Recommendation 1: Health workers should be trained in approaches to prevent FGM and manage FGMrelated health complications.

 

Strength of recommendation: Strong (moderate- to very-low-certainty evidence) 

Training and providing capacity-building resources for health workers can help to improve their knowledge about FGM and its complications, their skills in managing FGM-related complications and their ability to communicate effectively about FGM prevention. Participating in effective training will help health workers respond to the needs of their clients and patients while also contributing to FGM prevention and care as part of multisectoral efforts. Assessing the impact of training and capacity-building activities on service provision for a sensitive topic like FGM requires consideration of the positionality of health workers and how their own belief systems can impact the care they provide. Health workers are a bridge between the health system and the communities they live in. Those who live in FGM-practising communities would likely understand the social norms driving the practice of FGM, and they might also hold beliefs that are supportive of the practice. Training and capacity-building efforts in highprevalence settings must therefore not only build skills, but also address the underlying values and beliefs of health workers and encourage them to promote FGM prevention among their colleagues, peers, family members, clients and patients, and others in the communities they serve. Likewise, FGM-related training initiatives for health workers in diaspora settings or who are working with a variety of ethnic groups should also emphasize the provision of sensitive care and the prevention of FGM-related stigma.

- Summary of the evidence -

The systematic review of the evidence for this recommendation considered studies related to interventions designed to increase health workers’ knowledge of FGM practices and risks, knowledge of the management of FGM-related complications (immediate, obstetric/ neonatal, gynaecological, psychological and sexual), skills in providing compassionate care and FGM-prevention counselling, and knowledge on laws and policies related to FGM, including professional codes of conduct specific to FGM.2 Training, for the purposes of this review, was defined broadly to include didactic teaching, practical sessions, trainee supervision and mentoring. The evidence review included five studies using pre- and post-intervention assessments, two non-randomized controlled studies and one cluster randomized trial (CRT). All the studies were conducted among health workers. The pre–post studies were conducted in Kenya (1 study), Mali (1 study), the United Kingdom of Great Britain and Northern Ireland (2 studies) and the United States of America (USA) (1 study). The two non-randomized controlled studies were conducted in Mali and the USA (1 study each). The CRT was a multicentre study conducted in Guinea, Kenya and Somalia. Irrespective of study type, the certainty of the evidence was low (for the multi-country CRT) or very low (for the pre–post and non-randomized controlled studies), suggesting that training of health workers on the background of FGM, and approaches to treatment and prevention of FGM-related complications, whether face-to-face or virtual, improves their FGM-related knowledge and their confidence to identify and treat FGM-related complications as well as their communication and counselling skills. There was conflicting evidence regarding the effect of the training on health workers’ attitudes towards FGM, FGM medicalization and reinfibulation in settings where reinfibulation is commonly requested. The non-randomized controlled study from Mali by Diop et al. (n = 108) found that after three months, health workers who received the training intervention had improved knowledge of any type of FGM; better ability to identify FGM-related health complications; attitudes that were less supportive of FGM, its medicalization and reinfibulation; and improved willingness to lead anti-FGM efforts in their communities. The other non-randomized controlled study, from the USA by Jacoby & Smith (n = 11), reported an increase in health workers’ FGM-related knowledge and their mean confidence level when counselling women with Type III FGM after the training intervention. The mean confidence level of health workers also increased following the training on deinfibulation and repair, which used simulated pelvic models. Five pre–post studies were included in the evidence review. One study from the United Kingdom by Elliott et al. (n = 49) reported an increase in knowledge about the types of FGM but no significant difference in attitudes regarding FGM following a brief interactive training session. The study from Kenya by Kimani et al. (n = 26) reported an increase in knowledge on FGM, including the types of FGM and the health risks. In addition, all the participants responded correctly post-training that FGM violates women’s and girls’ human rights, and that FGM performed by medical personnel is not safer. The study found that, after training, health workers were significantly more likely to resist requests for reinfibulation by a woman under pressure from her husband to reinfibulate. However, participants’ knowledge was reported to be “poor” to “moderate” on the importance of leaving a woman deinfibulated. A study conducted among nursing students in the USA by Hess et al. using pre- and post-intervention assessments tested a training approach using a virtual patient simulation and found an improvement in knowledge on FGM and attitudes against medicalization and reinfibulation after childbirth. Two other pre–post studies tested a digital training intervention; the one conducted in the United Kingdom by Barnawi found increased knowledge on FGM complications and improved attitude scores while the one conducted in Mali by Newman & Nelson found improved management of complications, and both reported improvement in communication and competent care. The certainty of the evidence from all of these studies was considered very low. The three-country CRT by Balde et al. showed that health workers exposed to the training intervention had significantly improved FGM-related knowledge and skills and were more likely to communicate with antenatal care (ANC) clients about FGM prevention. Additionally, ANC clients served by these health workers were significantly more likely to be strongly opposed to FGM, to report that they did not intend to cut their daughters and to want to be actively engaged in FGM prevention. The GDG noted that some of these studies were conducted in high-income settings with low FGM prevalence and limited numbers of participants, and over a short time frame. It is therefore unclear whether the findings are applicable to lower-resource settings with high FGM prevalence or if the observed positive effects would be sustained over a longer follow-up period. In addition, the effects of the training intervention on patient values and preferences remain unclear. The studies also evaluated diverse training interventions in varied settings with varied cadres of health workers. This variability introduces significant uncertainty with regard to the generalizability of the observed effects of FGM-related training interventions. It is also not clear if the improved knowledge and attitudes of health workers will lead to better outcomes at the client or patient level.

