Female genital mutilation/cutting in Sierra Leone: Are educated women intending to circumcise their daughters?

BMC International Health and Human Rights, Volume 20, No. 1, Year 2020

Interpretation

Background: Female genital mutilation/cutting (FGM/C) has been recognized as a gross violation of human rights of girls and women. This is well established in numerous international legal instruments. It forms part of the initiation ceremony that confers womanhood in Sierra Leone. Girls and women who are subjected to this practice are considered to be ready for marriage by their parents and communities and are rewarded with celebrations, gifts, and public recognition. Following this, we examined the relationship between education and women’s FGM/C intention for their daughters in Sierra Leone. Methods: We used cross-sectional data from the women’s file of the 2013 Sierra Leone Demographic and Health Survey (SLDHS) to explore the influence of education on FGM/C intention among women in the reproductive age (15-49). A sample of 6543 women were included in the study. Our analysis involved descriptive computation of education and FGM/C intention. This was followed by a two-level multilevel analysis. Fixed effect results were reported as Odds Ratios and Adjusted Odds Ratios with their respective credible intervals (CrIs) whilst results of the random effects were presented as variance partition coefficients and median odds ratios. Results: Our findings showed that women who had no formal education were more likely to intend to circumcise their daughters [aOR = 4.3, CrI = 2.4-8.0]. Among the covariates, women aged 20-24 [aOR = 2.3, CrI = 1.5-3.4] were more likely to intend to circumcise their daughters compared to women between 45 and 49 years old. Poorest women were more likely to report intention of circumcising their daughters in the future compared with the richest [aOR = 2.1, CrI = 1.3-3.2]. We noted that, 63.3% of FGM/C intention in Sierra Leone is attributable to contextual factors. Conclusion: FGM/C intention is more common among women with no education, younger women as well as women in the lowest wealth category. We recommend segmented female-child educational and pro-poor policies that target uneducated women in Sierra Leone. The study further suggests that interventions to end FGM/C need to focus on broader contextual and social norms in Sierra Leone. Data for this study was obtained from the 2013 Sierra Leone Demographic and Health Survey (SLDHS) [38]. The 2013 SLDHS happens to be the second version of the Demographic and Health Survey following the first one in 2008. The survey intended to gather data for monitoring the population and health circumstances and to serve as a follow-up to the first survey. It captured information on female genital mutilation, fertility preferences, maternal and child health as well as sexual activity. It was implemented by the Statistics Sierra Leone (SSL) under the auspices of the Ministry of Health and Sanitation. The National Technical Committee and National Steering Committee provided technical and policy guidance for the conduct of the survey. Inner City Fund (ICF) International also offered technical assistance via the MEASURE DHS Program [38]. Sample for the survey was designed to generate dependable estimates for essential variables for the entire country in both rural and urban locations as well as across the four regions and the fourteen districts [38]. To ensure representation for all the aforementioned demarcations, the sample was stratified and selected in two stages. Primary Sampling Units (PSUs), also known as clusters were selected based on the list of enumeration areas (EAs) created in the preceding Population and Housing Census in the first stage [38]. The EAs offered the principal frame for selecting 435 clusters (158 from urban and 277 from rural) through probability proportional to their sizes. Excluded from the sampling frame were persons residing in collective housing units including hospitals, hotels and boarding schools [38]. Thirty (30) households were systematically selected from each of the clusters in the second stage. All eligible persons in the subsample of households participated in the study. This comprised women aged 15–49 and men aged 15–59. Although, 17, 1323 eligible women (15–49 years) were identified in all, complete interviews were conducted with 16,658 and this culminated in a 97% response rate. Nearly half of these women had at least one daughter (46.7%). The