Supporting health workers facing decision-making dilemmas
I’ve had the privilege to have interviewed many health professionals in Somaliland and Kenya in recent years on female genital cutting (FGC).
Increasingly, parents are approaching health workers, including nurses, midwives and doctors, in the belief that a cut carried out using anaesthetic, clean instruments and followed by a course of antibiotics will result in fewer complications than cutting by traditional cutters.
Governments and international bodies, understandably, talk of Zero Tolerance and are introducing punitive laws for health workers who cut. My personal goal is for the total abandonment of female genital cutting. However, I find the judgemental language of Zero Tolerance, less helpful in supporting nurses and midwives making difficult decisions.
Undoubtedly, some midwives are cutting to supplement their low pay, perhaps cutting in December to pay school fees in January. Others, however, do have the physical and emotional welfare of the young girls in their minds and I’ve been struck by the challenging decisions many of them are facing.
Research has shown that health workers are often aware of the complications arising from cutting, however, many feel under pressure to perform a ‘safer cut’ than that performed by traditional cutters. Some are even asking for training in ‘safe cutting’, aware that they are performing a delicate and high-risk procedure without training.
A Dilemma for Ruth
Ruth works in a District Hospital as a midwife. In her spare time she joins campaigns to end female genital cutting. However, is her role as a midwife she finds she faces difficult decisions alone.
One of her patients, Gertrude, asks for Ruth’s help.
Gertrude’s two grandchildren aged 10 and 12 years are due to be cut in December by the traditional cutter.
She knows that cutting can cause serious infections or even death when done by the community cutter. She has suffered complications since she was cut aged 12 and her daughters also have suffered from infections and difficulties giving birth. She hopes her own granddaughters will not be cut.
Gertrude asks Ruth if she will cut the girls safely and hygienically to save them from harm and keep to traditional practice.
These kinds of stories have helped health workers to discuss the pressures they are under and the reasons why some agree to cut young girls even thought they would prefer to see the end of female genital cutting.
By forming peer support groups, midwives and nurses are more able to support each other in changing their roles and playing a stronger role in promoting community dialogue and encouraging whole communities to abandon the practice of cutting.
I have used the example of decision-making in relation to FGC, however, the same concept is applicable to many other situations where we, as health professionals and educators try to change practice among community-based health workers.
There is a role for providing health information. However, equally important is providing safe spaces where health workers can discuss the pressures they are under to maintain existing practices and the difficult choices they need to make to bring about change.
A question perhaps to ask ourselves every time we plan a workshop for health workers is What are the decision-making dilemmas participants are facing and how can I provide a space for them to discuss them?
Dobson M (2017) FGC decision-making dilemmas in Somaliland. Available at https://orchidproject.org/fgc-decision-making-dilemmas-somaliland/
Newell-Jones K (2016) Female genital cutting in Somaliland: Baseline assessment. Available at https://www.popcouncil.org/uploads/pdfs/2017RH_FGMC-Somaliland_Baseline.pdf
