Decline of Supportive Attitudes among Husbands toward Female Genital Mutilation and Its Association to Those Practices in Yemen

Objectives To elucidate the attitudes of women and their husband’s towards female genital mutilation (FGM) and their associations with the continuation of FGM upon their daughters. Methods Subjects were 10,345 (in 1997) and 11,252 (in 2003) ever married women aged 15 to 49 years from the Yemen Demographic Health Surveys. Performances of FGM on the most-recently-born daughters were investigated. Attitudes of women and their husbands were assessed by their opinions on the continuation of FGM. The association between the attitudes of women and their husbands and performance of FGM on the most-recently-born daughters were investigated after adjusting for age and education of the women. Findings The percentage among the most-recently-born daughters who received FGM of women who had undergone FGM declined from 61.9% in 1997 to 56.5% in 2003 (p<0.001). The percentages of women who had undergone FGM and who supported the continuation of FGM and of husbands who also supported its continuation decreased from 78.2% and 60.1% in 1997 to 70.9% and 49.5% in 2003, respectively (both p<0.001). When the women or the husbands did not agree with FGM, it was less likely to be performed on their daughter than when the women or the husbands agreed in 1997 (odds ratio=0.11, 95% confidence interval 0.07-0.16 and odds ratio=0.07, 95% confidence interval 0.04-0.12, respectively) and in 2003 (odds ratio=0.12, 95% confidence interval 0.09-0.16 and odds ratio=0.11, 95% confidence interval 0.07-0.16, respectively). Conclusion Non-supportive attitudes of women and their husbands towards the continuation of FGM have become common and were associated with their decision not to perform FGM upon their daughters.


Introduction
Female genital mutilation (FGM) comprises all procedures involving partial or total removal of the external female genitalia or other intentional injuries to the female genital organs for nonmedical reasons. FGM is also known as female circumcision and female genital cutting. About 140 million girls and women worldwide are estimated to be living with the consequences of FGM, and more than 2 million girls are suggested to be at risk of undergoing the procedures every year [1,2].
The World Health Organization (WHO) reported that women who have had FGM are significantly more likely to experience difficulties during childbirth, and their babies are more likely to die as a result of the practice [1,3,4]. Immediate health risks of FGM include severe pain, shock, excessive bleeding, difficulty in passing urine, infection, Human Immunodeficiency Virus (HIV), death, psychological consequences, unintended labial fusion, and repeated FGM. Long-term consequences include pain, infection, keloid, HIV, reproductive tract infections and sexually transmitted infections, birth complication, danger to the new-born, psychological consequences, quality of sexual life, infertility, later surgery, painful sexual intercourse, and urinary and menstrual problems [5]. Moreover, FGM is usually performed by non-professionals who do not even know the anatomy of the female genitalia [3,4].
Every major international health and rights consensus document of the last decade condemns FGM, and the Programme of Action of the International Conference on Population and Development (ICPD) calls on governments "to prohibit female genital mutilation wherever it exists and to give vigorous support to efforts among nongovernmental and community organizations and religious institutions to eliminate such practices" (paragraph 4.22) [1,5]. In 2008, the World Health Assembly adopted resolution WHA61. 16 on the elimination of FGM, in which all member states agreed to work towards the abandonment of FGM, including ensuring that the procedure is not performed by health professionals [6].
The prevailing reasons for FGM are complex and numerous, and include the sociological (initiation of girls into womanhood), social integration and the maintenance of social cohesion; hygienic and aesthetic (belief that the female genitalia are dirty and unsightly); sexual (control or reduction of female sexuality); health (belief that it enhances fertility and child survival); religious (belief that it is a religious requirement); socioeconomic factors (belief that FGM is a prerequisite for marriage, and where women are largely dependent on men, economic necessity can be a determinant for undergoing the procedure, and the practice can also be a major source of income for circumcisers); migration and displacement [7,8].
A woman's attitude towards FGM-is very much related to her status as a woman within her community [9]. According to Maja and Litt, men are often left out of the picture when decisions about reproductive health issues are discussed, and male involvement in reproductive health should be mainstreamed in all major thrusts of the strategic framework, and men of all ages must be educated about responsible sexual behaviour [10].
FGM is performed in every social stratum, among both rich and poor, undereducated and highly educated, and both in cities and the countryside [11]. Countries may pass laws to eradicate FGM, but legal instruments by themselves cannot end the practice due to strong and deeply rooted traditions and beliefs in societies [12].
This study aims to highlight the attitudes of women of reproductive age (15-49 years old) and their husbands towards the practice of FGM, as well as their association with the performance of FGM upon their daughters. This is one of the first studies using Demographic Health Survey (DHS) data to show practice of FGM in Yemen from 1997 to 2003.

