Female genital mutilation / cutting (FGM/C) entails all procedures involving the partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons . There are four main types of FGM/C, the most severe being Type III: infibulation, also referred to as pharaonic . Globally, an estimated 200 million girls and women have undergone the cut , and approximately 70 million girls aged 0–14 years are at risk of being cut .
Historically performed by elderly women, barbers or traditional birth attendants, FGM/C is a physically invasive procedure often associated with multiple adverse impacts [5,6,7]. Immediate potential complications include, among others, infection or abscess formation, septicemia, shock, and death [8,9,10]. Longer-term complications can include pain, scarring, urinary tract infections , and poor obstetric and neonatal outcomes , among others [10, 13, 14].
In Somalia, FGM/C prevalence is nearly universal (98%) among females aged 15–49 years, with infibulation prevalence at 77% among the same group . In 2011 in the self-declared state of Somaliland, prevalence was 99 and 85%, respectively . In a 2016 study among 25 communities living in the Maroodi Jeex and Togdheer regions reported prevalence at 99%, with 80% having undergone infibulation . Despite its high prevalence, differences exist in support for the continuation of FGM/C. In Somaliland, only 29% of females aged 15–49 years favoured its continuation in 2011, compared with 65% in Somalia in 2006 .
Deeply rooted in custom, the social determinants underpinning FGM/C are many and diverse including, among others, rites of passage and cultural obligation, the preservation of chastity, and enhancing female marriageability prospects [18,19,20,21,22,23,24,25,26]. These factors often operate dynamically at the individual, family, community and national levels . In Somaliland, the popularity of the practice is strongly embedded in the Somali culture, despite the decades-long global campaign to eliminate it . The majority of community members (84%) living in Somaliland intend to cut their daughters in the future, with women in particular intending to select a less severe cut that they perceive the community expects them to use .
Programmatic work to prevent and eliminate FGM/C has been initiated that supports the United Nations’ Sustainable Development Goals  by strengthening the World Health Organization’s (WHO) six health system framework building blocks, which includes the health workforce . In 2016 the WHO disseminated guidelines for healthcare workers, managers and policymakers on caring for FGM/C-affected girls and women, service planning, and developing and implementing national and local healthcare protocols and policies . However, while such efforts to address the practice have focused on prevention, less attention has been devoted to treating health complications, building the capacity of healthcare workers to provide optimal care, and engaging care providers as potential agents of behavioural change [32, 33].
In high-income countries, especially those with immigrant communities from high FGM/C-prevalent countries, health systems’ challenges in addressing the needs of those affected are widely reported . Examples include limited staff knowledge around the concept, typology, and prevalence of FGM/C and the protocols for remedial action [33,34,35,36,37,38,39,40,41]. Similar FGM/C healthcare capacity limitations have been found in low-income settings. In sub-Saharan Africa (SSA), one of the few studies investigating healthcare workers’ capacity to manage FGM/C-related complications revealed challenges regarding knowledge and skill sets .
Healthcare providers are potentially critical actors in the prevention of FGM/C and care for its survivors. However, in SSA a considerable number of healthcare workers are either engaging in the practice as cutters, or supporting its continuation. A cross-sectional study of 1288 healthcare providers in six countries found that 25% embraced its continuation, and 24% expressed their intention of subjecting their own daughters to FGM/C . Moreover, the willingness to continue the practice increased among healthcare providers operating in rural-based health facilities, with 43% embracing its continuation and nearly half (47%) intending to subject their own daughters to the practice . Healthcare in Somaliland, as with other Somalia ‘zones’, is largely in the private sector, regulated by the Ministry of Health of the Federal Government of Somalia. The system is largely staffed by undertrained, under-supervised and -paid staff, dependent upon donations from international agencies. The national health system is implemented through the Essential Package of Health Services designed in 2008 to provide a common framework and minimum standards for the delivery of health services in within the framework of the health sector strategic plans. The essential package is implemented across four levels of service provision, each with a standardized service profile and each supported by a standardized set of management and support components and helps define health systems standards for the government, the United Nations, non-governmental agencies and private service providers .
In Somaliland, evidence exists of healthcare workers involvement in cutting, although most report intending to decline requests to cut a girl , a trend towards the medicalization of FGM/C that has been noted in other African countries [42, 43, 45].
Despite high FGM/C prevalence and an increase in the practice’s medicalization in Somaliland, minimal evidence exists on the capacity of healthcare providers and the health system to prevent medicalization of FGM/C and manage FGM/C-related complications. This study therefore investigated the capacity of the healthcare system to manage FGM/C cases and prevent the medicalization of the practice by exploring healthcare workers’ knowledge, training and skills.