Using electronic maternity records to estimate female genital mutilation in Lothian from 2010 to 2013

Female Genital Cutting and Deinfibulation: Applying the Theory of Planned Behavior to Research and Practice

At least 200 million girls and women across the world have experienced female genital cutting (FGC). International migration has grown substantially in recent decades, leading to a need for health care providers in regions of the world that do not practice FGC to become knowledgeable and skilled in their care of women who have undergone the procedure. There are four commonly recognized types of FGC (Types I, II, III, and IV). To adhere to recommendations advanced by the World Health Organization (WHO) and numerous professional organizations, providers should discuss and offer deinfibulation to female patients who have undergone infibulation (Type III FGC), particularly before intercourse and childbirth. Infibulation involves narrowing the vaginal orifice through cutting and appositioning the labia minora and/or labia majora, and creating a covering seal over the vagina with appositioned tissue. The WHO has published a handbook for health care providers that includes guidance in counseling patients about deinfibulation and performing the procedure. Providers may benefit from additional guidance in how to discuss FGC and deinfibulation in a manner that is sensitive to each patient's culture, community, and values. Little research is available to describe decision-making about deinfibulation among women. This article introduces a theoretically informed conceptual model to guide future research and clinical conversations about FGC and deinfibulation with women who have undergone FGC, as well as their partners and families. This conceptual model, based on the Theory of Planned Behavior, may facilitate conversations that lead to shared decision-making between providers and patients.

Improving care for women and girls who have undergone female genital mutilation/cutting: qualitative systematic reviews

Background

In a context of high migration, there are growing numbers of women living in the UK who have experienced female genital mutilation/cutting. Evidence is needed to understand how best to meet their health-care needs and to shape culturally appropriate service delivery.

Objectives

To undertake two systematic reviews of qualitative evidence to illuminate the experiences, needs, barriers and facilitators around seeking and providing female genital mutilation-/cutting-related health care from the perspectives of (1) women and girls who have experienced female genital mutilation/cutting (review 1) and (2) health professionals (review 2).

Review methods

The reviews were undertaken separately using a thematic synthesis approach and then combined into an overarching synthesis. Sixteen electronic databases (including grey literature sources) were searched from inception to 31 December 2017 and supplemented by reference list searching. Papers from any Organisation for Economic Co-operation and Development country with any date and in any language were included (Organisation for Economic Co-operation and Development membership was considered a proxy for comparable high-income migrant destination countries). Standardised tools were used for quality appraisal and data extraction. Findings were coded and thematically analysed using NVivo 11 (QSR International, Warrington, UK) software. Confidence in the review findings was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation – Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach. All review steps involved two or more reviewers and a team that included community-based and clinical experts.

Results

Seventy-eight papers (74 distinct studies) met the inclusion criteria for both reviews: 57 papers in review 1 (n = 18 from the UK), 30 papers in review 2 (n = 5 from the UK) and nine papers common to both. Review 1 comprised 17 descriptive themes synthesised into five analytical themes. Women’s health-care experiences related to female genital mutilation/cutting were shaped by silence and stigma, which hindered care-seeking and access to care, especially for non-pregnant women. Across all countries, women reported emotionally distressing and disempowering care experiences. There was limited awareness of specialist service provision. Good care depended on having a trusting relationship with a culturally sensitive and knowledgeable provider. Review 2 comprised 20 descriptive themes synthesised into six analytical themes. Providers from many settings reported feeling uncomfortable talking about female genital mutilation/cutting, lacking sufficient knowledge and struggling with language barriers. This led to missed opportunities for, and suboptimal management of, female genital mutilation-/cutting-related care. More positive experiences/practices were reported in contexts where there was input from specialists and where there were clear processes to address language barriers and to support timely identification, referral and follow-up.

Limitations

Most studies had an implicit focus on type III female genital mutilation/cutting and on maternity settings, but many studies combined groups or female genital mutilation/cutting types, making it hard to draw conclusions specific to different communities, conditions or contexts. There were no evaluations of service models, there was no research specifically on girls and there was limited evidence on psychological needs.

Conclusions

The evidence suggests that care and communication around female genital mutilation/cutting can pose significant challenges for women and health-care providers. Appropriate models of service delivery include language support, continuity models, clear care pathways (including for mental health and non-pregnant women), specialist provision and community engagement. Routinisation of female genital mutilation/cutting discussions within different health-care settings may be an important strategy to ensure timely entry into, and appropriate receipt of, female genital mutilation-/cutting-related care. Staff training is an ongoing need.

Future work

Future research should evaluate the most-effective models of training and of service delivery.

Study registration

This study is registered as PROSPERO CRD420150300012015 (review 1) and PROSPERO CRD420150300042015 (review 2).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Crossing cultural divides: A qualitative systematic review of factors influencing the provision of healthcare related to female genital mutilation from the perspective of health professionals

INTRODUCTION

As a result of global migration, health professionals in destination countries are increasingly being called upon to provide care for women and girls who have experienced female genital mutilation/cutting (FGM/C). There is considerable evidence to suggest that their care experiences are sub-optimal. This systematic review sought to illuminate possible reasons for this by exploring the views, experiences, barriers and facilitators to providing FGM-related healthcare in high income countries, from health professionals' perspectives.

METHODS

Sixteen electronic databases/resources were searched from inception to December 2017, supplemented by reference list searching and suggestions from experts. Inclusion criteria were: qualitative studies (including grey literature) of any design, any cadre of health worker, from OECD countries, of any date and any language. Two reviewers undertook screening, selection, quality appraisal and data extraction using tools from the Joanna Briggs Institute (JBI). Synthesis involved an inductive thematic approach to identify descriptive themes and interpret these into higher order analytical constructs. Confidence in the review findings was assessed using GRADE-CERQual. The review protocol was registered with PROSPERO (CRD420150300042015).

RESULTS

Thirty papers (representing 28 distinct studies) from nine different countries were included. The majority of studies focused on maternity contexts. No studies specifically examined health professionals' role in FGM/C prevention/safeguarding. There were 20 descriptive themes summarised into six analytical themes that highlighted factors perceived to influence care: knowledge and training, communication, cultural (mis)understandings, identification of FGM/C, clinical management practices and service configuration. Together, these inter-linked themes illuminate the ways in which confidence, communication and competence at provider level and the existence and enactment of pathways, protocols and specialist support at service/system level facilitate or hinder care.

CONCLUSIONS

FGM/C is a complex and culturally shaped phenomenon. In order to work effectively across cultural divides, there is a need for provider training, clear guidelines, care pathways and specialist FGM/C centres to support mainstream services.