Decision-Making Process in Female Genital Mutilation: A Systematic Review

Female genital mutilation/cutting “FGM/C” is a deep-rooted damaging practice. Despite the growing efforts to end this practice, the current trends of its decline are not enough to overcome the population’s underlying growth. The aim of this research is to investigate the FGM/C household decision-making process and identify the main household decision-makers. A review of peer-reviewed articles was conducted by searching PubMed, JSTOR, Ovid MEDLINE, Ovid EMBASE, EBSCO, and CINAHL Plus via systematic search using keywords. The found publications were screen using inclusion and exclusion criteria in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. After critical appraisal, seventeen articles were included in this review. The data extracted from the articles regarding FGM/C household-decision making process and decision-makers were analyzed using narrative analysis. FGM/C decision-making process varies from a region to another; however, it generally involves more than one individual, and each one has different power over the decision. Fathers, mothers, and grandmothers are the main decision-makers. It was shown from this review that opening the dialogue regarding FGM/C between sexes may lead to a productive decision-making process. The participation of fathers in the decision-making may free the mothers from the social-pressure and responsibility of carrying on traditions and create a more favorable environment to stop FGM/C practice.


Introduction
Female genital mutilation or female circumcision/cutting (FGM/C) is one of the most ancient deep-rooted damaging practices worldwide. It is defined by the World Health Organization (WHO) as "all procedures involving partial or total removal of the external female genitalia or other injuries to the female genital organs for non-medical reasons" [1]. It causes lifelong suffering for women and girls and creates health inequality without having any health benefits, by leading to life-lasting physical, mental and sexual problems among females who are exposed to the practice (severe pains, bleeding, death, kidney failure, infertility, difficulties during childbirth, fetal distress, death of the newborn, and/or maternal death) [2].The psychological consequences of FGM/C include behavior disturbances and loss of trust among girls and long-term consequences among women (depression, anxiety, feeling of incompleteness, and the inability to express their fears) [3].
The WHO and the United Nations Children's Fund (UNICEF) (1997) [3], classify it to four major types: "clitoridectomy" or Type I which involves the excision of the clitoral prepuce "the hood" or/and excision of all/ part of the clitoris, Type II is the excision of the clitoris with excision of part or all of the Previous systematic reviews have not addressed the FGM/C DMP or household decision-makers HHDM(s). The objective of this systematic review is to investigate the FGM/C households' decision-making process and to identify the main decision-makers in the household. In addition, we assess the need for further research in this field or the possibility of implementing interventions.

Study Design
This systematic review has included qualitative, quantitative, and mixed methods of primary research studies.

Search Strategy
In line with the Centre for Reviews and Dissemination (CRD) 2009 guidelines [23], an initial review of the existing literature was conducted to justify the need for this systematic review. The initial review of the literature was carried on PubMed, EMBASE, EBSCO CINAHL Plus databases. Then the database of reviews, the Cochrane Database of Systematic Reviews (CDSR), was searched for existing or ongoing systematic review being carried out. Different systematic reviews were found regarding FGM/C; however, no systematic review studied FGM/C DMP or decision-makers. Google Scholar was used to search for studies that are available online but not yet indexed in the database.
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for the systematic reviews, a comprehensive search of the published literature was conducted to identify different publications. The literature search was not limited to a certain country or year and was carried on different databases to avoid missing key studies and to minimize bias. The databases that were searched are PubMed, JSTOR, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL Plus, and BioMed Central. SPIDER search strategy tools (Sample, Phenomenon of Interest, Design, Evaluation, Research type) were used to identify the keywords due to its suitability (for a mixed-methods systematic review [24], refer to Table 1). Booleans operators conjunctions were used to achieve more focused results, and the MeSH browser was used for indexing articles. The keywords that were used to search the databases in combination: "Father" or "mother" or "husband" or "grandmother" or "grandparent" or "household" or "household decision" and (1) "female genital mutilation" or "FGM/C" or "FGM" or "female genital circumcision" or "FGC" or "female circumcision" or "female genital cutting" and (2) "decision-making" or "decision-maker" or "decision-making process" or "attitude".
Search limits were implemented to refine the scope of the search to primary peer-reviewed articles, available in the English language, and full-text articles.
Furthermore, the scanning of the reference lists of relevant studies that were obtained from the database search was carried out to identify further studies ("reference harvesting").
The databases search resulted in 1883 articles, and five articles were obtained from reference harvesting (refer to Figure 1).

