PLOS Glob Public Health plos plosgph PLOS Global Public Health 2767-3375 Public Library of Science San Francisco, CA USA 10.1371/journal.pgph.0000660 PGPH-D-21-01063 Research Article Medicine and health sciencesSurgical and invasive medical proceduresReproductive system proceduresCircumcision Biology and life sciencesPsychologyPsychological attitudes Social sciencesPsychologyPsychological attitudes Social sciencesAnthropologyCultural anthropologyReligion Social sciencesSociologyReligion People and placesPopulation groupingsFamiliesMothers Biology and life sciencesPsychologyBehaviorParenting behavior Social sciencesPsychologyBehaviorParenting behavior People and placesPopulation groupingsAge groupsChildren People and placesPopulation groupingsFamiliesChildren Social sciencesSociologySexual and gender issuesFemale genital mutilation People and placesGeographical locationsAfricaNigeria Circumcising daughters in Nigeria: To what extent does education influence mothers’ FGM/C continuation attitudes? Education, FGM/C continuation attitudes and daughter’s circumcision in Nigeria https://orcid.org/0000-0003-3840-0387 Ackah Josephine Akua Conceptualization Data curation Formal analysis Methodology Writing – original draft 1 2 * Ayerakwah Patience Ansomah Writing – original draft Writing – review & editing 3 https://orcid.org/0000-0001-5243-1855 Boakye Kingsley Writing – original draft Writing – review & editing 4 Owusu Bernard Afriyie Conceptualization Writing – original draft Writing – review & editing 2 https://orcid.org/0000-0002-6957-3216 Bediako Vincent Bio Writing – original draft Writing – review & editing 2 https://orcid.org/0000-0002-2934-5024 Gyesi Millicent Writing – review & editing 5 Ameyaw Edward Kwabena Supervision Writing – review & editing 6 7 Appiah Francis Conceptualization Supervision Writing – original draft Writing – review & editing 4 8 Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom Department of Population and Health, University of Cape Coast, Cape Coast, Ghana Department of Optometry, University of Cape Coast, Cape Coast, Ghana School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Department of Science, St. Vincent College of Education, Yendi, Ghana Institute of Policy Studies and School of Graduate Studies, Lingnan University, Lingnan, Hong Kong L & E Research Consult Ltd, Wa, Upper West Region, Ghana Department of Social Sciences, Berekum College of Education, Berekum, Bono Region, Ghana Robinson Julia Editor PLOS: Public Library of Science, UNITED STATES

The authors have declared that no competing interests exist.

 * E-mail: Josephine.Ackah@lshtm.ac.uk 18 11 2022 2022 2 11 e0000660 5 12 2021 21 10 2022 2022 Ackah et al This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Education has been adjudged as an important behavioural change intervention and a key player in combating Female Genital Mutilation/Cutting (FGM/C). An assumed pathway is that it influences FGM/C attitudes. However, empirical evidence that explores this assumption is scarce. Hence, our study examines whether the associative effect of FGM/C continuation attitudes on circumcision of daughters is influenced by the level of a mother’s education in Nigeria. We extracted data from the 2018 Nigeria Demographic and Health Survey (NDHS). The study focused on youngest daughters that were born in the last five years preceding the survey. A sample of 5,039 children with complete data on variables of interest to the study were analysed. The main outcome variable for this study is “circumcision among youngest daughters”. The key explanatory variables were maternal “FGM/C continuation attitudes” and “education”. At 95% confidence interval, we conducted a two-level logistic regression modelling and introduced interaction between the key independent variables. In the study’s sample, the prevalence of FGM/C was 34%. It was lower for daughters whose mothers had higher education (12%) and believe FGM/C should discontinue (11.1%). Results from the multivariate analysis show statistically significant odds of circumcision for a daughter whose mother has had higher education and believes FGM/C should discontinue (OR-0.28, 95%CI: 0.08–0.98). For women who believe FGM/C should discontinue, the probability of daughter’s circumcision reduced by 40% if the mother has attained higher education. Among those who believe FGM/C should continue, the probability of daughter’s circumcision worsened if the mother had attained higher education (64%), however, this result was influenced by mothers’ experience of circumcision. Education influences FGM/C attitudes, nonetheless, women’s cutting experience can be a conduit for which the practice persists. Promoting female education should be accompanied by strong political commitment towards enforcing laws on FGM/C practice.

