Female Genital Mutilation/Cutting in - Examining Progress or Lack of Progress at National and Subnational Levels

Robert P Ndugwa PhD1 and Dr Edward Addai2

1Global Urban Observatory, Research and Capacity Development Branch, United Nations Human Settlements Programme, , Kenya.

2UNICEF ESARO, Nairobi, Kenya

Abstract

Female genital mutilation or cutting (FGM/C) is widely outlawed globally, but continues to be practiced in selected communities across the globe. In Kenya, this practice is common among selected communities, and recent national trends show that the prevalence of the practice is declining. Using Multiple Indicator Cluster Surveys data collected in 2011 from 6 counties from the Western region of Kenya, we demonstrate that while national figures conspire to show that the prevalence of FGM has declined but among certain communities the practice remains almost universal. Underlying factors favouring the continuation of the practice within these communities are discussed, including examining the role of cultural traditions, tribe and religion. The study demonstrates the value of collecting data at lower levels, and highlights the need to step up the responses and engagement of communities who continue practicing FGM even after outlawing this practice.

Introduction

Female genital mutilation or cutting (FGM/C) has continued to dominate the discourse in women’s health and empowerment as well as remaining a dominate subject for human rights violations today. Female genital mutilation or cutting (FGM/C) is a procedure or practice where the parts of the female genitals are removed, and it is practiced in over twenty countries within sub-Saharan Africa. FGM/C practice has been widely documented to interfere with the natural functioning of the body, in addition to causing many short-term and long-term health and psychological consequences (Behrendt et al. 2005; Kaplan et al. 2013) To-date no known health benefits have been recorded as a result of undergoing FGM/C. The real physical consequences of FGM range from bleeding, wound infections, sepsis, shock, micturition problems and fractures, anaemia, infections of the urinary tract, infertility, repetitive abdominal pain, menstruation problems, irritability, etc (Almroth et al. 2005; Jones et al. 1999). Women who have undergone FGM also face an increased risk for HIV infections, plus other mental related consequences such as the feelings of incompleteness, fear, inferiority and low self- esteem (Elnashar & Abdelhady, 2007).

According to UNICEF and WHO publications, the prevalence of FGM varies from more than 70% in Burkina Faso, Djibouti, Egypt, Eritrea, Ethiopia, Guinea, Mali, Mauritania, Northern Sudan, and Somalia to less than 40% among Kenya, , Senegal, Tanzania, etc (WHO,2008). However, the above prevalence vary considerably within countries, reflecting regional, ethnic, religious, tribal and cultural drivers of FGM/C within states (PATH, 2005).

Among the proponents of FGM/C, they consider it necessary to raise a girl properly and to prepare her for adulthood and marriage (Yoder et al., 1999; Ahmadu, 2000; Hernlund, 2003; Dellenborg, 2004). FGM/C also occurs due to peer pressure because of fear of stigmatization and rejection by society. Girls who undergo the procedure may receive rewards and gifts (Behrendt, 2005; UNICEF, 2005a). In many communities, the practice is also upheld by beliefs associated with religion (Budiharsana, 2004; Dellenborg, 2004; Gruenbaum, 2006; Clarence-Smith, 2007; Abdi, 2007; Johnson, 2007) although the practice predates most religions (WHO & UNFPA, 2006). FGM/C is often upheld by local structures of power and authority such as traditional leaders, religious leaders, circumcisers, elders and even some medical personnel.

