A qualitative study exploring midwives/nurses' personal and cultural beliefs in the midwifery care of women with Female Genital Mutilation/Cutting (FGMC) in Nigeria.

A qualitative study exploring midwives/nurses' personal and cultural beliefs in the midwifery care of women with Female Genital Mutilation/Cutting (FGMC) in Nigeria. | 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 A qualitative study exploring midwives/nurses' personal and cultural beliefs in the midwifery care of women with Female Genital Mutilation/Cutting (FGMC) in Nigeria. Rukaiyya Muhammad, Kim Watts, Elsa Montgomery This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5320134/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Female Genital Mutilation/Cutting (FGMC) is a global issue with implications for maternal mortality/morbidity in Nigeria. Midwives/nurses are crucial in the provision of midwifery care for women with FGMC. Where the midwives/nurses have undergone FGMC as part of their cultural identity, this study seeks to explore the midwives/nurses' personal and cultural beliefs in the midwifery care of women with FGMC. Methods A qualitative descriptive study was conducted across the three tiers of healthcare facilities in Osun State Nigeria where twenty-four interviews were held with midwives/nurses. Data was collected by conducting semi-structured telephone interviews which were analysed using thematic analysis. Results To our knowledge, this is the first study to explore the experiences of midwives/nurses across the three tiers of healthcare provision with three themes derived from the interviews: Personal FGMC experience, culture vs medical knowledge and cultural Practice of FGMC: healthcare facility vs community. Conclusion Difficult FGMC experiences were used as drivers by the midwives/nurses in the motivation for the abandonment of FGMC. Although there was a strong aversion to the procedure, there is a continued need for awareness across healthcare facilities, educational institutions and local communities. Female Genital Mutilation/Cutting FGMC Midwives/nurses midwifery care culture Background Globally, over 230 million females have been subjected to (FGMC), a practice that encompasses various non-medical procedures. These procedures involve either partially or completely removing the external female genitalia or inflicting other injuries to the female genital organs thereby raising significant concerns about health, human rights, and gender equality [ 1 ]. FGMC results in permanent alterations and lifelong disfigurement of the female anatomy with Africa accounting for the largest proportion of these cases with over 144 million girls and women affected [ 1 ]. In their survey, [ 2 ] reported that Nigeria had the largest number of FGMC survivors globally, representing approximately one-quarter of women and girls affected by the different types of FGMC. The four major types of FGMC, according to WHO [ 3 , p. 24], include: Type1, or clitoridectomy , is the partial or total removal of the clitoris (a small, sensitive, and erectile part of the female genitalia), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris). Type 2, or excision , is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva). Type 3, or Infibulation, is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy). Type 4 (unclassified): includes all other harmful procedures to the female genitalia for non-medical purposes, e.g., pricking, piercing, incising, scraping, and cauterising the genital area where corrosive substances (and herbs) are introduced in the vagina. The type of FGMC varies by ethnic and sociocultural practices throughout the Nigeria with type II and IV being more widespread affecting over 20 million girls and women between the ages of 15–49 [4; 5]. In 2019, Osun State in South-west Nigeria reportedly had the highest overall FGMC prevalence by state at 76.6% with 85.2% having undergone type II [ 6 ]. FGMC has significant consequences for midwifery outcomes including maternal and infant mortality and morbidity [ 7 , 8 ]. One in four maternal deaths is attributable to FGMC while morbidity increases with the type [ 8 , 9 ] and aggravated by the ‘three delays’: delay in deciding to seek care, delay in reaching care in time, and delay in receiving adequate midwifery treatment [ 10 ]. Midwives/nurses constitute the first group of healthcare professionals to provide midwifery care to women, and in Osun State, render midwifery assistance to over 63.5 per cent of women with childbirth conducted in over 60.5 per cent of public healthcare facilities [ 11 ]. Authors have documented how midwives/nurses, embody the practices and culture of their local communities conducting different types of FGMC on women at different time points in their lives [ 12 , 13 , 14 ]. Therefore, this study aims to explore the midwives/nurses’ personal and cultural beliefs of FGMC and whether it has an impact on midwifery care. Methods Study design A qualitative descriptive design was sought to optimise the potential of capturing the midwives/nurses’ personal and cultural beliefs about FGMC in the midwifery care of women with FGMC in Osun state, and forms part of a larger mixed-method study. Qualitative descriptive research strives to offer straightforward narratives of real-world experiences. As little is known about this area, this design excels at capturing intricate details of previously unexplored phenomena especially as it relates to the midwives/nurses who first attend to the midwifery needs of women who have undergone FGMC. This design enhances the likelihood that researchers’ analyses accurately reflect participants' experiences and provides greater transparency in the researchers' interpretations. Following a pilot study to determine the best format to collect the interview data i.e., telephone, and whether the initial duration of 40–60 minutes was feasible; the feedback gathered was that the telephone was suitable for collecting their experiences but that the time to interview be shortened to half an hour given interviews were not paid with no obligation to their current place of work. The telephone interviews were conducted from November to December 2020 and were critical to data collection during the COVID-19 restriction on travel. Sensitive data and privacy Reflecting that FGMC is a sensitive topic, the researcher was conscious of allowing the participants to direct the telephone interviews as they wished and to provide as much or as little detail as they were willing to prevent the potential risks of painful flashbacks or recall of difficult experiences. Again, they were not pressured to provide any more explanation than they were willing to share respecting their personal ‘space’ ensuring research sensitivity and flexibility. Hence research questions were loose, short-structured and open-ended. Sensitive questions can be viewed as intrusive, especially where there is a threat to disclosure, i.e., concerns where there was a consequence of giving a truthful answer. In the case of FGMC, where midwives/nurses have been reported to conduct the practice, the role of privacy cannot be overemphasised. No disclosures were made during the telephone interviews (where participants were well within their ethical rights for the research), the researcher, under the code of professional conduct of the Nursing and Midwifery Council of Nigeria (N&MCN), noted the justification for breaching clients’ confidentiality during a disclosure. This is binding only where the disclosure follows a court ruling or to protect the consumer and public from danger, it excludes the reporting of crimes other than in cases of immediate danger [ 15 ]. While the foregoing presented another strong rationale for discussing FGMC over the telephone; it was also to help diffuse any possible awkward feelings and share their experiences easily with privacy, anonymity and confidentiality (on their own terms) [ 16 ]. Still, the midwives/nurses were reassured that demographic data would not be collected and where any information has been divulged naming a specific healthcare facility, it would be anonymised in the final report. Participant selection and setting All participants were registered midwives/nurses currently providing midwifery care with added administrative or managerial roles in any public healthcare facility in Osun state. Osun is a semi-urban state divided into thirty Local Government Areas (LGAs) where nineteen of the LGAs are mainly rural settlements while the other eleven are urban, including Osogbo, the state capital [ 17 ]. Between the rural and urban settings, there are 1094 healthcare facilities; 3 tertiary, 60 secondary, and 678 primary healthcare facilities, most of which provide midwifery care [ 18 ]. Public healthcare facilities in Osun state (like any other state in Nigeria) are formally organised based on the three levels of government- tertiary, secondary and primary care [ 19 , 20 ]. The Nigerian federal government is responsible for the tertiary level of care, which oversees the formulation of national maternal health policies and guidelines; standardisation of maternal care delivery, training of health care professionals; provision of health-related technical assistance to states; monitoring state-level implementation of national health policies [ 19 ]. In Osun State, the three tertiary hospitals are located in Ile-Ife, Ilesa and Osogbo- all urban areas providing specialised services whilst supporting the state government’s secondary (state/general) hospitals [ 21 ]. The state government, under the hospital management board, trains health personnel and provides technical assistance in health matters to local government health programs and facilities while maintaining responsibility for operationalising national maternal health policies and enforcing guidelines for care in local governments [ 19 ]. On the other hand, the state government and the National Primary Health Care Development Agency (NPHCDA) support primary health care (PHC) facilities. Both institutions are responsible for developing, operating, and providing public primary health care services and overseeing preventive maternal health activities, including community health education, hygiene, and sanitation [ 19 , 20 ]. Although, midwives/nurses were chosen based on their