Female Genital Mutilation/Cutting Related to Reproductive Health Needs During Pregnancy and Birth.

Female genital mutilation and cutting (FGM/C) is a human rights violation and a form of gender-based violence. Yet it is estimated that more than 230 million women and girls globally and over half a million women and girls living in the United States have been subjected to FGM/C or are at risk. Due to rising rates of immigration to the United States, it is more likely that health care providers will encounter patients subjected to FGM/C. In this column, I review clinicians' knowledge of and experience in delivering care to women with FGM/C, patient experiences, the role of clinical guidelines, screening, research gaps, laws, and data. I conclude with recommendations from professional organizations related to the reproductive health needs of women affected by FGM/C during pregnancy and birth.

The women's health needs study among women from countries with high prevalence of female genital mutilation living in the United States: Design, methods, and participant characteristics.

BACKGROUND: The Women's Health Needs Study (WHNS) collected information on the health characteristics, needs, and experiences, including female genital mutilation (FGM) experiences, attitudes, and beliefs, of women aged 18 to 49 years who were born, or whose mothers were born, in a country where FGM is prevalent living in the US. The purpose of this paper is to describe the WHNS design, methods, strengths and limitations, as well as select demographic and health-related characteristics of participants. METHODS: We conducted a cross-sectional survey from November 2020 -June 2021 in four US metropolitan areas, using a hybrid venue-based sampling (VBS) and respondent-driven sampling (RDS) approach to identify women for recruitment. RESULTS: Of 1,132 participants, 395 were recruited via VBS and 737 RDS. Most were born, or their mothers were born, in either a West African country (Burkina Faso, Guinea, Mali, Mauritania, Sierra Leone, The Gambia) (39.0%) or Ethiopia (30.7%). More than a third were aged 30-39 years (37.5%) with a majority who immigrated at ages ≥13 years (86.6%) and had lived in the United States for ≥5 years (68.9%). Medicaid was the top health insurer (52.5%), followed by private health insurance (30.5%); 17% of participants had no insurance. Nearly half of women reported 1-2 healthcare visits within the past 12 months (47.7%). One in seven did not get needed health care due to cost (14.8%). Over half have ever used contraception (52.1%) to delay or avoid pregnancy and 76.9% had their last pelvic and/or Papanicolaou (pap) exam within the past 3 years. More than half experienced FGM (55.0%). Nearly all women believed that FGM should be stopped (92.0%). CONCLUSION: The VBS/RDS approach enabled recruitment of a diverse study population. WHNS advances research related to the health characteristics, needs, and experiences of women living in the US from countries where FGM is prevalent.

ASRHR in Ethiopia: reviewing progress over the last 20 years and looking ahead to the next 10 years.

Over the last two decades, improvements in Ethiopia's socio-economic context, the prioritization of health and development in the national agenda, and ambitious national health and development policies and programmes have contributed to improvements in the living standards and well-being of the population as a whole including adolescents. Improvements have occurred in a number of health outcomes, for example reduction in levels of harmful practices i.e., in child marriage and female genital mutilation/cutting (FGM/C), reduction in adolescent childbearing, increase in positive health behaviours, for example adolescent contraceptive use, and maternal health care service use. However, this progress has been uneven. As we look to the next 10 years, Ethiopia must build on the progress made, and move ahead understanding and overcoming challenges and making full use of opportunities by (i) recommitting to strong political support for ASRHR policies and programmes and to sustaining this support in the next stage of policy and strategy development (ii) strengthening investment in and financing of interventions to meet the SRH needs of adolescents (iii) ensuring laws and policies are appropriately communicated, applied and monitored (iv) ensuring strategies are evidence-based and extend the availability of age-disaggregated data on SRHR, and that implementation of these strategies is managed well (v) enabling meaningful youth engagement by institutionalizing adolescent participation as an essential element of all programmes intended to benefit adolescents, and (vi) consolidating gains in the area of SRH while strategically broadening other areas without diluting the ASRHR focus.

