Health Care for Women International
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Female Genital Mutilation (FGM): Australian Midwives’ Knowledge and Attitudes Olayide Ogunsiji To cite this article: Olayide Ogunsiji (2015) Female Genital Mutilation (FGM): Australian Midwives’ Knowledge and Attitudes, Health Care for Women International, 36:11, 1179-1193, DOI: 10.1080/07399332.2014.992521 To link to this article: http://dx.doi.org/10.1080/07399332.2014.992521
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Date: 08 November 2015, At: 17:43
Health Care for Women International, 36:1179–1193, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.992521
Female Genital Mutilation (FGM): Australian Midwives’ Knowledge and Attitudes
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OLAYIDE OGUNSIJI School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
Female genital mutilation (FGM) is a women’s health and human rights issue attracting global interest. My purpose in this qualitative study was to report the knowledge and attitudes of Australian midwives toward FGM. Verbatim transcription and thematic analysis of semistructured interviews with 11 midwives resulted in these themes: knowledge of female genital mutilation and attitude toward female genital mutilation. Significant gaps in knowledge about FGM featured prominently. The midwives expressed anger toward FGM and empathy for affected women. Recommendations include increased information on FGM and associated legislation among midwives and other health providers in countries where FGM may be encountered. Increasing international migration has contributed to movement of women living with female genital mutilation (FGM) to other parts of the world, creating a peculiar health care challenge in the area of gynecological and obstetric care. This is particularly so in developed countries, where some health care providers find care provision for affected women both challenging and confronting. In this study, I explored the knowledge and attitude of Australian midwives caring for women living with FGM. This article is part of a larger qualitative study that explored meaning of care and care-giving experiences of Australian midwives who are caring for women with FGM. The researcher believes that FGM is a public health issue that needs attention from research community, midwives, women and children health nurses, and other health care providers as well as child welfare workers, counsellors, criminal justice,
Received 26 November 2013; accepted 19 November 2014. Address correspondence to Olayide Ogunsiji, School of Nursing and Midwifery, University of Western Sydney, Building G10, Room 62, Hawkesbury Campus, Locked Bag 1797, Penrith, NSW 2751, Australia. E-mail: [email protected] 1179
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and educators not only in Australia but also in other countries where FGM might be encountered.
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BACKGROUND FGM, also known as female circumcision or female cutting, refers to a range of procedures intended at partial or total removal of the female genital organs for nontherapeutic reasons (Ball, 2008; Garba, Muhammed, Abubakar, & Yakasai, 2012). The practice is widespread and according to the World Health Organization (WHO, 1998), it was estimated that between 100 million and 140 million females have undergone some kind of female genital cutting with an annual incidence of 3 million (Zenner, Liao, Richens, & Creighton, 2013). It is practiced in the Arabian Peninsula and Asia; however, female circumcision is most common in Africa, with more than 70 million of the affected women coming from this continent (Nour, 2008; WHO, 1998). FGM is practiced in more than 28 African countries, with a prevalence rate between 5% and 95% (Ball, 2008; Watson, 2005). There are four typologies depending on the intensity of the injury. The first type is called clitoridectomy, which is the partial or total removal of the clitoris, and the second type is called excision, which is the partial or total removal of the clitoris and the labia minora with or without excision of the labia majora (Lundberg & Gerezgiher, 2008; Ogunsiji, Wilkes, & Jackson, 2007). The third type is referred to as infibulation, which is the narrowing of the vaginal opening through the creation of a covering seal, and the fourth type includes all other harmful procedures to the female genitalia for nonmedical reasons such as pricking, piercing, incising, scraping, and cauterizing the genital area (Lundberg & Gerezgiher, 2008; Ogunsiji et al., 2007; WHO, 2006). The practice is associated with a number of physical, sexual, and psychological effects (Toubia, 1994; Utz-Billing & Kentenich, 2008). Physical complications of the practice include urinary tract infection, anemia, sepsis, and bleeding, while, psychologically, circumcised women are at greater risk of psychiatric and psychosomatic symptoms (Utz-Billing & Kentenich, 2008). In an empirical qualitative study of 10 African women giving birth in Brisbane, Australian researchers reported the women’s experience of embarrassment and shame, with the feeling of being different in terms of their genitalia (Murray, Windsor, Parker, & Tewfik, 2010). Predominant among the reasons proffered for FGM is the associated cultural meaning it holds for affected women in the sense that it is linked to women’s sexuality and a way of preparing women for marriage (Toubia, 1994; Utz-Billing & Kentenich, 2008). Due to migration, an increasing number of women affected by FGM are moving to other parts of the world where awareness of the practice is
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limited. This migration pattern has created a health care challenge particularly in the area of gynecological and obstetric care in developed countries such as the UK (Ball, 2008), U.S. (Watson, 2005), and Sweden (Litorp, Franck, & Almroth, 2008). Africans are an increasing migrant population in Australia. The challenge faced by Australian midwives in terms of knowledge and attitudes toward the practice, however, is yet to be reported. According to the Australian Bureau of Statistics (ABS, 2009), a total of 248,699 people born in Africa were living in Australia, constituting a 50% increase when compared with 147,876 in 1996. As the number of African immigrants to Australia increases, health care providers will be required to service the gynecological and obstetric health care needs of the African women, some of whom might have limited information about the practice. In supporting midwives and other health care providers in meeting these women’s health needs, it is important to determine their knowledge and attitudes toward FGM. My focus in this article is on the knowledge and attitudes of Australian midwives caring for women living with FGM.
Knowledge and Attitudes About FGM Gross deficits in knowledge about FGM in Western countries are reported in the literature (Carolan & Cassar, 2010; Chalmers & Omer-Hashi, 2002; Murray et al., 2010; Zaidi, Khalil, Roberts, & Browne, 2007). Significant gaps were identified in theoretical knowledge and practice among health care providers caring for migrant women living with the consequences of FGM in their new countries. Findings from a survey of 45 health care providers in the United Kingdom revealed areas of knowledge deficit (Zaidi et al., 2007). Only 40% (18) of the health care providers who participated in the study at a University Teaching Hospital were familiar with the FGM Act of 2003; 58% (26) could not list the different types of FGM (Zaidi et al., 2007). Similar findings were reported from a randomized sample of 600 certified nurse–midwives who participated in a quantitative study to determine their experience of caring for circumcized women in the United States of America (Hess, Weinland, & Saalinger, 2010). There was a knowledge deficit among the U.S. nurse–midwives in legal and cultural issues that surrounded FGM. While the areas of knowledge deficit are identified in the literature among health care providers in United Kingdom (Zaidi et al., 2007) and the United States (Hess et al., 2010), the situation in Australia is not known. Identifying this information is important in developing appropriate educational support initiatives. Limited literature is available internationally on the attitudes of health care providers toward FGM (Leye et al., 2008; Onuh et al., 2006; Relph, Inamdar, Singh, & Yoong, 2013), and with the exception of Ali (2012) there is paucity of empirical studies of midwives’ attitudes toward the practice.
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Literature on both health care providers generally and midwives specifically revealed positive attitudes. Ali (2012) conducted a quantitative study about the attitudes of 157 Eastern Sudan midwives between June 2012 and July 2012 and reported 76.4% of the respondents were of the opinion that some forms of FGM are not harmful and 74.5% considered FGM as a legal practice, suggesting a positive attitude. Contrary to the African study, only a third of the 334 Flemish gynecologists were discouraging women with previous FGM from circumcising their daughters (Leye et al., 2008), and many of these gynecologists were in support of medicalization of FGM. Not only this, 13.9% of the 79 health care providers who responded to a questionnaire gauging attitude toward FGM in inner-city London agreed that competent adults should be allowed to consent to FGM (Relph et al., 2013). Despite the intense international attention to the harmful practice of FGM, a large group of health care workers in Africa and some Western countries still have a positive attitude toward the practice. The attitude of Australian midwives toward FGM needs to be captured in targeting education interventions. Globally, the positive attitude of some health care providers toward FGM suggests the need to devote some attention to the attitude of health care providers too in efforts at eradicating FGM. The aim of this article is to provide insight into the knowledge and attitude of Australian midwives toward FMG.
