Hamda Cali, an activist, nurse and midwife in Somaliland, Somalia, often thinks of her sister and cousins when she trains health workers to stop female genital mutilation (FGM) in their communities.
“I have a younger sister, 15 years old, and two cousins, aged 13 and 15, who are untouched,” she says. “They have not been cut – I stopped it from happening.”
Hamda’s mother and aunt wanted all their daughters to undergo FGM soon after they turned five, a tradition in her community. Thanks to Hamda’s many years of work on FGM prevention and advocacy with the Somaliland Nursing and Midwifery Association, she was able to approach this sensitive issue with confidence, patience, trust and credibility – ultimately protecting her sisters.
In a country where 98% of women and girls aged 15-49 years have undergone FGM, Hamda’s story is still unusual. It is an inspiring example of how health workers, empowered with cultural, medical and psychosocial knowledge, can be agents of change.
Supporting and empowering: a new approach to preventing FGM
Global efforts to end FGM have been underway for decades, but rates are declining slowly. Although the vital role of the health sector is recognised, there is still a lack of clear evidence on what actually works.
Now, a new approach is putting antenatal care providers like Hamda and her colleagues at the centre of FGM prevention efforts.
WHO and HRP (the UN special programme of Research, Development and Research Training in Human Reproduction) are supporting national partners in Somalia, Kenya and Guinea to lead an implementation research study aimed at strengthening health workers’ communication to prevent FGM and care for survivors; not by decree, but through effective engagement and communication.
180 health facilities across the three countries are receiving a baseline FGM prevention and care package. After three months, health workers in half of the facilities will get additional training in a new person-centred communication curriculum.
“Person-centred communication is a key component of quality healthcare and human rights, and we are proud to be part of this novel training to empower midwives and nurses in their own communities,” said Dr Mamunur Rahman Malik, the WHO Representative for Somalia.
“Understanding each patient’s unique perspective and cultural context and working towards shared solutions is a long-term approach to supporting the abandonment of FGM: a commitment under the 2030 Agenda for Sustainable Development, and a core element of Universal Health Coverage.”
Conversation and communication are key
Midwives and nurses in Somaliland have a double perspective on FGM. At work, they see girls and women living with the health and psychological consequences of undergoing this harmful practice. As community members, they understand the social norms that sustain FGM as a rite of passage, whether through traditional practitioners of FGM or even sometimes by health workers themselves.
Person-centred communication recognises the unique conversations made possible by this double perspective. Using a range of interactive teaching methods drawing on behavioural theories, this new training programme supports antenatal care providers to communicate sensitively and effectively with their clients about FGM abandonment.
“With person-centred care, there are always two experts in the room: one is the patient and one is the health worker. They are at the same level,” explained Fardawsa Cisman, a public health and reproductive health specialist who works at the Ministry of Health and Development in Somaliland.
“The healthcare provider has a lot of information related to FGM. The one who is visiting the health clinic has a lot of information about themselves, and the practical ways that FGM exists in the community.”
Fardawsa recently completed the new training to become a trainer herself. She and her husband are determined that their three daughters will not undergo FGM.
Adapting safely during COVID-19
COVID-19 has disrupted health systems globally, presenting unexpected challenges – and dilemmas – for the research team.
As resources were redirected towards the pandemic effort, the team recognised that girls and women could be at increased risk of FGM at this time. Muna Abdi, the Principal Investigator in Somaliland, was determined that the study continue.
“I thought to myself – we cannot stop everything out of fear from this pandemic. We have to accept the situation and find a way forward, by protecting ourselves,” she said.
Partnership was crucial: Muna and her team of local researchers worked closely with WHO Country and Regional Offices and HRP colleagues, alongside the Ministry of Health. Together they assessed risk and developed a process for adapting and safely continuing the study.
COVID-19 prevention measures were integrated into the training programme for health workers and data collectors, ultimately supporting national efforts to expand public health education and access to personal protective equipment in health facilities. Virtual workshops were conducted when face-to-face training was not possible.
“We adapted and successfully finished the initial training and data collection. Across our research team, study participants, clients and health providers, we had no cases of COVID-19,” explained Muna, rightfully proud.
Results from the study are due at the end of 2021. Teams in all three countries are hopeful that implementation of the person-centred communication training will not only show positive results, but demonstrate how and why it can be a game-changer in efforts to abandon FGM.
WHO recommends person-centred communication in every country to ensure that health services are aligned with the needs of people – but as Fardawsa makes clear, this kind of change takes time.
“Person-centred communication is not something we start today and see change tomorrow. It needs design and discussion with your community. Changing the future for FGM is our wish, but it has a long vision.”