Evaluating the long-term impact of large-scale trainings: an exposure based cross-sectional study on female genital mutilation-related knowledge, attitudes and practices among Sudanese midwives in Khartoum State.

OBJECTIVES: To examine the long-term impact of large-scale training targeting midwives in a setting where they are the main female genital mutilation (FGM) practitioners. We hypothesised that trained midwives would have significantly higher knowledge, greater opposition to midwives' involvement in this practice, and improved clinical practice in FGM prevention and care compared with non-trained midwives. DESIGN: We conducted an exposure based cross-sectional study, using closed-ended and open-ended questions during phone interviews. SETTING: Khartoum State in Sudan has a high prevalence of FGM (88%) mainly performed by midwives. PARTICIPANTS: Midwives who received (n=127) and did not receive FGM training (n=55). PRIMARY AND SECONDARY OUTCOME MEASURES: We developed primary outcomes aligned to the three levels (reaction, learning and behaviour) of Kirkpatrick's training evaluation model for descriptive and multivariable analyses in Stata. RESULTS: All the midwives interviewed were female, mostly village midwives (92%) and worked in health centres (89%). The mean age and midwifery experience was 51 years (SD=10) and 23 years (SD=12), respectively. Overall, most midwives (>90%) reported being supportive of FGM discontinuation. Midwives who had FGM training were more aware that performing FGM violates code of conduct (p=0.001) and reported to always counsel patients to abandon FGM (p<0.001) compared with midwives who did not report training. However, these associations were not statistically significant in multivariable logistic regression model adjusting for age. Exploratory analysis of training curricula showed higher knowledge, correct attitude and practices among those who reported in-service training before 2016. CONCLUSION: Though past trainings were associated with higher knowledge and greater opposition to midwives' involvement in FGM, this was not translated into appropriate corrective clinical procedures among affected women during labour. The Sudan Ministry of Health invested heavily in training midwives and it would be important to investigate why trained midwives do not implement recommended FGM-related clinical management.

Understanding the uptake of HIV testing among women in Liberia: the role of female genital mutilation/cutting.

Past studies show that the processes of female genital mutilation/cutting (FGM/C) on women can increase their susceptibility to HIV infection. This is because genital tears or ruptures, scars and wounds from FGM/C may expose survivors to heightened risks of contracting sexually transmitted infections, including HIV, if they engage in unsafe sexual practices. Hence, there is the need to promote HIV screening and testing among this population. Yet, in Liberia, there is a dearth of studies exploring the uptake of HIV testing among women who have experienced FGM/C. To understand this relationship, we used the 2019-2020 Liberia Demographic and Health Survey (LDHS) and employed logistic regression analysis to answer the following questions: (1) Are FGM/C survivors less likely to have been tested for HIV compared to non-FGM/C women; and (2) How does this disparity in the uptake of HIV testing differ by women's marital status? We found that survivors of FGM/C were less likely to have been tested for HIV than non-FGM/C women, even after accounting for theoretically relevant variables (OR = 0.83, p < 0.01). In response to our second question, we found that survivors of FGM/C who were formerly married were less likely to have been tested for HIV compared to their non-FGM/C counterparts (OR = 0.48, p < 0.01). These findings highlight the importance of trauma-informed HIV prevention strategies in Liberia, and the need for policymakers to take a holistic approach to addressing the challenges that FGM/C survivors, especially formerly married women, may face in accessing HIV prevention and testing services, and to work towards creating a more inclusive and supportive environment for all at-risk groups.

Effectiveness of female genital mutilation/cutting education for health professionals: An integrative review.

