek medical support. Areas identified for improvement included access to the right interpreters, having more time during appointments, opportunities for continuity of care and the inclusion of family in care and treatment decisions.

CONCLUSION

Women with FGM/C have specific health and cultural needs that can be met through education and provision of woman-centred care.

Defibulation can recall the trauma of female genital mutilation/cutting: a case report

Background

Women with female genital mutilation/cutting are known to have psychological sequelae from the cutting and other traumatic experiences. However, very few studies report immediate psychological sequelae of genital reconstructive surgery in this population. The present case is the first to our knowledge to report post-traumatic stress disorder symptoms immediately following defibulation, a procedure common in women with female genital mutilation/cutting type III.

Case presentation

We present the case of a 31-year-old Sudanese nulliparous woman in the second trimester of pregnancy with female genital mutilation/cutting type IIIa who was referred for antepartum defibulation to facilitate a vaginal birth. Immediately after an uncomplicated surgery under local anesthesia and just before the first micturition, she developed post-traumatic stress disorder symptoms and suddenly recalled the traumatic experience of her first micturition after female genital mutilation/cutting when she was a child in Sudan. The woman was offered psychiatric follow-up with psychotherapy for 4 months and a short course of benzodiazepines. She had fully recovered by the time of delivery, 4 months after surgery.

Conclusions

We discuss the possibility of recall of a past traumatic experience of female genital mutilation/cutting during defibulation or other genital surgeries. We review the benefits and risks of defibulation, the impact of this procedure, and the setting and timing in which it is performed, focusing on women’s mental health and psychological support.

Cognitive-Emotional Aspects of Post-Traumatic Stress Disorder in the Context of Female Genital Mutilation

Around 200 million women and girls worldwide are affected by female genital mutilation/cutting (FGM/C). FGM/C is a procedure that harms or alters the external female genitals for non-medical reasons, and is usually performed on children. Often, this procedure leads to severe consequences for the women's physical and mental health. In a cross-sectional sample of 112 women seeking medical counseling, physical and mental health characteristics associated with FGM/C were examined and possible predictors for the development of post-traumatic stress disorder (PTSD) in women affected by FGM/C were identified. A total of 55.4% (n = 66) of the women reported symptom levels of probable PTSD. Predictors for higher PTSD symptomology were an older age at the time of the FGM/C procedure, feelings of guilt and the centrality of the event in the woman's life. Thus, cognitive-emotional processing was found to play an important role in the emergence of PTSD in women suffering from FGM/C. However, interventions taking into consideration these characteristics are mostly lacking and need to be investigated further in the context of FGM/C.

Polyvictimization and Psychiatric Sequelae Associated with Female Genital Mutilation/Cutting (FGM/C)

Female Genital mutilation/cutting (FGM/C) is associated with enduring psychiatric complications. In this study, we investigate the rates of co-morbid abuses and polyvictimization experienced by survivors of FGM/C. This is a sub-analysis of a cohort study examining the patient population at the EMPOWER Center for Survivors of Sex Trafficking and Sexual Violence in New York City. A retrospective chart-review of electronic medical records was conducted for all consenting adult patients who had FGM/C and had an intake visit between January 16, 2014 and March 6, 2020. Of the 80 participants, ages ranged from 20 to 62 years with a mean of 37.4 (SD = 9.1) years. In addition to FGM/C, participants were victims of physical abuse (43; 53.8%), emotional abuse (35; 43.8%), sexual abuse (35; 43.8%), forced marriage (20; 25%), child marriage (13; 16.3%), and sex trafficking (1; 1.4%). There was a high degree of polyvictimization, with 41 (51.2%) experiencing 3 or more of the aforementioned abuses. Having FGM/C on or after age 13 or having a higher total abuse score was also found to be strong predictors of depression and PTSD. The high rates of polyvictimization among survivors of FGM/C are associated with development of depression and PTSD. Despite co-morbid abuses, patients still attribute substantial psychiatric symptoms to their FGM/C. Health care providers should understand the high risk of polyvictimization when caring for this patient population.

