Variations in the Prevalence of Female Genital Mutilation Among Reproductive-aged Women in Nigeria Across Three Generations

1.1. Background of the Study

Globally, female genital mutilation (FGM) primarily takes the form of traditional procedures performed on girls and women. Firmly woven into cultural beliefs and perceptions, FGM has been in place for many years, particularly in developing countries, and has been passed down across many generations, making it challenging to change what has been practiced over decades.1 The dominance of its practice is mainly in many low and middle-income countries (LMICs) of Africa, Asia, and the Middle East.2 In Ethiopia, FGM is commonly performed, and it is a significant contributor to the country’s high maternal death rate. This practice is regarded as a major national public health issue since it impacts the physical and mental health of more than half of Ethiopia’s population, which in turn also impacts the country’s socio-economic development.3 Also, in Nigeria, subjecting girls and women to obscure traditional practices has been described as legendary.4 The World Health Organization (WHO) further described FGM as an “intentional alteration or infliction of injury to the female genital organs for non-medical reasons despite the evidence that it is of no benefit to females and can result in severe bleeding and problems with urination, cysts formation, infections, and other complications in childbirth and increased risk of infant deaths.5 The WHO strongly condemns FGM practice by health professionals in the process dubbed as medicalization because it violates the human rights of girls and women.1 The practice reflects deep-rooted inequality between the sexes and constitutes extreme discrimination against women.5 According to WHO, FGM is mainly performed on minors, and in most cases, the cutting occurs before the child is 14 years old.6

The global prevalence of FGM is declining, however, the body of published literature to support this decline is inadequate.6 Nigeria is one of the countries with the highest prevalence of FGM with about 115–130 million circumcised women currently living with the health consequences of FGM which accounts for about one of every four cases of the global burden.1 A study in Nigeria showed that although FGM awareness was high (93.6%) among mothers, the majority (67.2%) who have had FGM still practiced it and who have at least one daughter who has undergone FGM.7 Similarly, only 10.4% of these mothers believed that FGM was harmful.7

Several factors are associated with FGM practices, including education, religion, culture, and mother’s experience of FGM.2,8 The most important factor related to a daughter’s circumcision is her mother’s experience and level of education. Ogbu’s study confirmed that FGM is deeply rooted in religion, culture, and tradition in Nigeria and suggested that for this practice to be reduced, the government should enforce laws that will deter the perpetrators of this practice.9 While some studies found a significant association between FGM and religion, particularly the Islamic faith,6,8 other studies did not.10,11 Long-standing cultural beliefs and practices were cited as the main reasons for performing FGM in some parts of Nigeria,7 particularly among the Yorubas and the Igbos, which is higher compared to their Hausa counterparts.9

1.2. Objectives of the Study

The study objective was to determine the prevalence of FGM among three generations of Nigerian women of reproductive age.

1.3. Specific Aims and Hypothesis

Specifically, we sought to determine the association between cultural/ethnic requirements, the prevalence of FGM practices in Nigeria, mother’s education, history of FGM, religion, awareness of health problems, the adverse psychological effects of intergeneration variation, and the factors associated with mothers choosing for their daughters to be circumcised.

2.1. Study Design

This was a cross-sectional study among women of reproductive age between 15-49 years within the Federal Capital Territory (FCT), Abuja, in four participating public hospitals considered to have a high volume of women attending the antenatal clinics (ANC). These hospitals were located in Kubwa, Nyanya, Asokoro and Maitama. These locations were chosen because they are densely populated with people from diverse ethnic backgrounds. The study used questionnaires designed to obtain primary data from the respondents. The respondents were also interviewed. The data collectors documented the online responses using Google Forms.

2.2. Setting

Respondents in the study were pregnant women attending ANC at the participating health facilities. The study was conducted between May 28 and July 11, 2019. The study was carried out in Abuja, which comprises six Area Councils-Municipal: Abaji, Abuja Municipal, Bwari, Gwagwalada, Kuje, and Kwali. The city of Abuja is considered cosmopolitan, people from all the six geopolitical zones of Nigeria and other parts of the world reside in Abuja. As of 2016, its growth rate was estimated to be 6.11%, with an estimated population of 3,564,126; males 51%, and females 49%.12 The population of women of reproductive age in Abuja was estimated to be 855,747 (using the 2016 population estimate). The inhabitants identified primarily as Christians, Muslims, and other traditional worshippers.12 All participants of the study were women of reproductive age who had at least one daughter. Eligible respondents were consecutively enrolled until the required sample size from each facility was attained.

2.3. Study Variables

The dependent variables included the respondent mother’s FGM experience, respondents’ FGM experience, and daughter’s FGM status, while the major independent variables included the respondent’s education, religion, cultural requirement, and tribe.

2.4. Statistical Analysis

Aggregate data from the Google Form database was exported to Statistical Package for the Social Science (SPSS) version 25 for the analysis.13 Descriptive and inferential statistics were performed. The results are presented in Tables 1-3. Univariate and multivariate analyses were performed to determine the factors associated with women choosing for their daughters to be circumcised. A p-value of p<0.05 were considered significant. Ethical approval was obtained from the FCT Health Research Ethics Committee (approval number FHREC/2019/01/55/16-05-19 with one calendar year validity period).

2.5. Sample Size

The total sample size for the study was determined using Raosoft® online software.14 With an error margin set at 5%, confidence interval at 95%, and an estimated response rate of 50%, the minimum calculated sample size for the study is 384.