METHODS I report in this article part of the findings of a qualitative study titled “Experiences of Australian Midwives Caring for Women Living With the Consequences of Female Genital Mutilation (FGM).”
Participants Consistent with qualitative studies, a convenience voluntary sample of 11 midwives who satisfied the selection criteria were recruited using snowballing technique. Selection criteria consisted of the following: (a) be a registered midwife, (b) 18 years and above, and (c) have looked after a client/patient living with FGM. To access initial participants, a generic e-mail containing the title and aim of the study was sent to expert midwives in a school of nursing and midwifery at an Australian university. The expert midwives were identified from the university’s staff profiles posted on its website. Subsequent participants were accessed through referral (snow-balling technique; Borbasi, Jackson, & Langford, 2008; Burns & Grove, 2009) from initial participants. Participants were provided with an information sheet containing details of the study to offer an opportunity for potential participants to participate in an informed consent. Completion of a written and signed consent was an indication of participants’ decision to take part in the study.
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Data Collection An interpretive approach as suggested by Heidegger (1962), relies primarily on in-depth interviews with individuals who have experienced the phenomenon of interest. The researcher collected the data for this study between November 2011 and April 2012 using a face-to-face, semistructured, in-depth, audio-taped interview that lasted from 60 to 90 minutes. The participants nominated the place and time of the interviews. Most of the interviews took place in nearby university classrooms and public libraries. The midwives were identified in the order in which they were interviewed (Midwife 1 to Midwife 11). Verbatim transcription of interview data was completed immediately after each interview by a professional transcription service. The midwives responded to a number of open-ended questions, and some of the questions relevant to the content of this paper included, “Can you please tell me everything you know about female genital mutilation?” “What were your feelings seeing an anatomically different genitalia of affected women?” “How do you feel caring for women living with female genital mutilation?” Data saturation was obtained with the 11 midwives (Morse, 2000; Polit & Beck, 2006).
Data Analysis Transcripts of the 11 interviews were read and reread as suggested by van Manen (1997) to gain in-depth understanding of the participants’ experience of caring for women living with the consequences of FMG. Initial coding of data was attended through the use of Nvivo 10.0, which is a qualitative research tool for data analysis. Through constant comparison, emerging themes relevant to this article, namely, knowledge of female genital mutilation and attitudes toward female genital mutilation, were identified.
Rigor To ensure a rigorous effort while conducting qualitative research, Guba and Lincoln (1989) suggested a standardized evaluation criteria. They suggested credibility, dependability, transferability, and confirmability as central to rigor in qualitative research because these criteria determine the level of trustworthiness of the research (Streubert & Carpenter, 1995). In achieving credibility, I kept a journal of my relationships with the midwives as well as my personal reflection while transferability was attained through the provision of a detailed description of various approaches taken and demographic information of all the midwives (see Table 1). I used direct quotes from the transcripts to illustrate the emerging themes and subthemes in achieving confirmability.
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50–60
50–60
25–30
41–50
25–30
50–60
Midwife 3
Midwife 4
Midwife 5
Midwife 6
Midwife 7
Midwife 8
Midwife 9
Single
Married
Separated
Single
Married
Married
Married
Married
Married
30–40
Midwife 2
Married
Midwife 11 50–60
41–50
Midwife 1
Married
50–60
Midwife
Marital status
Midwife 10 30–40
Age (years)
Occupational role
Clinical academic
Clinical academic
Graduate diploma in midwifery Master’s in midwifery or equivalent
Master’s in midwifery or equivalent
Graduate certificate in midwifery Doctoral degree
Graduate diploma in midwifery
Registered midwife Clinical midwife specialist
Clinical midwifery educator Midwifery unit manager Registered midwife Midwife practitioner
Diploma in midwifery Clinical midwife specialist Diploma in midwifery Clinical midwife consultant
Master’s in midwifery or equivalent
Doctoral degree
Diploma in midwifery Clinical midwife specialist
Highest educational achievement
TABLE 1 Demographic Data of Midwives
Hospital
Hospital
Tertiary institution Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Place of training Setting of care
6–10 years 20 years and 11–15 years above
6–10 years
20 years and 6–10 years above
20 years and 1–5 years above 6–10 years 6–10 years
Perinatal/birthing unit
Antenatal, perinatal/birthing, postnatal Perinatal/birthing unit
Perinatal/birthing unit
Perinatal/birthing unit
Antenatal, perinatal/birthing units 20 years and 20 years and Antenatal, above above perinatal/birthing, postnatal, women’s health, community health center 16–20 years 11–15 years Antenatal, perinatal/birthing units 20 years and 6–10 years Postnatal above 20 years and 11–15 years Antenatal, above perinatal/birthing, postnatal 1–5 years 1–5 years Perinatal/birthing unit
Years of FGM care
20 years and 11–15 years above
Years of midwifery experience
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Meanwhile, explanation of every process involved in the research and how the midwives were accessed informed the achievement of dependability.
Ethical Consideration
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Ethics approval was obtained from relevant institutional human research ethics committee. No identifying features were used in describing the Australian midwives’ responses.
RESULTS All 11 midwives who participated in this study were female with age range between 25 and 60 years. Eight of them were married, two were single, and one midwife was separated. The majority (n = 8) of them were experienced midwives with more than 20 years’ experience in midwifery. Their years of experience in caring for women living with FGM ranged between 1 and 20 years. A full detail of the midwives’ demographic data is presented in Table 1.
