Factors associated with female genital mutilation in Burkina Faso and its policy implications

International Journal for Equity in Health, Volume 10, Year 2011

Interpretation

Background: Female genital mutilation (FGM) usually undertaken between the ages of 1-9 years and is widely practised in some part of Africa and by migrants from African countries in other parts of the world. Laws prohibit FGM in almost every country. FGM can cause immediate complications (pain, bleeding and infection) and delayed complications (sexual, obstetric, psychological problems). Several factors have been associated with an increased likelihood of FGM. In Burkina Faso, the prevalence of FGM appears to have increased in recent years. Methods. We investigated social, demographic and economic factors associated with FGM in Burkina Faso using the 2003 Demographic Health Survey (DHS). The DHS is a nationally representative cross-sectional survey (multistage stratified random sampling of households) of women of reproductive age (15-49 years). Associations between potential risk factors and the prevalence of FGM were explored using 2 and t-tests and Mann Whitney U-test as appropriate. Logistic regression modelling was used to investigate social, demographic and economic risk factors associated with FGM. Main outcome measures. i) whether a woman herself had had FGM; ii) whether she had one or more daughters with FGM. Results: Data were available on 12,049 women. Response rates by region were at least 90%. Women interviewed were representative of the underlying populations of the different regions of Burkina Faso. Seventy seven percent (9267) of the women interviewed had had FGM. 7336 women had a daughter of whom 2216 (30.2%) had a daughter with FGM and 334 (4.5%) said that they intended that their daughter should have it. Univariate analysis showed that age, religion, wealth, ethnicity, literacy, years of education, household affluence, region and who had responsibility for health care decisions in the household had (RHCD) were all significantly related to the two outcomes (p < 0.01). Multivariate analysis stratified by religion mainly confirmed these findings, however, education is significantly associated with a reduced likelihood of FGM only for Christian women. Conclusions and Policy implications. Factors associated with FGM are varied and complex. Younger women and those from specific groups and religions are less likely to have had FGM. A higher level of education may be protective for women from certain religions. Policies should capitalize on these findings and religious leaders should be involved in continuing programmes of action. © 2011 Karmaker et al; licensee BioMed Central Ltd. The Demographic Health Surveys (DHS) are periodic cross sectional health surveys funded by USAID (the U.S. Agency for International Development's) Bureau for Global Health. The DHS includes a number of modules on demographics and household affluence; fertility, reproductive health, maternal and child health; nutrition, and knowledge and practice related to HIV/AIDS [12]. Surveys allow for an optional additional series of questions about FGM [13]. Since the year 2000, when these optional questions were added as part of the DHS, the prevalence of FGM in women in 14 African countries has been found to range between 1% in Cameroon in 2004 to 97% in Egypt in 2000. The history of the development of the FGM questionnaire has been discussed elsewhere [13]. Briefly, DHS surveys collect data from nationally-representative probability samples of households and from adult women (age 15-49) and men in the sampled household. In general, surveys use a two-stage cluster sampling design, with over-sampling of certain categories of respondents. Response rates tend to vary across sampling domains and sample weights are used to obtain nationally representative estimates of indicators. DHS surveys yield nationally representative estimates of FGM for women age 15 to 49 in the survey countries. In the countries where the prevalence of FGM is of concern, a module of FGM Questions is added to the women's questionnaire. The questions are designed to generate information on prevalence rates and types of FGM for the women themselves and for their daughters. Respondents' attitudes towards FGM are also collected. Since 2000, UNICEF's Multiple Indicator Cluster Surveys (MICS) have used a similar module to collect information on FGM in selected countries [13]. Both