Survey of Women's Opinions on Female Genital Mutilation (FGM) in Southeast Nigeria: Study of Patients Attending Antenatal Clinic.

BACKGROUND: Female genital mutilation is known to exist especially in many third world countries including Nigeria with many women being victims of this harmful practice and its complications. The practice is rife in Southeast Nigeria and efforts have been made to discourage it.
OBJECTIVE: To determine women's views on aspects of female genital mutilation and the prevalence among the study population.
METHOD: Women attending the antenatal clinics of two university teaching hospitals in Southeast Nigeria were interviewed by means of structured pre-tested interviewer- administered questionnaires. The data obtained were analysed using SPSS version 10.0 and the results expressed in descriptive statistics as percentages.
RESULTS: The prevalence of FGM was 42.1%. However, only 14.3% of the respondents circumcised their own daughters or showed willingness to circumcise their daughters indicating considerable reduction in uptake of the practice. A larger proportion (63.7%) would support legislation against FGM.
CONCLUSION: There is a high opinion against the practice of FGM in Southeast Nigeria, with the majority of the women showing support for legislation against it.

Introduction

Female Genital Mutilation (FGM) or female circumcision is one of those traditional practices whose origin can be traced to antiquity. Even though it was first discovered in Egyptian mummies about 200BC, it is practiced on all the continents of the world.12 However, the worst types of FGM are practiced in Sudan, Egypt, Mali, Ghana and Nigeria.3 All the four types of FGM are practiced in various areas of these geographical locations.

Various reasons have been given for the practice of FGM in these different geographical and cultural settings ranging from culture, religion to superstition.4

The international movement against FGM gained momentum in the past two decades.5 Global interest has continued to rise in various aspects of FGM with a recent World Health Organisation (WHO) collaborative study associating FGM with increased risk of adverse obstetric outcome.6

Studies have shown that the practice is still persisting in Nigeria despite an increased awareness and increased general negative attitude towards it.78 More importantly, the practice of FGM has been documented to be higher in the Southeast Nigeria than other parts.7

Some interventions, aimed at reducing prevalence and changing attitudes towards FGM in Southeast Nigeria have been innitiated.8 These include advocacy and mass media activities. The Ndukaku (Igbo word for ‘health is better than wealth’ of National Association of Women Journalists (NAWOJ) and Women Action Research Organisation (WARO) in Enugu State, Southeast Nigeria was designed to raise awareness of the possible negative effects of FGM, increase community dialogue about the practice, address cultural and socioeconomic issues that reinforce the practice, and mobilise community members to abandon the practice.8

As the campaign against FGM continues to gather momentum globally, researchers have focused mainly on the sociocultural, legal and clinical aspects of FGM.79 There has also been an increasing awareness among clinicians and human rights campaigners that understanding the motives behind the sociocultural elements of FGM may be an avenue towards abandonment of the practice.591011 Interestingly, this aspect of FGM is the least studied, more so in settings with documented high prevalence like Southeast Nigeria,7 hence the need for this study. Furthermore, as some states in Nigeria like Enugu State have enacted legislations against FGM, it is reasonable to assess the opinion of women for whom these things are being done.8

Subjects and Methods

Study Area

A cross-sectional survey was carried out among women attending the antenatal clinics at University of Nigeria Teaching Hospital, Enugu from 2nd to 20th February, 2009 and Anambra State University Teaching Hospital, Awka from 8th to 19th March, 2010. Anambra State University Teaching Hospital, Awka primarily serves Anambra state while University of Nigeria Teaching Hospital is a referral centre for the five states in the Southeast geopolitical zone of the country.

Sample size determination

The minimum sample size for the study was obtained using the previously reported prevalence of FGM from this environment with the following formula;12 n= p × (1- p) × (Z2/ d)2. This is same as n = Z2pq/d2 where Z=1.96 (coefficient of Z statistics for normal distribution table), p = prevalence from previous studies, q = 1-p, d = sampling error tolerated = 0.05.

Methods

The respondents were interviewed using structured pre-tested interviewer- administered questionnaires containing questions to obtain basic sociodemographic characteristics after obtaining their informed verbal consent. The questionnaire was pre-tested among antenatal patients in a private hospital at Enugu-Ezike in Enugu State. Questions related to awareness of the campaign against FGM, experience of FGM themselves, readiness to subject their daughters to FGM, awareness and experience of any complication associated with FGM were also asked.

Female genital mutilation or female circumcision as defined by World Health Organisation (WHO) - ‘all intended partial or total removal of the female external genitalia, or other injury to the female genitals for non-therapeutic purposes’ was applied.13 Legislation as contained in the questionnaire means the use of law to stop FGM and all these were explained to the respondents.

