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. 2022 Aug 19;17(8):e0272934. doi: 10.1371/journal.pone.0272934

Does previous circumcision and wealth index influence women’s attitude to discontinue the practice of female genital mutilation and cutting (FGM/C) in Ethiopia?

Mohammed Ahmed 1,*, Abdu Seid 2, Seada Seid 1, Ali Yimer 1
Editor: Sebastian Shepherd3
PMCID: PMC9390897  PMID: 35984786

Abstract

Introduction

understanding women’s attitudes towards female genital mutilation is an important step towards eliminating this practice. We used the 2016 Ethiopia Demographic and Health Survey (EDHS) data set to examine the relationship between wealth index, and previous history of circumcision on women’s opinions whether female genital mutilation (FGM) should be continued or stopped in Ethiopia.

Methods

Data from 6984 women aged 15–49 years were extracted from the 2016 Ethiopia EDHS data set. Multivariable logistic regression analysis was performed to analyse the data.

Result

In this study, women with a higher level of education and wealth index were more likely to support the cessation of FGM. However, circumcised women (AOR: 0.22; 95% CI: 0.15–0.32), women from the Afar region (AOR: 0.34; 95% CI: 0.22–0.50), Somali region (AOR: 0.42; 95% CI: 0.27–0.65), and Dire Dawa region (AOR: 0.51; 95% CI: 0.32–0.83) were less likely to support discontinuation of FGM.

Conclusion

The present study revealed that wealth index, education level, history of circumcision, and regional variation are associated with women’s attitude towards discontinuation of the practice of FGM in Ethiopia. Empowering women in terms of socioeconomic status and education can change attitudes and might help prevent female genital mutilation in the future. Furthermore, interventions targeting FGM practices should focus on regional variance in order to have a meaningful impact on reducing this harmful cultural practice in Ethiopia.

Background

Female genital mutilation/cutting (FGM) is defined as any procedures that involve partial or entire removal of the external female genitalia or other harm to the female genital organs for non-medical reasons [1]. The prevalence of FGM become decreased in Ethiopia over the last 16 years, with prevalence declining from 80% in the 2000 Ethiopia Demographic and Health Survey (EDHS) to 74% in 2005, and 65% in 2016 EDHS [2]. However, the prevalence varies by regions: 99% in Somali, 91% in Afar, 33% in Gambela, and 24% in Tigray [2].

FGM is a dangerous procedure that predates all faiths and is carried out on children for a variety of reasons in different cultural and global contexts [3], resulting in acute and long-term repercussion’s such as bleeding, shock, urine retention, and infertility [4–7]. In addition, according to a study conducted in Ghana, FGM was linked to an 8.2% caesarean section rate compared to 6.7% in mothers who did not have FGM [8].

The first step toward ending FGM is to change people’s perceptions about it, which can be tough and psychologically painful [9]. In Ethiopia, 21% percent of women think that the practice should be continued [2]. Studies showed that attitude towards cessation of FGM was attributed to different factors such as male sex [10, 11], urban residence [12], educational attainment [5, 12–14], and access to media [12, 13]. In contrast, women with positive cultural conceptions of FGM, being muslim religion follower [12, 13, 15], 15–24 years age, living in rural areas, and being married [13] were less likely to support cessation of FGM.

When it comes to the impact of previous circumcision and socioeconomic status on attitudes towards FGM, the evidence is mixed. For example, one study in Egypt showed that previous circumcision favors discontinuation [11], while another study conducted in Ethiopia found that previous circumcision leads to the continuation of FGM [13]. Similarly, a higher levels of household wealth increased women’s support for discontinuation [16]. In some countries, wealth index was linked to support FGM, and in some countries the opposite is true [17].

Previous research in Ethiopia regarding the continuation of female genital mutilation [13, 18] did not include crucial factor such as wealth index, which is an important to alleviate the barriers for discontinuation of FGM. Therefore, the current study sought to fill this vacuum by examining the relationship between wealth index, and previous history of circumcision on women’s attitude to end the practice of FGM in Ethiopia, utilizing data from the country’s most recent 2016 national demographic and health survey.

Methods

Data source

The current research used the 2016 Ethiopia Demographic and Health Surveys (EDHS) data set. A stratified cluster sampling method with two stages was applied. A detailed description of the study design and survey methods may be read elsewhere [2]. In the 2016 EDHS, 15,683 women (15–49 years) were interviewed, with a 95% response rate. After excluding cases with missing values on the variables of interests, the analytic sample in this study consisted of 6984 reproductive age women (15–49 years).

