Characteristics of participants interviewed for qualitative data
A total of 23 IDIs and 34 KIIs were conducted as summarized in Table 2. The interviews were conducted with five clinical officers (medical assistants), six medical officers, and 12 nurse-midwives. Most (65%) of the participants for KIIs and IDIs were males from Pokot community (49%). Of the participants, a third (32%) were 21–30 years, 31–40 years were 25% while 40% were older than 40 years. Fifty-three percent of the HCWs had worked in the current health facility for over 6 years, while 47 percent reported to have worked in the work station for less than 6 years. Three group discussions were conducted with Nurse-Midwives, while only one was involved women living with FGM.
Table 2
Demographic characteristics of participants for in-depth interviews (IDIs) and key informant interviews (KIIs).
| IDIs (N = 23) | KIIs (N = 34) |
Characteristics | (n) | Percent | (n) | Percent |
Gender | | | | |
Male | 14 | 60.9 | 23 | 67.7 |
Female | 9 | 39.1 | 11 | 32.3 |
Ethnicity | | | | |
Pokot | 9 | 39.1 | 19 | 55.9 |
Other Ethnicity | 8 | 34.8 | 12 | 35.3 |
Other Kalenjin group | 4 | 17.4 | 1 | 2.9 |
Missing | 2 | 8.7 | 2 | 5.9 |
Age (years) | | | | |
21–30 | 14 | 60.9 | 4 | 11.7 |
31–40 | 2 | 8.7 | 12 | 35.3 |
41 or older | 6 | 26.1 | 17 | 50.0 |
Missing | 1 | 4.3 | 1 | 2.9 |
Years at the facility/ organisation | | | | |
0–5 years | 17 | 73.9 | 10 | 29.4 |
6 + years | 6 | 26.1 | 24 | 70.6 |
Section /department (only IDI) | | | | |
Clinical assessment room | 1 | 4.3 | - | - |
Maternity | 8 | 34.8 | - | - |
Obstetric | 3 | 13.0 | - | - |
OPD | 4 | 17.4 | - | - |
Theatre | 4 | 17.4 | - | - |
Other | 4 | 17.4 | - | - |
Cadre of the officer (only IDI) | | | - | - |
Clinical officer | 5 | 21.7 | - | - |
Medical officer | 6 | 26.1 | - | - |
Nurse/midwife | 12 | 52.1 | - | - |
Organisation Represented (Only KII) | | | | |
Government | - | - | 18 | 52.9 |
Health development partners | - | - | 3 | 8.8 |
Health professional associations | - | - | 4 | 11.8 |
NGOs players in FGM/C | - | - | 5 | 14.7 |
Missing | - | - | 4 | 11.8 |
Data on health facility assessment were obtained from 30 facilities identified and sampled for the evaluation. The facilities included 3 percent tertiary, 13 percent secondary and 83 percent primary or faith based facilities spread across four sub-counties of the county.
National Laws Noted To Address Fgm Prevention And Care
The participants noted that response to FGM prevention and care was guided by a number of nation-wide legal instruments. This was an indication of existence of favourable legal environment and government’s commitment to address human rights violation associated with FGM in solidarity with the global community. The aforementioned achievement is not a monopoly of one institution but multi-stakeholders’ collaboration, crosstalk, networking, and partnerships towards abandonment of FGM. The study participants identified legal instruments to be very critical in addressing FGM prevention and care. These instruments included the Constitution of Kenya which was cited to guarantee fundamental rights to women’s and girls’ for which FGM violates as quoted by a representative from Ministry of Health, “overall, we have the Constitution of Kenya, which protects and guarantees every one of their rights against violence, FGM being one of them.” These sentiments were echoed by a representative from an International NGO from Nairobi, “the Constitution of Kenya recognizes sexual reproductive health rights of women and girls and by virtue of that, it mandates the state to have laws on sexual reproductive health rights.”
A number of other relevant laws were identified to contain clauses that address FGM prevention and care. These included the Children’s Act 2001, which was cited to be the earliest legislation which attempted to address FGM. Specifically, the Act criminalised FGM among girls under 18 years. However, some gaps were identified regarding this law because families would wait until the girls were 18 years then subject them to FGM. This attempted to negate gains in response to FGM and thus stimulated development of relevant comprehensive laws that addressed FGM including the identified legal lacuna as explained by a representative of a national NGO on women’s rights, “the Children’s Act 2001, was the earliest to address FGM but in most cases, community members used to wait until girls are older than 18 years, then they would be cut.” The sentiments were corroborated by a participant from education sector in West Pokot, “the children’s act, provides for the children to have a right to good health, FGM interferes with their health and well-being in this case it contravenes their welfare and their well-being and development later on in life.”
