Menu
Menu
Menu
Menu
Background: In Liberia, approximately 70% of the women of the North-Central and North-Western regions could have undergone female genital mutilation/cutting (FGM/C) in their childhood during a traditional ceremony marking their entrance into Sande, a secret female society. Little is known about FGM/C from Liberian women’s perspective. This study aimed to understand the health implications of FGM/C as perceived by qualified female midwives. Methods: This qualitative study was conducted in 2017 in Monrovia, Liberia’s capital. Twenty midwives were approached. Of these, seventeen consented to participate in in-depth interviews. A thematic guide was used to gain insights about their knowledge on FGM/C and their experiences attending women victims of FGM/C. A feminist interpretation of constructivist grounded theory guided data generation and analysis. Results: The midwives participants described how clitoridectomy was the most common FGM/C type done to the girls during the Sande initiation ceremonies. Sexual impairment and intrapartum vulvo-perineal laceration with subsequent hemorrhage were described as frequent FGM/C-attributable complications that some midwives could be unable to address due to lack of knowledge and skills. The majority of midwives would advocate for the abandonment of FGM/C, and for the preservation of the traditional instructions that the girls in FGM/C-practicing regions receive when joining Sande. The midwives described how migration to urban areas, and improved access to information and communication technologies might be fuelling abandonment of FGM/C. Conclusion: Liberian midwives need tailored training to provide psychosexual counseling, and to attend the obstetric needs of pregnant women that have undergone FGM/C. In spite of FGM/C being seemingly in the decline, surveillance at clinic-level is warranted to prevent its medicalization. Any clinic- or community-based training, research, prevention and awareness intervention targeting FGM/C-practicing populations should be designed in collaboration with Sande members, and acknowledging that the Liberian population may place a high value in Sande’s traditional values.
This was a qualitative study that was conducted in Monrovia, Liberia’s capital, in 2017, and targeting registered midwives as study population. In Liberia, pregnant women may receive free-of-charge pregnancy care in government-run clinics. At community-level, traditional birth attendants (TBA) can accompany women during their pregnancy, but must refer them for delivery to their nearest clinic. At clinic-level, mothers may be attended by registered midwives or –in the absence of midwives–, by nurses. Since 2013, midwives can register as trained obstetric clinicians at the Liberian Medical and Dental Council [24]. The last DHS reported that approximately 61% of births had been attended by skilled birth attendants [15]. In spite of progresses in access to maternal health services, the utilization of clinic-based pregnancy care services significantly reduced during the 2014–16 Ebola outbreak in Liberia [25, 26]. Female registered midwives born in Liberia; knowledgeable of FGM/C; and who had worked as midwives for at least two years were targeted as study participants. One member of the research team, a female midwife with experience in qualitative research, was the recruiting agent and interviewer. Purposive sampling was used to approach the first two midwives participants. The recruiting agent purposively approached two midwives who were randomly selected from a list of trainees in a workshop on domestic violence that had been previously led by her. Purposive sampling continued from these first two participants, who recommended other potential participants to the recruiting agent. All midwives were contacted telephonically and invited to participate in an in-depth interview (IDI) in their location of choice within Monrovia. At the scheduled date, written informed consent was obtained prior to the start of the IDI. Recruitment was to continue until data saturation was gained. Nevertheless, recruitment was prematurely stopped due to the refusal to participate of three midwives who disclosed being Sande, and who manifested disagreement with the study. At that point, for security reasons, the research team decided to terminate sampling of participants. All IDIs were conducted in ‘colloquia’ (i.e. Liberian English) using a broad thematic or topics guide that aimed to gain insights about the midwives’ perceptions and knowledge on FGM/C, and about their experiences attending pregnant women who had undergone FGM/C. IDI recordings were transcribed verbatim into a MS Word. All transcriptions were cross-checked against the recordings. The final transcripts were imported into Dedoose software (®SocioCultural Research Consultants, Manhattan Beach, CA). A feminist interpretation of constructivist grounded theory was considered the most appropriate methodological approach to engage midwives in a study on practices that are harmful to women’s health [27–29]. In practical terms, most methodological decisions were taken in agreement with best guidance on constructivist grounded theory research conduct [27–29]. Hence, data generation, coding and analysis happened contemporaneously. As data analysis began whilst data generation was ongoing, an in-depth exploration of the themes that the participants referred to as especially relevant was possible. Data was first line-by-line coded in a printed set of transcriptions. Once a coding framework was developed based on concepts and categories emerging during the first five IDIs, this framework was used to recode the first transcripts and to code the following IDIs using Dedoose. To ensure trustworthibility, upon finalization of each IDI, the interviewer and the principal investigator jointly analyzed its transcription to detect recall and social desirability bias; discussion topics that seemed overly sensitive; and emerging themes that deserved more thorough discussion. Participants’ answers from the IDIs were triangulated with reports from the literature. At the end of the analysis phase, the study findings were presented at the University of Liberia institutional review board. During the whole data generation, analysis and reporting processes, the feminist interpretation involved that: i) the midwives were addressed as ‘co-interpreters’ of the meanings of the study findings in cooperation with the interviewer; ii) the interviewer (a woman) reflected upon the impact of her own characteristics on the midwives during her interactions with them; iii) the research team (two women, one man) was sensitive towards issues of oppression that might be affecting the participants; iv) the research team ensured that the findings were useful to promote social change, and, hence, that vi) the research team promoted local dissemination to translate findings into policy, healthcare and training practice change. Informed consent was sought for all participants. During the consent process, each participant was clearly informed about the study purpose; the organizations involved; the potential risk of social harm that could derive from their participation; their right to withdraw from the study at any time; the measures in place to protect their privacy and confidentiality. All participants received a signed copy of all consent documents. Strict measures to minimize the possibility of social harm were taken. To protect the participants’ privacy, interviews were held at a location of their choice, and no researcher other than the recruiting midwife met any of the participants. To prevent discomfort, participants were reassured that they did not have to answer any question they do not wish to, and that no questions on their own history with FGM/C were to be asked. To ensure confidentiality, socio-demographics were collected only if consent for such data to be registered was given. The consent forms were the only documents where the participants’ full names were included. No personal identifier from any research documents was captured in any database. Personal identifiers were removed from the IDI transcriptions. To further prevent unwanted identification of the participants, disaggregated socio-demographic data are not reported in this article, and all IDI recordings were deleted once the analysis on their transcriptions ended. Ethics approval was obtained from the University of Liberia-Pacific Institute for Research and Evaluation Institution Review Board.
N/A
