Engaging health workers to help end female genital mutilation

Engaging health workers to communicate on female genital mutilation (FGM) is a useful and effective tactic to prevent this harmful practice, according to a recently published study.

FGM, which includes any injury to female genitals for non-medical reasons, has serious health risks for women and girls, and is internationally recognized as a violation of human rights. While the health system can play a key role in stopping the practice, in some settings so-called "FGM medicalization" - when it is performed by health workers - is on the rise.

WHO is strongly opposed to health professionals performing FGM. As well as urging all health workers to uphold the medical code of ethics to "do no harm", and thereby reject such requests to preform FGM, it is also working with health systems to provide proactive health education about its immediate and long-term risks for women and girls.

A joint statement by United Nations' agency heads, including WHO Director-General, Dr Tedros Adhanom Ghebreyesus, commended a recent decision in the Republic of the Gambia not to overturn a ban on the practice, but also emphasized the importance of continued efforts in prevention. Engaging health workers will be a critical part of this approach.

"Recent months have emphasized the need for continued advocacy to advance gender equality, end violence against girls and women, and secure the gains made to accelerate progress to end FGM," they stated. "It also underscores the importance of engaging with communities and grassroots organizations, working with traditional, political, and religious leaders, training health workers, and raising awareness effectively on the harms caused by the practice."

In 2022, the World Health Organization published a FGM prevention training package for primary care health workers which strengthened their knowledge about the practice and its risks, while encouraging them to engage positively with communities and patients. The curriculum included interactive teaching methods such as storytelling, group discussions, values clarification exercises, and communication skills-building - all intended to sensitively consider the cultural context and local perspectives.

The new research, published in BMJ Open, evaluated the effectiveness of this approach. The study was conducted in 180 antenatal care clinics in Guinea, Kenya and Somalia. These countries were selected because of their high national prevalence of FGM including high rates of medicalization. Every clinic received general guidance and materials on FGM prevention and care, while half were randomly assigned to receive WHO's communication training at three months.

Three months later, researchers returned to all clinics to collect data from health workers and clients. Health workers who received the training were more likely to ask about clients' FGM status and beliefs, as well as discuss why or how it should be prevented. The results were encouraging; clients of workers who had undergone the training were less supportive of FGM overall and had lower intentions of having their own daughters undergo the practice.

Interviews were also conducted at some of the clinics providing pregnancy services. These showed that most health workers and clients were satisfied with how the topic was discussed, and that they felt it was appropriate to do so in this setting.

A health worker from Guinea told the researchers, "Because of this training, I am now able to raise women's awareness [of FGM] and persuade them about the ... disadvantages." Similarly, one client in Kenya, speaking to the researchers about her experience, described the encounter positively. "I feel that our discussion today was very important, it has helped me understand a lot," she said. "When I get home, I will sensitize others about FGM."

"The study shows clearly that health workers in primary care settings can be influential opinion leaders in changing attitudes on FGM," said senior study author Christina Pallitto, Scientist at WHO and the Human Reproduction Programme (HRP). "Engaging nurses and midwives should be a key element of prevention and response to FGM. Using this approach can help highly affected countries like The Gambia to prevent medicalized FGM as part of broader efforts to end the practice and protect the health of women and girls."

The papers were published in BMJ Open (https://bmjopen.bmj.com/content/14/7/e078771.full) and Global Public Health (https://www.tandfonline.com/doi/full/10.1080/17441692.2024.2369100).9