Programmatic changes

Prior to the baseline assessment, cutting by health professionals was not considered a major challenge as it was estimated to be 4.7 per cent (Ismail et al. 2016). In 2016, the baseline assessment found that 11 per cent of FGM/C was performed by health professionals, with young women under twenty-four more than twice as likely to be cut by a health professional than older women (Newell-Jones 2017:35). By 2018, the mid-term review found that 19 per cent of women reported being cut by a health professional, and 71 per cent of women intended using a health professional to perform the less severe snip or prick on their future daughters. This dramatic increase was largely in response to religious leaders being more vocal on FGM/C, actively promoting the 2018 fatwa. This fatwa, published by the Ministry of Religious Affairs (MORA), declared the pharaonic cut to be non-Islamic, but supported the sunnah, performed by health professionals. Many religious leaders felt the fatwa gave them the clarity and authority required to guide their communities. Conversely, anti-medicalisation policies were being developed and disseminated by the MOH. Midwives and nurses were caught in a dilemma between the increasing demands from their communities to perform the sunnah, now explicitly supported by religious leaders, and the risk of severe punishment by the MOH if they were caught. Clearly, more nuanced interventions were needed to avoid a further escalation in medicalisation. SOFHA responded by engaging key stakeholders in discussions about the ethical responsibilities of health professionals, and how to reduce demand from communities. Over 200 midwives and nurses participated in workshops on managing complications of FGM/C, and providing advice and guidance to mothers on the choices for their daughters. Health workers who participated in the workshops were more than twice as likely to support the abandonment of all types of cutting (62 per cent compared to 28 per cent) and significantly more likely to provide information on FGM/C to female patients (69 per cent compared to 41 per cent) (Newell-Jones 2019). By 2019, SOFHA had convened an anti-medicalisation workshop with key partners, including the WHO and the Somaliland Nursing and Midwifery Association, on reversing the trend of FGM/C medicalisation, and accelerating the licensing of healthcare workers.

During the COVID-19 pandemic, anecdotal evidence suggested an increase in FGM/C practices. In response, SOFHA and other CSOs launched mass media campaigns to ensure that anti-FGM/C efforts remained active during the crisis. Understanding the dilemmas faced by health workers, SOFHA sought to support them in redefining their role in relation to FGM/C. SOFHA’s involvement in a WHO pilot study in 2021 aimed to improve the communication skills of health workers, equipping them to handle FGM/C-related conversations more effectively (WHO 2022; Ahmed et al. 2021). The results indicated that participating midwives and nurses were more confident in their knowledge about the harm caused by FGM/C, more likely to engage mothers in conversations about their choices for their daughters, and that these mothers were less supportive of the practice (Balde et al. 2024).

This strategy, of redefining the role of health professionals and supporting them in engaging in these new roles, is showing promise in reducing the medicalisation of FGM/C. Midwives and nurses still face decision-making dilemmas; however, the balance might be tipping towards providing advice and counselling to community members on abandoning FGM/C and away from performing FGM/C. Once the community experiences this new approach by health professionals, the demand on them to cut may reduce. Further research is needed to explore this in greater depth, and to investigate whether mothers abandon FGM/C, or go elsewhere to cut their daughters.

* Note: Although the headteacher supported the abandonment of all types of FGM/C, several school staff were only comfortable with abandoning the pharaonic cut.

Initiatives were undertaken to empower schools and teachers to play a central role in the abandonment of FGM/C, i.e. redefining the role of schools and teachers and providing capacity strengthening to fulfil this role.

Anecdotal evidence is emerging of schools and teachers adopting new strategies in response to the teacher awareness and institutional support. Further research is needed to evaluate the initiatives and embed the learning.

In 2016, religious leaders tended not to speak about FGM/C in public and held a broad spectrum of opinions. By the mid-term review, the majority (85 per cent) of religious leaders were adopting the guidance of the 2018 fatwa which prohibited the more severe forms of FGM/C but supported medically supervised pricking or snipping. Although this was not the comprehensive prohibition SOFHA had hoped for, it marked significant progress and reflected the complexities of advocacy in such a context. The remaining 15 per cent of religious leaders were in favour of the abandonment of all types of FGM/C. Although a higher percentage of health professionals (34 per cent) and teachers (24 per cent) supported the abandonment of all types of cutting, religious leaders were unique in their unanimous opposition to the pharaonic cut (Newell-Jones 2019:36).

SOFHA, and other CSOs, have adopted a nuanced approach, amplifying the voices of religious leaders who said that individuals had the right to choose and would not be punished if they chose to abandon FGM/C. They also highlighted religious leaders who had publicly stated their personal choice of not cutting. As a direct result of their engagement in dialogue on FGM/C, MORA has established a gender unit which is redefining the role of religious leaders in addressing issues affecting women and girls, including FGM/C.