Study variables

The dependent variable was the attitude towards the discontinuation of female genital mutilation, which was measured by asking the questions “circumcision should be continued or stopped?”. There were two options for the respondents: continue or stop. The main exposure variables were whether or not women had ever been circumcised (yes or no) and the wealth index (a composite index based on the household’s ownership of several consumer items), which had five categories (poorest, poorer, middle, richer, and richest) according to the data set [2].

Covariates that affect attitudes towards the discontinuation of female genital mutilation include respondent’s age, religion, marital status, education status, type of residence, access to media, and regions.

Statistical analysis

SPSS version 21 was used to analyse the data. Frequencies and weighted percentages of study variables were reported. Bivariate analysis using Rao–Scott chi-square test was performed to examine the relationship between attitude towards the discontinuation of female genital mutilation and each of the independent variables and to select potential candidates for the multivariable model. A variable, which had a p-value of < 0.25 in bivariate analysis were entered into a multivariable logistic regression analysis to assess the association between wealth index, and previous circumcision towards women’s attitude to discontinue the practice of FGM by controlling confounders. To declare a statistically significant association, adjusted odds ratios (AOR) with 95% confidence interval (CI) were used.

Ethics approval and consent to participate

The study does not required ethical approval because it was a secondary data analysis using the 2016 EDHS database. After receiving the data from the USAID–DHS program, the researchers in this study maintained the data’s anonymity. During the survey, consent was received from the study participants prior to the start of study.

Results

Description of the study variables with attitude to discontinuation of FGM

A total of 6984 reproductive-aged women were included and analysed. In terms of age, 35.4% of women aged 20–29 years had an attitude toward discontinuation of female genital mutilation. When it came to circumcision, 65.8% of those who supported ending FGM had been circumcised at some point in their lives (Table 1).

Table 1. Univariate and bivariate analysis of the study variables with attitude to female genital mutilation among reproductive-age women in Ethiopia (n = 6984).

Variables Category Overall Attitude to FGM p-value
Discontinued Continued
n (wt.%) n (wt.%) n (wt.%)
Age 15–19 1523(21.4) 1225(22.5) 298(16.4) 0.004
20–29 2547(35.2) 1992(35.4) 555(34.4)
30–39 1879(28.3) 1461(27.3) 418(32.7)
40–49 1035(15.1) 789(14.7) 246(16.6)
Residence Urban 2543(23.4) 2284(26.5) 259(9.6) <0.001
Rural 4441(76.6) 3183(73.5) 1258(90.4)
Religion Non-Muslim 5862(76.5) 4462(75.2) 1400(82.7) 0.023
Muslim 1122(23.5) 1005(24.8) 117(17.3)
Marital Status Never Married 1942(25.8) 1674(28.0) 268(15.4) <0.001
Married 4333(64.7) 3209(62.3) 1124(75.8)
Separated/divorced 709(9.5) 584(9.7) 125(8.8)
Education No Education 3011(45.9) 1959(41.2) 1052(67.0) <0.001
Primary 2325(35.1) 1953(36.5) 372(28.9)
Secondary 1058(12.6) 985(14.6) 73(3.7)
Higher 590(6.4) 570(7.7) 20(0.4)
Wealth index Poorest 1605(15.4) 853(12.2) 752(29.9) <0.001
Poorer 862(17.5) 659(16.5) 203(22.0)
Middle 900(19.5) 730(19.4) 170(19.8)
Richer 910(19.9) 772(20.6) 138(16.4)
Richest 2707(27.8) 2453(31.3) 254(11.8)
Access to media No 3426(54.1) 2353(51.1) 1073(68.0) <0.001
Yes 3558(45.9) 3114(48.9) 444(32.0)
Ever been Circumcised No 2113(29.4) 2015(34.2) 98(7.7) <0.001
Yes 4871(70.6) 3452(65.8) 1419(92.3)
Region Tigray 658(6.4) 604(7.1) 54(2.9) <0.001
Afar 579(0.9) 226(0.5) 353(2.9)
Amhara 739(22.8) 601(22.9) 138(22.4)
Oromiya 876(38.0) 712(37.1) 164(41.7)
Somali 692(3.2) 312(1.9) 380(9.4)
Benishangul- Gumuz 475(1.0) 431(1.1) 44(0.5)
SNNPR 786(20.1) 670(20.6) 116(17.6)
Gambela 322(0.2) 296(0.2) 26(0.1)
Harari 414(0.3) 350(0.3) 64(0.2)
Addis Ababa 894(6.5) 861(7.7) 33(1.4)
Dire Dawa 549(0.6) 404(0.6) 145(0.9)
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Association between wealth index and women’s attitude to discontinue the practice of FGM in Ethiopia

