Measurement of female genital mutilation/cutting status: Perspectives from healthcare providers, policymakers, programme implementers, and researchers

Among practicing communities, female genital mutilation/cutting (FGM/C) is a highly sensitive and emotionally charged issue, and open discussion is often considered taboo. Not only may it be difficult to motivate people to discuss the topic, but the validity of their responses may be questionable. These factors make research on FGM/C challenging and hence the need for careful consideration of research methodologies. There is a need for proper documentation of the strengths and limitations of the various data-collection methodologies to assist in generating reliable data for programmatic efforts toward FGM/C abandonment. This working paper describes a study undertaken to highlight methodological opportunities and challenges in measuring the prevalence, drivers, and dynamics of FGM/C. The objectives were to: assess the advantages and challenges of having healthcare providers physically examine and report on women’s FGM/C status; understand the advantages and challenges of self-reporting as a method of data collection for FGM/C; explore the validity of responses from parents or guardians reporting their daughter’s FGM/C status; identify the preferred approaches in measuring FGM/C prevalence; and assess participants’ views about the World Health Organization classification of the different types of FGM/C

Considerations for collecting and documenting FGM/C data by health care providers

Data on female genital mutilation/cutting (FGM/C) are rarely collected in health facilities, yet routine collection of facility-based data through other health-seeking visits (e.g., during antenatal care) is considered good medical practice and can be an important source of data. Clinical exams provide an opportunity to identify women and girls who have undergone FGM/C, which is an important step in aiding the prevention of chronic complications that can be difficult to manage later in life. These exams also make it possible to refer those with FGM/C-related complications for specialized treatment. Clinical visits also present an opportunity to discuss prevention of the practice. In instances where women seeking asylum due to FGM/C are required to prove their status, physical exams can provide supporting evidence. This Guidance Note outlines critical considerations for the collecting and documenting of FGM/C data by health-care providers. Existing literature is drawn upon as well as key findings from a study conducted by the Evidence to End FGM/C research consortium that gathered data from professionals about their views and experiences in the measurement of FGM/C prevalence

A research agenda to strengthen evidence generation and utilisation to accelerate the elimination of female genital mutilation

This ‘Global Research Agenda’, produced by UNFPA, UNICEF, WHO and Population Council–Kenya, outlines evidence gaps and research priorities that need to be addressed to eliminate FGM over the next five years and provides approaches to enable uptake and effective use of the evidence generated

Tracing change in female genital mutilation/cutting: Shifting norms and practices among communities in Narok and Kisii counties, Kenya

In Kenya, there has been a steady and marked decline in the prevalence of female genital mutilation/cutting (FGM/C) but there is great variance in the prevalence of FGM/C across the country, with prevalence remaining high among certain ethnic groups such as Somali, Samburu, Kisii, and the Maasai. The objectives of this study were: 1) to explore whether and how unprogrammed factors or programmed FGM/C interventions (alternative rites of passage, legal and policy measures, religious-oriented approaches, promotion of girls’ education, intergenerational dialogues, use of rescue centers, and other undocumented approaches) influence community values deliberation in Narok and Kisii counties; 2) to assess what changes in FGM/C norms and practices have occurred in Narok and Kisii counties, and identify factors motivating these changes; and 3) to identify barriers to FGM/C abandonment in these key “hot spots,” and assess how, in light of empirical findings and theoretical models of behavior, intervention efforts might be optimized and coordinated to accelerate abandonment. The study clearly shows that norms and practices of FGM/C are not static even in these study areas. While there might not be widespread abandonment yet, people are reassessing norms and traditions in light of the current social climate. These changes may provide a useful starting point for intervention programs that seek to create dialogue and critical reflection on the practice of FGM/C in an effort to accelerate its abandonment

Using Demographic and Health Surveys in the campaign to end FGM/C: A Kenyan example

In order to design effective interventions to end female genital mutilation/cutting (FGM/C), we need to map where FGM/C is practiced and what factors influence it. Data from the Demographic and Health Surveys (DHS), nationally representative surveys conducted in low- and middle-income countries every five years, give us the opportunity to explore how FGM/C is influenced by both individual and community-level factors. Where FGM/C prevalence is not uniform, various research and analysis techniques can be used to improve estimates and draw further information from DHS data. This brief shares insights from two studies carried out in Kenya using DHS data collected in 1998, 2003, 2008, and 2014. The brief presents lessons learned and suggestions for the way forward

Community directed approaches to promote uptake of Sulfadoxine Pyrimethamine for intermittent preventive treatment of malaria in pregnancy: Baseline findings from Kisumu and Migori counties