 The authors received no specific funding for this work. Data Availability We used data from the 2018 Nigeria Demographic and Health Survey. The data is freely available upon registration at https://dhsprogram.com/data/available-datasets.cfm or IPUMS-DHS (idhsdata.org). Introduction

Female Genital Mutilation/Cutting (FGM/C) is a “surgical procedure involving partial or total removal of the external female genitalia or other injury to the female genitalia organs, whether for cultural or any other non-therapeutic reasons” [1, 2]. FGM/C has received considerable attention in both local and international discussions due to its dehumanizing act and violation of women’s health rights [3–7]. About 200 million women and girls have undergone FGM/C, and additional 68 million girls will undergo the cutting before 2030 if appropriate and timely interventions are not implemented [8]. FGM/C inflicts irreversible and devastating complications on women and they include sexual dysfunction, obstetric complications, psychological trauma [9–12], and death [13, 14]. Also, the use of unsterilized instruments in some contexts predisposes victims to human papillomavirus (HPV) and other infections [15]. As a result, FGM/C is globally recognized as a harmful cultural practice that needs to be eliminated [8].

In the face of increasing global attention, the tradition continues to be widespread and mostly prevails in developing regions with the highest prevalence of FGM/C in sub-Saharan Africa [7, 8] despite restrictions. FGM/C is deep-rooted in African culture and traditions largely due to social norms, quest to suppress female sexuality, aesthetic preferences, social cohesion and religion [16–18]. In Nigeria, the prevalence of FGM/C is high with about one in every five women (15–49) ever circumcised [8]. In the quest to achieve the Sustainable Development Goal (SDG) 5.3 aimed at eradicating all forms of harmful practices against women and children including FGM/C by the year 2030, the Nigerian government formulated and implemented laws, policies, programs and strategies to combat the practice. Notable are the Violence against Persons (Prohibition) Act 2015 (VAPP Act); the 2013/2017 National Policy and Plan for Action for Elimination of FGM/C in Nigeria as well as several anti-FGM/C campaign programs of which the UNFPA-UNICEF Joint Programme on Female Genital Mutilation [19] is noteworthy. “Odimma Nwanyi bu ka Chi Siri Ke” which translates as “wholeness of the female is as created by God” has been the Nigerian campaign slogan for the UNFPA-UNICEF joint programme [19].

The policies and programs have been beneficial, contributing to a decline in cases among women aged 15–49 years from 25 percent in 2013 to 20 percent in 2018 [20]. However, for girls aged 0–14 years, this has not been the case. Recent estimates reveal that the practice is on the rise from 16.9 percent in 2013 to 19.2 percent in 2018; a “worrying trend” [20]. Furthermore, majority of women in Nigeria are cut before reaching their fifth birthday [5]. Estimates from the 2018 Nigerian Demographic and Health Survey revealed that 86.5 percent of circumcised women aged 15–49 years were cut before reaching five years [21]. This implies that the first five years of life is a crucial period within which FGM/C occurs.

Several studies have investigated the underlying socio-demographic and economic predictors of the practice to inform policies and programs [1, 22–24]. Findings reveal that girls that belong to the Islamic religion; reside in poor households; live in rural areas; have mothers with no formal education and whose mothers have ever been circumcised are susceptible to the practice [1, 24]. On the basis of attitude, women who feel FGM/C should continue are more likely to circumcise their children [23] and in Nigeria, the proportion of such women (16-49years) is more than 20 percent [5, 21].

Maternal education plays an essential role in attitudinal and behavioural change, especially in eradicating FGM/C. Education exposes individuals to a wide information base that makes them more likely to adopt healthy behaviours [25]. Higher educational levels translate into better economic [26] and health [27] opportunities that impact women’s health decisions. Women are therefore more likely to opt for the discontinuation of FGM/C if they are highly educated [28–30] with reduced chances of circumcision among their daughters [23]. The associative effect of education on FGM/C has, however, been contested. De Cao and Giulia [31] investigated the impact of the Universal Primary Education program in Nigeria on daughters’ circumcision and found that despite the overall increase in years of education among women, there wasn’t a corresponding statistically significant influence on attitudes towards FGM/C and daughters’ circumcision. Segun [32] also shared that formal education and FGM/C are rather two parallel lines because a substantial number of educated women continue to circumcise their daughters in Nigeria. The results are mixed and further investigation is needed.

