Trends and shifts in the practice of FGM: facilitators/barriers to abandonment in

Kenya

Samuel Kimani, University of Nairobi & Africa Coordinating Centre for

Abandonment of FGM (ACCAF), Kenya

G3 Conference, Brussels, Belgium, 20th to 22nd May 2019

Co-Authors and Acknowledgements

Dr. Caroline Kabiru -Population Council, Kenya

Dr. Jacinta Muteshi -Population Council, Kenya

Dr. Dennis Matanda -Population Council, Kenya

This work has been Funded by DFID

Background: FGM is a Socio-Health & Human Rights-legal problem

• Female genital mutilation (FGM) has no medical benefits, is

associated with health complications, women rights abuse and

violation.

• 200 million women live with FGM, while 3.6 million risk being cut

annually.

• Some decline of FGM in countries like Kenya.

• Changes (shifts) in FGM-medicalization, less severe cutting and

cutting at younger age are observed in Kenya.

• Data capture approaches should accurately measure FGM and

related shifts for programing, policy and investments.

Accurate data is key to FGM response

• Despite decline in FGM,

• Shifts give momentum to FGM yet

poorly captured

• Accurate determination of trends

and patterns can identify FGM

shifts

• Shifts may facilitate or act as

barriers to abandonment- need

exploration

Objectives

•We conducted secondary analysis of the four most recent waves of Kenya Demographic and Health Surveys (KDHS) to assess changes in the practice of FGM

•Explored understanding of medicalized FGM among families and healthcare providers from selected communities (Kenyan Somali, Abagusii and Kuria)

Methods

Secondary analyses of the 4

most recent waves of KDHS

to assess change

Qualitative approach to understand

local context of medicalisation

QualitativeMethods

(FGDs, KIIs, IDIs)

Study Sites:Nairobi, Garissa, Kisii Counties &

Kuria East

Sample: Families using

medicalized/traditional FGM, & HCPs

Evidence of declining prevalence of FGM in Kenya

1 in 5 Kenyan women have undergone FGM/C 37,6

32,1 27,121

Decline in FGM in Kenya

National prevalence with sub-national variations

Nairobi

Central

Coast

Eastern

NorthEastern

Nyanza

Rift Valley

Western

(70,100](40,70]

(30,40](20,30](10,20][0,10]

Prevalence of FGM/C

FGM/C 2014 prevalence by provinces

0

10

20

30

40

50

60

70

80

90

100 2003 2008-09 2014

Source: Shell-Duncan et al, 2017

Ethnic variations in decline of FGM

0102030405060708090

100

Prevalence of FGC by Ethnicity Across Successive Surveys*

2003 2008-09 2014

??

Much focused here

Additional 2014 data

Variation in prevalence by ethnicity and age cohorts

0

10

20

30

40

50

60

70

80

90

100

45-49 40-44 35-39 30-34 25-29 20-24 15-19

Meru Somali Kikuyu Kalenjin KisiiSource: Shell-Duncan et al, 2017

Do socio-demographic characteristics tell us something?

0

10

20

30

40

50

60

70

urban rural noeducation

primary secondary higher romancatholic

protestant/other

christian

muslim no religion other

Residence Highest educational level Religion

1998 2003 2008_09 2014

Pro

port

ion

Age of cutting among girls is decreasing0

.00

0.2

50

.50

0.7

51

.00

0 5 10 15 20 25 30Age at cutting in years

Daughters Women

Kaplan-Meier Survival EstimatesAge at cutting for Eldest daughter and Woman in 2014 KDHS

Mean age at cutting

for

• Women: 11.3 years

• Daughters: 7.8

years

FGM among mothers compared to daughters, KDHS, 2014

6,4 8,3

80,5

2,5 0,5 1,93,5

16,2

72,9

2,0 0,05,4

Doctor Nurse/Midwife Traditionalcircumciser

TBA Other Don't know/Missing

Perc

enta

ge

Women (15-49)

Daughters (0-14)

Findings: FGM is undergoing Significant Shifts

Type

• Shift to lesser severe cutting (from III, I to I/IV) across the communities

Age• Shift to younger age (except among Kuria)

Performer

• Shift to medicalization (Except among Kuria)

Key findings: Drivers for the Shifts

Shifts in type, age &

performer of FGM

RELIGIOUS REASONS

CIRCUMVENTING THE LAW

SOCIAL/ PROFESSIONAL

NORMS

AWARENESS OF HEALTH EFFECTS

INCOME

Findings: Why communities choose providers to perform FGM?

“Nurse does the cutting, because one can

encounter a big problem and she will

address. She will stitch the girl if there is a

problem like bleeding, and she gives

medicine”

Mothers to cut girls, FGD, Eastleigh,

Kenya

“The difference is that back in old days, girls

were cut having reached a certain age, and was

a little mature but these days because it is being

done secretly the girl is being taken when she is

still very young and doesn’t know what is

happening”

Married men, FGD, Kisii, Kenya

Findings: Why Do health care providers perform FGM?

“For us it’s more of like I said earlier; doing a less severe form of FGM/C.

We mainly focused on providing counselling and educating the mothers

who were coming to our facility on the effects of severe forms of FGM/C. If

we failed to convince them to abandon FGM/C, we would decide to

perform a less severe form of FGM/C.”

Clinical officer, KII, Eastleigh

“When it is done by medics under medication, the probability of having

severe complications is very minimal. If there are complications, the

probability of solving them is very high so there will be a possibility of less

complications.”

Clinical officer, KII, Eastleigh

Facilitators to FGM abandonment•National FGM Data from KDHS

•Hot spots for FGM identified including medicalization

• Favourable legislative environment

•Vibrant Government-led anti-FGM board, funders, NGOs and researchers

•Availability of tools for FGM-prevention and intervention-WHO, MOH

• Favourable social-economic determinants-shifting of norms

Barriers to FGM abandonment

•Data not micro-analyzed

• Shifts in FGM including medicalization transcending socioeconomic status

• Some critical stakeholders lagging behind

• Lack of integration of FGM in critical sectors eg health

•Political double speak

•Change resistance

•Poverty and remoteness

•Unrest and civil unrest

Policy / Program Implications of These Findings

Differential decline in prevalence of FGM calls for community-specific interventions.

Shifts in FGM across communities highlighting the need for community-specific interventions to address norms underpinning the changes

Medicalisation of FGM creates implicit approval of the practice sustaining it, a need to target communities and health care providers

Medicalization appear to normalizes/modernizes FGM a call for more research/scale up appropriate interventions

FGM modules captures FGM and its related changes but there need for re-analyses of DHS/MICS data for accuracy, while supplementary health sector generated data is urgently required.

Call for Action

Strengthen health system to prevent and respond to FGM including medicalization.

Regular and structured mainstreaming of FGM in HCPs curricula and trainings.

Partnerships between HCPs, and communities to promote understanding norms underpinning FGM including Medicalisation

FGM intervention programs need to take advantage of debates over these shifts.

Strengthening & establishment of health system-related FGM monitoring surveillance system to curb medicalization

Summary

DHS & MICS will continue to be an important source of FGM information but health sector-generated data is required to identify some changes in the practice and help respond to barriers in abandonment within the high prevalent settings.

https://www.popcouncil.org/uploads/pdfs/2017RH_FGMC-ModelingMappingKenyaDHS.pdf.