Female Genital Mutilation and Associated Factors in GonchaSiso-Enessie District, East Gojjam Zone, Amhara Region, Ethiopia (2012)

Female genital mutilation (FGM/C), or female circumcision, includes all procedures involving partial or total removal of the external female genitalia or other injuries to the female genital organs whether for cultural or other non-therapeutic reasons [1,2]. There are four main types of FGM/Cs: Type 1: Clitoridectomy/Sunna involves the removal of the clitoral hood with or without removal of all or part of the clitoris. Type 2: excision varies from the removal of the clitoris and/ or clitoral prepuce to the removal of part or the entire clitoris together with part or all of the labia minora (the inner vaginal lips). Type 3: infibulation involves the removal of the clitoris, the labia minora, and part of the labia majora after which the edges of the wound are sutured to leave a small opening (vaginal orifice). Type 4: unclassified and the intermediate practice refers to the amputation of the clitoris and parts of the labia minora [2-4].

both quantitative and qualitative methods to assess the prevalence and determinant factors of FGM/C at GonchaSiso-Enessie district, East Gojjam, Western Ethiopia, 2013. The district is located about 345 Kms from Addis Ababa city and 153 Kms from Bahir Dar town; a capital city of Amhara Region. It has an area of 2,500.85 km 2 and had an estimated total population of 141,068 (71,240 male and 69,829 female). Its 95% population is living in rural areas and Agriculture is the backbone of its economy. The district has a total of 28 functioning health institutions (6 health centres and 22 health posts).
The study population were all women in reproductive age group  residing in the District who had daughter less than five years old. The sample size was calculated using single proportion formula by considering the following assumptions: 95% CI, prevalence of region is 68.5%, variation as 5%, 10% contingency and design effect 2. Five kebeles in the district were selected randomly and households from each selected kebeles were also selected randomly to select 730 participants. Then, women from randomly selected houses were interviewed until the total sample is attained.
Quantitative data were collected via interviewing using pretested and structured questionnaire. The questionnaire was prepared in English, translated to Amharic and then translated back to English to check for consistency. Seven health care workers and two supervisors were participated in the data collection. One day training was given to data collectors and supervisors about the objective, relevance of the study, confidentiality of information, participant's right, pre-test, informed consent and techniques of interview. Qualitative data were collected through Focus Group Discussion (FGD) using unstructured interviewing guidelines and tape recorder after getting consent from participants. The principal investigator conducted FGD among 23 women assumed to be key informants until reaching to the saturation with 3 groups consisting of eight women.
Two supervisors and the principal investigator made frequent checks on the data collection process to ensure the completeness and consistency of the gathered data. Data were cleaned manually, entered and cleaned using EPI info version 6 and exported to SPSS version 20 for further cleaning and analysis. Frequencies, cross tabulation, binary and multivariate analysis were done to see presence of association between dependant and independent variables. Odds ratio and confidence intervals were used to describe observed associations among variables.

Socio demographic characteristics of the participants
A total of 730 mothers with the mean age of 29 (± 7) years were included in the analysis. Majority of women; 710 (97.3%) were Amhara and the rest were Tigrie and Oromo. Most of the study participants; 705 (96.6%) were identified as orthodox and the left 25 (3.4%) were Muslim and other Christianity followers. Of 730 respondents, 87.7%, 67.3% and 18.9% were married, cannot read-write and primary school and above respectively. Only 13 (1.8%) respondents were employees and 343 (43%) had monthly income ranging from 556-1233 Ethiopian Birr (ETB). In case of qualitative study, only four of 23 had completed their primary school education. All, except three had husbands and all were farmers and orthodox followers (Table 1).