A plausible pathway linking maternal education to a daughter’s circumcision is through attitudes toward FGM/C. Ideally, education influences attitudes and it is expected that higher educational levels result in support for FGM/C discontinuation [28, 29] and consequently, reduced probability of circumcision among daughters [1, 23]. Studies that test this assumption are scarce. It is unclear the extent to which the associative effect of women’s disapproval attitudes and daughters’ circumcision varies by maternal educational levels. Furthermore, can an investigation into this explain the mixed results observed in existing findings? Our study addresses these issues by examining data from the 2018 Nigerian Demographic and Health Survey.

 Material and methods Data and sampling

We used data from the 2018 Nigeria Demographic and Health Survey (NDHS). It is a cross-sectional and nationally representative survey that collates information on demographic, health and other socioeconomic characteristics of women, men and children in households. Issues on FGM/C were also covered in this survey. Women were asked about their knowledge, attitude and experience of FGM/C as well as that of their daughters. We found the information on FGM/C in the 2018 NDHS data to be substantive in understanding the relationship linking women’s education, FGM continuation attitudes and circumcision among daughters.

The 2018 NDHS follows a two-stage sampling design. First, 1,400 clusters were selected from the 2006 Enumeration Area census frame [21]. Second, a fixed number of 30 households were sampled from each of the selected clusters resulting in a total sample size of 42,000 households. Additional details of the sampling design are available in the 2018 NDHS report [21]. Our study used data from the children’s and women’s recode files of the 2018 NDHS. The children’s file contains demographic, health and socioeconomic information on all children that were born in the last five years preceding the survey while the women’s file constituted information on all interviewed women from the selected households. Information on circumcision for all daughters born to interviewed women was only available in the women’s file. The data for this study was retrieved from the Integrated Public Use Microdata Series—Demographic and Health Surveys (IPUMS-DHS) website at IPUMS-DHS (idhsdata.org). Datasets from the children’s and women’s files were downloaded separately and later merged for analysis.

The children’s file housed information for 33, 924 children below the age of five years. For this study, all male children were excluded and they constituted 50.9% (17,257) of the sample. We further eliminated all female deaths, and this comprised 8.9% (1491) of the remaining sample. An important part of this research is the attitude of mothers toward FGM/C continuation. Attitudes are susceptible to changes over time or with each successive female birth experience. To ensure that information on attitudes towards FGM/C continuation among mothers during the time of the survey rightly aligns with the circumcision decision of their daughters, we decided to limit our sample to the most recent female birth—youngest daughters born in the last five years preceding the survey. An advantage for doing this was to reduce biases that could lead to reverse causality. In the women’s file, information on circumcision was available for a total of 8,471 youngest daughters. After merging this with the children’s file, the remaining sample reduced to 5300 youngest daughters who were only born in the last five years preceding the survey. After excluding “missing” and “don’t know” responses for the independent variables, our final sample for the analysis constituted 5,039 youngest daughters, born in the last five years preceding the survey and belonging to 1126 clusters.

 Variables Outcome variable

The main outcome variable for this study is “circumcision among youngest daughters”. For each daughter born to a mother, questions on whether they have been circumcised or not were asked. The responses were “No” (0), “Yes” (1) and “Don’t know” (7). Our study focused on FGM/C practice among youngest daughters born in the last five years preceding the survey. For this group, the frequency of “don’t know” responses was 0. FGM/C among youngest daughters reflects the most recent prevalence of the practice in Nigeria.

 Key independent variables

The primary factors for this study are maternal “FGM/C continuation attitudes” and “education”. Women were asked if FGM/C should continue. The responses included “Continue”, “Depends/Doctor recommends”, “Discontinue” and “Don’t know”. Don’t know responses were excluded due to its small sample (<1%). Women were asked about their level of education. Responses included “no education”, “primary”, “secondary” and “higher”.

 Control variables

We controlled for some important factors that existing literature have found to be associated with women’s FGM continuation attitudes and daughters’ circumcision. They were included if information on them were also available in the 2018 NDHS. They are household wealth, place of residence, religion, mother ever circumcised, mother’s age, marital status and whether FGM is an important religious practice [1, 22, 23, 33–37]. Richer household wealth enhances women’s financial access to resources and information that can consequently influence attitudes and circumcision [1, 35]. Opportunities in urban areas (information, access to social interventions and protection) place women and children at a better advantage against circumcision compared to rural areas [33]. We adjust for the influence of religion since it has been found to be associated with FGM practices and others view it as an important reason for which people engage in the practice [22, 36, 37]. If a mother has ever experienced circumcision, there is a higher likelihood that it will influence her FGM/C attitude and daughters’ circumcision [23]. Also, we controlled for marital status and maternal age to account for differences in lifetime FGM/C-related experiences and choices across age and marital groups [1, 37]. All variables and how they were recoded can be found in Table A in S1 Text.