It's a woman's thing: gender roles sustaining the practice of female genital mutilation among the Kassena-Nankana of northern Ghana.

INTRODUCTION: The practice of female genital mutilation (FGM/C) in traditional African societies is grounded in traditions of patriarchy that subjugate women. It is widely assumed that approaches to eradicating the practice must therefore focus on women's empowerment and changing gender roles. METHODS: This paper presents findings from a qualitative study of the FGM/C beliefs and opinions of men and women in Kassena-Nankana District of northern Ghana. Data are analyzed from 22 focus group panels of young women, young men, reproductive age women, and male social leaders. RESULTS: The social systemic influences on FGM/C decision-making are complex. Men represent exogenous sources of social influence on FGM/C decisions through their gender roles in the patriarchal system. As such, their FGM/C decision influence is more prominent for uncircumcised brides at the time of marriage than for FGM/C decisions concerning unmarried adolescents. Women in extended family compounds are relatively prominent as immediate sources of influence on FGM/C decision-making for both brides and adolescents. Circumcised women are the main source of social support for the practice, which they exercise through peer pressure in concert with co-wives. Junior wives entering a polygynous marriage or a large extended family are particularly vulnerable to this pressure. Men are less influential and more open to suggestions of eliminating the practice of FGM/C than women. CONCLUSION: Findings attest to the need for social research on ways to involve men in the promotion of FGM/C abandonment, building on their apparent openness to social change. Investigation is also needed on ways to marshal women's social networks for offsetting their extended family familial roles in sustaining FGM/C practices.

Evaluating changes in the prevalence of female genital mutilation/cutting among 0-14 years old girls in Nigeria using data from multiple surveys: A novel Bayesian hierarchical spatio-temporal model.

Female genital mutilation/cutting (FGM/C) is considered a public health and human rights concern, mainly concentrated in Africa, and has been targeted for elimination under the sustainable development goals. Interventions aimed at ending the practice often rely on data from household surveys which employ complex designs leading to outcomes that are not totally independent, thus requiring advanced statistical techniques. Combining data from multiple surveys within robust statistical framework holds promise to provide more precise estimates due to increased sample size, and accurately identify 'hotspots' and allow for assessment of changes over time. In this study, rich datasets from six (6) successive waves of the Nigeria Demographic and Health Surveys and Multiple Indicator Cluster Surveys undertaken between 2003 and 2016/17, were combined and analyzed in order to better assess changes in the likelihood and prevalence of FGM/C among 0-14-year old girls in Nigeria. We used Bayesian hierarchical regression models which explicitly accounted for the inherent spatial and temporal autocorrelations within the data while simultaneously adjusting for variations due to different survey methods and the effects of linear and non-linear covariates. Parameters were estimated using Markov chain Mote Carlo techniques and model fit assessments were based on Deviance Information Criterion. Results show that prevalence of FGM/C among 0-14 years old girls in Nigeria varied over time and across geographical locations and peaked in 2008 with a shift from South to North. A girl was more likely to be cut if her mother was cut, supported FGM/C continuation, or had no higher education. The effects of mother's age, wealth and type of residence (urban-rural) were no longer significant in 2016. These results reflect the gains of interventions over the years, but also echo the belief that FGM/C is a social norm thus requiring tailored all-inclusive interventions for the total abandonment of FGM/C in Nigeria.

Cost and impact of scaling up female genital mutilation prevention and care programs: Estimated resource requirements and impact on incidence and prevalence.

