Towards the elimination of FGM by 2030: A statistical assessment

Kathrin Weny; Romesh Silva; Rachel Snow; Berhanu Legesse; Nafissatou Diop

doi:10.1371/journal.pone.0238782

Peer Review History

Original SubmissionNovember 21, 2019
18 May 2020 Decision Letter - Fiona Cuthill, Editor PONE-D-19-32389 Eliminating FGM - is the 2030 agenda target within reach? PLOS ONE Dear Mrs. Weny, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. This is a very timely paper and we ask that you please address the minor points made by the reviewers to add clarity to your paper. We would appreciate receiving your revised manuscript by Jul 02 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Review Comments: Eliminating FGM - is the 2030 agenda target within reach?: PONE-D-19-32389 The authors report a secondary quantitative study titled “Eliminating FGM - is the 2030 agenda target within reach? Applying survival analysis to analyze FGM risks on a cross sectional dataset from 24 countries. The paper adopts a novel methodological approach to present critical findings and suggestions that can inform FGM-related interventions. The methodological approach and suggestions are bold leveraging on rich DHS/MICS FGM data collected over a long period to confidently inform policy and programming interventions. This paper is well thought and reads very well. Nonetheless I have some comments as follows; Methods 1. There is need to define risk of FGM? In this case a statement on that DHS/MICS data show the current FGM status of the girl/women as well as the risk for FGM should be included. This is important not to confuse the reader. 2. Page 4 line 70 “Our inclusion criteria for MICS and DHS surveys are principled and appropriate for the synthetic cohort modeling approach we use. Other studies include more surveys and cover more countries, some of which do not contain FGM survey modules with age-of-FGM data or are not comparable across successive surveys for a given country. It would be helpful to the readers to include some of the major inclusion and exclusion criteria. 3. It will be helpful to describe how many DHS/MICS data sets were included that were for before 2010 as well as those that were obtained after 2010? 4. Since the DHS/MICS FGM module has a question on the type of FGM, it would have been helpful to analyses the data around this component to see the age specific risk to help us understand role of health awareness campaigns in FGM. 5. The DHS/MICS FGM module has a question on who performed FGM. It would have been helpful to analyses the data around this component to see the age specific risk to help us infer the trends towards medicalization 6. An underdeveloped piece in this paper is the role of adoption and enactment of anti-FGM legislations in various countries around 2000s and later. This could have an impact on the DHS/MICS data because of underreporting. Discussion 1. I would be interested to see a concluding statement/paragraph in view of the current analysis and the projection for elimination of FGM by 2030. 2. Page 15 line 295-300: “In 2003, Toubia and Sharief wrote: “The greatest obstacle to a scientific answer [of a decline in FGM] is the fact that reliable baseline data were not collected (…)” [34]. More than 15 years later, we are still confronted with this problem, but we have attempted to address this by constructing a baseline synthetic cohort and estimating decline through cohorts thereafter”. What suggestions do the author have on improving FGM data collection, processing and presentation?. Are they of the view that that DHS/MICS could be inadequate? Or what improvements need to be done. Reviewer #2: This is an important and timely study of FGM/C to understand the extent which has been achieved in reducing this practice globally. Although the available data is rather limited in some countries, but the statistical analysis is rigorous and the result is supporting the main argument. This study provides clear trends of the decline of FGM/C risk in some countries which useful for strategic intervention planning. Hitherto, the discussion of FGM/C is predominantly focus on Africa and Middle East. There is a paucity of data from Asia Pacific region. For a brief picture of FGM/C in this region please refer to Dawson, A., Rashid, A., Shuib, R., Wickramage, K., Budiharsana, M., Hidayana, I. M., & Marranci, G. (2020). Addressing female genital mutilation in the Asia Pacific: the neglected sustainable development target. Australian and New Zealand Journal of Public Health. One minor correction, Indonesia has a publicly data on FGM/C, please check https://www.litbang.kemkes.go.id/laporan-riset-kesehatan-dasar-riskesdas/ ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Dr. Samuel Kimani Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. 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Revision 1
2 Jul 2020 Author Response Dear Sir or Madam, We would like to thank PlosOne’s academic editor and the peer reviewers for their helpful comments and suggestions with respect to our manuscript as well as providing us with the opportunity to submit a revision. The style requirements, including file names, positioning of abstracts as well as title of the manuscript have been amended according to the style requirements of PlosOne. The updated version of our manuscript has been uploaded in the submission form, as well as in the ‘Revised Manuscript with Track Changes’. Below we have drafted responses to all comments and questions by the reviewers listing amendments we have made within the manuscript. Reviewer 1: I. On the definition of risk of FGM We have included a particular note in the introduction outlining the definition of ‘risk of FGM’ as one of experiencing FGM at a given age IF one has not experienced FGM earlier in life. This provides a more explicit definition compared with the previous version. This note can be found in the ‘Introduction and background’ section. II. On the inclusion criteria of DHS/MICS surveys With respect to this question, we would like to note that ‘S7- Appendix. Data exclusions describes surveys that are not part of the analysis including the exclusion criteria. As per recommendations by the reviewers, we have also added the main exclusion criteria to the main body of the text in the ‘Materials and methods’ section. III. On the distinction between DHS/MICS before 2010 and after S8 Table in the Annex describes each single survey including survey year and number of responses that are ‘during infancy’. The cut-off between surveys