A separate systematic review and synthesis of qualitative evidence on the appropriateness, feasibility and acceptability of health workers facilitating access to legal and social service interventions for their clients and patients3 found that women and girls living with FGM felt that there was poor awareness of contemporary FGM issues among health workers (52) and lack of awareness of changing trends in the practice of FGM, especially among diaspora communities (53). According to the participants of one study in the United Kingdom by Karlsen et al., many of those in the diaspora had come to reject the practice but health workers were unaware of this and assumed that their clients and patients supported it (53). Some health workers were also not conversant with issues relating to FGM or how to identify it, and participants complained of their ignorance in this area. In addition, the review found that some health workers lacked knowledge about various aspects of FGM and required training on identifying FGM, current trends in FGM, and cultural competency/sensitization (52–54). In four studies included in the qualitative evidence review, participants said they thought health workers should undergo training in cultural competency and cultural sensitivity, which is particularly needed when they must facilitate referrals to legal or social service interventions (52–55). Although those four studies were conducted in high-income countries, the views came from participants who were originally from low- and lower-middle-income countries

- Rationale -

 Acknowledging the low certainty of the evidence, but noting the clear benefits of training health workers – based on the knowledge and experiences of GDG members and indirect evidence from established training programmes for other health conditions – the GDG made the decision to issue a strong recommendation to promote the training of health workers on key aspects of FGM as part of promoting the prevention of FGM and management of complications. There was consensus that training health workers on FGM prevention and care will improve equity since health workers rarely receive FGM-related training. 

- Implementation remarks -

The GDG noted that it is important for relevant training programmes to address health worker values and beliefs within a programmatically supportive legal and policy context. It is also important that mandatory reporting requirements for health workers are taken into consideration during training, as these policies could impact service provision and healthseeking behaviour. The GDG also highlighted the need for adaptation of training materials and approaches to ensure health workers receive context-specific content about FGM prevention and management of FGM-related complications. No study identified any harmful effects of training. However, it is not clear what inadvertent effect the training might have on FGM medicalization, and whether some health workers might use their knowledge to promote 

FGM medicalization or if it might drive the practice elsewhere. Inclusion of content on cultural competency, cultural sensitivity and ethical aspects of FGM prevention and management in training programmes for health workers could further improve the impact of such training. With regard to resource considerations, the GDG highlighted that while training might be expensive in the short term, the long-term impact on FGM prevention makes training a cost-effective strategy. A WHO-led study has estimated that if FGM were fully abandoned in all countries where it is practised with immediate effect, the costs of treating health complications would reduce by 60% over the next 30 years (the years 2018 to 2047 were used in the study). While some research has estimated the costs of conducting training, no study has presented the cost-effectiveness of implementing a training intervention, although it is assumed that incorporating health worker training into pre-service curricula of health workers would be more cost-effective than venue-based training programmes for licensed health workers, although both would be needed to reach current and future health workers. A systematic review of qualitative evidence on programme managers’ perceptions of health system interventions4 found that innovative approaches to training, awareness creation and fostering partnerships enhance the uptake of anti-FGM messages among medical students, although there was low confidence in these findings since they were based on one study included in the review, by Ahmed et al., which was conducted in Sudan, and were based on views of one programme manager from an international NGO and one representative from a governmental agency. Innovative approaches to awareness creation, such as the “SCORAtalk”, which mimics the TED Talk model, were perceived to improve the spread and uptake of anti-FGM messages by medical students. The partnership between medical students and professional health associations also facilitated the implementation of this innovative approach. “Medical students … sent messages to their peers and conducted a lot of forums with good attendance, for example the ‘SCORAtalk’ in 2017. They acted as change agents in universities in other states … they had amazing results!”. Furthermore, the systematic review found that health workers’ knowledge of FGM and their capacity for managing FGM complications was suboptimal. This finding is based on three studies conducted in three African countries. The poor knowledge and low capacity are perceived to be due to the absence of a training curriculum that included the topic of FGM, as reported by a participant from Guinea. The lack of adequate training in Sudan was also perceived to affect the self-efficacy of health workers. In this regard, the GDG noted that innovative approaches to training and capacity-building may need to be deployed for inschool awareness creation and training of health workers on FGM. GDG members also noted that health worker professional associations could facilitate awareness-building and training on FGM and that there may be a need for pre-service training curricula that include modules on FGM.

- Research gaps-

 There was a lack of evidence on the effects of the timing of training interventions on health worker outcomes and whether pre-service training involving students or in-service training of licensed health workers was more impactful, including a lack of evidence on any reduction in FGM medicalization. Likewise, the effect of mentorship in conjunction with training is not known but it could potentially enhance the impact of training. There is also a gap in the research about the long-term impact of training since most studies assessed short-term effects soon after training completion. Another important research gap relates to the lack of data on outcomes at the client or patient level, which would enhance understanding about how training can impact the experience of service delivery and the level of client/ patient satisfaction with the care they receive, and whether clients/patients seeing trained health workers are more likely to have better clinical outcomes, more likely to support FGM abandonment, and less likely to subject their daughters to it.