Predictors of Female Genital Mutilation or Cutting Among Daughters of Women in Guinea, West Africa

Background of the Study

Female genital mutilation/cutting (FGM/C) is a worldwide problem affecting Africa and the Middle East.¹ It is a common traditional practice which involves a partial or total removal of female's external genital organ for non-medical reasons.² This practice transpire in different communities with varied reasons which involves a complex mix of socio-cultural, psychosexual, hygienic and religious beliefs.³ According to UNICEF² more than two-hundred (200) million girls and women alive today have undergone some form of FGM/C in thirty (30) countries across Africa and the Middle East and in addition, thirty (30) million girls are at risk in the next decade.

Studies have identified four types of FGM/C: type 1, partial or total removal of the clitoris and/or the prepuce; type 2, partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves narrowing of the vaginal opening through the creation of a covering seal; and type 4, includes all other harmful procedures to the female genitalia for non-medical purpose such as piercing, pricking and scraping.^4,5

FGM/C is associated with numerous complications as a result of limited surgical competencies of most FGM/C practitioners (e.g. traditional birth attendants), non-utilization of anesthetic agents and nonexistence of antiseptic techniques.⁶ These complications include severe pain (usually in the absence of anesthetic agents), acute urinary retention, vaginal lacerations at coitus and hemorrhage inter alia.^7-9 In the long term, FGM/C may lead to poor quality of life, death or both.¹⁰

In some African countries like Guinea, FGM/C has been considered as an important social norm that is essential in ensuring girls' and women's virginity by reducing their sexual desires.⁹ The prevalence rate of the practice varies among countries. With a prevalence of 96%, Guinea is the country with the highest prevalence of FGM/C in girls and women aged 15-49 in Africa.¹¹

Previous studies on FGM/C in Africa⁸ and in particular countries such as Benin,¹² Burkina Faso,¹³ Cote D' Ivoire,⁴ Ethiopia^5,14 and Nigeria¹⁵ have identified factors such as place of residence (urban and rural settlement), education and household wealth to be associated with FGM/C. Despite the high prevalence of FGM/C in Guinea, there is no evidence to explain the high prevalence of FGM/C in the country.

Objectives of the Study

The objective of the study was to examine the factors associated with FGM/C among daughters of women aged 15-49 in Guinea.

Specific Hypothesis

This study is guided by the hypothesis that individual and contextual level factors are associated with FGM/C among daughters of women aged 15-49 in Guinea.

Study Variables

Data from the women's file of the 2018 Guinea Demographic and Health Survey (GDHS) was used in this study. GDHS is part of a number of surveys obtained from the MEASURE DHS Program and contains information on a number of population and health issues including FGM/C. Data of 10,721 women of reproductive age (15-49 years) who had at least one daughter aged 0-14 were considered for the analysis. In selecting all eligible women for interviews from households, the GDHS utilized a multi-stage, stratified sampling design. Detailed information about the methodology employed in the survey is in the final report.¹⁶

The dependent variable in this study was “FGM/C among daughters of women aged 15-49.” To derive this variable, respondents who had daughters were asked how many of their daughter(s) had their genital area “nicked with nothing removed;” “something removed,” or “sewn shut.” The response ranged from ‘no daughter’ to ‘1,2, 3, 4, 5, 6, 7 daughters.’ To provide a binary outcome, women who said none of their daughters went through FGM/C were coded as ‘No=0’ and those who had at least one daughter circumcised were coded as ‘Yes=1.’

Ten explanatory variables, consisting of seven individual level and three contextual level factors were considered in this study. The individual level variables were age (15-19, 20–24, 25–29, 30–34, 35–39, 40–44, 45-49 years), maternal education (no education, primary and secondary or higher), partner's education (no education, primary and secondary or higher), religion (Islam, Christianity, others-animist/ no religion), employment status (employed or unemployed), FGM/C status (yes or no) and wealth index (poorest, poorer, middle, richer, richest). The wealth index is a composite measure of a household's cumulative living standard and is calculated by employing Principal Component Analysis (PCS) using easy-to-collect data on a household's ownership of selected assets, such as televisions and bicycles; materials used for housing construction; and types of water access and sanitation facilities. It is then divided into quintiles (1-poorest, 2-poorer, 3-middle, 4-richer and 5-richest).¹⁷ The contextual factors were sex of family head (male or female), place of residence (urban or rural), and region of residence (Boke, Conakry, Faranah, Kankan, Kindia, Labe, Mamou, N'zerekore). The selection of these variables was based on their associations with FGM/C in previous studies.^18-22

Statistical Analysis

Stata version 14.2 for Windows (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP) was used in analyzing the data using a two-step analytical approach. First, the distribution of FGM/C among daughters of women aged 15-49 by the individual and contextual level factors were presented in frequencies and percentages. Statistical significance of the association between each of the factors and FGM/C among daughters of women aged 15-49 was assessed using chi-square test of independence [χ²] at a p-value of 0.05 (Table 1). A two-level multivariable multilevel logistic regression models to examine the effect of individual and contextual factors on FGM/C of girls followed this. The two-level models focused on women (level 1) and contextual factors (level 2). In terms of modelling, four models, comprising an empty model (model 0), model 1, model 2, and model 3 were fitted. Model 0 showed the variance in the outcome variable attributed to the contextual level factors without the explanatory variables. Model 1 contained only the individual-level factors while Model 2 had only the contextual level factors. Model 3 was the full model that contained all the individual and contextual level factors.

