World Health & Population
Estimates suggest that more than 130 million girls and women have been subjected to the various forms of female genital mutilation (FGM) worldwide. This paper discusses FGM and the perception of its consequences on women's reproductive health in Bere community, Ibadan, Southwest Nigeria. Data were collected through household surveys using semi-structured questionnaires, in-depth interviews and focus group discussions. Results showed that 93% of women surveyed were circumcised. One hundred per cent of these circumcised women believed that FGM enhances women's fertility, and they attributed their previous safe childbirths (without complications) to being circumcised. A few respondents (33.6%) were aware of the health consequences of FGM. Most respondents (76%) were not willing to stop the practice. Male respondents had better knowledge of the consequences of FGM than female respondents. Similarly, younger respondents and those with higher education knew the health consequences of FGM more than the older respondents and those with little or no education (p < 0.05). The findings suggest the need for appropriate health education interventions targeting people in communities where FGM is pervasive, emphasizing the consequences of FGM.
Estimates suggest that more than 130 million girls and women have been subjected to the various forms of female genital mutilation (FGM) worldwide (PATH/WHO 1999; Population Reference Bureau 2000, 2001). Nigerians are believed to comprise 24% of this number. In view of the current population growth rate in Africa, estimates suggest that about two million girls are at risk of being subjected to FGM every year, with some 6,000 cases being recorded every day (Toubia 1993; Dorkenoo 1994; Federal Office of Statistics/UNICEF 1996; PATH/WHO 1999; Population Reference Bureau 2001). In Nigeria, FGM is widespread, cutting across regional, ethnic and religious lines. There are estimates that about 60% of the Nigerian female population has undergone some form of FGM (CIHI 1996).
Among several harmful traditional practices in Nigeria is FGM. Female genital mutilation (FGM) involves the removal of part or whole of a female's genitals (Inter African Committee 1997). The health consequences of FGM are both immediate and lifelong, depending on the type of FGM that is done and the proficiency of the circumciser (Kiragu 1995). The consequences of FGM include bleeding, pain, haemorrhage, infections, urine retention, stress and shock, obstructed labour, vesicovaginal fistula (VVF) and rectovaginal fistula (RVF), infertility and death. The complications may be severe and directly responsible for maternal and fetal death. The risk of HIV infection through this practice is a strong possibility through the use of unsterilized instruments (Ras-Work 1991; Koso-Thomas 1992; O'Connell 1994; Brady 1999; WHO 2000; Jackson 2002).
Very little is known about the knowledge and perception of the consequences of FGM, particularly as it affects the reproductive health of women (Kiragu 1995). Information on the perception of the implications of FGM on health is important in understanding the factors that may contribute to the success of designing effective reforms that will support efforts to eradicate the practice. Here we present the knowledge, attitude and perception of the implications of FGM on women's reproductive health in a traditional community in Southwest Nigeria.
The study was carried out in Bere community in the central wards of Ibadan (geographic coordinates: 7° 22N, 3° 58E), Oyo State, Southwest Nigeria. Bere community is essentially a patriarchal society. Family units are patrilocal and strong emotional bonds exist among members of extended families despite rapid social change. The community is a typical traditional Yoruba community with a population of 5,303, of which 52% are females according to the 1991 national population census. The projected population of 2005 was 8,002. The people are predominantly subsistence farmers and small traders.
Clitoridectomy, which involves cutting of the prepuce, sometimes along with part or the entire clitoris, is the pervasive form of FGM in Oyo State where the study community is located. The prevalence rate of clitoridectomy in Oyo State ranges from 60-70% (Onaeko and Adekunle 1985). Bere community has modern basic social infrastructure such as water, telecommunication, educational and health facilities.
This study was designed for a cross-sectional description of the knowledge and perception of the consequences of FGM on women's reproductive health.
Data Collection Procedures
A total of 300 respondents, comprising 150 adult males and 150 adult females, were selected for the household survey using the multi-stage sampling procedure that involved both simple random and systematic random sampling techniques. Similarly, 20 of the identified 139 women who reported to have undergone FGM in the household survey were randomly selected for interview.
Interviewer-administered semi-structured questionnaires were used in the household surveys. Similarly, in-depth interview and focus group discussion (FGD) guides were used respectively for the qualitative data collection. A total of six FGD sessions were held among adult males and females in the community. The sessions were held with both sexes separately among participants with similar social background. Anonymity of the FGD participants was ensured until the convergence of each of the sessions started. Each FGD session was held in a comfortable and neutral setting and consisted of an average of eight participants plus a moderator. The discussions were tape-recorded and had an observer who took notes on the conversation and other non-verbal expressions.
