Socio-economic disparities in female genital circumcision: finding from a case- control study

Socio-economic disparities in female genital circumcision: finding from a case- control study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Socio-economic disparities in female genital circumcision: finding from a case- control study Shahla Shafaati Laleh, Ghodratollah Roshanaei, Farzaneh Soltani, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1650856/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Female genital circumcision is still one of the challenges in reproductive health. This study was conducted to investigate the socio-economic disparities in female genital circumcision in a Kurdish region of Iran. Methods We conducted a case-control study to assess the socio-economic factors associated with female genital circumcision. Using the available sampling method, 130 cases of circumcised girls and 130 controls without history of circumcision were enrolled. The demographic and circumcision information questionnaires were completed by self-report method. Data were analyzed using descriptive statistics, chi-square statistical methods as well as univariate and multivariate logistic regression models with a backward method at 95% confidence level. Results The chances of genital circumcision in girls under the age of 20 and then in the age group of 20 to 30 years were 5.77 and 8.55 times higher than those over 30 years, respectively. This chance in girls with elementary education was 6.6 times higher than those with a college education. The chances of girls being circumcised with mothers with elementary education were 5.75 times higher than girls with university-educated mothers. Also, the family history of circumcision increased the chance of female genital circumcision by 9.90 times. Conclusion The present study highlighted the importance of modifiable variable such as girls’ education as well as parents' education as predictors of female genital circumcision. Empowering women by creating opportunities for their education can lead to the success of global efforts to reduce and eradicate this health problem. Female genital circumcision Health Status Disparities Socioeconomic Factors Background Female genital circumcision (FGC) as defined by the World Health Organization; includes all methods that harm or eliminate all or a part of the genital organs of females for non-medical reasons [ 1 ]. It is estimated that by 2050, approximately one of three births will occur in 30 countries in Africa and the Middle East, where female genital circumcision is widespread [ 2 , 3 ]. Short-term consequences of FGC such as severe pain, bleeding, difficulty in urination and sepsis, as well as its long-term consequences included chronic pain and infections are well known. [ 4 ]. In Iran, FGC (Known as SONNAT) is common in some southern and western districts, such as Hormozgan province [up to 70%], Kermanshah (55.7% in Ravansar), and Kurdistan (up to 42%) [ 5 , 6 ]. There are various reasons for FGC, but the main reasons should be sought in severe gender discrimination against women, lack of awareness of the negative consequences of circumcision, as well as cultural traditions and beliefs. Sexual beliefs [controlling or reducing women's sexual desire], social beliefs (girls enter the stage of femininity), cosmetic beliefs (female genitalia is dirty or ugly), health beliefs (increasing female fertility) and religious beliefs are common beliefs associated with female genital circumcision [ 7 ]. FGC is sometimes such a powerful social norm in these societies that families circumcise their daughters even if they are aware of its consequences, and if a family does not do so, it endangers the marriage status of their daughters. [ 8 ]. All this is while a review study of 74 articles found that FGC was associated with a variety of consequences, including infection, urinary frequency, persistent bleeding, dysmenorrhea, dyspareunia, increased risk of hepatitis, and infertility. Serious complications can occur in all stages of FGC [ 6 ]. Many studies have examined the socioeconomic and demographic factors influencing the prevalence of FGC. Although the place of residence (urban versus rural)], level of education, religion, and ethnicity appear to be related to the prevalence of FGC in a given country, the nature of this relationship varies from country to country [ 9 ]. For example, the place of residence seems to be related to the prevalence of FGC, but this relationship is not always fixed in favor of urban or rural. For example, Iraqi Kurdish society is an agricultural society, and the majority of the population lives outside the cities, where a high prevalence of illiteracy and poverty appears to be associated with high FGC prevalence [ 10 – 12 ]. Major changes in the religious arrangement of countries, as well as the interaction between religion and place of residence, local customs and cultural traditions, and even fear of legal consequences or anti-FGC propaganda activities can be the main reasons for the lack of continuous relationship between socio-economic variables with the prevalence of female circumcision [ 13 ]. In this way, obtaining basic information and related social and economic factors can help decision-makers and health planners to design and implement effective interventions in order to eliminate or eradicate FGC. Therefore, this study was conducted to investigate the socioeconomic disparities that determine female genital circumcision in a Kurdish region of Iran. Methods Study design and participants The present case-control study was conducted on girls living in Mahabad, a Kurdish region in Iran, in 2018. The study was approved by the Ethics Committee of Hamadan University of Medical Sciences (IR.UMSHA.REC.1397.379), and performed according to the Helsinki Declaration. Informed consent was obtained from all individuals enrolled. Including criteria were being single, physical, and mental health according to the health record, and reading and writing literacy. Excluding criteria were physical and mental illness, smoking and drug addiction, and not responding to more than 10 percentages of the questionnaire items. Sample size The G*Power software version 3.1.9.7 was used for the calculated sample size. The G*Power software automatically provides the conventional effect size values suggested by Cohen. In this study, considering the medium effect size (odd = 0.5), type I error (α) = 0.05, and power (1-β) = 0.95 total sample size was calculated for 130 people for each group. Sampling Using the available sampling method, 130 circumcised girls and 130 uncircumcised girls were selected based on their health records available at the Mahabad health centers. Cases and controls were matched on residence area situation (urban or rural) as well as type of religious sect (Shafi'i or Hanafi). It should be noted that the Muslims living in the Kurdish regions of Iran are mainly "Sunni" in religion and belong to the two sects of Shafi'i and Hanafi. The variables studied included age, level of education, occupation statues, number of household members, birth order, parental education and occupation, family income, housing status, family history of circumcision, age of circumcision, circumciser and place of circumcision, awareness of female circumcision, and the sources of information. The questions were designed using the review of previous studies and revised and approved by six reproductive health professionals in terms of content validity. Data analysis Data were analyzed using descriptive statistics, chi-square statistical methods as well as univariate and multivariate regression logistic models with backward method at a 95% confidence level. In the multivariate model, all demographic and socioeconomic variables were entered into the model, and then using the backward method, each variable was excluded and the model was finalized in step 9. Results The majority of participants in