In describing the laws that address FGM prevention and care, the Prohibition of FGM Act 2011 was cited as one of the key laws. This legislation was noted to criminalise FGM by defining the offence, prescribing penalties for the violators as well as those who abate the practice and those found with tools for performing FGM including medicalisation, sentiments supported by a representative from a local NGO in West Pokot, “the prohibition of FGM law of 2011 entails arresting and persecution of someone caught with tools for FGM, circumcisers, and someone who hears of FGM is done somewhere and failed to report. Also if the FGM is done in your family, the neighbours will be arrested for not reporting”. Similarly, these responses were supported by an administrator with national government in West Pokot, “FGM is a practice outlawed in Kenya, through a prohibition of FGM Act of 2011 that criminalised FGM, banned the action, actual commitment of the act, those who procure, those who abate and any other person that might be key in commission of the FGM”.
Specific Laws Relevant To Regulation Of Health Professionals Lacked Provisions For Addressing Fgm
Although the participants were from diverse background including those from health sector, laws that regulated professional conduct of HCWs lacked content on ending FGM including its medicalisation. The legislations regulating the doctors, Nurses/midwives and clinical officers namely the medical practitioners and dentist Act, nurses Act and clinical Officers Act, lacked specific clauses that addressed FGM. This points to the general nature of the laws of being broad enough, all-inclusive as well as complementary to be read with other national laws and not necessarily lack of clauses that can deal with professional crimes of omission and commission. Further analyses showed that the protection against domestic violence Act of 2015 – a legislation that defines and categorises FGM as a form of violence was not cited in addressing FGM among the participants. This was a pointer to lack of in-depth understanding of the laws a fact attributed to limited involvement and sensitisation about the laws. This however, show existing gaps in knowledge and the need for training to build capacities of stakeholders about contents of laws.
Policies Mainly Addressed Fgm Prevention With Little Mention Of Care
The participants identified a number of policies with clauses that addressed FGM prevention and care. These included adolescent sexual and reproductive health, national eradication of FGM, and school health policies. Although these policies were cited to have provisions that respond to FGM, the specific components for FGM prevention and care were not mentioned. This is a pointer to lack of deeper or limited knowledge on the content of the policies as demonstrated in the responses from health specialist from West Pokot, “there is the adolescent youth and reproductive health policy that have components that address FGM because it is something close to reproductive health.” The sentiments were corroborated by those from a representative from end FGM coordinating body, “in the national eradication of FGM policy 2019, we have the necessary legislation in place that if we continue implementing will help us address FGM.” This position was reaffirmed by responses presented by a health care worker in West Pokot, “the national school health policy has a small component on FGM response to school pupils especially the girls who are almost at the adolescent stage. These policies also address on those issues the Anti-FGM issues in schools because of the young girls. The adolescent girls who are at upper primary they are more likely to be vulnerable to FGM activities in communities which have predominant cultural activities for FGM”.
Although prevention of FGM appeared to have been addressed vide a number of policies, participants felt that care of FGM-related complications had not received serious attention as expressed by a participant from a professional regulatory body, “most of the documents I've seen are fairly silent on management and care of FGM, because until recently it is when people started discussing about reconstructive surgeries, psychological and emotional management. So, most of the interventions previously have been targeted on either prohibiting or preventing FGM.”
Lack Of Guidelines Or Protocols For Addressing Fgm Prevention And Care Was Noted
The participants were not aware of any guidelines or protocols that addressed FGM prevention and care. However, most health sector participants expressed that such guidelines could be very instrumental in provision of care for women with FGM-related complications. Lack of these tools (guidelines and protocols) necessitated HCWs to implement a generic approach in addressing FGM-related complications as expressed by a HCW working in county referral hospital, "am not aware of any guidelines, actually I have not seen, I didn’t know there are any guidelines so am not aware, so do we have guidelines?". The sentiments on generic approach to FGM care were also expressed by a health professional trainer from a medical training institution in West Pokot who quipped, "I don’t think we have really specific guidelines. We need to come up with some. But in management of FGM it is just managed medically and symptomatically, the way we manage any other problem like bleeding." These responses are an indication of how problematic policy making process may be in Kenya. Clearly, policies (tools) are developed but they remain at high policy level, lacking dissemination and not necessarily benefiting the would be the beneficiaries. For example, a manual on management of FGM-related complications during perinatal period of 2007 (40) has been in existence, but very few HCWs were aware about it. This could be associated with governance challenges where the national ministry of health makes decisions and policies which do not trickle down to the lower structures as well as service points. This challenge was to be addressed through devolved governance where counties were given the mandate of developing their own laws and policies. However, this is unlikely to address the challenges in health because all functions except policy making were devolved (19).