INTRODUCTION: A plethora of research has identified the lack of educational opportunities for health professionals to support the biopsychosocial and cultural needs of women who have experienced female genital mutilation/cutting (FGM/C). As a result, some women with FGM/C can feel unsupported, discriminated against and fear to communicate their concerns with health providers. The aim of this review is to identify studies that have investigated the effectiveness of FGM/C education for health professionals. METHOD: Toronto and Remington's six-step framework for conducting an integrative literature review was used to identify studies that met the inclusion criteria. Searches were conducted across five primary databases and grey literature, between August and October 2021. The Joanna Briggs Institute critical appraisal tools for quasi-experimental studies was used to critically appraise included studies. The findings of the search were reported using preferred reporting items for systematic reviews and meta-analysis. RESULTS: A total of five studies met the criteria for inclusion. Studies examined education provided to midwives, nurses, obstetricians, gynaecologists, psychosexual counsellors and student nurses, from England, USA, Mali and Kenya. All studies demonstrated that the implementation of FGM/C education was effective in improving learning outcomes (knowledge, attitude and self-efficacy), However, the quality rating of the evidence ranged from very low to moderate and limited inferential analysis reported. CONCLUSION: This review confirms that FGM/C education, which is informed by evidence and developed in collaboration with practicing communities, is an effective way of improving FGM/C knowledge and attitudes among health professionals. STUDY REGISTRATION: Open Science Framework Register 10.17605/OSF.IO/SMJHX.

Maternity care provision for women living with female genital mutilation/cutting: A qualitative study from a high asylum-seeking dispersal context in the UK.

OBJECTIVE: To explore the perspectives of midwives and obstetrician/gynaecologists providing maternity care to women living with female genital mutilation/cutting (FGM/C) in a high asylum-seeker dispersal area in the North West of England. METHODS: We carried out a qualitative study in four hospitals providing maternal health services within the North West of England, with the highest population of asylum-seeking individuals (many from high-prevalence FGM/C countries) in the UK. Participants included 13 practicing midwives and an obstetrician/gynaecologist. In-depth interviews were conducted with study participants. Data collection and analysis were carried out concurrently until theoretical saturation was reached. Data were analysed thematically to generate three key overarching themes. RESULTS: There is a disconnect between Home Office dispersal policy and healthcare policy. Participants indicated that there was inconsistent identification or disclosure of FGM/C, constraining appropriate follow-up and care prior to labour and childbirth. All participants noted existing safeguarding policies and protocols, which were seen by most as being important to protect female dependants, but potentially detrimental to the patient-provider relationship and to the woman's care. Unique challenges around accessing and maintaining continuity of care for asylum-seeking women due to dispersal schemes were indicated. All participants highlighted a lack of specialised training for FGM/C to support provision of clinically appropriate and culturally sensitive care. CONCLUSIONS: There is a clear need for harmony between health and social policy as well as specialised training that centres holistic wellbeing for the woman living with FGM/C, particularly where there are increased numbers of asylum-seeking women from high-prevalence FGM/C countries.

Management of Female Genital Mutilation/Cutting-Related Obstetric Complications: A Training Evaluation.

Although female genital mutilation/cutting (FGM/C) is a prevalent practice in Liberia, healthcare workers lack the capacity to provide adequate care for FGM/C survivors. Therefore, Liberian nurses, physician assistants, midwives and trained traditional midwives were trained in sexual, obstetric and psychosocial care for FGM/C survivors in 2019. Through questionnaires, we assessed knowledge acquisition, trainee attitudes towards FGM/C care and acceptability to implement WHO-endorsed recommendations. The questionnaires were analyzed using descriptive statistics for quantitative data and an inductive approach for qualitative data. A total of 99 female and 34 male trainees participated. Most trainees perceived FGM/C as harmful to women's health, as a violation of women's rights and showed a willingness to change their clinical practice. While 82.8% (n = 74/90) perceived their role in advocating against FGM/C, 10.0% (n = 9/90) felt that they should train traditional circumcisers to practice FGM/C safely. The pre-training FGM/C knowledge test demonstrated higher scores among physician assistants (13.86 ± 3.02 points) than among nurses (12.11 ± 3.12 points) and midwives (11.75 ± 2.27 points). After the training, the mean test score increased by 1.69 points, from 12.18 (±2.91) points to 13.87 (±2.65) points. The trainings successfully increased theoretical knowledge of FGM/C-caused health effects and healthcare workers' demonstrated willingness to implement evidence-based guidelines when providing care to FMG/C survivors.

'Some women are proud of their experience and I have to respect that': an interview-study about midwives' experiences in caring for infibulated women during childbirth in Sweden.

