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A Qualitative Study Exploring How Somali Women Exposed to Female Genital Mutilation Experience and Perceive Antenatal and Intrapartum Care in England

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A Qualitative Study Exploring How Somali Women Exposed to Female Genital Mutilation Experience and Perceive Antenatal and Intrapartum Care in England Open Access Research BMJ Open: first published as 10.1136/bmjopen-2015-009846 on 7 January 2016. Downloaded from A qualitative study exploring how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England Jordan M Moxey, Laura L Jones To cite: Moxey JM, ABSTRACT Strengths and limitations of this study Jones LL. A qualitative study Objectives: To explore how Somali women exposed exploring how Somali women to female genital mutilation experience and perceive ▪ exposed to female genital This descriptive, exploratory qualitative study is antenatal and intrapartum care in England. We explored mutilation experience and the first, as far as the authors are aware, to ’ perceive antenatal and women s perceptions of deinfibulation, caesarean explore how Somali women exposed to female intrapartum care in England. section and vaginal delivery; their experiences of care genital mutilation experience and perceive ante- BMJ Open 2016;6:e009846. during pregnancy and labour; and factors that affect natal and intrapartum care in England. doi:10.1136/bmjopen-2015- ability to access these services, in order to make ▪ It is often difficult for non-community members 009846 recommendations about future practice. to engage the Somali community in research but Design: A descriptive, exploratory qualitative study we were able to successfully recruit a small ▸ Prepublication history for using face-to-face semistructured interviews. Interviews number of women who were willing to discuss this paper is available online. were audio-recorded, transcribed and data were this important and sensitive issue with the To view these files please analysed using a thematic approach. An interpreter was researchers. visit the journal online used when required (n=3). ▪ The use of lay interpreters may have promoted (http://dx.doi.org/10.1136/ Setting: Participants recruited from 2 community misinterpretation of questions and responses bmjopen-2015-009846). centres in Birmingham, England. during interview but overall, appeared to facilitate Received 27 August 2015 Participants: Convenience and snowball sample of 10 the development of rapport, put participants at http://bmjopen.bmj.com/ Revised 10 November 2015 Somali women resident in Birmingham, who had ease and encourage in-depth responses. Accepted 3 December 2015 accessed antenatal care services in England within the ▪ Face-to-face interviews may have encouraged past 5 years. socially desirable responses, by participants Results: 3 core themes were interpreted: (1) exaggerating positive experiences and downplay- Experiences of female genital mutilation during life, ing negative ones to avoid being overly critical of pregnancy and labour: Female genital mutilation had a English antenatal care services in front of the significant physical and psychological impact, interviewer. influencing decisions to undergo deinfibulation or ▪ There is a small, potential risk of selection bias caesarean section. Women delayed deinfibulation until using our method of sampling but nonetheless, on September 26, 2021 by guest. Protected copyright. labour to avoid undergoing multiple operations if an the insights gained are likely to be valuable when episiotomy was anticipated. (2) Experience of care considering how to improve English antenatal from midwives: Awareness of female genital mutilation and intrapartum care for Somali women. from midwives led to open communication and stronger relationships with women, resulting in more positive experiences. (3) Adaptation to English life: non-pregnant women, to align with current guidelines. Good language skills and social support networks Women with unfavourable social factors may require enabled women to access these services, while additional support to improve access to English unfavourable social factors (eg, inability to drive) antenatal care services. impeded. Institute of Applied Health Conclusions: Female genital mutilation impacts Research, University of Somali women’s experiences of antenatal and Birmingham, Birmingham, intrapartum care. This study suggests that midwives UK should routinely ask Somali women about female INTRODUCTION Female genital mutilation (FGM), also Correspondence to genital mutilation to encourage open communication Jordan Moxey; and facilitate more positive experiences. As antenatal known as female genital cutting or circumci- [email protected]. deinfibulation is unpopular, we should consider sion, is the partial or complete removal of, or uk developing strategies to promote deinfibulation to injury to, the external female genitalia for Moxey