Local government and community-level approval was obtained before the study commenced. The study subjects gave their informed consent to participate (in the form of a signature or thumbprint) in the household survey and FGDs after the purpose, benefits, risks and discomforts of participating in the study was explained to them. Those who could neither read nor write were asked to thumbprint their consent form in the presence of a witness.
The completed questionnaires were first edited for clarity, completeness and uniformity in the responses to the questions. Codes were then assigned to all the responses to the questions using a prepared coding guide to facilitate data entry. Thereafter, the coded data were entered into the computer using the EpiInfo 6.04a software for statistical analysis. Associations between relevant variables in the quantitative analysis were determined using chi-square test.
The qualitative data were analyzed using the Textbase Beta software. The tapes and notes of participant responses from the FGDs were first transcribed, expanded and formalized into English from the local language. The transcriptions were then typed and saved as ASCII text files. Subsequently, a standard node tree of domains and concepts of interest was developed for coding the texts using the software. The texts were thereafter summarized, categorized, coded and sorted into text segments according to similarities and differences in the opinions and views of the FGD participants using the textual analysis program.
Background of Respondents
The age of the respondents ranged from 18 to 90 years with a mean age of 50 years (males, 56 years; females, 44 years). A majority of the respondents (96% males and 92% females) were married. A majority of the respondents (81.4%) were Muslim, 18.9% were Christian and only 2.7% practiced indigenous religions. Generally, the respondents had a low literacy level. While 49.7% had no formal education, 31.7% and 11.3% had primary and secondary education respectively. Only 7.3% had tertiary education. A majority (61.3%) of the female respondents had no formal education compared to 38% for the male respondents. The respondents shared similar educational backgrounds with their spouses, as 78.8% of them had spouses with little or no formal education.
Age at Which FGM Is Performed
One hundred per cent of the respondents reported that FGM is practiced in their community. A majority of respondents (88.2%) indicated that FGM is done alongside body and facial scarifications when girls are in their infancy (<1 year), while 11.8% mentioned FGM is done in childhood (1-12 years).
Two hundred and seven (90%) of the 230 respondents who had daughters circumcised them, while 10% did not. Table 1 indicates the respondents' religious and educational backgrounds and their practice of FGM on their daughters. The respondents' level of education and their spouses' level of education significantly determined the likelihood to have circumcised their daughters (P < 0.05). Religion had no significant association with the practice of FGM among the respondents (p > 0.05).
Knowledge of Consequences of FGM
Table 2 indicates respondents' knowledge of the consequences of FGM. Generally, few (32.3%) respondents were aware of the health consequences associated with FGM. Of respondents with a low literacy level, 24.0% of females compared to 40.4% of males were aware of the consequences of FGM. Respondents mentioned these consequences of FGM: bleeding (45%) and pain (55%). The respondents' age, sex and level of education significantly influenced their knowledge of health consequences inherent in FGM (p < 0.05). Similarly, more females than males interviewed during household survey, and more female than male FGD participants reported not having knowledge of the consequences of FGM.
Many male but few female FGD participants reported the occurrence of minor consequences (such as bleeding) associated with FGM performed on their daughters or other girls in the community. FGD participants attributed reported cases of severe FGM consequences to diabolical forces. In recalling her experience, a female FGD participant said,
some children bleed severely after being circumcised…this is usually caused by the enemies around…by the time certain herbal preparations are applied, in addition [to] some incantations, the bleeding would cease. I actually had the experience when one of my granddaughters was circumcised many years ago…when the bleeding from the open cut did not cease after many minutes, my mother-in-law had to intervene telling us to provide some herbal items that were applied along with incantations she chanted. The bleeding ceased immediately [after] she completed the ritual…that baby girl is now married and has even started having her own children, too.
There was a consensus among the participants of the different FGD groups that without the involvement of any diabolical forces, the open cut is expected to heal within three to five days. They argued that the circumcisers are experienced, knew what to cut and how to do it well.
In affirmation of the FGD participants' perceived proficiency of the circumcisers, the circumcisers who were interviewed expressed doubts of any consequences relating to FGM. This is illustrated in the words of one circumciser: "For more than 30 years that I have been involved in this job that I learnt from my father, I have never circumcised a girl-child that later had complications…if I circumcise a girl-child now and tell you that the open cut will heal within three to five days, I want to assure you that it will heal within the specified time limit. I am very confident because it is a skill that I acquired from childhood from my father while following him to wherever he went to circumcise." The other circumciser who was interviewed stated that "I can circumcise a girl-child within a very few minutes with high precision since I know what to cut and how to go about it."
