Reproductive health and female genital cutting (FGC)

In Mozambique as in many countries, reduction of maternal mortality particularly due to unsafe abortion is claimed as the main reasons for legalization of voluntary termination of pregnancy and comprehensive abortion care. Although the comprehensive abortion care has been highlighted in government SRHR priorities, different evaluations acknowledge that the approach of increasing reproductive health service particularly to young people is being poorly implemented and not achieving the desired effect

Research questions:

• How is comprehensive abortion care services distributed throughout the country, taking into consideration population density and socio demographic characteristics, level of care, level of urbanization and regions?
• What are the perceptions and experiences on access to comprehensive abortion care in rural vs urban areas among young people? Are there any Gender and Equity differences?
• What are the perceptions and experiences of Healthcare providers on the provision of comprehensive abortion care for young people?
• What are the contextual driving factors that led different stakeholders to the agenda setting for changes in abortion legislation and policy and how are they mediating its implementation?

The overall aim of this project is to contribute to the existing evidence looking at challenges and opportunities in providing and accessing Comprehensive Abortion Care (CAC) with focus to Voluntary Termination of Pregnancy (VTP) among young people by looking at policy level, service provision and utilization in the legalized context. Qualitative and quantitative methods are used for the data collection in the project, which is run as a doctoral project in the field of global reproductive health.

Birgitta Essén, Professor
Pia Axemo, Associate professor
William Ugarte, Researcher
Gilda Gondola Sitefane, PhD Student

Eduardo Mondlane University, Maputo:
Khatia Munguambe, PhD
Esmeralda Mariano, PhD

Funding: Sida

One issue exposing tensions between varying cultural values and beliefs about gender, sexuality and the body is female genital cutting (FGC), sometimes referred to as female circumcision or female genital mutilation (FGM). With migration, people living with FGC in countries not traditionally associated with the practice have become more common. While the practice is usually cherished as a meaningful intervention and identity marker in regions where the procedures are customary, many western countries have reacted to the practices with bans and condemnation and official bodies have run programs aimed at protecting younger generations from the practice, including training for professionals, awareness-raising efforts and media campaigns. This project takes as its starting point these tensions between various cultural ideas about health, body and sexuality; What are the discourses on FGC in relation to sexuality among young women from FGC-practicing communities? How do professionals work with young women that have undergone FGC? What sort of issues, if any, are at stake in encounters with young women with FGC? How are universalizing claims of “rights” or “harm” reconciled with complex, local understandings of gender, sexuality and the body? How can national initiatives and professionals navigate this complex terrain?

Theoretically the project aims to investigate the influence of cultural constructions on the experiences of body and sexuality. There is also a more practical dimension to the project that speaks to the broader question of how to provide care and support for culturally diverse groups when it comes to sexual matters, with the overall aim to inform discussions about approaches for service provision to young cut women in the field of sexual and reproductive health.

Research questions

• How can sexual health interventions be designed to target the needs of young and older Somali women in general, and promote sexual wellbeing for circumcised women in particular?
• What happens with views on sexuality, body and health in relation to female genital cutting after migration to Sweden?

Birgitta Essén, PI, professor

Malmö University:
Camilla Larsson Palm, PhD student
Sara Johnsdotter, professor
Eva Elmestig, associate professor

Funding: VR, Forte

This project is a collaboration between six migrant-receiving states: Canada, France, Sweden, Belgium, Switzerland and Spain. The project goal is to improve the health care for immigrant women with female genital cutting (FGC). Given the variations in how the countries address the prevention of FGC the project is proposed:

• To develop a knowledge, attitudes and practices (KAP) questionnaire that will be country/region specific and reflective of women’s voices. This is to better understand the knowledge, attitudes and practices of health care professionals (obstetricians, general practitioners, paediatricians, midwives, nurses, social workers and psychologists), working in clinics that women and girls at-risk may attend.
• To identify the extent to which current healthcare provider training packages incorporate the voices of women who have been subject to FGC for the development of more efficient, culturally safe and gender sensitive training tools.
• To better define and contextualize the level of potential risk of FGC/M for women and girls in respective countries and to identify community services in relation to potential needs of women in the community.
• To compare and contrast laws in respective countries in order to identify if and to what extent the latter have contributed to change of behaviour among practicing communities in diaspora countries and of healthcare providers’ practices. This is to reach a better understanding of the best practices regarding policy implementations and legal frameworks with regards to the prevention of FGC.
• To provide an informative video developed with and for women on defibulation consistent with best practices in intercultural health literacy.

Birgitta Essén, Professor

Bilkis Vissandjee, Coordinator, Université de Montréal, Canada

Funding: VR

Research questions

• What are the individual, psychosocial and socio-environmental factors influencing adolescents’ decision-making around sexual activity, including contraceptive use in a rural community in Nicaragua?
• How adolescent girls experience the transition to motherhood in the rural community of Tololar in Nicaragua?
• What are the religious leaders’ views on SRH education in Bangladesh?
• What approach to SRH education religious leaders would consider acceptable in the context of Bangladesh?