PURPOSE: SDG 5.3 targets include eliminating harmful practices such as Female Genital Mutilation (FGM). Limited information is available about levels of investment needed and realistic estimates of potential incidence change. In this work, we estimate the cost and impact of FGM programs in 31 high burden countries. METHODS: This analysis combines program data, secondary data analysis, and population-level costing methods to estimate cost and impact of high and moderate scaleup of FGM programs between 2020 and 2030. Cost per person or community reached was multiplied by populations to estimate costs, and regression analysis was used to estimate new incidence rates, which were applied to populations to estimate cases averted. RESULTS: Reaching the high-coverage targets for 31 countries by 2030 would require an investment of US$ 3.3 billion. This scenario would avert more than 24 million cases of FGM, at an average cost of US$ 134 per case averted. A moderate-coverage scenario would cost US$ 1.6 billion and avert more than 12 million cases of FGM. However, average cost per case averted hides substantial variation based on country dynamics. The most cost-effective investment would be in countries with limited historic change in FGM incidence, with the average cost per case averted between US$ 3 and US$ 90. The next most effective would be those with high approval for FGM, but a preexisting trend downward, where cost per case averted is estimated at around US$ 240. INTERPRETATION: This analysis shows that although data on FGM is limited, we can draw useful findings from population-level surveys and program data to guide resource mobilization and program planning.

Towards the elimination of FGM by 2030: A statistical assessment.

In 2015, UN member states committed to eliminate female genital mutilation (FGM) by 2030 as part of the Sustainable Development Agenda. To reach this goal, interventions need to be targeted and guided by the best available evidence. To date, however, estimates of the number of girls and women affected by FGM and their trends over time and geographic space have been limited by the availability, specificity and quality of population-level data. We present new estimates based on all publicly available nationally representative surveys collected since the 1990s that contain both information on FGM status and on the age at which FGM occurred. Using survival analysis, we generate estimates of FGM risk by single year of age for all countries with available data, and for rural and urban areas separately. The likelihood of experiencing FGM has decreased at the global level, but progress has been starkly uneven between countries. The available data indicate no progress in reducing FGM risk in Gambia, Guinea-Bissau, Mali and Guinea. In addition, rural and urban areas have diverged over the last two decades, with FGM declining more rapidly in urban areas. We describe limitations in the availability and quality of data on FGM occurrence and age-at-FGM. Based on current trends, the SDG goal of eliminating FGM by 2030 is out of reach, and the pace at which the practice is being abandoned would need to accelerate to eliminate FGM by 2030. The heterogeneity in trends between countries and rural vs urban areas offers an opportunity to contrast countries where FGM is in rapid decline and explore potential policy lessons and programmatic implications for countries where the practice of FGM appears to remain entrenched.

Socio-economic and demographic determinants of female genital mutilation in sub-Saharan Africa: analysis of data from demographic and health surveys.

BACKGROUND: Owing to the severe repercussions associated with female genital mutilation (FGM) and its illicit status in many countries, the WHO, human rights organisations and governments of most sub-Saharan African countries have garnered concerted efforts to end the practice. This study examined the socioeconomic and demographic factors associated with FGM among women and their daughters in sub-Saharan Africa (SSA). METHODS: We used pooled data from current Demographic and Health Surveys (DHS) conducted between January 1, 2010 and December 31, 2018 in 12 countries in SSA. In this study, two different samples were considered. The first sample was made up of women aged 15-49 who responded to questions on whether they had undergone FGM. The second sample was made up of women aged 15-49 who had at least one daughter and responded to questions on whether their daughter(s) had undergone FGM. Both bivariate and multivariable analyses were performed using STATA version 13.0. RESULTS: The results showed that FGM among women and their daughters are significantly associated with household wealth index, with women in the richest wealth quintile (AOR, 0.51 CI 0.48-0.55) and their daughters (AOR, 0.64 CI 0.59-0.70) less likely to undergo FGM compared to those in the poorest wealth quintile. Across education, the odds of women and their daughters undergoing FGM decreased with increasing level of education as women with higher level of education had the lowest propensity of undergoing FGM (AOR, 0.62 CI 0.57-0.68) as well as their daughters (AOR, 0.32 CI 0.24-0.38). FGM among women and their daughters increased with age, with women aged 45-49 (AOR = 1.85, CI 1.73-1.99) and their daughters (AOR = 12.61, CI 10.86-14.64) more likely to undergo FGM. Whiles women in rural areas were less likely to undergo FGM (AOR = 0.81, CI 0.78-0.84), their daughters were more likely to undergo FGM (AOR = 1.09, CI 1.03-1.15). Married women (AOR = 1.67, CI 1.59-1.75) and their daughters (AOR = 8.24, CI 6.88-9.87) had the highest odds of undergoing FGM. CONCLUSION: Based on the findings, there is the need to implement multifaceted interventions such as advocacy and educational strategies like focus group discussions, peer teaching, mentor-mentee programmes at both national and community levels in countries in SSA where FGM is practiced. Other legislative instruments, women capacity-building (e.g., entrepreneurial training), media advocacy and community dialogue could help address the challenges associated with FGM. Future studies could consider the determinants of intention to discontinue or continue the practice using more accurate measures in countries identified with low to high FGM prevalence.