Female Genital Mutilation/Cutting Education for Midwives and Nurses as Informed by Women's Experiences: Protocol for an Exploratory Sequential Mixed Methods Study

Background

Female genital mutilation/cutting (FGM/C) is a complex and deeply rooted sociocultural custom that is innately entrenched in the lives of those who continue its practice despite the physical and psychological dangers it perpetrates. FGM/C is considered a significant independent risk factor for adverse maternal and fetal outcomes in pregnancy and childbirth. Several studies in high-income countries have explored the experiences and needs of women with FGM/C as well as the knowledge of the health professionals, particularly midwives and nurses, who care for them. However, to date, no studies have evaluated the implementation of education for health professionals in high-income countries to meet the specific needs of women with FGM/C.

Objective

This study aims to explore the impact of an FGM/C education program for midwives and nurses as informed by the experiences of women with FGM/C accessing maternity, gynecological, and sexual health services in South Australia.

Methods

This study will adopt a three-phase, exploratory sequential mixed methods design. Phase 1 will involve the exploration of women with FGM/C views and experiences accessing maternity and gynecological (including sexual health) services in South Australia. The findings from phase 1 will inform phase 2: the development of an educational program for midwives and nurses on the health and cultural needs of women with FGM/C. Phase 3 will involve the evaluation of the program by measuring midwives’ and nurses’ changes in knowledge, attitude, and practice immediately before and after the education as well as 4 months after completing the program. Phase 1 of this study has been approved by the Women’s and Children’s Health Network human research ethics committee (ID number 2021/HRE00156) and the University of South Australia human research ethics committee (ID number 204096).

Results

Phase 1 will commence in August 2021, with the interpretation of findings being undertaken by November 2021. Phase 2 will be developed and facilitated by February 2022, and the final phase of this study will begin in March 2022. This study is expected to be completed by February 2023.

Conclusions

The findings of this research will provide insight into the development and evaluation of education programs for midwives and nurses that includes collaboration with women from culturally and linguistically diverse backgrounds to address the specific cultural and health needs of communities.

International Registered Report Identifier (IRRID)

PRR1-10.2196/32911

Barriers and facilitators to the access to specialized female genital cutting healthcare services: Experiences of Somali and Sudanese women in Norway

BACKGROUND

Girls and women subjected to female genital cutting (FGC) risk experiencing obstetrical, gynecological, sexual, and psychological health problems. Therefore, Norway has established low-threshold specialized healthcare services where girls and women with FGC-related health problems can directly seek medical attention. Nevertheless, we lack data about access to these services, especially for non-maternity-related purposes. In this article, we explore experiences of seeking medical attention for health problems that are potentially FGC-related, aiming to identify factors that hinder or facilitate access to FGC-specialized services.

METHODS

We conducted a qualitative study in three Norwegian cities employing semi-structured repeat interviews with 26 girls and women subjected to FGC, participant observation, and three validation focus group discussions with 17 additional participants. We thematically analyzed the data and approached access as a dynamic process of interactions between individuals and the healthcare system that lasts from an initial perception of need until reception of healthcare appropriate to that need.

FINDINGS

We identified several barriers to healthcare, including 1) uncertainty about FGC as a cause of experienced health problems, 2) unfamiliarity with FGC-specialized services, 3) lack of assessment by general practitioners of FGC as a potential cause of health problems, and 4) negative interactions with healthcare providers. In contrast, factors facilitating healthcare included: 1) receiving information on FGC-related health problems and FGC-specialized services from a non-profit immigrant organization, 2) referral to gynecologists with good knowledge of FGC, and 3) positive interactions with healthcare providers.

CONCLUSION

Assessing whether FGC is the cause for experienced health problems requires diagnostic competency and should not be left entirely to the patients. We recommend that Norwegian policymakers acknowledge the central role of GPs in the clinical management of patients with FGC-related health problems and provide them with comprehensive training on FGC.

