What interventions are effective to prevent or respond to female genital mutilation? A review of existing evidence from 2008-2020

Correction: What interventions are effective to prevent or respond to female genital mutilation? A review of existing evidence from 2008-2020

[This corrects the article DOI: 10.1371/journal.pgph.0001855.].

Effectiveness of health education intervention on intention not to perform female genital mutilation/cutting in the future among key decision-makers: a systematic review and meta-analysis

BACKGROUND

Female Genital Mutilation/Cutting (FGM/C) is a form of gender-based violence that has negative health consequences. The decision to perform FGM/C is often made collectively and a variety of actors influence the decision. There is inconsistent and inconclusive evidence that health education interventions lead behavioural changes related to FGM/C among key decision-makers. Therefore, the aim of this systematic review and meta-analysis was to examine the effectiveness of health education interventions on decision-makers intentions not to perform FGM/C in the future.

METHODS

A systematic review and meta-analysis were performed according to the Preferred Item for Systematic Review and Meta-analysis (PRISRMA) guideline. Studies were obtained from databases such as PubMed, Google Scholar, EMBASE, CINAHL, Cochrane, African Journals Online and relevant lists of identified studies (interventional studies related to FGM/C among key decision-makers). Unpublished sources and organizational websites were also searched for relevant articles. The quality of studies was assessed using the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project's. The meta-analysis was carried out using STATA.17 and Review Manager 5.3 software. Heterogeneity and publication bias were assessed using the I2 statistic and funnel plot, respectively. The pooled effect size with a 95% confidence interval was presented using a forest plot and random effect model.

RESULTS

This meta-analysis included nineteen studies with a total of 13,326 study participants. The overall pooled relative risk of intention not to perform FGM/C in the future was 1.55 (95% CI;1.24, 1.94). In the subgroup analysis, the effect of health education on intention not to perform in the future was higher in studies that used both health education and other interventions (RR = 3.75, 95% CI; 2.04, 6.88) compared to those using only health education (RR = 1.35, 95% CI; 0.95, 1.92). Studies with longer intervention duration (above 12 months) had a greater effect on intention not to perform (RR = 1.34, 95% CI; 0.86, 2.09) compared to studies with a short intervention period (6-12 months) (RR = 1.14, 95% CI; 0.61, 2.15).

CONCLUSION

This review examined the impact of health education on key decisions-makers' intention not to perform FGM/C in the future. Although the pooled effect size estimate may have been influenced by heterogeneity, the results suggest that education about FGM/C has a positive influence on the intentions of key decision-makers. It is recommended that health education interventions target local decision-makers such as religious and clan leaders and include them in initiatives aimed at preventing and eliminating FGM/C.

PROSPERO REGISTRATION NUMBER

CRD42024542541.

"All you Gain is Pain and Sorrow": Facilitators and Barriers to the Prevention of Female Genital Mutilation in High-income Countries

BACKGROUND

Female genital mutilation (FGM) is a harmful practice that has long-lasting negative impacts on the physical and psychological health of victims. Deemed a global concern, this practice persists in high-income countries (HIC) among certain migrant communities. Given the deleterious effects of the practice, we conducted an updated systematic review of the facilitators and barriers associated with the prevention of FGM in HIC.

METHOD

A systematic review of published qualitative studies of FGM in HIC was conducted from 2012 to 2022. The search resulted in 276 studies. Of these, the majority were from low- and middle-income countries (LMIC) and excluded. A total of 14 studies were deemed fit for inclusion and none were excluded during quality appraisal. Relevant data were extracted from the studies and thematically analyzed to identify prevalent themes.

RESULTS

A total of 12 themes were identified and the majority reflected barriers to the prevention of FGM including beliefs about female virtue, beliefs about social sanctions, and the preservation of culture, among others. Facilitators to the prevention of FGM were fewer and included memory and trauma from experiencing FGM, knowledge and awareness of the female anatomy, and legislative protection from FGM due to migration. A few themes, such as religious beliefs, acted as both facilitators and barriers.

CONCLUSION

Findings highlight the importance of shared cultural and social threads among FGM practicing communities in HIC. Interventions can use these findings to guide the development of sociocultural strategies centered on community-level prevention and reduction of FGM in HIC.