INTRODUCTION As the immigrant communities in high-income countries become larger and increasingly multicultural and ethnically diverse, health professionals are more likely to see girls and women with, or at risk of, female genital mutilation or 'cutting' (FGM/C) in clinical practice. To provide good care and support, other health-care professionals may learn from the experiences of midwifes caring for infibulated women during labour in Sweden. AIM To describe Swedish midwives' experiences in caring for infibulated women during labour. METHODS This is a qualitative study. Semi-structured interviews with six midwives working at obstetric clinics in Sweden used open-ended questions. The interviews were recorded, transcribed verbatim and analysed by using thematic analysis. RESULTS Two main themes were identified: experienced challenges during the process of labour; and midwives' emotional experiences. Midwives experienced challenges during their professional encounters with infibulated women and a variety of emotions were evoked when caring for these women during labour. Lack of general guidelines and standardised routines complicated their work. DISCUSSION The midwives' experiences were negatively affected by organisational factors and being emotionally affected by the fact that these women were not perceived to be given appropriate care because of their FGM/C. Policymakers in Sweden should consider implementing national guidelines for how to care for women exposed to FGM/C, ideally at an early stage in their reproductive life.

Commentary: What should referral pathways have to improve healthcare experiences of women with female genital mutilation in Australia?

BACKGROUND: We examined the evidence derived from healthcare professionals' interfacing with women with female genital mutilation (FGM) to comprehend the referral pathways available to these women in Australia. MAIN BODY: Clinicians encountered FGM-related complications that included ruptured bladder and total urinary incontinence. Midwives and paediatricians indicated a lack of referral pathways for FGM, but used their discretion to refer such cases to social work departments, obstetric/gynaecological units, child protection service providers, psychological counsellors and surgeons. The continuum of care for women with FGM is characterised by inadequate and lack of clear referral pathways. This underscores the need to develop and strengthen referral pathways in response to physical, birthing and psychological complications of women with FGM to improve their care experiences in Australia. SHORT CONCLUSION: Capacity building initiatives on FGM-prevention and care for trainees and practising health providers and community involvement in high burden areas/populations should be implemented to promote uptake and utilization of the referral services. Provision of infrastructural support, including clinical management tools, job aids, posters, referral algorithms and electronic patient records with "drop-down menus" for referral sites for health complications of FGM to reinforce the providers' efforts are critical.

Traditional medicine among the community of Gash-Barka region, Eritrea: attitude, societal dependence, and pattern of use.

BACKGROUND: Despite the growing conventional healthcare coverage in Eritrea, traditional medicine (TM) remains an essential source of healthcare service to the population. This study, therefore, aims at exploring the attitude, societal dependence, and pattern of TM use of the Gash-Barka community. METHODS: A cross-sectional study was conducted between December 2018 and January 2019 in Gash-Barka region, one of the six regions of Eritrea. Two-stage stratified cluster sampling design was used to provide representative sample of households. The data collected through face-to-face interview using a structured questionnaire was entered twice and analyzed using CSPro7.2 and SPSS 23, respectively. Both descriptive and analytical analyses were performed to test statistical significance. RESULTS: Of the total 210 participants, 202 completed the interview with a response rate of 96.2%. Almost 97% of the respondents were aware of the general existence of TM. About half of the respondents (47.4%) had visited traditional health practitioners (THPs) at least once in their lifetime. The majority of the respondents claimed their medical condition had been improved (63.2%), were satisfied with the outcome (76.8%), and had not encountered complications (95.2%) due to TM use. Around 40% of the respondents admitted they do not disclose previous TM use to conventional health practitioners. Females are more likely to have had ever visited THPs (AOR = 1.85, CI: 1.01, 3.38) and use TM in the future (AOR = 2.26, CI: 0.92, 5.14) than males. Moreover, those who had visited THPs before (COR = 8.30, CI: 3.25, 21.20) are more likely to use TM as a primary treatment choice and prefer to use TM in the future (AOR = 4.40, CI: 1.97, 9.83) than those who had never visited THPs. About 61% of the total families claimed they had circumcised at least one female child, and 96.8% disclosed they had circumcised at least one male child. Out of which, 89.2% of the circumcisions were done by THPs. CONCLUSION: TM is popular and widely relayed upon by Gash-Barka residents with exposure of children to harmful TM practices. Since the reliance of the community on TM is expected to continue, further representative studies are recommended to inform regulatory interventions and integrate TM into the health system.

