Main findings
Our systematic review resulted in two studies—and one was from the late 1990’s. Both studies evaluated outcomes regarding the improvement of healthcare professionals’ knowledge and attitude towards FGM and confidence in clinical management pre and post training. The Malian study also evaluated outcomes related to the medicalization of FGM. Neither evaluated the effects of the training on the quality of the care offered, the clinical outcomes of women attended, the satisfaction of the care received and prevention.
Strengths and limitations
As far as we know, this is the first systematic review on interventions aimed at improving healthcare providers’ capacities of prevention and treatment of FGM. The strengths of our study are the inclusion of the grey literature, the retrieval of additional records through hand searching and by browsing webpages related to FGM and the absence of language restriction. The Malian study included in this systematic review was retrieved through the web-searches rather than standard peer-reviewed databases.
Our review was limited by the lack of available evidence. Despite placing no restriction on study design, only two studies met our inclusion criteria, and neither of these conducted statistical analysis to evaluate the outcomes. Because of that, the assessment of the quality of evidence was not the objective of our systematic review. The heterogeneity of study design, population included and outcome measures did not allow the computation of summary measures. As it is difficult to systematic search the grey literature, it is possible that we missed some interventions and evaluations.
Interpretation
Evidence on effective and feasible interventions aimed at increasing providers’ capacities is extremely limited. A recent analysis of the evidence on knowledge, experiences and attitudes of health professionals toward FGM resulted in six areas for improvement for health care providers:
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Knowledge of FGM and its consequences;
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Adherence to FGM protocols and guidelines;
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Socially constructed acceptance of FGM;
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Knowledge of legislation and legal status of FGM;
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Condoning, sanctioning or supporting FGM; and
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Information and training to work with women and girls living with FGM.
These authors [
14], in agreement with Dawson et al. [
15], point to the key role of nurses and midwives in FGM management, and the need to strengthen evidence-based guidelines and professional individual and services health capacities.
Different e-learning tools for FGM have been implemented in high-income countries [
6,
16]. However, their efficacy among caregivers has not been evaluated. FGM is a subject that requires specific cultural expertise to facilitate communication, counseling, care and prevention [
7] and many healthcare professionals do not have any previous experience on the subject and will benefit from more training. Such novel on-line platforms provide broader training opportunities, but before they can be recommended, high quality evaluations are needed. The study of Jacoby and Smith showed that the majority of the trained midwives had no previous clinical experience of caring a woman with infibulation. The part of the program the participants found most powerful was the one with the Somali cultural broker [
12]. In settings where FGM is not prevalent, but migrant women are living with FGM, collaborating with certified interpreters and cultural brokers could improve the training.
Iconographic material, including videos on defibulation [
17], together with practical sessions of simulation and role play could improve ability, communication and confidence of caregivers [
7].
In theory these interventions can work; however, evaluation will be needed. Evaluation measures should include knowledge and skills for providers working with women with FGM, as well as outcomes among women living with FGM, such as appropriate recording of FGM and type on clinical records, experiences of complications, surgical procedures linked to FGM, and obstetric and neonatal outcomes among others. Where hospital or national FGM registries and diagnostic codes are available, such as in United Kingdom [
18], the information collected could be used in pre and post training evaluations.
In lower-income settings where most of the FGM is performed, providers can play an instrumental role in the perpetuation of FGM, as well as treatment and management of women living with FGM. In these settings, important measures may include health care workers’ attitudes towards FGM, reinfibulation and defibulation as well as their knowledge of FGM. Monitoring rates of refusal of defibulation and request of reinfibulation in case of FGM type III would also be important. So little research has been done in this area as it is probably difficult to monitor at long term healthcare workers clinical practice, clinical outcomes and satisfaction of clients on a subject like FGM, which is considered taboo among most of the communities and illegal in many countries.
Interventions aimed at sensitizing and training healthcare providers should be based on the assessment of the needs of the site of implementation. Healthcare providers that work with women with FGM in the diaspora or in countries where FGM is ritual can present similarities, such as the difficulty in recognizing and classifying FGM [
19], but also differences and specific characteristics to be expressly addressed, such as the problem of medicalization in some African countries or the religious and cultural differences between Western caregivers and migrant patients. The study in Mali in fact, found that, before training, 35 % of the caregivers thought that FGM does not have health risks if performed in a safe environment [
11]. Healthcare workers in low prevalence settings may be unfamiliar with cultural issues explaining the persistence of the practice or, could find it difficult or uncomfortable to ask about it because of the fear of embarrassing or causing distress to their patient [
19].