Knowledge of Female Genital Mutilation The midwives’ knowledge about FGM centered on its typology, the countries of prevalence, reasons for the practice, the perpetrators of the practice, and the legality of the practice in Australia. Six midwives had some knowledge that there are certain degrees of classification of FGM based on the severity and, despite the years of experience of caring for circumcised women, only four midwives confidently stated, “there’s four” (Midwife 1); “Yeah, there are four types” (Midwife 4). Two midwives presented some vague explanation about their understanding of the various types of FGM: “So the women can either have their clitoris or their labia minora sewn up” (Midwife 8). One of the midwives who confessed that she did some reading about FGM prior to attending the face to face interview, however, was able to give a more detailed explanation of the four types. Midwife 3 with about 15 years’ experience of caring for women living with FGM conveyed her knowledge: I know there’s four types and the first is clitoridectomy, which is the removal of the clitoris. Second type is about excising the labia, the clitoris, and the labia minora, and the third type is called infibulation, which is basically removal of all of the genitalia plus or minus some oversewing. This only creates a small hole for the menses and also intercourse for the woman. And the fourth type, which I haven’t seen any of in caring for [women] in Australia in the hospitals I’ve worked in, is basically other types of injury where people do things like piercing and that sort of scratching type, scar type tissue. (Midwife 3)
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Even though six out of the 11 midwives knew the countries where FGM is prevalent, this knowledge is limited. With the exception of one midwife who was confident in her response, “Mainly African countries, although I do know it can occur in countries like Indonesia” (Midwife 3), most of the participants were either not sure of the countries where the practice is prevalent “It’s mainly . . . I think if I’m correct is it mainly North Africa” (Midwife 1) or were able to mention only a few names of the countries where the practice is predominant. Identified countries were Sierra Leone, Egypt, Malaysia, Indonesia, Djibouti, Sudan, and Somalia. A number of the participants sought clarification from the interviewer about the correctness of the information being provided on the countries of prevalence, and there was a mix up in the continents of the world where FGM is prevalent. Midwife 1, with about 15 years of caring for circumcised women, however, believed that she was capable of identifying the countries of prevalence if she had access to a map: “Oh, if I had a map, I could show you in Africa” (Midwife 1). With regards to the reasons for the practice and perpetrators of the practice, less than half of the midwives (n = 4) in this study spoke about the reasons proffered for the practice by the practicing countries. While most of these four midwives emphasized that the practice is informed by cultural consideration, a midwife previously considered FGM as a religious practice observed by the Muslims. One of the midwives with a doctoral degree, however, suggested that FGM is better understood as a gender issue whereby women are valued for their reproductive prowess: “Women are seen as less valuable if they don’t have it (FGM) . . . and where women are seen for their value as somebody who is married and becomes a wife and mother, then you can see how those things have a huge role” (Midwife 2). Some of the relatively experienced midwives in caring for the circumcised women provided a rich discussion that the practice is mainly perpetrated by mothers and grandmothers with a supposed good intention for their daughters and granddaughters: It (FGM) is really a mother’s love so that the girl can be married, when marriageable age comes. (Midwife 5) And often at the base of it (FGM) is about ensuring that their daughter remains pure and a virgin and they’re seen to be a good woman and they can guarantee her virtue by that. (Midwife 2)
There were a number of inconsistencies observed in the knowledge base of the midwives on the legality of FGM in Australia. All the midwives are aware that FGM is illegal in New South Wales, with resounding statements: “It’s illegal to perform FGM on girls in New South Wales” (Midwife 9); “In Australia it’s illegal; we don’t do it in New South Wales; no one does it
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here” (Midwife 3). Some of the midwives, however, were not sure if the legislation cuts across Australia. Perhaps because all the participants were midwives working in New South Wales, they were not confident in making generalizations to Australia: “It’s illegal in Australia to have their children circumcised. New South Wales, I don’t know if it’s Australia wide or not, but definitely it’s New South Wales” (Midwife 1). Most of the midwives explained that even though they are aware that some practitioners illegally suture the infibulated vulva back after a woman has given birth, it is illegal to resuture: I think the legal . . . very strong legal obligation that where people put the infibulated vulva back together I think that’s really, very problematic ‘cause I know some practitioners do, whereas I wouldn’t do that. (Midwife 2)
For some relatively inexperienced midwives, their knowledge of the illegality of the practice in Australia is difficult to explain to the circumcised women in the form of education or during the course of obtaining antenatal history. These midwives know that FGM is against the law in Australia and that one “could be prosecuted for child abuse or something like that if it’s done” (Midwife 3), but they could not imagine what to say if the women they were caring for requested further explanation. The experienced ones, however, presented no hesitation in giving detailed information about the law that surrounds FGM in Australia and the implications of having it performed on girls in Australia: You have to tell them (circumcised women) about the laws of the country, you know, when you are talking to them. So all this is in conversation you say, “When we have a little girl, you can’t take them and get circumcised. You will go to jail because they monitor you.” (Midwife 5)
Most of the midwives suggested a number of reasons for their limited knowledge of FGM, which included the lack of content about the practice in midwifery course curriculum and inservices: “When I did my diploma in midwifery, it wasn’t . . . to my recollection, it wasn’t covered, I mean FGM. . . . No services, nothing. No information. There are no pamphlets around. It’s not covered” (Midwife 7). Meanwhile, it was observed by a few participants that there are some educational workshops that the midwives were encouraged to attend. It was further observed from the interviews that not only were the workshops offered in locations a distance from where the midwives were working, they were not offered on a continuous basis.
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ATTITUDES TOWARD FEMALE GENITAL MUTILATION
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All the midwives’ stories on their attitude toward FGM revealed anger about the practice and empathy for the women living with consequences of FGM: “Angry as well, not necessarily angry at the women, but angry at the practice” (Midwife 4). According to the midwives who participated in this study, FGM takes a lot away from the women, and then it gives them other things that they don’t need, mentally, physically, and in all ramifications. It was difficult for a number of the midwives to rationalize how a woman or a mother could have her daughter undergo FGM with all its associated complications: How could you do that (FGM) to your daughter, who doesn’t have any anaesthetic on board for a start? Then the ramifications of bleeding, potential death, you know, there’s those sorts of things. (Midwife 3)
All the midwives expressed empathy for the women who have undergone FGM and showed their determination to provide the women with the best health care outcomes possible. For some of the midwives who cared for the women at the perinatal and birthing units, they were worried about the damage the women may experience after delivery and the mental implication of the repair on the women. While some of the midwives could understand the cultural explanation for the practice, they considered the enormous change that the suggestion of deinfibulation would have on the women. The midwives wondered how the women who have been used to the age-long practice of FGM would discuss the need for deinfibulation with their husbands and family members. The emotions and, the racing thoughts in the mind were part of the issues that concerned midwives for the women: “It’s not just such a physical thing, it’s just such a huge emotional and such a big decision, and I can only imagine what it must be like for them (the women) to go home and say, “. . . deinfibulation” (Midwife 5). A number of the midwives were convinced that the women who have been circumcised are in need of a solution rather than sympathy: And I think as long as you’re empathetic . . . and you come across as sincere, I think it makes a big difference to anything really don’t you, just like tolerance? That you’re here to help, you’re not judgemental. (Midwife 6)
DISCUSSION The major findings of this article were that there was a significant gap in the Australian midwives’ general knowledge about FGM and its legality in Australia. While the midwives expressed anger about the practice of FGM,
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they had a positive and empathetic attitude toward the women living with FGM in Australia. Australian midwives who participated in this study exhibited limited and fragmented knowledge about FGM. This is similar to a number of studies conducted in Western countries about the knowledge of health care providers about FGM (Hess et al., 2010; Leye et al., 2008; Relph et al., 2013; Zaidi et al., 2007), which reported significant knowledge gaps on FGM. Similar to the U.K. study of relevant professionals with 58% of the 45 participants being unable to list the different categories of FGM (Zaidi et al., 2007), only six midwives in the current study were able to mention the number of categories of FGM. One would have expected that with most of the midwives having a minimum of a graduate diploma in midwifery, they would be very knowledgeable about this practice that has been attracting international attention for the past two decades; however, this was not the case. A number of the midwives in the current study were not confident about the countries where the practice is prevalent and they were not sure if the legislation against FGM is only binding in NSW or in the whole of Australia. Due to increasing migration of women with a history of FGM to Western countries where the practice is unfamiliar, such as Australia, the United Kingdom, and Sweden, Western health care providers cannot afford not to have detailed information about FGM. Prior to the recent influx of Africans to Australia, there was no need to pay attention to this unfamiliar women’s health issue. Given the growth in the number of African women living with FGM in Australia and other countries of the world, however, access to comprehensive information becomes imperative among all health and allied health professionals. The gendered underlay of FGM, which is considered fundamental in understanding why it is perpetuated, was echoed in this study. While authors of previous literature point to the cultural and religious reasons for the perpetuation of the practice (Lundberg & Gerezgiher, 2008; Ogunsiji et al., 2007), the findings of the current study extend the few studies that have explained FGM as a reflection of the low value accorded to girls and women in countries where the practice is prevalent (Mathews, 2011). The explanation given in the current study that the role and status of women and the control of female sexuality is the issue at the heart of FGM broadens our understanding of the practice. Unfortunately, this is not an understanding that was widely presented by all the midwives in this study because it could be observed that only one of the doctoral-degree-prepared midwives offered this explanation. This suggests a gross knowledge gap not only among Australian midwives, but possibly among other health providers elsewhere. Unlike in the UK where similar explanation that FGM is a gendered issue has been previously offered (Hopkins, 1999), this is the first time the explanation will be reported among the midwives in Australia. Increased knowledge may enable the midwives anywhere FGM is encountered in engaging circumcised women in meaningful discussion aimed at discouraging the practice.