In terms of human rights, FGM/C violates the right of women to the freedom from bodily harm, the right to health and to freedom from torture, inhuman or degrading treatment and sometimes, the right to life (WHO, 2008). Support for the abandonment of FGM is well captured in many international and regional human rights treaties and consensus documents (WHO,2008). In some ways, FGM/C is a manifestation of gender inequality that is deeply entrenched in social, economic and political structures (UNICEF, 2005). Where female genital mutilation is widely practised, it is supported by both men and women, and sanctioned by condemnation, harassment, and ostracism at the society level. Primary factors in shaping social attitudes and beliefs towards the eradication of FGM/C as a human rights violation include tribe, religion and cultural impediments. For example, among women from communities that practice FGM/C, but who have since migrated to countries where FGM/C is not practiced openly and have strong legal frameworks in place, research shows that they express negative attitudes towards FGM and know about the serious complications associated with it, but they still exhibit religious justifications for the continued practice of FGM/C, and favour the medicalization of the practice (Thierfelder et al. 2005). Also for migrant women who have already had FGM, the medical attention and needs vary from women who have never had FGM, but appropriate care is often not well understood by caregivers during birth (Chalmers et al. 2000; Leye et al. 2008). Estimations for the impact of FGM on health systems and well-being show that on average, a girl of 15 years who undergoes total or partial excision of the external genitalia and stitching or narrowing of the vaginal opening will lose nearly one-fourth of a year of life and impose on the medical system a cost of US$ 5.82 over her lifetime. Clearly, any form of FGM has an impact on survival and will lead to monetary losses over each woman’s lifespan for many generations (Bishai et al. 2008).

Kenya and FGM/C

Kenya is one of many countries in the world where FGM/C is practiced in a number of communities with the major tribes being the Somali and Kisii communities. In the last two decades, Kenya has invested considerable educational efforts to increase awareness of the policy issues and health risks associated with FGM/C. The Kenyan government formally outlawed FGM in 2001 and ten years later passed the Prohibition of Female Genital Mutilation Act of 2011. The Children Act of 2001 also describes girls who are likely to be forced into circumcision as children in need of special care and protection. The Act further provides for courts of law to take action against the perpetrators. The existence of a legal framework, alongside the expansion of many educational programmes, has led to a significant increase in knowledge and awareness of health complications of FGM/C, with potential dividends expected in the decline of the prevalence of this practice in the coming years (Livermore et al. 2007)

This paper examines trends and predictors of FGM/C across one province in Kenya where in-depth data on women and child related indicators were collected two years after the 2008/9 Kenya demographic and Health survey. The paper provides an in-depth examination of the strength of the documented progress on FGM as observed through national averages, and further examines residual progress at subnational levels recorded on FGM prevalence across one region and within region.

Data and Methods

For this study, two sources of data are used-namely the Kenya demographic and health surveys conducted in 2003 and 2008/9, and a Multiple Indicator Cluster Survey (MICS) conducted in 2011 in one of Kenya’s provinces i.e .

Nyanza MICS data:

By 2011, Nyanza province was divided into six counties (, Homabay, , , Kisii, and County). Details on the Nyanza Province Multiple Indicator cluster Survey (MICS) methods are described elsewhere [Nyanza Multiple Indicator Cluster Survey 2011]. Briefly, the MICS is an international household survey programme developed by UNICEF. The Nyanza province MICS was conducted as part of the fourth global round of MICS surveys (MICS4). MICS provides up-to-date information on the situation of children and women and measures key indicators that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Additional information on the global MICS project, questionnaires and methodology is available at www.childinfo.org. For Nyanza MICS, a representative sample survey was drawn using the 2009 Census Enumeration Areas (EAs) as the sampling frame. A stand-alone statistical frame for each of the six Nyanza counties was constructed based on the 2009 census EAs for the purpose of this MICS survey. The survey used a two stage design. In the first stage, 300 EAs were sampled using the probability proportional to size (PPS) sampling methodology, and in the second stage households were selected systematically using a random start from the list of households. Within each sampled household, standard questionnaires for collecting information on characteristics for the household, women, and children under five years were administered. The indicators within MICS Questionnaires are modeled to be comparable to some of the global survey instruments such as those developed by the MEASURE DHS+ programme. Fieldwork was undertaken between October 2011 and December, 2011 and information from a total of 6828 households were collected. The household questionnaire was used to list all the usual members and visitors in the selected households and to identify eligible women for the individual interview and children aged 0–59 months for the children questionnaire. The household questionnaire collected basic information on the characteristics of each person listed, including age, sex, household's residence and assets, and ownership, etc. The woman’s questionnaire was used to collect information from all women aged 15–49 years on background characteristics, full reproductive history, prenatal care and preventive malaria treatment for most recent birth, prevalence and treatment of fever among children under five years, information on female genital mutilation/cutting, etc. Data analysis and quality assurance was achieved through strict adherence to the MICS protocols that provide the training materials and field supervision guidance, data processing using CSPRO, SPSS analysis templates, and tables review processes, etc. The Nyanza Province County-based MICS survey is the first largest household sample surveys ever conducted in Kenya with the inclusion of the county governance structures that came into effect as part of the promulgation of 2010 . The data were collected by twelve teams comprising of seven members each (one supervisor, one editor, one measurer and 4 interviewers). The survey was implemented by the Kenya National Bureau of Statistics (KNBS) with technical support from UNICEF. Through the Kenya statistical Act, KNBS is mandate to conduct all surveys with national and subnational importance, and they handled all the submissions and clearances for the Nyanza MICS survey ethical approvals.

