Female genital mutilation

A discussion on a cultural issue with multiple impacts exploring the effects of FGM in Eritrea, Africa, and the difficult obstetric challenges that the practice presents to midwives.

Midwives magazine: December 2009/January 2010

By Letezghi Afewerki Lhbsu (principal author), a registered midwife and nurse and a qualified midwife teacher at the College of Nursing and Health Technologies in Asmara, Eritrea, University of Dundee’s Distance Learning Centre academic lead for Eritrea Lorna Numbers, e-learning and research coordinator in the Distance Learning Centre (Nursing and Palliative Care) Linda Martindale.

Introduction and background

This study explores the effects of female genital mutilation (FGM) on the victim, family and community and specifically the practice of FGM in Eritrea. The perspective of ‘victim’ is used advisedly, as reflected in the discussion. During the period while this work was being developed, there has been a gradual change in attitudes to FGM, not only in Eritrea, but also internationally. The subject, always controversial, has been more openly discussed and awareness of the damage it causes to the health of women and their babies has increased. In Eritrea, and several other countries, legislation has recently been put in place to stop the practice.

Yet media reports rarely depict an accurate impression and it is understood that practising midwives who are not cognisant of the implications of FGM can be confronted with difficult obstetric challenges. The main author has drawn on her own professional experience as an Eritrean midwife to elucidate the outcomes of FGM for women, especially during pregnancy and delivery.

FGM, also known as female circumcision, or female genital cutting, is classified by the WHO (2001) in four types, as shown in Table 1. Zerai (2003) reports that all types  have been practised in different ethnic groups in Eritrea.


Table 1. FGM classifications

Type I     Excision of prepuce, with or without excision of part or all of clitoris
Type II    Excision of clitoris; partial or total excision of labia minor
Type III   Excision of part or all of external genitalia; stitching of vaginal orifice to narrow it (infibulation)
Type IV   Pricking, piercing or incising of clitoris and/or labia; stretching of clitoris and/or labia and cauterization (by burning) of clitoris and surrounding tissue

FGM is a painful physical and emotional experience for many women and young girls in developing countries. It persists in many African and some Asian and Middle Eastern countries, even where illegal. Considered a violation of human rights by UNICEF and the WHO (WHO, 2001), it can result in post-traumatic stress disorder (PTSD). According to the WHO (2001), about 100 to 140 million girls and women worldwide have undergone FGM; at least two million girls are annually at risk of mutilation. Although most victims are in the countries identified above, they are also increasingly found in Europe, Australia, Canada and the US, primarily among immigrants from Africa and South Western Asia.

In Eritrea, the Ministry of Health (MoH) reports that about 95% of women have experienced some form of FGM (National Statistics Office (NSO), 2002). Zerai’s study of Eritrean women (2003) indicates that versions of Types I, II, and III are commonly practised. The effects range from, at minimum, clitoridectomy to the most extreme procedure, infibulation, undertaken to narrow the vaginal orifice significantly. Infibulations are more common in rural Eritrean women (65%). De-infibulation widens the vaginal opening and is performed on the wedding day by traditional healers; healthcare practitioners also perform de-infibulation to avoid complications before or during delivery. Re-infibulation is then undertaken by traditional healers after the birth (Eritrea MoH, 2002).

Some key statistics are shown in Table 2. The persistence of FGM and its sequelae contributes significantly to these figures, but it is an avoidable cause of death.


Table 2. Eritrean statistics (Zerai, 2003; Mismay, 2003, cited in TASC, 2005; NSO, 2002)
   
Complications immediately following procedure    19%
Girls under 5 years when circumcised    56%
Lifetime risk of dying from pregnancy and delivery-related causes    1:14
Maternal mortality    752/100000
Childhood mortality    93/1000
Infant mortality    48/1000

