Quality of services offered to women with female genital mutilation across health facilities in a Kenyan County.

BACKGROUND: Female genital mutilation (FGM) curtails women's health, human rights and development. Health system as a critical pillar for social justice is key in addressing FGM while executing the core mandate of disease prevention and management. By leveraging opportune moments, events and experiences involving client-provider interactions, relevant FGM-related communications, behavior change and management interventions can be implemented through health facilities or in communities. It is unclear whether Kenyan health system has maximized this strategic advantage and positioning to address FGM. OBJECTIVE: Determine the quality of services offered to women with FGM across health facilities in West Pokot county, Kenya. METHODS: A mixed quantitative data collection strategies were used. These included: client-provider interactions observations with (61) health care workers (HCWs) and women with FGM seeking services; client-exit interviews with (360) women with FGM seeking services. These approaches sought to determine the content and quality of FGM-related care services; and service data abstractions involving records on services sought/offered from (10) facilities in West Pokot. RESULTS: A large (76%) proportion of women had experienced FGM aged 11-15 years, were married between 15 and 19 years (39%), had primary (47.5%) or no education (33%) with income <30 USD/month (43%). Only 14.8% HCWs identified FGM and related complications (11.5%) during consultations. Few FGM-related prevention interventions were implemented with IEC materials (4.9%) for reinforcing preventive messages lacking. Infrastructure (88.5%) for reproductive health services existed albeit limited human resources (14.8%) and capacity (42.6%) for FGM prevention and management; few (16%) health facilities and workers explained the negative consequences of FGM and need for stopping it (15.3%); and while data on women who sought antenatal (ANC), postnatal (PNC) and family planning (FP) care services were available no information of those with FGM or related complications. CONCLUSION: Health systems in high prevalent settings actively interface with women with FGM, despite the primary reason for seeking services not being FGM. Despite high number of women having undergone the cut, diagnosis, prevention, care services, and documentation of FGM and related complications are suboptimal. This underscores the need for health system strengthening in response to the practice with consideration for training kits for HCWs, empowering HCWs, anchoring of FGM indicators in the HMIS, documentation and IEC material to support FGM prevention at service delivery points, and overall integration of FGM into health programs.

Female genital mutilation/cutting: Emerging factors sustaining medicalization related changes in selected Kenyan communities.

Although female genital mutilation/cutting (FGM/C) has declined, it is pervasive albeit changing form among communities in Kenya. Transformation of FGM/C include medicalization although poorly understood has increased undermining abandonment efforts for the practice. We sought to understand drivers of medicalization in FGM/C among selected Kenyan communities. A qualitative study involving participants from Abagusii, Somali and Kuria communities and key informants with health care providers from four Kenyan counties was conducted. Data were collected using in-depth interviews (n = 54), key informant interviews (n = 56) and 45 focus group discussions. Data were transcribed and analyzed thematically using NVivo version 12. We found families practiced FGM/C for reasons including conformity to culture/tradition, religion, marriageability, fear of negative sanctions, and rite of passage. Medicalized FGM/C was only reported by participants from the Abagusii and Somali communities. Few Kuria participants shared that medicalized FGM/C was against their culture and would attract sanctions. Medicalized FGM/C was perceived to have few health complications, shorter healing, and enables families to hide from law. To avoid arrest or sanctions, medicalized FGM/C was performed at home/private clinics. Desire to mitigate health complications and income were cited as reasons for health providers performing of FGM/C. Medicalization was believed to perpetuate the practice as it was perceived as modernized FGM/C. FGM/C remains pervasive in the studied Kenyan communities albeit changed form and context. Findings suggest medicalization sustain FGM/C by allowing families and health providers to conform to social norms underpinning FGM/C while addressing risks of FGM/C complications and legal prohibitions. This underscores the need for more nuanced approaches targeting health providers, families and communities to promote abandonment of FGM/C while addressing medicalization.

Exploring barriers to seeking health care among Kenyan Somali women with female genital mutilation: a qualitative study.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a cultural practice associated with health consequences, women rights and deprivation of dignity. Despite FGM/C-related health consequences, circumcised women may encounter additional challenges while seeking interventions for reproductive health problems. Experiences of women/girls while accessing health services for reproductive health problems including FGM/C-related complications in poor, remote and hard to reach areas is poorly understood. We sought to explore barriers to care seeking among Somali women with complications related to FGM/C in public health facilities in Kenya. METHODS: We drew on qualitative data collected from purposively selected women aged 15-49 years living with FGM/C, their partners, community leaders, and health providers in Nairobi and Garissa Counties. Data were collected using in-depth interviews (n = 10), key informant interviews (n = 23) and 20 focus group discussions. Data were transcribed and analyzed thematically using NVivo version 12. RESULTS: Barriers were grouped into four thematic categories. Structural barriers to care-seeking, notably high cost of care, distance from health facilities, and lack of a referral system. Concerns regarding perceived quality of care also presented a barrier. Women questioned health professionals' and health facilities' capacity to offer culturally-sensitive FGM/C-specific care, plus ensuring confidentiality and privacy. Women faced socio-cultural barriers while seeking care particularly cultural taboos against discussing matters related to sexual health with male clinicians. Additionally, fear of legal sanctions given the anti-FGM/C law deterred women with FGM/C-related complications from seeking healthcare. CONCLUSION: Structural, socio-cultural, quality of service, and legal factors limit health seeking for reproductive health problems including FGM/C-related complications. Strengthening health system should consider integration of FGM/C-related interventions with existing maternal child health services for cost effectiveness, efficiency and quality care. The interventions should address health-related financial, physical and communication barriers, while ensuring culturally-sensitive and confidential care.