three questionnaires used (household questionnaire, woman’s questionnaire, and man’s questionnaire) emerged from the models developed by the MEASURE DHS Program. However, the questionnaires were modified to fit the context of Sierra Leone [38]. Intention to circumcise daughter in the future was the dependent variable for the study. As part of the survey, the women were asked “Do you intend to have daughter(s) circumcised in future?” The corresponding responses were ‘No’ coded as 0, ‘Yes’ coded as 1, and ‘Don’t Know’, coded as 8. To arrive at findings that reflect precision in thought and offer meaningful recommendations, women who responded ‘Don’t Know’ were excluded from the study. The principal independent variable was formal education. In the DHS survey, formal education is categorised into ‘No Education’, ‘Primary Education’, ‘Secondary Education’ and ‘Higher Education’. Some socio-demographic characteristics of these women were included in the study to access their association with intention of the women to circumcise their daughters in the future. These are age, wealth, religion, region, residence, healthcare decision making, number of daughters already circumcised, frequency of reading newspaper, frequency of listening to radio and frequency of watching television (TV). Following the hierarchical structure of the datasets, all the variables were categorised into individual (education, age, wealth, religion, healthcare decision making, number of daughters, number of daughters circumcised, frequency of reading newspaper, frequency of listening to radio, frequency of watching television) and contextual (family head, region and residence) level factors. To ensure clarity, two of the variables were recoded. These are religion-recoded as ‘Christian = 0’, ‘Islam = 1’, ‘Other = 2’ and number of daughters circumcised recoded as ‘No = 0’, ‘1 = 1’, ‘2 = 2’, ‘3 or more=3.’ We carried out descriptive analysis as well as two-level multilevel analysis. At the descriptive level, we calculated women’s education and the proportion of women who intended to circumcise their daughters in the future. Chi-square test was conducted in order to determine the socio-demographic variables that significantly relate with intention to circumcise daughter in the future. Due to the clustering and hierarchical nature of the datasets, these analyses were followed by the multilevel analysis conducted with the MLwinN command version 3.05 [39]. Prior to modelling, the dataset was ordered to account for the clustering nature of the survey. A total of four models were constructed with the first one being an empty model in order to ascertain the variance in FGM/C intention at the contextual level (model 1). The second model comprised fixed effects at the individual level (model 2) whereas model three accounted for fixed effects at the contextual level (model 3). In the final model (model 4), fixed effects at the individual and contextual level were fitted. Results of the fixed effects were presented as odds ratios (ORs) and adjusted odds ratios (aOR) together with their corresponding credible intervals (95% Crl). Credible interval was based on the Bayesian statistical approach whereby probability allocation for association measurements are derived whilst 95% credible intervals (95% Crls) are used for summarisation. The 95% CrI implies the possibility of the parameter assuming a value in the specified range [40]. Variance partition coefficient (VPC), also referred to as intraclass correlation coefficient (ICC), and median odds ratio (MOR) were reported for the random effects [41, 42]. The VPC assesses the magnitude of variance in the likelihood of FGM/C intention that is explained by or attributable to contextual factors. The MOR, on the order hand, accounts for the contextual variance in terms of odds ratio and calculates the propensity of FGM/C intention that is explained by contextual factors. Multicollinearity was assessed with the variance inflation factor before the models were developed [43]. Sample weight was applied and the entire analysis was executed with Stata version 13.0. Ethical approval was granted by the Ministry of Health and Sanitation of Sierra Leone as well as the ethics committee of the DHS Program. During the survey, informed consent was sought from all participants. We applied for and were granted access to the dataset by the Measure DHS Program. The dataset is freely available through https://dhsprogram.com/data/available-datasets.cfm.

