Introduction

Female genital mutilation (FGM) comprises all the procedures involving partial or total removal of the female external genitals or other injuries to the female genital organs whether for cultural or other non-therapeutic reasons.^1-5 The recognition of the harmful effects of the practice led to the adoption of female genital mutilation in preference to circumcision, which suggests a misleading similarity to male circumcision.³ It is an age long practice that cuts across nations, ethnic groups and socio- economic status. ^6-7The origin of the practice is not well known³ but it dates back to antiquity.⁷ Reference was made to it by a Greek papyrus dated 163 BC. ^8-9

It is currently estimated that over 120 million girls and women have undergone some form of genital mutilation and that at least two million girls and women are subjected to it yearly^2-4. FGM is practiced in at least 26-43 African countries¹⁰ that practice it.⁴ A rather high prevalence of 65% was reported in Benin, Southern Nigeria.⁷ However, it is gratifying to note that a generally downward trend is reported by many workers. ^8,11

In 1995, the World Health Organization (WHO) described four broad categories of FGM operations.¹² Type I is excision of the prepuce, with or without prepuce, with or without excision of part or the entire clitoris. Type II is excision of the clitoris with partial or total excision of the labia minora. Type III is excision of part or all of the external genitalia and stitching/ narrowing of the vaginal opening (infibulation). Type IV is pricking, piercing or incision of the clitoris and/ or the labia; cauterization by burning of the clitoris and surrounding tissues and any other procedure done on the external genitalia.¹ The degree of mutilation varies from place to place depending on the type of operation. Types 1 and 11 operations account for 85% of all FGM worldwide.³ In Nigeria, it varies among the different tribal groups and is determined by the anticipated benefits as well as traditional and religious beliefs.¹³

In the Muslim North, type I is more popular while among the Christians and amidst Igbos of the South, type II is preferred.¹⁴ Type III is uncommon in Nigeria.¹⁴

FGM is usually performed by traditional practitioners with crude instruments and without anaesthetics.^{5, 11} Among the more affluent in the society, it may be performed in a healthcare facility by a qualified personnel.⁵ The reasons given by families for having FGM includes enhancement of fertility, psychosexual reasons, cultural heritage, hygiene, aesthetic and faith.^8,9,15 Among the Ibos of Eastern Nigeria, it is believed to make women feminine and to promote chastity by attenuating sexual desire.^11,16

Complications are common and can lead to death. They vary depending on the type of operation, but generally may be immediate or remote.¹⁷ The immediate complications include haemorrhage, sepsis, tetanus, urinary retention, HIV infection, shock and death.¹ The late complications include infertility, implantation of dermoid cyst, cryptomenorrhoea, vulval adhesion, gynaestria, keloid formation, prolonged second stage of labour, scar or soft tissue dystocia with the attendant need for anterior episiotomy (deinfinbulation), perineal tears, fistulae, haemorrhage and infection.^18,19 In Sudan, 20-25% of female infertility has been linked to complications of FGM.²⁰

The WHO has adopted a number of resolutions urging member states to establish clear national policies to end this harmful tradition among girls and women.²¹ Many other governmental and on-governmental agencies including the United Nations Population Fund, United Nation Children Fund (UNICEF) and the International Planned Parenthood Federation have joined the WHO in advocating for the eradication of FGM.²²

This study is aimed at determining the awareness and attitude of female Nursing/Midwifery students in Afikpo, Nigeria towards female genital mutilation.

The study is focused on students because being women, they are the victims of this harmful practice and as mothers, their awareness and attitude to FGM will go a long way towards strategizing measures in abolishing this unhealthy practice.

Materials And methods

This study was done in Afikpo, a semi-urban town in Ebonyi State, Southeastern Nigeria. A semi-structured pretested questionnaire was designed to elicit information on the views and opinions of female students of Nursing and Midwifery on female genital mutilation.

Questions about their socio-demographic characteristics knowledge of FGM and its complications, attitude towards the practice of FGM were asked.

The questionnaires were distributed and were collected when completed. All the questionnaires were validated. The data generated from the validated questionnaires were statistically analyzed using the SSPS II software.

Results

Two hundred and eighty one (281) questionnaires were administered to the students, of which 269 were suitable for analysis, giving a response rate of 95.7%.

Table 1 shows the distribution of the respondents according to age. The age range in this study was 15-45 years with those aged 15-29 years accounting for 87.7% of the respondents. The mean age of the respondents was 25.4±3 years.

Age group 25-29 years constituted the majority of the respondents (44.2%) whilst age group 40-50 years constituted the least number of respondents (0.8%).

The marital status of the respondents is shown in table 2 with 208 (77.3%) single, and 61 (22.7%) married.

Table 3 shows the feelings expressed by the subjects concerning their circumcision status. One hundred and forty-six respondents claimed to be circumcised and 123 (45.7%) were not.

