Persistence of female genital mutilation/cutting in two Kenyan communities: What can we learn from change that falls short of abandonment?

Literature on dynamics of change in female genital mutilation/cutting (FGM/C) portray two common but conflicting views. On one side, FGM/C is seen as static and deeply entrenched, with parents lacking agency to interpret culture, evaluate options and adopt changes. An alternative perspective focuses on the fluidity of social norms, influencing whether and how FGM/C is practised. This study asks: in counties where FGM/C persists at high rates, Kisii and Narok, are there changes in the way that FGM/C is performed? and what drives these changes? In-depth interviews and focus group discussions were conducted to illuminate these questions. Data showed five ways that FGM/C practices have changed: (1) reduction in severity of cutting, (2) medicalised cutting, (3) performing FGM/C at younger ages, (4) cutting in secret, and (5) occasionally, abandonment of FGM/C. Messaging on health risks of FGM/C and fear of criminal punishment have motivated less severe cutting and medicalisation. Legislation has also driven the practice underground. Programmes aimed at ending FGM/C should create a critical dialogue on changes in norms with the intent of reducing stigmatisation of uncut girls and their families, and the ways cutting practices are shifting, thereby building on change that is already underway.

The perceived effects of COVID-19 pandemic on female genital mutilation/cutting and child or forced marriages in Kenya, Uganda, Ethiopia and Senegal.

BACKGROUND: The effects of COVID-19 on harmful traditional practices such Female Genital Mutilation/Cutting (FGM/C) and Child or Forced Marriages (CFM) have not been well documented. We examined respondents' perceptions on how the COVID-19 pandemic has affected FGM/C and CFM in Kenya, Uganda, Senegal, and Ethiopia. METHODS: A cross-sectional study design with a mixed methods approach was used. Data collection on participants' perceptions on the effects of COVID-19 on FGM/C and CFM took place between October-December 2020. Household surveys targeting women and men aged 15-49 years in Kenya (n = 312), Uganda (n = 278), Ethiopia (n = 251), and Senegal (n = 208) were conducted. Thirty-eight key informant interviews with programme implementers and policymakers were carried out in Kenya (n = 17), Uganda (n = 9), Ethiopia (n = 8), and Senegal (n = 4). RESULTS: In Kenya, the COVID-19 pandemic has contributed to the increase in both FGM/C and CFM cases. Minimal increase of FGM/C cases was reported in Uganda and a significant increase in CFM cases. In Ethiopia, the COVID-19 pandemic had a limited perceived effect on changes in FGM/C and CFM. In Senegal, there were minimal perceived effects of COVID-19 on the number of FGM/C and CFM cases. The pandemic negatively affected implementation of interventions by the justice and legal system, the health system, and civil societies. CONCLUSIONS: The pandemic has had varied perceived effects on FGM/C and CFM across the four countries. Generally, the pandemic has negatively affected implementation of interventions by the various sectors that are responsible for preventing and responding to FGM/C and CFM. This calls for innovative approaches in intervening in the various communities to ensure that women and girls at risk of FGM/C and CFM or in need of services are reached during the pandemic. Evidence on how effective alternative approaches such as the use of call centres, radio talk shows and the use of local champions as part of risk communication in preventing and responding to FGM/C and CFM amid COVID-19 is urgently required.

Plurality of beliefs about female genital mutilation amidst decades of intervention programming in Narok and Kisii Counties, Kenya.

Female genital mutilation derails efforts to achieve gender equality and the empowerment of girls and women. In Kenya, national estimates show a steady decline in prevalence, although there is considerable variation at the sub-national level. There is a need to better understand female genital mutilation-related norms and meanings and whether there have been changes in these given long-term and diverse efforts to promote abandonment. Focusing on Narok and Kisii counties, we conducted a cross-sectional qualitative study to identify social norms surrounding the practice of female genital mutilation, as well as consensus or contestation with respect to these norms. Ten focus group discussions were held with men and women aged 18 years and older from the Maasai and Abagusii communities that have traditionally practised female genital mutilation. Study findings showed that norms associated with female genital mutilation such as sexuality and marriageability were actively contested by community members. This change may provide a useful starting point for programmes that seek to create dialogue and critical reflection on female genital mutilation to accelerate its abandonment.

