Research article EMHJ – Vol. 25 No. 9 – 2019 Geographical variation in the prevalence of female genital mutilation in the Kurdistan region of Iraq Nazar Shabila 1 1Hawler Medical University, Erbil, Iraq (Correspondence to Nazar P. Shabila: [email protected]). Abstract Background: Female genital mutilation is practised in the Kurdistan Region of Iraq but the reasons for this are not well understood. Aims: This study aimed to determine the geographical clustering of female genital mutilation in the Kurdistan Region of Iraq. Methods: A secondary analysis of data from the Iraq Multiple Indicator Cluster Survey 2011 was done. The sample includ- ed 11 384 women of reproductive age who reported having undergone genital mutilation. The prevalence of female genital was analysed according to Iraqi governorate including the three governorates of the Kurdistan Region of Iraq, district of the Kurdistan Region of Iraq, and age group (15–30 and 31–49 years). Results: The prevalence of female genital mutilation was highest in Erbil (62.9%) and Sulaimany (55.8%) governorates in the Kurdistan Region of Iraq. The prevalence was highest in the districts of Pishdar (98.1%), Rania (95.1%), Choman (88.5%), Dukan (83.8%) and Koya (80.4%). In 20 of the 33 districts, the prevalence of female genital mutilation was significantly lower in the younger age group (15–30 years). The difference between the two age groups was small and not statistically significant in the districts of Pishdar, Rania and Dukan. The main cluster of districts with a high prevalence of female genital mutilation is located in the eastern part of the Kurdistan Region of Iraq along the border with the Islamic Republic of Iran. Conclusions: Further research is needed to explore the determinants of the continued high prevalence of female genital mutilation in this area. Keywords: female genital mutilation, prevalence, Kurdistan Region of Iraq Citation: Shabila N. Geographical variation in the prevalence of female genital mutilation in the Kurdistan region of Iraq. East Mediterr Health J. 2019;25(9):630–636. https://doi.org/10.26719/emhj.19.009 Received: 14/11/16; accepted: 25/12/17 Copyright © World Health Organization (WHO) 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license https:// creativecommons.org/licenses/by-nc-sa/3.0/igo Introduction the prepuce (clitoridectomy) (1). It is carried out on girls at an average age of 7 years (8). Female genital mutilation is the “partial or total removal of the external female genitalia or any other injury to the The roots of female genital mutilation in this region female genitalia for non-medical reasons”. Female geni- are not well understood. It is practised in the Iraqi and tal mutilation is considered a violation of human rights the Iranian Kurdish areas, but generally not in other parts of girls and women and is an important manifestation of of Iraq and the Kurdish areas of neighbouring Turkey gender inequality and discrimination (1). Furthermore, (9). Religious, social and cultural factors are together the procedure is associated with immediate and long- responsible for the practice of female genital mutilation term health risks and consequences. The immediate (5). An important, instigating factor for the continuation consequences of female genital mutilation include pain, of this practice is the inheritance of tradition and customs bleeding, infection and difficulty in passing urine, while in the family (8,10). Therefore, this study aimed to detect the long-term consequences include chronic pain, chron- clustering of female genital mutilation in the Kurdistan ic infections, poor quality of sexual life, birth complica- Region of Iraq and identify the areas in the region where tions and psychological problems (2,3). Female genital its prevalence is highest. A broader goal of the study was mutilation occurs most frequently in the western, east- to assess the time trend of the practice in the different ern and north-eastern regions of Africa and some coun- clusters by comparing the prevalence of female genital tries in Asia and the Middle East. More than 125 million mutilation in two age groups by geographical region. living girls and women from 29 countries have been af- fected by this harmful practice (4,5). Methods Female genital mutilation is commonly practised in the Kurdistan Region of Iraq. The prevalence of the Study design and sample practice is about 40% (6). The commonest type of female This was a secondary analysis of data from the Iraq Mul- genital mutilation in this region is type I (76–99%) (6–8), tiple Indicator Cluster Survey 2011 (6). The 2011 survey is which includes partial or total removal of the clitoris or the latest multiple indicator cluster survey conducted in 630 Research article EMHJ – Vol. 25 No. 9 – 2019 Iraq. The 2011 survey was conducted by the Iraqi Central health, any illness symptoms, use of contraception, un- Statistics Organization and the Kurdistan Regional Sta- met