For all models, the fixed effects (measures of association) together with their corresponding 95% credible intervals (95% CrIs) as opposed to 95% confidence intervals (95% CI) were presented. The use of Crls is based on the use of the Bayesian statistical inference, where probability distributions for association measures are derived (ORs) and allows for summarizing with 95% credible intervals (95% Crl) instead of 95% confidence intervals (95% CI). The choice of credible intervals is supported by the possibility of the parameter taking a value in the specified range. ²³ Mean odds ratio (MOR) was used to measure the possible contextual effects in the modelling. ²⁴ The proportion of the variance in FGM/C in girls which is explained by the contextual factors was assessed using Variance Partition Coefficient (VPC) (Table 2).

To check for correlation among the explanatory variables, a test for multicollinearity was carried out using the variance inflation factor (VIF) and the results showed no evidence of high collinearity (MeanVIF=1.35, MaximumVIF=2.20, and MinimumVIF=l.03). Sample weight (v005/l,000,000) and SVY command were used to correct for over and under-sampling and the complex survey design and generalizability of the findings respectively. The MLwinN software version 3.05 was used for the analysis.²⁵

Ethical Approval

For this study, ethical clearance was not demanded since pre-existing publicly available DHS dataset was used. Inner City Fund International as well as an Institutional Review Boards (IRB) of Guinea approved all the DHS surveys in line with the U.S. Department of Health and Human Services regulations for the protection of human subjects. The data for this study can be accessed here: https://bit.ly/3bFHOVp

Socio-demographic Characteristics

As shown in Table 1, most of the women whose daughters were circumcised were aged 35-39 (48.4%, CI=44.9-51.9), in the poorest wealth index (31.6%, CI=28.7-34.7), had no formal education (31.5%, CI=30.1-33.0), had partners with no formal education (36.7%, CI=35.1-38.3), were Muslims (27.3%, CI=26.0-28.6) and were employed (27.4%, CI=26.0-28.8). Majority of the women whose daughters were circumcised had undergone circumcision themselves (26.0%, CI=24.8-27.2), lived in male-headed households (26.3%, CI=25.1-27.6), lived in rural areas (29.7%, CI=28.1-31.3) and were from the Labe region (36.0%, CI=33.1-39.0). All the socio-demographic characteristics had significant relationship with circumcision of girls at 95% CI.

Individual and Contextual Factors Associated with FGM/C of Girls in Guinea

Table 2 shows results of the multivariable multilevel logistic regression models of the study. The full model contains all the individual and contextual level factors and circumcision of girls. In terms of the individual level factors, compared to women aged 15-19, women of all age categories had higher odds of having circumcised daughters with the substantially highest odds among those aged 35-39 (aOR=26.10, CrI= 11.22-53.94). We observed high likelihood of FGM/C among daughters of circumcised mothers (aOR=5.50, CrI=3.1 1 -9.72), compared to those who were not circumcised. Compared to Muslims, women who were either animists or had no religion were more likely to circumcise their daughters (aOR=2.13, CrI= 1.12-4.05). Conversely, with reference to women with no formal education and those whose partners had no formal education, those with secondary/higher education (aOR=0.78, CrI=0.62-0.97) and whose partners had secondary/ higher education (aOR=0.82, CrI=0.69-0.97) were less likely to have circumcised daughters. Women who were Christians were less likely to have circumcised daughters (aOR=0.57, CrI=0.41-.0.78) compared to Muslims. The likelihood of FGM/C among daughters was lower in women of richest wealth index compared to those of poorest wealth index (aOR=0.67, CrI=0.50-0.98). With the contextual factors, the likelihood of FGM/C among daughters was lower among women who lived in the Faranah region (aOR=0.69, CrI=0.54-0.89) and N'zerekore region (aOR=0.34, CrI=0.25-0.47) but higher among those who lived in the Kankan region (aOR=1.40, CrI= 1.09-1.79) compared to women who lived in the Boke region.

All the models showed significant variation in FGM/C of girls across the contextual levels especially in the final model. As shown in model 0, there were substantial disparities in the odds of FGM/C in girls across the contextual level (σ2= 0.34, 95% CrI 0.26 to 0.41). Results from the median odds ratio (MOR) also supported evidence of contextual factors shaping FGM/C in girls. From the full model (model 3), there is evidence that when a woman relocates to a different context, median increase will be 1.43% (1.31-1.53).

Strengths and Limitations of the Study

The strength of the study lies in filling the gap in literature on the predictors of FGM/C in girls in a high FGM/C prevalence country in Africa. The use of a nationally representative data also buttresses the reliability and generalizability of the findings to the whole country. Despite the strengths, some limitations inherent in the current study cannot be underestimated. First, the DHS data used followed a cross-sectional design, meaning that inferences drawn from the findings to represent causality should be interpreted with caution. Secondly, the use of secondary data which contains already existing variables limits the ability of the study to consider essential socio-cultural factors that can influence FGM/C in girls. Finally, collecting self-reported data on a sensitive issue like FGM/C may be influenced by social desirability bias which can lead to over- reporting or under-reporting.

Compliance with Ethical Standards