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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 10, Num. 2, 2006, pp. 7-9
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African Journal of Reproductive Health, Vol. 10, No. 2, August, 2006, pp. 7-9
Editorial
Female genital mutilation and reproductive health in Africa
Friday Okonofua
Code Number: rh06020
Available evidence indicates that about 130 million
women and girls worldwide have experienced female
genital mutilation (FGM). Of these, the large majority
are to be found in parts of East and West Africa as well
as the Nile Valley countries of Egypt and Sudan. Several
reasons have been given for the practice of FGM in
Africa, the most important of which surrounds
perceptions relating to cultural norms of femininity
and chastity and in a few instances the need to observe
religious injunctions.
In the last two decades, the international
community has very strongly condemned the practice
of FGM as an abuse of the bodily integrity and human
rights of women and girls. The World Health
Organization in particular, has issued a series of
statements recommending the discontinuation of the
FGM and has urged health practitioners not to
medicalize the procedure under any circumstance.
Several articles in this edition of the African Journal
of Reproductive Health describe the continuing practice
of FGM in African countries. The paper by Sakeah et
al1, reports that male preference for circumcised women
is an important factor associated with the perpetuation
of FGM in northern Ghana. The typology of FGM as
recommended by the WHO is well known. The most
severe type of FGM consisting of the excision of part
or all external genitalia and stitching/narrowing of the
vaginal opening (infibulation) is practiced in the northern
African countries of Egypt and Sudan, and some parts
of Ethiopia. In a large number of cases, infibulated
women often undergo a process of defibulation (recutting
of the vaginal passage) at the time of childbirth
to enable easy passage of the fetus. Under normal circumstances, the vagina should be left open
after defibulation to correct the deformity on a
permanent basis. However, reinfibulation is an option,
whereby some women are re-stitched after delivery in order
to maintain the state of genital mutilation. The paper
by Berggren et al2 in this edition of the journal reports
an interesting cultural dichotomy, whereby refibulation
is regarded by some women as a benefit of
sexuality, whereas a few regard it as evidence of the
continuing social victimization of women in efforts to sustain
the traditional practice of FGM.
The literature is replete with several
documentations of the incidence and socio-cultural determinants
of FGM in Africa. Thus, much of the ongoing debate surrounds what needs to be done to end the
practice, and to sustain the discontinuation over time. The
paper by Shell-Duncan3, analyzing results of
qualitative research in the Gambia, indicates that there may be
stages of social transformation in the practice of FGM.
This suggests that advocates seeking to reduce the
practice of FGM should not necessarily expect
immediate outcomes in terms of actual declines in the practice
but should be content with phased results based on
the recognition of the state of progression of
this transformational change. That means for example,
that intermediary results such as attitudinal
change documented by a reduction in the proportion of
people willing to mutilate their daughters or to
seek reinfibulation, are as good as the actual decline in
the incidence of FGM.
The good news is the report in this edition
by Adeokun et al4, which indicates that there may be
a trend towards a decline in the practice of FGM
in southwest Nigeria over time. This report is consistent
with our earlier report5 in Nigeria, which indicates a
secular trend towards a decline in the incidence of FGM.
Much of this decline is attributable to the effects of
modernization and education and as emphasized by
Finke6 in this edition of the journal, education and the
empowerment of women, are two key interventions
that will contribute significantly to ending FGM in Africa.
In time past, the international community has
expressed concern about the lack of strong scientific
evidence linking FGM with adverse reproductive health
outcomes. However, there are now a growing number
of well conducted studies which demonstrate significant
association between FGM and various gynecologic7 and
pregnancy complications8, 9.
In 2006, the WHO reported a study conducted in
six African countries (Burkina Faso, Ghana, Kenya,
Nigeria, Senegal and Sudan) that determined the effects
of FGM on various obstetric sequelae10. The study
examined 26,393 women in the six countries during
childbirth and showed that women with FGM were
more likely to undergo caesarean section, to experience
postpartum hemorrhage and extended hospital stay, to
require infant resuscitation and to experience stillbirth,
early neonatal death and low birth weight infants. This
study has now provided the best evidence to date of
the association between FGM and adverse obstetric
outcomes.