submission of interest to an anonymous form from a preceding research study, twenty-four midwives/nurses were purposefully selected to ensure a representative sample of the midwives/nurses providing care for women with FGMC across the public healthcare facilities. This way, only relevant information about midwifery care for women with FGMC across the three levels of healthcare is collected maximising understanding of the research aim [ 22 ]. Using the contact details provided in the anonymous form, a semi-structured telephone interview was scheduled at the midwives/nurses' convenient time. Data collection Data collected from the telephone semi-structured interviews lasting up to 30 minutes were transcribed, interpreted and analysed using thematic analysis [ 23 ]. Thematic analysis involves a reflexive approach, moving through the stages of data familiarization, coding, developing themes, revising, naming, and final writing. The process is iterative, allowing for progression as well as revisiting earlier steps to refine the analysis. Additionally, this approach was utilised as it aids in the examination of commonalities, differences and relationships across the data. Ethics The study was approved by the research ethics committee at Kings College London HR-19/20-14734 and the different entities for the primary, secondary and two tertiary healthcare facilities in Osun state. Thus, the Osun State National Primary Healthcare Development Board provided approval for the PHCs OSPHCDB/042/210; Osun State Ministry of Health for the state/secondary hospitals OSHREC/PRS/569T/169 and ethics committees for Obafemi Awolowo University Teaching Hospital Complex NHREC/27/02/2009a and Ladoke Akintola University of Technology Teaching Hospital (LAUTECH) LTH/EC/2020/09/472 for the tertiary institutions. The telephone interviews adhered to the research aim including the researcher’s ethical and moral obligation to the anonymity of all participating midwives/nurses. While confidentiality and anonymity were reemphasised, the participants were reminded that participation was voluntary. Informed consent was again obtained from participants during telephone interviews and asked if they consented to be recorded using a Dictaphone. Recordings were transcribed and transcripts were password-protected. Although no incentives were given, a meal voucher equivalent to £5 was given to all participants. Reflexivity RM is a registered midwife/nurse in the United Kingdom and Nigeria and conducted all interviews and maintained an audit trail and journal to assess the interview process and consider whether her own preconceptions or questioning style may have influenced participants' responses. These reflections were then discussed with the other authors to ensure the research process remained rigorous and unbiased. Results There were 13 double-qualified with registered midwifery and registered nursing qualifications (i.e., RM/RN); 6 had an additional BSc, and 5 had a master’s degree across the PHC, state/secondary and tertiary healthcare facilities presented in Table 1 . The midwives’/nurses’ clinical experience ranged from 5 to 30 years. Table 1 Distribution of the Midwives/nurses' Qualification/degrees by healthcare facility. Qualification/Degrees PHC State Tertiary RM/RN 3 10 0 RM/RN + BSc 3 2 1 RM/RN + MSc 0 1 4 Analysis of data identified three themes: Personal FGMC experience, culture vs medical knowledge and cultural Practice of FGMC: healthcare facility vs community. Personal FGMC experience FGMC has been a recognised cultural practice, particularly amongst the Yorubas, and most midwives/nurses in Osun State come from various tribes and family linkages that have endorsed the practice for their immediate family members. More than three-quarters of the staff had personally undergone FGMC at an early age. FGMC was described as a cultural practice that inflicted pain three times in the woman’s life: during the procedure, at childbirth, and first sexual intercourse. Pain resulting from FGMC at sexual debut was common amongst all the midwives/nurses who had undergone the procedure. This was the case for all except one midwife/nurse, who revealed that she did not experience pain during sexual intercourse. “Many people complain that they feel pain during sexual intercourse with their spouse…but I did not feel any pain like that [during sexual intercourse].”SH10 “Because they (individuals upholding FGMC) want to practice the culture does not mean that the girl must not enjoy sex; that is number one. Then number two, by the time you want to deliver the baby, the problem is still there. And that pain even started when they did the thing [FGMC] for her.” SH8 Some midwives/nurses were also aware of other colleagues not involved in this research who had, like themselves, undergone the procedure and had experienced problems in childbirth. “… I and so many others [staff I know] that had FGMC did not find it easy giving birth.” SH14 Personal experiences vary and only one midwife/nurse who had her labia excised revealed that she did not experience any difficulty during labour. “ I did not experience any difficulty in labour, even though I had my own [labia] cut off.” PHC2 While there may be limited intrapartum consequences of FGMC for a few women (with a mild type of the procedure), for many others, the procedure carries significant maternal mortality and morbidity driving motivation for its abandonment and culture change. This was described as follows: “It was a great challenge to me because most of the complications of FGMC, I faced it. I experienced many things: prolonged labour, obstructed labour, perineal tear, episiotomy and during the birth of my last baby, I had cervical laceration due to FGMC. I am a victim of FGMC… That is why I am campaigning for the elimination of FGMC in our society.” SH18 Another midwife/nurse narrated her experience: “My first baby is now 7 years old, and when I was giving birth, I had severe bleeding that I almost lost my life. I suffered; I was ‘paper white’ and had 3 units of blood. The hospital expenses were much but thank God I survived…you can imagine how many other women have experienced similar problems and because they live in the remote village will not be able to access good care…[ silence ] So being a victim of this thing (FGMC) has really made me think about how the culture has affected many other women and me. It has to change.” THC21 Given the state of the PHCs which ideally provide basic care to women, in complex situations where emergency obstetric care provided in the tertiary healthcare facilities was required, there was a potential for increased risks, with maternal and infant morbidity and mortality in remote parts of the state. Their personal experiences allowed the midwife/nurse to reflect on the need to change the culture of FGMC, empathy for other women who had undergone the procedure and more importantly, the resolve to become change agents against the practice. Culture vs Medical Knowledge Generally, the midwives/nurses explained that their personal and cultural beliefs did not influence their midwifery practice. Given their personal experiences with FGMC, many of the staff were not in support of the culture of FGMC and said they would not allow it to interfere with the way care was provided. The midwives/nurses affirmed the ethics of the midwifery profession, rationalising their position against FGMC. “Because we have been trained and licensed, the care we provide cannot be based on culture or ethnicity. If we do that then it is likely to be considered malpractice or going against the ethics of the profession….It cannot be based on culture or ethnicity.” THC23 Although the submission by one of the midwives/nurses suggested that FGMC was no longer conducted in the state/secondary healthcare facilities, birthing mothers still requested the procedure for their female children to which they were discouraged. “We do not do that thing [FGMC] here again. Even some of the nursing mothers, after birth, will still come back and say they want to circumcise the female child, but we used to erase the idea from their minds.” SH17 Overall, the understanding gathered from the staff was that no midwife or doctor consents to or aids the patients with FGMC although one midwife/nurse in the state/secondary remained neutral to the practice: “ I will not preach against it and I will not encourage it [FGMC].” SH10 Whilst only one midwife/nurse was indifferent to the cultural practice of FGMC; all the other staff seemed to have taken a stand against the procedure as a result of their midwifery/medical knowledge and professional ethics of care. Cultural Practice of FGMC: Healthcare Facility vs Community The consensus amongst the midwives/nurses was that the practice was declining due to awareness and community outreach against FGMC; however, there are still people (including healthcare workers) in the healthcare facilities and community who are sympathetic to the culture and endorse its continuation. “There are still people that are sympathetic to the culture. Some people are still practising it…the husband of one of our colleagues insisted that their daughter must undergo FGMC. The woman cried. There was nothing she could do even though she knew the disadvantages. The husband insisted that the child must be circumcised. Some people are still sympathetic to the culture and still practising it although the percentage of people practising it is low.” SH8 Pockets of (illiterate) women and their families in the community have justified FGMC based on the terminology used to describe it. Rather than female mutilation, ‘female circumcision’ has been equated with male circumcision- and the preferred phrase amongst many. “They [families] like to call it circumcision for female and male. They call it circumcision, but we [staff] know it is the same as female genital mutilation. Only the elites, the educated people, will say they do not want their female children to be circumcised; it is only the male ones that would be circumcised.” THC20 The staff believed that the procedure was mostly available to women/families in the community with the Iya Agbebi (i.e., TBAs) and Ololas (i.e., local circumcisers). The Olola is a male or female community member experienced in female and male circumcision. Circumcision