Kenya Demographic and Health surveys 2003 and 2008/9.

To analyse for trends in the prevalence’s of FGM/C, data from the two most recent Kenya Demographic and Health surveys (KDHS) i.e 2003 and 2008/9 were also analysed for this study. Estimates from these surveys are available up to the provincial levels. Nyanza province is one of the surveys where data was collected during the two previous rounds of DHS. The survey methodology used for DHS is very similar to what is applied for MICS surveys. More information on the methodology of the DHS is available at www.measuredhs.com.

Measurements and analysis

For all the surveys considered in this analysis, standard questions on knowledge, practice, types and prevalence of female genital mutilation and cutting were administered to women aged 15-49 years. This paper uses secondary data analysis from the three sources to examine estimates and trends for FGM/C prevalence across a number of characteristics, with special reference to Nyanza province where recent in-depth data were collected at county levels. The key research questions is to examine to what extent national level data is able to mask real inequities in prevalence’s of certain attributes such as FGM, in the absence of subnational data. In addition, the study examines key predictors of FGM over time at national and lower levels. This trends analysis examines prevalence’s and factors affecting FGM prevalence’s over the time period 2003-2011 in Kenya. Tabulations and cross tabulations are performed using Stata 12.1 (© StataCorp, College Station, TX, USA). Point estimates and 95% confidence intervals (CI) are reported. Data analyses took into account the survey design weights: Survey stratifications (urban/rural) and clustering of households within standard enumeration areas.

Results

A total of 8195, and 8444 women were interviewed for the DHS rounds of 2003 and 2008/9 surveys, with 1222 and 1389 women being respondents from Nyanza province region during the two rounds of surveys, respectively. For the 2011 Nyanza province MICS, 5908 women were interviewed –i.e nearly five times the samples of women interviewed in the KDHS surveys. The expanded number of women for the 2011 Nyanza MICS allows for examining a number of attributes within the province at lower levels and further assess or identify certain inequities that are otherwise not possible to examine from previously available national and provincial-level surveys.

Table 1 provides a summary of FGM/C prevalence at national level and Nyanza province level by selected characteristics. Overall, the prevalence of women who have undergone FGM/C for the period 2003 to 2009 at the national level has not changed that much. In 2008/9, on average 27% of female respondents in Kenya had undergone FGM, a decline from 32% in 2003 and 38% in 1998. From the KDHS 2008/9 findings, the proportion of women circumcised was higher among older women, with 15% of women aged 15-19 years having been circumcised, as opposed to 49% among those aged 45-49 years, further indicating that the prevalence of FGM is declining over the age cohorts. The 2008/09 KDHS found regional variations in prevalence of FGM - 98% of women in North had been circumcised, compared to only 1% of women in . In Nairobi Province, 14% of the women were circumcised, compared to 10% in . Analysis at the Nyanza provincial level shows a prevalence of 35% in 2003, to 34% in 2009 and 37% in 2011. Prevalence of FGM/C at national and provincial level varies by religion of women--Muslim women have higher prevalence rates than women from other religions. However, the patterns at the Nyanza provincial level shows that the prevalence among Muslim women has declined from 86% in 2003 to 20% and 7% in 2009 and 2011, respectively (see figure 1).

