Women's rights in Djibouti

Maternal obesity is highly prevalent in Djibouti, a condition which increases the risk of cesarean delivery.[4]

A high rate of cesarean delivery among obese women has been observed in Sub-Saharan Africa, with rates over 50% in some studies.[5]

Prevalence of maternal obesity is high in Djibouti City and is related to an excess risk of cesarean delivery, even after controlling for a range of medical and socioeconomic variables.[4] The present study has shown that maternal obesity is very prevalent in Djibouti City, with rates between 24.8% before 14 weeks of pregnancy and 43.2% at delivery.[4] Rates of cesarean were increased among obese women, especially among primiparae.[4]

International guidelines recommend that obese women should be referred for delivery in a facility with available skilled medical staff, but a recent study showed that the availability of such emergency obstetric care was poor in African hospitals and clinics.[4] However, at the Affi Hospital maternity clinic, midwives, pediatricians, anesthesiologists, and obstetricians are available 24 hours a day.[6]

Djibouti is the location with the highest rate of female genital mutilation in the world.[7] 93% of women in Djibouti undergo the procedure.[8]

In Djibouti, female genital mutilation is often done in traditional styles, without using sterile and sanitary tools.[4] It involves cutting a part of girls' genitals using cutting utensils such as knives, scissors, rulers, blades or even pieces of glass and then stitching it up with thread; thereafter, things like oil, honey, yogurt and tree leaves are applied to stop the bleeding.[7]

Type IV (infibulation) circumcision includes pricking, piercing, incising, scraping and cauterization. Infibulation is mostly practiced in the Horn of Africa including Djibouti.[9]

Map showing the prevalence of FGM

Since 1988, concerned authorities in Djibouti have been trying to abolish FGM. This practice was made illegal in 1990 and was specially mentioned as a violation of the rights of women and children.[4] The procedure is usually performed at home in the absence of sterile conditions or anesthesia and by traditional practitioners or trained midwives.[4] For urban populations, infibulation is frequently carried out by health professionals (nurse, midwife, doctor) acting clandestinely.[10]

In Djibouti in 1995 and 2009, the government recognized FGM as an act of crime and those who are encouraging or operating female genital mutilation are considered as criminals.[7]

The First Lady launched a campaign in 2008 with the presence of the President of the National Assembly and several Ministers and with the support from the United States Ambassador.[11]

Since 1988, the Djibouti Women's Association has run a huge campaign to ban this tradition.[7]

In 1995, the National Assembly declared illegal and punishable the practice of FGM/C but the article of the National Penal Code related to this issue has never been applied up to present.[12] In 1997 the Ministry of Health assisted with the United Nation Fund for Population (UNFP) promoted the “Project to Fight Female Circumcision” within a larger frame of "restoring the dignity and respect of women" and "to raise the condition of women within society."[11]

The consequences of this practice are evidenced by the high maternal death rate suffered in Djibouti and Somalia (> 700 per 100 000 live births) where FGM/ C is almost universal when compared to other nearby countries with a similar health and midwifery care but where FGM/C is much less common (Kenya and Tanzania: < 500 per 100 000 live births).[11]

A tight infibulation can be a high risk for the mother and fetus if not handled by a skilled operator.[10] It can lead to an unnecessary cesarean section as a result of the fear of handling infibulated women.[10]

A study was conducted regarding FGM and pregnancy in Djibouti.[13] Overall, 29 of 643 women did not have any form of mutilation (4.5%), as opposed to 238 of 643 women with infibulation (37.0%), 369 with type 2 (57.4%), and 7 with type 1 mutilation (1.1%).[13] Women with a severe type of mutilation were more likely to have socio-economic and medical risk factors.[13] Conclusions: Infibulation was not related with excess perinatal morbidity in this setting with a very high prevalence of female genital mutilation, but future research should concentrate on the relation between infibulation and meconium.[14]

At Peltier General Hospital in Djibouti, both the obstetricians and the midwives have developed a high level of expertise in caring for infibulated women.[10] Women with tight infibulation may be advised to have defibulation.[10] Physicians at the hospital have to demonstrate cultural and ethnic sensitivity while explaining the short- and long-term health risks posed by infibulation.[10] This treatment is regarded as a priority gynecologic procedure.[10]