the case group were 20–30 years old (63.1%), had a college education (43.8%), and were unemployed (45.4%). Regarding parents' occupation, their father occupied in self-employed (54.7%) and their mother had unemployed (85.5%) respectively. Both parents had elementary education levels of 50%, and 66.9% respectively. Regarding family size, family monthly income, and housing status, they were in a family of 1–5 people (50.6%), moderately adequate income (49.2%), and personal ownership (81.5%). Regarding FGC family history, 77.7% of participants had a history of FGC in their family. The majority of participants in the control group were 20–30 years old (53.8%), had a college education (66.2%), and were studying (55.4%). Regarding parents' jobs, their father occupied in self-employed (47.7%) and their mother had unemployed 73.8%) respectively. Their father had a guidance education level of 31.5%, and their mother's education in elementary level 38.5 percentage respectively. Regarding family size, family monthly income, and housing status, they were in a family of 1–5 people (56.2%), moderately adequate income (48.5%), and personal ownership (73.1%). Regarding FGC family history, 30% of participants had a history of FGC in their family (Table 1 ). Forty-five percent of circumcised girls had been circumcised under the age of 5 years, and about half of them were the first child in the family. More than half of the girls had been circumcised by local women and more than 90 percentage circumcised at home. Sixty percent of circumcised girls had information about circumcision, and the Internet was their most common source of information. Most girls did not have pain in their circumcision area (Table 2 ). Table 1 Comparison of demographic and socio-economic factors in term of two groups (N = 260) Variables Without FGC N (%) FGC N (%) OR CI, 95% P -value* Age(year) 31 27(20.8) 11(8.46) ref Education Elementary 4(3.1) 14(10.8) 5.28 1.65, 16.85 0.005 Guidance 20(15.4) 27(20.8) 2.03 1.04, 3.97 0.037 Diploma 20(15.4) 32(24.6) 2.41 1.25, 4.69 0.008 Academic 86(66.2) 57(43.8) ref Occupation status Employed 19(14.6) 26(20.0) 0.90 0.44, 1.85 0.784 Student 72(55.4) 45(34.6) 0.41 0.23, 0.71 0.002 Unemployed 39(30.0) 59(45.4) ref Father's job Government's employee 45(34.6) 32(25.0) 0.71 0.21, 2.40 0.584 worker 17(13.1) 20(15.6) 1.12 0.34, 3.68 0.841 Self-employed 62(47.7) 70(54.7) 1.17 0.32,4.33 0.807 Unemployed 6(4.7) 8(4.7) ref Father's education Elementary 28(21.5) 64(50.0) 5.48 2.31, 12.97 0.001 Guidance 41(31.5) 26(20.3) 1.52 0.62, 3.69 0.353 Diploma 37(28.5) 28(21.9) 1.81 0.74, 4.40 0.187 Academic 24(18.5) 10(7.8) ref Mother's job Employed 34(26.2) 19(14.6) 0.48 0.25, 0.90 0.022 Unemployed 96(73.8) 111(85.4) ref Mother's education Elementary 50(38.5) 85(66.9) 6.96 1.87, 25.84 0.004 Guidance 48(36.9) 28(20.0) 2.16 0.56, 8.37 0.262 Diploma 20(15.4) 14(10.8) 2.80 0.66, 11.79 0.160 Academic 12(9.2) 3(2.3) ref Family members size 1–5 73(56.2) 66(50.8) 0.67 0.14, 3.14 0.620 6–10 54(41.5) 60(46.2) 0.83 0.17, 3.89 0.817 ≥ 11 3(2.3) 4(3.1) ref Family monthly income Less than adequate 15(11.5) 8(6.2) 0.38 0.09, 1.59 0.187 Moderately adequate 63(48.5) 64(49.2) 0.72 0.21, 2.40 0.600 adequate 47(36.2) 51(39.2) 0.77 0.23, 2.61 0.681 More than adequate 5(3.8) 7(5.4) ref Ownership residence status Rental 28(21.5) 20(15.4) 1.25 0.32, 4.85 0.747 Personal residence 95(73.1) 106(81.5) 1.95 0.55, 6.87 0.298 Residence with family 7(5.4) 4(3.1) ref Family history of FGC Yes 39(30.0) 101(77.7) 8.12 4.65, 14.19 0.001 No 91(70.0) 29(22.3) ref FGC: Female Genital Circumcision; OR: Odds Ratio; CI: Confidence Interval. *Univariate logistic regression model Table 2 Descriptive characteristics of circumcised girls (n = 130) Variables Frequency % Age of circumcision (yr.) 1–4 59 45.4 5–9 52 40 ≥ 10 19 14.6 Birth order First order 50 38.5 second 32 24.6 Third 21 16.2 fourth≥ 27 20.8 Circumciser Rural women 73 65.2 Rural midwife 18 13.8 Educated midwife 7 5.4 Relatives 5 3.8 Others 27 20.8 Place of circumcision Home 122 93.8 Hospital 4 3.1 Health center 4 3.1 Awareness of FGC yes 78 60.00 No 52 40.00 Source of information about FGC Book 26 20 Internet 31 23.8 Mother 9 6.9 sister 6 4.6 Friends 5 3.8 Doctors 14 10.8 No response 39 30 Pain in scars Yes 14 10.8 No 116 86.2 Using the univariate regression model, the relationship between each demographic and socio-economic variable with the circumcision status was investigated. The results showed that the variables of age, education, job, parents' education, mother's job, and previous history of circumcision in their family were related to an increase in the chances of circumcision. Multivariate Logistic Analysis using the backward method, after adjusting the participants' job, father's job, father's education, mother's job, family size, family monthly income, housing status, showed that the age, education, mother's education, and the family history of circumcision were the predictive variables of circumcision. Accordingly, the chances of circumcision in girls under the age of 20 and then in the age group of 20 to 30 years were 5.77 [CI 95%; 1.86–17.84], and 8.55 [CI 95%; 3.09–23.62] times higher than those over 30 years, respectively. This chance in girls with elementary education was 6.6 [CI 95%; 1.34–33.22] times higher than those with a college education. The chances of girls being circumcised with mothers with elementary education were 5.75 [CI 95%; 1.23–26.76] times higher than girls with university-educated mothers. Also, the family history of circumcision increased the chances of female circumcision by 9.90 [CI 95%: 5.03–19.50] times (Table 3 ). Table 3 The socioeconomic - related disparities in female genital circumcision Variables OR CI95% P-value* Age 31 ref Education Elementary 6.68 1.34,33.22 0.020 Guidance 2.25 0.80,6.29 0.120 Diploma 2.20 0.95,5.09 0.065 Academic ref Mother's education Elementary 5.75 1.23,26.76 0.026 Guidance 1.41 0.29,6.79 0.665 Diploma 2.35 0.44,12.64 0.316 Academic ref Family history of FGC Yes 9.90 5.03,19.50 0.001 No ref * Multivariate Logistic analysis backward method (Occupation, Father's job, Father's education, Mother's job, Household members, Family income, housing status variable(s) removed on step 9) The socio- economic related factors in term of age of FGC, circumciser, and place of circumcision were examined. The results showed that age of circumcision was significantly related to the housing status of the family, so that circumcision of girls under the age of 5 years in the families with the personal house was more than other groups (P = 0.034). Circumcision by local women was also significantly higher in those whose father’s education level was elementary (P = 0.003), and whose family income was relatively adequate (P = 0.011). The place of the circumcision was significantly related to the father's job and education status, so that the girls whose father's level of education was elementary (P = 0.034), and retired (P = 0.024), were more likely to be circumcised at home. Mother's job and mother's education had no significant relationship with the three circumcision performance related variables (P > 0.05). Discussion About 200 million women suffered from the mutilation in 30 countries, and the more girls are being exposed to the mutilation per year due to the increasing rate of population in such countries [ 2 ]. According to the results of the present study, the family history of circumcision had increased the chances of girls being circumcised by almost 10 times. This suggests that FGC is passed from generation to generation within families. The majority of circumcised girls in our study (45.4%) had been circumcised under the age of 5 years. FGC is usually performed between the ages of 8 and 14, however, female circumcision cannot be limited to a certain age, and girls are always exposed to circumcision from birth to puberty. EDHS 2008 stated that all circumcised women had the procedure before the age of 15. It is tradition