DHS and MICS surveys provide FGM prevalence data. Female respondents are asked if they have ever heard of FGM; then those who have heard of the practice are asked about their own experience of it. The responses to these questions are used to calculate national prevalence rates of FGM [13]. Experts generally assume that women respond truthfully when asked about their own experience. If bias exists in some of the responses, it has not been documented. It is hypothetically possible that some women may say not admit to having undergone FGM in countries where the practice has been forbidden, but no solid evidence of this has been found. Few empirical studies dealing with FGM in Sub-Saharan Africa have been conducted. Although, there is now an increased amount of literature on the practice of FGM. Most of the literature deals with descriptive statistics and on issues of the origin, types, and justifications for the practice but little has been devoted to its patterns and mediating factors. Freymeyer et. al. 2007 [14] used the 2003 Nigerian DHS to explore attitudes towards FGM in Nigerian. Also using empirical data from the DHS, Kandala et al. 2010 [15] have published work on spatial risk factors for FGM in Nigeria. The DHS survey methods in Burkina Faso are described in detail elsewhere [12] A nationally representative cross-sectional survey of women of reproductive age (15-49 years) was identified using a stratified random two-stage cluster sample of households by enumeration area, to reflect the rural-urban ratio. 400 (of 11,000) enumeration districts were selected (90 urban and 310 rural). 9 470 households in these districts were selected (2340 urban and 7130 rural) and members of 9097 household successfully interviewed. Data collection was undertaken between June and December 2003 by face to face interview with women aged 15-49 in each selected household and with men aged 15-59 in every third household. Topics covered in the women's questionnaire included demographics: age, region, ethnicity, religion, education, literacy, nutrition, and fertility, family planning, and HIV/AIDS risk factors. Topics covered in the household questionnaire included who in the household had responsibility for health care decisions (RHCD); and a number of household characteristics allowing for a calculation of household affluence using an asset index (access to drinking water, toilet facilities, cooking fuel, consumer items (television, bike/car); wall/flooring material. Households were subsequently divided into quintiles using this asset index. The module on FGM included questions on whether the woman herself had undergone FGM; and whether if she had daughters they had also undergone the practice (Table (Table1)1) or whether she intended that they should. Distribution of factors analysed in Female Genital Mutilation (FGM) study in Burkina Faso (DHS 2003) * RHCD Responsibility for health care decisions Chi-square test was used for categorical data and Mann-Whitney test for continuous data. Data analysis was undertaken using SPSS Version 15 and STATA 10.0. Associations between potential risk factors and the prevalence of FGM were explored using two dichotomous outcome measures: i) whether a woman herself had had FGM; ii) whether she had one or more daughters with FGM; using chi-square, t-tests and Mann Whitney U test as appropriate. Logistic regression modeling was used to investigate social, demographic and economic risk factors associated with FGM and formal tests for interaction were undertaken. Four models one for each of the main religious groups were undertaken for the logistic regression modeling, these were Protestant, Catholic, Muslim and traditional or animist. The following items were included: demographic variables: age (three 10 year age groups (15-24, 25-34, 35-49), urban versus rural living, region, ethnicity and religion), social variables: (any versus no education and responsibility for health care decisions (RHCD*)), and household economic status (asset index (divided into quintiles)). Tests for interaction between religion and each of the selected characteristics were also performed. Since the test for interaction between religion and education proved significant, subsequent analysis was stratified by religion (Table (Table22). Adjusted Odd ratio of Female Genital Mutilation (FGM) in Burkina Faso stratified by religion for various respondent characteristics and 95% Confidence interval (DHS 2003)