Contextual determinants of generational continuation of female genital mutilation among women of reproductive age in nigeria: analysis of the 2018 demographic and health survey

BACKGROUND

Female genital mutilation (FGM) has negative health implications and has long been recognised as violating sexual rights. Despite the huge efforts expended on eradicating FGM, generational continuation of the practice, i.e. the act of mutilated women also mutilating their daughters, persists in Nigeria. This study investigated the individual, household, and community factors associated with generational continuation of FGM among women in Nigeria.

METHODS

The study analysed data from the 2018 Nigeria Demographic and Health Survey (NDHS). A weighted sample of 3835 women with FGM history and who had given birth to female children was analysed. Models were estimated using mixed-effects multilevel logistic regression with Stata 16.0.

RESULTS

The results showed that 40.0% of women continued FGM for their daughters. Regional prevalence of FGM continuation ranged from 14.9% in the South-South (the lowest) to 64.3% in the North-West (the highest). Women aged 15-24 years (uaOR = 0.40; 95% CI:0.28-0.57) and rich (uaOR = 0.44; 95% CI:0.35-0.56) had the least likelihood of generational continuation of FGM. In communities with low proportions of women unexposed to the media, the likelihood of FGM continuation was significantly higher (uaOR = 1.85; 95% CI:1.35-2.53). Generational continuation of FGM was significantly lower in communities with moderate proportions of uneducated mothers (aOR = 0.6; 95% CI:0.42-0.86).

CONCLUSION

FGM continuation was high in Nigeria, and it was most common among older and poor mothers and in communities with large proportions of uneducated women and those unexposed to the media. Existing National Policy and Plan on FGM elimination should be strengthened to target these characteristics.

"People will talk about her if she is not circumcised": Exploring the patterning, drivers and gender norms around female genital mutilation in Ethiopia's Somali region

Over the past decade there has been a burgeoning literature on social norms and the need to understand their context-specific patterning and trends to promote change, including to address the harmful practice of female genital mutilation (FGM), which affects around 200 million girls and women globally. This article draws on mixed-methods data collected in 2022 and 2023 with 1,020 adolescents and their caregivers, as well as key informants, from Ethiopia's Somali region to explore the patterning, drivers, and decision-making around FGM. Findings indicate that almost all Somali girls can expect to undergo FGM before age 15, and that infibulation is near universal. Critically, however, we find that respondents' understanding of infibulation is rooted in traditional practice, and many girls are now "partially" infibulated-an invasive procedure that girls nonetheless see as an improvement over the past. These shifts reflect religious leaders' efforts to eliminate traditional infibulation--and the health risks it entails--by promoting "less invasive" types of FGM as a requirement of Islam. We also find evidence of emergent medicalization of the practice, as mothers-who are the primary decision-makers-seek to further reduce risks. Adult and adolescent respondents agree that FGM is a deeply embedded social norm, but distinguish between FGM as a perceived religious requirement, and infibulation as a cultural requirement. For girls and women, the importance of FGM is framed around social acceptance, whereas boys and men focus on FGM as a requirement for marriage as it allows families to control girls' sexuality. The article concludes by reflecting on the implications of our findings for programming in high-prevalence contexts. Key conclusions include that FGM interventions should not rely on empowering individuals as "champions of change" but rather prioritize engagement with whole communities, and should be open in the short term to incremental harm-reduction approaches.

The feasibility, acceptability, appropriateness and impact of implementing person-centered communication for prevention of female genital mutilation in antenatal care settings in Guinea, Kenya and Somalia

BACKGROUND

There is limited evidence on how to engage health workers as advocates in preventing female genital mutilation (FGM). This study assesses the feasibility, acceptability, appropriateness and impact of a person-centered communication (PCC) approach for FGM prevention among antenatal care (ANC) providers in Guinea, Kenya and Somalia.

METHODS

Between August 2020 and September 2021, a cluster randomised trial was conducted in 180 ANC clinics in three countries testing an intervention on PCC for FGM prevention. A process evaluation was embedded, comprising in-depth interviews (IDIs) with 18 ANC providers and 18 ANC clients. A qualitative thematic analysis was conducted, guided by themes identified a priori and/or that emerged from the data.

RESULTS

ANC providers and clients agreed that the ANC context was a feasible, acceptable and appropriate entry point for FGM prevention counselling. ANC clients were satisfied with how FGM-related information was communicated by providers and viewed them as trusted and effective communicators. Respondents suggested training reinforcement, targeting other cadres of health workers and applying this approach at different service delivery points in health facilities and in the community to increase sustainability and impact.

CONCLUSION

These findings can inform the scale up this FGM prevention approach in high prevalence countries.