Because all of the variables in bivariate analysis had a p-value of less than 0.25, they were all incorporated into multivariable logistic regression analysis. The odds of attitude towards the discontinuation of female genital mutilation was 1.46 (AOR: 1.46; 95% CI: 1.02–2.01), 1.95 (AOR:1.95; 95% CI: 1.36–2.79), 2.22 (AOR: 2.22; 95% CI: 6.68–31.4), and 2.65 (AOR: 2.65; 95% CI: 1.57–4.46) times higher among women who had a poorer, middle, richer, and richest wealth index quintile, respectively compared to women who were in the poorest quintile.

Besides, the odds of attitude towards the discontinuation of female genital mutilation was 1.57 (AOR: 1.57; 95% CI: 1.17–2.12), 3.38 (AOR: 3.38; 95% CI: 1.96–5.83), 14.5(AOR: 14.5; 95% CI: 6.68–31.4) times higher among women attained primary, secondary, and higher education, respectively compared to non-educated one.

In addition, circumcised women compared to non-circumcised women lower the odds of the attitude towards the discontinuation of female genital mutilation by 78% (AOR: 0.22; 95% CI: 0.15–0.32). Besides, the odds of the attitude towards the discontinuation of female genital mutilation was lower by 66% (AOR: 0.34; 95% CI: 0.22–0.50) among women living in the Afar region, by 38% (AOR: 0.42; 95% CI: 0.27–0.65) among women living in the Somali region, by 59% (AOR: 0.51; 95% CI: 0.32–0.83) among women live in Dire Dawa region compared to Oromiya region. However, the odds of the attitude towards the discontinuation of female genital mutilation was higher among women living in Benishangul- Gumuz by 2.22 times (AOR: 2.22; 95% CI: 1.46–3.36), and Addis Ababa by 2.13 times (AOR: 2.13; 95% CI: 1.13–4.04) (Table 2).

Table 2. Multivariable analysis using binary logistic regression to identify independent predictors of attitude toward discontinuation of female genital mutilation among reproductive-age women in Ethiopia (n = 6984).

variables category Attitude to discontinuation FGM
COR(95% CI) AOR(95%CI)
Age 15–19 1 1
20–29 0.75(0.57–0.97) 1.08(0.77–1.52)
30–39 0.61(0.45–0.81) 1.25(0.82–1.94)
40–49 0.65(0.48–0.86) 1.32(0.89–1.94)
Residence Urban 3.39(2.49–4.60) 1.01(0.62–1.63)
Rural 1 1
Religion Non-Muslim 1 1
Muslim 1.58(1.06–2.36) 1.45(0.98–2.13)
Marital Status Never Married 1 1
Married 0.45(0.35–0.58) 0.96(0.67–1.36)
Separated/Divorced 0.61(0.42–0.87) 1.08(0.69–1.69)
Education No education 1 1
Primary 2.05(1.63–2.58) 1.57(1.17–2.12)*
Secondary 6.42(4.03–10.2) 3.38(1.96–5.83)*
Higher 30.5(16.3–57.5) 14.5(6.68–31.4)*
Wealth Index Poorest 1 1
Poorer 1.83(1.33–2.53) 1.46(1.02–2.01)*
Middle 2.40(1.75–3.28) 1.95(1.36–2.79)*
Richer 3.08(2.27–4.17) 2.22(1.55–3.19)*
Richest 6.48(4.65–9.03) 2.65(1.57–4.46)*
Access to media No 1 1
Yes 2.04(1.64–2.53) 0.85(0.65–1.13)
Ever been Circumcised No 1 1
Yes 0.16(0.11–0.23) 0.22(0.15–0.32)*
Region Tigray 2.75(1.65–4.55) 1.47(0.84–2.58)
Afar 0.19(0.14–0.28) 0.34(0.22–0.50)*
Amhara 1.14(0.78–1.66) 0.96(0.68–1.37)
Oromiya 1 1
Somali 0.22(0.15–0.33) 0.42(0.27–0.65)*
Benishangul- Gumuz 2.27(1.43–3.61) 2.22(1.46–3.36)*
SNNPR 1.31(0.83–2.06) 0.95(0.63–1.44)
Gambela 2.91(1.82–4.64) 1.22(0.72–2.07)
Harari 1.26(0.80–1.99) 1.02(0.65–1.57)
Addis Ababa 6.30(3.93–10.1) 2.13(1.13–4.04)*
Dire Dawa 0.74(0.49–1.10) 0.51(0.32–0.83)*
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*-showed significant association with AOR with a 95% confidence interval at a p-value of < 0.05