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The midwives in this study identified lack of access to continuous information and content during their professional training as being responsible for their limited knowledge about FGM. This is similar to authors of previous studies who have suggested reasons for the knowledge deficit about FGM among health care providers caring for circumcised women in Western countries (Ball, 2008; Leye et al., 2008). Similar to a Flemish quantitative study of 334 gynecologists and trainees where it was argued that limited attention paid to FGM in their basic or specialised training was responsible for the gap in their knowledge, the Australian midwives stated that if FGM was mentioned at all during their training, it was only done so in passing. There is need for more content in the curriculum of health care programs for professionals who will be caring for the growing number of women living with FGM in countries of the world. Most of the midwives in this study expressed anger toward FGM. The author of this paper is not aware of previous studies with similar report on the attitude of health care providers toward the practice. Health care providers’ perception that competent adults should be allowed to consent to FGM was reported among health professionals in inner-city London (Relph et al., 2013). Ali’s (2012) study indicated that about 64.3% of the 157 midwives who participated in a quantitative study in Sudan were of the opinion that FGM decreases sexual pleasure. It is comforting, however, that the attitude of the Australian midwives in this study reflects that of the international community that FGM is an unnecessary procedure that subjects affected women to various physical, emotional, mental, and gynecological agonies. Considering the small number of participants in the current qualitative study, it will be interesting to know not only the attitude of all the midwives in Australia, but also other health care providers anywhere in the world where FGM might be encountered. Larger quantitative international studies on the attitude of health care providers toward FGM are also suggested. Health care providers have significant roles to play in the international efforts toward eradication of the practice. The midwives raised an important issue on the need to be empathetic toward the women living with the consequences of FGM. This is of particular importance considering the negative experiences of obstetric care reported by circumcised women living in Western countries (Chalmers & Omer-Hashi, 2002; Murray et al., 2010; Straus, McEwen, & Hussein, 2009; Upvall, Mohammed, & Dodge, 2009). African women’s negative experience with midwives who were not knowledgeable in managing FGM was reported in Australia (Murray et al., 2010) and by Somali women in the UK (Straus et al., 2009). Harsh and offensive treatment experienced by Somali women was reported in Canada (Chalmers & Omer-Hashi, 2002), and Somali women experienced marginalization in the United States (Upvall et al., 2009). Even though circumcised women’s perspective of care is outside the focus of this study, this information is important in appreciating the expressed need for
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empathy in the interviews of the midwives in the current study. A contribution to the knowledge about women and health, and to potentially the health of children, is the finding that, central to Australian midwives in the current study, is the need to be available to support affected women. This is particularly so when we consider previous authors (Zenner et al., 2013) who have reported significant gaps in the provision of appropriate care to women living with the consequences of FGM and their at-risk daughters. The midwives’ attitudes might have been informed by the understanding that FGM is mainly conducted on children who had no voice but had to consent to their mothers. Merging the above perspectives, we find that there is much more to be desired about the attitudes of Western health care providers toward women living with FGM, many of whom are living with the consequences of a procedure to which they did not consent.
CONCLUSION AND RECOMMENDATIONS Every Australian midwife participant in this study had at least 1 year of experience caring for women living with the consequences of FGM. They expressed higher awareness in the area of identifying the number of categories of FGM and that the practice is illegal in New South Wales. It was noted from their interviews, however, that the midwives do not know the details of the law and were not sure if the practice is illegal in all the states in Australia. The only midwife who was able to list and describe the types of FGM attributed her knowledge to preinterview information that she personally sourced. Even though the midwives were empathetic toward the practice, there was a resounding anger toward FGM, and only the experienced midwives were able to draw attention to the good intension of the mothers of circumcised women. Further studies aimed at understanding the attitudes of other health providers and allied health workers toward the practice should be undertaken anywhere FGM might be encountered. Given the increasing global migration of women from countries where the practice is prevalent, midwives and health care providers generally are far more likely to find themselves caring for women living with FGM. Findings in this study will appeal to an interdisciplinary audience interested in women’s and children’s health such as obstetricians/gynecologists, pediatricians, psychiatric physicians, nurses, and others. This presents the need for nonfragmented and detailed knowledge of FGM. There must be more information presented on a continuous basis to midwives who are in the forefront of providing care to women with a history of FGM. In-services, brochures, and booklets that contain information on FGM as well as the national and international perspective about the practice should be made easily accessible to midwives and other health care providers in all developed nations of the world.
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FUNDING This study was funded through a University of Western Sydney seed grant.
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REFERENCES Ali, A. (2012). Knowledge and attitudes of female genital mutilation among midwives in Eastern Sudan. Reproductive Health, 9(1), 23–26. doi:10.1186/1742-4755-9-23 Australian Bureau of Statistics (ABS). (2009). Migration Australia 2007–2008. Catalogue no. 3412.0. Retrieved from http://www.abs.gov.au/AUSSTATS/[email protected]/ allprimarymainfeatures/31FDFD240EF88421CA25776E0017649F?opendocument Ball, T. (2008). Female genital mutilation. Nursing Standard (Royal College of Nursing [Great Britain], 23(5), 43–47. Borbasi, S., Jackson, D., & Langford, R. (2008). Navigating the maze of nursing research: An interactive learning adventure (2nd ed.). Marrickville, NSW, Australia: Elsevier Burns, N., & Grove, S. K. (2009). The practice of nursing research: Appraisal, synthesis, and generation of evidence (6th ed.). St. Louis, MO: Saunders. Carolan, M., & Cassar, L. (2010). Antenatal care perceptions of pregnant African women attending maternity services in Melbourne, Australia. Midwifery, 26(2), 189–201. Chalmers, B., & Omer-Hashi, K. (2002). What Somali women say about giving birth in Canada. Journal of Reproductive and Infant Psychology, 20, 267–282. Garba, I. D., Muhammed, Z., Abubakar, I. S., & Yakasai, I. A. (2012). Prevalence of female genital mutilation among female infants in Kano, Northern Nigeria. Archives of Gynecology and Obstetrics, 286, 423–428. Guba, E., & Lincoln, Y. (1989). Fourth generation evaluation. Newbury Park, CA: Sage Heidegger, M. (1962). Being and time (J. Macquarrie & E. Robinson, Trans.). Oxford, UK: Basil Blackwell. Hess, R. F., Weinland, J., & Saalinger, N. M. (2010). Knowledge of female genital cutting and experience with women who are circumcised: A survey of nursemidwives in the United States. Journal of Midwifery & Women’s Health, 55(1), 46–54. Hopkins, S. (1999). A discussion of the legal aspects of female genital mutilation. Journal of Advanced Nursing, 30(4), 926–933. Leye, E., Ysebaert, I., Deblonde, J., Claeys, P., Vermeulen, G., Jacquemyn, Y., & Temmerman, M. (2008). Female genital mutilation: Knowledge, attitudes and practices of Flemish gynaecologists. European Journal of Contraception and Reproductive Health Care, 13, 182–190. Litorp, H., Franck, M., & Almroth, L. (2008). Female genital mutilation among antenatal care and contraceptive advice attendees in Sweden. Acta Obstetricia et Gynecologica Scandinavica, 87, 716–722. Lundberg, P. C., & Gerezgiher, A. (2008). Experiences from pregnancy and childbirth related to female genital mutilation among Eritrean immigrant women in Sweden. Midwifery, 24, 214–225. Mathews, B. (2011). Female genital mutilation: Australian law, policy and practical challenges for doctors. Medical Journal of Australia, 194, 139–141.
