Combating Female Genital Mutilation: What is the role of health policy? [Archives:2007/1084/Health]

September 10 2007

By: Sawsan Al-Refai
For Yemen Times

Female Genital Mutilation has since many decades been considered as a major challenge for human rights and women activists. In spite of many decades of studies and research as well as funds pouring into anti-FGM programming, the prevalence rates of this practice are still shocking. More than 100 million women and girls are estimated to have had FGM worldwide mainly in Africa.

The very slow reduction of practice rates compared to resources allocated to anti-FGM programmes has encouraged all stakeholders to pause for a moment in reflection on the past efforts. Evaluation of previous programs revealed significant gaps.

One main aspect of programming that was subjected to evaluation was the scope and approaches of anti-FGM programmes. It was found that many reports and studies have been produced to address the root factors maintaining FGM mainly tradition and socioeconomic structures of the communities where this practice is prevalent. Many programs have focused at community level on advocacy for girls and women empowerment and women rights considering that FGM is a practice that infringes most of the rights at stake including right to health. Nevertheless, lack of comprehensiveness when addressing FGM stood out as one of the main obstacles on the path of FGM programmes. Programmes that addressed all health, social and economical consequences of the practice and engaged all stakeholders particularly those who make decisions or influence opinions were those of higher and more sustained impact. There has been also much evidence that contextualizing work is vital in developing the messages against FGM. There are no blanket approaches or one messages that could be applied in all regions.

Because FGM practice in Yemen is considerably low at the national level, compared to other countries in Africa, it is expected that FGM programmes are of both limited scope and effect. There are no reliable data sources on how prevalent the practice is within and outside the traditional coastal locations where practice in some districts may exceed 90%. There is almost no data neither on how many girls are at risk of FGM, nor on the complications of the practice.

The current efforts exerted by the civil society organizations in target areas are much appreciated, however these efforts are being dissolved time after time due to dwindling resources, lack of policy level commitment, as well as absence of advocacy networks at local levels. Furthermore, anti-FGM campaigns in many cases are unfocused and go in different strategic directions with diverse target groups. Lack of coordination and of comprehensiveness has resulted in incomplete or contradicting messages to the communities. Consequently results were fragmented and not very long-lasting.

There is a lot to be told on the sociocultural dilemma in Yemen when addressing FGM, but my main concern in relation to the above, is the extent to which health policy makers and polices are involved in the processes of combating FGM in Yemen. Since FGM programmers globally are now moving towards a prioritized and comprehensive approach, what is Yemen's position on this? More precisely, where do our health officials stand on this?

If intended to be introduced into the list of health priorities, FGM would be expected to fill a very bottom slot on the list. It is expected, but it is not right. It is well known that the ministry of health is facing large-scale challenges in terms of lack of health infrastructure, lack of qualified staff and devastating rates of mortality and morbidity. We cannot say that there is an excuse for health policy makers to put FGM on the margin though. We do not do the FGM victims justice by just looking at the current numbers that may not reflect the true magnitude of the problem. In areas where this practice is prevalent such as governorates of Hodeidah, Mahra, and Hadrmout, there are some indicators that the practice is not decreasing. Moreover, there is some alarming news that the practice is spreading in areas where it did not exist before and that it is actually increasing in other places due to external and internal migration of refugee communities.

Why is the health argument behind FGM?. FGM is a health problem that has grave health consequences. FGM victims do not only suffer physically but also mentally and psychologically. FGM prevents their entire well-being. In a place with such a very high rate of maternal mortality like Yemen, strategies, policies, and planned programs can not give deaf ears to FGM when talking about reproductive health for example. Reliable evidence about the effect of FGM, of various types, on obstetric outcome is now available. Most recently, a Lancet article published in 2006 (issue 367), showed that women with FGM are significantly more likely than those without FGM to have adverse obstetric outcomes and that risk seem to be greater with more extensive FGM. The new evidence states that FGM health impact extends beyond the classical information we have.

Medicalization of FGM is another main point which deserves the attention of the health authorities. As literacy increases and as more health staff become available, communities where FGM practice are starting to use health staff (including midwives and trained traditional birth attendants) to perform FGM in an attempt to fulfill their religious and tradition requirements on one hand and prevent complications of infection and bleeding on the other. Despite the ministerial decree that was issues in 2001 which banned all health staff from performing FGM, yet studies report that in places like Hadrmout where people are of high income, health staff are tempted to perform FGM in return for generous financial incentives. Medicalization of FGM not only puts the whole accountability of health cadre at stake, but furthermore maintains the practice by dealing with the short term complications of FGM but not with the medium and long-term ones.

It is interesting to know that health is also used an argument to promote for the FGM practice. Many of those who believe in FGM spread the notion that the practice is beneficial for the sexual and reproductive health of girls and women and some go further than that by claiming that infant mortality is low among women with FGM. These false claims are unfortunately promoted for by religious and community leaders who usually have no medical or health knowledge.

Therefore, the argument that health policy makers should provide more attention to the issue is strong. It also entitles us to challenge the current trend of having civil society organizations that work in the field of women and human rights to carry the heavy burden. In communities with high illiteracy rates and strong traditional power relations, as is the case in most rural areas in Yemen, “rights” or “gender empowerment” messages against FGM may not be taken well as we may imagine. However a clear and committed “health” message may go through more easily, at least for the time being.

More attention should be provided to FGM from health policy makers. Attention does not mean words on workshop banners or headlines in newspapers but should translate into policies and plans. Health authorities should be committed to spread the correct health messages on FGM and support them with reliable data from the ground on the health consequences of FGM. It is a shame that medical students and young physicians do not even know this practice exists in Yemen. Reproductive health in medical curricula should be inclusive of this practice and health staff including traditional birth attendants should be trained on its negative consequences and on dealing with its complications. Moreover health staff should be monitored and medicalization of FGM should be seriously addressed.

There is great need for data on health consequences of FGM on mothers and infants to be accessed by and transmitted to all those who maintain the practice including community and religion leaders, mothers, local health staff, and men. On the other hand, traditional means of advocacy and communication should be revisited to incorporate clear health information on FGM. It will be stating the obvious to say that all the above should be accompanied with improved reproductive health services at community levels.

There should be some space for FGM on the health policy agenda, otherwise a day may come when it climbs up the priority list by necessity. We do not want that day to come.