Similarly, ethnicity is one of the variables where variations in the practice of FGM are observed— in 2008 prevalence rates ranged from 97% among the Somali, Kisii (96%), Kuria (96%) and Masai (93%) ethnic groups and was relatively low among the Kikuyu, Kamba and Turkana, whilst among the Luo and Luhya less than 1% of the women reported having had FGM/C (KDHS 2008). Also, in 2008 there were some urban and rural differences in the prevalence of FGM, with on average 31% of women in the rural areas reporting that they were circumcised, versus 17% in urban areas. Education is also a another variable where variations were observed for FGM/C practices, with 54% of women with no formal education reporting to having been circumcised, compared to 19% among those with secondary school or higher levels (KDHS 2008/9).

Figure 1. Prevalence of FGM in Nyanza province: 2003-2011

90

80 2003

70 2009 60 2011 50 40 30

20 Prevalence of FGM (%) FGM of Prevalence 10 0 Catholic Protestant/Other Christian Muslim Other (Other/No religion)

The 2008/9 KDHS findings show that the majority of the women who reported having been circumcised had some flesh removed, which usually includes removal of the clitoris. Thirteen percent had the most invasive form, in which the labia are removed and sewn closed. Only 2% said they were nicked with no flesh removed. However, an analysis of national figures masks a number of underlying issues on the magnitude and trends of FGM prevalence and practice across regions. More attention is needed to monitor inequalities for all rights with better tools to measure where progress has been made, or track where inequality gaps are growing and ascertain why inequalities are still persistent. Using two rounds of DHS data and a latest MICS data from one region, the next section examines further the extent of FGM practices in one former province of Kenya- Nyanza province. The analysis provides more in-depth analysis of the predictors of FGM and how these vary across selected inequality measures (education, wealth, and locations). The present day former Nyanza province is divided into 6 counties-namely Kisii, Nyamira, Migori, Siaya, Homabay, and Kisumu counties. The latest Nyanza MICS survey was a large survey that provides for examining inequities at more lower levels such as counties within a province.

Table 1 Percent of female aged 15-49 years who have undergone FGM/C KDHS 2003, KDHS 2008/9, and Nyanza MICS 2011.

KDHS 2003 KDHS 2008-09 MICS 2011 Background characteristics Nyanza National Nyanza National Nyanza

TOTAL 35.1 32.2 33.8 27.1 36.5 Residence Urban 15.96 21.3 14.28 16.5 20.7 Rural 37.73 35.8 40.89 30.6 39.4 Marital status

Never married 42.3 18.21 39.67 16.37 38.27

Currently Married 34.2 37.94 37.99 34.6 36.42

Formerly Married 22.7 39.62 29.85 31.59 33.06 Education level

No education 30.63 58.2 38.48 53.7 31.4 Primary incomplete 31.0 32.8 31.89 28.8 31.1

Primary complete 29.2 31 34.85 26.4 x Secondary+ 48.35 21.1 45.16 19.1 49.4 Religion

Catholic 42.75 33.2 40.39 29.1 50.54 Protestant/Other Christian 31.65 29.5 36.9 23.5 32.49 Muslim 85.68 49.6 20.06 51.4 6.88 Other (Other/No religion) 47.56 39.6 23.1 38.3 41.65

Number of women 1222 8195 1389 8444 5908

Source: Kenya Demographic and Health Survey (KDHS) 2008-09

Subnational analysis of Nyanza MICS FGM data.

Table 2 presents data on FGM practices documented among women in Nyanza province by selected descriptive characteristics. It is evident that in Nyanza province, while 37% of women have had FGM/C, it is largely three locations (counties) within the province that account for this proportion i.e Nyamira, and Kisii report 94% of women having had FGM/C and to a certain extent (21%). The proportion of those who have had FGM/C ranges from 21% among women from urban areas of Nyanza province to 39% among those from rural areas (Table 1). About 23% of women from the richest household wealth quintile have had FGM/C while the corresponding figure for those from the poorest households is 48%. In Nyanza province, the most commonly practiced form of FGM/C is removal of flesh.