Discussion

In Ethiopia, the current study looked into whether women with higher wealth indexes have a higher possibility of opposing FGM. Studies from Guinea [16] and other countries [15] confirm this conclusion. This may be due to the increment of decision-making authority by monetarily empowered women [19].

This study also adds to the literature that educated women, and regional variation were significant predictors of women’s attitude to discontinue the practice of FGM in Ethiopia. Educational attainment of the women results in a higher odds of the attitude to discontinue female genital cutting. This finding is consistent with studies conducted in different places [5, 12–14]. This may be explained as educated women may be equipped with the knowledge to evaluate their beliefs about traditional practices, and it provides women with financial independence and empowerment to liberate themselves from harmful practices. Furthermore, the opinions of educated women are less likely to be influenced and shaped by traditions.

In comparison to uncircumcised women, circumcised women were less likely to support ending FGM. This result is consistent with the finding of a prior investigation in Ethiopia [13], This can be explained by the fact that having instilled in one’s upbringing might give FGM a deeper meaning and purpose. Circumcised women may have gained perks such as recognition and respect as a result of the procedure. However, this conclusion contradicts a study from Egypt [11], which found that previous circumcision leads to cessation of FGM. The discrepancy between the Egyptian study and the current study is attributable to changes in the study participants. The Egyptian study involved medical students whereas the current study involved reproductive-age women residing in the community. Because they were medical students, they were able to predict the health consequences of FGM more easily, which boosted their enthusiasm for the practice’s abolition.

Furthermore, women in Afar, Somalia, and Dire Dawa had a reduced likelihood of having a favourable attitude regarding the abolition of female genital mutilation. Women in Benishangul-Gumuz and Addis Ababa, on the other hand, had a more favourable attitude toward the cessation of female genital mutilation. This finding is consistent with previous studies conducted in Ethiopia [20, 21]. This could be due to significant spatio-temporal variation of FGM practice across the country [20].

Strength and limitation of the study

Although findings of this study are valuable for policymaking, there are a few limitations to be aware of. The data, for example, were gathered from secondary sources, and our study may not be free of the flaws that come with this method. Despite these limitations, our study is one of the few that have contributed to the discussion of the association between wealth index and women’s attitude to discontinue the practice of FGM in Ethiopia, as no other studies have been conducted in the country using the most recent 2016 national representative data set available to date.

Conclusions

The present study revealed that women’s wealth index, educated women, previous circumcision, and regional variation significantly predict women’s attitude to discontinue the practice of FGM in Ethiopia. Therefore, efforts need to be done in promoting women’s socioeconomic status concurrently empowering women in education. Furthermore, designing interventions that address FGM practices should focus on circumcised women along with addressing regional variation to have a significant effect on curtailing this harmful traditional practice from Ethiopia.

Acknowledgments

We would like to express gratitude to the USAID–DHS program for offering the 2016 Ethiopia Demographic and Health Survey data set.

Data Availability

We used the USAID–DHS program 2016 Ethiopian demographic and health survey data set for this analysis. To request the same or different data for another purpose, a new research project request should be submitted to the DHS program here: https://dhsprogram.com/data/Access-Instructions.cfm. After receiving permission, the researcher can log in and select the specific data in the format they prefer.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Sebastian Shepherd

18 Apr 2022

PONE-D-21-07908

Does previous circumcision and wealth index influencing women’s attitude to discontinue the practice of female genital mutilation and cutting (FGM/C) in Ethiopia?

