Factors associated with female genital mutilation among women of reproductive age and girls aged 0–14 in Chad: a mixed-effects multilevel analysis of the 2014–2015 Chad demographic and health survey data

Female genital mutilation (FGM) involves the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons [1]. Predominantly, it is conducted in Africa and the Middle East [2] and on young females between infancy and adolescence [1]. According to UNICEF [3], over 200 million girls and women alive today have undergone some form of FGM and 30 million girls are at risk of experiencing FGM in the next decade. FGM is associated with several complications which include severe pain (usually in the absence of anaesthetic agents), acute urinary retention, vaginal lacerations at coitus and haemorrhage [1, 4, 5]. In the long term, FGM may result in poor quality of life, death or both [6].

In Africa, FGM is practiced in 29 countries, with variations in terms of the proportion of girls and women who have undergone FGM in each country [7]. Two indicators have been used to measure the prevalence of FGM [7]. The first indicator reports on the prevalence of the practice as the percentage of girls and women of reproductive age (15–49) who have experienced any form of FGM [7]. For instance, in countries such as Mali, Guinea, Sierra Leone, Sudan, Egypt and Somalia, the percentage of women aged 15–49 who have undergone FGM is above 80%. In Ethiopia, Mauritania, Burkina Faso and Liberia, the proportion of women aged 15–49 who have undergone FGM is between 51 and 80% whiles in chad, 44% of women have undergone FGM [7].

The second indicator reports on FGM among daughters of women of reproductive age (15–49). This indicator is used to measure the prevalence of FGM among girls aged 0 to 14 [7]. Using this indicator, the prevalence of FGM in some sub-Saharan African countries such as Burkina Faso was 13% in 2010, 23.4% in Ethiopia in 2011, 56% in Gambia in 2010, 45% in Guinea in 2016, 3% in Kenya in 2014, 75% in Mali in 2014, 17% in Nigeria in 2013 and 15% in Senegal in 2015 [8]. A recent systematic analysis of pooled data from 29 countries spread across Africa and two countries in Western Asia found the practice of FGM among girls 0–14 to be high in a number of African countries including Chad. In that study, Chad was the country with the highest prevalence of FGM among girls 0–14 (13.9%) in Central Africa [9]. According to the 2014–15 Chad Demographic and Health Survey, 10% of girls aged 0–14 have been circumcised [10]. This indicates that literature on the practice of FGM among girls aged 0 to 14 is essential.

Despite the relatively high prevalence of FGM among women and girls in Chad, no study has examined the predictors of FGM among women aged 15–49 and girls aged 0–14 in the country. Hence, the aim of this study was to examine the factors associated with FGM among women aged 15–49 and girls aged 0–14 in Chad. Findings from this study will help develop strategic interventions and approaches in eliminating FGM in the country.

FGM is predominantly conducted in Africa and the Middle East [2] and on young females between infancy and adolescence [1]. This study sought to examine the predictors of FGM among women aged 15–49 and girls aged 0–14 in Chad. The study identified a 13% prevalence of FGM among girls and 50% among women. The prevalence of FGM among girls and women in the current study are relatively higher than the prevalence of reported in the Chad DHS [10]. The possible reason for the finding could be differences in sample size used in the current study and the Chad DHS report. For instance, while this study used a weighted sample of 6334 married and cohabiting women, the sample reported in the report in calculating FGM among girls aged 0–14 was 14,310 women of reproductive age. Among women aged 15–49, level of education, employment status, ethnicity, religion, wealth quintile and community literacy level were found as significant predictors of FGM. Age, partner’s level of education, marital status, employment status, ethnicity, religion and mother’s FGM status predicted FGM among girls aged 0–14. Aside ethnicity, the factors that predicted FGM among women and girls aged 0–14 at the same time portrayed similar patterns of influence. For instance, among women and girls aged 0–14, the odds of FGM reduced among women with higher level of education, those whose partners had higher level of education, Christians and non-working women. This is an indication that the predictors of FGM are not changing over time and hence the factors that predicted FGM among older cohorts (15–49 years) are similar to those that predict FGM among younger cohorts (0–14 years).

