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.