Health Facilities Provided Essential Reproductive Health Services But Minimal Fgm-related Care To Women/girls
The health facility assessment data showed that essential reproductive care services were offered to women in West Pokot (Table 3). These services included: HIV screening and testing (100%), antenatal care (100%), child growth monitoring and immunisation (100%), family planning (97%), gynaecological (97%), delivery (97%), post-partum care (97%), essential new-born care (87%), screening for sexually transmitted infections (STIs) and treatment (80%), infertility consultation (43%), and HIV/AIDS treatment and care (37%). However, only 23 percent of the facilities offered specific FGM-related care. These findings are an indication of adequate preparedness of the health system to provide reproductive health services in West Pokot. These are positive findings-an indication of infrastructural capacity for care services towards women and girls. This means, there would be minimal requirement for human resource re-orientation through training to complete the circuit for support to commence implementation of FGM-related care. Given the status of health system in West Pokot, the best approach should involve integration of end FGM prevention and care interventions into the existing reproductive health care services. This approach could be cost effective and efficient through resource maximisation.
Table 3
Essential reproductive health care services provided to women across facilities in West Pokot County
| Primary N = 25 | Secondary N = 4 | Tertiary N = 1 | Total N = 30 |
| n | % | n | % | n | % | n | % |
Reproductive health services | | | | | | | | |
STI screening and treatment | 19 | 76.0 | 4 | 100.0 | 1 | 100.0 | 24 | 80.0 |
HIV screening, testing and counselling | 25 | 100.0 | 4 | 100.0 | 1 | 100.0 | 30 | 100.0 |
HIV/AIDS treatment and care | 6 | 24.0 | 4 | 100.0 | 1 | 100.0 | 11 | 36.7 |
Family planning counselling | 25 | 100.0 | 3 | 75.0 | 1 | 100.0 | 29 | 96.7 |
Infertility consultation | 10 | 40.0 | 2 | 50.0 | 1 | 100.0 | 13 | 43.3 |
Gynaecological services | 24 | 96.0 | 4 | 100.0 | 1 | 100.0 | 29 | 96.7 |
Specific FGM/C Management | 4 | 16.0 | 3 | 75.0 | 0 | 0.0 | 7 | 23.3 |
Antenatal care | 25 | 100.0 | 4 | 100.0 | 1 | 100.0 | 30 | 100.0 |
Delivery | 24 | 96.0 | 4 | 100.0 | 1 | 100.0 | 29 | 96.7 |
Postpartum care | 24 | 96.0 | 4 | 100.0 | 1 | 100.0 | 29 | 96.7 |
Essential new-born care | 22 | 88.0 | 3 | 75.0 | 1 | 100.0 | 26 | 86.7 |
Child growth monitoring and immunisation | 25 | 100.0 | 4 | 100.0 | 1 | 100.0 | 30 | 100.0 |
Identified Fgm-related Complications And Their Corresponding Interventions
The participants noted that women and girls presented with a range of FGM-related complications. The complications included bleeding and infections; birth complications such as obstructed labour and post-partum haemorrhage; and long-term complications including scars, fistulas, and keloids. The fistulas were understood to be associated with prolonged and/or obstructed labour due to inelastic FGM-related scars as well as the infibulated external genitalia that created a pin-hole passage making birthing process very difficult. A summary of illustrative quotes describing how FGM-related complications were managed are provided in Table 4. As regard care and management of the complications, women with external genital scars were generally left untreated unless the lesions were severe. Most women in West Pokot traditionally underwent infibulation (type III) type FGM and therefore the care for their birth-related complications involved having to undergo episiotomy, de-infibulation, caesarean sections and referrals as illustrated in Table 4.
