THE PREVALENCE, SEVERITY AND RATIONALE OF THE PRACTICE OF FEMALE GENITAL MUTILATION AS SEEN IN BAPTIST MEDICAL CENTRE, EKU, DELTA STATE.

SUMMARY

A cross sectional study of the prevalence, severity and rationale of the practice of female genital mutilation was carried out at the obstetrics and gynaecological clinic of the Baptist Medical Centre, Eku from September 2002 to February 2003. It focused on females alone because they are the victims of this practice.

Data was collected using a pre-tested structured questionnaire interviews to determine the background sociodemographic characteristics of respondents, attitudes and clinical effects. A physical examination was done by the investigator by inspecting the vulva to confirm presence or absence of FGM using the WHO classification.

A total of 384 clients were involved aged 15 to 49 years with a mean age of 30.41 ± 6.36years. Out of the 384 clients, 226 (58.9%) were of the Urhobo tribe. Three hundred and seventy (96.4 %) out of the 384 clients were Christians.  Ninety four (24.5%) were non pregnant and 290 (75.5%) were pregnant.

Two hundred and eighty two clients out of 384 were mutilated, giving a prevalence rate of 73.4%.

Ninety-three (24.2%) of the mutilated women intended to circumcise their daughters.

The commonest mutilation was type I 200 – (70.9%). Type II was 78(27.7%) and type III – 4(1.4%).

There was no case of type IV.

The commonest age at circumcision was 10-19 years -178(63.1%). Two hundred and thirty  three (82.6%) of the clients’ mothers took their children for the procedure. Consent was obtained in only 147(52.1%) of clients before the procedure was performed on them. One hundred and ninety  two (68.1 %) of the procedures were carried out by females among whom 151(53.5%) were trained nurses. Medical doctors performed eight (2.8%) cases. The commonest instrument used for circumcision was scissors in 99 (35.1%) of cases. Cotton wool and gauze were the commonest materials used to arrest bleeding in 157 (55.7%) of cases.

One hundred and forty seven (52.1%) of the procedures took place at home and 128 (45.4%) in the hospital. Local anaesthesia was used in 162 (57.4%) of cases and the duration of the procedure lasted for ten minutes in 58 (20.6%) of cases. Twenty-five (8.9%) of the circumcisions were done in pregnant women.

The commonest reason for circumcision was tradition in 208 (73.8%) of cases and the commonest immediate complication was pain in 102 (36.2%) of cases. Fifty-four (19.2%) of the circumcised respondents had gynaecological complications and the commonest was infertility in 21 (7.4%) respondents.  This was also the commonest complication in the uncircumcised women – 9 (8.8%).The difference was not statistically significant (p=0.657).  Fifteen (5.32%) of circumcised women had obstetric complications and the commonest was fresh stillbirth in six (2.1%) due to prolonged labour. Nine of the uncircumcised women had obstetric complication. One hundred and forty one of those circumcised had psychological complications and the commonest was lack of sexual satisfaction. Three hundred and four (79.2%) of the clients supported the ban of the practice and the reason for doing so was because of its complication in 191 (49.7%) of clients. Educational exposure and attainment appeared to have a positive impact on refusal to practice FGM (p< 0.05). Women of low socioeconomic status were more favourably disposed to practicising this tradition than the elites (p <0.05). It was concluded that female genital mutilation is a prevalent condition and that there was no significant association between gynaecological complications and female genital mutilation but a significant association between obstetric and psychological complications and female genital mutilation.

It is therefore recommended that efforts should be made by health care practitioners to educate women in the obstetrics and gynaecological clinics about the detrimental effects of female genital mutilation. This effort should also extend by way of enlightenment to the traditional institutions who are the custodians of culture in the village.