Ethics statement
Not applicable.

Data source
The DHS programme was designed as a follow-up to the World Fertility Survey and the Contraceptive Prevalence Survey projects. The programme has been implemented in overlapping five-year phases. In Yemen, the survey was implemented by the

Sampling
The DHS was designed on the basis of the multi-stage sampling in order to provide estimates for general indicators for Yemen as a whole, for urban areas, and for rural areas. Islands were excluded from a sampling frame because of the small sizes of their populations and the difficulty in accessing them [13,14].
The data we extracted from the DHS database for the present analysis were 10,345 and 11,252 women of reproductive age (aged 15-49) who had ever married, in 1997 and 2003 respectively.

Measures and procedure
We collected information about characteristics of women (age and education) and FGM (if they had ever heard about FGM). The questions related to FGM were asked only of women who had heard of FGM. For women who reported that they had ever heard about FGM, further questions were asked about women and their husband's attitudes toward FGM, and if they had performed FGM on their most-recently-born daughters. The attitudes were assessed by asking respondents their opinions and their perceptions of their husband's opinions on the continuation of FGM. The response alternatives for this query were "practice should be continued", "practice should be stopped," "don't know", and the additional alternative "attitude not clear" only for the husbands attitude.
The variables of age, education, having heard of FGM, having ever undergone FGM, the performance of FGM on the most-recently-born daughter, the respondent's attitude, and husband's attitude towards FGM were used for the analysis. In addition where FGM took place, who performed the FGM, and the age of the most-recently-born daughter when she received FGM were reported.

