Changing attitudes towards female genital mutilation. From conflicts of loyalty to reconciliation with self and the community: The role of emotion regulation.

The practice of female genital mutilation (FGM) is a social norm embedded in the patriarchal system and is resistant to change due to its roots in the tradition of the practising communities. Despite this difficulty in change, some women succeed in changing their attitudes towards the practice. In trying to understand what makes these women change their attitudes, we identified in a previous study, the critical life events at which change occurs (turning point). These turning points were described with emotions and conflicting feelings based on which we hypothesised that emotion regulation and the resolution of conflicts of loyalty might be possible mechanisms that explain the change of attitudes by the women. In this article, we sought to investigate how the mechanisms interact and how they were at play to explain the change. We, therefore, triangulated our previous data, fifteen women interviewed twice, with the published life stories and public testimonies of 10 women with FGM, and interviews of six experts chosen for their complementary fields of expertise to discuss the emerging concepts and theory, generated by our study. The data were analysed using framework analysis and an element of the grounded theory approach (constant comparison). As a result of our theorisation process, we propose a model of change in five stages (Emotion suppression, The awakening, The clash, Re-appropriation of self, and Reconciliation). This describes the process of a woman's journey from compliance with FGM and community norms to non-compliance. Our study reveals how the women whose stories were analysed, moved from being full members of their community at the cost of suppressing their emotions and denying their selves, to becoming their whole selves while symbolically remaining members of their communities through the forgiveness of their mothers.

Pleasure, womanhood and the desire for reconstructive surgery after female genital cutting in Belgium.

Growing numbers of women are showing interest in clitoral reconstructive surgery after 'Female Genital Mutilation'. The safety and success of reconstructive surgery, however, has not clearly been established and due to lack of evidence the World Health Organization does not recommend it. Based on anthropological research among patients who requested surgery at the Brussels specialist clinic between 2017 and 2020, this paper looks at two cases of women who actually enjoy sex and experience pleasure but request the procedure to become 'whole again' after stigmatising experiences with health-care professionals, sexual partners or gossip among African migrant communities. An ethnographic approach was used including indepth interviews and participant observation during reception appointments, gynecological consultations, sexology and psychotherapy sessions. Despite limited evidence on the safety of the surgical intervention, surgery is often perceived as the ultimate remedy for the 'missing' clitoris. Such beliefs are nourished by predominant discourses of cut women as 'sexually mutilated'. Following Butler, this article elicits how discursive practices on the physiological sex of a woman can shape her gender identity as a complete or incomplete person. We also examine what it was that changed the patients' mind about the surgery in the process of re-building their confidence through sexology therapy and psychotherapy.

"When my mother called me to say that the time of cutting had arrived, I just escaped to Belgium with my daughter": identifying turning points in the change of attitudes towards the practice of female genital mutilation among migrant women in Belgium.

BACKGROUND: Female Genital Mutilation (FGM) is a public health concern with negative consequences on women's health. It is a harmful practice which is recognized in international discourses on public health as a form of gender-based violence. Women are not only victims of this, but also perpetrators. The practice of FGM remains a social norm which is difficult to change because it is deeply rooted in tradition and is embedded in the patriarchal system. However, some women have managed to change their attitudes towards it and have spoken out against it. This study identifies and describes turning points that have been defined as significant and critical events in the lives of the women, and that have engendered changes in their attitudes towards the practice of FGM. METHODS: We have conducted an inductive qualitative study based on the life story approach, where we interviewed 15 women who have undergone FGM. During the interviews, we discussed and identified the turning points that gave the research participants the courage to change their position regarding FGM. The analysis drew on lifeline constructions and thematic analysis. RESULTS: Six common turning points relating to a change in attitude towards FGM were identified: turning points related to (i) encounters with health professionals, (ii) education, (iii) social interactions with other cultures and their own culture, (iv) experiences of motherhood, (v) repeated pain during sexual or reproductive activity, and (vi) witnessing the effects of some harmful consequences of FGM on loved ones. CONCLUSIONS: The turning points identified challenged the understanding of what it means to be a 'member' of the community in a patriarchal system; a 'normal woman' according to the community; and what it means to be a 'good mother'. Moreover, the turning points manifested in conjunction with issues centered on emotional responses and coming to terms with conflicts of loyalty, which we see as possible triggers behind the shift experienced by the women in our sample.

