Interventions to reduce the prevalence of female genital mutilation/cutting in African countries
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Interventions to reduce the prevalence of female genital mutilation/cutting in African countries 29.-31. May 2012 Rigmor C Berg, Ph.D., CHES. BACKGROUND.

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Interventions to reduce the prevalence of female genital mutilation/cutting in African countries29.-31. May 2012Rigmor C Berg, Ph.D., CHES


  • Female genital mutilation / cutting (FGM/C): ”the partial or total removal of the female external genitalia or other injury to the female genital organs for cultural or other non-therapeutic reasons”(WHO, 1997)

  • 4 classifications / types: (WHO, 2008)

    • Clitoridectomy

    • Excision

    • Infibulations

    • Other

BACKGROUND - Prevalence

  • About 100 – 130 million worldwide

  • About 3 million at risk every year

  • Primarily in 28 countries in Africa

    • Some countries in the Middle East and Asia

    • Immigrant communities in Western countries


FGM/C prevalence among women aged 15-49

Source: Female genital mutilation/cutting : a statistical exploration. New York, NY, UNICEF; 2005.


  • Violates a series of well established human rights principles, norms and standards, e.g.:

    • Universal Declaration of Human Rights, 1948

    • International Covenant on Civil and Political Rights, 1966

    • Convention on the Elimination of all Forms of Discrimination against Women, 1979

    • Convention on the Rights of the Child, 1989

  • No known health benefits


  • Almost all cut girls/women experience health problems:

    • pain, chronic infections, difficulty in passing urine and faeces; obstetrical complications (WHO 2000, 2006, 2008)

    • systematic review on physical health complications following FGM/C underway at NOKC

  • Little or no change in prevalence over last decades

  • Usually carried out on girls under the age of 15  trend towards lowering of age

  • Usually performed by traditional practitioners trend towards “medicalization”

BACKGROUND – Our previous SRs re FGM/C

  • 3 systematic reviews

    Reasons Consequences Effectiveness

BACKGROUND – Our previous work re FGM/C

  • Reasons for and against FGM/C:

BACKGROUND – Our previous work re FGM/C

  • Consequences

    • Psychological:

      • may be more likely to experience psychological disturbances (have a psychiatric diagnosis, suffer from anxiety, somatisation, phobia, and low self-esteem)

    • Sexual:

      • more likely to experience pain during intercourse

      • more likely not to experience sexual desire

      • lower sexual satisfaction

BACKGROUND – Our previous work re FGM/C

  • Effectiveness of interventions

    • Included 6 studies of low methodological quality

    • Uncertainties regarding relevance of the interventions (e.g. regarding objectives, intervention targets, activities); reasons for limited effectiveness


  • What is the effectiveness of interventions designed to reduce the prevalence of FGM/C compared to no or other active intervention?

  • How do factors related to the continuance and discontinuance of FGM/C help explain the effectiveness of interventions designed to reduce the prevalence of FGM/C?


  • Systematic review (transparent, reproducible)

  • Search: 13 e-databases, organizations’ websites, reference lists, experts

  • Independent and paired screening, appraisal of methodological quality, data extraction

  • Data analysis

Research Questions:

1. What is the effectivenessofinterventionsdesigned to reduce the prevalenceof FGM/C compared to no or other


2. How do factorsrelated to the continuance and dicontinuanceof FGM/C helpexplainthyeeffectivenessof

interventionsdesigned to reduce the prevanelceof FGM/C?


One comprehensivesearch for empirical studies thataddress the topicof FGM/C


Screening 2:

Sorting ofpublicationsaboutfactorsrelated to the continuance and discontinuanceof FGM/C.


Screening 1:

Sorting ofpublicationsabout the effectivenessofintervention programs to reduce the prevalenceof FGM/C. Applicationofinclusioncriteria.

Synthesis 1: Effectiveness studies


-Description, in text and tables, of the programs


Synthesis 5: Realist synthesisapproach

Synthesisofresults from synthesis 1 (the effectivenessofinterventins) and

synthesis 4 (factorsrelated to the continuance and discontinuanceof FGM/C)

Synthesis 2:

Quantitative studies


-Extractionofquant. data

-Synthesisofquant. data

Synthesis 4: Quant-QualIntegrative

Quantitative and qualitative data synthesisoffactorsrelated to the continuance and discontinuanceof FGM/C)

Synthesis 3:

Qualitative studies


-Extractionofqual. data

-Synthesisofqual. data

METHODS – Realist synthesis

  • Realist synthesis attempts to explain how outcomes (efficacy) of an intervention varies depending on the particular configuration of its constituent mechanisms and contexts

    • The approach is hypothesis generating, the result of which leads to tentative recommendations meant to influence the design of new programs

  • “interventions offer resources which trigger choice mechanisms (M) which are taken up selectively according to the characteristics and circumstances of subjects (C), resulting in a varied pattern of impact (O)” (Pawson, 2006 p25)

  • Mechanisms are the engine behind behaviour (what is on offer in the program that may persuade participants to change)

  • Context is important because the action of mechanisms to some extent depends on the realities of the context in which they are used (Pawson, 2006; Pawson et al., 2005)


6,323 records identified through

database searching

472 records identified through

other sources


5,450 records after duplicates removed

5,450 records screened

5,344records excluded

1 study not obtained in full text


105 full texts assessed for eligibility

63 full texts excluded:

-7 effectiveness studies

-56 context studies


  • 35 studies included

  • 8 effectiveness studies (12 publications)