Data Analysis

Data was analysed using SPSS version 10.0. Results were presented in descriptive statistics as percentages. The parity of the respondents was expressed as follows: nulliparity= para 0, primiparity= para 1, multiparity= para 2 to 4, grandmultiparity= para 5 and above.

Results

There were 342 respondents. The mean age of the respondents was 31.5±9.7 (Range: 14-50) years. One hundred and thirteen (33.0%) of the respondents were nulliparous, 46 (13.5%) were primiparous, 88 (25.7%) were multiparous and 95 (27.8%) were grandmultiparous. Sixteen (4.6%) of the respondents had no formal education, forty (11.7%) had primary education while one hundred and two (29.8%) had secondary education. One hundred and eighty four (53.8%) had tertiary education.

Awareness of Campaign Against Female Genital Mutilation

Three hundred and thirty- two (97.1%) of the respondents were aware of campaign against female genital mutilation while only ten (2.9%) were not. One hundred and forty- four (42.1%) respondents had FGM, 157 (45.9%) did not while 41 (12%) did not know whether they had. Reasons for FGM (Table 1), prevalence of daughter circumcision (Table 2), prevalence of mother circumcision (Table 3) and reported negative effects of FGM on ‘circumcised’ respondents (Table 4) are also presented.

Table 1

Reason for FGM

Table 2

Prevalence of Daughter Circumcision

Table 3

Prevalence of Mother (Respondents’) Circumcision

Table 4

Reported negative effects of FGM on ‘circumcised’ respondents

Acceptance of Legislation Against FGM

Two hundred and eighteen (63.7%) of the total respondents would accept legislation against FGM while sixty-six (19.3%) would not. Forty-eight (17.0%) were not sure whether they would accept or not.

Discussion

The study was focused on women attending antenatal clinic with a mean age of 31.5±9.7 years. This is the reproductive age group so their opinion may well reflect the opinion of the target population for campaign against FGM.

Majority of the respondents (97.1%) were aware of the campaign against FGM. Abubakar, et al. (2004) reported 91.4% awareness among antenatal patients in their study at Aminu Kano Teaching Hospital Kano, Northern Nigeria.7 Prevention of promiscuity was the commonest reason among the respondents for the procedure followed by culture. This is not in keeping with the finding of Anuforo and colleagues (2004) who found culture/tradition as the most common reason.14 This shows a trend towards shift from blind adherence to culture to mother's own conviction. This is an important finding because practices based on individual conviction are easier to eradicate than those based on culture. The campaign against FGM may well be re-packaged to focus on convincing these women that non-practice of FGM does not have a direct relationship to promiscuity rather than its present emphasis on designating FGM as a bad culture. The implication of this is that advocacy campaigns should be stepped up with more emphasis on educating these women on the harmful effects of FGM. Another interesting finding is that 1.8% of the respondents viewed FGM as a means of aiding future childbirth. This erroneous impression they held despite being aware of the campaign against FGM means obviously that more work is needed to get the fact across to this group.

The prevalence of female circumcision among the respondents was 42.1% as against the finding of 53.0% by Adeokun, et al. (2006) in the Southwest Nigeria, 23.3% by Abubakar et al. (2004) in Kano and 53.2% found by Ugboma et al. (2004) in Port-Harcourt.5715

Forty-nine (14.3%) of the study population had circumcised or showed willingness to circumcise their daughters while Dare et al. (2004) found about 20% of their study population wanting to circumcise their daughters.16

Sexual dissatisfaction was the commonest reported negative effect (complication) of FGM (50%) while Abubakar et al. (2004) reported 25.7% of their study population with FGM having sexual dissatisfaction.7 Twenty two point four percent of those with complication reported difficult childbirth as against 8.6% reported by Abubakar et al. (2004).7 A good proportion (23.8%) of the respondents that had FGM reported feeling of incompleteness. This is important as previous studies did not highlight this aspect of FGM. The feeling of incompleteness has the potential of affecting the psyche of these women leading to feelings of physical violation and low self esteem. These may lead to psychosexual problems. This a new dimension that needs to be highlighted by campaigners against FGM.

It is heart-warming to note that majority of the respondents (63.7%) were ready to support legislation against FGM.

The limitations of this study include the over-representation of women with tertiary education (53.8%) which does not reflect the overall female literacy level of 43.7% in Nigeria.17 This may be because women with tertiary education are more likely to utilise tertiary health facility.

In conclusion, FGM viewed by the medical profession and current civilization as injurious to the female gender is still practiced in the Southeast Nigeria. However, there is a high opinion against the practice in the area with the majority of the women showing support for legislation against it. The practice of FGM may be showing a downward trend as prevalence of daughter circumcision is much lower than that among the respondents. Efforts should be redoubled towards advocacy against this ugly practice.