Health Science Journal

Keywords

Female genital cutting; Sampling technique; Health science

Introduction

Female Genital Cutting (FGC) is a destructive, invasive procedure that cuts away part or all of the external female genitalia before puberty [1]. Internationally, it is recognized as a violation of the human rights of girls and women [2]. In spite of the international community’s commitment to make a zero tolerance of FGC; it is undermining the well-being of 3 million girls annually [3].

Globally, more than 130 million women have undergone FGC and 125 million women recently alive have been cut in countries where female genital mutilation is concentrated (Africa and Middle East) [2,4]. If current situations are not addressed, by 2030 more than 15 million additional girls between ages 15 and19 might be subjected to FGC [5].

In Africa and Middle East countries, FGC remain a public health burden with its immediate and long term complication of shock, sepsis, urine retention, tetanus, infertility and child birth complication and new born deaths [3,4]. It has been performed by traditional circumcisers, birth attendants, grand mother and father, traditional healer and health care providers (midwives, nurses, doctors) [6-10]. The studies revealed that, attitudes and perception of the communities, women and health care providers about female genital mutilation is remain a big challenge in eliminating its practice in developing countries [7-11].

In Ethiopia, female genital mutilation has been practiced in different ethnic group for long period of time for the reasons of hygienic purposes, to avoid stigma of not being circumcised and maintaining cultural norms [10,12].

However, these all challenges to avoid female genital mutilation can be resolved by identifying the root cause in the specific society. Little is known about the female genital mutilation in Hababo Guduru district; understanding this will help police makers, stakeholders and program planners to eliminate FGC in the study area. Hence, this study provides information about why female genital cutting is remaining high in Hababo Guduru district, western Ethiopia.

Methods

Study area and population

Hababo Guduru is one of the districts in the Oromia national regional state of Ethiopia. It is one of the districts in Horro Guduru Wallaga Zone located in western parts of the country. The study area was about 303 kms far away from the capital city of Ethiopia, Addis Ababa. There are 13 kebeles in Hababo Guduru district. The 2007 national census of Ethiopia reported that, total populations of this district were 45,325, of whom 22,744 were male and 22,581 were female. The majority (42.15%) of the inhabitants was Ethiopian Orthodox Christianity, 40.19% were Protestant, and 16.93% were traditional beliefs [13]. According to information obtained from Hababo Guduru health office in May, 2014, the total numbers of the district mothers (15-49 years old) were 9867 and the total numbers of under 15 daughters were 12,893.

Study design and period

A community based ethnographic study design was conducted to determine why female genital mutilations remain high in Hababo Guduru district, western Ethiopia.

Source and study population

All traditional circumcisers, religious leaders, health extension workers, women affair officers, elder mother and father in Hababo Guduru district were considered as source population and those who are in the selected kebeles and available during data collection period of three successive weeks were considered as study population.

Sample size determination and sampling procedure

Sample size was determined during data collection based on the saturation point. Saturation point was made after 65 key informants (traditional circumcisers, religious leaders, health extension workers, women affair officers, elder mother and elder father) were interviewed. Among thirteen kebeles of Hababo Guduru district, three kebeles were randomly selected by lottery method. Then after, purposive sampling technique was applied to select key informants. Regardless of inclusion criteria, anyone who was supposed to give important information was interviewed.

Data collection instruments and analysis

Unstructured interviewer and interviewer administered guide line was used to collect data. Relevant literature was reviewed to develop the instrument and to include all the possible variables that address the objective of the study [2-4,7-12,14-17]. The interview guide line was prepared in English by investigators and translated in to local language, Afan Oromo. The interview guide line comprised different parts such as type of FGC they has been conducting, reasons of female genital cutting and their attitude towards female genital cutting.

The instrument was pre-tested on 8 respondents in Motuma kankegna district. Findings from the pre-test were used to modify the instrument. There were five data collectors and two supervisors. Supervisors’ were Oromo folklore degree holders and data collectors were health extension workers. All data collectors were female to maximize response rate since mothers are more freely talk about FGC with females than males. Before the actual work, both data collectors and supervisors were given one day training about the aim of the study, procedures, and data collection techniques by going through the questionnaires.

Based on their permission, voices of key informants was recorded by tape recorder, transcribed, imported to open code version 4.02 then data was coded and organized. Thematic data analysis was employed in analyzing and interpreting the raw data.