JM, Jones LL. BMJ Open 2016;6:e009846. doi:10.1136/bmjopen-2015-009846 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2015-009846 on 7 January 2016. Downloaded from non-medical reasons.1 The most severe form of FGM is affect ability to access ANC services, in order to make type III (infibulation), which involves the removal and recommendations about future practice. apposition of the inner and outer labia, with or without excision of the clitoris, leading to the creation of a cover- ing seal and narrowing of the vaginal orifice.1 METHODS Consequences may include haemorrhage, infection or This exploratory study used descriptive qualitative meth- death in the short-term and recurrent urinary tract odology and is reported against Consolidated criteria for infections, impaired sexual function and psychological reporting qualitative research (COREQ) guidelines.21 – issues in the longer term.1 3 Type III FGM also has Participants were purposively sampled22 using the follow- implications for future childbirth, with women at ing inclusion criteria: women over the age of 18; born in increased risk of adverse obstetric outcomes including: Somalia and resident in the West Midlands; with at least postpartum haemorrhage, perineal tearing, fistulae, one child under the age of 5 years or were at least obstructed labour or stillbirth.45 6 months pregnant with their first child at the time of FGM affects more than 125 million girls and women interview; and had the ability to provide informed worldwide and is reportedly practiced in 29 countries in consent to an audio-recorded interview. Specifically, sub-Saharan Africa and the Middle East.6 Recent esti- snowball sampling, a strategy often used in hard-to-reach mates revealed that 137 000 girls and women are living populations,23 and convenience sampling were used. with FGM in England and Wales, although their country Semistructured interviews were used in order to recon- of origin was not reported.7 In Somalia, a reported 98% struct perceptions of ANC experiences and facilitate an of 15–49-year old females have been affected, mostly by in-depth exploration of women’s views.24 Face-to-face type III (63%).6 There is a large Somali community interviews were conducted in a private room, offering living in England and Wales (n=101 370), with 9870 women privacy to discuss a potentially sensitive topic. (females=5365) located in the West Midlands.8 Given This study took place in Birmingham, West Midlands. the high prevalence of FGM in Somalia, it is not surpris- This location was selected due to the large resident ing that the majority (over 90%) of all pregnant women Somali community and high numbers of Somali women – with FGM accessing specialist antenatal care (ANC) ser- with FGM accessing ANC services locally.8 10 vices in Birmingham each year (n=349) are Somali.910 Recruitment and interviews took place between These women are more likely to present late and delay February and April 2015 (interviews started in March) at deinfibulation (reversal of FGM) until the intrapartum two community centres, which were identified using a period,911which contradicts current guidelines.12 specific recruitment strategy (box 1). Few studies have explored this community’s experi- Immediately prior to data collection, all participants ences of services in terms of care received, accessibility provided informed verbal consent and interpreter confi- and cultural sensitivity. A limited number of studies dentiality agreements were signed as appropriate. http://bmjopen.bmj.com/ suggest that a lack of health worker knowledge and Participants were also asked to complete a basic demo- understanding of FGM undermines confidence and trust graphic questionnaire following consent. A community in English health services.13 This may exacerbate feelings outreach worker at centre A reviewed both the topic of inadequacy and increase hesitancy of affected women guide and questionnaire during the initial visit in order to to speak about FGM.14 Similar thoughts have been ensure cultural sensitivity. No alterations were made to expressed in studies undertaken in Northern America.215 either document following this review. Semistructured Health worker knowledge of FGM is especially important interviews followed a topic guide (table 1), which was for ANC experiences,16 17 but surveys have shown that informed by both a review of the literature, advice from on September 26, 2021 by guest. Protected copyright. health workers lack knowledge18 19 according to profes- academics experienced in Somali community research sional guidelines.11 For example, FGM is not an absolute and discussion between the authors. The guide covered a indication for caesarean section12 yet women are at an variety of prespecified topics but remained flexible, allow- increased risk11 and may feel pressured by health workers ing women to highlight additional issues that were unfore- to have one.20
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