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Review of 'Female genital mutilation – why does it still exist in Africa?'

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4
Overall, this is a well written article and is of great importance to its field.
Average rating:
    Rated 4.5 of 5.
Level of importance:
    Rated 5 of 5.
Level of validity:
    Rated 4 of 5.
Level of completeness:
    Rated 4 of 5.
Level of comprehensibility:
    Rated 4 of 5.
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Female genital mutilation – why does it still exist in Africa?

Abstract Female genital mutilation (FGM) includes all procedures that involve partial or total removal of the external female genitalia for non-medical reasons. FGM is practised in many parts of the world – including 28 African countries, some countries in the Middle East and Asia, and some population groups in Central and South America. Its prevalence rates range from 0.6% up to 97.9%, and it has been classified as a violation of human and children’s rights. Consequently, several countries have passed laws against the practice and many international programmes have been implemented to abandon it. Yet, FGM still prevails in many countries. This literature review aimed at identifying the underlying reasons for the perpetuation of FGM, ascertaining forces that foster its promotion and persistence and who is responsible for pushing its continuation. The main goal was to try to understand the underlying causes that make FGM resistant against initiatives and campaigns targeting its elimination. A literature search was carried out using several databases. All sources that approached the topic of FGM were incorporated including literature reviews, systematic reviews, qualitative and quantitative as well as mixed-method studies that described attitudes towards FGM and factors associated with its practice. Different factors that were interlinked could be identified at the individual, interpersonal, organisational/institutional as well as the community/societal level as the underlying causes of the perpetuation for FGM. These factors varied within and between different settings, and include individual characteristics such as parents’ level of education, place of residence, personal beliefs (aesthetics, health benefits, hygiene) about FGM as well as the medicalisation of FGM and the involvement of health care professionals at the institutional level. Cultural factors like gender inequality, social norms and pressure also played an important role. Surprisingly, no evidence that supported religious motives could be found in any of the three monotheistic religions. This review suggests that the reasons behind the performance of FGM differ between and within countries and contexts, but cannot be found in the scriptures even though it is mainly practiced by Muslims. Girls with low education living in small Muslim communities, in rural areas in Africa and whose parents especially the mother had a low educational level, were at increased risk of undergoing FGM. Successful actions to eliminate this practice require a balance between respect of culture and human rights. Practising communities should be involved in each step of every programme. Finally, it is crucial to target the young generations through education, women empowerment and reduction of gender inequality.
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    Review information

    10.14293/S2199-1006.1.SOR-MED.ACOXMI.v1.RKDIUZ

    This work has been published open access under Creative Commons Attribution License CC BY 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at www.scienceopen.com.

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    Review text

    While the overall quality and structure of this manuscript is sound, there are a number of improvements that could be made. Major and minor comments are given below.



    Major comments:



    Introduction section



    -As stated by the authors, the main goal of the review was to “try to understand the underlying causes that make FGM resistant against initiatives and campaigns targeting its elimination.” However, nowhere in the paper is there any discussion of the types and scale of anti-FGM initiatives and campaigns. While I understand this is not the purpose of the review, it would be helpful for the reader to have some context of these efforts to better understand the causes that make FGD resistant to them. I would suggest putting a few sentences in the Introduction section about past and current anti-FGM initiatives, campaigns, and laws (and whether these campaigns are international in nature and/or directed by local governments and communities). For example, the final sentence of the introduction poses the question, “why does the practice still exist despite all the health risks described above and national and international efforts to ban it?” but the authors have not described in any detail these national and international efforts.





    Aim section



    -I would suggest revising and simplifying the objectives statement. As written it seems repetitive. I would suggest, “This literature review aims to investigate the factors and forces that perpetuate FGM in certain areas of the world despite initiatives to ban the practice.”



    -I would also suggest re-classifying this review as a “critical” or “systematic” review versus a “literature” review. With the strict inclusion criteria for articles, this would push me towards a “systematic” review, but since the authors conducted a lot of work to use a conceptual model or framework to synthesize the literature, I also think this manuscript meets the criteria for a critical review. The authors may reference the below article by Grant and colleagues or something similar:



    Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health information and libraries journal. 2009;26(2):91-108.





    Methods section



    -Please include the dates of your database searches in the Methods section.



    -I don’t agree with changing the title of the article due to a lack of studies in areas of the world outside of Africa. In either case (changing or not changing the title), I think the authors should include in their discussion a section on why there may be data lacking from other parts of the world where FGM is practiced and the implications of this lack of data. See my comments below in the discussion section.



    -It is unclear to me how the authors used the socio-ecological model in their methodology. Did the authors choose the socio-ecological model to analyze and interpret their data, or was the data analyzed at which point an appropriate model (i.e., socio-ecological model) was identified to best fit and illustrate the results? Either way is fine but as a reader this information on your approach to modeling would be helpful. I would suggest including some details in the Methods section describing why and how the socio-ecological model was selected.





    Results section



    -In the first paragraph, I would suggest describing in more detail the 17 articles that met all inclusion criteria and were included for review. For example, given a breakdown on the types of studies (systematic reviews, original studies, qualitative versus quantitative or mixed methods), where the studies were conducted (what countries), number of participants (if qualitative or quantitative), etc.