However, even before legislative change, there were signs that the FGM trend had been decreasing with time and as girls were better educated. NSO reported in 2002 the prevalence of FGM among women below 17 years was at about 75%, while high-school educated young women are much less likely to be circumcised than those with no education. These data correlate with the higher prevalence in rural areas where schooling is not readily available. During summer 2006, media reports from certain regions reflected increased commitment from community and religious leaders to seek statutory banning of FGM. Eritrean women living and working abroad also campaigned against the ritual. This community groundswell influenced government thinking, leading to statutory abolition in 2007 (State of Eritrea, 2007).
The MoH has taken a lead role in coordinating efforts to eliminate the practice through education and health promotion. FGM is on the list of primary healthcare priorities, impacting on policies and guidelines related to safe motherhood, child survival and management of HIV/AIDS (Eritrea, MoH, 2002). Health professionals must be effectively educated to prepare them for holistic management of mothers with FGM, so they can deal comfortably and confidently with their problems. The College of Nursing and Health Technology of Eritrea teaches health professionals both the dangers of FGM practice and preventive strategies to equip them with effective understanding and competence (College of Nursing and Health Technology, 2004). The range of agencies working to increase awareness and reduce the practice of FGM includes central government ministries and local government centres, community associations, religious groups (Christian and Islamic), international development groups and non-governmental organisations.

Traditional justification

Kwateng-Kluvitse (2006) discusses the different cultural and religious values that are invoked to support FGM practices; these include a desire to control sexual arousal outside marriage. One recurring belief is that uncircumcised girls have an over-active sex drive and are likely to lose their virginity before legal marriage and become unfaithful after marriage, disgracing the family and becoming a menace to men and the community. Observance of religious practice is an important part of Eritrean culture; arguably the Christian and the Islamic values of marital fidelity and virginity at marriage reinforce the tradition of FGM, even though neither religion explicitly demands it. However, virgin brides and faithful women are respected by their communities and bring pride to their husbands.

The WHO (2001) reports beliefs that the clitoris or surrounding tissue generates feelings of sexual arousal and must be cut; there is also a belief that the clitoris produces a bad odour, and should be removed. Infibulation is expected to increase male sexual pleasure, thereby reducing the divorce rate. However, the WHO (2001) also identified that not all men enjoy the tight orifice which can impede penetration, causing impotence.

Kwateng-Kluvitse (2006) states that neither the Koran nor Bible mention circumcision of females;  Zerai (2003) also refutes the association of FGM with the main Eritrean religions. Horowitz and Jackson (1995), supported by Kwateng-Kluvitse (2006), found that women hold conflicting values: although victims of FGM, they are strong proponents of the practice, taking responsibility for circumcising their daughters. The Eritrea MoH (1999) reports that, despite perceived benefits for men, they are not involved in FGM proceedings, except in preparing celebrations on the day. Traditional healers, arguably the most powerful women in Eritrean culture, perform the operation.

Kwateng-Kluvitse (2006) has linked the practice to social issues such as women’s inferior status, limited knowledge and understanding, and lack of financial independence. Although, historically and ethnically, gender equality is a complex issue in Eritrea, the principal author’s experiential evidence concurs with this view. Disempowered women find security in conforming to the social norms of FGM and most women do not consider the rite an issue of gender inequality.

Problems arising from FGM

Although a rite of passage within Eritrean traditional culture, there may be, alongside any feelings of belonging and acceptance, a crisis of confidence and trust in family and friends that can be long term. The experience is a vivid landmark in the girl’s mental development and is associated with fear, submission, and suppression of feelings, especially if performed after five years of age. Relations between the girl and her parents and her ability to form intimate relationships in the future, even with her own children, can be traumatised.

An MoH health promotion film showed a little girl being prepared for FGM. Outside people were dancing; older women were preparing for the procedure while the girl was waiting on the local bed. The film producer asked about her feelings and, without smiling, she told him she was happy because it was her great day, while her face reflected fear and tension. It is known that following FGM, a young girl will feel betrayal, bitterness, and anger at being subjected to such an ordeal despite the celebration.

It might be reasonable to expect that such an invasive procedure would be undertaken in a way that ensures the girl’s physical comfort and reduces risk of complication, immediate and longer term. However Table 3 shows some of the issues associated with FGM performed by traditional healers.

Table 3. Issues associated with FGM performed by traditional healers
Issues with traditional healers:
Limited understanding of anatomy and infection hazards
Dexterity not guaranteed
Use unsterilised incising and stitching material in different children
Apply traditional herbs to wounds
No analgesia

Immediate physical impacts of FGM include: severe pain and excessive bleeding that may result in shock and death; injury and deformity to adjacent tissues of urethra and vagina. The circumcised tissue is sewn together to heal in an unnatural position, leaving minimal outlets for menstrual flow and urine. Although not explicitly discussed, this anatomical alteration makes bladder voiding and the discomforts of menstruation more difficult for the young woman to manage. Different complications of FGM are shown in Figure 1.

