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  • Effectiveness of interventions designed to reduce the prevalence of female genital mutilation/ cutting

Systematic review

Effectiveness of interventions designed to reduce the prevalence of female genital mutilation/ cutting

Published Updated

What is the effectiveness of interventions designed to reduce the prevalence of female genital mutilation/cutting compared to no or any other intervention?

What is the effectiveness of interventions designed to reduce the prevalence of female genital mutilation/cutting compared to no or any other intervention?


About this publication

  • Year: 2009
  • By: Norwegian Knowledge Centre for the Health Services
  • Authors Denison EM-L, Berg RC, Lewin S, Fretheim A.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-300-5

Key message

Background
In November 2008, the Norwegian Knowledge Centre for Violence and Traumatic Stress Studies (NKVTS) commissioned the Norwegian Knowledge Centre for the Health Services (NOKC) to do a systematic review about the effectiveness of interventions to prevent female genital mutilation/cutting (FGM/C). The review would answer the question: What is the effectiveness of interventions designed to reduce the prevalence of female genital mutilation/cutting compared to no or any other intervention?

Methods
We searched systematically for relevant literature in international scientific databases, in databases of international organisations that are engaged in projects concerning FGM/C, and in reference lists of relevant reviews and included studies. We selected studies according to pre-specified criteria and appraised the methodological quality using checklists. We summarized the results using tables and calculated effect estimates (adjusted absolute risk difference and risk ratio) in outcomes for which pre- and post scores for both intervention and comparison groups were reported.

Results
We included and summarized results from six controlled before-and-after studies. All studies were set in Africa and compared an intervention with no intervention (except one study which included an educational module). There was great variation in prevalence, ethnicity, religion, and education among these settings. All studies were judged to have weak methodological quality and the quality of the evidence was low. The effect estimates suggest that 1) training health personnel likely produced no effects in knowledge or beliefs/attitudes about FGM/C; 2) educating female students may possibly have led to a small increase in knowledge/awareness about FGM/C; 3) multifaceted community activities may possibly have increased the proportion of participants having favourable cognitions and intentions about FGM/C; 4) community empowerment through education may possibly have positively affected prevalence of FGM/C, participants' knowledge about the consequences of FGM/C, and regrets about having had daughter cut. However, the low quality of the body of evidence affects the interpretation of results and raises doubts about the validity of the findings.

Conclusion
There is a paucity of high quality evidence regarding the effectiveness of interventions to prevent FGM/C and the evidence base is insufficient to draw solid conclusions. While first-generation anti-FGM/C intervention studies are informative, there is an urgent need for additional studies. Such second-generation studies should be randomized or at a minimum secure similar distribution of prognostic factors in the intervention and comparison groups; long-term to ensure viability and reliable assessment of changes in prevalence; take into account regional, ethnic and sociodemographic variation in the practice of FGM/C; focus on prevalence – assessed by physical examinations – behaviours, and intentions; and they should be cross-disciplinary, if possible through international collaborative initiatives.

Summary

Background
Female genital mutilation/cutting (FGM/C) is a traditional practice that involves the partial or total removal of or other injury to the female genital organs for cultural or other non-therapeutic reasons. FGM/C is practised in more than 28 countries in Africa and in immigrant communities in a number of countries, including Australia, Canada, France, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. The practice of FGM/C 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.

FGM/C is recognized as a harmful practice which violates human rights. It is prohibited by law in several African and Western countries. The current classification describes four types of FGM/C: Type 1, clitoridectomy , involves partial or total removal of the clitoris and/or the prepuce. Type 2, excision , involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3, infibulation , involves narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Type 4, other , involves all other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization. There is great variation in prevalence, reflecting ethnicity, tradition, and sociodemographic factors. Countries with very high prevalence, over 70%, include Egypt, Ethiopia, Mali, and Somalia. FGM/C is associated with several health risks such as severe pain, bleeding, and shock, difficulty in passing urine and faeces, and infections. Caesarean section, blood loss, low birth weight and increased perinatal mortality are associated birth risks. Several psychological, social, and sexual consequences such as anxiety, depression, memory loss, loss of libido, and dyspareneuia are associated with FGM/C.