Ethical consideration

Ethical clearance was obtained from research ethical review committee of institute public health, collage of medicine and health science, University of Gondar in order to obtain permission letter. Verbal consent was obtained from each participant prior to data collection.

Results

Sixty five key informants (eighteen traditional circumcisers, twelve religious leaders, six health extension workers, twelve elder mothers, eleven elder fathers and six women affair officers) were selected purposively for in-depth interview. Thirty five of the key informants were female. The mean age of key informants were 50.8+14.7 years.

More than 81% of key informants have negative attitude towards FGC. Fifty three of them were interested with the continuation of FGC. One elder father whose age was 61 stated that:” FGC shall be continued since it is our culture. It saves daughters from insult, it is used to reduce sexual desire, maintain virgin and avoid shame”.

Among 65 respondents 18 of them were traditional circumcisers. All traditional circumcisers have negative attitude towards FGC. One of the main reasons for why these groups of cohort were participated on FGC was considering it as means of income. Traditional circumcisers whose ages were 63 and 60 said that: “FGC serve me as a means of income and “It is one means of income for me” respectively. All traditional circumcisers cut only clitoris (type I). Eighteen of them stated that: “But the type of circumcision what I have conducting is very simple, I remove only the tip of clitoris”. “Unlike that of the previous circumcision the current is just to fill the formality which is very simple, now I remove only clitoris by using blade”. “The type of FGC what I have conducted is type one”.

The main reason for conducting FGC was to respect tradition, to avoid shame, to maintain virgin, to reduce sexual desire, and for hygiene. One elder woman whose age was 58 stated that: “Circumcised daughters are traditionally accepted, respect person, maintain her virginity, free of shame and clean.

The present study reports, religion is negatively associated with FGC. Protestant religion followers were advised in order not to circumcise their daughters. Protestant religion leader was said that: “Protestant religion acts on FGC negatively. We are highly working on it to avoid the practice. Awareness was given in the church for protestant followers from time to time. Due to this protestant followers were not highly circumcise their daughters as compared to other religion followers. The society trust what is said in the church than other place. So protestant religion plays significant role on the decrement of FGC practice”.

Even though legislation against FGC was made, it was not successfully enacted as required in the study area due to different reason. Women affair officers stated that: “Women’s affair is working with health extension worker taking FGC as important agenda to avoid or reduce FGC to the required level. But we cannot successfully do it since the practice is highly linked with culture and tradition. Even though eradication is difficult, currently FGC is significantly decreasing due to announcing the community as FGC is illegal. Majority of the society considers it as a good tradition and being left without it is completely impossible. Society has negative attitude towards it. To change the attitude of them great efforts are needed”.

Health extension workers were highly working on this agenda as compared to other as a result to some extent the prevalence is decreasing. One health extension worker whose age was 29 said that: “Efforts were made to combat circumcisions by health extension workers. We have taken different intervention to avoid this practice. If we see women who are circumcising daughters, first we advise them by telling the ill effects of it, and then warning if she continues to practice, at the end punishment will be made if she refused to stop circumcision. Since 2008 efforts were made to give awareness about the ill effects of FGC. This was made by collecting peoples in to one area and giving health education for them. Health extension workers also give advice by going home to home. Even though, different methods were made, FGC is still practiced but somewhat decreasing”.

One traditional circumciser whose age was 53 said that: “The average age at which circumcision conducted is 8 or 9 years, conducting it much less than or much greater than 8 have its own consequence”.

Discussion

Women’s affair officer’s stated that: “Even though eradication is difficult, currently FGC is significantly decreasing due to announcing the community as FGC is illegal saying this doesn’t mean that only criminalizing the practice is enough, rather it is better to have another technique which can support this for instance by creating awareness in the community about the ill effects of FGC. This means in another way round the ignorance of community about the ill effect of FGC is the main principal factor for the continual of this harmful traditional practice (FGC)”.

