FACTORS ASSOCIATED WITH THE PRACTICE AND ATTITUDE TOWARD GAVAGE AND FEMALE GENITAL MUTILATION IN MAURITANIA AN ABSTRACT SUBMITTED ON THE TWENTY-SIX DAY OF MARCH 2013 TO THE PAYSON CENTER FOR INTERNATIONAL DEVELOPMENT IN THE PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE SCHOOL OF LAW OF TULANE UNIVERSITY FOR THE DEGREE OF DOCTOR OF PHILOSOPHY BY Naceredine Ouldzeidoune, MD, MPH APPROVED: Janet Rice, PHD (Chair) Jane Bertrand, PHD Joseph Keating, PHD ABSTRACT Background: Force-feeding of girls (also known as ‘gavage’) and Female Genital Mutilation (FGM) are common practices in Mauritania. While FGM has been documented in most Sub-Saharan African Countries, gavage is somewhat unique in Mauritania; while there are other examples of pre-marriage “fattening houses” in West Africa; gavage is done only for the purpose of the immediate marriage, and is usually consensual. This paper is the first report that examines these two practices using the 2000-2001 Demographic and Health Survey (DHS). Objectives: To establish the prevalence of force-feeding (gavage) and Female Genital Mutilation (FGM) practices among women in Mauritania. Secondary objectives are to investigate factors associated with gavage and FGM practices and attitude (for women and men) towards them in Mauritania, to explore implications related to the protection of girls’ rights and welfare, and to recommend measures for enhancing effective protective mechanisms against these practices. Methods: The 2000-2001 Mauritanian DHS data were used in this analysis. Data were collected from men and women age 15 to 59 and 15 to 49 to determine attitudes about the continuation of gavage and FGM. Chi-square statistics were used to investigate differences in attitude and practice of gavage and FGM by demographic characteristics. Binary logistic regression was used to identify socio-demographic factors related to gavage and FGM outcomes. Findings: Almost a quarter (23%) of women reported being force-fed as a child, and 32% of women and 29% of men approved the continuation of the practice. Gavage is almost exclusively practiced among white Moors. The overall prevalence of FGM was 77% but varied depending on ethnicity. The majority of both female and male respondents favored the continuation of the practice (64% and 70%, respectively). Conclusion: The practice of both gavage and FGM is ongoing, although the prevalence and attitude towards both practices appears to vary as a function of ethnicity, wealth, education, marital status, and age. Contextually relevant intervention and enforcement strategies are needed to challenge these cultural norms and protect the rights and welfare of girls in Mauritania. FACTORS ASSOCIATED WITH THE PRACTICE AND ATTITUDE TOWARD GAVAGE AND FEMALE GENITAL MUTILATION IN MAURITANIA A DISSERTATION SUBMITTED ON THE TWENTY-SIX DAY OF MARCH 2013 TO THE PAYSON CENTER FOR INTERNATIONAL DEVELOPMENT IN THE PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE SCHOOL OF LAW OF TULANE UNIVERSITY FOR THE DEGREE OF DOCTOR OF PHILOSOPHY BY Naceredine Ouldzeidoune, MD, MPH APPROVED: Janet Rice, PHD (Chair) Jane Bertrand, PHD Joseph Keating, PHD ACKNOWLEDGEMENTS I would like to acknowledge and thank the members of my dissertation committee – Pr. Janet Rice, Pr. Jane Bertrand and Pr. Joe Keating – for their extreme patience in the face of numerous obstacles. This work would not have been possible without their guidance and their persistent help. I would like to thank my friends and colleagues for their support, feedback and friendship. Thank you to my mother, my wife, and my children for their love, support and understanding during the long years of my education. Lastly, I want to thank the Mauritanian government for granting permission to use the 2000-2001 DHS data. ii TABLE OF CONTENTS Acknowledgements ........................................................................................................... ii List of tables...................................................................................................................... iv List of figures ......................................................................................................................v Introduction ........................................................................................................................1 Statement of the problem ..................................................................................................2 Goals and objectives ..........................................................................................................4 Literature review ...............................................................................................................5 Background ........................................................................................................................8 Gavage in Mauritania ......................................................................................................11 Conceptual framework ....................................................................................................15 Overview of Female Genital Mutilation .........................................................................17 Conceptual framework ....................................................................................................20 FGM in Mauritania .........................................................................................................20 Methodology .....................................................................................................................21 Study objectives ..............................................................................................................21 Research questions and hypothesis .................................................................................22 Study design and sample size .........................................................................................24 Data analysis ...................................................................................................................25 Findings and discussion ...................................................................................................27 Socio-demographic profile of respondents .....................................................................27 Knowledge and attitude toward the practice of gavage ..................................................28 Intentions to have those practices performed on their daughters ....................................28 Practice of gavage ...........................................................................................................29 Knowledge and attitude toward the practice of FGM .....................................................29 Prevalence of FGM .........................................................................................................30 Bivariate analysis of sociodemographic factors related to FGM and gavage ................30 Multivariate analysis .......................................................................................................31 Practice of FGM and gavage ...........................................................................................36 Discussion..........................................................................................................................37 Policy implications ...........................................................................................................40 Conclusion ........................................................................................................................42 Bibliography .....................................................................................................................43 Appendix1- DHS household questionnaire ....................................................................01 Appendix2- DHS women’s questionnaire ......................................................................01 Appendix3- DHS men’s questionnaire ...........................................................................01 iii LIST OF TABLES Table 1. Socio-demographic characteristics of the sample ..............................................57 Table 2. Knowledge, attitudes and intentions toward the practice of gavage .................59 Table 3. Intentions to have these practices performed on their daughter(s) (among those with at least one daughter) .........................................................................60 Table 4. Prevalence of gavage .........................................................................................61 Table 5. Knowledge and attitude toward FGM ...............................................................62 Table 6. Prevalence of FGM .............................................................................................63 Table 7. Multivariate analysis of factors related to practice and attitude toward gavage ...................................................................64 Table 8. Multivariate analysis of factors related to the practice and attitude toward FGM .....................................................................66 iv LIST OF FIGURES Figure 1. Zayar: squeezing the fingers and/or the toe between two sticks ........................51 Figure 2. An illustration of the force-feeding process .......................................................52 Figure 3. Girl being force-fed with milk ............................................................................53 Figure 4. Girl vomiting during the force feeding