Study Selection
The inclusion and exclusion criteria are listed in Table 2: To avoid duplication bias, before the implementation of the inclusion and exclusion criteria, removal of the duplicated articles was done using RefWorks software, and they were manually screened. After the removal of the duplicated articles, the literature search resulted in a total of 1732 papers.
As the topic of this search does not have negative or positive results, the articles are most likely to be representative of all the studies conducted, published, and unpublished. Google Scholar was used to scan for articles in which they were not yet included or conference abstracts. In total, three articles were related to FGM/C decision-making process and decision-makers were found; however, they were excluded because they are not peer-reviewed. Only peer-reviewed articles are included in this search as they present higher quality research and this minimizes bias.

Inclusion Criteria and Exclusion Criteria Implementation
At the first stage, the articles that resulted from the search after implementing the limits were screened for study design. In the second stage, the title and abstract of the search result were scanned for sample and study designs limited to data collected through interviews, focus groups, questionnaires, and surveys, including qualitative, quantitative, and mixed methods researches.
From the literature, it was found that in some articles, the decision-making process or decision-makers were not the primary aim and therefore were not mentioned in the abstract, and thus, the "PI" and "E" inclusion and exclusion criteria were implemented at the third stage of screening.
In the fourth stage, 66 relevant studies to FGM/C (S-sample) resulted from the search; their full-text articles were scanned for data collected from participants regarding PI and E criteria, namely, the FGM/C decision-making process and who the decision-maker is regarding whether to cut or not.
Articles that provided insufficient or unfocused information regarding the DMP and/or decision-makers were excluded. After the implementation of the inclusion and exclusion criteria, 23 papers were chosen for the critical appraisal stage (refer to Figure 1 & Table 2).

Data Abstraction
Data were extracted in Microsoft Excel. The data extracted included the in-text citation of the article; the study design; the context of the study, e.g., "area, country"; sample size; if the main aim was related to FGM/C, DMP, and/or HHDMs; the aim of the study; the source of information regarding the DMP and HHDMs namely, household, mother, father, the woman who underwent FGM/C, healthcare professionals, or others; the results related to FGM/C DMP and/or HHDMs; the limitations of the study.

Analysis
This systematic review contains data from both qualitative and quantitative research, and therefore, meta-analysis could not be conducted. Microsoft Excel was used for organizing and analyzing the data extracted from the included articles. Then, a textual narrative synthesis was carried out.

Critical Appraisal
The critical appraisal was applied to the 23 studies to examine the studies' methodological strengths, weaknesses, the validity of the research, the trustworthiness of the results, and the presence of biases (refer to Table 3). It was also done to test whether the studies have been designed, carried on, and written in a reliable matter and whether they provide a meaningful answer to this systematic review question. The studies were appraised using different types of appraisal tools, where the qualitative research's quality assessment was conducted using the Critical Appraisal Skills Programme (CASP) [25]. Cross-sectional studies were appraised using the Appraisal tool for Cross-Sectional Studies (AXIS), which was developed specifically for the appraisal of this type of design [26] (refer to Table 4). This review included ethical appraisal, which carried out to improve the ethical and methodological quality of this review by avoiding papers with ethical inadequacies.

Ethical Statement
Application for ethical approval was made to the School Research Ethics Panel (SREP) Allied Health, Anglia Ruskin University, which concluded that no ethical approval is needed for this research as this systematic review only require to retrieve and synthesize of data from already published articles.

Outcome of the Critical Appraisal and Ethical Appraisal
The critical and ethical appraisal resulted in 17 studies that were included in the review. Six studies were excluded from this systematic review for the following reasons: low internal validity of the study, which affects the reliability of the results (one study [27]); low validity and reliability of the results, in addition to the lack of ethical considerations (two studies [14,28]); ethical appraisal due to lack information regarding participant consent, confidentiality, and obtaining ethical approval (three studies [29][30][31]).    (+) = item adequately addressed, (-) = item not adequately addressed, (+/-) = item partially addressed, NS= not stated or "I do not know", NA= not applicable.