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Morse, O. (2000). Determining sample size. Qualitative Health Research, 10, 3–5. Murray, L., Windsor, C., Parker, E., & Tewfik, O. (2010). The experiences of African women giving birth in Brisbane, Australia. Health Care for Women International, 31, 458–472. Nour, N. M. (2008). Female genital cutting: A persisting practice. Reviews in Obstetrics & Gynecology, 1, 135–139. Ogunsiji, O. O., Wilkes, L., & Jackson, D. (2007). Female genital mutilation: Origin, beliefs, prevalence and implications for health care workers caring for immigrant women in Australia. Contemporary Nurse, 25(1–2), 22–30. Onuh, S. O., Igberase, G. O., Umeora, J. O. U., Okogbenin, S. A., Otoide, V. O., & Gharoro, E. P. (2006). Female genital mutilation: Knowledge, attitude and practice among nurses. Journal of the National Medical Association, 98, 409–414. Polit, D. F., & Beck, C. T. (2006). Essentials of nursing research: Methods, appraisal, and utilization (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Relph, S., Inamdar, R., Singh, H., & Yoong, W. (2013). Female genital mutilation/cutting: Knowledge, attitude and training of health professionals in inner city London. European Journal of Obstetrics Gynecology and Reproductive Biology, 168, 195–198. Straus, L., McEwen, A., & Hussein, F. M. (2009). Somali women’s experience of childbirth in the UK: Perspectives from Somali health workers. Midwifery, 25, 181–186. Streubert, H. J., & Carpenter, D. R. (1995). Qualitative research in nursing: Advancing the humanistic interpretive. Philadelphia, PA: Lippincott. Toubia, N. (1994). Female circumcision as a public health issue. New England Journal of Medicine, 331, 712–716. Upvall, M. J., Mohammed, K., & Dodge, P. D. (2009). Perspectives of Somali Bantu refugee women living with circumcision in the United States: A focus group approach. International Journal of Nursing Studies, 46, 360–368. doi:http://dx.doi.org/10.1016/j.ijnurstu.2008.04.009 Utz-Billing, I., & Kentenich, H. (2008). Female genital mutilation: An injury, physical and mental harm. Journal of Psychosomatic Obstetrics & Gynecology, 29, 225–229. van Manen, M. (1997). Researching lived experience: Human science for an action sensitive pedagogy (2nd ed.). Toronto, Canada: Althouse Press. Watson, M. A. (2005). Female circumcision from Africa to the Americas: Slavery to the present. The Social Science Journal, 42, 421–437. doi:http://dx.doi.org/10.1016/j.soscij.2005.06.006 World Health Organization (WHO). (1998). Female genital mutilation: An overview. Geneva, Switzerland: Author. World Health Organization (WHO). (2006). Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet, 367, 1835–1841. Zaidi, N., Khalil, A., Roberts, C., & Browne, M. (2007). Knowledge of female genital mutilation among healthcare professionals. Journal of Obstetrics & Gynecology, 27(2), 161–164. Zenner, N., Liao, L. M., Richens, Y., & Creighton, S. M. (2013). Quality of obstetric and midwifery care for pregnant women who have undergone female genital mutilation. Journal of Obstetrics and Gynaecology, 33, 459–462.
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Female Genital Mutilation (FGM): Australian Midwives’ Knowledge and Attitudes Olayide Ogunsiji To cite this article: Olayide Ogunsiji (2015) Female Genital Mutilation (FGM): Australian Midwives’ Knowledge and Attitudes, Health Care for Women International, 36:11, 1179-1193, DOI: 10.1080/07399332.2014.992521 To link to this article: http://dx.doi.org/10.1080/07399332.2014.992521
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Health Care for Women International, 36:1179–1193, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.992521
Female Genital Mutilation (FGM): Australian Midwives’ Knowledge and Attitudes
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OLAYIDE OGUNSIJI School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
Female genital mutilation (FGM) is a women’s health and human rights issue attracting global interest. My purpose in this qualitative study was to report the knowledge and attitudes of Australian midwives toward FGM. Verbatim transcription and thematic analysis of semistructured interviews with 11 midwives resulted in these themes: knowledge of female genital mutilation and attitude toward female genital mutilation. Significant gaps in knowledge about FGM featured prominently. The midwives expressed anger toward FGM and empathy for affected women. Recommendations include increased information on FGM and associated legislation among midwives and other health providers in countries where FGM may be encountered. Increasing international migration has contributed to movement of women living with female genital mutilation (FGM) to other parts of the world, creating a peculiar health care challenge in the area of gynecological and obstetric care. This is particularly so in developed countries, where some health care providers find care provision for affected women both challenging and confronting. In this study, I explored the knowledge and attitude of Australian midwives caring for women living with FGM. This article is part of a larger qualitative study that explored meaning of care and care-giving experiences of Australian midwives who are caring for women with FGM. The researcher believes that FGM is a public health issue that needs attention from research community, midwives, women and children health nurses, and other health care providers as well as child welfare workers, counsellors, criminal justice,
Received 26 November 2013; accepted 19 November 2014. Address correspondence to Olayide Ogunsiji, School of Nursing and Midwifery, University of Western Sydney, Building G10, Room 62, Hawkesbury Campus, Locked Bag 1797, Penrith, NSW 2751, Australia. E-mail: [email protected] 1179
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and educators not only in Australia but also in other countries where FGM might be encountered.
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BACKGROUND FGM, also known as female circumcision or female cutting, refers to a range of procedures intended at partial or total removal of the female genital organs for nontherapeutic reasons (Ball, 2008; Garba, Muhammed, Abubakar, & Yakasai, 2012). The practice is widespread and according to the World Health Organization (WHO, 1998), it was estimated that between 100 million and 140 million females have undergone some kind of female genital cutting with an annual incidence of 3 million (Zenner, Liao, Richens, & Creighton, 2013). It is practiced in the Arabian Peninsula and Asia; however, female circumcision is most common in Africa, with more than 70 million of the affected women coming from this continent (Nour, 2008; WHO, 1998). FGM is practiced in more than 28 African countries, with a prevalence rate between 5% and 95% (Ball, 2008; Watson, 2005). There are four typologies depending on the intensity of the injury. The first type is called clitoridectomy, which is the partial or total removal of the clitoris, and the second type is called excision, which is the partial or total removal of the clitoris and the labia minora with or without excision of the labia majora (Lundberg & Gerezgiher, 2008; Ogunsiji, Wilkes, & Jackson, 2007). The third type is referred to as infibulation, which is the narrowing of the vaginal opening through the creation of a covering seal, and the fourth type includes all other harmful procedures to the female genitalia for nonmedical reasons such as pricking, piercing, incising, scraping, and cauterizing the genital area (Lundberg & Gerezgiher, 2008; Ogunsiji et al., 2007; WHO, 2006). The practice is associated with a number of physical, sexual, and psychological effects (Toubia, 1994; Utz-Billing & Kentenich, 2008). Physical complications of the practice include urinary tract infection, anemia, sepsis, and bleeding, while, psychologically, circumcised women are at greater risk of psychiatric and psychosomatic symptoms (Utz-Billing & Kentenich, 2008). In an empirical qualitative study of 10 African women giving birth in Brisbane, Australian researchers reported the women’s experience of embarrassment and shame, with the feeling of being different in terms of their genitalia (Murray, Windsor, Parker, & Tewfik, 2010). Predominant among the reasons proffered for FGM is the associated cultural meaning it holds for affected women in the sense that it is linked to women’s sexuality and a way of preparing women for marriage (Toubia, 1994; Utz-Billing & Kentenich, 2008). Due to migration, an increasing number of women affected by FGM are moving to other parts of the world where awareness of the practice is
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limited. This migration pattern has created a health care challenge particularly in the area of gynecological and obstetric care in developed countries such as the UK (Ball, 2008), U.S. (Watson, 2005), and Sweden (Litorp, Franck, & Almroth, 2008). Africans are an increasing migrant population in Australia. The challenge faced by Australian midwives in terms of knowledge and attitudes toward the practice, however, is yet to be reported. According to the Australian Bureau of Statistics (ABS, 2009), a total of 248,699 people born in Africa were living in Australia, constituting a 50% increase when compared with 147,876 in 1996. As the number of African immigrants to Australia increases, health care providers will be required to service the gynecological and obstetric health care needs of the African women, some of whom might have limited information about the practice. In supporting midwives and other health care providers in meeting these women’s health needs, it is important to determine their knowledge and attitudes toward FGM. My focus in this article is on the knowledge and attitudes of Australian midwives caring for women living with FGM.