    -The sub-headings in the Results section jump from Individual Level to Organization Level, without any sub-heading for the Intrapersonal Level. Was Intrapersonal combined with the Individual, and if so, I don’t see any results related to “peer pressure” as cited in Figure 4.



    - Individual level, 4th paragraph: The sentence “Mudege et al and Karmaker et al suggested that the education level of parents was a good predictor for letting their daughters undergo FGM or not” directly contradicts the next sentence, “However, while the mother’s level of education was significantly associated with the daughter’s circumcision, the father’s education level was not.” Did the research by Mudege and Karmaker suggest that both parents education level was a significant factor or just the mothers? Would suggest revising for clarity.





    Discussion section



    -Overall, the discussion reads more like a summary than a critical review and discussion of implications of findings. I would suggest revising in certain areas to highlight what these findings mean moving forward. The discussion section might be a good place to go into more detail around some of the anti-FGM initiatives and campaigns that have been launched but have been unsuccessful (or not as successful as hoped). The authors can then highlight certain findings from this review in terms of specific factors that might be protecting FGM in light of initiatives targeting its elimination.



    -Paragraph 2: The authors state that place of residence was significant in terms of rural versus urban, but can the authors elaborate on this and whether urban versus rural was a more significant factor in certain countries over others? The authors provide a nice map of prevalence rates of FGD in Figure 2 but including some more details in text around factors by geographic region or country would be helpful. Even if a country overall has low prevalence, a certain region of a country might have high prevalence, which is hard to see on the map since country boundaries are not shown.



    -In addition to more detail on the geography of the included studies related to the findings, the fact that the authors found no studies outside of Africa was very significant to me and should be included as a discussion point. What might be the reason for the lack of data in other parts of the world and what does this lack of data mean for efforts moving forward to eliminate this practice? The lack of data from outside Africa is an interesting finding of this study in and of itself. Would encourage the authors to elaborate.



    -Two findings that I found very interesting were not discussed in the Discussion section: 1) the U-formed association with FGM and economic status (i.e., middle class least likely to perform FGD) and 2) the idea of FGM as social capital. I would like to see the authors provide their expertise to discuss these findings and their implications for anti-FGD initiatives.





    Conclusion



    -This section should be shortened to only the major takeaways. As is, it reads too much like another summary of the article.





    Minor comments:



    -Overall, the paper is well written but I would suggest one or more of the authors re-read the manuscript for typos and to improve syntax. I’ve noted a few areas below:



    -Too many sentences begin with the word “However.”



    -I would suggest limiting in text citations of author names and move all numeric references to the end of sentences where appropriate to improve readability.



    Introduction, Paragraph 1: “However, it is not really clear when and where FGD originated exactly, but it can be traced back to Egypt earlier than 2000 before Christ (BC)” is an awkward sentence. I would suggest revising it.



    Introduction, Paragraph 2: You state that, “The procedure is performed without any anesthesia or medical personnel using a knife, sharp stone, scissors, razor blade, or even the fingernail while other members of the family or village are present to prevent the girl from moving.” But later in this section you state that “only 18% of the surgeries (FGM) are carried out within health care settings.” Presumably procedures that are carried out in health care settings are performed by medical personnel (with or without anesthesia). I would suggest modifying earlier sentence to convey that most, but not all, FGD are carried out in a more traditional way outside of health care settings.



    Introduction Paragraph 5: Please spell out UNFPA the first time it is used.



    Introduction Paragraph 5 and 6: I would suggest combining these paragraphs that addresses short-term and long-term health consequences of FGM. It does not make sense to separate risk of infection (paragraph 5) with the other potential negative health consequences (paragraph 6).



    Results, Organization level, 2nd paragraph: “The WHO also considered the availability of practitioners especially in rural areas as problem in the fight against FGM.” Awkward sentence and would change “problem” to “a challenge” or something similar.



    Results, Organization level, Religion section: I think this section is too long and some paragraphs can be combined. To me, the interesting finding that needs to be highlighted here is that while there is no religious basis found in any of the main scriptures of Islam, Judaism or Christianity, various religious justifications for FGM can be found in different communities of all three religions, although more commonly among Muslim communities. Would consider revising this section to bring out that point, rather than splitting up the sections by religion.



    Results, Organization level, 5th paragraph: “Apart from the fact that the practice of FGM is older than the Islam…” Please revise this sentence. In a number of places, the phrase “the Islam” is used. Please delete “the”.



    Results, Organization level, 5th paragraph: From the same sentence as above, which includes the phrase “the Qur’an does not contain any laws or mention about performing FGM and can therefore not be a basis for the practice” does not make sense since later you claim that religious leaders have used Islam as a basis to promote the continuation of FGM. Just because FGM is not cited in the Qur’an does not mean that religious leaders cannot use the Qur’an or Islam to justify its continuation.



    Results, Community level and societal level: The distinction between these two levels is not always clear. It may be better to recognize them as overlapping and tackle both community and societal levels together, while highlighting certain areas that would fall more distinctly in one level or the other. Would try to make this distinction more clear if you leave them as separate sections.

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