IMPACT OF COMMUNITY BASED EDUCATION ON FGM IN A RURAL ETHIOPIANCOMMUNITY 131st Annual Meeting and Exposition of the American Public Health Association San Francisco, CA November 17, 2003 Gabremaskal Habtemariam Ph.D. Senait Tibebu M.Sc. Yeshewamebrat Ejigsemahu M.Sc. PATHFINDER INTERNATIONAL

131st APHA Annual Meeting and Exposition Female Genital Mutilation (FGM) DEFINITION: “All procedures involving partial or total removal of the female external genitalia or other injury to female genital organs whether for cultural or other non-therapeutic reasons.” - WHO TYPES: Type I: Excision or removal of the clitoral hood with or without excision of part or the entire clitoris. Type II: Excision or removal of the clitoris together with partial or total excision of the labia minora. Type III: Infibulation or removal of part or all of the external genitalia and stitching/narrowing of the vaginal opening, leaving a small hole for urine and menstrual flow.

131st APHA Annual Meeting and Exposition Historical Origin of FGM  It was recorded as early as the fifth century BC and practiced in Egypt for at least 2000 years.  Slave traders sold infibulated women for higher prices, as their services were not interrupted by child bearing.  In Ethiopia, female circumcision is believed to precede the introduction of Christianity in the 4 th century.  It is a cross-cultural and cross religious practice.  It is known by different names, including female circumcision, female genital cutting, and female genital mutilation.  In the Oromo Culture, where this assessment was undertaken, girls are circumcised just before marriage. Other ethnic groups in the area practice female child circumcision.

131st APHA Annual Meeting and Exposition

Relevance of FGM to Reproductive Health IMMEDIATE EFFECTS:  Pain, shock, bleeding, urine retention, infection, and injury to neighboring organs LONG TERM EFFECTS:  Labial fusion, scarring, keloid formation, cyst formation, PID, HIV/AIDS, Dysmenorrhea, and Dyspareunia OBSTETRIC:  Delayed labor and perenial laceration PSYCHOSOCIAL:  Decreased sexual enjoyment

131st APHA Annual Meeting and Exposition Interventions to Mitigate Female Circumcision  IEC by community-based RH agents (CBRHAs)  Education by women promoters  Support by local administration  Support by the “Geda” system  Support by Project Advisory Committee (PACs) “Geda” is a system of social regulation and culture among the Oromo ethnic group.

131st APHA Annual Meeting and Exposition A Survey was Undertaken to Determine the Effects of Community- Based Educational on FGM  The Survey Included: –Interview of parents whose daughters married in the past six years before the survey –Qualitative assessment with different groups including: Men’s group Women’s group Uncircumcised women’s group CBRHA’s group Project Advisory Committee Members Case studies

131st APHA Annual Meeting and Exposition Educational Activities Against FGM Undertaken in the Community Mothers (%) Fathers (%) Parents reporting that they had information on FGM Major Sources of Information on FGM?  CBRHAs  Health Workers  Media  Community Animators

131st APHA Annual Meeting and Exposition Other Reasons Mothers and Fathers Gave for Practicing FGM Mothers % Fathers % Respect for tradition Avoid shame and stigmatization Religious commitment Better hygiene Community pressure Suppress woman’s sexuality0.61.0

131st APHA Annual Meeting and Exposition % with Knowledge of Other Major Harmful Traditional Practices Discussed at the Community Level TOPICSMothersFathers Marriage by Abduction Early Marriage Uvulectomy Milk Teeth Extraction Applying Cow Dung on New Born Umbilical Cord

131st APHA Annual Meeting and Exposition Other Reasons Mothers and Fathers Gave for Not Practicing FGM Mothers % Fathers % Not required by tradition It is harmful Advised not to practice it Community pressure0.91.4

131st APHA Annual Meeting and Exposition Mothers and Fathers Attitudes Towards FGM Mothers (%) Fathers (%) Is FGM harmful? Yes No Do not know Should FGM be stopped? Yes No Do not know Undecided

131st APHA Annual Meeting and Exposition Mothers and Fathers Attitudes Towards FGM (continued) Mothers (%) Fathers (%) Will your unmarried daughter be circumcised? Yes No Do not know Undecided

131st APHA Annual Meeting and Exposition Harmful Effects of FGM Identified by Respondents Mothers (%) Fathers (%) Bleeding Difficulties During Delivery Pain Infection Decreased Sexual Satisfaction HIV/AIDS Transmission Marriage Problem Death

131st APHA Annual Meeting and Exposition Focus Group Findings  There was a case of one circumciser who had her first daughter circumcised, but decided not to have her second daughter after receiving education. She is now educating against the practice of FGM.  Some of the uncircumcised girls said that they would now refuse to let their parents have them circumcised.  Educating on the negative health impacts tends to work better than other approaches (including regulations)s  Young unmarried men have said that they would not want their wives to be circumcised.  The community has promised the “Geda” elders that they would stop FGC.

131st APHA Annual Meeting and Exposition Trends in Female Circumcision in Shashamene Area of Oromia Region, Ethiopia-2003

131st APHA Annual Meeting and Exposition Conclusion  The trend shows a decrease in the proportion of girls circumcised during the three years before the survey, which coincides with the starting of a community based reproductive health project in the area. WHAT CAUSED THE REDUCTION OF FGM?  Education by CBRHAs appears to have initiated other actions by the community.  Formal and informal support from community leaders.  Opposition by authoritative “Geda” leaders reinforced educational initiatives.  Winning over circumcisers. Some parents have refused to allow their daughters to be circumcised.

131st APHA Annual Meeting and Exposition Recommendations  Education on the effects of FGM and other harmful traditional practices requires an understanding of local customs and traditions.  Collaboration among all community level actors.  Using health risk approach to fight FGC.  Raising awareness and gaining the support of young male and female stakeholders.  Involving and winning over local circumcisers is an effective way.

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