Table 4
Illustrative quotes on the management of FGM-related complications encountered in health facilities in West Pokot
Complication | Management |
Bleeding: | “complication of FGM… includes bleeding, which can even lead to death. The first thing we do is to arrest the bleeding through suturing, because with FGM they cut too deep or cut a vein or artery. Therefore, one has to manage the bleeding before you do anything else.” HCW, private health facility, West Pokot “we assess the extent of blood loss, grouping and cross matching before initiating blood transfusion. Once the transfusion is done, we can recheck the hemoglobin level and keep monitoring the patient.” HCW, County Referral Hospital, West Pokot |
Infections | “it depends with the severity, if the patient has come who is so severe we normally admit we give fluids, give iv antibiotics and we clean if there is a wound, for the minor case we clean and we give oral antibiotics and we make follow ups at times, we tell them to report if there are any complications that arise from” HCW, Sub-County Hospital, West Pokot |
Birth complications: a) obstructed labor b) postpartum hemorrhage | “the possible complications are difficulties in giving birth and delivering the baby because of the FGM scar. This requires having to do episiotomies which would otherwise be unwarranted to allow for passage of the baby.” HCW, County Referral Hospital, West Pokot “during delivery this mother with FGM has difficulty in delivery, we usually assist them by performing some surgical intervention called episiotomy so that the birth canal can be roomy enough for the mother to deliver and that is repaired of course after the delivery of the baby”. HCW, County Referral Hospital, West Pokot “we give the upside episiotomy because that is the most appropriate for the mothers who are circumcised” HCW, private health facility, West Pokot “most ladies when they come during labor, they have obstructed labor and difficulty in delivery and that means delivery is a problem most them end up in a theatre for caesarean section”. HCW, County Referral Hospital, West Pokot “we do refer and link with County referral hospital with most of difficult problems. Most of the time we handle the normal procedures, the abnormal we don’t” HCW, private health facility, West Pokot |
Long term complications: Scars, fistulas, keloids | “severe scar may require reconstructive surgery and that sometimes is not done since the level of expertise down in this marginalized county is actually really poor, and I want to imagine these ladies are left with so much pain” HCW, County Referral Hospital, West Pokot “those with fistula, are seen by the visiting gynecologist who are specialist in fistula repair. There is an AMREF fistula program that has been running for years supporting our women”. HCW, County Referral Hospital, West Pokot |
Fgm-related Sexual And Psychological Complications Were Identified Among Women In West Pokot
Participants expressed that women living with FGM experienced sexual and psychological complications. As illustrated in the following quotes, sexual complications included difficulty in penetration due to infibulation, painful intercourse, and lack of enjoyment. The psychological complications included psychological trauma and stigma consistent with responses obtained in a discussion with HCWs from West Pokot, “the one that underwent circumcision because of narrowed vaginal canal, when she meets a man (sexual intercourse), there is a struggle until she develops tears”. These responses were corroborated by sentiments from a HCWs regarding girls, “Girls are at times forced to undergo FGM, others are being taken away from school. The psychological trauma that these people undergo is because others are forced to go against their will”. In addition, a HCW from a private health facility echoed the sentiments on psychological effects attributed to stigma, “Also … stigmatisation, you know currently, people don’t want FGM and if you find someone who has done FGM and people talking about the bad effects, you will find that deep inside her, she will be feeling some form of stigmatisation”.
The findings on sexual and psychological complications were corroborated by the responses from discussions involving women who had underwent FGM, “when the girl gets to the man’s house, her genitalia has closed completely, all they can do is to find Lal {cows horn} so that they open her vagina. Imagine all these problems the girl has to go through all alone”. The women identified more complications, “the one that underwent circumcision, when she meets (sexual intercourse) a man, there is a struggle, tears and painful intercourse”. Furthermore, a member of the group expressed that the pain during sexual intercourse unbearable, “when you have sexual intercourse with a man, there must be pain. These young girls cannot have sexual contact with a man for the first three days; they just try around the outside part (genitalia) until when it slides in. But then there is so much pain. After three days they meet once again. The pain is unbearable.”