Clinical Features Associated with Female Genital Mutilation/Cutting: A Pilot Longitudinal Study

(1) Background: Female genital mutilation/cutting (FGM/C) is associated with physical and psychological complications. However, there is scarce literature on how women with FGM/C respond to treatment interventions. (2) Methods: In the present pilot longitudinal study, we assessed changes in general psychopathology (Symptom Check List-90-R), sexual functioning and distress (Female Sexual Function Index, Female Sexual Distress Scale-Revised, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) female sexual dysfunction criteria), body image (Body Shape Questionnaire), and sexual body image (Female Genital Self-Image Scale) in a sample of n = 15 women with FGM/C before and after reconstructive surgery. (3) Results: Sexual distress was significantly improved following surgery. We also observed an improvement in general psychopathology and genital self-image. However, sexual function was not improved. (4) Conclusions: These results provide evidence for the benefits of reconstructive surgery on sexual distress in women with FGM/C. The impact of surgery on sexual function cannot be conclusively evaluated.

Provider Knowledge and Attitudes About Female Genital Mutilation/Cutting in Philadelphia

BACKGROUND

Due to an increase in immigration from African countries, U.S. healthcare professionals are encountering women affected by Female Genital Mutilation/Cutting (FGM/C). Little formal education exists in medical, nursing or midwifery schools. Additionally, very few studies assess attitudes and knowledge of U.S. providers to care for these women. In order to eventually offer FGM/C-affected women informed and culturally competent care, assessments of provider readiness and attitudes must guide future educational efforts.

METHODS

A voluntary survey was administered to healthcare providers prior to thirteen separate education sessions on FGM/C at Philadelphia institutions.

RESULTS

Of the 229 surveys distributed, 227 were returned > 50% complete. 61.2% reported encountering FGM/C at least once in the past 5 years, yet 13.7% of participants reported receiving formal training in FGM/C; 77.5% felt unprepared and 47.1% uncomfortable serving patients with FGM/C. 34.1% of participants knew the matriarchal influence on the custom. The majority of providers accurately identified the short and long-term clinical consequences of FGM/C, but 67.7% of participants denied familiarity with laws regarding FGM/C. Attitude assessment revealed beliefs that all types of FGM/C are harmful and a practice rooted in tradition.

DISCUSSION

While most providers reported encountering patients with FGM/C, lack of formal training leaves them unprepared and uncomfortable serving them. Results demonstrate misunderstanding of the tradition and motives of FGM/C. Our findings support the need for expansion of provider education to provide culturally competent care for women affected by FGM/C.

Review of Web-Based Toolkits for Health Care Practitioners Working With Women and Girls Affected by or at Risk of Female Genital Mutilation/Cutting

Increased migration has given rise to more advocacy efforts against female genital mutilation or cutting (FGM/C), legislation that criminalizes the practice, and guidance to the health sector for managing care of affected groups. More women and girls who have been cut or who are at risk of FGM/C are migrating from regions where it is common to countries where it is not and interacting with health professionals and other community practitioners in these host countries. Despite numerous studies on the negative health impacts of FGM/C, little is known about toolkits on FGM/C that providers can use in their prevention and response efforts. We sought to explore the nature of Internet-based products referenced as toolkits and materials characteristic of toolkits aimed at different service providers who may interact with women and girls affected by FGM/C. Through an online search, we identified 45 toolkits and collected data about each one. We found that the toolkits targeted different audiences and offered a diverse set of information and resources. The majority of toolkits were aimed at health professionals and provided factual and epidemiological-focused content, yet many did not include research evidence, skills development application, or approaches for implementing the toolkit in practice. This review is the first completed in the area of FGM/C to show a rich diversity of online materials. Future toolkits can be improved with the provision of evidence-based information and practical skills development for use by health professionals in implementing best practices in working with women and girls affected by FGM/C.

Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviews

Background

In a context of high migration, there are growing numbers of women living in the UK who have experienced female genital mutilation/cutting. Evidence is needed to understand how best to meet their health-care needs and to shape culturally appropriate service delivery.

Objectives

To undertake two systematic reviews of qualitative evidence to illuminate the experiences, needs, barriers and facilitators around seeking and providing female genital mutilation-/cutting-related health care from the perspectives of (1) women and girls who have experienced female genital mutilation/cutting (review 1) and (2) health professionals (review 2).