Female genital cutting in the Gambia: can education of women bring change?

BACKGROUND: In the Gambia, three out of four women of reproductive age have undergone Female Genital Cutting (FGC). Many studies and policy advocates suggest that for such a practice that is deeply rooted in culture, a more holistic approach focusing on educating the population will have sustainable impact. This research examined whether educational level of women has an association with their attitude towards the practice of FGC. METHODS: Data from the 2013 Gambia Demographic Health Survey (GDHS) were analyzed. The sample included 6217 households: 10,233 females aged between 15 to 49 years and 3831 males between 15-59 years. This study focused only on women participants. The outcome variable was the attitude of women toward the practice of FGC. RESULTS: In multivariate regression model, women who were circumcised are found to have 80 times higher odds of supporting FGC [Odds Ratio = 80 (95% CI 50.93-124.4)] compared to uncircumcised women. Women with primary and secondary level education have lower odds of supporting FGC [OR = 0.73 (95% CI 0.915-0.007)) and those with higher education had the lowest odds [OR = 0.28 (95% CI 0.147-0.543)) of supporting FGC relative to women with no education at all. CONCLUSIONS: Education and awareness programs targeting women who are married and older, those with less education and those who are already circumcised can help change attitudes towards the practice of FGC.

Consideration of Cultural Practices When Characterizing the Vaginal Microbiota Among African and African American Women.

This manuscript considers intravaginal practices prevalent among African and African-American women, with the aim of providing a framework for how these practices may affect vaginal health and the vaginal microbiota, and consequently, impact pregnancy outcomes. Intravaginal practices are influenced by traditional socio-cultural beliefs and gender norms, with prominent practices including intravaginal insertion of substances (herbs and traditional medicines), intravaginal cleansing (douching), and anatomical modification of the female organs (labia elongation and female genital mutilation). Common motivations for such practices included hygiene, prevention of infection, enhancement of sexual pleasure, and compliance with societal or cultural norms. The use of soaps and other chemicals for vaginal douching has been reported to reduce diversity of the vaginal microbiota and lower pH, thus increasing the chances of bacterial vaginosis, but the evidence is minimal. The practice of vaginal insertion of natural or other substances is associated with physical abrasions, disruption of the vaginal flora, bacterial vaginosis, and HIV and other infections, but effects on pregnancy outcomes and the vaginal microbiota are unclear. Finally, female genital mutation has been reported to have immediate and prolonged physiological and psychological effects, including frequent infections and chronic inflammation, but similar to most other practices, consequences for preterm birth remain understudied and for the vaginal microbiota, unknown. Overall, findings identify the need for additional research, focusing on how these common practices influence both birth outcomes and the vaginal microbiota, so that nurses, midwives, physicians, and other providers worldwide are better equipped to assess and care for pregnant women.

A system analysis of the mental health services in Norway and its availability to women with female genital mutilation.

BACKGROUND: This article explores mental health services in Norway and their availability for women subjected to female genital mutilation/cutting (FGM/C). The article focus on the system of communication and referrals from the perspective of health workers, and aims to identify bottlenecks in the system, what and where they are to be found, and analyze how different mental health services deal with Sub Saharan African (SSA) women in general, but in particular with respect to FGM/C. METHOD: The study was conducted in Oslo, Norway, using a qualitative fieldwork research design, with the use of purposeful sampling, and a semi-structural guideline. One hundred interviews were done with general practitioners (GPs), gynecologists, psychologists, psychiatrists, midwives and nurses. ANALYSIS: A system analysis is applied using socio-cybernetics as a tool to identify the flow of communication and referrals of patients. FINDINGS: The study shows that borders of subsystems, silencing mechanisms, regulations and "attitudes" of the system can lead to women with SSA background having difficulty getting access to the specialist services. High standards for referral letters, waiting lists, out pushing to the lower levels, insecurities around treatment and deference rules silencing mental health issues during consultancies, have a negative impact on the accessibility of services. Consequences are that mental health problems due to FGM/C are under-investigated, under-referred, and under-treated and a silenced problem within the mental health services for women. CONCLUSION: A better integration of subsystems at the specialist level with the GP scheme is necessary, as well as providing competence on FGM/C to the different levels. It is also important to strengthen and integrating the services at the Municipal level and provide information to SSA women about the low threshold services.