Although some health professionals reported to have offered counselling to the women with FGM-related complications, some qualitative interviews suggested lack of attention to FGM may have stemmed from absence of guidelines for care of FGM-related consequences making the complications to be treated symptomatically as expressed by a representative from Ministry of Health, “health workers manage FGM cases like any other patient, so that if they present with acute bleeding, then you manage the presenting symptoms. If they present with obstructed labour, then you manage the obstruction, but you're not very keen on what caused the obstruction.” The responses were supported by a representative of health sector in West Pokot, “Even if it’s something (FGM) which was done illegally, when it has reached our hands, we need to treat as a patient, as somebody vulnerable. Not to start to ask who told you to do that without discrimination. So, you treat/manage accordingly for example, if its bleeding, infection you manage accordingly as signs and symptoms present to you”.
Referrals For Fgm-related Complications Across Health Facilities In West Pokot
There were reported instances where HCWs were unable to care for FGM-related complications prompting referrals to higher level facilities for further care. For example, birth related complications namely obstructed and prolonged labour were particularly referred to the county referral health facilities as expressed by a HCWs from a private facility in West Pokot, “we do refer and link with county referral hospital…if we can’t manage it, we refer to them. Most of the time we handle the normal delivery procedures, the abnormal we don’t”. The sentiments were supported by a HCW from a Sub-County hospital in West Pokot, “The woman has prolonged labour and because there is no way this baby can come out because FGM obstructs the baby from coming out and the woman labours for a long time. Most of the women coming from our periphery health facilities or communities come with prolonged and obstructed labour. So, by time they reach the county hospital, they are helped to deliver through caesarean section”.
As indicated in Table 5, health facility assessment showed that referral systems to higher level facilities existed in all primary, tertiary, and in some (25%) secondary facilities. Generally, FGM-related referrals were found in 63 percent of all facilities. The nature and cause of the referrals for the FGM-related cases were due to birth (48%), gynaecological (32%) and immediate (11%) FGM-related complications, respectively.
Table 5
Referrals for women with various reproductive health problems including FGM across health facilities
Category of health facility | Primary | Secondary | Tertiary | Total |
| n | % | n | % | n | % | n | % |
Existence of referral system to higher level facilities | 25 | 100.0 | 4 | 100.0 | 1 | 100.0 | 30 | 100.0 |
Average number of referrals done per week | | | | | | | | |
Rare | 1 | 4.0 | 0 | 0.0 | 0 | 0.0 | 1 | 3.3 |
1 | 14 | 56.0 | 0 | 0.0 | 0 | 0.0 | 14 | 46.7 |
2 | 5 | 20.0 | 0 | 0.0 | 0 | 0.0 | 5 | 16.7 |
3 to 7 | 2 | 8.0 | 4 | 100.0 | 0 | 0.0 | 6 | 20.0 |
Missing | 3 | 12.0 | 0 | 0.0 | 1 | 100.0 | 4 | 13.3 |
Availability of tools/documents used for referral | | | | | | | | |
No | 1 | 4.0 | 0 | 0.0 | 0 | 0.0 | 1 | 3.3 |
Yes | 23 | 92.0 | 4 | 100.0 | 1 | 100.0 | 28 | 93.3 |
Missing | 1 | 4.0 | 0 | 0.0 | 0 | 0.0 | 1 | 3.3 |
Services clients referred for (Yes = n): | | | | | | | | |
FGM/C | 15 | 60.0 | 3 | 75.0 | 1 | 100.0 | 19 | 63.3 |
STI | 8 | 32.0 | 1 | 25.0 | 0 | 0.0 | 9 | 30.0 |
HIV/AIDS | 19 | 76.0 | 2 | 50.0 | 0 | 0.0 | 21 | 70.0 |
Family planning | 8 | 32.0 | 3 | 75.0 | 0 | 0.0 | 11 | 36.7 |
Antenatal care | 12 | 48.0 | 3 | 75.0 | 1 | 100.0 | 16 | 53.3 |
Post-partum care | 10 | 40.0 | 2 | 50.0 | 0 | 0.0 | 12 | 40.0 |
Essential new-born care | 10 | 40.0 | 2 | 50.0 | 0 | 0.0 | 12 | 40.0 |
Child immunisation | 1 | 4.0 | 0 | 0.0 | 0 | 0.0 | 1 | 3.3 |
Others | 5 | 20.0 | 1 | 25.0 | 0 | 0.0 | 6 | 20.0 |
Nature of referred FGM/C cases | | | | | | | | |
Birth complications | 8 | 53.3 | 1 | 33.3 | 0 | 0.0 | 9 | 47.4 |
Gynaecological complications | 4 | 26.7 | 1 | 33.3 | 1 | 100.0 | 6 | 31.6 |
Immediate complications | 2 | 13.3 | 0 | 0.0 | 0 | 0.0 | 2 | 10.5 |
Missing | 1 | 6.7 | 1 | 33.3 | 0 | 0.0 | 2 | 10.5 |
Feedback after referral | | | | | | | | |
No | 18 | 72.0 | 2 | 50.0 | 1 | 100.0 | 21 | 70.0 |
Yes | 7 | 28.0 | 2 | 50.0 | 0 | 0.0 | 9 | 30.0 |
Fgm-related Prevention Services Implemented In Health Facilities
There were two categories of FGM-related prevention services implemented by health facilities namely health facility and community based services.