Female Genital Mutilation/Cutting: Innovative Training Approach for Nurse-Midwives in High Prevalent Settings.

BACKGROUND: Female genital mutilation/cutting (FGM/C) has no medical benefits and is associated with serious health complications. FGM/C including medicalization is illegal in Kenya. Capacity building for nurse-midwives to manage and prevent FGM/C is therefore critical. OBJECTIVE: Determine the current FGM/C knowledge and effect of training among nurse-midwives using an electronic tool derived from a paper-based quiz on FGM/C among nurse-midwives. METHODS: Nurse-midwives (n=26) were assessed pre- and post-FGM/C training using a quiz comprising 12 questions. The quiz assessed the following factors: definition, classification, determining factors, epidemiology, medicalization, prevention, health consequences, and nurse-midwives' roles in FGM/C prevention themes. The scores for individuals and all the questions were computed and compared using SPSS V22. RESULTS: The mean scores for the quiz were 64.8%, improving to 96.2% p < 0.05 after training. Before the training, the following proportions of participants correctly answered questions demonstrating their knowledge of types of cutting (84.6%), link with health problems (96.2%), FGM/C-related complications (96.2%), communities that practice FGM/C (61.5%), medicalization (43.6%), reinfibulation (46.2%), dissociation from religion (46.2%), and the law as it relates to FGM/C (46.2%). The participants demonstrated knowledge of FGM/C-related complications with the proportion of nurse-midwives correctly answering questions relating to physical impact (69.2%), psychological impact (69.2%), sexual impact (57.7%), and social impact (38.5%). Additionally, participant awareness of NM roles in managing FGM/C included the following: knowledge of the nurse-midwife as counselor (69.2%), advocate (80.8%), leader (26.9%), role model (42.3%), and caregiver (34.6%). These scores improved significantly after training. CONCLUSION: Substantial FGM/C-related knowledge was demonstrated by nurse-midwives. They, however, showed challenges in preventing/rejecting medicalization of FGM/C, and there were knowledge gaps concerning sexual and social complications, as well as the specific roles of NM. This underscores the need to implement innovative FGM/C training interventions to empower health professionals to better respond to its management and prevention.

The 'heat' goes away: sexual disorders of married women with female genital mutilation/cutting in Kenya.

BACKGROUND: Female genital mutilation/cutting (FGM/C) has been implicated in sexual complications among women, although there is paucity of research evidence on sexual experiences among married women who have undergone this cultural practice. The aim of this study was to investigate the sexual experiences among married women in Mauche Ward, Nakuru County. METHODS: Quantitative and qualitative data collection methods were used. Quantitative data were obtained from 318 married women selected through multistage sampling. The women were categorized into: cut before marriage, cut after marriage and the uncut. A questionnaire was used to collect demographic information while psychometric data were obtained using a female sexual functioning index (FSFI) tool. The resulting quantitative data were analyzed using SPSS® Version 22. Qualitative data were obtained from five FGDs and two case narratives. The data were organized into themes, analyzed and interpreted. Ethical approval for the study was granted by Kenyatta National Hospital-University of Nairobi Ethics and Research Committee. RESULTS: The mean age of the respondents was 30.59 ± 7.36 years. The majority (74.2%) had primary education and 76.1% were farmers. Age (p = 0.008), number of children (p = 0.035) and education (p = 0.038) were found to be associated with sexual functioning. The cut women reported lower sexual functioning compared to the uncut. ANOVA results show the reported overall sexual functioning to be significantly (p = 0.019) different across the three groups. Women cut after marriage (mean = 22.81 ± 4.87) scored significantly lower (p = 0.056) than the uncut (mean = 25.35 ± 3.56). However, in comparison to the cut before marriage there was no significant difference (mean = 23.99 ± 6.63). Among the sexual functioning domains, lubrication (p = 0.008), orgasm (p = 0.019) and satisfaction (p = 0.042) were significantly different across the three groups. However, desire, arousal and pain were not statistically different. CONCLUSION: Generally, cut women had negative sexual experiences and specifically adverse changes in desire, arousal and satisfaction were experienced among cut after marriage. FGM/C mitigating strategies need to routinely provide sexual complications management to safeguard women's sexual right to pleasure subsequently improving their general well-being.