 Statistical analysis

Univariate, bivariate and multivariate analyses were performed to examine the relationships linking mother’s FGM continuation attitudes, education and daughter’s circumcision as well as the influence of other factors. The test of significant differences was performed using the Pearson’s chi-square while percentage distributions were weighted using the sample weighting factor “PERWEIGHT” in the retrieved IPUMS -DHS data. For the multivariate analysis, we adjusted for clustering using multilevel analysis to reduce the overestimation or underestimation of the regression parameters. We conducted a two-level logistic regression modelling with children at level 1 and clusters at level 2. Since the outcome variable is binary, the level 1 variance was constrained to follow the binomial distribution. For the study’s sample, there were 1,126 clusters. To test whether the associative effect of women’s FGM/C continuation attitudes on youngest daughter’s circumcision differs by educational levels, an interaction term (education * FGM/C continuation) was introduced. We tested for multicollinearity using the Variation Inflation Factor (VIF) and the results showed low collinearity among the explanatory variables (Fig A in S1 Text).

A sequential modelling approach was adopted. The first model was an empty model (Model 0) to ascertain the proportion of the variation in circumcised youngest daughters that is attributable to cluster differences, without accounting for any predictors. Model 1 accounted for the key independent variables and the interaction of these key variables was introduced in Model 2. In Model 3, we controlled for some important factors. Confounders were retained in the final model only if they were significant at 5% alpha level. For each of the models, we computed additional model statistics such as the Akaike Information Criterion (AIC), R—squared, and the intraclass correlation coefficient (ICC). These were useful in determining the best candidate model and the contribution of the models to the overall variation in the circumcision of youngest daughters. The best candidate model has the lowest AIC relative to other models. We also show the proportional change in the variance (PVC) of the random effects to determine the contribution of variables in each model to the remaining cluster variance.

 Ethics statement

The 2018 Nigerian Demographic and Health Survey followed all ethical procedures to ensure that participants’ rights were not violated. The survey protocol was reviewed and sanctioned by the National Health Research Ethics Committee of Nigeria (NHREC) as well as the ICF Institutional Review Board [16]. Both written and verbal informed consent were sought from all participants. Consent was also sought from parents/guardian before any information about children were collected. Since the data used for the study was not collected by the authors, access to the data was requested on the DHS Program’s website for data use and was approved. Downloaded data was anonymized. The data is freely available upon registration at https://dhsprogram.com/data/available-datasets.cfm or IPUMS-DHS (idhsdata.org).

 Results Characteristics of sampled daughters

In Table 1, the weighted percentage distribution of sampled youngest daughters in Nigeria that were born in the last five years preceding the survey by their background characteristics has been presented (univariate). For most daughters, their mothers believed that FGM/C should discontinue (60.5%) and a higher proportion of mothers were not formally educated (44.6%). Most mothers (78.2%) disagreed that FGM/C is an important religious practice and for one-third of children, their mothers were circumcised (32.35). Only an estimated nine percent of mothers were aged 40 years and above. The common religion was Islam (66%) and majority of mothers (95.5%) were in union (either married or living with partner). More than half of the sample resided in rural areas (58.7%) and a substantial number of daughters belonged to poorest households (22.7%).