Knowledge and Attitudes About FGM Gross deficits in knowledge about FGM in Western countries are reported in the literature (Carolan & Cassar, 2010; Chalmers & Omer-Hashi, 2002; Murray et al., 2010; Zaidi, Khalil, Roberts, & Browne, 2007). Significant gaps were identified in theoretical knowledge and practice among health care providers caring for migrant women living with the consequences of FGM in their new countries. Findings from a survey of 45 health care providers in the United Kingdom revealed areas of knowledge deficit (Zaidi et al., 2007). Only 40% (18) of the health care providers who participated in the study at a University Teaching Hospital were familiar with the FGM Act of 2003; 58% (26) could not list the different types of FGM (Zaidi et al., 2007). Similar findings were reported from a randomized sample of 600 certified nurse–midwives who participated in a quantitative study to determine their experience of caring for circumcized women in the United States of America (Hess, Weinland, & Saalinger, 2010). There was a knowledge deficit among the U.S. nurse–midwives in legal and cultural issues that surrounded FGM. While the areas of knowledge deficit are identified in the literature among health care providers in United Kingdom (Zaidi et al., 2007) and the United States (Hess et al., 2010), the situation in Australia is not known. Identifying this information is important in developing appropriate educational support initiatives. Limited literature is available internationally on the attitudes of health care providers toward FGM (Leye et al., 2008; Onuh et al., 2006; Relph, Inamdar, Singh, & Yoong, 2013), and with the exception of Ali (2012) there is paucity of empirical studies of midwives’ attitudes toward the practice.
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Literature on both health care providers generally and midwives specifically revealed positive attitudes. Ali (2012) conducted a quantitative study about the attitudes of 157 Eastern Sudan midwives between June 2012 and July 2012 and reported 76.4% of the respondents were of the opinion that some forms of FGM are not harmful and 74.5% considered FGM as a legal practice, suggesting a positive attitude. Contrary to the African study, only a third of the 334 Flemish gynecologists were discouraging women with previous FGM from circumcising their daughters (Leye et al., 2008), and many of these gynecologists were in support of medicalization of FGM. Not only this, 13.9% of the 79 health care providers who responded to a questionnaire gauging attitude toward FGM in inner-city London agreed that competent adults should be allowed to consent to FGM (Relph et al., 2013). Despite the intense international attention to the harmful practice of FGM, a large group of health care workers in Africa and some Western countries still have a positive attitude toward the practice. The attitude of Australian midwives toward FGM needs to be captured in targeting education interventions. Globally, the positive attitude of some health care providers toward FGM suggests the need to devote some attention to the attitude of health care providers too in efforts at eradicating FGM. The aim of this article is to provide insight into the knowledge and attitude of Australian midwives toward FMG.
METHODS I report in this article part of the findings of a qualitative study titled “Experiences of Australian Midwives Caring for Women Living With the Consequences of Female Genital Mutilation (FGM).”
Participants Consistent with qualitative studies, a convenience voluntary sample of 11 midwives who satisfied the selection criteria were recruited using snowballing technique. Selection criteria consisted of the following: (a) be a registered midwife, (b) 18 years and above, and (c) have looked after a client/patient living with FGM. To access initial participants, a generic e-mail containing the title and aim of the study was sent to expert midwives in a school of nursing and midwifery at an Australian university. The expert midwives were identified from the university’s staff profiles posted on its website. Subsequent participants were accessed through referral (snow-balling technique; Borbasi, Jackson, & Langford, 2008; Burns & Grove, 2009) from initial participants. Participants were provided with an information sheet containing details of the study to offer an opportunity for potential participants to participate in an informed consent. Completion of a written and signed consent was an indication of participants’ decision to take part in the study.
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Data Collection An interpretive approach as suggested by Heidegger (1962), relies primarily on in-depth interviews with individuals who have experienced the phenomenon of interest. The researcher collected the data for this study between November 2011 and April 2012 using a face-to-face, semistructured, in-depth, audio-taped interview that lasted from 60 to 90 minutes. The participants nominated the place and time of the interviews. Most of the interviews took place in nearby university classrooms and public libraries. The midwives were identified in the order in which they were interviewed (Midwife 1 to Midwife 11). Verbatim transcription of interview data was completed immediately after each interview by a professional transcription service. The midwives responded to a number of open-ended questions, and some of the questions relevant to the content of this paper included, “Can you please tell me everything you know about female genital mutilation?” “What were your feelings seeing an anatomically different genitalia of affected women?” “How do you feel caring for women living with female genital mutilation?” Data saturation was obtained with the 11 midwives (Morse, 2000; Polit & Beck, 2006).
Data Analysis Transcripts of the 11 interviews were read and reread as suggested by van Manen (1997) to gain in-depth understanding of the participants’ experience of caring for women living with the consequences of FMG. Initial coding of data was attended through the use of Nvivo 10.0, which is a qualitative research tool for data analysis. Through constant comparison, emerging themes relevant to this article, namely, knowledge of female genital mutilation and attitudes toward female genital mutilation, were identified.
Rigor To ensure a rigorous effort while conducting qualitative research, Guba and Lincoln (1989) suggested a standardized evaluation criteria. They suggested credibility, dependability, transferability, and confirmability as central to rigor in qualitative research because these criteria determine the level of trustworthiness of the research (Streubert & Carpenter, 1995). In achieving credibility, I kept a journal of my relationships with the midwives as well as my personal reflection while transferability was attained through the provision of a detailed description of various approaches taken and demographic information of all the midwives (see Table 1). I used direct quotes from the transcripts to illustrate the emerging themes and subthemes in achieving confirmability.
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50–60
50–60
25–30
41–50
25–30
50–60
Midwife 3
Midwife 4
Midwife 5
Midwife 6
Midwife 7
Midwife 8
Midwife 9
Single
Married
Separated
Single
Married
Married
Married
Married
Married
30–40
Midwife 2
Married
Midwife 11 50–60
41–50
Midwife 1
Married
50–60
Midwife
Marital status
Midwife 10 30–40
Age (years)
Occupational role
Clinical academic
Clinical academic
Graduate diploma in midwifery Master’s in midwifery or equivalent
Master’s in midwifery or equivalent
Graduate certificate in midwifery Doctoral degree
Graduate diploma in midwifery
Registered midwife Clinical midwife specialist
Clinical midwifery educator Midwifery unit manager Registered midwife Midwife practitioner
Diploma in midwifery Clinical midwife specialist Diploma in midwifery Clinical midwife consultant
Master’s in midwifery or equivalent
Doctoral degree
Diploma in midwifery Clinical midwife specialist
Highest educational achievement
TABLE 1 Demographic Data of Midwives
Hospital
Hospital
Tertiary institution Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital
Place of training Setting of care
6–10 years 20 years and 11–15 years above
6–10 years
20 years and 6–10 years above
20 years and 1–5 years above 6–10 years 6–10 years
Perinatal/birthing unit
Antenatal, perinatal/birthing, postnatal Perinatal/birthing unit
Perinatal/birthing unit
Perinatal/birthing unit
Antenatal, perinatal/birthing units 20 years and 20 years and Antenatal, above above perinatal/birthing, postnatal, women’s health, community health center 16–20 years 11–15 years Antenatal, perinatal/birthing units 20 years and 6–10 years Postnatal above 20 years and 11–15 years Antenatal, above perinatal/birthing, postnatal 1–5 years 1–5 years Perinatal/birthing unit
Years of FGM care
20 years and 11–15 years above
Years of midwifery experience
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Meanwhile, explanation of every process involved in the research and how the midwives were accessed informed the achievement of dependability.