that all girls should be circumcised before puberty [ 15 , 16 ].While the age of circumcision varies between tribes and countries, it seems Muslims as well as women without a university degree circumcise their daughters at a younger age. Kandala et al., found that female circumcision at the age of about 5 years is similar in both urban and rural areas, but circumcision over 5 years seems to be more common in urban areas. In rural areas, circumcision is still performed at older ages and even over 20 years of age, but in urban areas, it is stopped at the age of 15 [ 17 ]. A cross-sectional study on 492 people in three refugee camps in the state of Somalia found that 42.4% of circumcised girls were less than 12 years of age. The prevalence of circumcision had been increased with age, and 52% and 95% of girls had been circumcised at the ages of 7–8 and 11–12, respectively [ 18 ]. In our study, in more than half of the cases, FGC was performed by rural women and in more than 90% of cases at home. Numerous studies have shown that although FGC is usually performed by indigenous people with the earliest tools [ 19 – 20 , 13 ], the increasing participation of health care staff members in female genital mutilation is one of the barriers to eradication of this practice and in some countries more than one-third case of circumcision is performed by members of the medical team [ 21 ]. In the study of Fesharaki Nia et al., an uneducated woman had been circumcised the girls in 48.8% cases, who is in line with our study, but in contrast with our study 51.1% of the circumcisions had been performed at medical centers [ 20 ]. In a study by Pashaei et al., in Ravansar, 96.4% of circumcised girls reported that they had been circumcised by local women and at home [ 5 ]. Gebremariam et al., in their study reported that about three-quarters of FGC cases was performed by a traditional local circumciser and 1.6 percentage by a health professional [ 13 ]. It seems that people's respect for traditional circumcisers can help the continuation of female circumcision. However, the involvement of medical specialists in female circumcision can help prevent the spread of infectious diseases by preventing the use of non-sterile devices and performing unnecessary FGC procedures [by someone unaware of women's anatomy]. In the present study, girls with elementary education had been circumcised nearly 7 times more than those with university education. The lack of formal education had been significantly associated with an increased risk of FGC in several studies [ 22 , 13 ]. The Egyptian Demographic Health Survey 2008 (EDHS) found that the likelihood of circumcision decreased with an increased level of education and was higher among women belonging to the lower social classes [ 23 ]. Other studies have shown that education and self-empowerment are associated with circumcision rejection [ 24 – 26 ]. The educational level of participants in the study of Gebremariam et al. was an important independent predictor of circumcision [ 13 ], and a study in Ethiopia found that uncircumcised women and those who had been studied in high school or higher did not want to continue circumcision compared to those who could not read and write [ 27 ]. In general, education can be interpreted as a kind of women’s empowerment that can probably equalize the balance between them and men [ 28 ]. Since circumcision occurs before starting formal education, many believe that the mother's level of education is a more significant variable for assessing the relationship between FGC and education [ 17 ]. Researches show that in 85.1% of cases, the main decision-makers for girls’ circumcision are mothers and grandmothers [ 29 ]. Mothers' education is an important predictor of FGC in young girls, as several studies have reported that with increasing education of a woman, the incidence of female circumcision decreases and opposition to it increases [ 17 ]. In the study of Ali et al., in Egypt girls with illiterate parents reported a much higher rate of exposure to circumcision [ 30 ]. Another study in Nigeria found that daughters of uneducated mothers are circumcised three and a half time more than the daughters of educated mothers [ 31 ]. Educated women are likely to make wiser decisions about their health and are more likely to seek appropriate and modern health care. In addition, they are likely to be aware of the dangerous effects of FGC and more likely to fight against it [ 13 ]. Another noteworthy point in the present study is that fathers' education and occupation, as well as family income, have been related to the circumciser and the place of circumcision so that girls whose fathers had elementary education and were retired, and whose family incomes were lower, had been mostly circumcised by a rural midwife and at home. It seems while low-educated mothers are more likely to circumcise their daughters, low-educated fathers as well as low economic and social status of the family are also related to how circumcision is performed. These results show the impact of the socio-economic level of families on the quantity and quality of female circumcision. The main limitation of this study is the limitation of the participants who were Kurdish girls living in a Kurdish region in Iran, which impedes the generalization of the study results to other ethnic groups and nationalities. Another limitation was the small sample size. A wide confidence interval is noted in some of the variables as a result of a small sample size. Conducting further studies with larger sample sizes and in another setting are needed to increase the accuracy and generalizability of the findings obtained from this study. Conclusions The present study showed that multivariate regression can provide a strong insight into the socio-economic disparities related to FGC. Designing effective interventions should specifically focus on modifiable variables. Our results highlighted the importance of modifiable variable such as girls’ education as well as parents' education (primarily mothers' education) as predictors of female genital circumcision. It is assumed that educated women are primarily aware of their rights and will be more able to claim and defend these rights for themselves and their daughters. Secondarily, education may reduce women's dependence and give them greater economic stability. Empowering women by creating opportunities for their education can lead to the success of global efforts to restrict and eradicate female genital circumcision. Abbreviations FGC Female Genital Circumcision WHO World Health Organization, Declarations Acknowledgements The authors sincerely appreciated from financial support of Research Deputy of Hamadan University of Medical Sciences. In addition, all participants and personnel in health care centers who helped in the research process are appreciated. Author’s contributions SSL and FS: study concept and design, and acquisition of data analysis and interpretation of data, and drafting of the manuscript. GR: analysis and interpretation of data and drafting of the manuscript. FS, SSL, FGM and GR: critical revision of the manuscript for important intellectual content; FS: study supervision. The manuscript has been read and approved by all the authors. Funding This work was supported by Vice-chancellor for Research and Technology, Hamadan University of Medical Sciences of Iran [Grant number 9706063438]. Availability of data and materials The datasets used and/or analyzed for this study are available by the corresponding author upon reasonable request. Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and was approved by the ethics committee of the Research Council of Hamadan University of Medical Sciences (IR.UMSHA.REC.1397.379). Written consent was obtained from the participants, and they were assured of the confidentiality of their information. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 18 Jul, 2022 Reviews received at journal 09 Jul, 2022 Reviewers agreed at journal 30 Jun, 2022 Reviewers agreed at journal 07 Jun, 2022 Reviewers invited by journal 25 May, 2022 Editor assigned by journal 21 May, 2022 Editor invited by journal 21 May, 2022 Submission checks completed at journal 21 May, 2022 First submitted to journal 12 May, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1650856","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":107691791,"identity":"e57277ef-2962-47ef-9f90-ff8eaa2826fe","order_by":0,"name":"Shahla Shafaati Laleh","email":"","orcid":"","institution":"Hamadan University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shahla","middleName":"Shafaati","lastName":"Laleh","suffix":""},{"id":107691792,"identity":"f1c93038-1f03-42ad-958e-a166c3646b1c","order_by":1,"name":"Ghodratollah Roshanaei","email":"","orcid":"","institution":"Hamadan University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ghodratollah","middleName":"","lastName":"Roshanaei","suffix":""},{"id":107691793,"identity":"c005ec33-470b-4704-b0af-b22ae7c3256c","order_by":2,"name":"Farzaneh Soltani","email":"data:image/png;base64,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","orcid":"","institution":"Hamadan University of Medical Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Farzaneh","middleName":"","lastName":"Soltani","suffix":""},{"id":107691795,"identity":"8e4b6d22-c32b-4776-aa27-d93dc74ce67d","order_by":3,"name":"Fatemeh Ghamari","email":"","orcid":"","institution":"Hamadan University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"","lastName":"Ghamari","suffix":""}],"badges":[],"createdAt":"2022-05-12 20:14:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1650856/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1650856/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":21774666,"identity":"08a607f2-b773-49e5-99cd-63088c7ec6b5","added_by":"auto","created_at":"2022-05-23 13:08:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":318216,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1650856/v1/a554dda6-b38a-4a5c-a15a-e55c68d094bb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Socio-economic disparities in female genital circumcision: finding from a case- control study","fulltext":[{"header":"Background","content":"\u003cp\u003eFemale genital circumcision (FGC) as defined by the World Health Organization; includes all methods that harm or eliminate all or a part of the genital organs of females for non-medical reasons [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is estimated that by 2050, approximately one of three births will occur in 30 countries in Africa and the Middle East, where female genital circumcision is widespread [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Short-term consequences of FGC such as severe pain, bleeding, difficulty in urination and sepsis, as well as its long-term consequences included chronic pain and infections are well known. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Iran, FGC (Known as SONNAT) is common in some southern and western districts, such as Hormozgan province [up to 70%], Kermanshah (55.7% in Ravansar), and Kurdistan (up to 42%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. There are various reasons for FGC, but the main reasons should be sought in severe gender discrimination against women, lack of awareness of the negative consequences of circumcision, as well as cultural traditions and beliefs. Sexual beliefs [controlling or reducing women's sexual desire], social beliefs (girls enter the stage of femininity), cosmetic beliefs (female genitalia is dirty or ugly), health beliefs (increasing female fertility) and religious beliefs are common beliefs associated with female genital circumcision [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. FGC is sometimes such a powerful social norm in these societies that families circumcise their daughters even if they are aware of its consequences, and if a family does not do so, it endangers the marriage status of their daughters. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. All this is while a review study of 74 articles found that FGC was associated with a variety of consequences, including infection, urinary frequency, persistent bleeding, dysmenorrhea, dyspareunia, increased risk of hepatitis, and infertility. Serious complications can occur in all stages of FGC [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany studies have examined the socioeconomic and demographic factors influencing the prevalence of FGC. Although the place of residence (urban versus rural)], level of education, religion, and ethnicity appear to be related to the prevalence of FGC in a given country, the nature of this relationship varies from country to country [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. For example, the place of residence seems to be related to the prevalence of FGC, but this relationship is not always fixed in favor of urban or rural. For example, Iraqi Kurdish society is an agricultural society, and the majority of the population lives outside the cities, where a high prevalence of illiteracy and poverty appears to be associated with high FGC prevalence [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Major changes in the religious arrangement of countries, as well as the interaction between religion and place of residence, local customs and cultural traditions, and even fear of legal consequences or anti-FGC propaganda activities can be the main reasons for the lack of continuous relationship between socio-economic variables with the prevalence of female circumcision [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this way, obtaining basic information and related social and economic factors can help decision-makers and health planners to design and implement effective interventions in order to eliminate or eradicate FGC. Therefore, this study was conducted to investigate the socioeconomic disparities that determine female genital circumcision in a Kurdish region of Iran.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eThe present case-control study was conducted on girls living in Mahabad, a Kurdish region in Iran, in 2018. The study was approved by the Ethics Committee of Hamadan University of Medical Sciences (IR.UMSHA.REC.1397.379), and performed according to the Helsinki Declaration. Informed consent was obtained from all individuals enrolled. Including criteria were being single, physical, and mental health according to the health record, and reading and writing literacy. Excluding criteria were physical and mental illness, smoking and drug addiction, and not responding to more than 10 percentages of the questionnaire items.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eThe G*Power software version 3.1.9.7 was used for the calculated sample size. The G*Power software automatically provides the conventional effect size values suggested by Cohen. In this study, considering the medium effect size (odd\u0026thinsp;=\u0026thinsp;0.5), type I error (α)\u0026thinsp;=\u0026thinsp;0.05, and power (1-β)\u0026thinsp;=\u0026thinsp;0.95 total sample size was calculated for 130 people for each group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSampling\u003c/h2\u003e \u003cp\u003eUsing the available sampling method, 130 circumcised girls and 130 uncircumcised girls were selected based on their health records available at the Mahabad health centers. Cases and controls were matched on residence area situation (urban or rural) as well as type of religious sect (Shafi'i or Hanafi). It should be noted that the Muslims living in the Kurdish regions of Iran are mainly \"Sunni\" in religion and belong to the two sects of Shafi'i and Hanafi. The variables studied included age, level of education, occupation statues, number of household members, birth order, parental education and occupation, family income, housing status, family history of circumcision, age of circumcision, circumciser and place of circumcision, awareness of female circumcision, and the sources of information. The questions were designed using the review of previous studies and revised and approved by six reproductive health professionals in terms of content validity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using descriptive statistics, chi-square statistical methods as well as univariate and multivariate regression logistic models with backward method at a 95% confidence level. In the multivariate model, all demographic and socioeconomic variables were entered into the model, and then using the backward method, each variable was excluded and the model was finalized in step 9.