TABLE OF CONTENTS

TITLE PAGE                                                                                                                                   i

CERTIFICATION                                                                                                                           ii

DECLARATION                                                                                                                            iii

DEDICATION                                                                                                                                iv

ACKNOWLEDGEMENT                                                                                                              v

TABLE OF CONTENTS                                                                                                         vi-viii

LIST OF TABLES                                                                                                                          ix

LIST OF FIGURES                                                                                                                     x-xi

LIST OF ABBREVIATIONS                                                                                                        xii

SUMMARY                                                                                                                              xiii-xv

CHAPTER ONE: 

1.0          INTRODUCTION                                                                                                   1-4

1.2          DEFINITION OF TERMS                                                                                      4-5

1.1         OBJECTIVES OF STUDY                                                                                         6

1.2          JUSTIFICATION/RELEVANCE OF STUDY                                                      6-7

CHAPTER TWO

             REVIEW OF LITERATURE                                                                                                  

2.0         STRUCTURE AND FUNCTION OF EXTERNAL GENITALIA                      8-9

2.1        HISTORICAL BACKGROUND                                                                          9-10

2.2        HISTORY OF TERMINOLOGY                                                                         10-11

2.3        WORLD HEALTH ORGANIZATION’S CLASSIFICATION                          11-13

2.4        EPIDEMIOLOGY OF FEMALE GENITAL MUTILATION                                 13

2.5         PREVALENCE AND DISTRIBUTION OF FGM                                             13-14

2.6         THE NATURE AND SCOPE OF FGM IN NIGERIA                                       14-15

2.7          REASONS FOR FEMALE GENITAL MUTILATION                                    15-26

2.8         HEALTH CONSEQUENCES OF FEMALE GENITAL MUTILATION          26-43

2.9         THE LEGAL STATUS OF FEMALE GENITAL MUTILATION                      43-46

2.10       SECULAR TRENDS                                                                                                  46

2.11       EFFORTS AT ELIMINATION OF FEMALE GENITAL MUTILATION         46-49

CHAPTER THREE:                                                                                  

MATERIALS AND METHODS                                                                            50- 53

CHAPTER FOUR:                                                                                                            

RESULTS                                                                                                                54-87 CHAPTER FIVE:                                                                                                              

5.0 DISCUSSION                                                                                                    88-92

5.2 RECOMMENDATIONS                                                                                                   93-94      5.3 LIMITATIONS OF STUDY                                                                                  95

REFERENCES                                                                                                96-106

APPENDIX I   ETHICAL CLEARANCE                                                         107

• CONSENT FORM 108
• QUESTIONNAIRE                                    109-121

                                                              CHAPTER ONE

INTRODUCTION

Female genital mutilation (FGM) commonly, but incorrectly known as female circumcision (FC),

according to the World Health Organization’s definition encompasses a number of traditional operations that involve cutting away parts of the female external genitalia or other injuries to the female genitals, whether for cultural or any other non-therapeutic reasons ^1-6.

Female genital mutilation is practiced in one form or another in twenty-eight nations in the African Continent, in a few countries on the Arab peninsula (parts of Oman, United Arab Emirate and Yemen), among some minority communities in Asia including Malaysia and Indonesia and among immigrants from these areas who have settled in Europe, Australia and North  America 7-10.

There is evidence that this harmful traditional practice (HTP) existed before Christianity, Islam or Judaism began.  It is as old as the pyramids of ancient Egypt ^{11, 12}.

There are four types of FGM operations as defined by WHO based on the extent of amputation of the tissues ^13-16.  These are type I (Sunna) – excision of the clitoral hood (prepuce) with or without partial or total clitoral excision, type II – total clitoral excision with partial or total excision of the labia minora, type III – (infibulation, Pharaonic): partial or total excision of the external genital (clitoris, labia minora and labia majora) and stitching and /or narrowing of the vaginal opening, type IV – (unclassified):  all other operations on the female genitalia including introcision (e.g. Gishiri cuts), piercing or incising the clitoris and/or cutting of the vagina, introduction of corrosive substances and herbs into the vagina with the aim of tightening it.  Types I and II belong to a broad group called clitoridectomy (reduction operation) and type III to infibulation (covering operation).  The relative distribution of clitoridectomies and infibulation is not well documented.  A crude estimate of eighty to eighty-five percent clitoridectomies and fifteen to twenty percent infibulation or a ratio of 4:1 is made based on

review of both statistical and non-statistical data ^2,5,7,14-21.