Table 2: percentage distribution of women aged 15-49 and FGM/C status

Percent distribution of women age 15-49 years:

Who had FGM/C Percentage Table 2 Form of who had any Had flesh Were Were sewn FGM/C not form of Number of No FGM/C removed nicked closed determined FGM/C women County Siaya 99.5 0.1 0.0 0.0 0.4 0.5 916 Kisumu 97.8 0.7 0.1 0.3 1.1 2.2 1057 Homabay 98.2 0.6 0.3 0.3 0.6 1.8 944 Migori 79.4 18.2 0.3 1.7 0.5 20.6 963

Kisii 5.6 88.8 3.0 0.9 1.5 94.4 1404 Nyamira 6.1 71.8 9.8 2.7 9.6 93.9 623 Age 15-19 67.1 28.3 1.1 1.3 2.2 32.9 1216 20-24 61.0 34.7 1.4 0.7 2.1 39.0 1192 25-29 63.7 31.5 2.6 1.0 1.2 36.3 1159 30-34 63.7 32.5 1.3 0.6 1.9 36.3 747 35-39 62.2 33.7 2.0 1.0 1.2 37.8 675 40-44 66.5 27.8 3.2 0.8 1.7 33.5 478 45-49 58.7 35.7 2.8 0.2 2.5 41.3 440 Wealth Poorest 52.1 43.1 2.8 0.8 1.2 47.9 1115 index Second 51.3 44.0 1.6 0.9 2.2 48.7 1144 quintiles Middle 65.1 30.3 1.7 1.1 1.8 34.9 1150 Fourth 69.8 25.9 1.3 0.8 2.2 30.2 1188 Richest 76.9 18.6 2.0 0.8 1.7 23.1 1311 Total 63.5 31.9 1.9 0.9 1.8 36.5 5908

A substantial proportion of women in Nyanza’s six counties (82%) have heard of FGM/C (Table 3). Among those who have heard of FGM/C, 20% believe that FGM/C should continue to be practiced, although this opinion is more commonly shared among women from Nyamira and Kisii counties. About 69% of women believe that the practice should be discontinued, with the highest proportion in Migori county (80%) and (77%), and the lowest in Homabay county (58%), Kisii (63%), and Nyamira (66%). Inter-age group discontinuation differences don’t seem to exist e.g among the 15-19 year old women, 69% favor discontinuation which is similar for those aged 45-49 years. However, 65% of women from the poorest households favor discontinuation of the FGM/C practice, while the corresponding figure for those from the richest households is 77% (Table 3).

Table 3: Percentage distribution of women who believe the practice of FGM/C should be continued, Nyanza.

% of women % distribution of women who believe the practice of No. of women aged FGM/C should be: 15-49 years Table 3 who have heard of Continued Don't FGM/C [1] Discontinued Depends know/Missing County Siaya 64.8 13.6 76.7 4.7 5.1 916 Kisumu 78.1 14.4 75.8 5.5 4.3 1057 Homabay 63.1 20.6 57.9 12.7 8.8 944 Migori 85.0 5.6 80.0 13.4 1.0 963 Kisii 99.7 30.3 62.5 5.0 2.1 1404 Nyamira 99.7 28.0 65.9 2.1 4.1 623 Area Rural 81.9 20.9 67.8 7.4 3.9 4985 Urban 83.7 14.7 77.1 5.2 3.0 923 Age 15-19 79.5 21.4 69.0 6.1 3.5 1216 20-24 84.2 23.9 66.8 6.2 3.1 1192 25-29 84.0 20.7 68.0 8.0 3.3 1159 30-34 81.7 18.7 71.5 6.3 3.5 747 35-39 82.0 15.9 71.9 8.7 3.6 675 40-44 80.2 16.6 73.1 5.7 4.6 478 45-49 82.5 14.5 68.7 9.8 7.0 440 Education None 90.0 13.2 78.0 4.7 4.2 430 Primary 77.5 21.8 65.7 8.0 4.5 3752 Secondary 90.3 18.1 73.9 5.9 2.2 1725 Wealth index Poorest+ 82.4 24.4 64.9 7.0 3.7 1115 quintiles Second 83.2 23.9 65.0 7.1 4.0 1144 Middle 80.8 20.0 68.7 8.4 2.9 1150 Fourth 80.1 18.5 70.0 6.6 4.9 1188 Richest 84.2 13.8 76.7 6.3 3.2 1311 Total 82.2 19.9 69.3 7.0 3.7 5908