Review methods

The reviews were undertaken separately using a thematic synthesis approach and then combined into an overarching synthesis. Sixteen electronic databases (including grey literature sources) were searched from inception to 31 December 2017 and supplemented by reference list searching. Papers from any Organisation for Economic Co-operation and Development country with any date and in any language were included (Organisation for Economic Co-operation and Development membership was considered a proxy for comparable high-income migrant destination countries). Standardised tools were used for quality appraisal and data extraction. Findings were coded and thematically analysed using NVivo 11 (QSR International, Warrington, UK) software. Confidence in the review findings was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation – Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach. All review steps involved two or more reviewers and a team that included community-based and clinical experts.

Results

Seventy-eight papers (74 distinct studies) met the inclusion criteria for both reviews: 57 papers in review 1 (n = 18 from the UK), 30 papers in review 2 (n = 5 from the UK) and nine papers common to both. Review 1 comprised 17 descriptive themes synthesised into five analytical themes. Women’s health-care experiences related to female genital mutilation/cutting were shaped by silence and stigma, which hindered care-seeking and access to care, especially for non-pregnant women. Across all countries, women reported emotionally distressing and disempowering care experiences. There was limited awareness of specialist service provision. Good care depended on having a trusting relationship with a culturally sensitive and knowledgeable provider. Review 2 comprised 20 descriptive themes synthesised into six analytical themes. Providers from many settings reported feeling uncomfortable talking about female genital mutilation/cutting, lacking sufficient knowledge and struggling with language barriers. This led to missed opportunities for, and suboptimal management of, female genital mutilation-/cutting-related care. More positive experiences/practices were reported in contexts where there was input from specialists and where there were clear processes to address language barriers and to support timely identification, referral and follow-up.

Limitations

Most studies had an implicit focus on type III female genital mutilation/cutting and on maternity settings, but many studies combined groups or female genital mutilation/cutting types, making it hard to draw conclusions specific to different communities, conditions or contexts. There were no evaluations of service models, there was no research specifically on girls and there was limited evidence on psychological needs.

Conclusions

The evidence suggests that care and communication around female genital mutilation/cutting can pose significant challenges for women and health-care providers. Appropriate models of service delivery include language support, continuity models, clear care pathways (including for mental health and non-pregnant women), specialist provision and community engagement. Routinisation of female genital mutilation/cutting discussions within different health-care settings may be an important strategy to ensure timely entry into, and appropriate receipt of, female genital mutilation-/cutting-related care. Staff training is an ongoing need.

Future work

Future research should evaluate the most-effective models of training and of service delivery.

Study registration

This study is registered as PROSPERO CRD420150300012015 (review 1) and PROSPERO CRD420150300042015 (review 2).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Female genital mutilation: implications for clinical practice

Female genital mutilation (FGM) is an established cultural practice in over 30 countries. It has no health benefits, carries a high risk of physical and psychological harm, and is illegal in many countries including the UK. A sensitive approach is required, both in the management of complications and prevention of this practice. This article discusses the prevalence and classification of FGM, and offers practical advice to nurses and midwives involved in general and obstetric care. Legal aspects, including safeguarding responsibilities and the mandatory duty to report FGM in England and Wales, are outlined.

Risk assessment for antenatal depression among women who have undergone female genital mutilation or cutting: Are we missing the mark?

BACKGROUND

Although prohibited by specific legislation in Australia, patterns of global migration underscore the importance for local clinicians to recognise and manage potential complications associated with female genital mutilation/cutting (FGM/C). The incidence of antenatal depression in Australia is 10% and may be higher among those with a history of FGM/C (RANZCOG 2 statement: Perinatal Anxiety and Depression, 2012). The phenomenon of cultural embedding could represent a protective factor against an increase in mental health problems among these women.

AIM

To determine whether women who have undergone FGM/C are at greater risk of depression in the antenatal period as defined by the Edinburgh Postnatal Depression Scale (EPDS).

MATERIALS AND METHODS

A multicentre retrospective case-control study was performed. Participants who had delivered at either of two hospitals, had migrated from FGM/C-prevalent countries and who had undergone FGM/C were assessed and compared with the control group, case-matched by language and religion.