The obstetric care subsidy policy in Burkina Faso: what are the effects after five years of implementation? Findings of a complex evaluation.

BACKGROUND: Burkina Faso, like many low and middle income countries, has been taking a range of actions to address its poor maternal and neonatal health indicators. In 2006 the government introduced an innovative national subsidy scheme for deliveries and emergency obstetric care in public facilities. This article reports on a complex evaluation of this policy, carried out 5 years after its introduction, which examined its effects on utilisation, quality of care, equity and the health system as a whole, as well as its cost and sustainability. METHODS: The evaluation was carried out in six purposively selected districts, as well as at national level, using a case study approach. Data sources included: national and district routine and survey data, household interviews with women who had recently given birth, data extraction from hospital and medical records, and key informant and health worker interviews. RESULTS: The underlying secular trend of a 1% annual increase in the facility-based delivery rate (1988-2010) was augmented by an additional 4% annual increase from 2007 onwards (after the policy was introduced), especially in rural areas and amongst women from poor households. The absence of baseline quality of care data made it difficult to assess the impact of the policy on quality of care, but hospitals with the best level of implementation of the subsidy offered higher quality of care (as measured by health care near-misses), so there is no evidence of a negative impact on quality (as is often feared). Similarly, there is little evidence of unintended negative effects on untargeted services. Household payments for facility-based deliveries have reduced significantly, compared with payments before the policy, and the policy as a whole is affordable, costing about 2% of total public health expenditure. Concerns include that the amounts paid by households are higher than the rates set by the policy, and also that 7% of households still say that they cannot afford to pay. Wealthier women have higher utilisation of services, as before, and the policy of fully exempting indigents is not being put into practice. CONCLUSIONS: These findings highlight the importance of maintaining the subsidy policy, given the evidence of positive outcomes, but they also point out areas where attention is needed to ensure the poor and most vulnerable population benefit fully from the policy.

Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality.

This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.

Stillbirth--a neglected priority: understanding its social meaning in Pakistan.

Despite being ranked 3rd among the countries having highest burden of stillbirths, it remains a neglected priority in Pakistan. We review the evidence regarding social and biomedical understanding of stillbirths by both communities and healthcare providers. The terminology used to define stillbirth worldwide remains inconsistent. Not only do the health professionals mis-classify and under-report stillbirths, but also the parents and families are unclear about the difference between miscarriage, stillbirth and early neonatal deaths. Stillbirths occur more in poor families and are not recognised by tradition and religion as a loss comparable to a newborn who was born alive. There is need to understand perspective of communities and healthcare providers to identify prevention and management strategies along with providing support for coping with the implications of stillbirths. Future government policies on stillbirths must be informed by the influence of culture on the attitudes, beliefs and practices of the communities and the healthcare providers.

Fear, guilt, and debt: an exploration of women's experience and perception of cesarean birth in Burkina Faso, West Africa.

BACKGROUND: This paper explores women's experience and perception of cesarean birth in Burkina Faso and its social and economic implications within the household. METHODS: Five focus groups comprising mothers or pregnant women were conducted among residents of Bogodogo Health District in Ouagadougou to assess the perceptions of cesarean section (CS) by women in the community. In addition, 35 individual semistructured interviews were held at the homes of women who had just undergone CS in the referral hospital, and were conducted by an anthropologist and a midwife. RESULTS: Home visits to women with CS identified common fears about the procedure, such as "once you have had a CS, you will always have to deliver by CS". The central and recurring theme in the interviews was communication between patients and care providers, ie, women were often not informed of the imminence of CS in the delivery room. Information given by health care professionals was often either not explicit enough or not understood. The women received insufficient information about postoperative personal hygiene, diet, resumption of sexual activity, and contraception. Overall, analysis of the experiences of women who had undergone CS highlighted feelings of guilt in the aftermath of CS. Other concerns included the feeling of not being a "good mother" who can give birth normally, alongside concerns about needing a CS in future pregnancies, the high costs that this might incur for their households, general fatigue, and possible medical complications after surgery. CONCLUSION: Poor quality of care and the economic burden of CS place women in a multifaceted situation of vulnerability within the family. CS has a medical, emotional, social, and economic impact on poor African women that cannot be ignored. Managers of maternal health programs need to understand women's perceptions of CS so as to overcome existing barriers to this life-saving procedure.

