Female genital mutilation : studies on primary and repeat female genital cutting

Background: Worldwide at least 130 million now living women and girls have undergone female genital mutilation (FGM), also called female genital cutting (FGC). Reinfibulation (RI) is a secondary form, mainly performed after delivery. In spite of documented complications, the procedures continue, and it seems essential to further reveal the underlying motives in order to increase the understanding of its persistency and to elucidate the encounter in maternity care after migration. Objectives: To explore FGC and RI in a country of origin, Sudan, and after immigration to Sweden. More specifically the objectives were: (I) to describe the perceptions and practice of FGC among rural Sudanese women and men's views; (II) to describe the prevalence of RI in hospital settings; (III) to elucidate knowledge, attitude and practice of FGC and RI in a rural setting in Sudan; (IV) to explore the experiences and perceptions of RI after delivery among Sudanese midwives; (V) to investigate the experiences of FGC and RI among Sudanese women and men; and (VI) to explore the experiences of FGC and the encounter with Swedish maternity care among women immigrants from Sudan, Somalia and Eritrea. Methods: These studies were conducted in El Gezira and in Khartoum State, Sudan, and in Sweden after immigration. The studies employed both qualitative and quantitative methods: (I) interview-administered questionnaires to 120 villagers; (II) participant observations and digital examination at 100 deliveries; (III) interview-administered questionnaires; (IV) nonparticipant observations and open-ended interviews; (V) focus groups and open-ended interviews; (VI) openended interviews. Results: (I) A high prevalence of FGC (100%) was stated among the respondents. Tradition and social importance were the main motives. The younger generation stated a change in practice, preferring the least severe form of FGC for their daughters. (II) 61% of the women included had undergone tightening vulvar operations after delivery, at the delivery wards, including women who had not been subjected to primary FGC. (III) Reinfibulation after delivery was widely practised and the main motives were social reason/tradition and alleged male sexual satisfaction. The younger generation of women described the midwife and older female relatives as being behind the decision. (IV) The midwives' motives for RI were to respond to the social requests and to benefit the women by increasing their beauty and value. (V) Women and men explained both negative health implications and perceived benefits of the practices. Both men and women were seen as victims of the consequences of the practices and blamed each other and the midwives for its persistence. (VI) The immigrant women's experienced suffering from being abandoned and mutilated, feeling vulnerable in the encounter with Swedish healthcare personnel, which led them to avoid seeking maternity care. Conclusion: This thesis indicates high prevalence of FGC and RI in settings in Sudan and health complications associated with the practices. The motives are not only social, sexual, traditional and economic, but also embrace normality, identity and power relations related to paternalism, maternalism and patriarchy. Deficient communication was demonstrated between women and men in Sudan and between women and midwives, both in Sudan and in Sweden. This thesis also shows that there is still a need of increased practical skills related to FGC among Swedish healthcare personnel and continuous training to meet culturally specific health needs