Challenges and prospects for implementation of community health volunteers' digital health solutions in Kenya: a qualitative study.

BACKGROUND: The value of digital health technologies in delivering vital health care interventions, especially in low resource settings is increasingly appreciated. We co-developed and tested a decision support mobile health (m-Health) application (app);with some of the forms used by Community Health Volunteers (CHVs) in Kenya to collect data and connected to health facilities. This paper explores the experiences of CHVs, health workers and members of Sub-County Health Management Teams following implementation of the project. METHODS: Data were collected in December 2017 through in-depth interviews and focus group discussions with CHVs and key informant interviews with health care workers and health managers in Kamukunji sub-County of Nairobi, Kenya. Data coding and analysis was performed in NVivo 12. RESULTS: Regarding users and health managers' perceptions towards the system; three main themes were identified: 1) variations in use, 2) barriers to use and 3) recommendations to improve use. Health workers at the private facility and some CHVs used the system more than health workers at the public facilities. Four sub-themes under barriers to use were socio-political environment, attitudes and behaviour, issues related to the system and poor infrastructure. A prolonged health workers' strike, the contentious presidential election in the year of implementation, interrupted electricity supply and lack of basic electric fixtures were major barriers to use. Suggestions to improve usage were: 1) integration of the system with others in use and making it available on users' regular phones, and 2) explore sustainable motivation models to users as well as performance based remuneration. CONCLUSIONS: The findings reveal the importance of considering the readiness of information and communication technologies (ICT) users before rollout of ICT solutions. The political and sociocultural environment in which the innovation is to be implemented and integration of new solutions into existing ones is critical for success. As more healthcare delivery models are developed, harnessing the potential of digital technologies, strengthening health systems is critical as this provides the backbone on which such innovations draw support.

Exploring the capacity of the Somaliland healthcare system to manage female genital mutilation / cutting-related complications and prevent the medicalization of the practice: a cross-sectional study.

BACKGROUND: Female genital mutilation/cutting (FGM/C) negatively impacts the wellbeing of girls and women throughout their lifecycle. In Somalia, FGM/C prevalence is nearly universal (98%) among females aged 15-49 years, with infibulation prevalence at 77%. Whilst there is need to engage healthcare workers in the prevention and management of FGM/C, minimal information exists indicating healthcare systems' capacity to fulfil this role. This study explored factors impacting the capacity of the Somaliland healthcare system to prevent the medicalization, and manage the complications of, FGM/C. METHODS: A cross-sectional qualitative study using semi-structured key informant interviews, conducted in the Somali language, was undertaken in the Maroodi Jeex and Awdal regions of Somaliland, in rural and urban Borama and Hargeisa districts in December 2016. A total of 20 interviews were conducted with healthcare workers comprised of medical doctors, nurses, midwives and system administrators. Transcribed and translated interview data were analysed using the template analysis approach. RESULTS: Healthcare workers reported understanding the adverse impact of FGM/C on the health of girls and women. However, they faced multiple contextual challenges in their preventative and management roles at the individual level, e.g., they lacked specific formal training on the prevention and management of FGM/C complications and its medicalization; institutional level, e.g., many facilities lacked funding and equipment for effective FGM/C management; and policy level, e.g., no national policies exist on the management of FGM/C complications and against its medicalization. CONCLUSION: Healthcare systems in urban and rural Somaliland have limited capacity to prevent, diagnose and manage FGM/C. There is a need to strengthen healthcare workers' skill deficits through training and address gaps in the health system by incorporating the care of girls and women with FGM-related complications into primary healthcare services through multi-sectoral collaboration and coordination, establishing clinical guidelines for FGM/C management, providing related equipment, and enacting policies to prevent the medicalization of the practice.