Multivariate analysis Table 4 provides findings from the logistic regression analysis with odds ratios and 95% confidence intervals derived from this analysis after adjusting for regions/provinces (for national level models). Based on logistic regression results, no statistically significant differences of having undergone FGM/C across urban and rural locations were observed in 2003 in Kenya as a whole (OR=1.45 CI: 0.80-1.64). This pattern was consistent five years later (2008 KDHS), and equally for the Nyanza province for the period 2003-2011 (Table 4). Using the reference age group of 15-19 years, the odds of being circumcised increased with increasing levels of age groups for 2003 and 2008 KDHS data. For example, in 2003 for Kenya as a whole, the odds of being circumcised among 45-49 old women was 4.9 times the odds for younger 15-19 year old women. This pattern was consistent in 2008, albeit with a doubling of the odds ratio from 4.9 to 11.4 (95% CI: 6.3-20.7). However, analysis at the Nyanza provincial levels does not show significant differences in the odds of having undergone FGM across age groups for the period 2003 to 2011. In 2003, the odds of having had FGM for a woman with secondary or higher levels versus one with no education were 0.22 (95% CI: 0.12-0.39). This pattern was not observed for 2008 KDHS data. Similarly at the Nyanza provincial level, no significant differences were observed for the odds of having had FGM across the education levels for the period 2003 to 2011. In 2003, using catholic religion as the reference category, no significant differences where observed in odds of having had FGM for all other religions. However, in 2008 Muslim women were 3.4 times more likely to have had FGM compared to catholic women. Women from other Christian faith were less likely to report FGM compared to catholic women (OR=0.7, 95% CI: 0.51- 0.96). Models 3 to 5 provide findings for the impact of religion on women’s FGM status for the Nyanza region. In 2003, Muslim women were 141 times more likely to report having had FGM compared to catholic women. Women from Other Christian religions as well as those with no religion were not significantly likely to report FGM experience when compared to catholic women. Five years later (2008), the observed trends on the impact of religion on FGM experience seem to have disappeared. In 2011 MICS for Nyanza, an interesting pattern emerges with women with no religion being 3.8 times more likely to have had FGM compared to catholic women. Also this latter data shows a reduced risk of having FGM among women from other Christian faith versus those from catholic faith. As observed for the 2008 data, there is again no significant difference in the odds of having had FGM among Muslim versus catholic women in 2011 (OR=0.250 95% CI :0.03-1.92). Results from all 5 models shows a significant impact on FGM experience by wealth quintiles. Women from the richest households are increasingly less likely to have had FGM compared to those from the poorest households. Ethnicity as a predictor variable was available for all known ethnicities in Kenya for the DHS data at the national level. National level findings shows that compared to Kikuyu women, the odds of having had FGM is consistently much higher for Kisii and Somali women, for 2003 and 2008 data respectively. For Nyanza data, only a few ethnicities apply for this province and this revised variable was included in the model with a new categorization of Kisii, Luo and all other tribes. Results shows that women from Kisii tribe in the Nyanza province are significantly more likely to report FGM experience compared to women from other tribes. On the other hand, women from Luo ethnic background are less likely to report FGM experience compared to women from other tribes after excluding those from Kisii ethnic background. At the national level, women who are currently married or formerly married are more likely to have had FGM compared to those who have never married. This pattern is however less observed for the Nyanza province analysis, with the exception 2008 data wher women who were formerly married were less likely to report FGM experience versus those who have never married (OR=0.15 95% CI: 0.03- 0.78).

Table 4. Results from logistic regression models for FGM/C in Nyanza and Kenya: 2003-2011 FGM/Circumcised 1 2 3 4 5 Kenya 2003 Kenya 2008 Nyanza 2003 Nyanza 2008 Nyanza Mics 2011 Variables OR [95% CI] OR [95% CI] OR [95% CI] OR [95% CI] Location [ref rural] 1.149 [0.804,1.642] 0.989 [0.653,1.497] 1.076 [0.0984,11.78] 0.998 [0.442,2.255] 0.676 [0.331 - 1.383]