Female genital mutilation/cutting (FGM/C) practices
Of the total 730 women, 567 (77.7%) were genitally circumcised and 458 (62.7%) of their daughters were genitally circumcised. This finding was in agreement with qualitative result where majority of women themselves and their under-five daughters were circumcised.
Of the total 458 circumcised daughters, 439 (95.9%) were under one year old, 18 (3.9%) were from 1-2 years old and only one was 3-4 years old. This circumcision age was also true in qualitative result. Majority, 380 (83%) were circumcised by traditional circumcisers and the rest 78 (17%) were circumcised by traditional birth attendant (TBA). Majority, 411 (89.7%) were circumcised by their own blade and the rest 47 (10.2%) were circumcised by shared blade, but in case of FGD, almost all participants agreed as they used own blade for circumcision purpose. One 21years respondent said, "I did not use shared blade, because it is the cause for HIV/AIDs". From the total circumcised daughters, 444 (96.9%) circumcised at their own home, 11 (2.4%) at others' home and the rest 3 (.7%) were circumcised at circumcisers' home. This was also true in qualitative study.
In general, of the 730 respondents, 455 (62.9%) of women did not know that FGC was associated with health problems. Similarly, majority of respondents in qualitative study did not know whether FGM/C resulted in health problems on circumcised groups. More than half, 449 (61.5%) of respondents supported the continuation of FGM/C practice by mentioning some reasons like to get acceptance within community, to respect values/traditions, to get husband easily, to be free from taboo, etc ( Table 2). Majority of qualitative respondents agreed on this idea and mentioned reasons in their discussion: one 30 years woman said that, "If female genital cutting didn't take place, women could be suffered from illness and many difficulties". According to her explanation, "a woman from their neighbourgot suffered from difficulties during delivery for two days because of absence of female circumcision".
However, few were against to FGM/C practice; for example, one 23 years old participant in FGD said "I saw previously women who were circumcised and non-circumcised, but gave birthwithout any problems, so the reasons were bad traditions came from ancestors called AbatAder" (local language to mean it is culture or value).
Regarding to health education access to the respondents, 264 (36.2%) and 466 (63.8%) respondents got and did not get health education from any source respectively. About 516 (70.7%) respondents agreed that FGM/C is not violation of human rights/criminal (Table  3). Concerning decision makers on FGM/C in households, all family members were participated inDoing decisions on their daughters, except daughters themselves. Majority of decisions; 72.5% Were passed by mothers, 16.2% by fathers, 8.7% by grandmothers and 2.6% were made by grandfathers. Some of the mentioned reasons by both quantitative and qualitative respondents why communities practiced FGM/C in the study area were: tradition/custom, simple to give births, simple to disverge, it is value, it increases happiness during sex, it increases society acceptance,easy to get husband and gives society respection to their families ( Figure 1). For example, one 35 years old woman raised that; "FGM/C should be practiced because ithelps women to be respected by the society, unless she is blamed by the community so called Difin Qil or Woshela/Qintiram", which is a local word/name given to none circumcised women.

Factors associated with FDM/C in reproductive age group women
According to binary and multivariate logistic regression analysis of this study, women's age, educational level, previous circumcision, FGC knowhow, health education and women's opinion on EGC as criminal    The above result was in line with results obtained from qualitative study. For example, A 38 years old farmer women said; "Iffemale genital cutting didn't take place, women could besuffered from illness and many difficulties during delivery and sexual intercourse".
Majority of respondents from qualitative study did not take health education on FGC; thereby they did not know their country's law on traditional malpractices. Two respondents told that; "FGC practice will not stop by this condition, unless there strong education on it and thenpunishment by the rule of law of a country".
Another participant also said that; "There should be uninterrupted health education including law of the country on traditionalpractices within the community using different opportunities like Edir, Ekub, elders, kebeles leaders, health extension workers, religious leaders, female associations, and similar means".

