in East Africa (P value = 0.44), 0.01% in North Africa (P value = 0.32), 0.01% in West Africa (P value = 0.56) and 0.04% in Western Asia (P value = 0.57). However, there is a non-significant increase of 3.61% recorded in Central Africa (P value = 0.42). Overall, from the period covering 1990–2016, there is no annual decline or increase in the prevalence of FGM/C when all the countries are combined (0.024%, trend = 0.008, P value = 0.186). We also found nothing to justify any mod- est and significant decline in the prevalence of FGM/C in these countries where data are available in the last three decades. The fact that there is no significant difference in the changes seen when the rates between 1990/1999, 2000/2009 and 2010/2016 are compared make the current result even more acceptable and strong.
We also compared the age-specific prevalence rate among the most recent esti- mates of FGM/C across countries and regions as shown in Fig. 2.5. As expected, we found a significant difference in annualised pooled prevalence estimates of FGM/C across 10–14, 15–49 and 50 years and over age cohorts, 43.88% (33.98–
53.78) vs 49.30% (34.33–64.27) vs 53.77% (35.72–72.39), P < 0.001. As expected we found that there is a very slight but non-significant change resulting in 0.10%
(trend = 0.026, P value = 0.41). We also observed a similar change among those aged 15–59 years (0.06%, trend = 0.021, P = 0.52). This is consistent with review evidence that as age increased the proportion of respondents and their daughters who had undergone FGM increased. This is also consistent with other socioeco- nomic and demographic factors including respondents educational status and asset quintiles (Karmaker et al. 2011).
Additionally, the relationship between FGM/C and other socioeconomic factors including education (data not reported) appears to have been over interpreted across countries (Gupta 2013). Thus, any such causation should be read with great caution given that no recent trend analysis and evaluation targeting educational intervention have suggested anything different from initial DHS/MICS reports (Demographic Health Survey 1991; El-Zanaty et al. 1996)—confirming such positive association alongside other factors including religion, ethnic group and asset quintiles. Secondly, a recent and robust systematic review conducted by the International Initiative for Impact Evaluation found that there is absolutely no evidence that educational inter- vention has led to any decline in the prevalence of FGM/C anywhere in the world (Berg and Denison 2012).
We reasoned that the legal prohibition alone against FGM/C currently in place in most of these countries were the data were obtained may not have been effective in abolishing the practice. This also applies to international responses including fund- ing interventions against the FGM/C practice. What may have been the case as seen from the slight but non-significant change of 0.10%, is that there may be a slight shift from children (0–14 years) undergoing the practice to adults (15 years and over). It could mean that the slight waiting period, which may have seen a drop in the number of children undergoing the practice, may have been attenuated by the increase in FGM/C uptake in adulthood. This line of reasoning supports the argu- ment that the international pressure may have little or no influence on the strong cultural practice. It may not be entirely correct to dismiss this line of argument given the fact that a slight decline among the 10–14 year-old cohort may have taken
advantage of their human right position to yield to socio-cultural pressure in favour of the practice in their adult life. This shift in age-specific prevalence portends dan- ger in the fight against FGM/C as a human rights issue.
It is not a surprise that the practice has not declined. A recent and most consistent evidence on behavioural ecology found that FGM/C is tied to socio-cultural ideals including reproductive success, hence, individuals will behave in a way that maximizes reproductive success given their specific circumstances, despite any negative effects this may have on their immediate wellbeing (Dawkins 1978; Nettle et al. 2013; Howard and Gibson 2017). This is why the current efforts that concentrate on funding interven- tions that never worked should begin to look beyond legislation, advocacy, outreach, education and multimedia communication (Faith and People 1998; Easton et al. 2002;
Mounir et al. 2002; Chege et al. 2004; Babalola et al. 2006; Ako and Akweongo 2009;
Diop and Askew 2009) to more culturally-sensitive and community-engaging strate- gies including sincere partnership with youths and health workers to drive the practice downward (Berg and Denison 2012; World Health Organization 2012).