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe majority of participants in the case group were 20\u0026ndash;30 years old (63.1%), had a college education (43.8%), and were unemployed (45.4%). Regarding parents' occupation, their father occupied in self-employed (54.7%) and their mother had unemployed (85.5%) respectively. Both parents had elementary education levels of 50%, and 66.9% respectively.\u003c/p\u003e \u003cp\u003eRegarding family size, family monthly income, and housing status, they were in a family of 1\u0026ndash;5 people (50.6%), moderately adequate income (49.2%), and personal ownership (81.5%). Regarding FGC family history, 77.7% of participants had a history of FGC in their family. The majority of participants in the control group were 20\u0026ndash;30 years old (53.8%), had a college education (66.2%), and were studying (55.4%). Regarding parents' jobs, their father occupied in self-employed (47.7%) and their mother had unemployed 73.8%) respectively. Their father had a guidance education level of 31.5%, and their mother's education in elementary level 38.5 percentage respectively. Regarding family size, family monthly income, and housing status, they were in a family of 1\u0026ndash;5 people (56.2%), moderately adequate income (48.5%), and personal ownership (73.1%). Regarding FGC family history, 30% of participants had a history of FGC in their family (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Forty-five percent of circumcised girls had been circumcised under the age of 5 years, and about half of them were the first child in the family. More than half of the girls had been circumcised by local women and more than 90 percentage circumcised at home. Sixty percent of circumcised girls had information about circumcision, and the Internet was their most common source of information. Most girls did not have pain in their circumcision area (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of demographic and socio-economic factors in term of two groups (N\u0026thinsp;=\u0026thinsp;260)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout FGC\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFGC\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCI, 95%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP -value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge(year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33(25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37(28.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.18, 6.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70(53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82(63.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.33,6.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(8.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducation\u003c/p\u003e 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\u003cp\u003e86(66.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57(43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOccupation status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26(20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.44, 1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72(55.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45(34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.23, 0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59(45.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eFather's job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment's employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45(34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32(25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.21, 2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.584\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eworker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.34, 3.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.841\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62(47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70(54.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.32,4.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.807\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eFather's education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64(50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.31, 12.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGuidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41(31.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26(20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.62, 3.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.353\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37(28.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28(21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.74, 4.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMother's job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(26.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19(14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.25, 0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96(73.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111(85.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMother's education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50(38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85(66.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.87, 25.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGuidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48(36.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28(20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.56, 8.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.262\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.66, 11.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFamily members size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73(56.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66(50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.14, 3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.620\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54(41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60(46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.17, 3.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eFamily monthly income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than adequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.09, 1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerately adequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63(48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64(49.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.21, 2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eadequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47(36.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51(39.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.23, 2.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.681\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than adequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eOwnership residence status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.32, 4.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersonal residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95(73.