Characteristics of the Included Studies
The review included 17 studies from 11 different countries; 13 of the studies were conducted in the African countries of Ethiopia, Sudan, Somaliland, Sierra Leone, Guinea, Gambia, and Senegal; two studies were conducted in Mideastern country Kurdistan regions in Iraqi; two studies were carried among immigrant communities, one in the United States of America, and the other in Canada. Only four of the studies' main aim was to explore the DMP and/or HHDMs [19,20,22,32]. The remaining studies' [33][34][35][36][37][38][39][40][41][42][43][44][45] main objectives did not include the DMP and/or HHDMs; however, they collected sufficient data regarding the DMP and/or HHDMs from their samples.

The Designs of the Included Studies
Nine qualitative studies were included, in which data were collected using either in-depth interviews or FGDs or both. Furthermore, eight cross-sectional studies-community-based, school-based, household surveys-were included where data were collected using a self-administered questionnaire, face-to-face interview, or audio computer-assisted self-interviews. Two of the cross-sectional studies collected both qualitative and quantitative data.

Source of Information Regarding the DMP and/or HHDMs
The data extracted from the studies were self-reported by the participants in the studies mentioned. The studies included various samples differing in age groups, social positions, and education levels. Some samples reported on their own experience regarding FGM/C, while others reflected on their community's DMP and decision-makers.
Characteristics, designs, sources of information, and summaries of the findings are presented in Table 5.
The most cited FGM/C HHDMs by the samples of the reviewed articles are mothers, fathers, and grandmothers. Three main themes regarding the DMP and HHDMs emerged during the analysis: (1) the decision-making process, (2) are females the main decision-makers?, and (3) the role of fathers as decision-makers. The available data shed light on the decision-making process within the household and the community, revealing the complexity of the process and the shift that took place over time. The themes below reflect the variation of the DMP among different regions that practice it. The data shed light on the main FGM/C household decision-makers and the power-relations in regard to the DMP.  Participants (women aged  years old, and 10 men aged 28-47 years old)-younger or older age groups were not explained Younger females stated that older women are the ones with power and the ones insisting on FGM/C, preferably type III. The few older women admitted their interference and stressed that it is an important tradition. Several of the men claimed that they were hardly involved at all in the decision to perform FGM/C. However, a few men described how they opposed their wives and taken the decision themselves, not to circumcise their daughters.
Men participants were more educated than average. Also, as the interviewers were females; when women interview men, there might be a tendency to present a favorable image, the socially desirable response that refers to giving the answers that are consistent with prevailing social mores.
Bjälkander et al. 2012 [20] Cross-sectional community-based survey using interviews The girls who were cut (N=190) reflecting on their own experience, if they did not know, the parent or guardian reported for them.
Females reportedly dominate the decision-making process; however, fathers (n=54) were mentioned equally often as mothers (n=51) as the HHDMs. Other decision-makers mentioned in responses were grandmothers (n=39) and aunts (n=29) and, to a lesser extent, grandfathers, husbands, guardians, grandmothers and mothers jointly, and sisters. In seven instances, a combination of relatives made the decision for FGM/C: in six cases, it was the mother and father together, and in one case, it was the mother and grandmother together. Two girls reported themselves as the decision-makers.
The sample participant is not representative of the population in Sierra Leone, as it does not cover all ethnic groups and has geographical limitation. The methodology of the study did not aim to address the whole decision-making process.

Midwives reflecting on their community
All midwives agreed it is first and foremost the mother in the family who decide regarding FGM/C. The mother and grandmother propose the idea, and the father pays the practitioner.  Small majority of interviewees counted women in the family as those who were in charge of the decision to carry out FGM/C, as it is considered women's affair. This view was mainly among religious and community leaders; 25% of interviewees cited men as those who decide regarding FGM/C within the family, and nearly 20% said that the decision-maker was either the aunt, the mother, the husband, the two parents together, or someone else from the same social group.   Large group circumcisions have become less common, and the decision making regarding when and how to circumcise has shifted to the family. The increase in inter-ethnic marriages between ethnicity that practice FGM/C to others who do not practice it, complicated decision-making, and cause debates about modifying or ending FGM/C. Several members of the extended family, mothers, co-wives, grandmothers, aunts, and fathers, participate in decision making. In case of conflict, these individuals have different degrees of power regarding the decision.
The research sites do not provide nationally-representative sample.
*Limitation of the study was not stated in the article.

