Background: Characteristics of the study area

Burkina Faso is an African country located the Western Africa with a population of about 15,757,000 (2009 estimate [10]). Burkina Faso has a population growth rate of about 3.1% percent/year and a total fertility rate of 6.28 children born/woman [11] with a gross national product (GNP) of 183 US$/person/year, around two-thirds of the population live on less than a dollar a day and Burkina Faso is among the 20 least economically developed countries in the world, ranking 161 in term of the Human Development index (HDI) [11].

Life expectancy at birth is 53.7 years with a mean length of schooling (of adults) of 1.3 years. The poverty level or intensity of deprivation is 64.9%. Burkina Faso is a country with a huge gender inequality index. The maternal mortality ratio is estimated at 700 deaths of women per 100,000 live births and the literacy rate (percentage age 15 and over that can read and write) is 21%.

In Burkina Faso the most recent survey shows a small (3%) rise in prevalence of FGM from 73% in 2000 to just over 76% of women in 2003. We used this survey (including the optional additional questions on FGM); to investigate social and household factors associated with FGM in Burkina Faso, in order to consider policy options for next the steps in reducing the prevalence of FGM.

Survey Methods

The Demographic Health Surveys (DHS) are periodic cross sectional health surveys funded by USAID (the U.S. Agency for International Development's) Bureau for Global Health. The DHS includes a number of modules on demographics and household affluence; fertility, reproductive health, maternal and child health; nutrition, and knowledge and practice related to HIV/AIDS [12]. Surveys allow for an optional additional series of questions about FGM [13]. Since the year 2000, when these optional questions were added as part of the DHS, the prevalence of FGM in women in 14 African countries has been found to range between 1% in Cameroon in 2004 to 97% in Egypt in 2000.

The history of the development of the FGM questionnaire has been discussed elsewhere [13]. Briefly, DHS surveys collect data from nationally-representative probability samples of households and from adult women (age 15-49) and men in the sampled household. In general, surveys use a two-stage cluster sampling design, with over-sampling of certain categories of respondents. Response rates tend to vary across sampling domains and sample weights are used to obtain nationally representative estimates of indicators. DHS surveys yield nationally representative estimates of FGM for women age 15 to 49 in the survey countries.

In the countries where the prevalence of FGM is of concern, a module of FGM Questions is added to the women's questionnaire. The questions are designed to generate information on prevalence rates and types of FGM for the women themselves and for their daughters. Respondents' attitudes towards FGM are also collected. Since 2000, UNICEF's Multiple Indicator Cluster Surveys (MICS) have used a similar module to collect information on FGM in selected countries [13]. Both DHS and MICS surveys provide FGM prevalence data. Female respondents are asked if they have ever heard of FGM; then those who have heard of the practice are asked about their own experience of it. The responses to these questions are used to calculate national prevalence rates of FGM [13].

Experts generally assume that women respond truthfully when asked about their own experience. If bias exists in some of the responses, it has not been documented. It is hypothetically possible that some women may say not admit to having undergone FGM in countries where the practice has been forbidden, but no solid evidence of this has been found.

Few empirical studies dealing with FGM in Sub-Saharan Africa have been conducted. Although, there is now an increased amount of literature on the practice of FGM. Most of the literature deals with descriptive statistics and on issues of the origin, types, and justifications for the practice but little has been devoted to its patterns and mediating factors. Freymeyer et. al. 2007 [14] used the 2003 Nigerian DHS to explore attitudes towards FGM in Nigerian. Also using empirical data from the DHS, Kandala et al. 2010 [15] have published work on spatial risk factors for FGM in Nigeria.

The DHS survey methods in Burkina Faso are described in detail elsewhere [12] A nationally representative cross-sectional survey of women of reproductive age (15-49 years) was identified using a stratified random two-stage cluster sample of households by enumeration area, to reflect the rural-urban ratio. 400 (of 11,000) enumeration districts were selected (90 urban and 310 rural). 9 470 households in these districts were selected (2340 urban and 7130 rural) and members of 9097 household successfully interviewed. Data collection was undertaken between June and December 2003 by face to face interview with women aged 15-49 in each selected household and with men aged 15-59 in every third household. Topics covered in the women's questionnaire included demographics: age, region, ethnicity, religion, education, literacy, nutrition, and fertility, family planning, and HIV/AIDS risk factors. Topics covered in the household questionnaire included who in the household had responsibility for health care decisions (RHCD); and a number of household characteristics allowing for a calculation of household affluence using an asset index (access to drinking water, toilet facilities, cooking fuel, consumer items (television, bike/car); wall/flooring material. Households were subsequently divided into quintiles using this asset index.

Data management and analysis

Data analysis was undertaken using SPSS Version 15 and STATA 10.0. Associations between potential risk factors and the prevalence of FGM were explored using two dichotomous outcome measures: i) whether a woman herself had had FGM; ii) whether she had one or more daughters with FGM; using chi-square, t-tests and Mann Whitney U test as appropriate. Logistic regression modeling was used to investigate social, demographic and economic risk factors associated with FGM and formal tests for interaction were undertaken.

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.