10.1371/journal.pgph.0000660.t001 Weighted percentage distribution of circumcision among youngest daughters by background characteristics.
Background characteristics Univariate Bivariate X2
Youngest daughter circumcised
No Yes
% n % [95%CI] % [95%CI]
FGM continuation attitudes 2111.051***
 Continue 31.5 1495 22.2[20.2,24.3] 77.8[75.7,80.0]
 Discontinue 60.5 3168 88.9[87.8,90.0] 11.1[10.0,12.2]
 Depends/Doctor recommends 8.1 376 64.7[60.0,69.2] 35.3[30.8,40.0]
Mother’s education 435.404***
 No education 44.6 2256 51.3[49.2,53.3] 48.7[46.7,50.8]
 Primary 15.3 767 71.0[67.9,74.2] 29.0[25.8,32.1]
 Secondary 30.8 1553 78.0[76.0,80.0] 22.0[20.0,24.0]
 Higher 9.4 463 88.0[85.0,90.8] 12.0[9.2, 15.0]
FGM is an important religious tradition 549.368***
 Agree 21.8 1120 36.6[33.8,39.5] 63.4[60.5,66.2]
 Disagree 78.2 3919 74.1[72.8,75.5] 25.9[24.5,27.2]
Mother circumcised 847.925***
 No 67.7 3534 79.2[77.9,80.6] 20.8[19.4,22.1]
 Yes 32.3 1505 38.1[35.8,40.5] 61.9[59.5,64.2]
Mother’s age 108.034***
 < 25 24.0 1182 54.5[51.2,57.1] 45.6[42.9,48.4]
 25–29 27.4 1363 69.1[66.7,71.5] 30.9[28.5,33.3]
 30–34 23.6 1170 71.4[68.9,74.0] 28.6[26.0,31.1]
 35–39 15.7 822 71.4[68.2,74.5] 28.6[25.5,31.8]
 40+ 9.3 502 63.7[59.5,68.1] 36.3[31.9,40.5]
Religion 564.298***
 Christian 34.4 1874 87.6[86.1,89.1] 12.4[10.9,13.9]
 Muslima 65.6 3165 54.6[52.9,56.3] 45.4[43.7,47.1]
Marital Status 33.724***
 Not in Union 4.5 233 83.6[78.7,88.3] 16.4[11.7,21.3]
 In Union 95.5 4806 65.1[63.8,66.5] 34.9[33.5,36.2]
Place of Residence 161.491***
 Urban 41.3 1875 76.0[74.1,77.8] 24.0[22.2,25.9]
 Rural 58.7 3164 58.9[57.2,60.7] 41.1[39.3,42.8]
Wealth Status 219.217***
 Poorest 22.7 1198 52.9[50.0,55.8] 47.1[44.2,50.0]
 Poorer 21.1 1075 63.0[60.1,65.9] 37.0[34.1,39.9]
 Middle 20.4 1001 64.3[61.4,67.2] 35.7[32.8,38.6]
 Richer 19.3 939 71.7[68.9,74.5] 28.3[25.5,31.1]
 Richest 16.6 826 83.0[80.5,85.5] 17.0[14.5,19.5]
Overall 100 5039 66.0 34.0

% Percentages are weighted CI—Confidence interval

*** p < 0.001

aMuslim category includes a small percentage of Traditional/Other (0.6%)

 Bivariate results

The weighted percentage distribution of sampled daughters by their circumcision status and background characteristics, corresponding 95% confidence intervals as well as Pearson’s chi-square are shown in Table 1. Overall, about one-third of all youngest daughters (34%) that were born in the last five years preceding the survey in Nigeria had been circumcised. The Pearson’s chi-square test results revealed that the observed differences in circumcision status across all background characteristics were significant. Circumcision among children whose mothers feel FGM/C should continue was high and ranged between 75.7% and 80.0%. There was lower prevalence among youngest daughters whose mothers had attained secondary and higher education at 22.0% and 12.0%, respectively compared to those whose mothers have no education (48.7%).

Among children whose mothers agreed to FGM/C as an important religious practice, there was high prevalence of circumcision and it ranged between 60.5% and 66.2%. Likewise, if a mother had been circumcised, the probability of circumcision for her daughter ranged between 59.5% and 64.2%. The practice was also highest among children whose mothers were aged less than 25 years (45.6%). For children whose mothers were Christians, a higher proportion was not yet circumcised at the time of the survey (87.6%). However, for children whose mothers were Muslims, the proportion of uncircumcised daughters was 54.6%. Among mothers in union, higher prevalence of circumcision was observed among their daughters (34.9%) compared to those not in union (16.4%). Residing in rural areas and belonging to poorest households were characterized by high prevalence of 41.1% and 47.1% compared to other residential and wealth categories, respectively.