Supporting patients with female genital mutilation in primary care: a qualitative study exploring the perspectives of GPs' working in England.

BACKGROUND: Female genital mutilation (FGM) includes all procedures that intentionally harm or alter female genitalia for non-medical reasons. In 2015, reporting duties were introduced, applicable to GPs working in England including a mandatory reporting duty and FGM Enhanced Dataset. Our patient and public involvement work identified the exploration of potential impacts of these duties as a research priority. AIM: To explore the perspectives of GPs working in England on potential challenges and resource needs when supporting women and families affected by FGM. DESIGN AND SETTING: Qualitative study with GPs working in English primary care. METHOD: Semi-structured interviews focused around a fictional scenario of managing FGM in primary care. The authors spoke to 17 GPs from five English cities, including those who saw women who have experienced FGM often, rarely, or never. Interviews were audio recorded and transcribed verbatim for thematic analysis. Lipsky's theory of street-level bureaucracy was drawn on to support analysis. RESULTS: Managing women with FGM was experienced as complex. Challenges included knowing how and when to speak about FGM, balancing care of women and their family's potential care and safeguarding needs, and managing the mandated reporting and recording requirements. GPs described strategies to manage these tensions that helped them balance maintaining patient-doctor relationships with reporting requirements. This was facilitated by access to FGM holistic services. CONCLUSION: FGM reporting requirements complicate consultations. The potential consequences on trust between women affected by FGM and their GP are clear. The tensions that GPs experience in supporting women affected by FGM can be understood through the theoretical lens of street-level bureaucracy. This is likely to be relevant to other areas of proposed mandated reporting.

Estimates of female genital mutilation/cutting in the Netherlands: a comparison between a nationwide survey in midwifery practices and extrapolation-model.

BACKGROUND: Owing to migration, female genital mutilation or cutting (FGM/C) has become a growing concern in host countries in which FGM/C is not familiar. There is a need for reliable estimates of FGM/C prevalence to inform medical and public health policy. We aimed to advance methodology for estimating the prevalence of FGM/C in diaspora by determining the prevalence of FGM/C among women giving birth in the Netherlands. METHODS: Two methods were applied to estimate the prevalence of FGM/C in women giving birth: (I) direct estimation of FGM/C was performed through a nationwide survey of all midwifery practices in the Netherlands and (II) the extrapolation model was adopted for indirect estimation of FGM/C, by applying population-based-survey data on FGM/C in country of origin to migrant women who gave birth in 2018 in the Netherlands. RESULTS: A nationwide survey among primary care midwifery practices that provided care for 57.5% of all deliveries in 2018 in the Netherlands, reported 523 cases of FGM/C, constituting FGM/C prevalence of 0.54%. The indirect estimation of FGM/C in an extrapolation-model resulted in an estimated prevalence of 1.55%. Possible reasons for the difference in FGM/C prevalence between direct- and indirect estimation include that the midwives were not being able to recognize, record or classify FGM/C, referral to an obstetrician before assessing FGM/C status of women and selective responding to the survey. Also, migrants might differ from people in their country of origin in terms of acculturation toward discontinuation of the practice. This may have contributed to the higher indirect-estimation of FGM/C compared to direct estimation of FGM/C. CONCLUSIONS: The current study has provided insight into direct estimation of FGM/C through a survey of midwifery practices in the Netherlands. Evidence based on midwifery practices data can be regarded as a minimum benchmark for actual prevalence among the subpopulation of women who gave birth in a given year.

Exploring young people's interpretations of female genital mutilation in the UK using a community-based participatory research approach.