AI Digest

Study Justification:

– Female genital mutilation (FGM) is a harmful practice that has immediate and long-term health consequences for women and girls.
– The prevalence of FGM in Burkina Faso appears to have increased in recent years.
– Understanding the factors associated with FGM can help inform policies and interventions to prevent and eliminate the practice.

Study Highlights:

– The study used data from the 2003 Demographic Health Survey (DHS) in Burkina Faso.
– The survey included a nationally representative sample of women of reproductive age.
– The study found that factors such as age, religion, wealth, ethnicity, literacy, education, household affluence, region, and responsibility for health care decisions were significantly related to the prevalence of FGM.
– Education was found to be protective against FGM for Christian women.
– The study highlights the complex and varied factors associated with FGM.

Recommendations for Lay Reader:

– Policies should capitalize on the findings of the study to prevent and eliminate FGM.
– Religious leaders should be involved in continuing programs of action.
– Education can play a protective role against FGM, particularly for Christian women.

Recommendations for Policy Maker:

– Develop and implement policies and interventions to prevent and eliminate FGM.
– Engage religious leaders in promoting awareness and education about the harmful effects of FGM.
– Invest in education programs that empower women and girls and promote gender equality.
– Allocate resources for research, monitoring, and evaluation of FGM prevention and elimination efforts.

Key Role Players:

– Government agencies responsible for health, education, and women’s affairs.
– Non-governmental organizations (NGOs) working on women’s rights and health.
– Religious leaders and community influencers.
– Health professionals and educators.
– Researchers and academics.

Cost Items for Planning Recommendations:

– Funding for education programs and awareness campaigns.
– Resources for training and capacity building of health professionals and educators.
– Research and data collection on FGM prevalence and associated factors.
– Monitoring and evaluation of FGM prevention and elimination efforts.
– Support for NGOs and community-based organizations working on FGM prevention.
– Infrastructure and equipment for healthcare facilities providing support to FGM survivors.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study used a nationally representative cross-sectional survey with a large sample size (12,049 women) and high response rates (at least 90%). The study explored various social, demographic, and economic factors associated with female genital mutilation (FGM) in Burkina Faso. The findings showed significant associations between FGM and factors such as age, religion, wealth, ethnicity, literacy, education, household affluence, region, and responsibility for health care decisions. However, the study relied on self-reported data, which may be subject to recall bias or social desirability bias. To improve the strength of the evidence, future studies could consider using longitudinal designs or qualitative methods to gain a deeper understanding of the factors influencing FGM. Additionally, incorporating objective measures of FGM and exploring the cultural and societal factors underlying the practice could provide further insights.