[Therapeutic gîtes in child psychiatry]. / Les gîtes thérapeutiques en pédopsychiatrie.

Therapeutic gîtes in child psychiatry. A therapeutic stay in a gîte is a project led by a multidisciplinary team. It enables children to experiment with the notion of pleasure and to develop their level of socialisation, their personality and their independence, outside the family environment. For caregivers, it provides a rich source of clinical material and strengthens the team dynamics.

Sub-Saharan Africa and the health MDGs: the need to move beyond the "quick impact" model.

The Millennium Development Goals (MDGs) were defined in 2001, making poverty the central focus of the global political agenda. In response to MDG targets for health, new funding instruments called Global Health Initiatives were set up to target specific diseases, with an emphasis on "quick win" interventions, in order to show improvements by 2015. In 2005 the UN Millennium Project defined quick wins as simple, proven interventions with "very high potential short-term impact that can be immediately implemented", in contrast to "other interventions which are more complicated and will take a decade of effort or have delayed benefits". Although the terminology has evolved from "quick wins" to "quick impact initiatives" and then to "high impact interventions", the short-termism of the approach remains. This paper examines the merits and limitations of MDG indicators for assessing progress and their relationship to quick impact interventions. It then assesses specific health interventions through both the lens of time and their integration into health care services, and examines the role of health systems strengthening in support of the MDGs. We argue that fast-track interventions promoted by donors and Global Health Initiatives need to be complemented by mid- and long-term strategies, cutting across specific health problems. Implementing the MDGs is more than a process of "money changing hands". Combating poverty needs a radical overhaul of the partnership between rich and poor countries and between rich and poor people within countries.

The national subsidy for deliveries and emergency obstetric care in Burkina Faso.

INTRODUCTION: To reduce financial barriers to health care services presented by user fees, Burkina Faso adopted a policy to subsidize deliveries and emergency obstetric care for the period 2006-2015. Deliveries and caesarean sections are subsidized at 80%; women must pay the remainder. The worst-off are fully exempted. METHODS The aim of this article is to document this policy's entire process using a health policy analytical framework. Qualitative data are drawn from individual interviews (n = 113 persons) and focus groups conducted with 344 persons in central government, three rural districts and one urban district. Quantitative data are taken from the national health information system in eight districts. RESULTS The policy was initiated in all districts concurrently, before all the technical instruments were ready. The subsidy is paid by the national budget (US$60 million, including US$10 million for the worst-off). Information activities, implementation and evaluation support have been minimal because of insufficient funding. Health workers and lay people have not always had the same information, such that the policy has not been uniformly applied. Coping strategies have been noted among health workers and the population, but there has been no attempt to impede the policy's implementation. At the time of the study, fixed-rate reimbursement for delivery (output-based) and overestimation of input costs were financially advantageous to health workers (bonuses) and management committees (hoarding). Very few of the worst-off have been exempted from payment because selection processes and criteria have not yet been defined and most health workers are unaware of this possibility. The upward trend in assisted deliveries since 2004 continued after the policy's introduction. CONCLUSIONS This ambitious policy expresses a strong political commitment but has not been adequately supported by international partners. Despite relatively tight administrative controls, health workers have figured out how to take advantage of the system. Some of the policy's instruments should be reviewed and clarified to improve its effectiveness.

Communities of practice: the missing link for knowledge management on implementation issues in low-income countries?