Figure 1. Infection risks following FGM

Zerai (2003) also reports that because infibulations obstruct menstrual flow, at de-infibulation the accumulated clotted blood is manually removed, further exposing the young woman to infection.

The de- and re-infibulations begin with the wedding night, when the “hood” is often cut open to allow intercourse. Cutting the FGM stitch site with a razor blade is painful and robs the woman of any sexual pleasure she might have on her wedding night and often thereafter in the marriage. Many victims of FGM suffer from forms of sexual dysfunction and frigidity and young girls develop nightmares and often fear their wedding night (WHO, 2001).
Like other trauma, FGM is associated with mental and psychosomatic disorders as described by Driscoll, Skinner and Earlam (2000) and shown in Table 4. 

Table 4. Disorders associated with FGM (Driscoll et al, 2000; WHO, 2001)

Loss of appetite
Weight loss
Difficulty in concentration and learning
Low self-esteem
Inability to express pain and fear
Depression and chronic anxiety
Psychotic disorders

As discussed above, the impact of FGM on marriage can be the opposite of what is intended. Irrespective of type, FGM deprives the victim of an essential part of her body and control of her sexuality. In the principal author’s personal professional experience, young married Eritrean women commonly talk about hating their husbands, remembering the pain during their first sexual intercourse. Some leave their husbands; arguably long-lasting trauma associated with sexual activity is, at least, a contributing factor.

In the longer term, women experiencing painful de-infibulations and re-infibulations associated with childbirth may deprive their children of maternal love; while women may dislike their husbands because of painful sexual acts, according to Zerai, (2003) husbands may also suffer painful coitus. The mutual unpleasantness can lead to divorce.

FGM affects not just the victim, but also family, community and husbands. Families must pay for the circumcision and may also have to prepare a celebratory feast for the community and gifts for the circumcisers. The Eritrea MoH (1999) notes that the resultant economic burden is excessive if the family has many daughters. Further financial burden can arise if the circumcised child requires medical treatment for complications.

In the community, suffering and crying of little girls during FGM procedures causes terror and emotional trauma in others waiting for their turn. The Eritrea MoH (1999) explains that loud singing, dancing and drum beating, traditional in some communities, drown the victim’s cries.

Management of pregnant women with FGM

In respect of pregnancy and delivery, the WHO (2001) reports that circumcised pregnant women risk obstructed labour, which can result in uterine rupture, with severe, often fatal bleeding, or postpartum vesical or rectal fistula.

Accordingly, the WHO (2001) identifies objectives for managing mothers with FGM during pregnancy: early recognition of potential obstetric complications facilitates appropriate treatment at all stages. Problems are multi-dimensional with physical, emotional and social components, therefore Campbell-Krijgh and Abreha (2003) advise that effective health care for managing an FGM mother should be multidisciplinary and multisectoral. Team members must respect her values.

In the principal author’s experience, women with FGM are assessed for physical, psychosocial and sexual complications in antenatal clinics. They often suffer anxiety during vaginal examinations and may fear being examined, anticipating pain. The Eritrea MoH (2002) stresses the importance of respecting confidentiality and explaining procedures. Therefore, before examination, trust is developed through reassurance and optimising comfort to encourage relaxation. Open discussion enables the mother to understand and participate in planning for intervention to help all aspects of the birth; the birth plan is therefore a shared effort. Through active and careful listening, mothers are encouraged to talk. Manji et al (2006) advise showing understanding and concern when women respond to sensitive questions and share their problems.

When the mother is comfortable and relaxed, the risk of trauma during pelvic examinations is minimised. The presence of a rigid introitus, keloid tissue and scarring are assessed in respect of potential problems at delivery, along with evidence of infection or its effects, such as abscess or cysts.

Mothers with a tight introitus (i.e. an opening of one centimetre or less) are at special risk of major perineal damage during labour and are referred to hospital for antenatal care and delivery. If two fingers can be introduced into the vagina without discomfort, major physical problems at delivery are unlikely, whether the FGM has been Type I, II, or IV. The birth plan can therefore focus on health facility care rather than hospital. When there is a rigid introitus, most likely following Type III FGM, the victim and her husband (and/or other family members where appropriate) are counselled on the importance of de-infibulation before delivery.

Antenatal de-infibulation

Second trimester de-infibulation is recommended (20-28 weeks):
•    It allows time for healing before delivery
•    Opening the vulva in the first trimester may stimulate spontaneous abortion.