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e106(81.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.55, 6.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.298\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResidence with family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFamily history of FGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101(77.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.65, 14.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91(70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29(22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eFGC: Female Genital Circumcision; OR: Odds Ratio; CI: Confidence Interval.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*Univariate logistic regression model\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive characteristics of circumcised girls (n\u0026thinsp;=\u0026thinsp;130)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge of circumcision (yr.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBirth order\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst order\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThird\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efourth\u0026ge;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eCircumciser\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducated midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlace of circumcision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAwareness of FGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eSource of information\u003c/p\u003e \u003cp\u003eabout FGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBook\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esister\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFriends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePain in scars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUsing the univariate regression model, the relationship between each demographic and socio-economic variable with the circumcision status was investigated. The results showed that the variables of age, education, job, parents' education, mother's job, and previous history of circumcision in their family were related to an increase in the chances of circumcision. Multivariate Logistic Analysis using the backward method, after adjusting the participants' job, father's job, father's education, mother's job, family size, family monthly income, housing status, showed that the age, education, mother's education, and the family history of circumcision were the predictive variables of circumcision. Accordingly, the chances of circumcision in girls under the age of 20 and then in the age group of 20 to 30 years were 5.77 [CI 95%; 1.86\u0026ndash;17.84], and 8.55 [CI 95%; 3.09\u0026ndash;23.62] times higher than those over 30 years, respectively. This chance in girls with elementary education was 6.6 [CI 95%; 1.34\u0026ndash;33.22] times higher than those with a college education. The chances of girls being circumcised with mothers with elementary education were 5.75 [CI 95%; 1.23\u0026ndash;26.76] times higher than girls with university-educated mothers. Also, the family history of circumcision increased the chances of female circumcision by 9.90 [CI 95%: 5.03\u0026ndash;19.50] times (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe socioeconomic - related disparities in female genital circumcision\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCI95%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.86,17.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.09,23.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.34,33.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGuidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80,6.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95,5.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMother's education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.23,26.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGuidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29,6.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.44,12.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.316\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFamily history of FGC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.03,19.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Multivariate Logistic analysis backward method (Occupation, Father's job, Father's education, Mother's job, Household members, Family income, housing status variable(s) removed on step 9)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe socio- economic related factors in term of age of FGC, circumciser, and place of circumcision were examined. The results showed that age of circumcision was significantly related to the housing status of the family, so that circumcision of girls under the age of 5 years in the families with the personal house was more than other groups (P\u0026thinsp;=\u0026thinsp;0.034). Circumcision by local women was also significantly higher in those whose father\u0026rsquo;s education level was elementary (P\u0026thinsp;=\u0026thinsp;0.003), and whose family income was relatively adequate (P\u0026thinsp;=\u0026thinsp;0.011). The place of the circumcision was significantly related to the father's job and education status, so that the girls whose father's level of education was elementary (P\u0026thinsp;=\u0026thinsp;0.034), and retired (P\u0026thinsp;=\u0026thinsp;0.024), were more likely to be circumcised at home. Mother's job and mother's education had no significant relationship with the three circumcision performance related variables (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAbout 200\u0026nbsp;million women suffered from the mutilation in 30 countries, and the more girls are being exposed to the mutilation per year due to the increasing rate of population in such countries [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the results of the present study, the family history of circumcision had increased the chances of girls being circumcised by almost 10 times. This suggests that FGC is passed from generation to generation within families. The majority of circumcised girls in our study (45.4%) had been circumcised under the age of 5 years. FGC is usually performed between the ages of 8 and 14, however, female circumcision cannot be limited to a certain age, and girls are always exposed to circumcision from birth to puberty. EDHS 2008 stated that all circumcised women had the procedure before the age of 15. It is tradition that all girls should be circumcised before puberty [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].While the age of circumcision varies between tribes and countries, it seems Muslims as well as women without a university degree circumcise their daughters at a younger age. Kandala et al., found that female circumcision at the age of about 5 years is similar in both urban and rural areas, but circumcision over 5 years seems to be more common in urban areas. In rural areas, circumcision is still performed at older ages and even over 20 years of age, but in urban areas, it is stopped at the age of 15 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A cross-sectional study on 492 people in three refugee camps in the state of Somalia found that 42.4% of circumcised girls were less than 12 years of age. The prevalence of circumcision had been increased with age, and 52% and 95% of girls had been circumcised at the ages of 7\u0026ndash;8 and 11\u0026ndash;12, respectively [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our study, in more than half of the cases, FGC was performed by rural women and in more than 90% of cases at home. Numerous studies have shown that although FGC is usually performed by indigenous people with the earliest tools [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], the increasing participation of health care staff members in female genital mutilation