During pregnancy, malaria has a devastating impact on health outcomes for mothers and infants. Uptake of Sulfadoxine-Pyrimethamine (SP) for intermittent preventive treatment of malaria during pregnancy (IPTp) is a safe and clinically proven medical intervention for the prevention of malaria in pregnancy (MiP). Despite Kenya’s adoption of this intervention in its national policies and guidelines, uptake of IPTp for MiP has been persistently low. To realize effective coverage of IPTp, the Population Council, Kenya in collaboration with Kisumu Medical and Education Trust (KMET) and County Governments, is implementing the Revive IPTp project in Kisumu and Migori counties. The project seeks to increase community engagement in IPTp and promote self-care by pregnant women. This study’s main objective is to generate baseline evidence to inform the design, monitoring, and evaluation of interventions to improve IPTp-SP uptake in two malaria endemic counties in Kenya

Exploring changes in female genital mutilation/cutting: Shifting norms and practices among communities in Fafan and West Arsi zones, Ethiopia

Globally, more than 200 million women and girls have undergone FGM/C. More than half of these girls and women live in three high-prevalence countries: Egypt, Ethiopia, and Indonesia. Given the increase in population growth, recent estimates show that the number of girls and women subject to FGM/C will continue to rise in the coming years unless sufficient efforts are undertaken to encourage abandonment of the practice. A descriptive analysis of changes in FGM/C prevalence over time in Ethiopia shows that the percentage of women aged 15–49 years who report undergoing FGM/C has been declining. Despite the decline, the FGM/C prevalence is still high at 65 percent with new incidences of girls being cut frequently reported. Various interventions have been implemented in Ethiopia for decades with varying success. This working paper provides details of a cross-sectional qualitative study that explores changes in social norms and practices associated with FGM/C in two “hot spot” regions: Somali and Oromia

Guidance document on the use of the Confidante tool to track new or recent cases of female genital mutilation

Female genital mutilation (FGM) is internationally recognised as a violation of human rights that is rooted in social norms including harmful gender norms. In countries where it is prevalent, FGM contributes to bottlenecks that curtail realisation of full potential by girls and women. In settings where FGM is illegal, practising communities may adopt strategies such as cutting girls at very young ages, performing supposedly less severe cuts, or conducting FGM in secret, and thus underreport the occurrence of the practice due to fear of legal consequences. This may hamper tracking and/or measuring the effectiveness and/or impact of interventions and actions to end the practice. Adopting methods from other related fields used to measure sensitive or hidden behaviours may provide an innovative approach to more accurately capturing new or recent cases of FGM, which are a powerful indicator of ongoing violations of human rights. Such data can support advocacy activities as well as strengthen the evaluation of legal frameworks and health systems approaches to address FGM. To this end, the FGM Data Hub developed and piloted a tool that involved the use of the Confidante Method to document new or recent cases of FGM. The evidence generated from piloting the tool was shared with a team of experts (Annex 1) in measurement of sensitive or hidden behaviours during a half-day virtual convening to provide feedback on the application of the tool. The evidence and the tool were further reviewed by end-FGM programme implementers from The Girl Generation-Africa-led Movement to End FGM (TGG-ALM) and other partners across Kenya during a three-day workshop held in Nairobi in June 2023. The tool and this accompanying guide were finalised based on feedback obtained from those engagements

Effectiveness of interventions designed to prevent or respond to female genital mutilation: A review of evidence

Girls are one-third less likely to be subjected to female genital mutilation (FGM) today than 30 years ago. However, rapid population growth in some of the world’s poorest countries, where FGM persists, threatens to roll back progress. In 2020 alone, an estimated 4.1 million girls were at risk of being subjected to FGM. Without concerted and accelerated actions to end the practice, an estimated 68 million additional girls will have been subjected to FGM by 2030. Despite intensified global research efforts to inform strategies to address FGM, there has been little synergy between evidence generation and the implementation of programs and policies designed to end the practice. As the final decade of acceleration toward zero new cases of FGM by 2030 begins, increasing the rigor of research for programming, policy development, and resource allocation is critical. This report synthesized and assessed the quality and strength of existing evidence on FGM interventions reported between 2008 and 2020. Study findings will contribute to strengthening the synergy between evidence generation and FGM programs and inform a global research agenda for FGM

Modelling and mapping of regional disparities associated with female genital mutilation/cutting prevalence among girls aged 0–14 Years in Senegal: Evidence from Senegal (SDHS) Surveys 2005–2017

Between 2005 and 2017, Senegal experienced a slight national decline in the prevalence of female genital mutilation/cutting (FGM/C) among women aged 15–49 years and girls younger than 15 years. However, significant differences in prevalence exist as a result of multifarious risk factors. Our previous research in Senegal described the national trends in FGM/C, showing where, when, and why FGM/C is practiced in Senegal. However, no recent study exists to analyze the geographical patterns of FGM/C and the effect of individual-and community-level risk factors on the likelihood of cutting among girls younger than 15 years. This working paper presents results from a report that provided a more consistent evidence base on the patterns of FGM/C and the impact of multilevel factors on geographical variations in the risk of girls’ cutting. Specifically, this study examined the spatial distribution of FGM/C risks among girls younger than 15 years and identified individual-and community-level characteristics associated with the probability for such girls facing cutting in Senegal. This evidence base is necessary for well-informed targeting of prevention strategies