Health Facility Based Fgm-related Prevention Services
The health facility assessment showed that some facilities in the county implemented health talks. These talks were delivered to women as they waited in the antenatal (57%) and postnatal (37%) care service points. The topics covered during the health talks included: HIV/AIDS, family planning, nutrition, pregnancy/labour and delivery, new-born care and immunisation. However, only in twenty-three percent of the facilities was FGM discussed during the health talks (Table 6).
Table 6
Topics covered during health talks conducted in health service points in West Pokot
Category of health facility | Primary | Secondary | Tertiary | Total |
| n | % | n | % | n | % | n | % |
Frequency of health talk per week | | | | | | | | |
None | 1 | 4.0 | 0 | 0.0 | 0 | 0.0 | 1 | 3.3 |
Once | 9 | 36.0 | 1 | 25.0 | 0 | 0.0 | 10 | 33.3 |
Twice | 4 | 16.0 | 1 | 25.0 | 0 | 0.0 | 5 | 16.7 |
3–4 times | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 |
5 times | 8 | 32.0 | 0 | 0.0 | 0 | 0.0 | 8 | 26.7 |
Daily | 2 | 8.0 | 1 | 25.0 | 0 | 0.0 | 3 | 10.0 |
Missing | 1 | 4.0 | 1 | 25.0 | 1 | 100.0 | 3 | 10.0 |
Platform of health talk | | | | | | | | |
Antenatal gathering | 14 | 56.0 | 2 | 50.0 | 1 | 100.0 | 17 | 56.7 |
Postnatal gathering | 9 | 36.0 | 2 | 50.0 | 0 | 0.0 | 11 | 36.7 |
Part of youth friendly services | 1 | 4.0 | 0 | 0.0 | 0 | 0.0 | 1 | 3.3 |
Others | 17 | 68.0 | 3 | 75.0 | 0 | 0.0 | 20 | 66.7 |
Topics covered | | | | | | | | |
FGM/C | 6 | 24.0 | 1 | 25.0 | 0 | 0.0 | 7 | 23.3 |
STI | 16 | 64.0 | 4 | 100.0 | 1 | 100.0 | 21 | 70.0 |
HIV/AIDS | 22 | 88.0 | 4 | 100.0 | 1 | 100.0 | 27 | 90.0 |
Family planning | 22 | 88.0 | 4 | 100.0 | 1 | 100.0 | 27 | 90.0 |
Nutrition | 21 | 84.0 | 4 | 100.0 | 1 | 100.0 | 26 | 86.7 |
Pregnancy/labour and delivery | 21 | 84.0 | 4 | 100.0 | 1 | 100.0 | 26 | 86.7 |
New-born care | 19 | 76.0 | 4 | 100.0 | 1 | 100.0 | 24 | 80.0 |
Immunisation | 21 | 84.0 | 4 | 100.0 | 1 | 100.0 | 26 | 86.7 |
Others | 3 | 12.0 | 1 | 25.0 | 0 | 0.0 | 4 | 13.3 |
Community Based Fgm-related Prevention Services
A children’s officer in West Pokot noted that there were no FGM-specific outreach programmes that were being conducted, “you know for health sector they do outreaches on maybe immunisation, and nutrition teaching people on how to get good and well balanced nutritive food, also prevention of may be cholera, yeah those issues, but they have never had a specific outreach on FGM to talk about FGM”. However, some participants noted that HCWs participated in various community-based activities aimed at increasing awareness of FGM. These interventions included school health talks, community outreach programmes, community health volunteer (CHV)-led sensitisation, and radio talks. Reliance on community health volunteers (CHVs) was partly attributed with challenges in funding and the potential for them to reach a wider network of community. Participants also noted the need for providers to leverage on other ongoing outreach programmes that address critical problems in the county. A summary of illustrative quotes describing these activities are provided in Table 7.