Perception of the Implications of FGM on Reproductive Health
Overall, of the 207 (90%) of the 230 that have daughters and circumcised them, 203 (98%) reported that their children had no consequences from FGM. Only 2% reported their children had severe bleeding following the procedure of FGM.
The personal experience of the female respondents surveyed concerning FGM showed that 93% were circumcised and 7% were not. This is contrary to those interviewed as case studies who were all circumcised. One hundred per cent of the uncircumcised women in the survey were married to men who came from other communities where FGM is not practiced.
One hundred per cent of the circumcised women interviewed believed their being circumcised did not in any way affect their sex and reproductive lives. They reported to have had safe child deliveries without difficulties. On the contrary, they attributed their safe childbirth experiences to being circumcised. A 55-year-old woman, for example, explained that "throughout my childbearing age, I never experienced any difficulty which those campaigning are now attributing to circumcising a girl despite the fact that I was circumcised since my childhood... there were times when I had to deliver my babies myself at home without any assistance, and no complication developed thereafter...the complications that are being used to campaign against FGM could be obtainable elsewhere though, but there is nothing of such in this our community, because when women go into the labour room, they come out hale and hearty with their babies."
The limitations of the study should be pointed out before discussing the results. The primary limitation is that the study lacked a national focus, because the data reflect only one community among many ethnic groups and areas of the country. This, however, does not undermine the validity of the study results, as the scope and nature of FGM are still sketchy and incomplete in Nigeria. This implies that further studies are needed with wider coverage of the country using a larger sample.
The study examined the knowledge and perception of the consequences of FGM on women's reproductive health. It is evident from the study that FGM is widely practiced in the study community. A significant proportion of the people who participated in this study, particularly women, are yet to realize the consequences inherent in the practice as identified by health experts and emphasized in the campaign against the practice.
The perception of most female respondents that FGM is of no consequence to their health illustrates either their sincere lack of awareness of the health consequences inherent in FGM, which may perhaps be related to the mild form of FGM that they perform, or a denial of the reality of these consequences. The lack of awareness of the consequences of FGM, particularly among females and those with little or no formal education, exhibits the need for appropriate health education using information, education and communication (IEC) and or behavioural change communication (BCC) materials, including both audio and visual aids, such as posters and video tapes, targeting these groups as successfully applied in other BCC activities such as the control of sexually transmitted infections and HIV/AIDS. Emphasis needs to be placed on providing education to people who practice FGM about the implications of FGM to discourage them from the practice.
It is suggested that intensive efforts are needed to substantially explain and prove to people who practice FGM why the practice should cease, because it is natural that they may not easily compromise their practices, because of its socio-cultural sensitivity. In view of the fact that FGM is often at the heart of the community's belief system, the community first needs to acknowledge the practice as detrimental to the health of women and girls before it will begin to change. It is agreeable that people will change their behaviour and accept change once they realize that it is in their best interests and that of their children. It is important that members of the community, particularly the political, religious and opinion leaders, play a role in the design and conduct of the FGM eradication activities, in particular, to advocate ending the practice. This, we believe, will provide a strong basis for developing an appropriate strategy for a successful eradication of FGM in the study community and other communities where the practice is rife.
About the Author(s)
A.K. Adeneye, Public Health Division, Nigerian Institute of Medical Research,
6 Edmond Crescent, P.M.B 2013, Yaba, Lagos, Nigeria
E.A. Oke, Department of Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria
A.A. Adeneye, Department of Pharmacology, Lagos State University College of Medicine, Lagos, Nigeria
Corresponding Author: A.K. Adeneye
Phone (mobile): +234-805-788-7698, +234-803-349-1386
AcknowledgmentThis paper is in loving memory of Dr. Irene Modupeola Thomas (1917-2005), who was Executive Director of the Inter African Committee (IAC), Nigeria, on harmful traditional practices affecting the health of women and children. Dr. Modupeola passed away during preparation of the manuscript. We are grateful to the field assistants and the people of Bere Community, Ibadan, Oyo State, Nigeria, for their cooperation and assistance during the survey. We thank Dr. Bola Adedimeji, Dr. R.A. Okunola and Professor W.R. Brieger for their technical assistance and useful comments on the manuscript.
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