Pain relief
•    Local anaesthesia during de-infibulations (Eritrea MOH, 2001; 2003)
•    Prescribe diclofenac sodium and paracetamol afterwards.

Healing/infection prevention
•    Advice given on vulval hygiene
•    Refrain from intercourse for four to six weeks.

Monitoring
•    Clinic follow-up.

Healthcare professionals are involved in counselling and educating women during antenatal care about de-infibulation; mothers refusing de-infibulations during pregnancy in spite of counselling, are advised to deliver in hospital. Then de-infibulation becomes necessary during the second stage of labour. Mothers may choose de-infibulation by traditional healers; the Eritrea MoH (2002) reports that they often present afterwards at health facilities with infection or anaemia.

Until the law in Eritrea was changed, ethically uncomfortable decisions were also necessary after delivery in respect of re-infibulation, in respect of deciding whether to re-stitch the vulva postpartum aseptically and safely, or discharge the mother knowing she would seek traditional practitioners with all the associated risks.

In respect of the psychological and emotional wellbeing of FGM mothers, midwives and nurses have a significant role, since Eritrea has few psychologists and psychiatrists. Confidentiality and continuity of care are safeguarded; all interventions, counselling, and referrals are recorded with a summary of FGM history, type and sequelae.


Education

Harmful traditions, taboos and beliefs develop over generations, influencing a community’s behaviour and responses. To bring positive, health-enhancing behavioural changes in the community, it is important to understand this process and recognise that entrenched harmful actions and responses require effort, patience and time before they are discarded (Naidoo and Wills, 2002).

A range of health education strategies can promote change; insightful listening and communicating, underpinned by the professional’s appreciation of the time and effort required are critical elements. People also need time to examine their feelings, values and attitudes about FGM to enable informed decisions for personal change. Naidoo and Wills (2002) explain that involvement in planning and implementation of preventive strategies promotes a sense of ownership for individuals, families and community.

Effective FGM health education is a community activity, targeting, not only victims (who themselves will become mothers, who can refuse to prolong the ritual tradition), but also families, husbands, religious groups, traditional healers, birth attendants, and school children. The concept of self-help, where victims use their experience to pioneer change, is appropriate, providing they are motivated; community support is vital. Sensitive timing of teaching helps make it effective; the appropriate moment to encourage FGM victims and their husbands to change attitudes and behaviour might be after the shock of wedding-night pain, or following de-infibulations or delivery.

Data from NSO (2002), discussed above, demonstrate that education is significant in reducing the impact of FGM. Therefore, improving educational opportunity and status for girls is an important, powerful component of change. Education empowers women, making them financially independent. Otherwise they lack wage-earning ability and if they remain unmarried, or if they divorce, they are a burden on their family. The majority of uneducated Eritrean women live in rural areas, and are economically dependent on their husbands. Already having suffered FGM and its effects themselves, in this situation they are incapable of rejecting the practice for their daughters. Zerai (2003) found that although more than 36% of illiterate Eritrean women said FGM is unhealthy, they accept it because of their financially dependent status. 

Zerai’s work (2003) suggests that when FGM is undertaken by near relatives, financial problems are unlikely. However, in response to the statutory abolition, traditional healers with financial interests may resist change. The multi-sectoral approach can help identify alternative sources of income for these people. Since FGM is a rite of passage in some Eritrean communities, the WHO (2001) recommends that alternative non-harmful ceremonies need to be part of the education strategy.

Reducing the practice of FGM: legal and ethical implications

The abolition law, passed in Eritrea in spring 2007 (State of Eritrea, 2007) protects girls and women by providing legal rights to relatives, police, community health committees, and health professionals to intervene; yet traditional healers might continue clandestinely, which could be more dangerous. Girls and women suffering complications may be hidden for fear of persecution. For many, this avoidance of health care could be fatal (Sweet and Tiran, 1997; WHO, 2001; Zerai, 2003).  

The statutory instrument also clarifies the position of the medical profession in respect of female circumcision; for them, the standard sentence of imprisonment or fine will be ‘aggravated and the court may suspend such an offender from practising his/her profession for a maximum period of two years’ (State of Eritrea, 2007).

Additionally, whether a mother wishes re-infibulation or not after delivery (as discussed above), the new law does not permit healthcare professionals to undertake the practice.
The potential difficulties that might arise from this change, no matter how welcome it is, make it clear that no law can be a substitute for informed positive behavioral change through education. Legal and educational change modes must operate together if they are to be effective, especially as many of the people most concerned accept new ideas only gradually and/or their situation means they are not sufficiently self-empowered.