Abstract

The Demographic Health Surveys (DHS) are periodic cross sectional health surveys funded by USAID (the U.S. Agency for International Development's) Bureau for Global Health. The DHS includes a number of modules on demographics and household affluence; fertility, reproductive health, maternal and child health; nutrition, and knowledge and practice related to HIV/AIDS [12]. Surveys allow for an optional additional series of questions about FGM [13]. Since the year 2000, when these optional questions were added as part of the DHS, the prevalence of FGM in women in 14 African countries has been found to range between 1% in Cameroon in 2004 to 97% in Egypt in 2000. The history of the development of the FGM questionnaire has been discussed elsewhere [13]. Briefly, DHS surveys collect data from nationally-representative probability samples of households and from adult women (age 15-49) and men in the sampled household. In general, surveys use a two-stage cluster sampling design, with over-sampling of certain categories of respondents. Response rates tend to vary across sampling domains and sample weights are used to obtain nationally representative estimates of indicators. DHS surveys yield nationally representative estimates of FGM for women age 15 to 49 in the survey countries. In the countries where the prevalence of FGM is of concern, a module of FGM Questions is added to the women's questionnaire. The questions are designed to generate information on prevalence rates and types of FGM for the women themselves and for their daughters. Respondents' attitudes towards FGM are also collected. Since 2000, UNICEF's Multiple Indicator Cluster Surveys (MICS) have used a similar module to collect information on FGM in selected countries [13]. Both DHS and MICS surveys provide FGM prevalence data. Female respondents are asked if they have ever heard of FGM; then those who have heard of the practice are asked about their own experience of it. The responses to these questions are used to calculate national prevalence rates of FGM [13]. Experts generally assume that women respond truthfully when asked about their own experience. If bias exists in some of the responses, it has not been documented. It is hypothetically possible that some women may say not admit to having undergone FGM in countries where the practice has been forbidden, but no solid evidence of this has been found. Few empirical studies dealing with FGM in Sub-Saharan Africa have been conducted. Although, there is now an increased amount of literature on the practice of FGM. Most of the literature deals with descriptive statistics and on issues of the origin, types, and justifications for the practice but little has been devoted to its patterns and mediating factors. Freymeyer et. al. 2007 [14] used the 2003 Nigerian DHS to explore attitudes towards FGM in Nigerian. Also using empirical data from the DHS, Kandala et al. 2010 [15] have published work on spatial risk factors for FGM in Nigeria. The DHS survey methods in Burkina Faso are described in detail elsewhere [12] A nationally representative cross-sectional survey of women of reproductive age (15-49 years) was identified using a stratified random two-stage cluster sample of households by enumeration area, to reflect the rural-urban ratio. 400 (of 11,000) enumeration districts were selected (90 urban and 310 rural). 9 470 households in these districts were selected (2340 urban and 7130 rural) and members of 9097 household successfully interviewed. Data collection was undertaken between June and December 2003 by face to face interview with women aged 15-49 in each selected household and with men aged 15-59 in every third household. Topics covered in the women's questionnaire included demographics: age, region, ethnicity, religion, education, literacy, nutrition, and fertility, family planning, and HIV/AIDS risk factors. Topics covered in the household questionnaire included who in the household had responsibility for health care decisions (RHCD); and a number of household characteristics allowing for a calculation of household affluence using an asset index (access to drinking water, toilet facilities, cooking fuel, consumer items (television, bike/car); wall/flooring material. Households were subsequently divided into quintiles using this asset index. The module on FGM included questions on whether the woman herself had undergone FGM; and whether if she had daughters they had also undergone the practice (Table (Table1)1) or whether she intended that they should. Distribution of factors analysed in Female Genital Mutilation (FGM) study in Burkina Faso (DHS 2003) * RHCD Responsibility for health care decisions Chi-square test was used for categorical data and Mann-Whitney test for continuous data. Data analysis was undertaken using SPSS Version 15 and STATA 10.0. Associations between potential risk factors and the prevalence of FGM were explored using two dichotomous outcome measures: i) whether a woman herself had had FGM; ii) whether she had one or more daughters with FGM; using chi-square, t-tests and Mann Whitney U test as appropriate. Logistic regression modeling was used to investigate social, demographic and economic risk factors associated with FGM and formal tests for interaction were undertaken. Four models one for each of the main religious groups were undertaken for the logistic regression modeling, these were Protestant, Catholic, Muslim and traditional or animist. The following items were included: demographic variables: age (three 10 year age groups (15-24, 25-34, 35-49), urban versus rural living, region, ethnicity and religion), social variables: (any versus no education and responsibility for health care decisions (RHCD*)), and household economic status (asset index (divided into quintiles)). Tests for interaction between religion and each of the selected characteristics were also performed. Since the test for interaction between religion and education proved significant, subsequent analysis was stratified by religion (Table (Table22). Adjusted Odd ratio of Female Genital Mutilation (FGM) in Burkina Faso stratified by religion for various respondent characteristics and 95% Confidence interval (DHS 2003)

Materials

N/A

Innovations

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

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide information and resources related to maternal health, including information on FGM, its risks, and alternatives. These apps can also provide access to healthcare providers, appointment scheduling, and reminders for prenatal care.

2. Community Education and Awareness Programs: Implement community-based education programs to raise awareness about the risks and consequences of FGM, emphasizing the importance of maternal health and the availability of alternative practices. These programs can involve local leaders, religious leaders, and community health workers.

3. Training and Capacity Building: Provide training and capacity building programs for healthcare providers, including midwives and nurses, to enhance their knowledge and skills in providing comprehensive maternal healthcare. This can include training on identifying and managing complications related to FGM.

4. Policy Advocacy and Legal Frameworks: Advocate for stronger policies and legal frameworks that prohibit FGM and promote maternal health. This can involve working with policymakers, lawmakers, and international organizations to enforce existing laws and develop new policies that prioritize maternal health.

5. Collaborative Partnerships: Foster partnerships between government agencies, non-governmental organizations, and community-based organizations to address the issue of FGM and improve access to maternal health services. These partnerships can leverage resources, expertise, and networks to implement comprehensive interventions.