Pregnancy history and current use of contraception among women of reproductive age in Burundi, Kenya, Rwanda, Tanzania and Uganda: analysis of demographic and health survey data.

OBJECTIVE: To examine the relationship between pregnancy history and the use of contraception among women of reproductive age (15-49 years) in East Africa. METHODS: Demographic and Health Surveys data from Burundi (2010), Kenya (2008-2009), Rwanda (2010), Tanzania (2010) and Uganda (2011) were used in the analysis. Logistic regression was used to determine the effects of women's pregnancy history on their use of contraception. SETTING: Burundi, Kenya, Rwanda, Tanzania and Uganda. PARTICIPANTS: 3226, 2377, 4396, 3250 and 2596 women of reproductive age (15-49 years) from Burundi, Kenya, Rwanda, Tanzania and Uganda, respectively, were included in the analysis. RESULTS: Women who had experienced a mistimed pregnancy were more likely to use a modern contraceptive method during their most recent sexual encounter in Kenya, Rwanda, Burundi and Uganda. Other significant correlates of women's contraceptive use were: desire for more children, parity, household wealth, maternal education and access information through radio. In-country regional differences on use of modern contraceptive methods were noted across five East African countries. CONCLUSIONS: Women's birth histories were significantly associated with their decision to adopt a modern contraceptive method. This highlights the importance of considering women's birth histories, especially women with mistimed births, in the promotion of contraceptive use in East Africa. Variations as a result of place of residency, educational attainment, access to family planning information and products, and wealth ought to be addressed in efforts to increase use of modern contraceptive methods in the East African region.

Influence of childcare practices on nutritional status of Ghanaian children: a regression analysis of the Ghana Demographic and Health Surveys.

OBJECTIVES: Guided by the UNICEF framework for childcare, this study examined the association of childcare practices (CCP) with infant and young children's growth (height-for-age Z-scores, HAZ), and investigated whether care practices are more important to growth in some sociodemographic subgroups of children. DESIGN: Cross-sectional survey. SETTING: Urban and rural Ghana. PARTICIPANTS: The study sample comprised 1187 dyads of mothers aged 15-49 years and their youngest child (aged 6-36 months). RESULTS: The results showed that CCP was a significant predictor of HAZ, after controlling for covariates/confounders at child, maternal and household levels. Children with higher CCP scores had higher HAZ. A 1-unit increase in the CCP score was associated with a 0.17-unit increase in HAZ. Child's and mother's age, number of children under 5 years, place of residence, maternal weight and wealth index were also significantly associated with HAZ. Statistical interaction analyses revealed no subgroup differences in the CCP/HAZ relationship. CONCLUSIONS: This study found a significant, positive association between CCP and child growth, after accounting for other important determinants of child growth at maternal and household levels. This calls for research into the effects on growth of various CCP components, with longitudinal cohort study designs that can disentangle causal relationships.

Breast-, complementary and bottle-feeding practices in Kenya: stagnant trends were experienced from 1998 to 2009.

The pattern of infant and young child feeding that provides the most benefit includes being put to the breast within an hour of birth, exclusive breastfeeding for 6 months, continued breastfeeding along with complementary foods up to 2 years of age or beyond, and avoidance of any bottle-feeding. However, since there are no published data from Kenya regarding trends in these feeding practices, this research undertook time trend estimation of these feeding practices using the 1998, 2003, and 2008-2009 Kenya Demographic and Health Survey and also examined the multivariate relationships between sociodemographic factors and feeding practices with data from 2008 to 2009. Logistic regression was used to test the significance of trends and to analyze sociodemographic characteristics associated with feeding practices. There was a significant decline in early initiation of breastfeeding among children in Central and Western provinces and those residing in urban areas. Trends in exclusive breastfeeding showed significant improvement in most sociodemographic segments, whereas trends in complementary feeding and breastfeeding remained stable. Bottle-feeding significantly decreased among children aged 12 to 23 months, as well as those living in Coast, Eastern, and Rift Valley provinces. In the multivariate analysis, the province was significantly associated with feeding practices, after controlling for child's size, birth order, and parity. The stagnant (and in some cases worsening) trends in early initiation of breastfeeding and complementary feeding with breastfeeding paint a worrisome picture of breastfeeding practices in Kenya; therefore, efforts to promote the most beneficial feeding practices should be intensified.