Female genital mutilation and contraceptive use: findings from the 2014 Egypt demographic health survey.

OBJECTIVES: Female genital mutilation (FGM) includes procedures that remove partial or total external female genitalia, or causes other injury to female genital organs with no medical reason. Physical and psychological trauma associated with FGM may interfere with a woman's ability and intent to utilize contraception. Our study examines the association between FGM and utilization of contraception methods among sexually active reproductive-aged women in Egypt. METHODS: Data from the 2014 Egypt Demographic and Health Survey were analyzed (n = 20,055). Multinomial logistic regression was used to obtain odds ratios (OR) and 95% confidence intervals. RESULTS: Our study found that FGM was performed on over 90% of Egyptian women and almost half (45%) of women did not use contraception. Women with FGM had significantly lower odds (OR = 0.6) of using barrier/natural contraceptive methods (e.g., condoms) than intrauterine devices (IUDs). However, women with FGM were more likely to use hormonal methods (OR = 1.2) than IUDs compared to those who had not experienced FGM. CONCLUSIONS: In order to promote women's health and support use of effective contraception methods, a large reduction in FGM practice is essential.

Estimating utility value for female genital mutilation.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a clear violation of women's rights and can have adverse and irreversible health effects as well. Worldwide, more than 200 million women and girls have undergone FGM/C. Utility value of FGM/C has not been estimated yet, so we designed this study to extract the health utility value of FGM/C for the first time in the world. METHODS: In a cross-sectional study in Iran, 125 girls and women who underwent FGM/C procedure were examined by the trained midwives in order to determine its type. In addition, a questionnaire was completed for identifying the socio-demographic factors and extracting the health utility of these individuals. Health utility was measured using Time Trade-off method and also to determine the effects of the socio-demographic factors on the health utility a two-limit censored regression model was applied. RESULTS: The mean and median of the health utility of women with FGM/C were 0.971 (SE: 0.003) and 0.968 (IQR: 1-0.95), respectively. Number of non-traders was 58 (46.4%) who reported perfect health utility. However, the mean of health utility among traders was 0.946 (SE: 0.002). Only type 1 (Clitoridectomy) and type 2 (Excision) FGM/C were seen in this study. Women with Type 1 FGM/C had significantly lower health utility value (Mean: 0.968, Median: 0.957) than their type 2 counterparts (Mean: 0.987, Median: 1.00). Moreover, women in the age group of 31-45 years (Mean: 0.962, Median: 0.956), single (Mean: 0.950, Median: 0.954), divorced (Mean: 0.951, Median: 0.950), employed (Mean: 0.959, Median: 0.956), and with supplementary insurance (Mean: 0.962, Median: 0.950) had significantly lower health utility than their counterparts. CONCLUSION: FGM/C affects physical and psychological well-being of these individuals, resulting in a lack of personal and marital satisfaction, which ultimately leads to a 3% reduction in their health related quality of life. Therefore, preventing from this practice is very important and should be considered by health system policy makers more than before.

Female Genital Mutilation/Cutting as Grounds for Asylum Requests in the US: An Analysis of More than 100 Cases.