 Predictors of FGM/C among youngest daughters

Table 2 shows the odds of being circumcised, their corresponding 95% confidence intervals, random effect and other model statistics. The intraclass correlation coefficient (ICC) in the null model indicates that without accounting for any predictors, 69.1% of the variation in FGM/C among sampled youngest daughters is attributable to cluster differences. In Model 1, we accounted for the key independent variables—FGM/C should continue and education—and both were significant. When these key factors were included in Model 1, the cluster variance reduced by 50.9%. This means that, women’s belief on whether FGM/C should continue and their educational background explain half of the variation in the circumcision of youngest daughters that is attributable to cluster differences in Nigeria. Interaction between these two factors was introduced in Model 2 to investigate whether a mother’s education is important in influencing the associative effect of her FGM/C continuation attitudes on daughter’s circumcision. The interaction was significant. The inclusion of the interaction term increased the remaining cluster variance marginally by 4.3%. Model 3 controlled for the influence of potential confounders. Adding the confounders reduced the remaining cluster variance by 10.4%. When the control variables were introduced, the interaction remained statistically significant at p<0.05. We find Model 3 to be the best candidate model since it had the lowest AIC (3305.9) compared to the other models. The R-squared for this model reveal that an estimated 50% of the variation in circumcision among youngest daughters is explained by the independent variables in the model. The interpretation of the odds ratio is based on Model 3.

10.1371/journal.pgph.0000660.t002 Logistic regression results of circumcised daughters by background characteristics.
Background characteristics Model 0 Model 1 Model 2 Model 3
OR[95%CI] OR[95%CI] OR[95%CI] OR[95%CI]
FGM/C continuation attitudes
 Continue 1.00 1.00 1.00
 Depends/Doctor recommends 0.07[0.05,0.11]*** 0.07[0.05,0.11]*** 0.09[0.06,0.16]***
 Discontinue 0.02[0.016,0.029]*** 0.03[0.02,0.04]*** 0.05[0.04,0.08]***
Mother’s education
 No education 1.00 1.00 1.00
 Primary 0.68[0.48,0.94]* 0.83[0.48,1.46] 0.95[0.52,1.73]
 Secondary 0.68[0.51,0.92]* 1.04[0.64,1.69] 1.28[0.74,2.21]
 Higher 0.43[0.26,0.70]*** 1.59[0.53,4.76] 1.83[0.58,5.79]
FGM/C continuation attitudes: Education
 Continue: No education 1.00 1.00
 Depends: Primary 1.74[0.57,5.34] 1.48[0.44,4.98]
 Discontinue: Primary 0.60[0.30,1.21] 0.61[0.29,1.28]
 Depends: Secondary 0.95[0.35,2.58] 0.99[0.34,2.95]
 Discontinue: Secondary 0.47[0.26,0.85]* 0.66[0.36,1.21]
 Depends: Higher 0.69[0.09,5.15] 0.98[0.12,8.10]
 Discontinue: Higher 0.15[0.04,0.50]** 0.28[0.08,0.98]*
Control variables
FGM/C is an important religious practice
 Agree 1.00
 Disagree 0.69[0.50,0.93]*
Mother circumcised
 No 1.00
 Yes 13.06[9.70,17.58]***
Mother’s age
 < 25 1.00
 25–29 0.65[0.48,0.88]**
 30–34 0.63[0.46,0.88]**
 35–39 0.72[0.50,1.03]
 40+ 0.82[0.55,1.22]
Religion
 Christian 1.00
 Muslima 4.54[3.03,6.79]***
Marital status
 Not in Union 1.00
 In Union 2.50[1.31,4.76]**
Place of Residence
 Urban 1.00
 Rural 1.79[1.21,2.65]**
Wealth Status
 Poorest 1.00
 Poorer 0.71[0.51,1.00]*
 Middle 0.72[0.49,1.06]
 Richer 0.58[0.38,0.88]*
 Richest 0.53[0.32,0.88]*
Random Effect
Cluster Variance [SE] 7.34[0.08] 3.604[0.06] 3.76[0.06] 3.37[0.05]
Δ% Cluster variance - -50.9 4.3 -10.4
Model statistics
Marginal R-squared (%) 0.00 32.5 32.7 49.9
AIC 4794.8 3715.1 3710.0 3305.9
ICC (%) 69.1 52.3 53.3 50.6

OR—Odds Ratio CI—Confidence interval

*p<0.05,

**p<0.01,

*** p < 0.001

aMuslim category includes a small percentage of Traditional/Other (0.7%).