Table 7
Illustrative quotes citing various health facility and community based FGM-related prevention services in West Pokot County
Activity | Illustrative quotes |
Health facility-based FGM health talks. | “in terms of advocacy, it has been done very well and people have a lot of information about FGM and its effects. Many of our health workers engage with community members in health talks, especially for women when they come to for antenatal, postnatal and immunisation services.” HCW, County referral Hospital, West Pokot “what health care providers do is to provide information against FGM, it’s consequences for example it leads to death, haemorrhage and so forth and should not be performed. Health facilities provide health education, sensitisation and awareness on FGM. They are given information on what they should do as far as FGM is concerned, disadvantages of FGM, why FGM should not be entertained in our communities. In case of those who have undergone FGM they are treated at the facility”. Health Care Administrator, West Pokot |
School health talks | “the strategy that we have actually included is that of creating awareness at the county level and even at the facility level. Educating school children for example during school health programmes, sometimes we go for school health programmes and we talk to the girls and the boys on issues of FGM”. HCW, West Pokot |
Community outreach | “we also have the community outreaches, outreach advocating against the FGM basically, talking of these FGM practices, they should be against the FGM activities”. Health care administrator, West Pokot |
Community health volunteer-led sensitisation | “we also have community engagement though in the few areas that have community volunteers, the community strategy system, and we also use them to pass the FGM/C messages … because of lack of funds, it can hinder the effectiveness of addressing FGM/C… We are now doing a lot of outreaches and encouraging mothers to come to the hospital, we are giving them tokens if they come to deliver in the hospitals … CHVs in every village are really advocating about that mothers to come and deliver at the hospitals” Health care administrator, West Pokot |
Radio talks | “We use radio a lot to raise awareness and engage the community on matters FGM and the need for its abandonment. In these sessions the health care providers clarify why FGM is harmful especially health wise as well as its compromises on the rights of women and girls”. Health Sector administrator, West Pokot |
Notable Challenges Affecting Fgm Prevention And Care In West Pokot
Limited awareness of laws/policies
The participants at the national and county levels cited several governance factors that hindered implementation of FGM interventions at county level. These included strategies adapted for use at county level for example; non-involvement of stakeholders from counties in the formulation of laws and policies was cited to have led to local resistance. These challenges were highlighted through quotes from a representative of a professional regulatory body, “mostly you find they have formulated top bottom where a team is picked from the national government. And then you get a few guys to come who may not necessarily be in touch in the ground they sit in a conference somewhere then now they make an attempt to disseminate. And by the time you come with a fully formed policy, people are resistant.” The responses were supported by a representative of Ministry of Health who indicated the need for local policies, “we are just using the national strategies; there is none that has been domesticated specifically for West Pokot.” The sentiments were reaffirmed by a HCW from West Pokot, “FGM is illegal in this country by law, as a health provider, we were not very much in the formulation of that law that disallowed the practice of FGM, but I know there is that law and we use that law to dissuade because this is a community that circumcises the girls. That law has been used here to try and reduce that practice”
Lack Of Guidelines Or Protocols For Fgm Prevention And Care
The participants from national and county levels noted lack of guidelines or protocols for supporting FGM prevention and care. There was also reported lack of supportive tools such as information, education and communication (IEC) materials for addressing FGM. These challenges were raised by a trainers of health professionals in West Pokot, "I don’t think we have really specific guidelines; we need to come up with some. But in management of FGM it is just managed medically and symptomatically, the way we manage any other problem like bleeding." Similar responses were given by HCW from West Pokot, “at the community level, we don’t have guidelines on prevention of FGM activities. But in terms of proper implementation of health talks in the community they can do it but they don’t have even the IEC materials for prevention of FGM, and the key messages”. These messages were echoed by a representative from National Ministry of Health, “in the previous documents there is nothing that was talking specifically about FGM management, breaking it down for the health worker on how they're supposed to manage the specific complications.”