is said to be a ‘ trade of prestige’ in the community, and the circumcisers pride themselves on the skill handed over and protected through generations in that particular family lineage. “Olola [circumcisers] they are proud to be called that and proud to continue it as a family business….” THC23 “They will go to Iya Agbebi [TBAs]; they do not come to the hospital for the thing [FGMC].” PHC3 Some staff speculated that the procedure was only provided in private hospitals and some PHCs. The midwives/nurses suggested that healthcare professionals in the PHCs may concede to the practice since it is more common in rural areas (where most of the PHCs are located) and opposing it may be met with great difficulty. “Some healthcare staff in the hospitals still do it [FGMC], especially in private hospitals.”SH10 “…people in the community are still practising this awful practice. They are still engaging in it. Some midwives working in these Primary healthcare facilities find themselves getting involved with it [since they cannot resist].” THC24 The midwives/nurses, TBAs and Ololas in many communities and rural areas, respectively, are recognised members of the healthcare team that women and families consult for childbirth services and midwifery care, including FGMC. Aside from the notion that FGMC provided by healthcare professionals is ‘safe’, it is a source of income for these professionals in private clinics and rural PHCs, who, having emerged from the communities themselves, continue to propagate the culture. The continuation of FGMC among local communities is grounded in their cultural beliefs; for example, it is believed that an uncircumcised child will become promiscuous later in life. It is also believed that the face of the newborn must not come in contact with the vulva during childbirth, as this will lead to its death; thus, females have to be circumcised in preparation for giving birth as adults. “They believe that during labour if the head of the foetus touches that place [the vulva], the child will die.” THC22 “People believe that a child that is not cut will be promiscuous or will not be able to give birth in future.” PHC2 Having had vaginal deliveries, many staff denounced these superstitions stating how newborns coming in contact with the vulva during childbirth does not result in promiscuity. The midwives/nurses agreed that these were false beliefs which are circulated amongst practising communities to encourage the continuation of the practice. There was a notion that women generally preferred to labour and birth with TBAs who were attached to PHCs, churches, missionary houses, or personal houses where FGMC consultations were provided to clients. TBA services have strong patronage; however, the midwives/nurses have discredited TBA services and criticised them for perpetrating FGMC and poor or delayed recognition of complications especially with women with FGMC. “So most of them [women] prefer the TBAs…they end up with series of complications like postpartum haemorrhage, infections, obstructed labour, cervical tear….” SH8 “With my years of working in maternity, I have seen that most women with female genital mutilation will go to TBAs and end up coming to the hospital with complications. When the complications set in and they [TBAs] cannot deal with it…like cases of severe bleeding, they will send them [women] late to the hospital.” PHC5 Finally, there was an observed reference to FGMC as a ‘ thing ’ in the midwives/nurses' narratives of personal experiences which carries a derogatory meaning as a result of its impact on themselves and the wider community. It would seem that these experiences have an influence on the perceived shift and support of FGMC discontinuation amongst the study participants. Discussion FGMC is a deeply rooted cultural practice with ethnicity being one of the most important determining factors. Midwives/nurses are a product of the society where they practice and undoubtedly embody the practices and culture of their people. This study utilised a qualitative approach to explore the midwives/nurses’ personal and cultural beliefs of FGMC in the midwifery care of women with FGMC. There were difficult narrations regarding their personal experiences of FGMC but significantly how this was shaping their outlook on the FGMC culture and its impact on women and families. Midwives/nurses appear to become strongly averse to FGMC due to their own negative childbirth experience and midwifery education. Although this aversion was amongst the midwives/nurses across healthcare facilities, they reported that FGMC was still practised in small pockets of the community (and women’s homes) with healthcare professionals or traditional providers (including TBAs). The same was confirmed in Ethiopia [ 24 ], Kenya [ 25 , 26 ], Nigeria [ 27 ], Senegal [ 28 ], and Sudan [ 29 ] where women/girls were discreetly being cut and that the practice was purportedly going underground. On the other hand, an observed shift in the severe to the less severe types of FGMC was observed amongst midwives in Somaliland in the hopes that it reduced the physical and psychological suffering associated with the more severe types of the procedure [ 14 ]. The beliefs that fostered FGMC were mostly enshrined in superstition. Studies have illustrated how midwives/nurses' affiliation with their communities enforced the practice [ 12 , 14 , 25 , 30 ], sympathise with FGMC [ 31 ], and medicalise the practice [ 13 , 25 , 30 , 32 , 33 , 34 , 35 ]. FGMC was being cloaked under the preferred terminological guise of circumcision, which girls, women, and boys underwent. This was also the case in [ 27 ], where female circumcision was compared to male circumcision and regarded as a ‘minor procedure’ that took less than a week to heal. ‘Female circumcision’ is not a new phrase but the preferred term by practising groups, intended to draw a parallel with male circumcision and create confusion between the two distinct practices [ 3 , 36 ]. This research acknowledges that the definition of the practice has proved problematic for many decades, where families resented female genital ‘mutilation’ as they believed that they were not mutilating their daughters [ 37 ]. Hence, researchers conducting research in core communities where FGMC is practised have been observed to use the local term by which the practice is known, e.g., sunna, pharonic or ‘cutting’ representing plain language [ 12 , 14 , 38 ]. This research adds to this understanding by retaining the midwives/nurses' description of the local circumcisers. Echoing these phrases and words within research and in communication with practising groups has been encouraged by international organisations and peacekeepers to avoid the volatile risk of demonising cultures and traditions, which may breed animosity and difficult dialogue [ 3 , 39 ]. Therefore, this finding is useful during multi-national/cultural dialogue in the ongoing abandonment campaign. Silence and metaphors were not overlooked but highlighted within the context of the participants’ narrations and experiences with FGMC. Researchers have explored their experiences while reporting that traumatic experiences and building a rapport where no signal is overlooked, continuing to ask, albeit gently and sensitively, questions that help expand our understanding of difficult situations are inherently difficult [ 40 ]. Still, efforts to preserve the sensitivity in the dialogue with FGMC are as important as the inherent yet uncertain dangers that abound with its covertness. As dialogue on the zero tolerance of FGMC in communities continues; the gatekeepers of healthcare in these communities remain key to unlocking cultural dimensions of reasoning that promote traditional and cultural practices beneficial to the health of women with FGMC. Prior to this research, an inquiry into midwives/nurse’s sociocultural influence of FGMC on midwifery care was slightly addressed in high-income countries [ 31 ] where this study attempts to fill in that gap in Nigeria. A lot still needs to be done where the current study agrees with the recommendation posed by [ 41 ], stating the need for more research on how sociocultural practices influence healthcare practitioner behaviour in (southwest) Nigeria. The observed aversion and subsequent reduction in the conduct of FGMC amongst the midwives/nurses is still fragile. It should therefore be nurtured through culturally appropriate teaching, awareness creation and stories from survivors throughout the healthcare facilities, educational institutions and local communities. Limitations This study has captured the experiences of midwives/nurses in public healthcare facilities and not the private sector. While it was not the intention of the study to cover the latter and midwives/nurses who solely worked in private institutions were automatically excluded; it is not uncommon that midwives/nurses in Nigeria combined a job in the public healthcare facilities with extra hours in the private sector to maximise income. There is a potential that this study reflects the views of midwives/nurses in private institutions, the results are truer for public healthcare facilities. This study has not captured the experiences of the women who underwent FGMC and their experiences with midwifery care within (and outside) the healthcare facilities. We do not have the perspectives of other professionals providing midwifery care such as the doctors in public healthcare facilities and TBAs in the communities. Conclusions This study reported three themes- midwives/nurses' personal FGMC experience, culture vs medical knowledge and cultural practice of FGMC: healthcare facility vs community- that influence their midwifery care of women with FGMC. A significant number of the midwives/nurses in our study, as part of their cultural identity, have undergone FGMC resulting in complications already reported in the data on maternal morbidity associated with FGMC. Their personal experiences with labour and childbirth after undergoing FGMC, in addition to their midwifery education, have resulted in an aversion to the practice and an active stand against the procedure. This study adds evidence of the benefit of sharing similar experiences in sensitive research, continuous awareness and educating midwives/nurses on the impact of FGMC steering the move to abandonment of the practice. Universal coverage with critical information regarding the implications of the procedure should target staff in (and outside) the three levels of healthcare, educational institutions and communities if this position is to be sustained. Declarations Acknowledgements We would like to thank all the midwives/nurses for their time and valuable contribution to the study. Funding This study is part of a larger research study funded by the Petroleum Technology Development Fund (PTDF) Nigeria. The views expressed are those of the authors and should not be attributed to PTDF. Author Affiliation College of Health, Psychology and Social Care, University of Derby - Rukaiyya Muhammad. Faculty of Medicine and Health sciences, University of Nottingham - Kim Watts. Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London - Elsa Montgomery. Contributions RM conducted and wrote the study. K.W and E.M read, edited and supervised the study. Corresponding author Correspondence to Rukaiyya Muhammad. Ethics declarations The authors declared no potential conflict of interest with respect to the research, authorship and publication of this article. Ethics declaration and consent to participate Ethical approval for the study was obtained from the Psychiatry Nursing and Midwifery PNM research ethics committee of Kings College London HR-19/20-14734 and the Osun State primary health care development board OSPHCDB/042/210, Osun State health research ethics committee OSHREC/PRS/569T/169, and the ethics and research committees at Obafemi Awolowo University Teaching hospitals complex NHREC/27/02/2009a and Ladoke Akintola University of Technology Teaching Hospital (LAUTECH) LTH/EC/2020/09/472. All participants gave their written consent. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. 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Midwives’ Experiences in Providing Care and Counselling to Women with Female Genital Mutilation (FGM) Related Problems. Obstetrics and Gynecology International , 2013 , 1–9. https://doi.org/10.1155/2013/785148 Nursing & Midwifery Council of Nigeria. (2019). Code of Conduct. https://bytesclients.com/nursing/code-of-conduct/ Accessed 10 October 2024. Drabble L, Trocki KF, Salcedo B, Walker PC, Korcha RA. Conducting qualitative interviews by telephone: Lessons learned from a study of alcohol use among sexual minority and heterosexual women. Qualitative Social Work. 2016;15(1). https://doi.org/10.1177/1473325015585613 . Osun State Hospitals Management Board. (2014). Monthly Report of Patients Torn-over Deliveries and Deaths in all the Health Facilities of Osun State Hospitals for the month of March, 2014, Osogbo . NPHCDA. (2015). Primary health care under one roof implementation scorecard iii report . November , 130. https://www.yumpu.com/en/document/read/55490886/primary-health-care-under-one-roof-implementation-scorecard-iii-report#google Accessed: 16 October 2024. Izugbara CO, Wekesah FM, Adedini SA. (2016). Maternal Health in Nigeria: A Situation Update . https://doi.org/10.13140/RG.2.1.1291.9924 Federal Ministry of Health. (2010). National Strategic Health Development Plan (NSHDP) 2010–2015. Federal Ministry of Health , November 2010 , 136. Ajala OA, Sanni L, Adeyinka SA. Accessibility to health care facilities: A panacea for sustainable rural development in Osun State Southwestern, Nigeria. J Hum Ecol. 2005;18(2):121–8. Onwuegbuzie A, Collins KM. A typology of mixed methods sampling designs in social science research. Qualitative Rep. 2007;12(2):474–98. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2). https://doi.org/10.1191/1478088706qp063oa . Adinew YM, Mekete BT. I knew how it feels but couldn’t save my daughter; testimony of an Ethiopian mother on female genital mutilation/cutting. Reproductive health. 2017;14:1–5. Kimani S, Kabiru CW, Muteshi J, Guyo J. (2020). Female genital mutilation/cutting: Emerging factors sustaining medicalization related changes in selected Kenyan communities. PLoS ONE, 15(3), e0228410. Parsitau D. (2018). How outlawing female genital mutilation in Kenya has driven it underground and led to its medicalization . https://www.brookings.edu/articles/how-outlawing-female-genital-mutilation-in-kenya-has-driven-it-underground-and-led-to-its-medicalization/ Obiora, O. L., Maree, J. E., & Nkosi-Mafutha, N. G. (2021). A lot of them have scary tears during childbirth… experiences of healthcare workers who care for genitally mutilated females. PloS One , 16 (1), e0246130. Kandala NB, Komba PN. Geographic variation of female genital mutilation and legal enforcement in sub-saharan Africa: a case study of Senegal. Am J Trop Med Hyg. 2015;92(4):838. Ali AAA. Knowledge and attitudes of female genital mutilation among midwives in Eastern Sudan. Reproductive Health. 2012;9(1):2–5. https://doi.org/10.1186/1742-4755-9-23 . Ibrahim I, Oyeyemi A, Ekine A. Knowledge, attitude and practice of female genital mutilation among doctors and nurses in Bayelsa state, Niger-Delta of Nigeria. Int J Med Biomedical Res. 2013;2(1):40–7. https://doi.org/10.14194/ijmbr.218 . Relph S, Inamdar R, Singh H, Yoong W. Female genital mutilation/cutting: Knowledge, attitude and training of health professionals in inner city London. Eur J Obstet Gynecol Reproductive Biology. 2013;168(2):195–8. https://doi.org/10.1016/j.ejogrb.2013.01.004 . Adekanle A, Isawumi A, Adeyemi A. Health Workers’ Knowledge of and Experience with Female Genital Cutting in Southwestern, Nigeria. Sierra Leone J Biomedical Res. 2011;3(2). https://doi.org/10.4314/sljbr.v3i2.71808 . Reig-Alcaraz M, Siles-González J, Solano-Ruiz C. A mixed-method synthesis of knowledge, experiences and attitudes of health professionals to Female Genital Mutilation. J Adv Nurs. 2016;72(2):245–60. https://doi.org/10.1111/jan.12823 . Saleh WF, Torky HA, Youssef MA, Ragab WS, Ahmed MAS, Eldaly A. Effect of female genital cutting performed by health care professionals on labor complications in Egyptian women: A prospective cohort study. J Perinat Med. 2018;46(4):419–24. https://doi.org/10.1515/jpm-2016-0429 . Shell-Duncan B, Moore Z, Njue C. (2017). The medicalization of female genital mutilation/cutting: what do the data reveal? Evidence to End FGM/C: Research to Help Women Thrive. New York: Population Council. , February . https://doi.org/10.4324/9780429450464 Vissandjée B, Denetto S, Migliardi P, Proctor J. Female genital cutting (FGC) and the ethics of care: community engagement and cultural sensitivity at the interface of migration experiences. BMC Int Health Hum Rights. 2014;14(1):13. https://doi.org/10.1186/1472-698X-14-13 . Williams-Breault BD. Eradicating Female Genital Mutilation/Cutting: Human Rights-Based Approaches of Legislation, Education, and Community Empowerment. Health Hum Rights. 2018;20(2):223–33. https://pubmed.ncbi.nlm.nih.gov/30568416 . Widmark C, Tishelman C, Ahlberg BM. (2002). Astudy of Swedishmidwives’ encounters with infibulatedAfrican women in Sweden . https://doi.org/10.1054/ymidw.0307 Dunn F. Is it possible to end female circumcision in Africa? Clin J Obstet Gynecol. 2018;1(1):7–13. Silverio SA, Sheen KS, Bramante A, Knighting K, Koops TU, Montgomery E, November L, Soulsby LK, Stevenson JH, Watkins M, Easter A. (2022). Sensitive, challenging, and difficult topics: Experiences and practical considerations for qualitative researchers. International Journal of Qualitative Methods , 21 , p.16094069221124739. Adeyinka A, Adedotun O, Asabi O. Knowledge and practice of female circumcision among women of reproductive ages in South West Nigeria. J Humanit Soc Sci. 2012;2(3):38–45. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Feb, 2026 Reviews received at journal 22 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviews received at journal 14 Dec, 2024 Reviewers agreed at journal 07 Dec, 2024 Reviewers agreed at journal 07 Dec, 2024 Reviewers invited by journal 28 Nov, 2024 Editor invited by journal 30 Oct, 2024 Editor assigned by journal 28 Oct, 2024 Submission checks completed at journal 28 Oct, 2024 First submitted to journal 23 Oct, 2024 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. 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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-5320134","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":373536403,"identity":"acce35b9-d50e-4829-bd35-b65b94d1880e","order_by":0,"name":"Rukaiyya Muhammad","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYJACZgiVfECCgeEAVOwADrWoWtISSNaSY0CcFvMG7jTpgppt0fztOR9vfNxzJ7GB/fADZp4zuLXIHODdJj3j2O3cGWfebrac8exZYgNPmgEzzw3cWiQYgFp42G7nNtzIBTIOHE5sYMhhYOb5QEjLv9u582/kPJP+A9LC/4YILbxtt3M33Mhhk2YAaZEA2YLPYcy8m615+27nbjzzzNiy58Az4zaJZwYH5+DxvgR778bbPN9u5847nvzwxo8Dd2T7+ZMfPnhzDLcWWKTAgWMbA8GIRAP2JKkeBaNgFIyCEQEA/XxZs3Lnla8AAAAASUVORK5CYII=","orcid":"","institution":"University of Derby","correspondingAuthor":true,"prefix":"","firstName":"Rukaiyya","middleName":"","lastName":"Muhammad","suffix":""},{"id":373536405,"identity":"c1f9c557-a89c-4b23-a5bd-90799ed4f618","order_by":1,"name":"Kim Watts","email":"","orcid":"","institution":"University of Nottingham","correspondingAuthor":false,"prefix":"","firstName":"Kim","middleName":"","lastName":"Watts","suffix":""},{"id":373536407,"identity":"73a316f6-ade5-4c50-a4b0-41b8cf64aa34","order_by":2,"name":"Elsa Montgomery","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Elsa","middleName":"","lastName":"Montgomery","suffix":""}],"badges":[],"createdAt":"2024-10-23 15:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5320134/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5320134/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":68454705,"identity":"77ea2238-e1d9-4e47-af4e-d7058607700c","added_by":"auto","created_at":"2024-11-07 12:28:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":448580,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5320134/v1/4eb8bd95-0bd6-402d-8d88-5fef19564c17.