RESULTS

Eighty-nine cases were included with an equal number of matched controls. No significant difference in the EPDS score was demonstrated when analysed as a continuous variable (P = 0.41) or as a categorical variable with a cut-off score of 12 (P = 0.12). There was no difference in the number of women who identified as having thoughts of self-harm between the two groups.

CONCLUSION

There was no identified increase in the risk of antenatal depression among women who have undergone FGM/C from high-prevalence countries. Consideration must be given to the utility of the EPDS in this population, as well as factors such as cultural embedding.

Seeking culturally safe care: a qualitative systematic review of the healthcare experiences of women and girls who have undergone female genital mutilation/cutting

OBJECTIVE

To explore the experiences of accessing and receiving healthcare related to female genital mutilation/cutting (FGM/C) across the life course from the perspective of women and girls who have undergone FGM/C.

DESIGN

A systematic review of qualitative research studies using a thematic synthesis approach.

METHODS

Inclusion criteria were qualitative studies (including grey literature) of any design, from Organisation for Economic Co-operation and Development (OECD) countries, of any date and any language. Sixteen electronic databases were searched from inception to December 2017, supplemented by reference list searching. Papers were screened, selected and quality-appraised by two reviewers using established tools from the Joanna Briggs Institute. NVivo software was used to extract study characteristics and code study findings. An inductive thematic synthesis approach was undertaken to identify descriptive themes and interpret these into higher order analytical constructs. Confidence in the review findings was assessed using Grading of Recommendations, Assessment, Development and Evaluations-Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual).

RESULTS

Fifty-seven papers (from 55 distinct studies) from 14 different OECD countries were included (50% published within the last 8 years). One-third of studies focused exclusively on maternity care experiences, whereas others covered a range of foci. No studies reported explicitly on girls' experiences or on experiences of health service-led safeguarding interventions. Only three studies addressed psychological care. The synthesis developed 17 descriptive themes, organised into 5 analytical constructs. These related to communication, access to care, experiences of cultural dissonance/integrity, disempowering care experiences and positive care encounters. The themes illuminate significant challenges to obtaining timely and holistic care (especially for deinfibulation), and highlight different ways in which women may experience care as disrespectful, unsafe and disempowering. Key elements of 'culturally safe care' are identified.

CONCLUSIONS

This review has highlighted key knowledge gaps, especially around (1) girls'/unmarried women's experiences and (2) the impact of recent safeguarding interventions. There is an ongoing need for community engagement, service development and staff training.

PROSPERO REGISTRATION NUMBER

CRD420150300012015.

'Birds of the same feathers fly together': midwives' experiences with pregnant women and FGM/C complications - a grounded theory study in Liberia

Background

In Liberia, approximately 70% of the women of the North-Central and North-Western regions could have undergone female genital mutilation/cutting (FGM/C) in their childhood during a traditional ceremony marking their entrance into Sande, a secret female society. Little is known about FGM/C from Liberian women’s perspective. This study aimed to understand the health implications of FGM/C as perceived by qualified female midwives.

Methods

This qualitative study was conducted in 2017 in Monrovia, Liberia’s capital. Twenty midwives were approached. Of these, seventeen consented to participate in in-depth interviews. A thematic guide was used to gain insights about their knowledge on FGM/C and their experiences attending women victims of FGM/C. A feminist interpretation of constructivist grounded theory guided data generation and analysis.

Results

The midwives participants described how clitoridectomy was the most common FGM/C type done to the girls during the Sande initiation ceremonies. Sexual impairment and intrapartum vulvo-perineal laceration with subsequent hemorrhage were described as frequent FGM/C-attributable complications that some midwives could be unable to address due to lack of knowledge and skills. The majority of midwives would advocate for the abandonment of FGM/C, and for the preservation of the traditional instructions that the girls in FGM/C-practicing regions receive when joining Sande. The midwives described how migration to urban areas, and improved access to information and communication technologies might be fuelling abandonment of FGM/C.