Reliability of demographic and socioeconomic variables in predicting early initiation of breastfeeding: a replication analysis using the Kenya Demographic and Health Survey data.

OBJECTIVES: Examine the reliability of sociodemographic variables in predicting initiation of breastfeeding within an hour of birth (EarlyBF), using data from 1998, 2003 and 2008-2009. STUDY DESIGN: A replication analysis using the Kenya Demographic and Health Survey (KDHS) data collected in 1998, 2003 and 2008-2009. The candidate predictor variables were child's gender, home or health facility place of birth, vaginal or caesarean mode of birth, urban or rural setting, province of residence, Wealth Index and maternal education, occupation, literacy and media exposure. SETTING: Kenya. PARTICIPANTS: 6375 dyads of mothers aged 15-49 and their children aged 0-23 months (2125 dyads in each of the survey years). RESULTS: Mode of birth and province were statistically significant predictors of EarlyBF in 1998, 2003 and 2008-2009. Children delivered through caesarean section were non-EarlyBF in 1998 (OR 2.63, 95% CI 1.72 to 4.04), 2003 (OR 3.36, 95% CI 1.83 to 6.16) and 2008 (OR 3.51, 95% CI 2.17 to 5.69). The same was true of those living in the Western province in 1998 (OR 2.67, 95% CI 1.61 to 4.43), 2003 (OR 4.92, 95% CI 3.01 to 8.04) and 2008 (OR 6.07, 95% CI 3.54 to 10.39). CONCLUSIONS: The 1998 KDHS data do not provide the basis for reliable prediction of EarlyBF, with reliability conceptualised as replicability of findings using highly similar data sets from 2003 and 2008-2009. Most of the demographic and socioeconomic variables were unreliable predictors of EarlyBF. We speculate that activities in parts or all of Kenya changed the analysis context in the period between 1998 and 2008-2009, and these changes were of a sufficient magnitude to affect the relationships under investigation. The degree to which this is a general problem in child health research is not known, calling for further research to investigate this methodological issue with other health end points and other data.

Child undernutrition in Kenya: trend analyses from 1993 to 2008-09.

BACKGROUND: Research on trends in child undernutrition in Kenya has been hindered by the challenges of changing criteria for classifying undernutrition, and an emphasis in the literature on international comparisons of countries' situations. There has been little attention to within-country trend analyses. This paper presents child undernutrition trend analyses from 1993 to 2008-09, using the 2006 WHO criteria for undernutrition. The analyses are decomposed by child's sex and age, and by maternal education level, household Wealth Index, and province, to reveal any departures from the overall national trends. METHODS: The study uses the Kenya Demographic and Health Survey data collected from women aged 15-49 years and children aged 0-35 months in 1993, 1998, 2003 and 2008-09. Logistic regression was used to test trends. RESULTS: The prevalence of wasting for boys and girls combined remained stable at the national level but declined significantly among girls aged 0-35 months (p < 0.05). While stunting prevalence remained stagnant generally, the trend for boys aged 0-35 months significantly decreased and that for girls aged 12-23 months significantly increased (p < 0.05). The pattern for underweight in most socio-demographic groups showed a decline. CONCLUSION: The national trends in childhood undernutrition in Kenya showed significant declines in underweight while trends in wasting and stunting were stagnant. Analyses disaggregated by demographic and socio-economic segments revealed some significant departures from these overall trends, some improving and some worsening. These findings support the importance of conducting trend analyses at detailed levels within countries, to inform the development of better-targeted childcare and feeding interventions.