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A qualitative study exploring midwives/nurses' personal and cultural beliefs in the midwifery care of women with Female Genital Mutilation/Cutting (FGMC) in Nigeria.","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, over 230\u0026nbsp;million females have been subjected to (FGMC), a practice that encompasses various non-medical procedures. These procedures involve either partially or completely removing the external female genitalia or inflicting other injuries to the female genital organs thereby raising significant concerns about health, human rights, and gender equality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. FGMC results in permanent alterations and lifelong disfigurement of the female anatomy with Africa accounting for the largest proportion of these cases with over 144\u0026nbsp;million girls and women affected [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In their survey, [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] reported that Nigeria had the largest number of FGMC survivors globally, representing approximately one-quarter of women and girls affected by the different types of FGMC. The four major types of FGMC, according to WHO [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, p. 24], include:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eType1, or \u003cem\u003eclitoridectomy\u003c/em\u003e, is the partial or total removal of the clitoris (a small, sensitive, and erectile part of the female genitalia), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eType 2, or \u003cem\u003eexcision\u003c/em\u003e, is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eType 3, or Infibulation, is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eType 4 (unclassified): includes all other harmful procedures to the female genitalia for non-medical purposes, e.g., pricking, piercing, incising, scraping, and cauterising the genital area where corrosive substances (and herbs) are introduced in the vagina.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe type of FGMC varies by ethnic and sociocultural practices throughout the Nigeria with type II and IV being more widespread affecting over 20\u0026nbsp;million girls and women between the ages of 15\u0026ndash;49 [4; 5]. In 2019, Osun State in South-west Nigeria reportedly had the highest overall FGMC prevalence by state at 76.6% with 85.2% having undergone type II [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. FGMC has significant consequences for midwifery outcomes including maternal and infant mortality and morbidity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. One in four maternal deaths is attributable to FGMC while morbidity increases with the type [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and aggravated by the \u0026lsquo;three delays\u0026rsquo;: delay in deciding to seek care, delay in reaching care in time, and delay in receiving adequate midwifery treatment [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMidwives/nurses constitute the first group of healthcare professionals to provide midwifery care to women, and in Osun State, render midwifery assistance to over 63.5 per cent of women with childbirth conducted in over 60.5 per cent of public healthcare facilities [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Authors have documented how midwives/nurses, embody the practices and culture of their local communities conducting different types of FGMC on women at different time points in their lives [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Therefore, this study aims to explore the midwives/nurses\u0026rsquo; personal and cultural beliefs of FGMC and whether it has an impact on midwifery care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e A qualitative descriptive design was sought to optimise the potential of capturing the midwives/nurses\u0026rsquo; personal and cultural beliefs about FGMC in the midwifery care of women with FGMC in Osun state, and forms part of a larger mixed-method study. Qualitative descriptive research strives to offer straightforward narratives of real-world experiences. As little is known about this area, this design excels at capturing intricate details of previously unexplored phenomena especially as it relates to the midwives/nurses who first attend to the midwifery needs of women who have undergone FGMC. This design enhances the likelihood that researchers\u0026rsquo; analyses accurately reflect participants' experiences and provides greater transparency in the researchers' interpretations. Following a pilot study to determine the best format to collect the interview data i.e., telephone, and whether the initial duration of 40\u0026ndash;60 minutes was feasible; the feedback gathered was that the telephone was suitable for collecting their experiences but that the time to interview be shortened to half an hour given interviews were not paid with no obligation to their current place of work. The telephone interviews were conducted from November to December 2020 and were critical to data collection during the COVID-19 restriction on travel.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSensitive data and privacy\u003c/h3\u003e\n\u003cp\u003e Reflecting that FGMC is a sensitive topic, the researcher was conscious of allowing the participants to direct the telephone interviews as they wished and to provide as much or as little detail as they were willing to prevent the potential risks of painful flashbacks or recall of difficult experiences. Again, they were not pressured to provide any more explanation than they were willing to share respecting their personal \u0026lsquo;space\u0026rsquo; ensuring research sensitivity and flexibility. Hence research questions were loose, short-structured and open-ended.\u003c/p\u003e \u003cp\u003eSensitive questions can be viewed as intrusive, especially where there is a threat to disclosure, i.e., concerns where there was a consequence of giving a truthful answer. In the case of FGMC, where midwives/nurses have been reported to conduct the practice, the role of privacy cannot be overemphasised. No disclosures were made during the telephone interviews (where participants were well within their ethical rights for the research), the researcher, under the code of professional conduct of the Nursing and Midwifery Council of Nigeria (N\u0026amp;MCN), noted the justification for breaching clients\u0026rsquo; confidentiality during a disclosure. This is binding only where the disclosure follows a court ruling or to protect the consumer and public from danger, it excludes the reporting of crimes other than in cases of immediate danger [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the foregoing presented another strong rationale for discussing FGMC over the telephone; it was also to help diffuse any possible awkward feelings and share their experiences easily with privacy, anonymity and confidentiality (on their own terms) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Still, the midwives/nurses were reassured that demographic data would not be collected and where any information has been divulged naming a specific healthcare facility, it would be anonymised in the final report.\u003c/p\u003e\n\u003ch3\u003eParticipant selection and setting\u003c/h3\u003e\n\u003cp\u003eAll participants were registered midwives/nurses currently providing midwifery care with added administrative or managerial roles in any public healthcare facility in Osun state. Osun is a semi-urban state divided into thirty Local Government Areas (LGAs) where nineteen of the LGAs are mainly rural settlements while the other eleven are urban, including Osogbo, the state capital [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Between the rural and urban settings, there are 1094 healthcare facilities; 3 tertiary, 60 secondary, and 678 primary healthcare facilities, most of which provide midwifery care [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePublic healthcare facilities in Osun state (like any other state in Nigeria) are formally organised based on the three levels of government- tertiary, secondary and primary care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The Nigerian federal government is responsible for the tertiary level of care, which oversees the formulation of national maternal health policies and guidelines; standardisation of maternal care delivery, training of health care professionals; provision of health-related technical assistance to states; monitoring state-level implementation of national health policies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In Osun State, the three tertiary hospitals are located in Ile-Ife, Ilesa and Osogbo- all urban areas providing specialised services whilst supporting the state government\u0026rsquo;s secondary (state/general) hospitals [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The state government, under the hospital management board, trains health personnel and provides technical assistance in health matters to local government health programs and facilities while maintaining responsibility for operationalising national maternal health policies and enforcing guidelines for care in local governments [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. On the other hand, the state government and the National Primary Health Care Development Agency (NPHCDA) support primary health care (PHC) facilities. Both institutions are responsible for developing, operating, and providing public primary health care services and overseeing preventive maternal health activities, including community health education, hygiene, and sanitation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Although, midwives/nurses were chosen based on their submission of interest to an anonymous form from a preceding research study, twenty-four midwives/nurses were purposefully selected to ensure a representative sample of the midwives/nurses providing care for women with FGMC across the public healthcare facilities. This way, only relevant information about midwifery care for women with FGMC across the three levels of healthcare is collected maximising understanding of the research aim [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Using the contact details provided in the anonymous form, a semi-structured telephone interview was scheduled at the midwives/nurses' convenient time.