Elsevier

Midwifery

Volume 20, Issue 4, December 2004, Pages 299-311
Midwifery

An explorative study of Sudanese midwives’ motives, perceptions and experiences of re-infibulation after birth

https://doi.org/10.1016/j.midw.2004.05.001Get rights and content

Summary

Objective:

to explore Sudanese midwives’ motives for and perceptions and experiences of re-infibulation after birth and to elucidate its context and determinants.

Design:

triangulation of methods, using observational techniques and open-ended interviews.

Setting and participants:

two government hospitals in Khartoum/Omdurman, Sudan, for the observations and in-depth interviews with 17 midwives.

Findings:

midwives are among the major stakeholders in the performance of primary female genital cutting (FGC) as well as re-infibulation. Focusing on re-infibulation after birth, midwives were trying to satisfy differing, and sometimes contradictory, perspectives. The practice of re-infibulation (El Adel) represented a considerable source of income for the midwives. The midwives integrated the practice of re-infibulation into a greater whole of doing well for the woman, through an endeavour to increase her value by helping her to maintain her marriage as well as striving for beautification and completion. They were also trying to meet socio-cultural requests, dealing with pressure from the family while balancing on the edge of the law.

Key conclusions and implications for practice:

the findings confirm that midwives are important stakeholders in perpetuating re-infibulation, and indicate that the motives are more complex than being only economic. The constant balancing between demands from others puts the midwives in a difficult position. Midwives’ potential role to influence views in the preventative work against FGC and re-infibulation should be acknowledged in further abolition efforts.

Introduction

The global discourse on female genital cutting (FGC) has largely focused on condemning and combating the practice, using arguments formed through a Western perspective (Koso-Thomas, 1987; Hosken, 1994; Toubia, 1994). Few studies have managed to capture why the practice persists, and much of the same information is just repeated (van der Kwaak, 1992; Shweder et al., 2000). Recent research has indicated that, as the next step, the perceptions of various stakeholders need to be considered in order to facilitate more culturally sensitive preventative work against harmful practices (van der Kwaak, 1992; Lane and Rubinstein, 1996; Obermeyer, 1999; Ahmed et al., 2000; Almroth-Berggren et al., 2001). In some settings, as in Sudan, the midwife has a recognised stake in FGC by performing the operation and gaining financially from it, as well as being in a position of trust and authority in the reproductive lives of women (Ahmed et al., 2000; Hassan, 2000; Gerais and Bayoumi, 2001). However, because of its sensitive nature, this has rarely been highlighted in the literature.

Global estimates claim that 132 million now living women have undergone some kind of genital cutting (WHO, 1998). The terms used to describe this ancient practice vary. For the purposes of this study, FGC will be used in an attempt to address the complexity of the issue. Different forms have been categorised, varying in severity (WHO, 1998). The most severe form is infibulation (meaning tightening, from Latin fibula), where the clitoris and labia minora are cut away and the raw edges of the labia majora are brought together to fuse, leaving only a very small opening. This is the most prevalent form of FGC practised in Sudan. About 90% of the women in northern Sudan have undergone infibulation in girlhood (Sudan DHS, 1991; Central Bureau of Statistics, 2001).

Re-infibulation is a secondary form of FGC performed on women who have previously undergone infibulation or other severe forms of FGC. It is a re-narrowing of the vaginal introitus by cutting and re-suturing. There is some confusion in the literature about the definition of re-infibulation, which might partly explain the lack of research specifically related to it. Re-infibulation has been defined as the re-stitching together after birth of the scar tissue resulting from infibulation (Rushwan, 2000). The English translation of the Arabic word, El Adel, literally means ‘putting right and improving’ (Verzin, 1975, p. 169). In parts of Sudan, re-infibulation is seen as a desirable and even a necessary procedure to be performed after childbirth. By mimicking the narrow vulva of a virgin it is believed to increase the sexual pleasure of the husband (El Dareer, 1982; Cloudsley, 1983; Lightfoot-Klein, 1983; Sami, 1986; Khaled and Vause, 1996; Ahmed et al., 2000; Gerais and Bayoumi, 2001).

Several studies have mentioned the phenomenon of re-infibulation, but few have estimated its prevalence. Even in 1982, El Dareer (1982) estimated that over 50% of Sudanese women underwent re-infibulation, one or more times postpartum. Ahmed et al. (2000) claimed that most infibulated Sudanese women undergo re-infibulation after birth. Among some ethnic groups, re-infibulation additionally takes place up to several times every year, with the purpose of increasing the sexual pleasure for the man (Ahmed et al., 2000).

Previous research has raised a number of questions concerning the motives behind the practice of re-infibulation and the role of midwives (Ahmed et al., 2000; Hassan, 2000; Gruenbaum, 2001). In Sudan, midwives perform most FGCs, whereas Traditional Birth Attendants (TBA) perform around one-third and medical doctors are estimated to perform less than 2% (El Dareer, 1982; Gerais and Bayoumi, 2001). To our knowledge, no qualitative studies focus on Sudanese midwives’ perceptions of re-infibulation. Complicating the issue of such research is the current legal situation in Sudan, that it is illegal and punishable by law for midwives to perform primary infibulation (Rahman and Toubia, 2000), and the hospital boards may take punitive action against midwives performing re-infibulation. There are thus several aspects that complicate the accessibility to further knowledge of re-infibulation. However, the procedure continues and it seems essential to reveal the underlying motives in order to increase the understanding of its persistency.

The objective of this study was to explore Sudanese midwives’ motives, perceptions and experiences of re-infibulation after birth and to elucidate its context and determinants.

Section snippets

Methods

Triangulation of methods and researchers was applied in this study (Hallberg, 2002). In accordance with the method of focused ethnography, observations, field notes and open-ended interviews were used for collecting data (Morse, 1995). Patton (1990) described the importance of triangulation by using different forms of data, in order to cross-validate. Thus a combination of observations and interviews was used to give a broader perspective of the phenomena in focus.

Findings

All 17 health staff agreed to participate in the interviews. They were between 32 and 65 years old and had between 1 and 37 years midwifery experience. They represented several different ethnic groups coming from different parts of Sudan. Among the respondents, 11 were nurse-midwives, two were health visitors and four were district midwives. Most of them had themselves undergone FGC and re-infibulation, and 11 had daughters who had undergone different forms of FGC (Table 1).

Interviews were

Discussion

The objective of this study was to explore Sudanese midwives’ motives, perceptions and experiences of re-infibulation and to elucidate its context. Two main categories emerged: trying to satisfy the demands of the community and trying to enhance the women's value, with sub-categories seen as variations of the main categories. The categories are related to the midwives’ views of being the one performing El Adel after birth. There are, however, several methodological aspects that have to be taken

Conclusion

To conclude, the findings from this study confirm that midwives are important stakeholders in perpetuating El Adel, but the issue is more complex than previously described. More research is needed that focuses on women's and men's perceptions of the practice. By recognising midwives for their important role in the community related to the whole well-being of women, society ought to acknowledge the midwives to be the group most able to affect people in the prevention of both El Adel and primary

Acknowledgement

The authors would like to thank all those midwives who participated in the research. We would also like to thank Professor Ahmed Mageed at Ahfad University for Women, Professor Farouk Abdel Aziz, Khartoum University and Ahfad University for Women, and Professor Osman Mahmoud Hassanein, El Nilain University, for help and advice in conducting the research. We would like to thank Ylva Hernlund, University of Washington, USA, and Sara Johnsdotter, Lund University, Sweden, for anthropological

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