that included a module on daughters cannot be strictly made in the year 2010, as countries, such as Iraq, do not include a daughter module, even after 2010. Therefore, the full list of countries in S8 - Table is necessary for complete transparency and has now been added in the appendix. IV. On the inclusion of analysis of the type of FGM The type of FGM is indeed included in the vast majority of FGM survey modules both for DHS and MICS. However, we have not included an analysis of type of FGM in this analysis and estimated the overall risk of FGM of all types for several reasons. First and foremost, entrenched gender inequality is behind all types of FGM, independent of their invasiveness. In addition, all forms of FGM are associated with increased health risk and violates the sexual and reproductive health and rights of women and girls. With the adoption of the Sustainable Development Goals, the UN and its member states have pledged to eliminate the practice by 2030, in all types and forms, and our analysis is providing a background evaluation of the feasibility of this pledge. Zero tolerance to all forms of female genital mutilation is the guiding principle of this analysis. V. On the inclusion of analysis regarding medicalization of FGM It is true that medicalization of female genital mutilation (practice of female genital mutilation by health care providers) is an alarming trend which requires due attention. Medicalization of female genital mutilation is more common in certain countries and programmes need to respond to this context in these countries. However, discussion on medicalization is beyond the scope of this article. For the article, the main emphasis is to project the number of girls at risk of female genital mutilation based on population data instead of going into details of who performs the practice. VI. On the inclusion of analysis on anti-FGM legislation This is a very valuable comment with respect to reliability of survey results retrieved from self-reporting by women, and proxy reporting of women with respect to their daughters. We have included that validation analysis is of particular importance given the recall bias as well as the changing landscape of national legal frameworks in paragraph 9 of the discussion section. We feel that given the other potential sources of biases, such as the self-reporting for women and the proxy reporting for girls, the different age groups and the extent of the recall bias, among others, the point is covered with due justice and further elaboration is beyond the scope of the current analysis. VII. On the inclusion of more language connecting the current analysis and the projection for elimination of FGM by 2030 This is a very helpful comment, and we have added a further explanation in paragraphs 4 and 10 of the discussion section on the meaning of the results of our analysis for the probability of the global elimination of FGM by 2030. VIII. On the question on improving FGM data collection, processing and presentation We have added more details with respect to increased data collection efforts beyond DHS/MICS that would be necessary to estimate FGM trends (Please see paragraphs 6 and 9 of discussion section). However, it is important to emphasize that there has been improvement in the questionnaire used by DHS/MICS (such as having a module to report on the prevalence for 10-14 years of old) and trend analysis is becoming possible for different countries as there are different data sets from DHS/MICS and through cohort approaches. We have added further possible expansion of quantitative data sources for the estimation of FGM in the ‘Discussion’ section, such as the increased use of administrative records. Reviewer 2: IX. On the inclusion of data form the Asia and Pacific region, and in particular Indonesia We agree with the inclusion of this academic resource to enhance our discussion section (paragraph 6 of discussion section). In this section, we maintain that in order that countries in which FGM has been reported anecdotally have to be included in ‘truly global level and trend estimates’, and the suggested literature review on FGM in Asia and the Pacific is a meaningful addition (paragraph 9 of discussion section). Indeed, Indonesia has conducted a national survey in 2013 including information on the FGM for girls age 0-11. The current analysis, however, required micro data in order to be able to perform the estimations. We amended the relevant reference in the text to make clear that the lack of data in the case of Indonesia refers to the lack of publicly available micro datasets, not published prevalence estimates in general (paragraph 6 of discussion section). With kind regards, Kathrin Weny, Romesh Silva, Rachel Snow, Berhanu Legesse, and Nafissatou Diop Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0238782.r002
25 Aug 2020 Decision Letter - Fiona Cuthill, Editor Towards the elimination of FGM by 2030: A statistical assessment PONE-D-19-32389R1 Dear Dr. Weny, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. 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Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Review Comments: Towards the elimination of FGM by 2030: A statistical assessment: PONE-D-19-32389R1 The authors report a secondary quantitative study titled “Towards the elimination of FGM by 2030: A statistical assessment? Applying survival analysis to analyze FGM risks on a cross sectional dataset from 24 countries. The paper adopts a novel methodological approach to present critical findings and suggestions that can inform FGM-related interventions. The methodological approach and suggestions are bold leveraging on rich DHS/MICS FGM data collected over a long period to confidently inform policy and programming interventions. The manuscript has substantially and significantly improved, while the authors have comprehensively addressed the comments that were raised earlier. I am satisfied with the level of improvement of the manuscript and responses to the comments by the authors. Reviewer #2: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Samuel Kimani Reviewer #2: No https://doi.org/10.1371/journal.pone.0238782.r003
Formally Accepted
3 Sep 2020 Acceptance Letter - Fiona Cuthill, Editor PONE-D-19-32389R1 Towards the elimination of FGM by 2030: A statistical assessment Dear Dr. Weny: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Fiona Cuthill Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0238782.r004

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