Major Findings

In Bangladesh, both conservatives and progressive views expressed by the religious leaders implies that there are opportunities for policy makers to explore areas of compromise and shared values regarding SRH education for young people in Bangladesh today.

In Nicaragua, despite the challenges of becoming a teenage mother, many of the young women also expressed positive feelings in relation to becoming a mother. Some of the participants meant that their newly achieved responsibility as teenage mothers provided them with a feeling of purpose in life.

There is considerable evidence that adolescence is a period of overwhelming changes and challenges, which expose the adolescents to high-risk behaviors. However, adolescents from rural Nicaragua embrace positive thoughts around access to sex education, sexual health care, and opportunities for healthier relationships.

It is hoped that these findings will help to understand the different expressions of adolescents’ sexual and reproductive health. These research projects focus on the views and experiences of religious leaders in Bangladesh to the experiences of adolescents in Nicaragua about the challenges and opportunities for an effective response to the high-risk behaviors in adolescents’ lives.

William Ugarte, Researcher
Birgitta Essén, Professor
Jonna Arousell, PhD
Sara Ohlsson, MSc
Frida Larsson, MSc
Mohamad Ali, MSc

Location: Nicaragua, Bangladesh

Funding: Swedish International Development Cooperation Agency (Sida), Stiftelsen Familjeplaneringsfonden

This study, conducted by an anthropologist and a gynaecologist, aims at reaching an understanding of societal views of the relation between ’sex’, ’gender’ and genitals, through analysing the political positions that have given rise to decisions to advocate, accept or criminalise certain surgical genital modifications. The phenomena analysed are male and female circumcision, cosmetic genital surgery, hymenoplasty and operations on transsexual adults/intersexual infants. Society’s views of these procedures have their own social, medical and political history, and as yet there is no systematic analysis juxtaposing them. The theoretical approach is social constructivist, inspired by gender theory and critical medical anthropology. Empirical data include legislative texts and qualitative interviews with professionals in medicine and with key activists. Through discourse analysis we will explore the social values about ’sex’ and ’gender’ that are conveyed in legal decisions and medical practice in this field, and in alternative discourses. The study adds to our research about female genital cutting and cosmetic genital surgery. Procedures involving the genitals provide an arena where medicine and culture converge. Understandings of ‘sex’ are interwoven with politicised socio-cultural constructions of ‘gender’. What is ‘given by nature’ can be modified through surgery, but medical practice itself develops within a norm structure that is time- and culture-bound.

Maternal mortality is high in India (178/100000 LB), especially in Rajasthan (255/100000 LB), one of the government’s priority states due to its poor health outcomes. Although abortion was legalized in 1971, access to safe abortion services is still inadequate. Unsafe abortions are estimated to account for 8-18% of maternal deaths in India, in addition to substantial morbidity. Contraceptive use is low and so is women’s general awareness of their reproductive health and available reproductive health services. This project aims to simplify medical abortion and make it more acceptable to women as well as to health care providers. Simplifying and demedicalising medical abortion can decrease service costs and make services more affordable to women in low-resource settings. Moreover, combining medical abortion with contraceptive counseling and health promotion may enhance women’s motivation to adapt a contraceptive method post-abortion. In addition, making abortion services more acceptable to women may motivate women to seek future reproductive health care services from the public health system, something that is not widely seen today.

A randomized control trial is carried out to investigate the efficacy, safety and acceptability of a simplified medical abortion regime in a rural and urban low-resource setting in Rajasthan, India. Studies in Europe and USA have shown an increased acceptability among both women and providers when fewer clinical visits are required for a medical abortion, however, these studies do neither take the low-resource setting, the lack of mobile phones and infrastructure, and the low literacy level into account. This study aims to fill the knowledge gap and investigate the feasibility of simplified follow-up in low-resource settings. Additionally, the contraceptive use among women post-abortion will be investigated, and barriers to access to safe abortion services and contraceptive use will be explored. Furthermore young women’s reproductive choices and partner involvement in the reproductive decision-making process among rural youth will also be explored outside of the randomized control trial.

Research questions

• How can we create a patient-centered health system that caters to reproductive health needs and increase access to medical abortion and contraception services among Indian women living in low-resource settings?
• What are the potential barriers to preventable severe maternal morbidity and partner involvement during early pregnancy in a low-resource setting like Rwanda with a very strong policy program of improving women’s health.
• How does the construction of parenthood and surrogate motherhood relate to the use of transnational surrogates in Sweden and India?
• How to understand the dynamics of the HIV epidemic by estimating prevalence and exploring the relationship between HIV-related knowledge, attitudes, behavior and HIV status and stigma in Nicaragua.

Major findings

• Despite the MDG agenda, inadequate care options force life-threatening solutions to unwanted pregnancy in Rwanda.
• Indian women do not desire sterilization, but prefer reversible contraceptive methods post-abortion.
• Simplified follow-up using a low-sensitivity pregnancy test two weeks post early medical abortion is as effective, acceptable and feasible as in-clinic follow-up by a doctor.
• Surrogacy in India is a reproduction method that fulfills the cultural expectations of parenthood, as having an “own child”, while it is also attached with complex views of the surrogate mother.
• Transnational surrogacy in India involves moral qualms but the exploitation of surrogate mothers is defied.
• Although seven out of ten Men who have Sex with Men (MSM) and six out of ten women were concerned about becoming infected with HIV, inconsistent condom use was common in Nicaragua
• MSM have a better understanding of HIV transmission than men and women of the general population.