6. Research and Data Collection: Conduct further research and data collection to better understand the factors associated with FGM and its impact on maternal health. This can help inform evidence-based interventions and policies to improve access to maternal health services.

It is important to note that these recommendations are general and may need to be tailored to the specific context of Burkina Faso.

AI Innovations Description

Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Increase education and awareness: Develop and implement comprehensive education programs that target communities where female genital mutilation (FGM) is prevalent. These programs should focus on raising awareness about the immediate and long-term health risks associated with FGM, as well as promoting alternative cultural practices that do not harm women and girls.

2. Engage religious leaders: Collaborate with religious leaders to advocate against FGM and promote safe and healthy practices. Religious leaders hold significant influence within communities and can play a crucial role in changing cultural norms and attitudes towards FGM.

3. Strengthen healthcare systems: Invest in improving healthcare infrastructure and services, particularly in rural areas where access to maternal health services may be limited. This includes increasing the number of skilled healthcare providers, ensuring the availability of essential medical supplies and equipment, and improving transportation networks to facilitate access to healthcare facilities.

4. Provide comprehensive reproductive healthcare: Ensure that maternal health services include comprehensive reproductive healthcare, including prenatal care, skilled birth attendance, postnatal care, and family planning services. This will help address the specific needs of women and girls affected by FGM and promote their overall well-being.

5. Collaborate with international organizations: Partner with international organizations, such as UNICEF and WHO, to leverage their expertise, resources, and networks in addressing FGM and improving access to maternal health. This collaboration can help facilitate knowledge sharing, capacity building, and the implementation of evidence-based interventions.

By implementing these recommendations, it is possible to develop innovative approaches that can effectively improve access to maternal health and reduce the prevalence of FGM in Burkina Faso.

AI Innovations Methodology

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

1. Increase education and awareness: Implement educational programs to raise awareness about the risks and consequences of female genital mutilation (FGM) among communities where it is prevalent. This can help change attitudes and behaviors towards FGM and promote safer alternatives.

2. Strengthen healthcare infrastructure: Improve access to quality maternal healthcare services, including skilled birth attendants, emergency obstetric care, and postnatal care. This can be achieved by investing in healthcare facilities, training healthcare providers, and ensuring the availability of essential medical supplies and equipment.

3. Empower women and girls: Promote gender equality and empower women and girls by providing them with education, economic opportunities, and access to reproductive healthcare services. This can help reduce the prevalence of FGM and improve overall maternal health outcomes.

4. Engage religious and community leaders: Collaborate with religious and community leaders to advocate for the abandonment of FGM and promote positive social norms. Their influence can play a crucial role in changing cultural practices and attitudes towards FGM.

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

1. Baseline data collection: Gather data on the current prevalence of FGM, maternal health indicators, and other relevant factors in the target population.

2. Define indicators: Identify specific indicators to measure the impact of the recommendations, such as the reduction in FGM prevalence, increase in skilled birth attendance, or improvement in maternal mortality rates.

3. Develop a simulation model: Create a mathematical or statistical model that simulates the potential impact of the recommendations on the defined indicators. This model should consider the interplay between various factors, such as education, healthcare infrastructure, and community engagement.

4. Input data and parameters: Input the baseline data and relevant parameters into the simulation model. This may include data on population demographics, healthcare resources, education levels, and cultural practices.

5. Run simulations: Run multiple simulations using different scenarios, such as varying levels of education, healthcare investments, or community engagement. This will help assess the potential impact of different interventions on improving access to maternal health.

6. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on the defined indicators. This can help identify the most effective interventions and prioritize resource allocation.

7. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from experts and stakeholders. This will ensure the accuracy and reliability of the model’s predictions.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of different interventions on improving access to maternal health and make informed decisions to prioritize and implement effective strategies.

Author

Dima Health

Statistics:

Citations: 29

Identifiers:

DOI: 10.1186/1475-9276-10-20

Research Areas:

Disparities, Environmental, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Burkina Faso, Cameroon, Egypt, Multi-Countries, Nigeria

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Male & Female