BACKGROUND: Female genital mutilation (FGM) is a deeply-rooted cultural practice mainly undertaken in Africa, the Middle East and Asian countries. Evidence to date suggests that although first-generation migrants to the West are abandoning FGM, the custom continues in some places, albeit in small numbers. This study examined how young people living in FGM affected communities in the United Kingdom (UK), interpreted and explained FGM. METHODS: A community-based participatory research (CBPR) approach was used to recruit and train nine young people aged 15-18 as co-researchers. These comprised eight females and one male from second-generation FGM affected communities, living in Bristol. The co-researchers then undertook focus groups and semi-structured interviews with twenty participants aged 13-15 living in Bristol, Cardiff and Milton Keynes. The qualitative data from the training workshops, interviews and focus groups were collected and analysed using thematic analysis. RESULTS: There were conflicting views among participants. Some perceived FGM as a historical tradition that was of very little, if any, relevance to them. In contrast, others perceived that the more archaic, cultural interpretation of FGM, more commonly shared by older generations, had been supplanted by a new form of FGM, which they believed to be a safe procedure, made so by the availability of highly-trained, qualified doctors and better equipment in the UK. Participants spoke of challenges encountered when attempting to raise the issue of FGM with parents. Nevertheless, they acknowledged that- being born and raised in the UK - enabled them to talk openly and to challenge others. CONCLUSION: Future strategies to address and prevent FGM in the UK will require a public health approach that is holistic, intersectional and empowering. Such measures should be relevant to young people born and raised in the UK who interpret FGM differently to previous first-generation migrant relatives and communities. Tackling FGM requires a shift away from a principal preoccupation with harm reduction and criminalisation towards collaboration and active dialogue with communities, in positive and productive ways that acknowledge and engage issues of identity, race, gender, and generation, enabling people affected by FGM to take control of their health and well-being.

Might Reinfibulation be Medically Plausible in Carefully Screened Cases?

In light of the relational account of autonomy and the modern (holistic and phenomenological) account of health, this paper examines ethical justifications for ̳consensual' reinfibulation. Significant and constant discomfort in the body following deinfibulation might make a case for reinfibulation (considered as medical treatment in the traditional sense of the term). In any other case, the following requirements should be met for reinfibulation to be considered medically plausible: a) strong evidence that reinfibulation could help effectively improve woman's relational well-being, b) insignificant complications are expected, c) congruence between first-order and second-order autonomy or -in the context of political liberalism- strong second-order autonomy, d) an -open door‖ for the woman to exit an oppressive context, e) rigorous scrutiny of woman's psychology, and f) woman's practical wisdom to organize her identity-related values, find a balance between her extreme emotions and realize her own goal of meaningful life in accordance with her own conception of the good. Conclusively, in carefully screened cases and individually judged requests for reinfibulation, it should not be ruled out that, after having been conducted a multi-disciplinary in- depth investigation at social, psychological and medical level may be met conditions that make a case for reinfibulation.

Sexual health counselling targeting girls and young women with female genital cutting in Sweden: mind-body dualism affecting social and health care professionals' perspectives.

Female genital mutilation (FGM), also referred to as female genital cutting (FGC), has become the subject of an intense debate exposing tensions between varying cultural values about bodies and sexuality. These issues are brought to the fore in settings where professionals provide sexual counselling to young circumcised women and girls in Western, multicultural societies. This article is based on interviews and focus group discussions with professionals in social and healthcare services. The aim of this study was to examine how professionals reflect upon and talk about sexuality and the promotion of sexual wellbeing in young circumcised women and girls. Policy documents guide their obligations, yet they are also influenced by culture-specific notions about bodies and sexuality and what can be called "the FGM standard tale". The study found that professionals showed great commitment to helping the girls and young women in the best possible way. Their basic starting point, however, was characterised by a reductionist focus on the genitalia's role in sexuality, thus neglecting other important dimensions in lived sexuality. In some cases, such an attitude may negatively affect an individual's body image and sexual self-esteem. Future policy making in the field of sexual health among girls and young women with FGC would benefit from taking a broader holistic approach to sexuality. Professionals need to find ways of working that promote sexual wellbeing in girls, and must avoid messages that evoke body shame or feelings of loss of sexual capacity among those affected by FGC.