Age groups [ref 15-19] 20-24 1.344+ [1.000,1.807] 1.619* [1.049,2.498] 0.343+ [0.112,1.050] 0.691 [0.203,2.359] 0.991 [0.617 - 1.593] 25-29 2.071** [1.455,2.948] 1.894** [1.196,2.999] 1.607 [0.640,4.036] 1.513 [0.274,8.339] 1.357 [0.794 - 2.318] 30-34 2.731** [1.831,4.074] 2.788** [1.593,4.878] 0.806 [0.129,5.023] 2.153 [0.422,10.97] 1.265 [0.735 - 2.179] 35-39 3.531** [2.330,5.352] 3.841** [2.414,6.112] 0.287 [0.0509,1.620] 3.918 [0.529,29.04] 1.161 [0.658 - 2.047] 40-44 4.336** [2.779,6.767] 6.852** [4.069,11.54] 0.658 [0.0808,5.363] 4.162* [1.020,16.98] 1.129 [0.630 - 2.024] 45-49 4.912** [3.000,8.043] 11.44** [6.336,20.65] 0.0786 [0.00247,2.504] 3.399 [0.585,19.74] 1.716 [0.784 - 3.758]

Education level [ref none] Primary 0.678 [0.378,1.216] 1.447 [0.693,3.021] 1.034 [0.170,6.285] 0.574 [0.134,2.461] 1.240 [0.645 - 2.381] Secondary+ 0.216** [0.119,0.393] 0.481+ [0.226,1.023] 0.623 [0.0711,5.468] 0.29 [0.0626,1.345] 1.416 [0.739 - 2.710] Religion [ref catholic]

Other Christian 0.996 [0.753,1.319] 0.700* [0.510,0.962] 0.297+ [0.0878,1.002] 0.834 [0.368,1.889] 0.683 * [0.487 - 0.958]

1.139 [0.511,2.535] 3.371** [1.751,6.488] 141.5** [4.140,4837.5] 1.47 [0.0398,54.28] 0.250 [0.0326 - 1.915] Muslim No religion 1.008 [0.532,1.910] 1.133 [0.489,2.623] 1.088 [0.205,5.773] 1.044 [0.158,6.902] 3.882 *[1.089 - 13.84]

Wealth index [ref poorest] Poorer 1.161 [0.836,1.613] 0.887 [0.595,1.324] 1.075 [0.332,3.479] 0.802 [0.211,3.054] 0.806 [0.564 - 1.150] Middle 1.047 [0.705,1.555] 0.659+ [0.413,1.053] 1.224 [0.261,5.736] 0.576 [0.149,2.231] 0.584* [0.406 - 0.839] 0.483** [0.342 - Richer 0.852 [0.567,1.279] 0.594* [0.355,0.994] 0.509 [0.0764,3.395] 0.389 [0.0838,1.807] 0.684] 0.162** [0.095 - Richest 0.443** [0.273,0.719] 0.286** [0.159,0.517] 0.0506* [0.00514,0.498] 0.085** [0.0247,0.292] 0.277] Ethnicity [ref Kikuyu]

Kalenjin 1.298 [0.783,2.151] 1.813+ [0.945,3.476]

Kamba 0.452* [0.229,0.890] 0.688 [0.357,1.326]

Kisii 84.41** [42.10,169.3] 223.7** [89.25,560.6]

Luhya 0.0067** [0.0024,0.018] 0.0037** [0.0007,0.0192]

Luo 0.0071** [0.003,0.019] 0.0025** [0.0006,0.0106]

Swahili 0.042** [0.017,0.105] 0.033** [0.0078,0.140]

Somali 39.96** [12.44,128.4] 62.35** [20.15,192.9]

Other 1.372+ [0.954,1.974] 1.972** [1.289,3.016]

Nyanza tribes [ref Others]

60.25** [43.40 - Kisii 181.2** [43.94,747.2] 240.3** [80.78,715.0] 83.65] 0.0710 [0.0490 - Luo 0.0023** [0.00024,0.022] 0.0026** [0.0004,0.017] 0.103] Marital status [ref Never ]