Seventy two (49.3%) of the circumcised group and 102 (82.9%) of the uncircumcised women claimed to be happy. Almost 8.9% of the circumcised women and 5.7% of the uncircumcised group expressed the feeling of being unhappy. The feelings expressed by the 2 groups is statistically significant (X² = 41.98; P< 0.005).

The expressed complications associated with FGM are summarized in table 4. Bleeding was expressed by 233 (86.6%) of the respondents. Infections including HIV/AIDS by (84.4%) and painful coitus was mentioned by 204 (75.6%) of the women.

Expressed reasons for circumcision are depicted in table 5. One hundred and thirty eight n (51.3%) of the respondents expressed the view that curtailing promiscuity was the reason for FGM followed by ‘external genitalia to look neat’ which was mentioned by 47 (17.4%) of the respondents.

All the respondents in the circumcised group were circumcised during infancy and claimed that they were circumcised by traditional birth attendants. They also claimed that their sisters were also circumcised.

On the opinions expressed on benefits of the female genital mutilation, 122 (45.3%) reported no benefits, while 38 (14 .1%) were of the view that it prevented sexual promiscuity and 19 (7.1%) proffered spiritual satisfaction as a ‘benefit’.

All the respondents would not wish to have their daughters or wards circumcised and were aware of the legislations banning FGM in some states. They would want the practice of female genital mutilation stopped. Almost all (96%) were aware that FGM is a crime against humanity. Two hundred and nineteen (81.4%) of the women were of the view that FGM can be best stopped by public enlightenment, 68 (25.3%) of the women suggested counseling of parents and couples on the adverse effects of FGM and 20 (7.4%)were of the view that punishing any person who aids and abets the practice of FGM is the best way to stop the practice.

Figure 1

Table 1: Age distribution of the respondents

Figure 2

Table 2: Marital status of the respondents

Figure 3

Table 3: Respondents feeling about their circumcision

Figure 4

Table 4: *Complications associated with FGM

Figure 5

Table 5: *Reasons for circumcision

Discussion

The prevalence rate of FGM probably, would be a better indicator of the magnitude of the problem.

In this study majority of the respondents were of the young age group. This is a very important target population. It is important to note that the attitude and awareness towards FGM of this young age group will reflect on the impact of on-going campaigns on FGM.

The prevalence rate of FGM in this study of 54.3%, is in keeping with the 56.4% reported by Parakoyi and Musa in Ilorin.²¹ It is however lower than the 68% reported by Megafu amongst the Ibos of Nigeria.¹⁴ The differences may be due to the variance in the groups studied or falling trend in prevalence.^11,16

The feelings expressed concerning their circumcision status when compared to that expressed by those not circumcised showed that a significant proportion of the circumcised subjects were not happy with their status. This agrees with the works of other authors.²⁴ This may be due to the fact that some of them have experienced or are still nursing some of the complications known to be associated with female genital mutilation.^18,22

Among the complications that result from FGM as listed by the respondents include bleeding, infection and painful coitus. These are also the experience of other workers.²⁵ Infections, including HIV/AIDS was mentioned by 84.4% of the respondents, a fairly large number, as in a study in Ilorin.²¹ This is indicative of high awareness of FGM as possible route of transmission of HIV among the respondents.

The ascribed ‘benefits’ of FGM include prevention of sexual promiscuity, protection of virginity and spiritual satisfaction. These benefits however cannot be scientifically substantiated.

All the respondents were opposed to the practice of FGM. This contrasts with other studies.^12,23 The reason for the observed differences may be due to the differing levels o education of the respondents and the increased awareness as a result of current campaigns. It has been shown that education plays an important role in the eradication of FGM. ^6,811,26The completion of even primary education broadens one’s outlook on life and increases one’s ability to understand more complex information and question attitudes, beliefs and practices.²³ Education is one of the strategies recommended by WHO towards abolishing FGM²⁷

Interestingly, all the respondents expressed unwillingness to have their daughters circumcised and would want the practice stopped and majority are aware that it is a crime against humanity. This contrasts with earlier reports.²¹ This positive development could be due to the fact that the World Health Organization (WHO) has integrated health workers including nurses and midwives in the African and Eastern Mediterranean region in the advocacy against FGM.²⁷ Public enlightenment and legislation suggested by these respondents as ways of abolishing FGM were in line with some of the strategies outlined by the WHO^1,12 and reported by other researchers.^21,25

In conclusion, the views, attitudes and perceptions expressed by the Nursing and Midwifery students though impressive, there is still the need to raise awareness about the associated harmful effects of FGM among women, both literate and illiterate. Education plays an important role in the eradication of FGM. Efforts should be directed towards integrating appropriate information on FGM in literacy classes and other public awareness programmes.

Reaching children at the primary level is important so that they understand what might be done to them and the potential implications. Youths can also be reached through the media, schools and other channels. Education materials should include information that will stress the harmful effects associated with the practice as well as be able to correct the misconceptions, taboos and false beliefs attached to the practice. There is need for further studies on attitude and perceptions on harmful traditional practices towards women and children with a view to abolishing such practices.