The number of women who have already undergone FGM means that there is a legacy of health impairment to address. It is evident that there will be a requirement for ongoing educational and remedial health care for a very long time.

Eritrea is not alone in banning FGM, yet, despite national and international effort, the practice may persist. Then it becomes important, albeit controversial, to discuss infection prevention as part of the procedure, rather than focusing exclusively on stopping the practice.

The challenge

Multi-sectoral approaches to health challenges are the norm in Eritrea, as demonstrated in success with controlling malaria and tuberculosis. Ending FGM will clearly have significant impact on health and quality of life, however, compliance is likely to remain an issue. The NSO report (2002) indicated ongoing support (95% of a population sample) for the practice. Health professionals totally oppose FGM practices, especially infibulation, de-infibulation and re-infibulation. Even after FGM practices end in Eritrea and in other countries, there will still be (for example in the Eritrean Diaspora community who live abroad), a challenge not only in respect of compliance, but also sensitive education. Ensuring adaptation of strongly held values, which have for centuries been integral to the culture, will require effective outreach alongside ongoing health management of the many women who continue to live with the effects of FGM.

Conclusion

Mothers continue to experience diverse traumatic effects of FGM, because immediate behavioral change to eradicate the practice is an unrealistic objective. Change begins with parental and community leader education, addressing negative health impacts and with sensitive and insightful public education campaigns. Educating and re-training traditional birth attendants, and optimising health education for the community at large will bring positive change. The importance of improving the educational and financial status of women is paramount.

While this analysis has focused on Eritrea, the problems of FGM are international and demand knowledge, skill, and commitment, especially from midwives, if the present legacy of mortality and morbidity from the procedure is to be ameliorated.

References

Campbell-Krijgh E, Abreha T. (2003) Mending torn lives: a series of open conversations with women suffering from obstetric fistula in Eritrea. UNFPA and Ministry of Health: Asmara, Eritrea.

College of Nursing and Health Technology. (2004) Curriculum for nurses. Sabur Printing Press Asmara: Eritrea.

Driscoll P, Skinner D, Earlam R. (2000) ABC of major trauma. BMJ Books Group: London.

Eritrea Ministry Of Health. (1999) FGM eradication communication strategy development workshop: report of proceedings. Ministry of Health: Asmara, Eritrea.

Eritrea Ministry of Health. (2001) Eritrean national list of drugs. Ministry of Health: Asmara, Eritrea.

Eritrea Ministry of Health. (2002) Clinical protocol on safe motherhood. Ministry of Health: Asmara, Eritrea.

Eritrea Ministry of Health. (2003) Standard treatment guidelines. Ministry of Health: Asmara, Eritrea.

Horowitz RC, Jackson C. (1997) Female circumcision: African women confront. American Medicine Journal of General Internal Medicine 12: 513-15.

Kwateng-Kluvitse A. (2006) Female genital mutilation: an RCN educational resource for nursing and midwifery staff. RCN: London.

Manji AL, Al Badawi I, El Enbaby A, Al Bareedy N. (2006) Female circumcision (female genital mutilation): a problem for brachytherapy in cervical cancer. International Journal of Gynecological Cancer 16: 675-80.

Naidoo J, Wills J. (2002) Health promotion: foundations for practice. Baillière Tindall and RCN: Edinburgh.

National Statistics Office. (2002) Demographic and health survey. NSO: Asmara, Eritrea.

State Of Eritrea. (2007) Proclamation 158/2007. A proclamation to abolish female circumcision. Gazette of Eritrean Laws. See: www.unhcr.org/refworld/docid/48578c812.html (accessed 12 November 2009).

Sweet B, Tiran D. (1997) Mayes’ midwifery. Baillière Tindall: London.

TASC. (2005) Improving health care delivery systems in Eritrea: Technical Assistance and Support (TASC) Final Report. USAID: Baltimore. See: http://www.jsi.com/Managed/Docs/Publications/WomensHealth/PDABZ409.pdf (accessed 12 November 2009).

WHO. (2001) Female genital mutilation: integrating the prevention and the management of the health complications into the curricula of nursing and midwifery. WHO: Geneva. See: www.who.int/reproductivehealth/publications/fgm/RHR_01_17/en/index.html (accessed 12 November 2009).

Zerai W. (2003) A study on female genital mutilation in Eritrea. Ministry of Health: Asmara, Eritrea.