Seeking culturally safe care: a qualitative systematic review of the healthcare experiences of women and girls who have undergone female genital mutilation/cutting.

OBJECTIVE: To explore the experiences of accessing and receiving healthcare related to female genital mutilation/cutting (FGM/C) across the life course from the perspective of women and girls who have undergone FGM/C. DESIGN: A systematic review of qualitative research studies using a thematic synthesis approach. METHODS: Inclusion criteria were qualitative studies (including grey literature) of any design, from Organisation for Economic Co-operation and Development (OECD) countries, of any date and any language. Sixteen electronic databases were searched from inception to December 2017, supplemented by reference list searching. Papers were screened, selected and quality-appraised by two reviewers using established tools from the Joanna Briggs Institute. NVivo software was used to extract study characteristics and code study findings. An inductive thematic synthesis approach was undertaken to identify descriptive themes and interpret these into higher order analytical constructs. Confidence in the review findings was assessed using Grading of Recommendations, Assessment, Development and Evaluations-Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual). RESULTS: Fifty-seven papers (from 55 distinct studies) from 14 different OECD countries were included (50% published within the last 8 years). One-third of studies focused exclusively on maternity care experiences, whereas others covered a range of foci. No studies reported explicitly on girls' experiences or on experiences of health service-led safeguarding interventions. Only three studies addressed psychological care. The synthesis developed 17 descriptive themes, organised into 5 analytical constructs. These related to communication, access to care, experiences of cultural dissonance/integrity, disempowering care experiences and positive care encounters. The themes illuminate significant challenges to obtaining timely and holistic care (especially for deinfibulation), and highlight different ways in which women may experience care as disrespectful, unsafe and disempowering. Key elements of 'culturally safe care' are identified. CONCLUSIONS: This review has highlighted key knowledge gaps, especially around (1) girls'/unmarried women's experiences and (2) the impact of recent safeguarding interventions. There is an ongoing need for community engagement, service development and staff training. PROSPERO REGISTRATION NUMBER: CRD420150300012015.

'Birds of the same feathers fly together': midwives' experiences with pregnant women and FGM/C complications - a grounded theory study in Liberia.

BACKGROUND: In Liberia, approximately 70% of the women of the North-Central and North-Western regions could have undergone female genital mutilation/cutting (FGM/C) in their childhood during a traditional ceremony marking their entrance into Sande, a secret female society. Little is known about FGM/C from Liberian women's perspective. This study aimed to understand the health implications of FGM/C as perceived by qualified female midwives. METHODS: This qualitative study was conducted in 2017 in Monrovia, Liberia's capital. Twenty midwives were approached. Of these, seventeen consented to participate in in-depth interviews. A thematic guide was used to gain insights about their knowledge on FGM/C and their experiences attending women victims of FGM/C. A feminist interpretation of constructivist grounded theory guided data generation and analysis. RESULTS: The midwives participants described how clitoridectomy was the most common FGM/C type done to the girls during the Sande initiation ceremonies. Sexual impairment and intrapartum vulvo-perineal laceration with subsequent hemorrhage were described as frequent FGM/C-attributable complications that some midwives could be unable to address due to lack of knowledge and skills. The majority of midwives would advocate for the abandonment of FGM/C, and for the preservation of the traditional instructions that the girls in FGM/C-practicing regions receive when joining Sande. The midwives described how migration to urban areas, and improved access to information and communication technologies might be fuelling abandonment of FGM/C. CONCLUSION: Liberian midwives need tailored training to provide psychosexual counseling, and to attend the obstetric needs of pregnant women that have undergone FGM/C. In spite of FGM/C being seemingly in the decline, surveillance at clinic-level is warranted to prevent its medicalization. Any clinic- or community-based training, research, prevention and awareness intervention targeting FGM/C-practicing populations should be designed in collaboration with Sande members, and acknowledging that the Liberian population may place a high value in Sande's traditional values.