Currently married 2.309** [1.743,3.058] 2.426** [1.694,3.473] 0.738 [0.304,1.794] 0.815 [0.252,2.633] 1.318 [0.822 - 2.113] Formerly married 2.685** [1.909,3.777] 2.336** [1.440,3.789] 1.501 [0.499,4.515] 0.152* [0.0295,0.784] 1.402 [0.786 - 2.501] Observations 8185 8433 1025 1318 4829

Models 1 and 2 adjusted for regions (provinces)

Discussion

This study has shown that nearly a third of women in Kenya continue to experience FGM and this trend has hardly changed for over a decade. The same pattern is true for Nyanza province data for the 10 year period examined in this analysis. However, analysis at the national level and at the provincial levels masks a number of insights in tracking the progress or lack of progress made on the FGM experiences in Kenya. Findings from the provincial level analysis show that FGM is predominantly in two former provinces i.e North Eastern and Nyanza province. North Eastern province is mostly occupied by Somali, who are known to have high FGM prevalence rates (Simister 2010). They are also nearly 99% Muslim, and hence there is a strong link of FGM with religion in this part of the country. However, results for Nyanza province based on KDHS shows that about a third of the women residents in Nyanza have had FGM. But latest in-depth data for 2011 has shown that indeed, within Nyanza area, there are two counties where FGM prevalence is over 90% i.e Kisii and , while other counties report rates that are far below 30%. By being able to zero down to the locations and communities that practice FGM in this region, better targeting of efforts can easily be done. Interestingly, many studies have shown a strong link between religion and FGM practice. For example among the Somali community, a strong link with Muslim faith has been established, and this is true for Somali communities in other countries within the east African region (Yoder 2004). However, in Nyanza region, religion is not a significant predictor for FGM prevalence, but rather ethnicity emerges as a key predictor. The two counties of Kisii and Nyamira are predominantly occupied by Kisii tribe, and majority are affiliated with the dominant Christian faiths within Kenya i.e Seventh day Adventist, catholic, and protestants.

Furthermore, findings show that a considerable proportion of women from Nyanza province have heard of FGM/C and that overall, the trends of those who have had FGM at the national level does not show any reductions across the board. What is rather interesting to note is that among Muslim women in Nyanza, the proportion of those reporting FGM/C has dropped for the period 2003 to 2011. Similarly it is clear that a considerable number of women in Nyanza want the practice discontinued. This gradual change in attitudes is expected to lead to declining FGM/C prevalence rates in the province, but this will only have an impact if proper targeting of the interventions is undertaken. The growing evidence of successful programmes addressing FGM/C and other forms of negative traditional practices underscore the importance of an integrated programme that also centers on advocacy and empowering women in affected communities. The existence of legislation and policies against FGM/C is expected to contribute to the decline in the observed prevalence’s at the national level, but if and only if the appropriate set of interventions are targeted to the right locations and communities. The findings of significant differences among counties in the practice and attitude of FGM/C shows how strongly locational and ethnic identity might be playing a significant role in the elimination of FGM/C. The two counties of Nyamira and Kisii are predominantly occupied by the Kisii tribe of Kenya and for many years there is well documented evidence of FGM practices among the Kisii tribe and communities. Equally in Migori County, FGM has mostly been documented among the Kuria tribe that forms up nearly 35% of the population of Migori county. Other counties i.e Kisumu, Homabay, and Siaya are occupied by mostly the Luo tribe of Kenya which are known not to practice FGM/C. It is not surprising therefore that when the province is taken together as homogenous on the measure of FGM/C practice, the findings show a paltry problem at hand for policy relevance, while with an analysis of the county levels, it is clear that within this former province of Kenya, all efforts for FGM elimination should go to the two counties of Nyamira and and partly to Migori county. Within these counties, some women still show strong support in favour of the continuation of FGM/C.

A decline in the prevalence of FGM/C in Nyanza province among Muslim women was observed. Reasons for this decline may range from changes in reporting patterns due to the new laws, migrations, to changes in practice due to the increased advocacy around FGM practices. The outlawing of FGM in Kenya remains a positive advance in achieving the rights of women and young girls. However, this may have the detrimental effect of deterring women from seeking medical assistance for complications relating to FGM. Mechanisms for addressing the health needs for those in need have to be put in place to ensure that victims are not punished twice.

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