Female Genital Mutilation and Reproductive Health in Africa

Abstract

Available evidence indicates that about 130 million women and girls worldwide have experienced female genital mutilation (FGM). Of these, the large majority are to be found in parts of East and West Africa as well as the Nile Valley countries of Egypt and Sudan. Several reasons have been given for the practice of FGM in Africa, the most important of which surrounds perceptions relating to cultural norms of femininity and chastity and in a few instances the need to observe religious injunctions. In the last two decades, the international community has very strongly condemned the practice of FGM as an abuse of the bodily integrity and human rights of women and girls. The World Health Organization in particular, has issued a series of statements recommending the discontinuation of the FGM and has urged health practitioners not to medicalize the procedure under any circumstance. Several articles in this edition of the African Journal of Reproductive Health describe the continuing practice of FGM in African countries. The paper by Sakeah et al1, reports that male preference for circumcised women is an important factor associated with the perpetuation of FGM in northern Ghana. The typology of FGM as recommended by the WHO is well known. The most severe type of FGM consisting of the excision of part or all external genitalia and stitching/narrowing of the vaginal opening (infibulation) is practiced in the northern African countries of Egypt and Sudan, and some parts of Ethiopia. In a large number of cases, infibulated women often undergo a process of defibulation (recutting of the vaginal passage) at the time of childbirth to enable easy passage of the fetus. Under normal circumstances, the vagina should be left open after defibulation to correct the deformity on a permanent basis. However, reinfibulation is an option, whereby some women are re-stitched after delivery in order to maintain the state of genital mutilation. The paper by Berggren et al2 in this edition of the journal reports an interesting cultural dichotomy, whereby refibulation is regarded by some women as a benefit of sexuality, whereas a few regard it as evidence of the continuing social victimization of women in efforts to sustain the traditional practice of FGM. The literature is replete with several documentations of the incidence and socio-cultural determinants of FGM in Africa. Thus, much of the ongoing debate surrounds what needs to be done to end the practice, and to sustain the discontinuation over time. The paper by Shell-Duncan3, analyzing results of qualitative research in the Gambia, indicates that there may be stages of social transformation in the practice of FGM. This suggests that advocates seeking to reduce the practice of FGM should not necessarily expect immediate outcomes in terms of actual declines in the practice but should be content with phased results based on the recognition of the state of progression of this transformational change. That means for example, that intermediary results such as attitudinal change documented by a reduction in the proportion of people willing to mutilate their daughters or to seek reinfibulation, are as good as the actual decline in the incidence of FGM. The good news is the report in this edition by Adeokun et al4, which indicates that there may be a trend towards a decline in the practice of FGM in southwest Nigeria over time. This report is consistent with our earlier report5 in Nigeria, which indicates a secular trend towards a decline in the incidence of FGM. Much of this decline is attributable to the effects of modernization and education and as emphasized by Finke6 in this edition of the journal, education and the empowerment of women, are two key interventions that will contribute significantly to ending FGM in Africa. In time past, the international community has expressed concern about the lack of strong scientific evidence linking FGM with adverse reproductive health outcomes. However, there are now a growing number of well conducted studies which demonstrate significant association between FGM and various gynecologic7 and pregnancy complications8, 9.
In 2006, the WHO reported a study conducted in six African countries (Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan) that determined the effects of FGM on various obstetric sequelae10. The study examined 26,393 women in the six countries during childbirth and showed that women with FGM were more likely to undergo caesarean section, to experience postpartum hemorrhage and extended hospital stay, to require infant resuscitation and to experience stillbirth, early neonatal death and low birth weight infants. This study has now provided the best evidence to date of the association between FGM and adverse obstetric outcomes. Clearly, there can be no doubt that FGM has negative implications for women's health in Africa. The elimination of all forms of FGM is now regarded as a major component of social and economic development strategies in many African countries. Although the elimination of FGM was not specifically mentioned as one of the expected outcomes of the Millennium Development Goals, the fact that FGM has negative implications for maternal health means that it must be addressed as part of efforts to achieve MDGs 4 and 5. In turn, we believe that if the remaining MDGs are adequately addressed, they can contribute significantly to eliminating FGM in African countries. While there has been intense international advocacy to eliminate FGM, limited results have been achieved, mainly because of the vertical approach hitherto used to address prevention efforts. We believe that to achieve and sustain results over time, FGM prevention must be integrated to the broader sexual and reproductive health programs. Additionally, research must be intensified to provide evidence for best practices for reducing FGM in Africa, and to monitor impact of interventions over time. In conclusion, the continued practice of FGM testifies to the human rights abuse and social disempowerment of women, and is a sad reminder of the poor state of women's reproductive health in Africa. African countries must give the highest priority to the elimination of FGM in their social developmental agenda. A systematic decline in the incidence of FGM is one indicator that any African country can show as proof of its willingness to address social and gender inequities among its people. In turn, the international community must not relent in its efforts to support the total abandonment of this unnecessary and harmful tradition in Africa. Surely, the current global crusade for social justice, equity and ethical practices cannot be achieved unless FGM is completely eliminated from the world.