3.1. Sociodemographic Characteristics

This study comprised 634 females from four major healthcare facilities, namely: Asokoro (124, 19.6%), Kubwa (141, 22.2%), Maitama (88, 13.9%), and Nyanya (281, 44.3%) general hospitals in Abuja, the federal capital city of Nigeria. The average age of the respondents was 33 ± 60 years with a minimum and maximum of 20 and 49 years, respectively. The most common ethnic group was Igbo 194 (30.6%), followed by Hausa, 172 (27.1%), and Yoruba, 147 (23.2%). Other tribes constituted 19.1% of all the respondents; they include tribes that cannot be directly classified within the three major ethnic groups. Slightly more than half of the respondents were self-employed (50.3%), 33.1% were civil servants, and 16.6% were unemployed. More than 3 out of every 5 respondents had post-secondary education (62.6%). The majority of respondents were Christians, 489 (77.1%), and married (96.8%).

The association between Yoruba ethnicity status with circumcision status for the first and second generations was 49.7% and 32.7%, respectively. The association between Igbos ethnicity status and circumcision status was 41.2% and 31.4% for the first and second generations respectively. The association between Hausa ethnicity status and circumcision status was 20.3% and 16.9% for the first and second generations respectively. The association between other ethnic status and circumcision status was 42.1% and 35.5% for first and second generations, respectively.

The prevalence of FGM practices declined from 37.7% reported for the first generation to 28.5% for the second generation, to 8.7% reported for the third generation. FGM was most common among the Yorubas with 49.7%, 32.7%, and 10.9% prevalence reported across the three generations. FGM prevalence among Igbos across the three generations was 41.2%, 31.4%, and 7.2%, respectively, while prevalence among Hausa was 20.3%, 16.9%, and 9.3% respectively. Among the other tribes (Akwa Ibom, Bayelsa, Edo, Rivers, Idoma, Benue, Urhobo as the major ones), the prevalence of FGM was reported at 42.1%, 35.5%, and 7.4% across the three generations respectively.

The practice of FGM was associated with lower formal education status attainment(55.6% of respondents without formal education and 58.6% of the respondents who attained only a primary level of formal education reported that their daughter/s were circumcised). Of mothers who reported that their own mothers were circumcised, 44.4% of respondents with no formal education were circumcised, 41.2% of these respondents who had only primary education were circumcised of these mothers, 11.1% of those who had no formal education chose to circumcise their daughters, while 27.6% of the mothers who had only primary education, chose to circumcise their daughters. Among respondents that attained post-secondary education, the proportions of circumcision across the three generations were 35.0%, 27.5%, and 7.6%, respectively. However, the proportion of circumcision in the third generation is statistically significant (p = 0.03). The practice of FGM is significantly higher in the third generation among traditionalists than the other religions. FGM practice was not reported as being significantly associated with marital status or age for any of the three generations (p>0.05), Table 1.

3.2. FGM Prevalence Among Women of Childbearing Age and Direction of Change in Prevalence Across the Three Generations

As shown in Table 2, a significantly higher proportion of respondents (64.9%) whose mothers were circumcised also had the procedure themselves, in comparison to those whose mothers were not circumcised (2.2%) or who did not know whether their mothers were circumcised (25.0%) p<0.001. Similarly, a higher proportion of respondents whose mothers were circumcised (18.0%) also chose to circumcise their daughters in comparison to 0.2% of those whose mothers were uncircumcised (p<0.001). A significantly higher proportion of circumcised women (29.2%) chose to circumcise their daughters in comparison to the 0.4% of uncircumcised women. Also, among respondents that were not sure whether their mothers were circumcised, only 8.7% circumcised their daughters (p<0.001).

As shown in Table 3, circumcising status of daughters in primary/non-educated was 1.48 (95% CI:0.41-5.31; p<0.05) times higher than that of secondary/higher (p<0.005) while for religion, the circumcising status in traditional and Islam were 4.94 (95% CI: 0.29-84.56; p<0.05) and 2.27 (95% CI: 0.94-5.49; p<0.05) times respectively higher than that of Christian. Respondent’s mother being circumcised was 1.69 (95% CI 0.26-10.85; p<0.05) times or mother’s circumcision unknown was 5.41 (95% CI: 0.78-37.34; p<0.05) times higher than that of respondent’s mother not being circumcised, respondents being circumcised was 54.71 (95% CI:0.78-37.34; p<0.001) times higher than that of not being circumcised, FGM being allowed by respondent’s religion was 2.03 (95% CI: 0.79-5.23; p<0.05) times higher than that of not being allowed, FGM required by culture was 2.48 (95% CI:1.00-6.19; p<0.05) times higher than that of not required by culture, and not knowing any adverse psycho-social/emotional effect of FGM was 4.39 (95% CI:1.46-13.17; p<0.05) times higher than those who knew.

4.1. Strengths and Limitations of the Study

The respondents reported all information obtained for this study (including those of the first and third generations). Direct reports from these other two-generation women and girls could have limited possibilities of recall errors. This study did not explore whether FGM is allowed by their husband’s religion and culture and did not extend to verify whether the mothers-in-law of the respondents were circumcised. Some respondents have not been circumcised as well as their mothers, but their daughters were circumcised. Variables including the husband’s and mothers-in-law may provide insight into these occurrences and are recommended as new areas for further research. This might be why some women were not circumcised, but their daughters were cut. However, the strength of this study lies in the study location. The study was conducted in the capital of Nigeria, which comprised women from all ethnic groups and backgrounds.