AI Digest

Study Justification:

– Female genital mutilation/cutting (FGM/C) is a violation of human rights and is recognized as such in international legal instruments.
– This study aims to explore the relationship between education and women’s intention to circumcise their daughters in Sierra Leone.
– Understanding this relationship can inform targeted policies and interventions to address FGM/C in the country.

Highlights:

– The study used data from the 2013 Sierra Leone Demographic and Health Survey.
– Findings showed that women with no formal education were more likely to intend to circumcise their daughters.
– Younger women and women in the lowest wealth category were also more likely to have this intention.
– Contextual factors accounted for 63.3% of FGM/C intention in Sierra Leone.

Recommendations:

– Implement segmented female-child educational policies targeting uneducated women in Sierra Leone.
– Develop pro-poor policies to address FGM/C, considering the higher intention among women in the lowest wealth category.
– Focus interventions on broader contextual and social norms in Sierra Leone to effectively end FGM/C.

Key Role Players:

– Ministry of Education: Responsible for implementing segmented female-child educational policies.
– Ministry of Health and Sanitation: Involved in developing and implementing interventions to address FGM/C.
– Non-governmental organizations (NGOs): Collaborate with the government to provide support and resources for educational and intervention programs.
– Community leaders and religious leaders: Play a crucial role in changing social norms and attitudes towards FGM/C.

Cost Items for Planning Recommendations:

– Educational programs: Budget for developing and implementing segmented female-child educational policies.
– Awareness campaigns: Allocate funds for raising awareness about the harmful effects of FGM/C and promoting behavior change.
– Training and capacity building: Provide resources for training healthcare providers, educators, and community leaders on FGM/C prevention and intervention strategies.
– Monitoring and evaluation: Include budget items for monitoring the progress and impact of interventions and programs.
– Research and data collection: Allocate funds for conducting further research and collecting data to inform evidence-based interventions.
Please note that the cost items provided are general categories and not actual cost estimates. The specific budget items would need to be determined based on the context and scope of the interventions and programs.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional study using data from the 2013 Sierra Leone Demographic and Health Survey. The study involved a large sample size of 6543 women and used multilevel analysis to examine the relationship between education and women’s intention to circumcise their daughters. The findings showed that women with no formal education were more likely to intend to circumcise their daughters. The study also identified other factors associated with FGM/C intention, such as age and wealth. The study provides important insights into the factors influencing FGM/C intention in Sierra Leone. However, it is important to note that the study is based on self-reported intentions and does not provide information on actual FGM/C practices. To improve the strength of the evidence, future research could include longitudinal studies to assess actual FGM/C practices and explore the effectiveness of interventions targeting uneducated women.