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData collected from the telephone semi-structured interviews lasting up to 30 minutes were transcribed, interpreted and analysed using thematic analysis [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Thematic analysis involves a reflexive approach, moving through the stages of data familiarization, coding, developing themes, revising, naming, and final writing. The process is iterative, allowing for progression as well as revisiting earlier steps to refine the analysis. Additionally, this approach was utilised as it aids in the examination of commonalities, differences and relationships across the data.\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e The study was approved by the research ethics committee at Kings College London HR-19/20-14734 and the different entities for the primary, secondary and two tertiary healthcare facilities in Osun state. Thus, the Osun State National Primary Healthcare Development Board provided approval for the PHCs OSPHCDB/042/210; Osun State Ministry of Health for the state/secondary hospitals OSHREC/PRS/569T/169 and ethics committees for Obafemi Awolowo University Teaching Hospital Complex NHREC/27/02/2009a and Ladoke Akintola University of Technology Teaching Hospital (LAUTECH) LTH/EC/2020/09/472 for the tertiary institutions.\u003c/p\u003e \u003cp\u003e The telephone interviews adhered to the research aim including the researcher\u0026rsquo;s ethical and moral obligation to the anonymity of all participating midwives/nurses. While confidentiality and anonymity were reemphasised, the participants were reminded that participation was voluntary. Informed consent was again obtained from participants during telephone interviews and asked if they consented to be recorded using a Dictaphone. Recordings were transcribed and transcripts were password-protected. Although no incentives were given, a meal voucher equivalent to \u0026pound;5 was given to all participants.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReflexivity\u003c/h2\u003e \u003cp\u003eRM is a registered midwife/nurse in the United Kingdom and Nigeria and conducted all interviews and maintained an audit trail and journal to assess the interview process and consider whether her own preconceptions or questioning style may have influenced participants' responses. These reflections were then discussed with the other authors to ensure the research process remained rigorous and unbiased.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were 13 double-qualified with registered midwifery and registered nursing qualifications (i.e., RM/RN); 6 had an additional BSc, and 5 had a master\u0026rsquo;s degree across the PHC, state/secondary and tertiary healthcare facilities presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The midwives\u0026rsquo;/nurses\u0026rsquo; clinical experience ranged from 5 to 30 years.\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\u003eDistribution of the Midwives/nurses' Qualification/degrees by healthcare facility.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQualification/Degrees\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eState\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRM/RN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRM/RN\u0026thinsp;+\u0026thinsp;BSc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRM/RN\u0026thinsp;+\u0026thinsp;MSc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003cp\u003eAnalysis of data identified three themes: \u003cem\u003ePersonal FGMC experience, culture vs medical knowledge and cultural Practice of FGMC: healthcare facility vs community.\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePersonal FGMC experience\u003c/h2\u003e \u003cp\u003eFGMC has been a recognised cultural practice, particularly amongst the Yorubas, and most midwives/nurses in Osun State come from various tribes and family linkages that have endorsed the practice for their immediate family members. More than three-quarters of the staff had personally undergone FGMC at an early age. FGMC was described as a cultural practice that inflicted pain three times in the woman\u0026rsquo;s life: during the procedure, at childbirth, and first sexual intercourse. Pain resulting from FGMC at sexual debut was common amongst all the midwives/nurses who had undergone the procedure. This was the case for all except one midwife/nurse, who revealed that she did not experience pain during sexual intercourse.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Many people complain that they feel pain during sexual intercourse with their spouse\u0026hellip;but I did not feel any pain like that [during sexual intercourse].\u0026rdquo;SH10\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Because they (individuals upholding FGMC) want to practice the culture does not mean that the girl must not enjoy sex; that is number one. Then number two, by the time you want to deliver the baby, the problem is still there. And that pain even started when they did the\u003c/em\u003e \u003cb\u003ething\u003c/b\u003e \u003cem\u003e[FGMC] for her.\u0026rdquo; SH8\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSome midwives/nurses were also aware of other colleagues not involved in this research who had, like themselves, undergone the procedure and had experienced problems in childbirth.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eI and so many others [staff I know] that had FGMC did not find it easy giving birth.\u0026rdquo; SH14\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePersonal experiences vary and only one midwife/nurse who had her labia excised revealed that she did not experience any difficulty during labour.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI did not experience any difficulty in labour, even though I had my own [labia] cut off.\u0026rdquo; PHC2\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWhile there may be limited intrapartum consequences of FGMC for a few women (with a mild type of the procedure), for many others, the procedure carries significant maternal mortality and morbidity driving motivation for its abandonment and culture change. This was described as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It was a great challenge to me because most of the complications of FGMC, I faced it. I experienced many things: prolonged labour, obstructed labour, perineal tear, episiotomy and during the birth of my last baby, I had cervical laceration due to FGMC. I am a victim of FGMC\u0026hellip; That is why I am campaigning for the elimination of FGMC in our society.\u0026rdquo; SH18\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAnother midwife/nurse narrated her experience:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My first baby is now 7 years old, and when I was giving birth, I had severe bleeding that I almost lost my life. I suffered; I was \u0026lsquo;paper white\u0026rsquo; and had 3 units of blood. The hospital expenses were much but thank God I survived\u0026hellip;you can imagine how many other women have experienced similar problems and because they live in the remote village will not be able to access good care\u0026hellip;[\u003c/em\u003esilence\u003cem\u003e] So being a victim of this\u003c/em\u003e \u003cb\u003ething\u003c/b\u003e \u003cem\u003e(FGMC) has really made me think about how the culture has affected many other women and me. It has to change.\u0026rdquo; THC21\u003c/em\u003e\u003c/p\u003e \u003cp\u003eGiven the state of the PHCs which ideally provide basic care to women, in complex situations where emergency obstetric care provided in the tertiary healthcare facilities was required, there was a potential for increased risks, with maternal and infant morbidity and mortality in remote parts of the state.\u003c/p\u003e \u003cp\u003eTheir personal experiences allowed the midwife/nurse to reflect on the need to change the culture of FGMC, empathy for other women who had undergone the procedure and more importantly, the resolve to become change agents against the practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCulture vs Medical Knowledge\u003c/h2\u003e \u003cp\u003eGenerally, the midwives/nurses explained that their personal and cultural beliefs did not influence their midwifery practice. Given their personal experiences with FGMC, many of the staff were not in support of the culture of FGMC and said they would not allow it to interfere with the way care was provided. The midwives/nurses affirmed the ethics of the midwifery profession, rationalising their position against FGMC.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Because we have been trained and licensed, the care we provide cannot be based on culture or ethnicity. If we do that then it is likely to be considered malpractice or going against the ethics of the profession\u0026hellip;.It cannot be based on culture or ethnicity.\u0026rdquo; THC23\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAlthough the submission by one of the midwives/nurses suggested that FGMC was no longer conducted in the state/secondary healthcare facilities, birthing mothers still requested the procedure for their female children to which they were discouraged.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We do not do that\u003c/em\u003e \u003cb\u003ething\u003c/b\u003e \u003cem\u003e[FGMC] here again. Even some of the nursing mothers, after birth, will still come back and say they want to circumcise the female child, but we used to erase the idea from their minds.\u0026rdquo; SH17\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOverall, the understanding gathered from the staff was that no midwife or doctor consents to or aids the patients with FGMC although one midwife/nurse in the state/secondary remained neutral to the practice:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI will not preach against it and I will not encourage it [FGMC].\u0026rdquo; SH10\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWhilst only one midwife/nurse was indifferent to the cultural practice of FGMC; all the other staff seemed to have taken a stand against the procedure as a result of their midwifery/medical knowledge and professional ethics of care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCultural Practice of FGMC: Healthcare Facility vs Community\u003c/h2\u003e \u003cp\u003eThe consensus amongst the midwives/nurses was that the practice was declining due to awareness and community outreach against FGMC; however, there are still people (including healthcare workers) in the healthcare facilities and community who are sympathetic to the culture and endorse its continuation.