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**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you so much for submitting this manuscript to PLOS ONE. The manuscript focused on a very important women’s health issue of global relevance for which health providers are in the forefront for care provision and advocacy.

It was indeed a great delight to reviewing this manuscript which has been well conceived and written. Well-done to the team. To further improve on the quality of the manuscript and make it publishable for international audience, below are my suggestions:

General comment on the manuscript.

FGM/C and FGM acronyms and circumcision were inconsistently used in the manuscript. Please make up your mind on the one you want to use and be consistent with its use throughout the manuscript. You also need to clarify that female genital mutilation/cutting is also known as female circumcision so that this becomes clearer for lay global audience.

The manuscript will benefit from editing from primary speakers of English language.

Title: This looks clumsy and unclear. I suggest that you write it out in a clear statement. If you insist on presenting it as a question, kindly revise to ensure clarity.

Abstract

Conclusion: The 1st sentence is not complete. Kindly revise

Background

As previously indicated, you need clearly clarify female genital mutilation/cutting is also known as female circumcision so that this becomes clearer for lay global audience. For example, in paragraph 4, 1st sentence and the entire paragraph you used circumcision for the first time despite previous use of female genital mutilation/cutting. Be consistent throughout the manuscript.

Methodology

Data source: 3rd sentence “A detailed description… were founded elsewhere (2)” Do you mean were reported somewhere?

How did you arrive at your sample size? Any statistical power analysis?

Study variables: You stated that the wealth index were five, however, you mentioned 4- poorest, poorer, middle richer, and richest. Please check and amend.

Ethics Analysis

How did you contact and obtain consent from 6984 women of reproductive age whose data you used? This needs to be clearly presented.

Results

Well presented, thank you.

Discussion

You stated in your findings that “Also, circumcised women compared to non-circumcised women lower the odds of the attitude towards the discontinuation of female genital mutilation by 78%” suggesting that women with FGM/C are more likely to want to continue the practice. However, in the 2nd paragraph of your discussion, you included previous FGM/C as a predictor for discontinuing the practice. Please check and amend.

Your conflicting discussion of your finding is further depicted in the 3rd paragraph where the content here is different to that of paragraph 2 with reference previous FGM/C and attitude to continue or discontinue FGM/C. Please check and amend.

In general, thank you for this manuscript. Best wishes.

Reviewer #2: Corrections about References (See revised Manuscript)

Reviewer #3: The topic of what explains the persistence of FGC, and attitudes in support of FGC, is an important one. The authors use one survey in one country to examine the correlation between FGC attitudes and wealth and education. Unfortunately I do not see how this piece adds to our knowledge of the perpetuation of FGC above and beyond works that have already been published. The authors note that there are some mixed results regarding socioeconomic status and the practice of FGC. However this study does not help us resolve or make sense of these conflicting results but rather adds another case, which has also been included in past studies. It does not attempt to help us theoretically understand the reason for these conflicting results or present results that help in this regard either. As such, I cannot recommend the article for publication as I do not see it contributing new knowledge to the study of FGC, however I commend the authors for their effort. Perhaps including more countries and over a longer period of time, both of which are possible with the DHS data, could help. Note however that a number of scholars have also already done this.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Dr Olayide Ogunsiji

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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Attachment

Submitted filename: Filled Review Form for PONE-D-21-07908 BALDE Mamadou Dioulde 10.02.2022 (2).docx

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PLoS One. 2022 Aug 19;17(8):e0272934. doi: 10.1371/journal.pone.0272934.r002

Author response to Decision Letter 0

26 Apr 2022

Thank you very much for PLOS one editorial office, academic editors, as well as reviewers of this manuscript entitled Does previous circumcision and wealth index influence women’s attitude to discontinue the practice of female genital mutilation in Ethiopia? For their astonished effort.

The written documents below explained point by point response for respective editor and reviewer’s comment.

Editor comments and author response

During your revisions, please note that a simple title correction is required: The grammar choice of 'influencing' in the title is not correct, one suggested edit to the title could be - 'Does previous circumcision and wealth index influence women’s attitude to discontinue the practice of female genital mutilation and cutting (FGM/C) in Ethiopia?'.

Author response: Thank you so much. The authors amended the manuscript based on the reviewer comments and included in the revised manuscript.

Reviewer 1 comments and authors response:

Reviewer #1:

General comment on the manuscript.