Abstract

Data for this study was obtained from the 2013 Sierra Leone Demographic and Health Survey (SLDHS) [38]. The 2013 SLDHS happens to be the second version of the Demographic and Health Survey following the first one in 2008. The survey intended to gather data for monitoring the population and health circumstances and to serve as a follow-up to the first survey. It captured information on female genital mutilation, fertility preferences, maternal and child health as well as sexual activity. It was implemented by the Statistics Sierra Leone (SSL) under the auspices of the Ministry of Health and Sanitation. The National Technical Committee and National Steering Committee provided technical and policy guidance for the conduct of the survey. Inner City Fund (ICF) International also offered technical assistance via the MEASURE DHS Program [38]. Sample for the survey was designed to generate dependable estimates for essential variables for the entire country in both rural and urban locations as well as across the four regions and the fourteen districts [38]. To ensure representation for all the aforementioned demarcations, the sample was stratified and selected in two stages. Primary Sampling Units (PSUs), also known as clusters were selected based on the list of enumeration areas (EAs) created in the preceding Population and Housing Census in the first stage [38]. The EAs offered the principal frame for selecting 435 clusters (158 from urban and 277 from rural) through probability proportional to their sizes. Excluded from the sampling frame were persons residing in collective housing units including hospitals, hotels and boarding schools [38]. Thirty (30) households were systematically selected from each of the clusters in the second stage. All eligible persons in the subsample of households participated in the study. This comprised women aged 15–49 and men aged 15–59. Although, 17, 1323 eligible women (15–49 years) were identified in all, complete interviews were conducted with 16,658 and this culminated in a 97% response rate. Nearly half of these women had at least one daughter (46.7%). The three questionnaires used (household questionnaire, woman’s questionnaire, and man’s questionnaire) emerged from the models developed by the MEASURE DHS Program. However, the questionnaires were modified to fit the context of Sierra Leone [38]. Intention to circumcise daughter in the future was the dependent variable for the study. As part of the survey, the women were asked “Do you intend to have daughter(s) circumcised in future?” The corresponding responses were ‘No’ coded as 0, ‘Yes’ coded as 1, and ‘Don’t Know’, coded as 8. To arrive at findings that reflect precision in thought and offer meaningful recommendations, women who responded ‘Don’t Know’ were excluded from the study. The principal independent variable was formal education. In the DHS survey, formal education is categorised into ‘No Education’, ‘Primary Education’, ‘Secondary Education’ and ‘Higher Education’. Some socio-demographic characteristics of these women were included in the study to access their association with intention of the women to circumcise their daughters in the future. These are age, wealth, religion, region, residence, healthcare decision making, number of daughters already circumcised, frequency of reading newspaper, frequency of listening to radio and frequency of watching television (TV). Following the hierarchical structure of the datasets, all the variables were categorised into individual (education, age, wealth, religion, healthcare decision making, number of daughters, number of daughters circumcised, frequency of reading newspaper, frequency of listening to radio, frequency of watching television) and contextual (family head, region and residence) level factors. To ensure clarity, two of the variables were recoded. These are religion-recoded as ‘Christian = 0’, ‘Islam = 1’, ‘Other = 2’ and number of daughters circumcised recoded as ‘No = 0’, ‘1 = 1’, ‘2 = 2’, ‘3 or more=3.’ We carried out descriptive analysis as well as two-level multilevel analysis. At the descriptive level, we calculated women’s education and the proportion of women who intended to circumcise their daughters in the future. Chi-square test was conducted in order to determine the socio-demographic variables that significantly relate with intention to circumcise daughter in the future. Due to the clustering and hierarchical nature of the datasets, these analyses were followed by the multilevel analysis conducted with the MLwinN command version 3.05 [39]. Prior to modelling, the dataset was ordered to account for the clustering nature of the survey. A total of four models were constructed with the first one being an empty model in order to ascertain the variance in FGM/C intention at the contextual level (model 1). The second model comprised fixed effects at the individual level (model 2) whereas model three accounted for fixed effects at the contextual level (model 3). In the final model (model 4), fixed effects at the individual and contextual level were fitted. Results of the fixed effects were presented as odds ratios (ORs) and adjusted odds ratios (aOR) together with their corresponding credible intervals (95% Crl). Credible interval was based on the Bayesian statistical approach whereby probability allocation for association measurements are derived whilst 95% credible intervals (95% Crls) are used for summarisation. The 95% CrI implies the possibility of the parameter assuming a value in the specified range [40]. Variance partition coefficient (VPC), also referred to as intraclass correlation coefficient (ICC), and median odds ratio (MOR) were reported for the random effects [41, 42]. The VPC assesses the magnitude of variance in the likelihood of FGM/C intention that is explained by or attributable to contextual factors. The MOR, on the order hand, accounts for the contextual variance in terms of odds ratio and calculates the propensity of FGM/C intention that is explained by contextual factors. Multicollinearity was assessed with the variance inflation factor before the models were developed [43]. Sample weight was applied and the entire analysis was executed with Stata version 13.0. Ethical approval was granted by the Ministry of Health and Sanitation of Sierra Leone as well as the ethics committee of the DHS Program. During the survey, informed consent was sought from all participants. We applied for and were granted access to the dataset by the Measure DHS Program. The dataset is freely available through https://dhsprogram.com/data/available-datasets.cfm.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could be used to improve access to maternal health in Sierra Leone:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide information and resources related to maternal health, including information on female genital mutilation/cutting (FGM/C). These apps could provide educational materials, access to healthcare providers, appointment reminders, and emergency helplines.

2. Community Health Workers: Train and deploy community health workers to educate women and families about the risks and consequences of FGM/C, as well as the importance of maternal health. These workers can provide counseling, support, and referrals to healthcare services.