Female Genital Mutilation or Cutting (FGM/C) is a human rights violation used to claim asylum in the US. We sought to understand the nature of these asylum requests. Analysis of 121 FGM/C-focused medical affidavits, and 132 legal case reports. Of 119 eligible affidavits analyzed, 84% were reportedly cut: 4.6% Type I, 84.6% Type II, 16.5% Type III. Average age: 9. Reported acute effects: bleeding (76.3%), infection (27.6%), shock (6.7%), broken bones (2.7%), and hospitalization (2.7%). Reported chronic issues: intercourse difficulty (81.7%), pregnancy complications (54.2%), chronic pain (42.4%), scarring (37.3%), urinary difficulty (31.8%). Psychological consequences included PTSD (72.4%), depression (65.9%), anxiety (51.1%), and lack of trust (10.1%). Co-occurring abuses included domestic violence (62.4%), forced marriage (46%), rape (33.3%), torture (33.3%), child marriage (31.3%), assault due to LGBTQ + status (2.9%). Women claiming asylum based on FGM/C report high rates of chronic health issues. Their histories suggest FGM/C co-occurs with other forms of gender-based violence.

Barriers to access to the Norwegian healthcare system among sub-Saharan African immigrant women exposed to female genital cutting.

INTRODUCTION: Millions of women and girls have been exposed to female genital cutting (FGC). The practice of FGC extends beyond countries in Africa and Asia in which it is traditionally practiced. Women living with FGC in Norway have been reported to be in need of healthcare, but there is evidence of suboptimal use of healthcare services among this group, and we lack the women's perspective about this problem. This study aims to explore the experiences and perceptions hindering access and use of the Norwegian healthcare system among sub- Saharan African (SSA) immigrant women exposed to FGC. METHOD: This qualitative research was conducted using purposive and snowball sampling to recruit thirteen SSA immigrant women in Norway previously exposed to FGC. Interviews were conducted from October 2017 to July 2018. The Interpretative Phenomenological Analysis method was used. RESULTS: The findings indicate that women experience barriers both in reaching out to the healthcare system and within the healthcare system. Barriers prior to contact with the healthcare system include lack of information, husband and family influence on healthcare, and avoiding disclosing health problems. Barriers within the healthcare system include care providers with insufficient knowledge and poor attitudes of care providers. CONCLUSION: This study reveals multiple barriers to healthcare access that co-exist and overlap. This indicates that SSA immigrant women are 'left behind' in being able to access and use the Norwegian healthcare system. Therefore, appropriate interventions to improve access to healthcare should be considered in order to reach Universal Health Coverage, thus having a positive impact on the health of these women. Equitable healthcare should be reflected in policy and practice.

Risk assessment for antenatal depression among women who have undergone female genital mutilation or cutting: Are we missing the mark?

BACKGROUND: Although prohibited by specific legislation in Australia, patterns of global migration underscore the importance for local clinicians to recognise and manage potential complications associated with female genital mutilation/cutting (FGM/C). The incidence of antenatal depression in Australia is 10% and may be higher among those with a history of FGM/C (RANZCOG 2 statement: Perinatal Anxiety and Depression, 2012). The phenomenon of cultural embedding could represent a protective factor against an increase in mental health problems among these women. AIM: To determine whether women who have undergone FGM/C are at greater risk of depression in the antenatal period as defined by the Edinburgh Postnatal Depression Scale (EPDS). MATERIALS AND METHODS: A multicentre retrospective case-control study was performed. Participants who had delivered at either of two hospitals, had migrated from FGM/C-prevalent countries and who had undergone FGM/C were assessed and compared with the control group, case-matched by language and religion. RESULTS: Eighty-nine cases were included with an equal number of matched controls. No significant difference in the EPDS score was demonstrated when analysed as a continuous variable (P = 0.41) or as a categorical variable with a cut-off score of 12 (P = 0.12). There was no difference in the number of women who identified as having thoughts of self-harm between the two groups. CONCLUSION: There was no identified increase in the risk of antenatal depression among women who have undergone FGM/C from high-prevalence countries. Consideration must be given to the utility of the EPDS in this population, as well as factors such as cultural embedding.

Maternity care of women affected by female genital mutilation/cutting: An audit of two Australian hospitals.

