PROTOCOL: Interventions to reduce the prevalence of female genital mutilation/cutting in African countries

Female genital mutilation/cutting (FGM/C) is a traditional practice that involves the partial or total removal or other injury to the female genital organs for cultural or other non-therapeutic reasons (WHO, 2008). The current classification describes four types of FGM/C: Type 1, clitoridectomy involves partial or total removal of the clitoris and/or the prepuce. Type 2, excision, involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3, infibulation, involves narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Infibulation is considered the most invasive type of FGM/C. Defibulation, opening of the covering seal, is often necessary prior to childbirth. Reinfibulation refers to the recreation of an infibulation after defibulation. Type 4, other, involves all other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterizing (WHO, 1997). FGM/C is practised in more than 28 countries in Africa, usually on girls under the age of 15 years, and in some countries in the Middle East and Asia. FGM/C is also practised by immigrant communities in a number of other countries, including Australia, Canada, France, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States (HRP, 2006). Recent figures for African countries show a prevalence of FGM/C of more than 70 percent in Burkina Faso, Djibouti, Egypt, Eritrea, Ethiopia, Guinea, Mali, Mauritania, Northern Sudan, and Somalia (Yoder & Kahn, 2008). However, there is great variation in prevalence between and within countries, reflecting ethnicity and tradition. Therefore, UNICEF (2005) has proposed that countries be categorized in three groups according to FGM/C prevalence rates: Group 1, 80 percent or higher prevalence, e.g. Ethiopia and Somalia, Group 2, 25-79 percent, e.g. Senegal and Kenya, and Group 3, 1-24 percent, e.g. Nigeria (Table 1). The practice of FGM/C is rooted in religious, personal and societal beliefs within a frame of psycho-sexual and social reasons such as control of women's sexuality and family honour, which is enforced by community mechanisms (WHO, 1999). While reasons for the practice vary across cultural groups, social reasons may include FGM/C as an initiation act for girls into womanhood, as an act of social integration and for the maintenance of social cohesion. Socio-economic reasons include beliefs that FGM/C is a prerequisite for marriage or an economic necessity in cases where women are largely dependent on men. Religious reasons rest on the belief that it is a religious requirement. Hygienic and aesthetic reasons for FGM/C include beliefs that the female genitalia are dirty and unsightly, and health reasons include beliefs that FGM/C enhances fertility and child survival. FGM/C may also be an important source of income for circumcisers (UNFPA, 2007). Girls exposed to FGM/C are at risk of immediate physical consequences, such as severe pain, bleeding, and shock, difficulty in passing urine and faeces, and infections. Long term consequences can include chronic pain and infections (WHO, 2008). In general, the consequences are similar for FGM/C Type I, II, and III, but they tend to be more severe and more prevalent the more extensive the procedure (WHO, 2008). A systematic review of the health complications of FGM/C (WHO, 2000) identified a range of obstetrical problems, the most common being prolonged labour and/or obstruction, episiotomies and perineal tears, post partum haemorrhage, and maternal and foetal death. A recent study investigating 28,393 women attending 28 obstetric centres in several African countries (Banks et al, 2006) concluded that women with FGM/C are significantly more likely than those without to have adverse obstetric outcomes such as a caesarean, postpartum blood loss 500 mL, extended materna I hospital stay, birth weight <2500 g, infant resuscitation, and inpatient perinatal death. The authors also concluded that the risks seemed to be greater with more extensive FGM/C. For many girls and women, undergoing FGM/C is a traumatic experience that leaves a lasting psychological mark and may adversely affect their mental health. In fact, several psychological and psychosomatic disorders such as disordered eating and sleeping habits have been attributed to FGM/C (HRP, 2006). There are also reports of posttraumatic stress disorder, anxiety, and depression associated with FGM/C (WHO, 2008). FGM/C is a deeply entrenched social convention among some ethnic groups and as such carries consequences both when it is and when it is not practised. When girls and families conform to the practice they acquire social status and respect. For girls, undergoing FGM/C promotes honour and her full acceptance in the community, as well as imparts a sense of pride and of coming of age (UNICEF, 2005). In some societies, the link between FGM/C and value is explicit: girls who undergo FGM/C often receive rewards in the form of celebrations and gifts, and the bride price for a girl who has been cut is much higher than that for one who has not (Wheeler, 2003). For families, fulfilling the cultural expectation that girls should be cut assigns status and community membership. Conversely, failure to conform leads to difficulty in finding a husband for the girl, shame, stigmatization, as well as loss of social status, honour and protection, resulting in the family's social exclusion in the community (UNICEF, 2005). Sexual consequences of FGM/C were summarized in a non-systematic literature review (Obermayer, 2005), which concluded that the available evidence does not support the notion that FGM/C automatically precludes sexual activity or the enjoyment of sexual relations. The results from a recent systematic review by the authors of the present project proposal suggest that women with FGM/C experience pain and reduction in sexual satisfaction and desire compared to women without FGM/C. The evidence base is however insufficient to draw causal conclusions about the consequences of FGM/C (Berg et al, 2010a). Efforts to abandon the practice of FGM/C in Africa have used several different approaches which, in turn, have had implication for interventions. These approaches include those based on human rights frameworks, legal mechanisms, health risks, alternative rites, positive deviance, training health workers as change agents, training and converting circumcisers, and the use of comprehensive social development processes. Interventions based on these approaches have targeted stakeholders at individual, interpersonal, community and national levels (Muteshi & Sass, 2005). In 2007, the Population Reference Bureau (PRB) published their results of an extensive survey of current intervention projects taking place in African countries (Feldman-Jacobs & Ryniak, 2007). In total, PRB identified 92 projects, 27 of which were evaluated, mostly by observational designs. Only four of the 27 evaluated projects (15%) used a controlled before-and-after design, and about a dozen of the evaluations used cross-sectional or pre-post intervention questionnaires or interviews without a comparison group. While contributing great understanding about the range of interventions initiated to curb the prevalence of FGM/C, the overview did not reach any conclusions about the effectiveness of interventions. More recently, the authors of the proposed project specifically examined the effectiveness of interventions to reduce the prevalence of FGM/C in a systematic review (Denison et al, 2009). Through our literature search of February 2009 we identified a total of seven controlled studies, six of which could be obtained in full text. All six studies were controlled before-and-after studies carried out in African countries. In contrast to the PRB overview (Feldman-Jacobs & Ryniak, 2007), we included only controlled studies, i.e. studies with reference to a non-intervention comparison group, and we concluded that while the evidence base is insufficient to draw definite conclusions, there are possible advantageous developments as a result of interventions. Notably, the review highlighted the uncertainties regarding relevance of the interventions (e.g. regarding objectives, intervention targets, activities). That is, it not a of the systematic we were to any of the to which the interventions were to the with to FGM/C, including the to which that to the of the practice were into in the interventions. is that the of relevance of the intervention a on an effectiveness in and may to a variation in and other outcomes among of In recent have examined of interventions to reduce the prevalence of FGM/C. However, the effectiveness of interventions in the of relevance has to be FGM/C is a that has from ethnic and social among many groups (UNICEF, 2005). of from the and that the practice of FGM/C by such as and or and also by such as ethnicity and (Yoder et al, of by UNICEF that a status and ethnicity have the in support or to the practice (UNICEF, 2005). to reduce the prevalence of FGM/C should be and to ethnic and while also taking into the reasons FGM/C is practised among a ethnic or cultural (UNICEF, 2005). 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