The implementation of policies remains a huge challenge in many low-income countries. Several factors play a role in this, but improper management of existing knowledge is no doubt a major issue. In this article, we argue that new platforms should be created that gather all stakeholders who hold pieces of relevant knowledge for successful policies. To build our case, we capitalize on our experience in our domain of practice, health care financing in sub-Saharan Africa. We recently adopted a community of practice strategy in the region. More in general, we consider these platforms as the way forward for knowledge management of implementation issues.

Estimating the number of women with female genital mutilation in Belgium.

OBJECTIVE: To estimate the number of women with female genital mutilation (FGM) living in Belgium, the number of girls at risk, and the target population of medical and social services (MSSs) concerned. METHODS: Data about prevalence of FGM from the most recently published Demographic and Health Surveys and Multiple Indicator Cluster Surveys were applied to females living in Belgium who migrated from countries where excision or infibulation are being practised, and to their daughters. RESULTS: Amongst the 22,840 women and girls living in Belgium who are from a country concerned, 6,260 have 'most probably already undergone a FGM' (women born in the country of origin), and 1,975 are 'at risk' (second generation born in Belgium). The target population of MSSs comprises 1,190 girls less than five years old attending well-baby clinics, 1,690 girls aged 5-19 years attending preventive school health centres, 4,905 women 20-49 years old and 450 women over 50 years of age attending reproductive health services. The population of women concerned is unequally dispersed in Belgium and reflects the distribution of migrant settlement in the different provinces. CONCLUSION: FGM in Belgium requires a more concerted approach in terms of prevention, and medical and social care. Accurate information about the distribution of women concerned should permit better planning of competent services.

Innovative approaches to reducing financial barriers to obstetric care in low-income countries.

Lack of access to quality care is the main obstacle to reducing maternal mortality in low-income countries. In many settings, women must pay out-of-pocket fees, resulting in delays, some of them fatal, and catastrophic expenditure that push households into poverty. Various innovative approaches have targeted the poor or exempted specific services, such as cesarean deliveries. We analyzed 8 case studies to better understand current experiments in reducing financial barriers to maternal care. Although service utilization increased in most of the settings, concerns remain about quality of care, equity between rich and poor patients and between urban and rural residents, and financial sustainability to support these new strategies.

Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn.

The huge majority of the annual 6.3 million perinatal deaths and half a million maternal deaths take place in developing countries and are avoidable. However, most of the interventions aiming at reducing perinatal and maternal deaths need a health care system offering appropriate antenatal care and quality delivery care, including basic and comprehensive emergency obstetric care facilities. To promote the uptake of quality care, there are two possible approaches: influencing the demand and/or the supply of care. Five lessons emerged from experiences. First, it is difficult to obtain robust evidence of the effects of a particular intervention in a context, where they are always associated with other interventions. Second, the interventions tend to have relatively modest short-term impacts, when they address only part of the health system. Third, the long-term effects of an intervention on the whole health system are uncertain. Fourth, because newborn health is intimately linked with maternal health, it is of paramount importance to organise the continuum of care between mother and newborn. Finally, the transfer of experiences is delicate, and an intervention package that has proved to have a positive effect in one setting may have very different effects in other settings.

Identifying barriers from home to the appropriate hospital through near-miss audits in developing countries.

Near-miss cases often arrive in critical condition in referral hospitals in developing countries. Understanding the reasons why women arrive at these hospitals in a moribund state is crucial to the reduction of the incidence and case fatality of severe obstetric complications. This paper discusses how near-miss audits can empower the hospital teams to document and help reduce barriers to obstetric care in the most useful way and makes practical suggestions on interviews, analytical framework, ethical issues and staff motivation. Review of the evidence shows that case reviews and confidential enquiries appear particularly suitable to the understanding of delays. Criterion-based audits can also achieve this by establishing criteria for referral. However, hospital staff have limited intervention tools at their disposal to address barriers to emergency care at the community level. It is therefore important to involve the district management team and representatives of the community in auditing the health care seeking and treatment of women with near-miss complications.