3. Awareness Campaigns: Launch targeted awareness campaigns to educate the general population about the harmful effects of FGM/C and promote alternative initiation ceremonies that do not involve cutting. These campaigns can use various media channels, such as radio, television, and social media, to reach a wide audience.

4. School-Based Education: Integrate comprehensive sexual and reproductive health education, including information on FGM/C, into the school curriculum. This can help empower young girls with knowledge and skills to make informed decisions about their own bodies and health.

5. Policy and Legal Reforms: Advocate for stronger policies and laws that protect girls and women from FGM/C and promote their access to maternal health services. This includes enforcing existing laws, increasing penalties for perpetrators, and providing support and resources for survivors.

6. Partnerships and Collaboration: Foster partnerships between government agencies, non-governmental organizations, healthcare providers, and community leaders to work together towards eliminating FGM/C and improving access to maternal health services. This collaboration can help leverage resources, share best practices, and coordinate efforts for maximum impact.

It is important to note that these recommendations are based on the specific context of Sierra Leone and the issue of FGM/C. They should be tailored and adapted to the local cultural, social, and healthcare systems to ensure effectiveness and sustainability.

AI Innovations Description

The recommendation to improve access to maternal health based on the study’s findings is to implement segmented female-child educational and pro-poor policies that target uneducated women in Sierra Leone. This means providing educational opportunities specifically for women and girls who have not received formal education. By increasing access to education, particularly for those in the lowest wealth category, it can help empower women and change social norms surrounding female genital mutilation/cutting (FGM/C). Additionally, interventions to end FGM/C should focus on broader contextual and social norms in Sierra Leone. This could involve community-based education programs, awareness campaigns, and engaging with religious and community leaders to promote the abandonment of FGM/C.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health in Sierra Leone:

1. Increase female education: The study found that women with no formal education were more likely to intend to circumcise their daughters. Implementing policies that promote and prioritize female education can help empower women and reduce the prevalence of harmful practices like female genital mutilation/cutting (FGM/C).

2. Targeted educational interventions: Design and implement educational programs specifically aimed at raising awareness about the health risks and consequences of FGM/C. These interventions should target uneducated women and focus on changing social norms and attitudes towards the practice.

3. Pro-poor policies: Develop policies that address the socio-economic factors influencing FGM/C intention. Targeting the poorest women with access to healthcare services, financial support, and education can help reduce the prevalence of FGM/C.

4. Strengthen healthcare infrastructure: Improve access to quality maternal healthcare services, especially in rural areas. This can be achieved by increasing the number of healthcare facilities, trained healthcare professionals, and ensuring the availability of essential maternal health supplies.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators that measure access to maternal health, such as the percentage of women receiving antenatal care, skilled birth attendance, or postnatal care.

2. Baseline data: Collect baseline data on the selected indicators from reliable sources, such as national health surveys or health facility records.

3. Introduce interventions: Simulate the impact of the recommendations by introducing changes in the selected indicators based on the expected outcomes of the interventions. For example, increase the percentage of women receiving antenatal care or skilled birth attendance among the target population.

4. Model the impact: Use statistical modeling techniques, such as regression analysis or mathematical modeling, to estimate the potential impact of the interventions on the selected indicators. This can help quantify the expected improvements in access to maternal health.

5. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the results and explore different scenarios or assumptions. This can help understand the potential variations in the impact of the interventions under different conditions.

6. Monitor and evaluate: Continuously monitor and evaluate the actual impact of the implemented interventions on the selected indicators. This will provide feedback on the effectiveness of the recommendations and guide further improvements in access to maternal health.

It is important to note that the methodology for simulating the impact may vary depending on the available data, resources, and specific context of the study.

Author

Dima Health

Statistics:

Citations: 11

Identifiers:

DOI: 10.1186/s12914-020-00240-0

Research Areas:

Community Interventions, Environmental, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Sierra Leone

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Male & Female