Limited Financing
Although the health system provided essential reproductive care services, FGM-related prevention and care faced some financial challenges. Most participants cited lack of budget or resource allocation by the county government as a barrier to the implementation of FGM-related response. Participants noted that majority of the funding was provided by NGOs but that it was inadequate limiting the reach of interventions as noted by a representative of a women’s CBO from West Pokot, “I think 100 percent of the resource usually come from the NGO’s who were fighting against FGM and not the government.” These sentiments were reaffirmed by a representative of County government in development sector, “The NGOs are only reaching a small percentage in the community, like here in West Pokot we have only 3 NGOs that are working to fight against FGM, but are not covering the whole county, the other parts are not accessible, but it would be now the part of the county government, so in that case I could say that the resources are not sufficient to reach the whole county.”
Inadequate Skills Among Health Care Workers
Some participants noted that HCWs had challenges in conducting critical procedures such as de-infibulation due to inadequate knowledge and skills. They for example, explained that few providers had been trained on techniques of performing de-infibulation as expressed by HCW from West Pokot, “there are these issues of like de-infibulation, though many staff have not been trained. We lack support for the training of staff who are actually working in the maternity but for the few that have been trained, when there is a serious case of FGM they can be able to perform that procedure and help the survivor”. The sentiments were affirmed by a HCW from the Sub-County Hospital in West Pokot, “we just try though we don’t have enough knowledge on how to manage the complications, but one tries whatever they can. But I feel, we need to have some, or more knowledge on how perform de-infibulation because it is not easy to assist the woman whose episiotomy is already done at home”.
Capacity building through training of HCW was cited as an important strategy to implement FGM prevention as expressed by a representative of the Ministry of Health, “What is very important when it comes to the health workers is creating capacity for them to share messages on FGM-related complications with the community."
Lack Of Essential Resources
Some participants expressed lacking essential lifesaving resources like blood banks that were critical for managing heavy bleeding-a common complication associated with FGM as expressed by HCW from the Sub County hospital in West Pokot, “mostly like here we don’t have a blood bank. So, if patients come with a lot of bleeding, we just refer them. We don’t have a blood bank so that blood transfusion cannot be conducted”.
Lack Of Specialists
The participants highlighted that many facilities lacked specialist HCWs like the gynaecologist prompting referrals of clients to higher level facilities where the specialist may be available, sentiments expressed during a discussion with HCWs in West Pokot, “our facility we are still below average in terms of quality because currently we don’t have a gynaecologist and we have a deficit of doctors also so in terms of management of complications we are still below average. The shortage has affected such that we cannot handle conditions like fistulas”.
Lack Of Fgm Data Capture In The Health Information Systems
“A well-functioning health information system ensures production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status” (39). For example, maternal child health departments keep data on number of women and children who present for antenatal, postnatal, family planning and immunisation services. These data can strengthen programming, policy formulation and inform the allocation of resources. A common theme from the interviews/discussions was that the health system rarely collected data on FGM cases including practice related complications. Reasons for limited collection of FGM-related data included the low priority placed on FGM relative to other health issues such as HIV and malaria. The lack of data was viewed as a barrier to planning, programming and resource allocation as noted by a representative from an NGO dealing with legal issues for women from Nairobi, “We don't capture the data on how many girls or women came into the health facility because of FGM or related deaths, what caused the death? I don't know whether if you go to those facilities to look for such kind of data you will get it ... So that brings in the medical board to come up with a way where they can capture all the data...”.
The challenges concerning FGM data capture were also raised by a representative of a UN agency critical in supporting end FGM interventions, “the issue of medical coding relevant to FGM is neglected. It will be very important for the Health Information Management System to capture complications related to FGM since currently they are not recorded. For example, it's through FGM that there will be prolonged labour. But this something is not captured within the health system or recorded in the health system. Health system focus more on is those indicators such as how many people have malaria, how many have HIV and those other pressing issues, thus FGM issues are neglected. The health practitioners coming from communities who perceive FGM as a normal rite of passage for girls they don't see it as a form of violation”. The challenge was further supported by sentiments from a representative of Ministry of Health, “all along we keep referring to the KDHS and we all know, it's like done every five years and not very specific to the needs of the health sector. They basically have data on prevalence, which is important. But in terms of the health sector, we don't know how many women are presenting with those complications. How many health workers have been trained on managing this specifically, trained for managing FGM and providing care, we do not have data on who is actually carrying out FGM. So, it's really difficult to justify policy change without evidence that is why we have seen the need to collect that data, to advise policy change to advise allocation of resources”.