Decision-Making Process
Some studies examined the time-shift in the FGM/C DMP, such as studies in Senegal and Gambia [37] that examined how overtime large group circumcisions were replaced with private circumcisions within the family, which shifted the decision-making from "when" to circumcise to "whether" to circumcise, taking the power of decision-making from the community and handing it to the family. Additionally, the paper reveals that inter-ethnic marriages between one family practicing FGM/C to another who does not lead to a debate regarding the decision of circumcising the daughter. Another study revealed the differences between young parents' generation and the generation of grandparents and reported more involvement of young men in the DMP than the grandparents' generation [41].
Several studies established that when it comes to decision-making, the process involves several members of the nuclear family, extended family, and acquaintances. There is involvement of the mothers, co-wives, grandmothers, aunts, and fathers [32], and when there is conflict, each individual has a different degree of power over the decision. The young females usually have limited authority in the decision compared to older women, but they can strengthen their opinion by asking the support of senior females in the family who have more power. The study participants from Sudan shared similar findings regarding younger women having less power than older women, who insist on FGM/C [34]. In another study of Keita and Blankhart (2001) in Guinea [33], among Malinke families, the FGM/C decision is taken by agreement among all the adult members of the family, extended family, and members of the social circle. Sabahelzain et al.'s (2019) household surveys conducted in Sudan indicated that the FGM/C HHDMP involved discussions among the nuclear and extended family and non-family members, including "mothers, fathers, maternal grandmothers, paternal grandmothers, aunts, professional or anti-FGM/C activists, sons, daughters, and uncles", with different degree of participation among them [22]. In Sierra Leone, participants shared that the decision involves "mothers, grandmothers, aunts, and fathers" and, to a lesser extent, grandfathers, husbands, guardians, sisters; two of the participants even reported themselves as the ones who made the decision to undergo FGM/C [20].
This review reveals the comparison of the DMP in the Iraqi Kurdistan region with the DMP in African countries, where the decision to circumcise the daughter is only made by closed females family members and that males in the family are not included in the decision nor informed about the circumcision [38,40].

Are Females the Main Decision-Makers?
According to a study in the Somali and Harari society of eastern Ethiopia, mothers are the decision-makers for female circumcision and play a major role in the practice. The mothers desire to circumcise their daughters to optimize their future prospects due to their own fear of violating the tradition [37]. A more recent study in the same area [43] confirmed their previous findings, where the majority of the sample cited their mothers as the decision-makers for their circumcision, followed by their grandmother, while a small percentage claimed that their fathers were the decision-makers. The study also reported that in 5% of the sample, the girls themselves made the decision to undergo FGM/C. Similarly, another study among Canadian-Somali participants who reported their own FGM/C experiences said that their mothers were responsible for arranging their FGM/C, with the exception of one participant who cited her grandmother [39]. The study reported silence regarding the fathers' role in decision-making, and that the fathers and uncles were away or disagreed with their partner regarding the FGM/C of the daughter. The sample from Somalian midwives reported mothers as the first FGM/C decision-makers, and that, generally, the mother and grandmother in a family proposed the idea, while the father pays the practitioner [35]. However, in case of disagreement in the decision, the final decision is carried out by the father. Another study in Somaliland shared [36] that most of the participants claimed the mother is the main decision-maker regarding FGM/C with a small percentage of participation in the decision-making by fathers. The study also supports the finding that the mothers' decision is influenced by the social structure of the community and emerges from her desire to ensure better chances for marriageability for her daughter and fear of being shamed by society. A study of Erbil, Iraq Kurdistan, likewise indicated that mothers or grandmothers are the main decision-makers, while fathers are not involved in the decision [40]. These findings are supported by another research conducted in the same location, which also reported that the circumcision of the girl is done without the knowledge of fathers or brothers as it is a matter of females, i.e., "mothers, grandmothers, aunts" [38]. In the study in Guinea, Keita and Blankhart (2001) stated that religious leaders and community samples viewed FGM/C as a women affair, with a small majority of interviewees stating that the women in the family are the ones responsible for the decision to carry out FGM/C, a quarter of the sample citing men, and a fifth of the sample citing "others" as the decision-makers [33].

