Despite legislative and other efforts to reduce the prevalence of female genital cutting (often called female circumcision), the practice persists throughout western Africa, although its frequency varies widely among countries, a multinational study indicates.1 From 2% to 94% of women in the 10 study countries had been circumcised, while 1–64% had had at least one daughter undergo the procedure. Women who were older, uneducated, currently or previously married, or Muslim were generally more likely than other women to have been circumcised and to have had their daughters circumcised. In most countries, more than 25% of women believed that the practice should continue.
A deeply rooted tradition that is often practiced in unsanitary conditions and without anesthesia, female genital cutting can lead to reproductive health problems, psychological trauma, and even maternal and infant death. To determine the frequency of the practice and identify the populations most at risk, investigators examined data from countries that participated in the third round of the Multiple Indicator Cluster Survey between 2005 and 2007. Using a two-stage, stratified design, the survey systematically sampled households in urban and rural areas of Burkina Faso, Côte d’Ivoire, The Gambia, Ghana, Guinea-Bissau, Mauritania, Niger, Nigeria, Sierra Leone and Togo; sample sizes ranged from 5,890 to 24,566. The survey asked all women aged 15–49 in each household whether they had been circumcised, had had any of their living daughters circumcised and thought the practice should continue. Analyses were performed separately for each country and controlled for age, educational level, marital status, household wealth and religion.
A total of 106,016 women were interviewed. More than half of the women from each country were 15–29 years old (53–62%), and most respondents from Burkina Faso, Côte d’Ivoire, The Gambia, Guinea-Bissau, Niger and Sierra Leone had never attended school (53–84%). In every country but Côte d’Ivoire, the majority of women were married (59–86%); the proportion of Muslims ranged from 14% to 99%.
The prevalence of female genital cutting varied widely among countries: It was very high in Sierra Leone (94%), The Gambia (79%), Burkina Faso (74%) and Mauritania (72%), but low in Togo, Ghana and Niger (2–6%). Among daughters, genital cutting was most prevalent in The Gambia and Mauritania (64% each), and least prevalent in Togo, Ghana and Niger (1% each). In only three countries—Mauritania, The Gambia and Sierra Leone—did the majority of women support the continuation of female genital cutting (59–88%). The lowest rates of support (4–11%) occurred in the three countries where genital cutting was least common: Ghana, Niger and Togo. Nevertheless, in six of the 10 countries, more than 25% of women believed that female circumcision should continue.
In every country, the proportion of women who had undergone genital cutting was greater than the proportion who had had their daughters circumcised, suggesting that the prevalence of genital cutting may be waning. However, in most countries, the proportion of women who thought that the practice of female genital cutting should continue exceeded that of women who had had their daughters circumcised; the exceptions were Burkina Faso and Mauritania, both of which have banned the practice.
In multivariate analyses, women who were older, had no formal education, were currently or formerly married, or were Muslim tended to have elevated odds of having been circumcised or of having had a daughter circumcised. For example, in about half of the countries, women aged 35–39 were more likely than those aged 15–19 to have been circumcised (odds ratios, 2.1–4.3), or to have had their daughters circumcised (2.5–20.0); in nine countries, women with some degree of education were generally less likely than uneducated women to have been circumcised, to have had their daughters circumcised, or both (0.2–0.7). The main exception to these trends was The Gambia, where older women were less likely than 15–19-year-olds to have been circumcised (0.6–0.8), and where (along with Burkina Faso) education was not linked with mothers’ circumcision. However, in Nigeria, education was positively linked with circumcision among both women and daughters (2.1–3.9). Wealth was inconsistently associated with genital cutting. For example, the risk for both women and daughters was greater in the wealthiest households than in the poorest ones in Burkina Faso (1.7 for each) and Nigeria (2.8–3.1), but in six countries the risk for mothers, daughters or both was lower in the wealthiest households than in the poorest. Finally, in most countries, women who were older, educated, married and wealthy tended to be less likely than others to believe that female genital cutting should continue.
The investigators acknowledge several limitations to their study. The multivariate analyses included only characteristics for which data were available for all countries, which limited the researchers’ ability to identify factors associated with female genital cutting. Social desirability or recall bias may have influenced participants’ responses; for example, women may have underreported circumcision and their support for it, especially in countries where the practice is illegal. Moreover, practices and beliefs may have changed since the data were collected. Finally, analyses did not consider the types of genital cutting that participants had experienced.
As the investigators conclude, however, understanding national variations in female genital cutting practices and attitudes “is particularly important” for tailoring interventions to curb the procedure. They suggest a multifaceted strategy that combines community education and awareness, support from prominent groups and practitioners, and enforced legislation to help reduce the practice while preserving communities’ cultural identities and social values. “Such concerted societal commitments are necessary for the benefit of future generations of women and girls,” they note.—A. Kott
1. Sipsma HL et al., Female genital cutting: current practices and beliefs in western Africa, Bulletin of the World Health Organization, 2012, 90(1):120–127.