Even though no religious scripts state FGC as religious requirement, some people relate FGC to Islamic religion [14]. On the contrary, the current data reports that, FGC was not religious requirement. Since, none of the religious scripts order this practice. Even some religions are giving contribution on elimination of FGC. Protestant religion leader stated that: “FGC is not religion requirement for protestant; we are negatively acting on FGC. We have advised the religious followers in order to not circumcise their daughters by stating the health problems which are caused by FGC. Many protestant were not refused to stop FGC since the message was from religious leaders”. Except protestant religion the rests are kept silent and some of them are standing beside the culture to make FGC more prevalent. But in Kenya particularly in the south Nyanza region (kuria and kisii) seventh day Adventist church is playing a significant role to end FGC [15].

The current study reveals that, the FGC is only conducted by traditional circumciser. One health extension worker stated that “FGC is only conducted by traditional circumciser and nobody brings his/her daughters to the health facility for FGC purpose. Currently the society is prevalently conducting this harmful practice in hidden. Because of this we (health extension workers) can’t fully control this practice and this makes FGC highly prevalent and everlasting unless the communities are convinced about the ill effects of FGC”.

The common reason of conducting circumcision for traditional circumcisers was to get income. This is also true for circumcised daughters; the circumcised daughters get money from her relatives when she is circumcised. This is also another factor which motivates the daughters to undergo FGC. This finding is also in line with different studies and reports [15,16].

The current finding stated that, blade is the only instrument used for circumcision currently. Some of the circumciser from the key informants were stated that, “knife was the type of instrument used for FGC when they were circumcised. But currently blade is the only instrument which is used for this purpose. Even if type II and III FGC were rarely practiced in the past four decades, but now this is totally avoided and we are conducting only type I by using blade”.

In the current study, the most common reasons for conducting FGC were: to decrease the sexual desire of their daughters, to avoid shame, and to prepare daughters for marriage: these are the most frequently stated reason by the key informants. If the daughters are not circumcised, they lost their virginity before marriage. The sexual desire of uncircumcised daughters is very high as a result they need opposite sex whoever he is to fulfill their interest. And when the daughters are married without virgin her family feels a great shame. One mother from the key informants said that:” Whatever the case I can’t leave my daughters without circumcision. Since, I would like to be free of shame at the day of wedding”. Similar reasons also stated by different studies [15-17].

One elder mother stated that “Even circumcised boys insult our daughters if they are left without circumcision. The community uses different word to insult the uncircumcised daughters. The word “qanxaram” is the common word to insult the uncircumcised daughters. Even if the family agrees to uncut their daughters, the daughters are not agreeing to be left without circumcision in order to save themselves from insulting, labeling-name like qanxaram, isolation and shame”. Study conducted in Tanzania [16] also put similar reasons.

The other main principal factor for continual of FGC is cultural perspective. The current study shows that, FGC is a mandatory action to be acceptable by the society and it is the main criteria for the local culture. Uncircumcised women have no room in the society to participate in any kind of social life. They are also not eligible to be asked for marriage, to give a birth, to be treated/respected equally like their counter parts. This and the like wrong attitudes provide a hope for this harmful traditional practice (FGC) to be practiced forever in the community. Culture is renewable fuel for conducting FGC unless the immediate action is taken on it in addition to the making FGC illegal. Since information about female genital cutting was obtained from key informants through interview, social desirability bias is the potential limitations of this study. However, numerous scientific procedures have been employed to minimize the possible effects. To reduce the response bias, for instance, detail about the aim of the study was shared with the key informants.

Conclusion and Recommendations

Female genital mutilation has no religious requirement since; none of the religious scripts order this practice. The current study reveals that, the FGC is only conducted by traditional circumciser. In addition, the most common reasons for conducting FGC were: to decrease the sexual desire of their daughters, to avoid shame, and to prepare daughters for marriage. Hence, programs made based up on giving attention on traditional circumcisers and giving awareness about the negative side effect of FGC for community through religious leaders will be efficient and effective. Moreover, providing the health education concerning to the disadvantages of FGC is strongly recommended.

Limitations of the study

This study was not supplemented with quantitative method of data collection. Similarly, social desirability bias was the potential limitation of the current study.

Competing Interests

The authors declare that they have no competing interests.

Authors’ Contributions

Gajaa M, Kebede Y, Derseh L, participated in the design of the study, data collection, analyzed the data and drafted the paper. Wakgari N participated in the analysis, drafted and revised subsequent drafts of the paper. All authors read and approved the final manuscript.

Acknowledgements

We are grateful to the University of Gondar for technical and financial support. We would also like to thank the data collectors and study participants.

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