Statistical analysis
The percentage of performance of FGM on the mostrecently-born daughters and attitudes of women and their husbands toward FGM were compared between 1997 and 2003 by using chi-square test.
Logistic regression analyses were applied to investigate the association of attitudes of women and their husbands towards FGM and performance of FGM on the most-recently-born daughters among women who had undergone FGM and women who hadn't undergone FGM separately. The independent variables were age and education of women and women's and husband's attitudes towards the continuation of FGM. These analyses were done separately for 1997 and 2003.
To investigate independent association of the year of survey on performance of FGM on the most-recently-born daughters, another logistic regression model was applied after pooling data from two survey years.
Sample weight was applied to correct disproportional sampling probabilities and to adjust the collected data to represent the population from which the sample was drawn.
Incomplete data on FGM related and other variables were excluded from the analyses. The level of statistical significance for all analysis was set at α=0.05. All statistical analyses were performed with SPSS version 18. Table 1  The DHS data showed that FGM was performed on the most-recently-born daughter mainly within the first month after birth (92.8% in 1997 and 81.1% in 2003), and at home (96.9% in 1997 and 94.8% in 2003). In 71.4% of the cases, FGM was performed by a traditional birth attendance (daya or Kharshofa) in 1997; and this percentage dropped to 59.8% in 2003. Table 2 shows FGM practice on most-recently-born daughters and the attitudes of women and their husbands for women who had undergone FGM and for women who had not. Women who had undergone FGM were more likely to perform FGM on their daughters (61.9% in 1997 and 56.5% in 2003, p<0.001) and were more likely to be supportive of FGM continuation (78.2% and 70.9%, p<0.001) than women who had not. Husbands of women who had undergone FGM were supportive of FGM continuation (60.1% and 49.5%, p<0.001). Both the women and their husbands were more supportive regarding performance of FGM when the women had not undergone FGM (57.5% and 47.4%, p<0.001). Table 3 shows the adjusted association of women and their husband's attitude towards FGM with FGM being performed on the most-recently-born daughter among women who undergone FGM in 1997 and 2003, separately. When women did not agree with FGM, daughters were less likely to receive FGM in 1997 (odds ratio 0.11, 95% confidence interval 0.07-0.16) and in 2003 (odds ratio 0.12, 95% confidence interval 0.09-0.16). When husbands did not agree with FGM, daughters were less likely to receive FGM in 1997 (odds ratio 0.07, 95% confidence interval 0.04-0.12) and in 2003 (odds ratio 0.11, 95% confidence interval 0.06-0.17). Table 4 shows the adjusted association of women and their husband's attitude toward FGM with FGM being performed on the most-recently-born daughter among women who hadn't undergone FGM in 1997 and 2003, separately. When women did not agree with FGM, daughters were less likely to receive FGM in 1997 (odds ratio 0.13, 95% confidence interval 0.07-0.23) and in 2003 (odds ratio 0.14, 95% confidence interval 0.06-0.33). When husbands did not agree with FGM, daughters were less likely to receive FGM in 1997 (odds ratio 0.14, 95% confidence interval 0.06-0.31) and in 2003 (odds ratio 0.12, 95% confidence interval 0.04-0.38). Table 5 shows the adjusted differences in the performance of FGM on the most-recently-born daughter between survey years after combining 1997 and 2003 data of women's experience in having undergone FGM. Daughters were less likely to receive FGM in 2003 than in 1997 among women who had undergone FGM (odds ratio 0.72, 95% confidence interval 0.58-0.88) after adjustment for age and education of women and attitudes of women and their husbands. Moreover, the odds ratio for performance of FGM on the most-recently-born daughter among women who hadn't undergone FGM showed further decline of FGM on daughters from 1997 to 2003 (odds ratio 0.53, 95% confidence interval 0.36-0.80).