Location: India, Rwanda, Sweden, Nicaragua 

Infertility often creates social and financial problems because of the importance of having children to secure the support in old age and ensure the continuation of the lineage. Especially women suffer from not being able to bear children and childlessness carries social stigma. Even though infertility treatment can be found within the public health care system in India it is in a very small scale and difficult to access. ART is mainly provided to a high cost in private clinics, and there has been a rapid increase of clinics. Many clinics also provide surrogacy but the service is in large part used by childless couples outside of India. The enormous increase in ART clinics providing surrogacy also means that they are no longer located only in big cities, but have spread all over India even to places where they lack basic health care facilities.

Thesis: Arvidsson, Anna, Challenges of transnational parenthood: Exploring different perspectives of surrogacy in Sweden and India, 2019 Full text To DiVA

Thesis: Paul, Mandira. Simplifying Reproductive Health in Low-Resource Settings: Access to medical abortion and contraceptive choice, the importance of gendered structures in Rajasthan. Full text To DiVA

Thesis: Ugarte Guevara, William J. Averting HIV and AIDS epidemic in Nicaragua: Studies of prevalence, knowledge, attitudes, and behavior. Full text To DiVA

Thesis: Wahlberg, Anna. Continuity or Change?: Improved Understanding of Attitudes Towards Female Genital Cutting after Migration from Somalia to Sweden. Full text To DiVA

Arvidsson, A., Vauquline, P., Johnsdotter, S., Essén. B. (2017). Surrogate mother – praiseworthy or stigmatized: a qualitative study on perceptions of surrogacy in Assam, India. Global Health Action, 10(1): 1328890. Full text To DiVA

Arvidsson A, Johnsdotter S, Essén B. Views of Swedish commissioning parents relating to the exploitation discourse in using transnational surrogacy. PLoS One. 2015: 8.

Arvidsson A, Johnsdotter S, Emmelin M, Essén B. Gauging the interests of birth mother and child: a qualitative study of Swedish social workers’ experiences of transnational gestational surrogacy. European Journal of Social Work. 2016: 23:1-4.

Arvidsson A, Johnsdotter S, Emmelin M, Essén B. Being questioned as parents: An interview study with Swedish commissioning parents using transnational surrogacy. Reproductive BioMedicine and Society Online, 2019;8: 23–31.

Bergström, Anna; Ugarte Guevara, William J.; Eustachio Colombo, Patricia. Knowledge about Sexual and Reproductive Health among School Enrolled Adolescents in Tololar, Nicaragua, A Cross-Sectional Study. Part of Journal of Public Health International, p. 27 27-38 38, 2018. DOI Full text To DiVA

Jordal M, Wahlberg A., 2018. Challenges in providing quality care for women with female genital cutting in Sweden – a literature review. Sexual & Reproductive Healthcare 17(October): 91-96. To DiVA

Wahlberg A. 2020. Female genital cutting and the applicability of social convention theory in a migration context.  Journal of Obstetrics and Gynaecology Canada;10(2):e17. 

Wahlberg A et al. The Brussels Collaboration on Bodily Integrity. 2019. “Medically Unnecessary Genital Cutting and the Rights of the Child: Moving Toward Consensus.” The American Journal of Bioethics 19 (10). Taylor & Francis: 17–28.

Wahlberg, Anna; Johnsdotter, Sara; Ekholm Selling, Katarina; Essén, Birgitta. Shifting perceptions of female genital cutting in a Swedish migration context. Part of PLoS ONE, 2019. DOI To DiVA

Wahlberg A, Påfs J, Jordal M. 2019. Pricking in the African Diaspora: Current Evidence and Recurrent Debates. Current Sexual Health Reports. https://doi.org/10.1007/s11930-019-00198-8.

Wahlberg, Anna; Essén, Birgitta; Johnsdotter, Sara. From sameness to difference: Swedish Somalis’ post-migration perceptions of the circumcision of girls and boys. Part of Culture, Health and Sexuality, p. 619-635, 2019. DOI Full text To DiVA

Wahlberg A et al., 2017. Female Genital Mutilation/Cutting: sharing data and experiences to accelerate eradication and improve care: part 2: Geneva, Switzerland. March 13-14, 2017. Reproductive Health 14(Suppl 2):115.

Wahlberg A, Johnsdotter S, Ekholm Selling K, Källestål C, Essén B., 2017. Factors associated with the support of pricking (female genital cutting type IV) – a cross sectional study in Sweden. Reproductive Health, 14:92. To DiVA.

Wahlberg A, Johnsdotter S, Ekholm Selling K, Källestål C, Essén B., 2017. Baseline data from a planned RCT on attitudes to female genital cutting after migration – when are interventions justified? 2017. BMJ Open, 7(E017506). To DiVA.