The Fathers' Role as Decision-Makers
Although several articles mentioned that FGM/C as women's business, other articles have mentioned fathers as the sole decision-makers or part of the DMP.A study in Sierra Leone found fathers as the solo FGM/C decision-maker were as equally mentioned as mothers, while some participants reported both parents taking the decision together [20]. It was also reported that in almost two-thirds of cases, fathers were involved in the decision-making process when the final decision was to leave the girl uncut, while their involvement was less than a third when the final decision is to cut the girl [22]. Almroth et al. (2001) reported that fathers were more involved in the decision-making when the decision was not to perform FGM/C and, in some cases, the final decision not to circumcise was made only by the father [41], while the young male sample in Berggren et al.'s (2006) study described that they took the FGM/C final decision, opposing their wives not to circumcise their daughters [34].
A study found that less than the majority of men participate in the DMP, especially if they were single, and less than a tenth of fathers act as the final decision-makers [19]. However, the study recognized that men who come from families that do not practice FGM/C do not intend to circumcise their daughters, and expect the same attitude from their family. In contrast, for men who come from families that practice FGM/C, the majority of them appear to be supportive of the practice, intend to circumcise their daughters, and they expect their families to share their attitude. Therefore, they do not participate in the decision-making process on the assumption that the final decision is similar to their own unspoken decision; additionally, females are unable to make the decision not to circumcise their daughter without the active support of their husbands. On the other hand, research in Bale Zone, Ethiopia, discovered that most of the participants identified both parents as the decision-makers; however, they rarely identified the father as the only decision-maker (1.6%). Although it might be the mother who introduces the practice, it is the father that facilitates the action of the practice beforehand [43]. Another study in Addis Ababa, Ethiopia, found that almost a quarter of the sample cited only fathers as decision-makers, while one-third of the sample claimed only mothers and the rest of the decisions were made by either parents or relatives [42]. Meanwhile, among West African immigrants in the USA, mothers followed by maternal and paternal grandmothers were the most cited decision-makers by both male and female participants, while forty percent of the sample cited fathers as decision-makers [44]. Finally, although the research by Isman et al. (2013) cited females as the main decision-makers, they also reported that when there is a different opinion regarding performing FGM/C, the father of the girl appears to be the final decision-maker [35].