FGM/C and FGM acronyms and circumcision were inconsistently used in the manuscript. Please make up your mind on the one you want to use and be consistent with its use throughout the manuscript. You also need to clarify that female genital mutilation/cutting is also known as female circumcision so that this becomes clearer for lay global audience. The manuscript will benefit from editing from primary speakers of English language.

Author response: Thank you so much. The authors amended the manuscript based on the reviewer comments and included in the revised manuscript.

Title: This looks clumsy and unclear. I suggest that you write it out in a clear statement. If you insist on presenting it as a question, kindly revise to ensure clarity.

Author response: The authors amended the manuscript based on the reviewer comments and included in the revised manuscript.

Abstract

Conclusion: The 1st sentence is not complete. Kindly revise

Author response: The authors amended the manuscript based on the reviewer comments and included in the revised manuscript.

Background

As previously indicated, you need clearly clarify female genital mutilation/cutting is also known as female circumcision so that this becomes clearer for lay global audience. For example, in paragraph 4, 1st sentence and the entire paragraph you used circumcision for the first time despite previous use of female genital mutilation/cutting. Be consistent throughout the manuscript.

Author response: The authors amended the manuscript based on the reviewer comments and included in the revised manuscript.

Methodology

Data source: 3rd sentence “A detailed description… were founded elsewhere (2)” Do you mean were reported somewhere? How did you arrive at your sample size? Any statistical power analysis?

Study variables: You stated that the wealth index were five, however, you mentioned 4- poorest, poorer, middle, richer, and richest. Please check and amend.

Author response: The authors amended the manuscript based on the reviewer comments and included in the revised manuscript. In the 2016 EDHS, 15,683 women (15–49 years) were interviewed, For studying FGM, after excluding cases with missing values on the variables of interests, the analytic sample in this study consisted of 6984 reproductive age women (15- 49 years).

Ethics Analysis

How did you contact and obtain consent from 6984 women of reproductive age whose data you used? This needs to be clearly presented.

Author response: The authors amended the manuscript based on the reviewer comments and included in the revised manuscript.

Results

Well presented, thank you.

Discussion

You stated in your findings that “Also, circumcised women compared to non-circumcised women lower the odds of the attitude towards the discontinuation of female genital mutilation by 78%” suggesting that women with FGM/C are more likely to want to continue the practice. However, in the 2nd paragraph of your discussion, you included previous FGM/C as a predictor for discontinuing the practice. Please check and amend.

Author response: The authors amended the manuscript based on the reviewer comments and included in the revised manuscript.

Your conflicting discussion of your finding is further depicted in the 3rd paragraph where the content here is different to that of paragraph 2 with reference previous FGM/C and attitude to continue or discontinue FGM/C. Please check and amend.

In general, thank you for this manuscript. Best wishes.

Author response: The authors amended the manuscript based on the reviewer comments and included in the revised manuscript.

Reviewer 2 comments and author response

Reviewer #2: Corrections about References (See revised Manuscript)

Author response: The authors amended the manuscript based on the reviewer comments and included in the revised manuscript.

Reviewer #3: The topic of what explains the persistence of FGC, and attitudes in support of FGC, is an important one. The authors use one survey in one country to examine the correlation between FGC attitudes and wealth and education. Unfortunately I do not see how this piece adds to our knowledge of the perpetuation of FGC above and beyond works that have already been published. The authors note that there are some mixed results regarding socioeconomic status and the practice of FGC. However this study does not help us resolve or make sense of these conflicting results but rather adds another case, which has also been included in past studies. It does not attempt to help us theoretically understand the reason for these conflicting results or present results that help in this regard either. As such, I cannot recommend the article for publication as I do not see it contributing new knowledge to the study of FGC, however I commend the authors for their effort. Perhaps including more countries and over a longer period of time, both of which are possible with the DHS data, could help. Note however that a number of scholars have also already done this

Author response: There was no study conducted so far in relation to wealth index and attitude to discontinue FGM in Ethiopia. That is why we eager to undertake this study.

Thank you

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (14.9KB, docx)

Decision Letter 1

Sebastian Shepherd

8 Jul 2022

PONE-D-21-07908R1Does previous circumcision and wealth index influence women’s attitude to discontinue the practice of female genital mutilation and cutting (FGM/C) in Ethiopia?PLOS ONE

Dear Dr. Ahmed,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript has been evaluated by one reviewer and their comments are available below.