Ethical Consideration
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Ethics approval was obtained from relevant institutional human research ethics committee. No identifying features were used in describing the Australian midwives’ responses.
RESULTS All 11 midwives who participated in this study were female with age range between 25 and 60 years. Eight of them were married, two were single, and one midwife was separated. The majority (n = 8) of them were experienced midwives with more than 20 years’ experience in midwifery. Their years of experience in caring for women living with FGM ranged between 1 and 20 years. A full detail of the midwives’ demographic data is presented in Table 1.
Knowledge of Female Genital Mutilation The midwives’ knowledge about FGM centered on its typology, the countries of prevalence, reasons for the practice, the perpetrators of the practice, and the legality of the practice in Australia. Six midwives had some knowledge that there are certain degrees of classification of FGM based on the severity and, despite the years of experience of caring for circumcised women, only four midwives confidently stated, “there’s four” (Midwife 1); “Yeah, there are four types” (Midwife 4). Two midwives presented some vague explanation about their understanding of the various types of FGM: “So the women can either have their clitoris or their labia minora sewn up” (Midwife 8). One of the midwives who confessed that she did some reading about FGM prior to attending the face to face interview, however, was able to give a more detailed explanation of the four types. Midwife 3 with about 15 years’ experience of caring for women living with FGM conveyed her knowledge: I know there’s four types and the first is clitoridectomy, which is the removal of the clitoris. Second type is about excising the labia, the clitoris, and the labia minora, and the third type is called infibulation, which is basically removal of all of the genitalia plus or minus some oversewing. This only creates a small hole for the menses and also intercourse for the woman. And the fourth type, which I haven’t seen any of in caring for [women] in Australia in the hospitals I’ve worked in, is basically other types of injury where people do things like piercing and that sort of scratching type, scar type tissue. (Midwife 3)
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Even though six out of the 11 midwives knew the countries where FGM is prevalent, this knowledge is limited. With the exception of one midwife who was confident in her response, “Mainly African countries, although I do know it can occur in countries like Indonesia” (Midwife 3), most of the participants were either not sure of the countries where the practice is prevalent “It’s mainly . . . I think if I’m correct is it mainly North Africa” (Midwife 1) or were able to mention only a few names of the countries where the practice is predominant. Identified countries were Sierra Leone, Egypt, Malaysia, Indonesia, Djibouti, Sudan, and Somalia. A number of the participants sought clarification from the interviewer about the correctness of the information being provided on the countries of prevalence, and there was a mix up in the continents of the world where FGM is prevalent. Midwife 1, with about 15 years of caring for circumcised women, however, believed that she was capable of identifying the countries of prevalence if she had access to a map: “Oh, if I had a map, I could show you in Africa” (Midwife 1). With regards to the reasons for the practice and perpetrators of the practice, less than half of the midwives (n = 4) in this study spoke about the reasons proffered for the practice by the practicing countries. While most of these four midwives emphasized that the practice is informed by cultural consideration, a midwife previously considered FGM as a religious practice observed by the Muslims. One of the midwives with a doctoral degree, however, suggested that FGM is better understood as a gender issue whereby women are valued for their reproductive prowess: “Women are seen as less valuable if they don’t have it (FGM) . . . and where women are seen for their value as somebody who is married and becomes a wife and mother, then you can see how those things have a huge role” (Midwife 2). Some of the relatively experienced midwives in caring for the circumcised women provided a rich discussion that the practice is mainly perpetrated by mothers and grandmothers with a supposed good intention for their daughters and granddaughters: It (FGM) is really a mother’s love so that the girl can be married, when marriageable age comes. (Midwife 5) And often at the base of it (FGM) is about ensuring that their daughter remains pure and a virgin and they’re seen to be a good woman and they can guarantee her virtue by that. (Midwife 2)
There were a number of inconsistencies observed in the knowledge base of the midwives on the legality of FGM in Australia. All the midwives are aware that FGM is illegal in New South Wales, with resounding statements: “It’s illegal to perform FGM on girls in New South Wales” (Midwife 9); “In Australia it’s illegal; we don’t do it in New South Wales; no one does it
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here” (Midwife 3). Some of the midwives, however, were not sure if the legislation cuts across Australia. Perhaps because all the participants were midwives working in New South Wales, they were not confident in making generalizations to Australia: “It’s illegal in Australia to have their children circumcised. New South Wales, I don’t know if it’s Australia wide or not, but definitely it’s New South Wales” (Midwife 1). Most of the midwives explained that even though they are aware that some practitioners illegally suture the infibulated vulva back after a woman has given birth, it is illegal to resuture: I think the legal . . . very strong legal obligation that where people put the infibulated vulva back together I think that’s really, very problematic ‘cause I know some practitioners do, whereas I wouldn’t do that. (Midwife 2)
For some relatively inexperienced midwives, their knowledge of the illegality of the practice in Australia is difficult to explain to the circumcised women in the form of education or during the course of obtaining antenatal history. These midwives know that FGM is against the law in Australia and that one “could be prosecuted for child abuse or something like that if it’s done” (Midwife 3), but they could not imagine what to say if the women they were caring for requested further explanation. The experienced ones, however, presented no hesitation in giving detailed information about the law that surrounds FGM in Australia and the implications of having it performed on girls in Australia: You have to tell them (circumcised women) about the laws of the country, you know, when you are talking to them. So all this is in conversation you say, “When we have a little girl, you can’t take them and get circumcised. You will go to jail because they monitor you.” (Midwife 5)
Most of the midwives suggested a number of reasons for their limited knowledge of FGM, which included the lack of content about the practice in midwifery course curriculum and inservices: “When I did my diploma in midwifery, it wasn’t . . . to my recollection, it wasn’t covered, I mean FGM. . . . No services, nothing. No information. There are no pamphlets around. It’s not covered” (Midwife 7). Meanwhile, it was observed by a few participants that there are some educational workshops that the midwives were encouraged to attend. It was further observed from the interviews that not only were the workshops offered in locations a distance from where the midwives were working, they were not offered on a continuous basis.