is one of the barriers to eradication of this practice and in some countries more than one-third case of circumcision is performed by members of the medical team [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In the study of Fesharaki Nia et al., an uneducated woman had been circumcised the girls in 48.8% cases, who is in line with our study, but in contrast with our study 51.1% of the circumcisions had been performed at medical centers [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In a study by Pashaei et al., in Ravansar, 96.4% of circumcised girls reported that they had been circumcised by local women and at home [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Gebremariam et al., in their study reported that about three-quarters of FGC cases was performed by a traditional local circumciser and 1.6 percentage by a health professional [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It seems that people's respect for traditional circumcisers can help the continuation of female circumcision. However, the involvement of medical specialists in female circumcision can help prevent the spread of infectious diseases by preventing the use of non-sterile devices and performing unnecessary FGC procedures [by someone unaware of women's anatomy].\u003c/p\u003e \u003cp\u003eIn the present study, girls with elementary education had been circumcised nearly 7 times more than those with university education. The lack of formal education had been significantly associated with an increased risk of FGC in several studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The Egyptian Demographic Health Survey 2008 (EDHS) found that the likelihood of circumcision decreased with an increased level of education and was higher among women belonging to the lower social classes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Other studies have shown that education and self-empowerment are associated with circumcision rejection [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The educational level of participants in the study of Gebremariam et al. was an important independent predictor of circumcision [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and a study in Ethiopia found that uncircumcised women and those who had been studied in high school or higher did not want to continue circumcision compared to those who could not read and write [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In general, education can be interpreted as a kind of women\u0026rsquo;s empowerment that can probably equalize the balance between them and men [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Since circumcision occurs before starting formal education, many believe that the mother's level of education is a more significant variable for assessing the relationship between FGC and education [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Researches show that in 85.1% of cases, the main decision-makers for girls\u0026rsquo; circumcision are mothers and grandmothers [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Mothers' education is an important predictor of FGC in young girls, as several studies have reported that with increasing education of a woman, the incidence of female circumcision decreases and opposition to it increases [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In the study of Ali et al., in Egypt girls with illiterate parents reported a much higher rate of exposure to circumcision [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Another study in Nigeria found that daughters of uneducated mothers are circumcised three and a half time more than the daughters of educated mothers [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Educated women are likely to make wiser decisions about their health and are more likely to seek appropriate and modern health care. In addition, they are likely to be aware of the dangerous effects of FGC and more likely to fight against it [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Another noteworthy point in the present study is that fathers' education and occupation, as well as family income, have been related to the circumciser and the place of circumcision so that girls whose fathers had elementary education and were retired, and whose family incomes were lower, had been mostly circumcised by a rural midwife and at home. It seems while low-educated mothers are more likely to circumcise their daughters, low-educated fathers as well as low economic and social status of the family are also related to how circumcision is performed. These results show the impact of the socio-economic level of families on the quantity and quality of female circumcision. The main limitation of this study is the limitation of the participants who were Kurdish girls living in a Kurdish region in Iran, which impedes the generalization of the study results to other ethnic groups and nationalities. Another limitation was the small sample size. A wide confidence interval is noted in some of the variables as a result of a small sample size. Conducting further studies with larger sample sizes and in another setting are needed to increase the accuracy and generalizability of the findings obtained from this study.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe present study showed that multivariate regression can provide a strong insight into the socio-economic disparities related to FGC. Designing effective interventions should specifically focus on modifiable variables. Our results highlighted the importance of modifiable variable such as girls\u0026rsquo; education as well as parents' education (primarily mothers' education) as predictors of female genital circumcision. It is assumed that educated women are primarily aware of their rights and will be more able to claim and defend these rights for themselves and their daughters. Secondarily, education may reduce women's dependence and give them greater economic stability. Empowering women by creating opportunities for their education can lead to the success of global efforts to restrict and eradicate female genital circumcision.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFemale Genital Circumcision\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization,\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely appreciated from financial support of Research Deputy of Hamadan University of Medical Sciences. In addition, all participants and personnel in health care centers who helped in the research process are appreciated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSSL and FS: study concept and design, and acquisition of data analysis and interpretation of data, and drafting of the manuscript. GR: analysis and interpretation of data and drafting of the manuscript. FS, SSL, FGM and GR: critical revision of the manuscript for important intellectual content; FS: study supervision. The manuscript has been read and approved by all the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Vice-chancellor for Research and Technology, Hamadan University of Medical Sciences of Iran [Grant number 9706063438].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed for this study are available by the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and\u003cbr\u003e\u0026nbsp;was approved by the ethics committee of the Research Council of Hamadan University of Medical Sciences (IR.UMSHA.REC.1397.379). Written consent was obtained from the participants, and they were assured of the confidentiality of their information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShafaati Laleh S, Maleki A, Samiei V, Roshanaei G, Soltani F. The comparison of sexual function in women with or without experience of female genital circumcision: A case-control study in a Kurdish region of Iran. 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BMC women's health. 