We have provided a comprehensive and up-to-date review of FGM/C prevalence in 29 countries across five sub-regions. This enabled a critical and comparative estimate of FGM/C. The strength of this work lies on the use of DHS and MICS datasets, both of which are large well-conducted national representative surveys with a high response rate. Interviewers were trained; questions were standardized and data management procedures were exemplary. In addition, the surveys utilised appropriate design taking into account all the important socioeconomic and prog- nostic factors including ethnicities, religion and residential areas or regions. We also included the most recent datasets available from 2015/2016 that have rarely been used to describe the overall patterns and identify important changes over time. We also adopted a robust analytical approach to provide the accurate and quantifiable estimates of FGM/C prevalence and trends both within and between regions.
While informative, the results of this review should be interpreted with caution.
First, in large continental region such as Africa there were insufficient studies or survey data to entirely represent the regions or countries. We did not consider study- level participants’ characteristics, which may have further increased the knowledge of the dynamics of FGM/C practices, however, the influence of survey year, and study sample size did not modify the prevalence estimates evaluated. This made an application of multivariate analysis unreasonable. As with similar studies of this kind, we were unable to deal with bias associated with self-reports due in part to the secondary nature of the data. It is possible that responses to cultural sensitive issues such as FGM/C may have distorted the findings. In fact, there is a recent body of evidence that there could be under-reporting of FGM/C cases resulting due to new legislation abolishing the practice across many jurisdictions. Evidence found that respondents were uncomfortable or unsure of the intended use of the information by strangers and were less likely to disclose their FGM/C status due in part to fear of prosecution and social exclusion (Karmaker et al. 2011).
Another important limitation of this review is that the survey data was from cross sectional studies. A major limitation of this design is because it is conducted at just one point in time, and therefore, is not suited for the study of estimates of FGM/C
changes (Davies 1994). Although the data was recorded in a succession of DHS/
MICS surveys, it is possible that either of these surveys contains entirely different sets of FGM/C cases for each period or there may be overlap so small as to be con- sidered negligible. Therefore, incorporating a time trend in such a design may not entirely be adequate in assessing the determinants of FGM/C practices, which could be better evaluated using a longitudinal survey, which allows a diachronic analysis of the incidence of FGM/C from one period to another and also allows for determi- nation of causality (Davies 1994). Evidence found that some relevant cohort effect may be missed even with a succession of cross sectional data available in DHS/
MICS (Karmaker et al. 2011).
In sum, the global evidence review provided in this chapter reflects the signifi- cant prevalence of FMC/C in 29 countries that spread across five United Nations sub-regions in Africa and Asia. We have shown that on account of the socio- economic and health implications the prevalence of FGM/C is very high across; but that such a prevalence must be construed within the framework of countries and regions that are already afflicted by the twin-burden of communicable and non- communicable diseases including poverty, hunger and malnutrition (Boutayeb 2006; Agyei-Mensah and Aikins 2010). Though the North African region accounts for the largest prevalence of FGM/C compared to other regions where the practice is endemic, Somalia and Guinea have experienced the highest prevalence estimates overall with values of 98.34% and 97.04% respective. This picture contrasts with the situation in Uganda and Cameroon where the annualised prevalence of estimates has been recorded to be of 0.84% and 1.40% respectively. In essence, the prevalence of FGM/C among children or adults aged 15–49 years is not declining or signifi- cantly increasing as widely reported by many state-of the-art reviews worldwide.
We could not find any significant evidence in the declining or increasing in the prevalence within and between regions. Surprisingly, we noted an upward trend in the Central African region despite the influence in the estimates recorded in Central African Republic. We also found that the large population base of those who have undergone FGM/C is increasing in Nigeria; however, these estimates could not sig- nificantly reverse the current direction of FGM/C prevalence seen in the current review. The findings of this chapter can assist in the mapping and modelling of such prevalence within countries and regions further based on the Bayesian geo-additive approach. It is to such an effort that the next chapter will direct itself.
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