Overall findings
Age and religion were the most significant demographic variables associated with the risk of FGM in Burkina Faso. As age increased, the proportion of respondents and their daughters who had undergone FGM increased.
We found that FGM was strongly associated with religion. And our findings indicate that the pattern of associations with other variables was affected by women's religion: so that for Christian women, education appeared to have a protective effect, but this was not the case for Muslim women or for women who followed a traditional or animist religious tradition. Perhaps surprisingly, women taking responsibility for their own health care decisions were more likely to have had FGM. There were substantial variations between different regions of Burkina Faso and between different ethnic groups, although regional differences appeared greater than ethnic differences. Household asset index had varying associations depending on religion, with some evidence that in general, women in the middle asset quintiles were more likely to report themselves as having had FGM.
Returning to the relationship between women's own experience of FGM and that of their daughters we found that the difference between the percentage of younger and older women whose daughters had undergone FGM was much greater than the difference between the percentage of respondents who had undergone FGM themselves (Table 1). This could represent an important change in cultural mores with decreased use of FGM, whereby younger women are less willing to have their daughters undergo FGM. This offers possible hope that the practice may be reducing over time. However, this finding could also represent a cohort effect - younger women have younger children who are not yet at risk. We found a large difference in Burkina Faso in the risk of FGM between provinces and ethnicity with some provinces and ethnic groups having a higher risk of FGM. It is worth investigating these findings further as spatial variation and ethnicity may be indicative of an association of place of residence with FGM practice as a proxy for social norms.
Strengths and weaknesses
The strength of this work is that it is based on a large well-conducted representative survey with a high response rate. Interviewers were trained; questions were standardized and data management procedures were exemplary [12].
The survey involved taking account of a large number of different factors including regions, ethnicities and others, but it is possible that some important factors particularly relevant for Burkina Faso have been missed. In addition, the topic area constitutes a complex social and policy issue affecting women's most intimate views of themselves and their lives. As with similar studies of this kind, we were dependent on women's self-reports to trained interviewers and cannot account for social acceptability bias which may have distorted findings, in particular involving selective under-reporting of FGM. There is likely to be a strong social pressure to conform, because of fear of social criticism, or pressure and disapproval from elders [16], which, coupled with the illegality of FGM in Burkina Faso may mean that individuals may have felt uncomfortable or unsure discussing or reporting FGM to strangers. However, notwithstanding, reported rates of FGM are high overall and appreciable even amongst daughters.
The survey was cross sectional. This may mean that we will have missed important cohort effects, for example in relation to FGM amongst daughters of younger women, although these would be of interest because of implications for future patterns and policy. For example, the difference between the percentage of younger and older participants whose daughters had undergone FGM was much greater than the difference between the percentages of respondents who had had FGM themselves (see Table 1). Whilst this could represent a change, whereby younger women are less willing to let their daughters have FGM, it could also represent the fact that younger women have younger children, who are not yet at risk.
Implications for policy practice and research
There is already strong political opposition to the practice of FGM and consequently, it is internationally recognized as violation of human rights and an illegal activity in many countries. Burkina Faso is one of 16 African states which have outlawed FGM. Legislation was passed in 1996 with fines of up to 900,000 CFA (US $1,800) and prison sentences of up to three years for undertaking FGM. However making it illegal may have hampered women's reporting and seeking of safe medical treatment and of remedial measures where these are needed. Given the very personal effects of FGM and the contentious cultural mores associated with the practices of FGM, it would be valuable to review the law pertaining to FGM in Burkina Faso to identify any differences the law may be making. Religious links are clearly important, and although no religion prescribes the practice, policies which actively encourage engagement of religious leaders in its refutation would be beneficial.
As far as practical intervention is concerned, some strategies in Kenya have advocated alternative rites with the aim of involving communities alongside enforcing legislation.1 And in Mali a programme of activities has been undertaken involving educating the women practitioners of FGM and giving them alternative skills for earning a living and spreading information to reduce public demand [17].
It has been suggested that FGM is a social convention in a country such as Nigeria [15] and that modernisation has little effect. However our results suggest that in the context of Burkina Faso, the education that modernization brings may benefit women from other religions more than Muslim women. Increasing assets and increasing women's responsibility for their own healthcare decision may have unexpected effects in increasing access to FGM, but there may be important benefits to be gained from projects which encourage women to work across and between different regions and ethnicities capitalizing on the geographical and cultural variations within Burkina Faso which exist.
In relation to promoting changing amongst populations of African communities living in countries such as the UK and Australia, the public health approach has tended to involve a confidential and supportive health service for women alongside a community education approach which is intended to raise awareness, changing attitudes to FGM and ultimately stop further FGM being carried out in the current country or country of origin.
Research should focus on cultural beliefs, reasons for ethnic, regional, religious and socio-economic differences in rates, on the optimal content of educational programmes, and methods for involving religious leaders. Longitudinal data would enable better tracking of practice through families.