It is estimated that 100 to 140 million women now living have undergone the

procedure ^{2, 4, 6, 8, 18, 21-24}.  At least three million girls a year are at risk of genital mutilation –

approximately 6,000 per day or five every minute ^{6, 16, 18, 25-28}.  

The variation in prevalence between countries ranges from five percent in Uganda and Zaire to almost ninety-eight percent in Somalia and Djibouti ^{12, 23}. The most severe forms are observed among Somalis

and Sudanese populations ^{[1] , 12, 29}.

With an overall national prevalence of fifty percent, Nigeria has the highest absolute number of

genitally mutilated women throughout the world ^{2, 10, 13, 30}.  The prevalence ranges from 0% in parts of Kogi and Ogun states to 100% in Benue and kebbi States ². In some parts notably Osun, Oyo, and Edo states, the prevalence of FGM among women of reproductive age exceeds ninety percent ².  In the Southern parts of Nigeria where Types I and II are found mainly, it is prevalent in Akwa Ibom, Cross River, Delta, Anambra, Imo, Ondo and Rivers states.  Type III can be found among the Igbos in Imo state and girls from Edo and Delta states. Type IV is generally practiced among Hausas in Kaduna and Katsina in the Northern States of Nigeria ¹².

The age at which FGM is performed varies widely depending on the Ethnic group and geographical when she dies, she is not spared from this procedure if she is to receive a decent burial.  However, the

procedure is more commonly undertaken between the ages of four and ten years ^{22, 26, 31, 32}.

The operation, which lasts for about fifteen to twenty minutes, is normally carried out with special

knives, sharp stones, scissors, scalpels, and pieces of glass or razor blades ^{15, 32, 33}.  The instruments are often not sterilized.  Anaesthetics, antiseptics and analgesics are usually not  used ^{27, 34} and pastes containing herbs, cow dung, local porridge, ashes, barks and roots of trees are

frequently rubbed on the wounds to stop bleeding ^{12, 35}.  The procedure is usually undertaken by elderly

women in the community specially designated for this task or by traditional birth attendants^{12, 35}.

However, some orthodox health practitioners such as midwives and doctors have been known to carry

16, 21, 25, 28, 29, 36, 37 out this procedure .

Advocates and practitioners of FGM often cite its value as the initiation rite into womanhood, restriction of female sexual desires and preservation of virginity, prevention of promiscuity and

infertility, the maintenance of hygiene and cosmetics ^{5, 14, 38}.  Men have been known to refuse marriage to women not yet circumcised.  Interestingly, women are often the strongest proponents of the procedure as the rejection of FGM may carry with it a potential loss of status and acceptance within

the community ^{3, 24}.  In addition those who perform FGM advocate strongly for its continuation because it provides them a ready source of income as well as a status  symbol 19, 23, 24, 30.

The health consequences are both immediate and life-long ^{5, 9}.  These complications may be psychosexual and physical.  The complications of circumcision can be detected and treated in gynaecological and antenatal clinics.  The psychosexual consequences have not been

well-studied  ^{1, 8 11, 21, 26, 30, 39 – 41}.   The physical complications are well documented and common to all

types of FGM but worse with infibulation ^{7,8, 39, 40}.

The eradication of FGM requires a global action. This can be achieved through education, advocacy, legislation and research ^{5, 19}.

Advice against female circumcision can become part of comprehensive reproductive health information and counseling package delivered through oral, written or audio-visual media ^{40, 42}.

DEFINITION OF TERMS:

1.          SOCIO- ECONOMIC STATUS

The social class (or socio –economic status) of the women was obtained through a scoring system

(index) combining the women’s level of education with thei husband’s occupation.

