The WHO updates us on their end FGM work

1 May 2018

Today, the World Health Organization (WHO) has launched a new clinical handbook on high-quality care for girls and women living with Female Genital Mutilation (FGM).

The Girl Generation recently caught up with Christina Pallitto, Scientist at the WHO Department of Reproductive Health and Research in Geneva, and their focal person for FGM since 2016. At The Girl Generation, we celebrate champions working day in, day out, to end FGM, and Christina is an impressive example of someone doing just this. She’s delivering a complex portfolio of work, including rolling out this newly-launched package of evidence-based tools to help strengthen health systems around the world, to improve comprehensive FGM prevention and treatment. This has the potential to make a huge difference to both preventing FGM in future, and supporting women and girls who need care and support because of its harmful effects.

Christina has been working at WHO for more than 10 years and is passionate about improving the lives of women throughout the world. She is leading research that draws on her multi-disciplinary background in Anthropology, Epidemiology and Public Health and her experience working with community groups.

Q. What is most encouraging about the movement to end FGM at the moment?

There’s lots of energy, lots of innovation and people are very engaged in how to improve policies and programming. I’m encouraged by the fact that you do see signs of the younger generation not being cut in a lot of countries. There are so many committed, passionate people, working from different angles to end FGM. The more we can come together, support each other, and fill the gaps, the better. More and more there is a multi-sectoral response, and this is really important. There is recognition of the importance of prevention and treatment, and that these need to go together. Collaboration and learning from others is so important, and seems to be happening more and more.

Q. Remind us of the WHO’s role is in relation to FGM.

For all health topics, countries look to WHO for guidance and norms (the standards that healthcare providers should be meeting). We produce evidence-based recommendations for how to treat patients, or how to prevent conditions. For FGM, we have just translated these recommendations into practical tools for healthcare providers, including job aids, clinical handbooks and training materials to help them prevent FGM and manage its complications. We also generate evidence on issues like the health impacts and economic costs of FGM, and support countries to take up our recommendations and tools.

Q. What are some of WHO’s significant contributions to the global movement to end FGM?

We’ve led important international declarations on FGM, and developed evidence based tools for the health sector. When you visit the countries most affected by FGM, they are mainly using a 2001 Manual on FGM for students, which integrates prevention and care for FGM into nursing and midwifery curricula. Countries have adapted it to various degrees, and it’s been widely taken up, and very influential. Now that we have clinical guidelines on management of complications, countries are adapting their national guidelines to align with these as well.

In 2006, WHO published a landmark obstetric health study in six countries, to really establish the obstetric health risks of FGM. This has been important for advocacy at the international, national and even community level. In 2010, we developed the global strategy to stop healthcare providers from performing FGM – so-called “medicalisation”. It’s designed to help countries put actions in place to stop the medicalisation of FGM, recognising that there are different ways of approaching this issue. Sudan has started to put the strategy into practice: they are doing trainings and pledges with midwives, and they have integrated the training into curricula for midwives (since there is evidence that some midwives are carrying out FGM).

Two years ago, for the first time, WHO developed and launched clinical guidelines for the treatment and care of women and girls who have undergone FGM. These guidelines support health systems to help girls and women, and help to make sure that providers recognise that FGM has health consequences – and that they take actions to prevent and manage potential complications. In some high prevalence countries, FGM is not even documented in health records. This needs to change. Healthcare providers need to bear in mind that the underlying cause of a woman’s health problem might be FGM.

The recommendations of the guidelines have now been developed into a practical handbook, with chapters on the immediate health problems, as well as obstetric, gynaecological, sexual health and psychological health issues. This pushes the thinking about the needs of women and girls who have undergone FGM beyond where it was in the past – when we didn’t address the psychosexual needs directly. We are working with countries to integrate treatment and care aspects into the pre-service training for schools of Nursing and Midwifery.

So more and more, we have a package of tools to help health systems comprehensively address FGM.

Q. And what is WHO working on at the moment?

We’ll be rolling out the clinical handbook which has been published today. It’s designed for frontline providers, even lower-level providers, and so is accessible and easy to use. It’s designed to be used worldwide, in all settings, but we also recognise that many countries will need to adapt it to some degree.

We are also working to understand better what works to ensure that healthcare providers prevent and champion the need to put an end to the medicalisation of FGM. We are already doing some work with providers to prevent medicalisation, including integrating trainings into their curricula. We need to know more about what works however, particularly how we can shift attitudes.

We understand the main motivating factors for such medicalisation: the financial aspect, the fact that healthcare providers are members of the same community as the girls and women on whom they carry out FGM, the fact there is demand for FGM in the community, and the misguided belief of some healthcare providers that they are helping to reduce harm. Sometimes healthcare providers are carrying out FGM with the best of intentions, and you can’t just show them a presentation about FGM, and think that they will stop doing it. We have to develop clever strategies to address this issue and really grapple with how providers’ minds can be changed.

One such strategy, for example, could be by reaching healthcare providers through schools of nursing and midwifery or through faculties of medicine. In these contexts, providers also have access to students, their peers, patients, families and communities. If you can influence healthcare providers to abandon FGM in these schools and systems, you can influence all sorts of other people too. This is  a priority right now – finding ways in which healthcare providers can help prevent FGM across their spheres of influence, and through the healthcare system.

We’re also doing a study on the health burden and economic costs of FGM. We’ve been compiling and reviewing all health studies, and now have a database. We are using this to calculate the health burden and cost of FGM – which may help to make the case that if you can prevent it, you can prevent the burden and costs.

Q. How does WHO support countries in taking up its recommendations and tools?

Supporting countries can happen in a number of different ways. For example, in May, we are having a workshop with countries from the Middle East and African regions of WHO which have the highest prevalence of FGM. We will be bringing together representatives from the Ministry of Health, health Professional Associations, academics, UN partners and civil society organizations. During the meeting, we plan to introduce these representatives to new resources, and support them to assess their readiness for implementing change, which includes developing plans of action and strengthening training curricula. Some countries require active support from the WHO, others just take the resources and run with them. Others can be linked up with countries that are further along in terms of rolling out the process. It’s challenging, because there are 194 Member States, and we want this information to reach everywhere!

Q. Do you have a message for our members?

I admire and encourage them. What they are doing is really important, they are doing the work at the community level that will end FGM. They need everyone to support them.

We are trying to listen to the perspective of community groups as we’re doing implementation research at country level, and bring that into our response. Community members will be more likely to seek health services if providers have been sensitised to the topic of FGM. If providers are more empathetic and familiar with the complications of FGM, and if we can help them improve their communication, then communities will be more likely to seek their services, and this will work towards prevention of FGM in future.

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