2014;14:11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGebremariam K, Assefa D, Weldegebreal F. Prevalence and associated factors of female genital cutting among young adult females in Jigjiga district, eastern Ethiopia: a cross-sectional mixed study. Int J Womens Health. 2016; 8:357\u0026ndash;365.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahrami M, Ghaderi E, Farazi E, Bahramy A. The prevalence of female genital mutilation and related factors among women in Kamyaran, Iran. Chronic Diseases Journal. 2018; 6 (3):113\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Eliminating Female Genital Mutilation. Geneva: World Health Organization; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchultz JH, Lien IL. Meaning-making of female genital cutting: children's perception and acquired knowledge of the ritual. Int J Womens Health. 2013; 15 (5):165\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKandala NB, Nwakeze N, Kandala SN. Spatial distribution of female genital mutilation in Nigeria. Am J Trop Med Hyg. 2009; 81(5):784\u0026ndash;792.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGetnet M, Deressa W. Prevalence and associated factors of female genital mutilation among Somali refugees in eastern Ethiopia, 2009. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.biomedcentral.com/1471-2458/9/264/\u003c/span\u003e\u003cspan address=\"http://www.biomedcentral.com/1471-2458/9/264/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli S, de Viggiani N, Abzhaparova A, Salmon D, Gray S. Exploring young people's interpretations of female genital mutilation in the UK using a community-based participatory research approach. BMC Public Health. 2020;20(1):1132.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGee A, Kraus E, Bilyeu A. Female Genital Cutting: Considerations for the Western Physician. Mo Med. 2019; 116(1):32\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGholami A, Moghadami N. Possible Crimes in Female Circumcision and the Need for its Criminalization. Medical Law Journal. 2018; 12 (45):59\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaigwa S, Doos L, Bradbury-Jones C, Taylor J. Effectiveness of health education as an intervention designed to prevent female genital mutilation/cutting (FGM/C): a systematic review. Reprod Health. 2018;15(1):62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl-Zanaty F, Way AA. Egypt demographic and health survey 2008. Calverton, Maryland, USA: Ministry of Health and Population [Arab Republic of Egypt], National Population Council [Arab Republic of Egypt], and ORC Macro; 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbathun AD, Gele AA, Sundby J. Attitude towards the Practice of Female Genital Cutting among School Boys and Girls in Somali and Harari Regions, Eastern Ethiopia. Obstet Gynecol Int. 2017;2017:1567368.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams-Breault BD. Eradicating Female Genital Mutilation/Cutting: Human Rights-Based Approaches of Legislation, Education, and Community Empowerment. Health Hum Rights. 2018;20(2):223\u0026ndash;233.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmeyaw EK, Yaya S, Seidu AA, Ahinkorah BO, Baatiema L, Njue C. Do educated women in Sierra Leone support discontinuation of female genital mutilation/cutting? Evidence from the 2013 Demographic and Health Survey. Reprod Health. 2020; 17(1):174.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBogale D, Markos D, Kaso M. Intention toward the continuation of female genital mutilation in Bale Zone, Ethiopia. Int J Womens Health. 2015; 7:85\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaheiraei A, Soltani F, Ebadi A, Rahimi Foroushani A, Cheraghi, MA. Risk and protective profile of tobacco and alcohol use among Iranian adolescents: a population- based study. Int J Adolesc Med Health. 2017; 29 (3): 20150089.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlradie-Mohamed A, Kabir R, Arafat SMY. Decision-Making Process in Female Genital Mutilation: A Systematic Review. Int J Environ Res Public Health. 2020; 17(10):3362.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli HAAEW, Arafa AE, El Fattah Abd Allah Shehata NA, Fahim AS. Prevalence of Female Circumcision among Young Women in Beni-Suef, Egypt: A Cross-Sectional Study. J Pediatr Adolesc Gynecol. 2018; 31(6):571\u0026ndash;574.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGajaa M, Wakgari N, Kebede Y, Derseh L. Prevalence and associated factors of circumcision among daughters of reproductive aged women in the Hababo Guduru District, Western Ethiopia: a cross-sectional study. BMC Womens Health. 2016; 16:42.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Female genital circumcision, Health Status Disparities, Socioeconomic Factors","lastPublishedDoi":"10.21203/rs.3.rs-1650856/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1650856/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFemale genital circumcision is still one of the challenges in reproductive health. This study was conducted to investigate the socio-economic disparities in female genital circumcision in a Kurdish region of Iran.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a case-control study to assess the socio-economic factors associated with female genital circumcision. Using the available sampling method, 130 cases of circumcised girls and 130 controls without history of circumcision were enrolled. The demographic and circumcision information questionnaires were completed by self-report method. Data were analyzed using descriptive statistics, chi-square statistical methods as well as univariate and multivariate logistic regression models with a backward method at 95% confidence level.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe chances of genital circumcision in girls under the age of 20 and then in the age group of 20 to 30 years were 5.77 and 8.55 times higher than those over 30 years, respectively. This chance in girls with elementary education was 6.6 times higher than those with a college education. The chances of girls being circumcised with mothers with elementary education were 5.75 times higher than girls with university-educated mothers. Also, the family history of circumcision increased the chance of female genital circumcision by 9.90 times.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe present study highlighted the importance of modifiable variable such as girls\u0026rsquo; education as well as parents' education as predictors of female genital circumcision. Empowering women by creating opportunities for their education can lead to the success of global efforts to reduce and eradicate this health problem.\u003c/p\u003e","manuscriptTitle":"Socio-economic disparities in female genital circumcision: finding from a case- control study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-05-23 13:08:05","doi":"10.21203/rs.3.rs-1650856/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-07-18T10:32:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-07-09T13:40:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"a66c8efd-b2ea-4c5b-943f-15ab89452630","date":"2022-06-30T15:10:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6080da20-94f0-4f9a-b7ef-9a9991411491","date":"2022-06-07T05:23:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-05-25T10:16:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-05-21T07:10:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-05-21T06:27:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-05-21T06:21:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2022-05-12T20:08:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dfce4ddb-d044-4d19-940a-3f58a81abc81","owner":[],"postedDate":"May 23rd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-09-27T07:44:30+00:00","versionOfRecord":[],"versionCreatedAt":"2022-05-23 13:08:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1650856","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1650856","identity":"rs-1650856","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}