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ATTITUDES TOWARD FEMALE GENITAL MUTILATION
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All the midwives’ stories on their attitude toward FGM revealed anger about the practice and empathy for the women living with consequences of FGM: “Angry as well, not necessarily angry at the women, but angry at the practice” (Midwife 4). According to the midwives who participated in this study, FGM takes a lot away from the women, and then it gives them other things that they don’t need, mentally, physically, and in all ramifications. It was difficult for a number of the midwives to rationalize how a woman or a mother could have her daughter undergo FGM with all its associated complications: How could you do that (FGM) to your daughter, who doesn’t have any anaesthetic on board for a start? Then the ramifications of bleeding, potential death, you know, there’s those sorts of things. (Midwife 3)
All the midwives expressed empathy for the women who have undergone FGM and showed their determination to provide the women with the best health care outcomes possible. For some of the midwives who cared for the women at the perinatal and birthing units, they were worried about the damage the women may experience after delivery and the mental implication of the repair on the women. While some of the midwives could understand the cultural explanation for the practice, they considered the enormous change that the suggestion of deinfibulation would have on the women. The midwives wondered how the women who have been used to the age-long practice of FGM would discuss the need for deinfibulation with their husbands and family members. The emotions and, the racing thoughts in the mind were part of the issues that concerned midwives for the women: “It’s not just such a physical thing, it’s just such a huge emotional and such a big decision, and I can only imagine what it must be like for them (the women) to go home and say, “. . . deinfibulation” (Midwife 5). A number of the midwives were convinced that the women who have been circumcised are in need of a solution rather than sympathy: And I think as long as you’re empathetic . . . and you come across as sincere, I think it makes a big difference to anything really don’t you, just like tolerance? That you’re here to help, you’re not judgemental. (Midwife 6)
DISCUSSION The major findings of this article were that there was a significant gap in the Australian midwives’ general knowledge about FGM and its legality in Australia. While the midwives expressed anger about the practice of FGM,
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they had a positive and empathetic attitude toward the women living with FGM in Australia. Australian midwives who participated in this study exhibited limited and fragmented knowledge about FGM. This is similar to a number of studies conducted in Western countries about the knowledge of health care providers about FGM (Hess et al., 2010; Leye et al., 2008; Relph et al., 2013; Zaidi et al., 2007), which reported significant knowledge gaps on FGM. Similar to the U.K. study of relevant professionals with 58% of the 45 participants being unable to list the different categories of FGM (Zaidi et al., 2007), only six midwives in the current study were able to mention the number of categories of FGM. One would have expected that with most of the midwives having a minimum of a graduate diploma in midwifery, they would be very knowledgeable about this practice that has been attracting international attention for the past two decades; however, this was not the case. A number of the midwives in the current study were not confident about the countries where the practice is prevalent and they were not sure if the legislation against FGM is only binding in NSW or in the whole of Australia. Due to increasing migration of women with a history of FGM to Western countries where the practice is unfamiliar, such as Australia, the United Kingdom, and Sweden, Western health care providers cannot afford not to have detailed information about FGM. Prior to the recent influx of Africans to Australia, there was no need to pay attention to this unfamiliar women’s health issue. Given the growth in the number of African women living with FGM in Australia and other countries of the world, however, access to comprehensive information becomes imperative among all health and allied health professionals. The gendered underlay of FGM, which is considered fundamental in understanding why it is perpetuated, was echoed in this study. While authors of previous literature point to the cultural and religious reasons for the perpetuation of the practice (Lundberg & Gerezgiher, 2008; Ogunsiji et al., 2007), the findings of the current study extend the few studies that have explained FGM as a reflection of the low value accorded to girls and women in countries where the practice is prevalent (Mathews, 2011). The explanation given in the current study that the role and status of women and the control of female sexuality is the issue at the heart of FGM broadens our understanding of the practice. Unfortunately, this is not an understanding that was widely presented by all the midwives in this study because it could be observed that only one of the doctoral-degree-prepared midwives offered this explanation. This suggests a gross knowledge gap not only among Australian midwives, but possibly among other health providers elsewhere. Unlike in the UK where similar explanation that FGM is a gendered issue has been previously offered (Hopkins, 1999), this is the first time the explanation will be reported among the midwives in Australia. Increased knowledge may enable the midwives anywhere FGM is encountered in engaging circumcised women in meaningful discussion aimed at discouraging the practice.
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The midwives in this study identified lack of access to continuous information and content during their professional training as being responsible for their limited knowledge about FGM. This is similar to authors of previous studies who have suggested reasons for the knowledge deficit about FGM among health care providers caring for circumcised women in Western countries (Ball, 2008; Leye et al., 2008). Similar to a Flemish quantitative study of 334 gynecologists and trainees where it was argued that limited attention paid to FGM in their basic or specialised training was responsible for the gap in their knowledge, the Australian midwives stated that if FGM was mentioned at all during their training, it was only done so in passing. There is need for more content in the curriculum of health care programs for professionals who will be caring for the growing number of women living with FGM in countries of the world. Most of the midwives in this study expressed anger toward FGM. The author of this paper is not aware of previous studies with similar report on the attitude of health care providers toward the practice. Health care providers’ perception that competent adults should be allowed to consent to FGM was reported among health professionals in inner-city London (Relph et al., 2013). Ali’s (2012) study indicated that about 64.3% of the 157 midwives who participated in a quantitative study in Sudan were of the opinion that FGM decreases sexual pleasure. It is comforting, however, that the attitude of the Australian midwives in this study reflects that of the international community that FGM is an unnecessary procedure that subjects affected women to various physical, emotional, mental, and gynecological agonies. Considering the small number of participants in the current qualitative study, it will be interesting to know not only the attitude of all the midwives in Australia, but also other health care providers anywhere in the world where FGM might be encountered. Larger quantitative international studies on the attitude of health care providers toward FGM are also suggested. Health care providers have significant roles to play in the international efforts toward eradication of the practice. The midwives raised an important issue on the need to be empathetic toward the women living with the consequences of FGM. This is of particular importance considering the negative experiences of obstetric care reported by circumcised women living in Western countries (Chalmers & Omer-Hashi, 2002; Murray et al., 2010; Straus, McEwen, & Hussein, 2009; Upvall, Mohammed, & Dodge, 2009). African women’s negative experience with midwives who were not knowledgeable in managing FGM was reported in Australia (Murray et al., 2010) and by Somali women in the UK (Straus et al., 2009). Harsh and offensive treatment experienced by Somali women was reported in Canada (Chalmers & Omer-Hashi, 2002), and Somali women experienced marginalization in the United States (Upvall et al., 2009). Even though circumcised women’s perspective of care is outside the focus of this study, this information is important in appreciating the expressed need for
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empathy in the interviews of the midwives in the current study. A contribution to the knowledge about women and health, and to potentially the health of children, is the finding that, central to Australian midwives in the current study, is the need to be available to support affected women. This is particularly so when we consider previous authors (Zenner et al., 2013) who have reported significant gaps in the provision of appropriate care to women living with the consequences of FGM and their at-risk daughters. The midwives’ attitudes might have been informed by the understanding that FGM is mainly conducted on children who had no voice but had to consent to their mothers. Merging the above perspectives, we find that there is much more to be desired about the attitudes of Western health care providers toward women living with FGM, many of whom are living with the consequences of a procedure to which they did not consent.
CONCLUSION AND RECOMMENDATIONS Every Australian midwife participant in this study had at least 1 year of experience caring for women living with the consequences of FGM. They expressed higher awareness in the area of identifying the number of categories of FGM and that the practice is illegal in New South Wales. It was noted from their interviews, however, that the midwives do not know the details of the law and were not sure if the practice is illegal in all the states in Australia. The only midwife who was able to list and describe the types of FGM attributed her knowledge to preinterview information that she personally sourced. Even though the midwives were empathetic toward the practice, there was a resounding anger toward FGM, and only the experienced midwives were able to draw attention to the good intension of the mothers of circumcised women. Further studies aimed at understanding the attitudes of other health providers and allied health workers toward the practice should be undertaken anywhere FGM might be encountered. Given the increasing global migration of women from countries where the practice is prevalent, midwives and health care providers generally are far more likely to find themselves caring for women living with FGM. Findings in this study will appeal to an interdisciplinary audience interested in women’s and children’s health such as obstetricians/gynecologists, pediatricians, psychiatric physicians, nurses, and others. This presents the need for nonfragmented and detailed knowledge of FGM. There must be more information presented on a continuous basis to midwives who are in the forefront of providing care to women with a history of FGM. In-services, brochures, and booklets that contain information on FGM as well as the national and international perspective about the practice should be made easily accessible to midwives and other health care providers in all developed nations of the world.
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FUNDING This study was funded through a University of Western Sydney seed grant.
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