Discussion
The FGM/C household decision-making process is complex that differs from one area to another and changes with time. Putting into consideration that FGM/C is an old tradition in which some communities (such as African) that practice it adhered to it a long time ago, those communities have already passed by all the phases of the decision-making process and established their decision and implementation process [16]. Therefore, when those communities receive new information regarding the practice, some of them re-evaluate their decision bypassing the five stages of the decision-making process [16] all over again (1-gain new knowledge about the FGM/C practice, 2-forming either an inclination to change the practice or continue with the tradition, 3-making a choice depending on the inclination, 4-implementing their choice, 5-when faced with debate, seek reinforcement of the decision). Some members might decide at any phase not to change their practice and follow tradition, as dictated by the social norms.
In some communities, e.g., Sierra Leone, Sudan, Gambia, Senegal, Guinea and Egypt, where there is open dialog regarding this practice, especially when part of the community have abandoned the practice, the DMP first three stages seems to involve several individuals from close family and others [20,22,[31][32][33]. On the other hand, the sensitivity of FGM/C topic among other communities, e.g., Iraq Kurdistan, Somalia, Somali, and Harari regions, affect the possibility of opening dialog regarding the practice between the sexes; therefore, making the FGM/C decision a women's responsibility [36,[38][39][40]43], where the mothers have full responsibility of their daughters and fathers are responsible for the males [37]. However, the statement that females, especially mothers, are the ones controlling the DMP in these communities should be treated with caution. Although fathers are not the main decision-makers, they appear to facilitate the practice [43] by maintaining passive attitudes when they have the power to influence the decision [36] or paying for the circumcision. Moreover, fathers have the power to make the final decision, and they appear to exercise their power when they oppose circumcising their daughters [34,35].
Females' or mothers' decisions are influenced by their desire to maintain tradition and fulfill their obligations within the society by ensuring the marriageability of their daughters where circumcised females are more favorable for marriage [36,37,43]. Furthermore, mothers might hold low power in decision-making and limited authority to contest to the practice in opposing to older females who support tradition and hold higher power in the community and within the family [32]. The mothers' desire to maintain tradition could be caused by the overall patriarchal context of the society and the unequal power relations rooted in the maternalistic relations between females and their mothers [34]. However, researchers [15] argued that the decision-making power is not fixed and can change over time, which can explain the findings of different studies [22,41,46] reported women with high education and possibility to work outside tend to decide not to circumcise their daughter, as education and financial stability increases the woman's decision-making power within the household.
The results of two studies (Amusan and Asekun-Olarinmoye 2008; Garba et al. 2012) conducted in Nigeria mentioned contradictory findings and claimed that within the majority, males in the family are the FGM/C decision-makers, who often request the circumcision to be performed, with the paternal grandfather being the main decision-maker, followed by the father and maternal grandfather [14,30]. This contradiction can be explained by the variation of the DMP and HHDMs between countries and regions due to the differences in the social structure.
While examining the role of men in the decision-making process and as decision-makers, the findings of this systematic review support that fathers tend to have a more active role in participating in the decision-making and act as decision-makers when the decision is not to circumcise the daughter [22,41]. The men do not participate in the decision-making process when their attitude toward the practice is similar to that of their families [19], and this emphasizes the fact that females in a patriarchal society are unable to leave their daughters uncircumcised without the active support of the father. Thus, men might not be actively participating in FGM/C decision-making process, but they are still decision-makers. Some studies [41,42,44] mentioned higher participation among males in the DMP, which can be due to high exposure to anti-FGM/C campaign, their sample being composed of educated males, or immigrants that live outside their country of origin.
Healthcare professionals working in gynecology and obstetrics can encourage open conversation regarding FGM/C decision-making by play an essential role in engaging partners who come to healthcare facilities in active dialogues about the practice, especially if the female partner underwent the practice herself. Thus, it is essential to provide education of all aspects of FGM/C, including the DMP to gynecologists, obstetrics, midwives, and healthcare workers, in both developed and undeveloped countries. FGM/C has severe clinical implications on women because it affects their sexual, psychological, and reproductive health; furthermore, it puts the lives of the mother and child at risk during delivery.

Strengths and Limitations
To the best of the authors' knowledge, this study is the first systematic review conducted regarding the FGM/C decision-making process and decision-makers that identifies the DMP and key decision-makers. To minimize bias, the critical appraisal was carried out on two different occasions with a one-week period between the first and second appraisals, and then the two appraisals for each study were compared. The study only included peer-reviewed articles, which is considered a strength as well as a weakness. The review only includes articles published in the English language, which introduce location and language bias. Additionally, excluding articles that are not available in full-text can cause articles that are up-to-date to be missed out. The quality assessment and data extraction were carried out by the first author only; cross-checking was not conducted, which might have affected the quality of reporting and the analysis. Finally, variation in the collected data can be observed as it is caused by the different range of samples in the studies reviewed.

Conclusions
This review is the first to provides summarized information about the DMP, HHDMs, and FGM/C. The most cited FGM/C HHDMs by the samples of the reviewed articles are mothers, fathers, and grandmothers. This review introduces the presence of silence when discussing FGM/C among the sexes, caused by social and cultural obligations that influence the DMP. This causes confusion in regards to who has more authority in the DMP.
It was shown that the DMP is an important issue in FGM/C in different countries and ethnicities. However, due to limited studies that focus on the topic, further research is needed.
The findings of this review show that active participation of fathers in the decision-making process could free mothers from the social-pressure and responsibility of carrying on traditions, creating a more favorable environment for FGM/C abandonment. Designing and implementing community programs that involve males and females in open conversations regarding the practice, and education programs for men regarding their important role in DMP may also assist in ending the practice.