BACKGROUND: Pregnant women affected by female genital mutilation/cutting are at risk of adverse maternal outcomes compared to unaffected women, and sometimes require procedures to facilitate giving birth that midwives and doctors do not routinely perform. These women require culturally sensitive care. Current health professional literature provides evidence that midwives and doctors need further knowledge and training in this area. AIMS: This audit aimed to describe the demographic characteristics of pregnant women with female genital mutilation/cutting giving birth at two Perth maternity units, in addition to assessing health provider compliance with the local female genital mutilation/cutting Clinical Guideline. MATERIALS AND METHODS: The clinical database used by public maternity units in Western Australia was used to identify affected women who gave birth during 2014 at King Edward Memorial Hospital or Osborne Park Hospital. Demographic characteristics and information about antenatal care and maternal outcomes were collected. RESULTS: 53 women fulfilled the audit criteria. Prevalence of pregnant women with female genital mutilation/cutting varied from 0.33% to 2.18% between the two units. Compliance with the Female Genital Mutilation/Cutting Clinical Guideline was generally suboptimal. While no woman was deinfibulated antenatally, 26% of women required intrapartum deinfibulation to give birth. CONCLUSIONS: Women with female genital mutilation/cutting make up more than 2% of the antenatal population in some Perth metropolitan maternity units. Health care provider knowledge of, and compliance with, the Female Genital Mutilation/Cutting Clinical Guideline was poor in the two units studied. It appears that healthcare professionals need more education and training to provide affected women with the best care.

Debating medicalization of Female Genital Mutilation/Cutting (FGM/C): learning from (policy) experiences across countries.

BACKGROUND: Although Female Genital Mutilation/Cutting (FGM/C) is internationally considered a harmful practice, it is increasingly being medicalized allegedly to reduce its negative health effects, and is thus suggested as a harm reduction strategy in response to these perceived health risks. In many countries where FGM/C is traditionally practiced, the prevalence rates of medicalization are increasing, and in countries of migration, such as the United Kingdom, the United States of America or Sweden, court cases or the repeated issuing of statements in favor of presumed minimal forms of FGM/C to replace more invasive forms, has raised the debate between the medical harm reduction arguments and the human rights approach. MAIN BODY: The purpose of this paper is to discuss the arguments associated with the medicalization of FGM/C, a trend that could undermine the achievement of Sustainable Development Goal 5.3. The paper uses four country case studies, Egypt, Indonesia, Kenya and UK, to discuss the reasons for engaging in medicalized forms of FGM/C, or not, and explores the ongoing public discourse in those countries concerning harm reduction versus human rights, and the contradiction between medical ethics, national criminal justice systems and international conventions. The discussion is structured around four key hotly contested ethical dilemmas. Firstly, that the WHO definition of medicalized FGM/C is too narrow allowing medicalized FGM to be justified by many healthcare professionals as a form of harm reduction which contradicts the medical oath of do no harm. Secondly, that medicalized FGM/C is a human rights abuse with lifelong consequences, no matter who performs it. Thirdly, that health care professionals who perform medicalized FGM/C are sustaining cultural norms that they themselves support and are also gaining financially. Fourthly, the contradiction between protecting traditional cultural rights in legal constitutions versus human rights legislation, which criminalizes FGM/C. CONCLUSION: More research needs to be done in order to understand the complexities that are facilitating the medicalization of FGM/C as well as how policy strategies can be strengthened to have a greater de-medicalization impact. Tackling medicalization of FGM/C will accelerate the achievement of the Sustainable Development Goal of ending FGM by 2030.

Survey on female genital mutilation/cutting in Jeddah, Saudi Arabia.