The results indicate that daughters of women aged 25–34 and 35 years and above were more likely to undergo FGM compared to those aged 15–24. Consistent with the findings of the current study, previous studies have also indicated that the odds of FGM among girls increases with the age of the mother [12, 18, 19]. The possible reason for this finding could be the strong connection to socio-cultural norms and practices among older women, who are more likely to uphold such norms and practices even when they have negative effects on their health [20]. Other reasons could be that older women may consider practices such as FGM as inheritance from their parents and grandparents that need to be upheld. For instance, in many high prevalent FGM societies, the practice is considered as a rite of passage to womanhood with strong ancestral and sociocultural roots [21]. Again, it is possible that the daughters of this younger group of women would not have ‘arrived’ at the age girls are commonly cut in Chad (5–14 years) as indicated in the 2013 UNICEF report on FGM [7].

The likelihood of a woman and a girl undergoing circumcision decreased among women with secondary/higher education, those whose partners had secondary/higher education and those who lived in communities with higher literacy. Similar findings on the inverse relationship between education/literacy level and FGM have been obtained in previous studies [12, 13, 18, 19, 22]. Education and literacy have been considered as essential tools for changing one’s attitude towards numerous negative socio-cultural practices, including FGM [23]. Consequently, having higher levels of education and an educated partner gives women some level of empowerment to object negative socio-cultural norms and practices including FGM of girls even when there is societal pressure to observe the practice [22]. Such empowerment is predominant in non-working women and women with rich wealth quintile, who in this study were found to be less likely to be circumcised.

Apart from women gaining empowerment though partners with higher levels of education to stop the practice of FGM, other studies have shown that FGM goes beyond geography and culture and that the practice could be influenced by patriarchal attitudes towards women and how women internalise these values. Hence, FGM and other practices are patriarchal sanctioned practices. Therefore, although FGM “appears to be a woman’s matter”, the process is influenced by patriarchy. In all of these instances, women are inflicting these harms upon their daughters or other young girls in order to ensure their future survival within their respective societies [24‐26]. However, a report by UNICEF [7] has shown that the over decades view of FGM as a manifestation of patriarchal oppression of women, which would suggest that men are ardent supporters of the practice has changed and that in countries like Guinea, Sierra Leone and Chad, substantially more men than women want FGM to end. This to some extent could be as a result of high levels of education.

Ethnicity was found to be play significant role in the circumcision of women and girls in Chad. In terms of ethnicity, women who belonged to Kenemu-Borno ethnic group had the highest odds of FGM among daughters compared with those of the Sara ethnic group. The lowest risk of FGM among daughters of women belonging to Sara ethnic group could be traced to history, where the Sara ethnic group has been considered as the ethnic group with the highest level of education and highest socio-economic status, compared to the other ethnic groups in Chad [27]. Such education and socio-economic status may give women in the Sara ethnic group the empowerment to resist negative socio-cultural practices, including FGM of daughters. Surprisingly, the odds of FGM among women was higher among those of the Sara Ethnic compared to women who belonged to other ethnic groups. It is not clear why women of the Sara ethnic groups are more likely to be circumcised but less likely to have daughters who have undergone FGM. However, this can still be linked to their higher levels of education and socio-economic status which might have taken precedence over their circumcision status and influenced their decision not to circumcise their daughters.

Religion was found as a significant predictor of FGM among women and girls in Chad. With religion, Christian women were less likely to get their daughters circumcised compared to Muslim women. The findings of several studies [25, 28, 29] support the findings of the current study. This association has been deemed to be understood in line with culturally specific interpretations of religious identity [28]. Hence, despite the higher odds of FGM among Muslim women and girls aged 0–14 compared to Christians, it is possible that not all Muslim women have undergone FGM nor cut their daughters and thus the practice could be influenced by individual interpretations of religious doctrine. Although Muslim women are more likely to be circumcised and to have their daughters circumcised, the findings support the significance of a collective rather than individual Muslim identity for the discontinuation of the practice.

The results further showed women who had never experienced FGM were more likely to have their daughters circumcised. In contrast to this finding, previous studies have indicated that women who have been circumcised are more likely to condemn the practice because of its negative effects on their health [30, 31]. Further research is needed to explore the reasons why women who have been circumcised in the current study are more likely to have their daughters circumcised.

This study has identified several individual and contextual factors as predictors of FGM among women and girls in Chad. The findings imply the need to adopt strategies aimed at addressing these factors in order to help eliminate the practice of FGM. Government and non-governmental organisations in Chad need to implement policies that enhance media advocacy and community dialogue to help deal with FGM in the country. Future studies should examine the attitudes of women of Chad towards FGM and the factors that account for the attitudes. Also, there is the need for studies that employ qualitative research methods to compliment this type of analysis and help to explain why women who have been circumcised in the current study are more likely to have their daughters circumcised.