  • 27 context studies (30 publications)






  • 8 studies

  • Weak methodological quality

  • Controlled before-and-after design

  • 7 countries

  • N=7,042




Burkina Faso


  • 1997 – 2004; duration 2 weeks – 18 months

RESULTS – Study level

  • 49 study level outcomes

  • 19 of 49 (39%) of outcomes for which there was baseline similarity showed significant differences between the groups

    • Most of these (74%) were for the secondary outcomes attitudes/beliefs and knowledge regarding FGM/C in the community-based interventions

RESULTS - Pooled

Figure 3. Forest plot, belief that FGM/C compromise human rights of women

  • Belief that FGM/C compromised the human rights of women

  • Prevalence of FGM/C among girls 0-10 years

RESULTS - Pooled

Figure 3. Forest plot, belief that FGM/C compromise human rights of women

  • Knowledge of harmful consequences of FGM/C (women)

  • Knowledge of harmful consequences of FGM/C (men)




Egypt k=9



  • 27 studies (1 qual)

  • Methodological quality= 9 high, 12 moderate, 6 low

  • N= 67 to 15,573 (median= 1,020)



Kenya (Somalis)




Burkina Faso k=2

Training of health personnel (Mali)

  • Pro: custom (61%), good tradition (28%), religious necessity (13%)

  • Con: medical complications (45%), bad tradition (30%), prevents sexual satisfaction (13%), painful experience (13%)

  • Improvements not triggered by the intervention

  • Not clear extent to which contextual factors embedded in program

  • Intervention seems to be fitting response:

    • Program embedded in local public health services

    • Aimed at improving health providers’ involvement with FGM/C

    • Medical complications the most frequently voiced reason for opposing the practice among Malians thinking FGM/C should be stopped

Education of female students (Egypt)

  • Pro: custom (45%), sexual morals (30%), reduce sexual desires/preserve virginity (16%)

  • Con: complications (22%), sexual problems (16%), no benefit or value (14%)

  • Increase in knowledge of dangers of FGM/C

  • Not clear extent to which contextual factors embedded in the curriculum

  • Benefits of placing FGM/C in a reproductive health context

    • Egypt DHS data showed few women recognized the potential adverse physical consequences of the practice for women.

Communication program (Nigeria)

  • Pro: custom (61%), reduce/control female sexual desire (37%), religion (19%)

  • Con: medical complications (38%), bad tradition (49%), unnecessesary (19%)

  • Some positive effects

  • Not clear extent to which identified cultural factors were embedded in the communication intervention

  • Sound fit between the program theory of change and program components

  • With convention theory as a driver of change, dosage of program messages important (advantage of exposure to a combination of activities and mass media)

Outreach and advocacy (Kenya & Ethiopia)

  • 97% of Somalis in favour of FGM/C: custom license for marriage (84%), religious obligation (70%), protection of virginity (27%)

  • Pre intervention research, embedded in program

  • In Kenya, change in comparison group

  • In Ethiopia, some positive effects in intervention group

  • Embedded in existing reproductive health projects

  • Critical factors:

    • religious leaders

    • program exposure

Tostan educ. prog. (Mali, Senegal, Burkina Faso)

  • Mali:

    • Pro: custom (61%), good tradition (28%), religious necessity (13%)

    • Con: medical complications (45%), bad tradition (30%), prevents sexual satisfaction (13%), painful experience (13%)

    • Senegal:

      • Pro: respect tradition (94%), obey religious demand (39%), guarantee women’s cleanliness (52%), initiate girls (53%), for women to get married (22%), men prefer cut women (21%)

    • Burkina Faso:

      • Pro: custom (77%), hygiene (15%), avoid immoral behaviour/preserve virginity (15%)Con: medical complications (59%), prohibited by law (35%)

Tostan educ. prog. (Mali, Senegal, Burkina Faso)

  • Unclear whether pre-implementation research

  • Issue of FGM/C integrated within a larger project curriculum

  • Mali: Marginal effects

  • Senegal: Several positive effects

  • Burkina Faso: Several positive effects

  • Role of religion addressed? Religious leaders’ engagement and commitment sought?

  • Major implementation problems


  • Some positive developments as a result of interventions, but:

    • low quality of the body of evidence affects the interpretation of results and draws the validity of the findings into doubt

    • none of the studies randomised, most contained prognostically dissimilar intervention and comparison groups, contamination of the intervention seems to have occurred in four sites


  • Extent to which can conclude regarding how factors related to the continuance and discontinuance of FGM/C help explain the effectiveness of interventions is limited, because:

    • difficult judging match between the interventions’ content components and factors related to FGM/C’s continuation, because effectiveness reports lacked descriptions on intervention content

    • studies did not explicitly report on the relevant effective components of the mechanisms that were assumed to bring about FGM/C related behavior change


  • All programs based on a theory that provision of information improves cognitions about FGM/C

    • All measured change in knowledge or beliefs related to FGM/C; positive results from six programs

  • Success contingent upon contextual factors:

    • Integrating the issue of FGM/C in a larger set of community-relevant issues facilitated acceptance

    • Alliance with religious leaders

  • Process factors:

    • Participants not aware of or signed up to take account of the research dimension of the study; information was not recalled/retained

    • Role conflict or uncertainties for staff

    • Insufficient measures in place to reduce confounding

    • Adverse prevailing program and evaluation climate


  • Financial support: 3ie (International Initiative for Impact Evaluation)

  • Colleague: Eva Denison


Contact details:

Rigmor "Rimo" C Berg

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