This allocated each woman to social class I to V, social class V being the bottom of the social stratification. The suitability and application of this social classification system for our environment has been well tested ⁴³.

THE SCORING SYSTEM OF SOCIAL CLASSIFICATION.

Indices                                                                            Score

1. Husband’s occupation

Professional                                                                      1

Middle level                                                                      2

Unskilled                                                                          3

1. Woman’s Education

University                                                                          0

Secondary/ Postsecondary (Below university)                         1

Primary/Nil                                                                        2

Each woman’s social class (1-V) is obtained by adding the scores from A and B above.

2. CIRCUMCISION INDEX: This is the ratio of circumcised to uncircumcised respondents. It is an age related measure of the trend of circumcision

3. HARMFUL TRADITIONAL PRACTICES – This is a general term used to describe acts based on culture, beliefs and norms that have been passed from generation to

generation 16, 40, 42, 44.

These include:

i     FGM ii    Nutritional taboos iii   Seclusion in labour iv   Child marriage and teenage pregnancy v    Gishiri cut vi   Hot puerperal bath vii   Male child preference

viii  Clitoral massage with vaseline

        1.1     OBJECTIVES OF STUDY

General:

To determine the prevalence of FGM in Baptist Medical Centre, Eku, Delta State

Specific:

1. To determine women’s’ attitudes and practices towards FGM
2. To determine the physical and psycho-sexual complications of FGM
3. To determine the type or types of FGM practiced

1.2      RELEVANCE/JUSTIFICATION OF STUDY

Female genital mutilation has been practiced in various parts of Nigeria over several generations.

However, it was only recently that its adverse effects on women’s reproductive health began to receive attention.

A female worker in the Hospital under study who is an indigene of Eku invited the investigator to the circumcision ceremony of her daughter and refused to be convinced that it is a harmful practice.  In this same Hospital, in the course of examining female clients at the antenatal and gynaecological clinic, a number of genitally mutilated women were seen with various complications such as keloid, clitoral cyst, dyspareunia, and infertility. This study focused on females because they are the victims of this harmful practice and, as mothers, their attitudes towards FGM will go a long way in determining the success of any control measures. Increased education and public enlightenment on the risks and numerous disadvantages of FGM are expected to reduce the practice, but there are still major gaps in knowledge about the extent and nature of the problem and the kinds of intervention that can be successful in eliminating it.

The Family Physician has a number of roles to play in the eradication of female genital mutilation. These include: Treatment of complications, health education of individuals and families and research to find effective interventions to eradicate the practice. Therefore, the family Physician should look out for genital cutting and its complications while doing vaginal examination on any girl or woman and treat and /or counsel such women appropriately. He may mount health education posters in his office and may through counseling influence key or dominant decision-makers in the families as they come for treatment or call for interviews with family decision-makers as and when necessary – promoting health by a good patient-doctor relationship that must have resulted over the years. Furthermore, the Family Physician may notify appropriate quarters of the incidence rate of FGM and its complications in his locality. The public health physician may thereby be mobilized for effective community action.

Similar studies have been conducted at Abia state University¹³ and Amino Kano Teaching Hospital in Kano State of Nigeria⁴⁵ but no such study has been carried out at the Baptist Medical Centre, Eku. All these have stimulated this study to document every aspect of the practice in order to provide a framework for target interventions to eradicate the practice. It is hoped that the knowledge derived from this study will be useful:

1. As a background information on which further studies which may be community based will be done
2. As a basis for health education of women of reproductive age in the antenatal and

gynaecological unit about the ills of female genital mutilation.

3. As a basis for planning for the healthcare needs of those already mutilated.

[1] ^{, 31}

location .  In some groups, it is performed on babies, while in others, it is performed in menarche, pregnancy or childbirth.  In other communities if a woman escapes being circumcised during her life,

THE PREVALENCE, SEVERITY AND RATIONALE OF THE PRACTICE OF FEMALE GENITAL MUTILATION AS SEEN IN BAPTIST MEDICAL CENTRE, EKU, DELTA STATE.