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There are still people that are sympathetic to the culture. Some people are still practising it\u0026hellip;the husband of one of our colleagues insisted that their daughter must undergo FGMC. The woman cried. There was nothing she could do even though she knew the disadvantages. The husband insisted that the child must be circumcised. Some people are still sympathetic to the culture and still practising it although the percentage of people practising it is low.\u0026rdquo; SH8\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePockets of (illiterate) women and their families in the community have justified FGMC based on the terminology used to describe it. Rather than female mutilation, \u0026lsquo;female circumcision\u0026rsquo; has been equated with male circumcision- and the preferred phrase amongst many.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They [families] like to call it circumcision for female and male. They call it circumcision, but we [staff] know it is the same as female genital mutilation. Only the elites, the educated people, will say they do not want their female children to be circumcised; it is only the male ones that would be circumcised.\u0026rdquo; THC20\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe staff believed that the procedure was mostly available to women/families in the community with the \u003cem\u003eIya Agbebi\u003c/em\u003e (i.e., TBAs) and \u003cem\u003eOlolas\u003c/em\u003e (i.e., local circumcisers). The \u003cem\u003eOlola\u003c/em\u003e is a male or female community member experienced in female and male circumcision. Circumcision is said to be a \u0026lsquo;\u003cem\u003etrade of prestige\u0026rsquo;\u003c/em\u003e in the community, and the circumcisers pride themselves on the skill handed over and protected through generations in that particular family lineage.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Olola [circumcisers] they are proud to be called that and proud to continue it as a family business\u0026hellip;.\u0026rdquo; THC23\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They will go to Iya Agbebi [TBAs]; they do not come to the hospital for the\u003c/em\u003e \u003cb\u003ething\u003c/b\u003e \u003cem\u003e[FGMC].\u0026rdquo; PHC3\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSome staff speculated that the procedure was only provided in private hospitals and some PHCs. The midwives/nurses suggested that healthcare professionals in the PHCs may concede to the practice since it is more common in rural areas (where most of the PHCs are located) and opposing it may be met with great difficulty.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Some healthcare staff in the hospitals still do it [FGMC], especially in private hospitals.\u0026rdquo;SH10\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;people in the community are still practising this awful practice. They are still engaging in it. Some midwives working in these Primary healthcare facilities find themselves getting involved with it [since they cannot resist].\u0026rdquo; THC24\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe midwives/nurses, TBAs and Ololas in many communities and rural areas, respectively, are recognised members of the healthcare team that women and families consult for childbirth services and midwifery care, including FGMC. Aside from the notion that FGMC provided by healthcare professionals is \u0026lsquo;safe\u0026rsquo;, it is a source of income for these professionals in private clinics and rural PHCs, who, having emerged from the communities themselves, continue to propagate the culture. The continuation of FGMC among local communities is grounded in their cultural beliefs; for example, it is believed that an uncircumcised child will become promiscuous later in life. It is also believed that the face of the newborn must not come in contact with the vulva during childbirth, as this will lead to its death; thus, females have to be circumcised in preparation for giving birth as adults.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They believe that during labour if the head of the foetus touches that place [the vulva], the child will die.\u0026rdquo; THC22\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;People believe that a child that is not cut will be promiscuous or will not be able to give birth in future.\u0026rdquo; PHC2\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHaving had vaginal deliveries, many staff denounced these superstitions stating how newborns coming in contact with the vulva during childbirth does not result in promiscuity. The midwives/nurses agreed that these were false beliefs which are circulated amongst practising communities to encourage the continuation of the practice.\u003c/p\u003e \u003cp\u003eThere was a notion that women generally preferred to labour and birth with TBAs who were attached to PHCs, churches, missionary houses, or personal houses where FGMC consultations were provided to clients. TBA services have strong patronage; however, the midwives/nurses have discredited TBA services and criticised them for perpetrating FGMC and poor or delayed recognition of complications especially with women with FGMC.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So most of them [women] prefer the TBAs\u0026hellip;they end up with series of complications like postpartum haemorrhage, infections, obstructed labour, cervical tear\u0026hellip;.\u0026rdquo; SH8\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;With my years of working in maternity, I have seen that most women with female genital mutilation will go to TBAs and end up coming to the hospital with complications. When the complications set in and they [TBAs] cannot deal with it\u0026hellip;like cases of severe bleeding, they will send them [women] late to the hospital.\u0026rdquo; PHC5\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFinally, there was an observed reference to FGMC as a \u0026lsquo;\u003cem\u003ething\u003c/em\u003e\u0026rsquo; in the midwives/nurses' narratives of personal experiences which carries a derogatory meaning as a result of its impact on themselves and the wider community. It would seem that these experiences have an influence on the perceived shift and support of FGMC discontinuation amongst the study participants.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eFGMC is a deeply rooted cultural practice with ethnicity being one of the most important determining factors. Midwives/nurses are a product of the society where they practice and undoubtedly embody the practices and culture of their people. This study utilised a qualitative approach to explore the midwives/nurses\u0026rsquo; personal and cultural beliefs of FGMC in the midwifery care of women with FGMC. There were difficult narrations regarding their personal experiences of FGMC but significantly how this was shaping their outlook on the FGMC culture and its impact on women and families.\u003c/p\u003e \u003cp\u003eMidwives/nurses appear to become strongly averse to FGMC due to their own negative childbirth experience and midwifery education. Although this aversion was amongst the midwives/nurses across healthcare facilities, they reported that FGMC was still practised in small pockets of the community (and women\u0026rsquo;s homes) with healthcare professionals or traditional providers (including TBAs). The same was confirmed in Ethiopia [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], Kenya [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], Nigeria [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], Senegal [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and Sudan [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] where women/girls were discreetly being cut and that the practice was purportedly going underground. On the other hand, an observed shift in the severe to the less severe types of FGMC was observed amongst midwives in Somaliland in the hopes that it reduced the physical and psychological suffering associated with the more severe types of the procedure [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe beliefs that fostered FGMC were mostly enshrined in superstition. Studies have illustrated how midwives/nurses' affiliation with their communities enforced the practice [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], sympathise with FGMC [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and medicalise the practice [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFGMC was being cloaked under the preferred terminological guise of circumcision, which girls, women, and boys underwent. This was also the case in [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], where female circumcision was compared to male circumcision and regarded as a \u0026lsquo;minor procedure\u0026rsquo; that took less than a week to heal. \u0026lsquo;Female circumcision\u0026rsquo; is not a new phrase but the preferred term by practising groups, intended to draw a parallel with male circumcision and create confusion between the two distinct practices [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This research acknowledges that the definition of the practice has proved problematic for many decades, where families resented female genital \u0026lsquo;mutilation\u0026rsquo; as they believed that they were not mutilating their daughters [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Hence, researchers conducting research in core communities where FGMC is practised have been observed to use the local term by which the practice is known, e.g., \u003cem\u003esunna, pharonic\u003c/em\u003e or \u0026lsquo;cutting\u0026rsquo; representing plain language [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This research adds to this understanding by retaining the midwives/nurses' description of the local circumcisers. Echoing these phrases and words within research and in communication with practising groups has been encouraged by international organisations and peacekeepers to avoid the volatile risk of demonising cultures and traditions, which may breed animosity and difficult dialogue [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Therefore, this finding is useful during multi-national/cultural dialogue in the ongoing abandonment campaign.