Efforts to abandon the practice of FGM/C in Africa have used several different approaches, including those based on human rights frameworks, a health risk approach, training health workers as change agents, and the use of comprehensive social development approaches. Although there are indications of the effectiveness of some anti-FGM/C interventions in achieving changes in knowledge, beliefs, attitudes, behaviours and practices related to FGM/C, systematic appraisal of the evidence is lacking. Further, much research has used observational designs that make it difficult to draw causal inferences, thus hampering valid conclusions about the effects of these interventions.

We asked the following question: What is the effectiveness of interventions designed to reduce the prevalence of female genital mutilation/cutting compared to no or any other intervention?

Methods
In February 2009, we searched systematically for literature in the following scientific databases: African Index Medicus, Anthropology Plus, British Nursing Index and Archive, The Cochrane Library (CENTRAL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects), EMBASE, EPOC, MEDLINE, PILOTS, POPLINE, PsychINFO, Social Services Abstracts, Sociological Abstracts, and WHOLIS. We also searched in databases of international organisations that are engaged in projects concerning FGM/C, and manually in reference lists of relevant reviews and studies included in this systematic review. We searched for studies that used the following study designs: systematic reviews, randomized controlled studies, and controlled before-and-after studies.

Two of the authors independently assessed studies for inclusion according to pre-specified criteria and the methodological quality of the studies using checklists. We summarized the results in text and tables and calculated effect estimates (adjusted absolute risk difference and risk ratio) in outcomes for which pre- and post scores for both intervention and comparison groups were reported.

Results
We identified 3,667 publications and after having assessed titles, abstracts, and articles in full text we included six studies that fulfilled the inclusion criteria. All studies were controlled before-and-after studies that were carried out in African countries. We failed to obtain two potentially relevant publications, despite extensive retrieval efforts.

All the included studies were judged to have weak methodological quality and the quality of the evidence was low. Collectively, the studies involved a total of 6,803 participants at entry. All studies compared an intervention with no intervention (except one which included an education module). Each study was set in a different country in Africa: Burkina Faso, Egypt, Ethiopia / Kenya, Mali, Nigeria, and Senegal. There was great variation in prevalence, ethnicity, religion, and education among these settings. Two of the studies were directed at the individual level, and four at the community level. The first individually-based study consisted of educational activities delivered to health personnel in Mali, who learned about context and local rationale of FGM/C as well as the different types of cutting and its health complications. The other individually-based study took place in Egypt and involved female university students, who received information about reproductive health aspects, including FGM/C. The multifaceted, community-based intervention in Kenya was delivered in a Somali refugee camp, and six village communities in Ethiopia received a nearly identical intervention, consisting of community meetings, theatre performances, video sessions, and mass media activities. In Nigeria, the multifaceted community activities, involving programmes such as multimedia and development of action plans to improve women's situation, was delivered at three community levels. The community empowerment intervention took place first in Senegal and then it was replicated in Burkina Faso. It consisted of educational sessions in human rights, problem solving, environmental hygiene, and women’s health. 

The most frequently reported outcomes were beliefs/attitudes, knowledge/awareness, and intentions concerning FGM/C. Less frequently reported outcomes were self-reported prevalence, behaviours such as talking to others about FGM/C, perceptions regarding spouse’s disapproval of  FGM/C, and regrets of having had daughter cut. The effect estimates suggest that 1) training health personnel likely produced no effects in knowledge or beliefs/attitudes about FGM/C; 2) educating female students may possibly have led to a small increase in knowledge/awareness about FGM/C; 3) multifaceted community activities may possibly have increased the proportion of participants having favourable cognitions and intentions about FGM/C; 4) community empowerment through education may possibly have positively affected prevalence of FGM/C, participants' knowledge about the consequences of FGM/C, and regrets about having had daughter cut. However, the low quality of the body of evidence affects the interpretation of results and raises doubts about the validity of the findings.

Conclusion
There is a paucity of high quality evidence regarding the effectiveness of interventions to reduce the prevalence of FGM/C and the evidence base is insufficient to draw solid conclusions. While first-generation anti-FGM/C intervention studies are informative, there is an urgent need for additional studies. Such second-generation studies should be randomized or at a minimum secure similar distribution of prognostic factors in the intervention and comparison groups; long-term to ensure viability and reliable assessment of changes in prevalence; take into account regional, ethnic and sociodemographic variation in the practice of FGM/C; focus on prevalence – assessed by physical examinations – behaviours, and intentions; and they should be cross-disciplinary, if possible through international collaborative initiatives.