contraception needs, whether they had undergone tistics Office with the support of the United Nations Chil- female genital mutilation, and attitudes towards do- dren’s Fund (UNICEF) and the Iraqi Ministry of Health. mestic violence. The under-5 questionnaire for children The survey aimed to provide estimates for a number of was done with mothers or caregivers of children under 5 indicators on the situation of children and women at years of age living in the households, and included ques- both the national and regional levels. The survey covered tions about the age, birth registration, breastfeeding, ear- all 18 governorates and 118 districts of Iraq, including the ly childhood development, immunization, care of illness three governorates (Duhok, Erbil and Sulaimany) and the and anthropometry. 33 districts in the Kurdistan Region of Iraq. Access to the Data collection in the Kurdistan Region of Iraq was datasets was granted by UNICEF. carried out from 13 February to 18 March 2011. In each The survey included a representative sample of 36 592 district, a female physician administered the women’s households in 3658 primary sampling units for the whole questionnaire to the participating women by direct of Iraq including a sample of 10 231 households in 1023 interview and in private. primary sampling units in the Kurdistan Region of Iraq. The main outcome variable of interest of this study Of these 10 231 households, 9761 were occupied and 9717 was the self-reported genital mutilation status of the included individuals who were successfully interviewed. women who participated in the survey. This outcome Thus, the household response rate was 99.5%. In the variable was extracted from the dataset of the female interviewed households, 14 106 women aged 15–49 years genital mutilation module of the women’s questionnaire. were identified. The exposure variables included the age of the women A two-stage sampling strategy was adopted by the and the governorate and district of residence. 2011 survey (6). Firstly, 31 primary sampling units were selected within each district with systematic probability Data analysis proportional to size. Within each district, the primary SPSS, version 19 was used for data analyses. The prev- sampling units were proportionately distributed alence of female genital mutilation was calculated by between urban and rural areas. Secondly, the selected governorate for the whole of Iraq and by district for the primary sampling units were mapped and numbered. Kurdistan Region of Iraq. The chi-squared test was used The list of the households within each selected primary to assess the difference in the prevalence of female gen- sampling unit was prepared, and a systematic random ital mutilation between two age groups (15–30 years and sample of 10 households was selected from the list. All 31–49 years) for each district of the region. A P value of women aged 15–49 years in each selected household ≤ 0.05 was considered statistically significant. The prev- were invited to participate in the study. Of 14 106 alence of female genital mutilation by governorate of eligible women, 13 442 participated in the survey giving Iraq and district of the Kurdistan Region of Iraq and the a response rate of 95.3%. Of these 13 442 women, 11 384 difference in the prevalence between the two age groups responded to a question on whether they had undergone were analysed spatially and are presented in maps. genital mutilation; these women were included in the data analysis. For the whole of the country of Iraq, Ethical considerations 26 456 eligible women responded to the question on The survey protocol of the Multiple Indicator Clus- genital mutilation status and were included in the data ter Survey 2011 was approved by the Iraqi Ministry of analysis for calculating the prevalence of female genital Health, and the survey was conducted in coordination mutilation in the different governorates of Iraq. and cooperation with the ministry. All the participants of the Multiple Indicator Cluster Survey 2011 were request- Data collection ed to provide written or verbal informed consent before The Multiple Indicator Cluster Survey 2011 included participation. three questionnaires: a household survey questionnaire, This study, which used data from the 2011 survey, was a women’s questionnaire, and an under-5 questionnaire. approved by the Research Ethics Committee of Hawler The questionnaires were based on the Multiple Indicator Medical University. Cluster Survey 4 model questionnaires (11). The house- hold questionnaire was administered to a knowledgeable adult living in the household and included questions on Results the household members, education, water and sanitation, The sociodemographic characteristics of the 11 384 household characteristics, child labour, child discipline, women from Kurdistan Region of Iraq who were includ- handwashing, salt iodization and water testing. The ed in this study are shown in Table 1.