Discussion
The results showed that frequency of FGM on daughters has declined from 1997 to 2003. During this period, the awareness of FGM practice has increased among women. Women who undergone FGM were more likely to have it performed on their daughters. Women's and husbands' attitudes not supportive to the continuation of FGM was significantly associated with not having performed FGM on their daughters regardless of women's age and education.
There was a decline in the FGM supportive attitudes and practice in the population from 1997 to 2003. The reduction in practice over the years was partly explained by the changes of women's and their husbands' attitudes towards FGM, and improvement in education among women from 1997 to 2003. The changes in attitudes of women and their husbands could be due to the ministerial decree prohibiting health providers from performing FGM in Yemen. This ministerial decree was a result of the Clinical-Based Investigation of Female Genital Mutilation in Selected Areas of Yemen in 1999 by different government entities. However, health officials mentioned that the decree's effectiveness couldn't be monitored in all medical facilities [3]. Recent exposure by the population to the information from health providers, media, and health projects that help in raising awareness on health issues, including FGM could also have contributed to the change of attitudes of people in Yemen towards FGM. Literate women were less likely to perform FGM on their daughters than illiterate women. Access to education can help end FGM because there is a significant relationship between education and FGM. The attitude of the illiterate women was more supportive towards FGM than that of literate women. It was reported that the more educated the mothers are, the less likely they are to have their daughters circumcised [15]. Education in the case of FGM is seen as a source of empowerment for women because it can facilitate their abilities to gather and assimilate information [16]; this point agrees with other studies that the practice of FGM and support for its discontinuation by women changes with education and awareness.
This study showed that the attitudes of husbands are also important. A daughter is more likely to receive FGM when the attitude towards FGM of her father is positive. The roles of women's attitudes to FGM in decision making are complex and differ based on the society. It is possible in some societies that women who think that FGM should be stopped should ensure that their own daughters undergo the procedure against their wish due to pressure from family and society. Yemen is a traditional society in which prevailing cultural attitudes bestow low status upon women in the family as well as in the community, and men are dominant [17][18][19]. Insufficient attention had been paid to men's attitudes.
Men's positive attitude towards FGM has declined. In 1998, WHO emphasized that males should be empowered through the provision of information and services targeting boys, youth, and adults within the home, community, and work setting [10,17,20,21]. In the past, men's involvement has sometimes been opposed by women's health advocates, who understandably fear that adding these services will damage the quality of women's services and create additional competition for already scarce resources [11]. Since men were excluded most of the time from women's reproductive health education and programmes, this could explain the lack of resources related to men attitude towards women's reproductive health. Now, programmes on health education and women's reproductive health include both the women and men. Most FGM was performed at home by a traditional birth attendant and not a trained health provider. The practice depends on the community or individual family [7] and girls are not aware that they have been circumcised until they get married or have been examined. The practice at homes by a traditional birth attendant involves the use of unsterilized tools and instruments and the location could endanger the child's life because it could be far from a health facility [1]. FGM is performed in early age of a girl's life. The analysis of the DHS revealed that most of the practice of FGM in Yemen was performed within the first month after birth. This could be due to tradition and it could be to avoid pain. The daughters might not remember the immediate consequences or even did not know if she had been circumcised, but long-term risks will be faced by the girl when she grows up and get married. According to WHO, FGM involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies [1]. Women's health is affected by their capacity to conceive, and this includes the risk of disorders associated with reproductive organs [22]. It was reported that pregnant women who had undergone FGM had risks at obstructed labour, which result in uterine rupture, with severe, often fatal bleeding, or postpartum vesical or rectal fistula [23].
There is a complex interplay between women and husbands attitudes [24]. Our analyses tease out the association of husbands' attitudes with performance of FGM on daughters while controlling for wives' attitudes.
This study measures the attitudes of husbands as perceived by their wives. There is a concern that the norms of women reflect social norms rather than the actual attitude of their husbands. However, in this study the likelihood of this was low because the women were given the options to answer "don't know" or "not clear". Therefore, the question on their husband's attitudes did indeed measure it.
Yemen is one of the developing countries selected as a pilot for the Millennium Development Goal (MDG) project. Yet, the country had concerns about achieving the MDG5 (improving maternal health) because of widely practiced FGM which has consequences of infection, pain, and trauma leading to negative health impacts. The health complications lead by FGM are associated with pregnancy, childbirth and the postpartum, which makes childbirth painful and dangerous as it prolongs labour, obstructs the birth canal and often causes perianal tears [25,26]. As a follow-up to the International Conference on Population and Development (ICPD), which states that governments are urged to prohibit female genital mutilation and to prevent infanticide [27], Yemen's Ministry of Public Health and Population (MoPHP) drafted a law to prohibit female genital mutilation by anyone, including health providers in 2008. However, the law was not passed by parliament and challenged by questions raised by religious leaders in the Ministry of Endowment about the actual health consequences of FGM. Meantime in 2012, the MoPHP again drafted a law to prohibit female genital mutilation; in addition to educational and awareness programs on FGM by Yemeni government and partners for targeted population that started from 1999. ICPD also addressed sexual and reproductive health issues under chapter VII (Reproductive Rights and Reproductive Health) [27]. Studies and reviews confirm the need for sexual and reproductive health awareness and education for both men and women [28][29][30]. Therefore, there is a need for sexual and reproductive health education inducting the health risks from FGM at the community, school, and university levels. Men and boys should be included in measures addressing women's health because they play a very important role in decision making.
In conclusion, non-supportive attitudes by women and their husbands towards the practice of FGM influenced their decisions to abstain from having FGM performed upon their daughters. Significant factors in the decline in performance of FGM were changes in women's and their husband's attitudes towards FGM, and improved education of women.