Discussion
Even though FGM/C is a very deeply rooted harmful tradition practice which will result in several complicated health problems including loss of body parts within the community, it is preventable if there is a coordinated action on it at community level starting from awareness creation to punishing those who become ignorant to the program [11,12,[14][15][16].
Based on the current study findings, about more than half, 62.7% of study participants were circumcised at different levels of their age. This finding was lower when compared with study findings from Sudan where its practice was over 90% and in Egypt as its practicing rate was 95.7% [10,12,17]. This figure was also slightly low as compared with findings of EDHS 2011 report, which was 68.5% among 15-49 aged women for Amhara Region [11]. This may be due to the variation in study area and period, variation in efforts of health extension workers and timely increase to visit health institutions for other services. The presence of high of FGM/C in regional level is an indicator of the presence of other districts or zones with higher FGM/C prevalence than the current study area.
On the other hand, this figure was considerably higher than studies conducted in Burkina Faso [18] where FGC prevalence was 30.2% and in Somali refugees in Ethiopia, which was only 30% of daughters aged below five years were circumcised [14]. This is most probably due to cultural variation, where FGM/C is less practiced in Somali region for various reasons like controlling method for girls from sexual activities unless they married and also due to respondents' age variation. Educational status and age had shown statistically significant association with FGM/C practices in the study. Individuals with educational status of primary and above were less likely practices than those who had no formal education. This finding is in line with other studies done in Ethiopia [15,19]. This might be due to individuals' exposure variation for information about FGM/C and its consequences. It is obvious that people at learning are more likely to get information on various issues than their counter parts.
In the study area, majority; 62.3% of respondents did not have knowledge on health related complications of FGM/C practices. From the above, 91.4% their daughters were circumcised, whereas 15.3% of daughters of none circumcised women were circumcised. The same study findings were observed from studies conducted in Sierra Leone [20], and in Northern Iraq [21] and in Kersa district, East Hararge, Ethiopia [15]. This is mainly due to knowledge variation on the topic among those who have exposure and their counter parts. However, the Traditional circumcisers and traditional birth attendants performed most circumcision activities in the study area. This finding was similar with other study findings in different regions and districts of Ethiopia [14,15,22]. The most logical reasons for performing circumcision by traditional way could be pushes from elders and circumcisionors, free of getting acceptance from health professionals, fear of operational free and transportation problems.
Respondents who took health education concerning FGM/C were poorly practiced the issue compared to the majority of their counter parts. This finding was in line with study findings conducted in Ethiopia and Egypt [10,12,14,15]. The most clear and probable reason for this may be knowledge gaps between the two comparative groups. It is clear that if someone knows something is harmful, its involvement in doing that activity will be less, but may not be still zero. Even though health education was the primary activity of health extension workers, majority of respondents did not get the service in the study area. This is the major identified gap and another possible reason for the presence of high prevalence of FGM/C practices there.
Even if FGM/C practices were considered as criminals by the federal government, its implementation was not still on ground. Only few, 37.8% respondents knew that FGM/C is criminal. It agreed with study findings from South Africa [23] where community awareness of law against harmful traditional practices. This was also another clear gap on disclosure and implementation of law from government and other concerned bodies. It would be one measure for giving emphasis on the issue among the community if it were done accordingly. Providing the right information to the right body at the right time and within the right means is the duty of governing body and the right of the community for doing their day-to-day activities without affecting their environment.

Conclusions
The results of this study showed that FGM/C is practiced at higher level; the determinants of FGM/C are mostly socio-demographic related. Women's age, education, previous circumcised, health education, enforced legislation, know how on FGM/C, opinion of circumcisionors, traditions and community values were the most identified significant factors for the presence of high FGM/C prevalence in the study area. Encouraging women to complete primary and above schools, providing uninterrupted integrated health education through elders, health extension workers, women affairs, youth associations and applying enforced legislation are important means to slowdown the prevalence and prevent FGM/C related health complications. Researchers should also explore effective ways of preventing FGM/C at regional and then nationwide level since it is a harmful tradition on human's body.

Authors' Contributions
The author Mulusew Andualem participated in all steps of the study from its commencement to write up, result dissemination, manuscript preparation and reviewing activities through the consultation of senior researchers and advisors.