\u003c/p\u003e \u003cp\u003e Silence and metaphors were not overlooked but highlighted within the context of the participants\u0026rsquo; narrations and experiences with FGMC. Researchers have explored their experiences while reporting that traumatic experiences and building a rapport where no signal is overlooked, continuing to ask, albeit gently and sensitively, questions that help expand our understanding of difficult situations are inherently difficult [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Still, efforts to preserve the sensitivity in the dialogue with FGMC are as important as the inherent yet uncertain dangers that abound with its covertness. As dialogue on the zero tolerance of FGMC in communities continues; the gatekeepers of healthcare in these communities remain key to unlocking cultural dimensions of reasoning that promote traditional and cultural practices beneficial to the health of women with FGMC. Prior to this research, an inquiry into midwives/nurse\u0026rsquo;s sociocultural influence of FGMC on midwifery care was slightly addressed in high-income countries [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] where this study attempts to fill in that gap in Nigeria. A lot still needs to be done where the current study agrees with the recommendation posed by [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], stating the need for more research on how sociocultural practices influence healthcare practitioner behaviour in (southwest) Nigeria. The observed aversion and subsequent reduction in the conduct of FGMC amongst the midwives/nurses is still fragile. It should therefore be nurtured through culturally appropriate teaching, awareness creation and stories from survivors throughout the healthcare facilities, educational institutions and local communities.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has captured the experiences of midwives/nurses in public healthcare facilities and not the private sector. While it was not the intention of the study to cover the latter and midwives/nurses who solely worked in private institutions were automatically excluded; it is not uncommon that midwives/nurses in Nigeria combined a job in the public healthcare facilities with extra hours in the private sector to maximise income. There is a potential that this study reflects the views of midwives/nurses in private institutions, the results are truer for public healthcare facilities.\u003c/p\u003e \u003cp\u003eThis study has not captured the experiences of the women who underwent FGMC and their experiences with midwifery care within (and outside) the healthcare facilities. We do not have the perspectives of other professionals providing midwifery care such as the doctors in public healthcare facilities and TBAs in the communities.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study reported three themes- midwives/nurses' personal FGMC experience, culture vs medical knowledge and cultural practice of FGMC: healthcare facility vs community- that influence their midwifery care of women with FGMC. A significant number of the midwives/nurses in our study, as part of their cultural identity, have undergone FGMC resulting in complications already reported in the data on maternal morbidity associated with FGMC. Their personal experiences with labour and childbirth after undergoing FGMC, in addition to their midwifery education, have resulted in an aversion to the practice and an active stand against the procedure.\u003c/p\u003e \u003cp\u003eThis study adds evidence of the benefit of sharing similar experiences in sensitive research, continuous awareness and educating midwives/nurses on the impact of FGMC steering the move to abandonment of the practice. Universal coverage with critical information regarding the implications of the procedure should target staff in (and outside) the three levels of healthcare, educational institutions and communities if this position is to be sustained.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the midwives/nurses for their time and valuable contribution to the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is part of a larger research study funded by the Petroleum Technology Development Fund (PTDF) Nigeria. The views expressed are those of the authors and should not be attributed to PTDF.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Affiliation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCollege of Health, Psychology and Social Care, University of Derby - Rukaiyya Muhammad.\u003c/p\u003e\n\u003cp\u003eFaculty of Medicine and Health sciences, University of Nottingham - Kim Watts.\u003c/p\u003e\n\u003cp\u003eFlorence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London - Elsa Montgomery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRM conducted and wrote the study. K.W and E.M read, edited and supervised the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Rukaiyya Muhammad.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflict of interest with respect to the research, authorship and publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Psychiatry Nursing and Midwifery PNM research ethics committee of Kings College London HR-19/20-14734 and the Osun State primary health care development board OSPHCDB/042/210, Osun State health research ethics committee OSHREC/PRS/569T/169, and the ethics and research committees at Obafemi Awolowo University Teaching hospitals complex NHREC/27/02/2009a and Ladoke Akintola University of Technology Teaching Hospital (LAUTECH) LTH/EC/2020/09/472. All participants gave their written consent. \u0026nbsp;\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\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and/or analysed during the current study is available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF. (2024). 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Is it possible to end female circumcision in Africa? Clin J Obstet Gynecol. 2018;1(1):7\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverio SA, Sheen KS, Bramante A, Knighting K, Koops TU, Montgomery E, November L, Soulsby LK, Stevenson JH, Watkins M, Easter A. (2022). Sensitive, challenging, and difficult topics: Experiences and practical considerations for qualitative researchers. \u003cem\u003eInternational Journal of Qualitative Methods\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e, p.16094069221124739.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdeyinka A, Adedotun O, Asabi O. Knowledge and practice of female circumcision among women of reproductive ages in South West Nigeria. J Humanit Soc Sci. 2012;2(3):38\u0026ndash;45.\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":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Female Genital Mutilation/Cutting, FGMC, Midwives/nurses, midwifery care, culture","lastPublishedDoi":"10.21203/rs.3.rs-5320134/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5320134/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFemale Genital Mutilation/Cutting (FGMC) is a global issue with implications for maternal mortality/morbidity in Nigeria. Midwives/nurses are crucial in the provision of midwifery care for women with FGMC. Where the midwives/nurses have undergone FGMC as part of their cultural identity, this study seeks to explore the midwives/nurses' personal and cultural beliefs in the midwifery care of women with FGMC.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative descriptive study was conducted across the three tiers of healthcare facilities in Osun State Nigeria where twenty-four interviews were held with midwives/nurses. Data was collected by conducting semi-structured telephone interviews which were analysed using thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTo our knowledge, this is the first study to explore the experiences of midwives/nurses across the three tiers of healthcare provision with three themes derived from the interviews: Personal FGMC experience, culture vs medical knowledge and cultural Practice of FGMC: healthcare facility vs community.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDifficult FGMC experiences were used as drivers by the midwives/nurses in the motivation for the abandonment of FGMC. Although there was a strong aversion to the procedure, there is a continued need for awareness across healthcare facilities, educational institutions and local communities.\u003c/p\u003e","manuscriptTitle":"A qualitative study exploring midwives/nurses' personal and cultural beliefs in the midwifery care of women with Female Genital Mutilation/Cutting (FGMC) in Nigeria.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-07 12:20:42","doi":"10.21203/rs.3.rs-5320134/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-23T11:35:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-22T07:33:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29352449139175561180091082700308185587","date":"2026-02-15T20:48:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79973964431901512616119034527228120019","date":"2026-02-15T11:53:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-14T12:41:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173433479296962679876224355972605947960","date":"2024-12-07T11:50:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78768676237646912489477960078173800834","date":"2024-12-07T08:56:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-28T07:17:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-30T06:43:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-29T02:00:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-29T01:59:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-10-23T15:20:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9b9c81d8-81df-4b7f-a854-91bcc24c624d","owner":[],"postedDate":"November 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T22:08:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-07 12:20:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5320134","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5320134","identity":"rs-5320134","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}