Clearly, there can be no doubt that FGM
has negative implications for women's health in Africa.
The elimination of all forms of FGM is now regarded as
a major component of social and economic
development strategies in many African countries. Although
the elimination of FGM was not specifically mentioned
as one of the expected outcomes of the Millennium Development Goals, the fact that FGM has
negative implications for maternal health means that it must
be addressed as part of efforts to achieve MDGs 4 and 5.
In turn, we believe that if the remaining MDGs
are adequately addressed, they can contribute
significantly to eliminating FGM in African countries. While
there has been intense international advocacy to
eliminate FGM, limited results have been achieved, mainly
because of the vertical approach hitherto used to
address prevention efforts. We believe that to achieve and
sustain results over time, FGM prevention must be
integrated to the broader sexual and reproductive health
programs. Additionally, research must be intensified to
provide
evidence for best practices for reducing FGM in
Africa, and to monitor impact of interventions over time.
In conclusion, the continued practice of
FGM testifies to the human rights abuse and social disempowerment of women, and is a sad reminder
of the poor state of women's reproductive health in
Africa. African countries must give the highest priority to
the elimination of FGM in their social
developmental agenda. A systematic decline in the incidence of FGM
is one indicator that any African country can show as
proof of its willingness to address social and gender
inequities among its people. In turn, the international
community must not relent in its efforts to support the
total abandonment of this unnecessary and harmful
tradition in Africa. Surely, the current global crusade for
social justice, equity and ethical practices cannot be
achieved unless FGM is completely eliminated from the world.
References
- Sakeah E, Doctor HV, Beke A, Hodgson AV.
Males' preference for circumcised women in northern Ghana.
African Journal of Reproductive Health 2006;
- Berggren V, Ahmed M, Hermlund S, Johansson
E, Habbani B, Edberg AK. Being victims or
Beneficiaries? Perspectives on female genital cutting and
re-infibulation in Sudan. African Journal of
Reproductive Health 2006;
- Shell-Duncan B. Are there "stages of change" in
the practice of female genital cutting? Qualitative
research findings from Senegal and the Gambia. African
Journal of Reproductive Health 2006;
- Adeokun LA, Oduwole M, Oronsaye F,
Gbogboade AO, Aliyu A, Adekunle W, Sadiq G, Sutton I,
Taiwo M. Trends in female circumcision between 1933
and 2003 in Osun and Ogun States, Nigeria. A
cohort analysis. African Journal of Reproductive Health 2006;
- Finke E. Genital mutilation as an expression of
power structures: Ending FGM through education, empowerment of women and removal of
taboos. African Journal of Reproductive Health 2006;
- Snow RC, Slanger TE, Okonofua FE, Oronsaye
F, Wacker J. Female genital cutting in southern
urban and peri-urban Nigeria: self-reported validity,
social determinants and secular decline Trop Med Int
Health 2002; 7(1): 91-100.
- Okonofua FE Larsen U, Oronsaye F, Snow RC,
Slanger TE. The association between female genital
cutting and correlates of sexual and gynecological
morbidity in Edo State, Nigeria. British Journal of
Obstetrics and Gynecology 2002; 109, 1089-1096.
- Larsen U, Okonofua FE. Female circumcision
and obstetrics complications. International Journal
of Obstetrics and Gynecology 2002 Jun; 77 (3): 255-65.
- Slanger TE, Snow RC, Okonofua FE: The impact
of female genital cutting on first delivery in
southwest Nigeria. Studies in Family Planning 2002; 23(2):
173-184.
- WHO Study Group on Female Mutilation
and Obstetric Outcome. Female genital mutilation
and obstetric outcome: WHO collaborative study in
six African countries. Lancet 2006 June 3; 367
(9525): 1799-800.
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