Conclusion

Liberian midwives need tailored training to provide psychosexual counseling, and to attend the obstetric needs of pregnant women that have undergone FGM/C. In spite of FGM/C being seemingly in the decline, surveillance at clinic-level is warranted to prevent its medicalization. Any clinic- or community-based training, research, prevention and awareness intervention targeting FGM/C-practicing populations should be designed in collaboration with Sande members, and acknowledging that the Liberian population may place a high value in Sande’s traditional values.

It is a problem and it is not a problem: Dilemmatic talk of the psychological effects of female genital cutting

This qualitative study aimed to explore the psychological effects of female genital cutting in the United Kingdom within a systemic psychological framework. Semi-structured interviews were carried out with 13 women who had experienced female genital cutting. Four key themes emerged from thematic analysis of the data: (1) wholeness contested, (2) sexuality milestones and female genital cutting awareness, (3) salvaging family relationships and (4) for our own good. Findings highlight the importance of recognising the relational nature of how women perceive the psychological effects of female genital cutting and how these reactions are negotiated in their social sphere.

Addressing Female Genital Mutilation/Cutting (FGM/C) in the Era of Clitoral Reconstruction: Plastic Surgery

PURPOSE OF THE REVIEW

The aim of this review is to give an overview of the recent evidence on clitoral reconstruction and other relevant reconstructive plastic surgery measures after female genital mutilation/cutting (FGM/C).

RECENT FINDINGS

Recent publications present refinements and modifications of the surgical technique of clitoral reconstruction along with reconstruction of the labia majora and clitoral hood. Novel approaches with reposition of the clitoral nerve, anchoring of the labia majora, fat grafting, and full thickness mucosa grafts have been introduced. The current evidence on outcomes of clitoral reconstruction shows potential benefits. However, there is a risk of postoperative complications and a negative outcome. Experts in the field advocate for a multidisciplinary approach including psychosexual counseling and health education with or without subsequent clitoral reconstructive surgery.

SUMMARY

The evolution of reconstructive treatment for women with FGM/C is expanding, however at a slow rate. The scarcity of evidence on clitoral reconstruction halters availability of clinical guidelines and consensus regarding best practice. Clitoral reconstruction should be provided by multidisciplinary referral centers in a research setting with long-term follow-up on outcomes of postoperative morbidity and possible benefits.

What are the experiences of seeking, receiving and providing FGM-related healthcare? Perspectives of health professionals and women/girls who have undergone FGM: protocol for a systematic review of qualitative evidence

INTRODUCTION

Female genital mutilation (FGM) is an issue of global concern. High levels of migration mean that healthcare systems in higher-income western countries are increasingly being challenged to respond to the care needs of affected communities. Research has identified significant challenges in the provision of, and access to, FGM-related healthcare. There is a lack of confidence and competence among health professionals in providing appropriate care, suggesting an urgent need for evidence-based service development in this area. This study will involve two systematic reviews of qualitative evidence to explore the experiences, needs, barriers and facilitators to seeking and providing FGM-related healthcare in high-income (Organisation for Economic Cooperation and Development) countries, from the perspectives of: (1) women and girls who have undergone FGM and (2) health professionals.

REVIEW METHODS

Twelve databases including MEDLINE, EMBASE, PsycINFO, ASSIA, Web of Science, ERIC, CINAHL, and POPLINE will be searched with no limits on publication year. Relevant grey literature will be identified from digital sources and professional networks.Two reviewers will independently screen, select and critically appraise the studies. Study quality will be assessed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument appraisal tool. Findings will be extracted into NVivo software. Synthesis will involve inductive thematic analysis, including in-depth reading, line by line coding of the findings, development of descriptive themes and re-coding to higher level analytical themes. Confidence in the review findings will be assessed using the CERQual approach. Findings will be integrated into a comprehensive set of recommendations for research, policy and practice.

DISSEMINATION

The syntheses will be reported as per the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. Two reviews will be published in peer-reviewed journals and an integrated report disseminated at stakeholder engagement events.

PROSPEROREGISTRATION NUMBER

CRD42015030001: 2015 and CRD42015030004: 2015.