Prosjekt: Interventions to prevent the practice of female genital mutilation

Summary
Female Genital Mutilation (FGM; also known as female circumcision and female genital cutting), a traditional practice that involves partial or total removal or alteration of female genitalia, is recognized to violate human rights – civil, cultural, economic, political and social – of girls and women. It is also associated with several health risks. Systematic appraisal of the evidence concerning the effects of interventions to prevent FGM, of the perspectives and understandings of stakeholders in FGM, of the psychosocial consequences of FGM, and of “best practice” policies to prevent the practice of FGM is lacking. We will review the literature relating to these issues.

Commission
The Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) has been given the task of establishing a competence centre on FGM. To support their efforts in doing this, they contacted The Norwegian Knowledge Centre for the Health Services (NOKC) in November 2008 to discuss the potential for collaboration in this area.

Specifically, NOKC was asked to:

• prepare a systematic review of the available evidence regarding the effects of interventions to prevent the practice of FGM
• prepare a systematic review of  qualitative studies addressing the perspectives and understandings of stakeholders in FGM, with particular emphasis on immigrant communities in Europe
• prepare a systematic review of the psychosocial consequences of FGM, from an epidemiological perspective (spectrum of consequences, prevalence)
• prepare an overview of “best practice” for policies to prevent the practice of FGM
• identify and describe recent national/regional studies that have evaluated the process of implementing “best practice” guidelines to prevent the practice of FGM.
  

Introduction
Female Genital Mutilation (FGM) is a traditional practice that involves partial or total removal or alteration of female genitalia (Muteshi & Sass, 2005). FGM is practised in more than 28 countries in Africa and in some countries in the Middle East and Asia (HRP, 2006). It is estimated that between 100 million and 130 million girls and women living today worldwide have undergone some form of FGM and that about 3 million experience FGM every year. FGM is usually carried out on girls under the age of 15 years (HRP, 2006). Recently, figures for African countries were reported, showing a prevalence of more than 70% in Burkina Faso, Djibouti, Egypt, Eritrea, Ethiopia, Guinea, Mali, Mauretania, Northern Sudan, and Somalia (Yoder & Kahn, 2008). FGM is also practised by immigrant communities in a number of countries, including France, the UK, Norway, Sweden, Switzerland, Canada, the US, Australia, and New Zealand (HRP, 2006).

The practice of FGM 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).

FGM is recognized as a harmful practice which violates the human rights – civil, cultural, economic, political and social – of girls and women (WHO, 2008). FGM is associated with several health risks and consequences such as caesarean section, postpartum haemorrhage, episiotomy, extended maternal hospital stay, resuscitation of the infant after birth, and inpatient perinatal death (WHO, 2000; 2006).

Efforts to abandon the practice of FGM 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, a health risk approach, training health workers as change agents, training and converting circumcisers, an alternative rites approach, the positive deviance approach, and the use of comprehensive social development approach. Interventions based on these approaches have targeted stakeholders at individual, interpersonal, community and national levels (Muteshi & Sass, 2005).

In Norway, FGM has been prohibited by law since 1995. A project, OK-prosjektet, was launched in 2001 as a national programme for the implementation of the 2001 Action Plan against Female Genital Mutilation. The objectives of OK-prosjektet were to prevent the practice of FGM in Norway and provide care for those already mutilated or at risk of FGM. The working methods comprised the development of educational materials, the building of competence, and the elaboration of methods for work against FGM within the health care system and among the concerned ethnic groups (Johansen, 2007). An evaluation of the project took place in 2005 and the results suggest that the public authorities became more skilled at putting FGM on the agenda, that competence was improved and that procedures and that collaboration relating to work with FGM was developed (Lien, 2005). Data from a recent Norwegian survey show that in 2007 there were about 6000 girls aged 0 – 19 years who came from, or had parents who came from, countries where FGM is practised. Of these, about 3800 girls were within the age group in which FGM would be practised in their home country, possibly placing them at risk of FGM. However, there seem to be few instances of FGM that have taken place in Norway or during trips to the home country (Lidén & Bentzen, 2008). 

Although there are indications of the effectiveness of some interventions against FGM in achieving desired outcomes such as changes in knowledge, beliefs, attitudes, behaviours and practices related to FGM (Lien, 2005; Muteshi & Sass, 2005), systematic appraisal of the evidence is lacking. Further, much research has used observational designs that do not permit causal inferences, thus hampering valid conclusions about the effects of these interventions (Askew, 2005).

There are also indications that perspectives and understandings of FGM are different in immigrant communities in European countries compared to perspectives in their countries of origin (summarized in Lidén & Bentzen, 2008).  A deeper and/or broader[*] understanding of the views of stakeholders in immigrant communities on the practice of FGM may allow more nuanced knowledge and inform further intervention strategies in immigrant communities in Norway.

The health complications of FGM have been reviewed systematically (WHO, 2000), but a systematic review of the psychosocial consequences of FGM seems to be lacking. Such knowledge may also usefully inform further intervention strategies.