We found that the odds of circumcision among youngest daughters were low if the mother who believes FGM/C should discontinue has also attained higher education. There were reduced odds of 0.28[0.08,0.98] of being circumcised among such women compared to those whose mothers approve of FGM/C continuation and have no formal education. Fig 1 shows the predicted probabilities (marginal effects) for the interaction (values for Fig 1 are shown in Table 3). As observed, daughters of women who believe FGM/C should discontinue have the lowest chances of being circumcised irrespective of mother’s education, compared to the other attitude categories. For this group, it can be observed that the probability decreased further by an estimated 40% if the woman has had higher education (3.0%) compared to having no education (5.0%). Among women who believe FGM/C should continue, the probability of their daughter being circumcised worsened for those with secondary (55%) and higher education (64%) compared to those with no formal education (49%). Given this result, we decided to further investigate the characteristics of mothers who believe FGM/C should continue. In our study’s sub-sample of only women who believe FGM/C should continue, a higher proportion of those who have secondary and higher education had been circumcised (Table B in S1 Text).

10.1371/journal.pgph.0000660.g001 Predicted probabilities of circumcision among youngest daughters by mother’s education and attitude to FGM/C continuation. 10.1371/journal.pgph.0000660.t003 Values for <xref ref-type="fig" rid="pgph.0000660.g001">Fig 1</xref>.
Continue Depends Discontinue
No education 49.0% [38.0%,61.0%] 8.0% [0.5%,14.0%] 5.0% [3.0%,8.0%]
Primary 48.0% [33.0%,63.0%] 11.0% [4.0%,27.0%] 3.0% [2.0%,5.0%]
Secondary 55.0% [43.0%,67.0%] 10.0% [4.0%,23.0%] 4.0% [3.0%,7.0%]
Higher 64.0% [36.0%,85.0%] 14.0% [3.0%,50.0%] 3.0% [1.0%,5.0%]

The daughters of mothers who disagreed that FGM/C is a religious practice had lower odds of being circumcised, compared to those whose mothers agree that FGM/C is a religious practice (OR = 0.69, 95% CI: 0.50–0.93). If a mother had been circumcised, her youngest daughter had an increased odds of being circumcised as well (OR = 13.06, 95% CI: 9.70–17.58). The associative effect of mother’s age on daughter’s circumcision was only significant among some specific age groups. Compared to the daughters of women aged less than 25 years, there were statistically significant lower odds of 0.65[0.48,0.88] and 0.63[0.46,0.88] of being circumcised for those whose mothers were within the 25–29 and 30–34 age groups, respectively. Children whose mothers were Muslims (with a small proportion of Traditional and Other religion) had increased odds of 4.54[3.03,6.79] of being circumcised compared to those whose mothers were Christians. There were also higher odds of 2.50 [1.31,4.76] of being circumcised if the mother was in union compared to those whose mothers were not in union. Living in rural areas increased the odds of being circumcised by 79% (OR = 1.79, 95% CI: 1.21–2.65) relative to living in urban areas. Furthermore, living in the richer and richest household was protective as it reduced the odds of the youngest daughter being circumcised by 42% (OR = 0.58, 95%CI: 0.38–0.88) and 47% (OR = 0.53, 95%CI: 0.32–0.88), respectively, compared to living in poorest households. Those that were in the middle and poorer households were not significantly different from those in poorest households. The actual p-values for Model 3 can be found in Table C in S1 Text.

 Discussion

Our study affirms the worrying concerns raised by UNICEF on the rise of FGM/C among young girls in Nigeria [20]. In our study, among the most recent female births in the last five years preceding the survey, a third had already been circumcised. This implies that future prevalence of the practice is likely to have a corresponding increase and reveals inherent relapses that call for more stringent interventions. For most advocacies and social interventions, education has been adopted as a key strategy—either through public education or the formal educational system [38]. Our study investigated the latter and corroborating the findings from other studies [23, 28], we found that individuals who have attained higher education are less likely to circumcise their daughters. The formal education system exposes women to health information and interventions that enhance their knowledge levels and contributes to attitudinal changes [38]. They are also more likely to be empowered to advocate against harmful traditional practices such as FGM/C, thus the evidence in their decision not to circumcise their daughters.

While the formal educational system is key, expanding public education on FGM/C to reach women with no or little education is also crucial. Asekun-Olarinmoye and Amusan [39] conducted an intervention study to examine the impact of health education on attitudes towards FGM/C in a rural Nigerian community and reported that after the health education on FGM was introduced, there were positive changes in FGM attitudes, not only among women but also men. There was a decrease in men who did not want the practice to stop and an increase in women with no intention to excise future female children. Their study also drew attention to the fact that changing attitudes requires more than just health communication. It also requires skill building and support to enhance individuals’ economic capacities. Affirming this is Doucet et al.’s study in Conakry, Guinea [40] who identified that addressing the FGM/C problem involves moving beyond one’s “will” to adopt essential empowerment conditions such as the provision of social support and financial independence.

