Thesis (Ph.D.)--University of Washington, 2022About 87% of Sudanese women (15 – 49 years) have undergone female genital mutilation (FGM) mostly performed by midwives (64%). Since 2016, Sudan’s federal ministry of health (FMoH) initiated the largest health program focused on FGM in the country, with an aim of changing midwives’ involvement from being the ones performing FGM to instead being agents of change promoting FGM abandonment to their clients and communities as well as providing appropriate care to those with health related complications. There is a limited body of evidence for this programmatic approach in FGM prevalent and low resource settings as it is a nascent area of work. We used mixed methods, primary and secondary data, as well as implementation science and evaluation frameworks, to study Sudan’s first three years of this program (2016 – 2018). The specific objectives of the study were to 1) determine its scope and scale using program data; 2) identify facilitators and barriers that influenced planning and implementation as perceived by program managers through in-depth interviews; and 3) examine associations between past trainings and current midwives’ knowledge, attitudes and practices in Khartoum state using an exposure based comparative cross-sectional study.
The program data analysis showed that Sudan addressed the World Health Organization’s (WHO) four recommended strategic pillars of action for 1) governance and finance, 2) knowledge and skills of health workers, 3) monitoring and evaluation and accountabilty, and 4) creating an enabling environment with significant achievements. There was governmental buy-in with national funds that matched donors’ funds for training activities (pillar 1). A third of all midwives (N=16,183) were trained (pillar 2) and there were several foundational activities on monitoring and evaluation as well as an accountability mechanism for midwives who perform FGM (pillar 3). Various professional and health students’ association members (10 – 59%) made calls to end practice or for its criminalization (pillar 4).
Program managers felt that Sudan’s context and FMoH characteristics strongly influenced the health program design and implementation. Reported facilitators included both international and national funding availability, integrating FGM related activities within existent priority health intervention packages, and presence of an evaluation and feedback culture within international organizations. The barriers included power asymetries in decision making and engagement of all players for national and international funds during planning and implementation, low health system functionality and non-willingness to provide FGM prevention services among health workers in health centers.
The exposure based cross-sectional study found that trained midwives were more likely to have higher knowledge on FGM types, to be aware that performing FGM was a violation of professional code of conduct and to have greater knowledge on de-infibulation procedure compared to non-trained midwives.
In conclusion, Sudan’s experience generated several lessons for its existing program moving forward as well as other countries with a similar profile intending to implement or adopt WHO’s strategic pillars at a large scale. Though the existent programmatic data were rich and of good quality it was not centralized into a database for use by the FMoH. A centralized database which includes costs and interventions’ outcomes will enable program managers to test different scale up modalities to optimize costs and effectiveness. There is a need to identify approaches to strengthen joint accountability, decision-making and engagement of relevant stakeholders as equals and the impact on intervention outcomes, scale and sustainability studied. Training programs targeting midwives would need to address their values and self-efficacy in changing their FGM practices, as well as provide essential clinical skills for managing FGM related health complications. Health system and societal factors that deter midwives from abandoning FGM practice would need to be addressed in tandem through health system strengthening in coordination with other multi-sectoral interventions. Finally, frequent evaluations using dissemination and implementation science frameworks would enable health stakeholders assess implementation effectiveness in timely manner so that the health sector has a meaningful contribution into FGM abandonment efforts as well as improving the quality of life for girls and women affected by FGM