WHO has suggested that comprehensive efforts to eliminate FGM should be multisectoral, sustained, and community-led (WHO, 2008). Systematic knowledge and description of both national/local policies or guidelines to prevent the practice of FGM and the implementation of such policies/guidelines seems to be lacking in Norway.

Methods
The populations, interventions, comparisons and outcomes (PICO) for the systematic review of interventions are outlined below.

 

Population	Girls and/or young women at risk of FGM Communities practising FGM
Interventions	Any intervention intended to prevent, or reduce the incidence of,, FGM including: Legislation against FGM Education about health risks associated with FGM Training health workers as change agents Training and converting circumcisers Alternative rites Positive deviance Comprehensive social development training child- or social welfare workers change agents
Comparison	No intervention or one or more other interventions
Outcomes	These will include: Rates of FGM (although we expect this to be available rarely) Public declarations to abandon FGM Proportion of sample in favour of abandoning FGM Behaviours related to FGM Attitudes towards FGM Beliefs related to FGM Knowledge of adverse effects of FGM Awareness of rights

 

Study designs to be included in the reviews

• In the systematic review of interventions to prevent FGM we will include randomised controlled trials and quasi-randomised controlled trials. We also include observational studies that include a reasonably reliable control group, e.g. “controlled before-after studies” where findings among those receiving the intervention are compared with findings during the same time-period among similar groups not receiving the intervention. We will exclude simple before-after comparisons that do not include a control group.
• In the systematic review of qualitative studies of the perspectives and understandings of stakeholders in FGM we will include studies that utilise qualitative methods for both data collection and analysis and that are primarily conducted in immigrant communities in European countries.
• In the systematic review of psychosocial consequences we will primarily include observational comparison studies, case control studies and cohort studies that describe the prevalence of psychosocial consequences of FGM in ethnic groups or compare psychosocial consequences across groups.
• For the review of “best practices” and implementation of “best practice” guidelines or policies we will include guidelines and studies that describe evaluation of implementation processes.

Literature searches
For each review, we will search for studies in a number of databases indexing original research and/or clinical practice guidelines. The choice of databases and the search strategies will be developed together with a information science specialist from NOKC and partners at NKVTS.

Language
The literature-search will not exclude studies based on language of publication. All eligible English and Scandinavian-language articles will be included in the review. We will also include studies in other languages if feasible and if these studies are considered sufficiently important.

Quality assessment of studies for systematic reviews
Two independent researchers will assess study quality using accepted checklists and/or risk of bias tables.

Grading of evidence (for intervention studies):
The strength of evidence for outcome effects for any intervention will be graded using the GRADE method (GRADE working group, 2004) and presented in text or tables.

For a more detailed description of the methods used for systematic reviews at The Norwegian Knowledge Centre for the Health Services, please refer to our web site (http://www.nokc.no)

Activities and time plan
The project starts in December 2008, and the plan is to finalise it by 31.07.2010.

Report/publication
The main final products are

1. A systematic review of the effects of interventions to prevent the practice of FGM.
2. A systematic review of qualitative studies addressing the perspectives and understandings of stakeholders in FGM, with particular emphasis on immigrant communities in Europe.
3. A systematic review of the psychosocial consequences of FGM, from an epidemiological perspective (spectrum of consequences, prevelance)
4. An overview of “best practice” for policies to prevent the practice of FGM
5. Descriptive, brief review of recent higher level/national studies that have evaluated the process of implementing “best practice” guidelines to prevent the practice of FGM

References

Askew I 2005 Methodological issues in measuring the impact of interventions against female genital cutting. Culture, Health & Sexuality, 7:463-477.

GRADE working group 2004 Grading quality of evidence and strength of recommendations. BMJ, 328:1490-1594

HRP 2006 (The UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction) Progress Newsletter No. 72

Johansen E 2007 Endring innenfra. Sluttrapport for OK-prosjektet 2001-2004. Oslo: NAKMI

Lidén L, Bentzen T 2008 Kjønnslemlestelse I Norge. Institutt for samfunnsforskning. Rapport 2008:8

Lien I-L 2005 Tiltak mot kjønnslemlestelse. Evaluering av OK-prosjektet - det nasjonale prosjektet for iverksetting av tiltak i handlingsplanen mot kjønnslemlestelse. NIBR-rapport 2005:8

Muteshi J, Sass J. 2005 Female genital mutilation in Africa: an analysis of current abandonment approaches. Nairobi: PATH

WHO 1999 Female genital mutilation. Programmes to date: what works and what doesn’t? A review. Department of Women’s Health, Health Systems and Community Health.

WHO 2000 A systematic review of the health complications of female genital mutilation including sequelae in childbirth. Department of Women’s Health, Health Systems and Community Health.

WHO Study Group on Female Genital Mutilation and Obstetric Outcome 2006 Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet, 367:1835−1841

WHO 2008 Eliminating female genital mutilation: an interagency statement. UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCHR,UNHCR, UNICEF, UNIFEM, WHO

Yoder S, Kahn S 2008 Numbers of women circumcised in Africa: the production of a total. USAID, DHS Working Papers No. 39