The reviewer has raised a concern that the manuscript still requires extensive copyediting. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.  

Could you please revise the manuscript to carefully address the concerns raised?

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services. If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Please submit your revised manuscript by Aug 22 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Sebastian Shepherd

Staff Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for responding to majority of my comments in the previous version of this manuscript. However, the manuscript will still benefit from editing done by a primary speaker of English language. This is important for the international audience that this journal targets.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Aug 19;17(8):e0272934. doi: 10.1371/journal.pone.0272934.r004

Author response to Decision Letter 1

11 Jul 2022

Thank you very much for PLOS one editorial office, academic editors, as well as reviewers of this manuscript entitled Does previous circumcision and wealth index influence women’s attitude to discontinue the practice of female genital mutilation and cutting (FGM/C) in Ethiopia?.

The written documents below explained point by point response for respective reviewer and editor comments.

Reviewer 1 comments and authors response:

Comment 1: the reviewer raised a concern that the manuscript still requires extensive copyediting. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar.

Author response: the authors addressed all of the issue raised by the reviewer in the revised manuscript. The copy-editing was done by the authors.

Editor comments and author response

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Author response: I have reviewed the references in the manuscript and I did not found retracted articles.

Thank you for reviewers and editors (staff as well as academic editors) for their extensive and constructive comments throughout the process

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (13KB, docx)

Decision Letter 2

Sebastian Shepherd

1 Aug 2022

Does previous circumcision and wealth index influence women’s attitude to discontinue the practice of female genital mutilation and cutting (FGM/C) in Ethiopia?

PONE-D-21-07908R2

Dear Dr. Ahmed,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sebastian Shepherd

Staff Editor

PLOS ONE

Additional Editor Comments (optional):

Please note, we have edited your abstract for clarity and style (the edited version is below - and we have also attached a copy of the edited abstract as a word file). Please review these changes and incorporate those that you agree with for the final version of the manuscript.

*** Abstract Edit ***

Introduction: Understanding women’s attitudes towards female genital mutilation is an important step towards eliminating this practice. We used the 2016 Ethiopia Demographic and Health Survey (EDHS) data set to examine the relationship between wealth index and previous history of circumcision on women's opinions whether female genital mutilation (FGM) should be continued or stopped in Ethiopia.

Methods: Data from 6984 women aged 15-49 years were extracted from the 2016 EDHS data set. Multivariable logistic regression analysis was performed to analyse the data.

Result: In this study, women with a higher level of education and wealth index were more likely to support the cessation of FGM. However, circumcised women (AOR: 0.22; 95% CI: 0.15-0.32), women from the Afar region (AOR: 0.34; 95% CI: 0.22-0.50), Somali region (AOR: 0.42; 95% CI: 0.27-0.65), and Dire Dawa region (AOR: 0.51; 95% CI: 0.32-0.83) were less likely to support discontinuation of FGM.

Conclusion: The present study revealed that wealth index, education level, history of circumcision, and regional variation are associated with women’s attitude towards discontinuation of the practice of FGM in Ethiopia. Empowering women in terms of socioeconomic status and education can change attitudes and might help prevent female genital mutilation in the future. Furthermore, interventions targeting FGM practices should focus on regional variance in order to have a meaningful impact on reducing this harmful cultural practice in Ethiopia.

Reviewers' comments:

Attachment

Submitted filename: Abstract - ONE Edit.docx

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Acceptance letter

Sebastian Shepherd

11 Aug 2022

PONE-D-21-07908R2

Does previous circumcision and wealth index influence women’s attitude to discontinue the practice of female genital mutilation and cutting (FGM/C) in Ethiopia?

Dear Dr. Ahmed:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr Sebastian Shepherd

Staff Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    Attachment

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    Attachment

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    Attachment

    Submitted filename: Response to reviewers.docx

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    Attachment

    Submitted filename: Abstract - ONE Edit.docx

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    Data Availability Statement

    We used the USAID–DHS program 2016 Ethiopian demographic and health survey data set for this analysis. To request the same or different data for another purpose, a new research project request should be submitted to the DHS program here: https://dhsprogram.com/data/Access-Instructions.cfm. After receiving permission, the researcher can log in and select the specific data in the format they prefer.

    Articles from PLoS ONE are provided here courtesy of PLOS

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