OBJECTIVES: The objective of this study was to determine whether female genital mutilation/cutting (FGM/C) exists in Jeddah, Saudi Arabia. DESIGN: A cross-sectional study. SETTING: King Abdulaziz University Hospital, Jeddah, Saudi Arabia. PARTICIPANTS: Between December 2016 and August 2017, women attending the obstetrics and gynaecology clinics were asked to participate in a cross-sectional survey. This included questions on demographics, FGM/C status and type and attitudes towards the practice. RESULTS: In a convenience sample of 963 women aged 18 to 75 years, 175 (18.2%) had undergone FGM/C. Compared with women without FGM/C, women with FGM/C were older, married, non-Saudi and had a lower monthly income. Thirty-seven (21.1%) women had had FGM/C with some cutting of body parts (type I or II), 11 (6.3%) with suturing (type III), 46 (26.3%) with no cutting of body parts (type IV) and 81 (46.3%) did not know their type of FGM/C. There was also a significant association between nationality and age at which FGM/C was performed, with Saudi women undergoing the procedure earlier than Egyptian, Somali, Yemeni and Sudanese women. CONCLUSIONS: FGM/C is prevalent in Jeddah, Saudi Arabia, among immigrant women from other countries, and it is practised among Saudi women. Further research is needed to determine its prevalence.

Factors associated with female genital cutting in Yemen and its policy implications.

BACKGROUND: A tremendous number of girls in Yemen are still subjected to female genital cutting (FGC), which carries an increased risk of health complications and violates children's rights. This study describes the prevalence of FGC in four Yemeni provinces and investigates the determinants of FGC. METHODS: We analyzed data from women aged 15 to 49 years who responded to a sub-national household survey conducted in six rural districts of four Yemeni provinces in 2008-2009. Logistic regression was used to estimate the association between individual and household socioeconomic factors and FGC practices and attitudes. RESULTS: The prevalence of women's FGC was 48% while daughters' FGC was 34%. Almost 45.8% of the women surveyed believe the FGC practice should discontinue. Higher odds of FGC practice and positive attitude towards it were associated with older age, family marriage, and lower tertiles of wealth and education indices. Early marriage was also associated with increased odds of FGC practice (p < 0.01). CONCLUSIONS: Socioeconomic indices and other individual factors associated with FGC are differing and complex. Younger generations of women are more likely to not have FGC and to express negative attitudes towards the tradition. Appropriate strategies to invest in girls' education and women's empowerment with effective engagement of religious and community leaders might support the change of attitudes and practice of FGC in the younger generation.

Pupil's perspectives on female genital cutting abandonment in Harari and Somali regions of Ethiopia.

BACKGROUND: Female Genital Cutting (FGC) is a harmful traditional practice that affects the physical and mental health of girls and women in many ways. In Ethiopia, although both governmental institutions and None-Governmental- Institutions (NGOs) launched different campaigns against FGC, their effects on the peoples' attitudes towards the practice have not been deeply investigated yet. Hence, this study particularly aimed to investigate the pupils' perspectives on FGC abandonment in the Harari and the Somali Regional States of Ethiopia where the prevalence of the practice was thought to be high. METHODS: A school-based cross-sectional study was conducted in the Somali and the Harari Regional States of eastern Ethiopia from October to December 2015. While purposive sampling was implemented to select the study areas from the two Regional States, stratified random sampling method was used to select 480 study subjects from those areas. RESULTS: The findings showed that the participants who received information through multiple information channels were more likely to support the abandonment of FGC than those who received information from a single source (p < 0.05). Similarly, the findings indicated that school-based awareness campaigns and TV-based media communications were the main sources of information that influenced a high proportion of young people to support the abandonment of the practice. The findings revealed that the majority of the participants strongly supported the abandonment of FGC. CONCLUSIONS: Multiple information channels that include school-based awareness campaigns were found to be the best way to support the abandonment of FGC. Although the study shows an impressive improvement among the school girls and boys in recognizing the harmful effects FGC, complete abandonment of the practice might not be easily achieved due to its deep-rooted nature. Thus, to quicken the perpetuation of FGC in the stated Regional States, awareness creating campaigns that change the attitudes of youths towards the practice should be delivered through various sources. In this regard, school-based education, school mini-media, social media, and using the co-curricular activities to uncover the danger of this harmful practice could play significant roles in changing the pupils' attitudes towards the practice.