Our study investigated whether the associative effect of FGM continuation attitudes on the circumcision of daughters is partly dependent on maternal education. The results revealed mixed effects. For daughters whose mothers believe FGM/C should discontinue, though the probability of being circumcised was generally low, it further reduced by 40% if the mother had received higher education. This supports the importance of formal education in influencing FGM/C attitudes and practices among daughters. Our findings are, however, contradictory to what De Cao and Giulia [31] found when they explored the impact of the universal primary education programme. De Cao and Giulia [31] reported that the Universal Primary Education programme in Nigeria helped increase the mean years of schooling among women, however, it did not necessarily translate into reduced circumcision among their daughters or drastic changes in their attitude to FGM/C. While their study focused on the contributions of primary education, our findings included those with higher levels of education and show sharp difference. Efforts at the formal education front need to encourage and promote women’s education to higher levels.

The results, nevertheless, also revealed that among those who believe FGM/C should continue, the probability of a daughter being circumcised worsened if the woman had attained secondary or higher education (Fig 1). Similar pattern was also observed for those in the “Depends/Doctor recommends” category. The large confidence intervals (Fig 1) show high uncertainty for this result, nonetheless, the estimates reveal nuances that could be explored. Further investigation showed that among the sub-sample of women who believe FGM/C should continue, a higher proportion of those who had attained secondary or higher education had been circumcised (Table B in S1 Text). We therefore consider women’s circumcision experience as the underlying (indirect) cause for this observed relationship. Among daughters whose mothers had ever experienced the practice, the odds of being circumcised increased by thirteen folds. This means that despite women’s high educational levels, their experience of circumcision can still affect their FGM/C continuation attitudes and consequently, increase the chances of daughter’s circumcision. Future studies that explore the role of education on FGM/C need to highlight the boundaries and limitations of women’s self-experience of the practice and consider an in-depth look at the socio-cultural processes that come into play to influence women’s beliefs and/or choice to circumcise their daughters.

We controlled for the influence of other factors—mother’s age, religion, marital status, whether FGM/C is an important religious practice, place of residence and household wealth. Our findings of reducing odds of daughter’s circumcision with increasing mother’s age contradicts what has been reported in existing literature [37, 41]. In the study’s sample, almost half of women aged less than 25 years (45%) had circumcised their daughters and this was high relative to the other age categories. Women of younger ages may be susceptible to lower autonomy levels and strong influence of significant others in favor of FGM/C.

The high prevalence of FGM/C among Muslims has been affirmed in other studies [1, 37]. In this religious group, female circumcision is considered as “Makramah” (means, honourable deed) for women [42] and thus provides some form of identity/belongingness. Therefore, for mothers who believe FGM/C is an important religious practice, daughter’s circumcision is high. Towards ending the practice, religious leaders need to be involved in every stage of FGM/C intervention design and implementation.

A perceived social advantage of FGM/C is the matrimonial opportunities it provides and through this, a conduit for FGM/C to persist [6]. Women in union, as found in other studies[1, 43], are more likely to circumcise their children, not only because they have experienced the practice themselves, but also, to enhance their daughter’s marriageability, which perhaps, they might have benefitted from. Rural areas and poorest households are nests for FGM/C among girls as affirmed in other studies [1, 33, 35]. These socio-economic conditions are associated with vulnerability, socio-cultural influences and limit to information access which influence women’s decision to circumcise or not circumcise their daughters.

FGM/C is a global public health issue and the findings from Nigeria reveal dynamics that could explain evidence found in similar socio-cultural contexts. Our results show that global public health interventions that prioritize female education as a conduit to modifying attitudinal changes regarding FGM/C need to keenly consider circumcision experience of mothers and what that means for them in their social and familial context. The quest to enhance attitudinal and behavioural change towards FGM/C must take into consideration all possible external factors to ensure a holistic implementation of interventions and achievement of desired results.

Strengths and limitations

Our study has some strengths and limitations. First, it is novel in investigating the pathway linking education, FGM/C continuation attitudes and daughters’ circumcision. Our results are also drawn from a nationally representative data which makes our findings generalizable, however, relationships derived are only associations and not causation. Our work was limited to a cross-section of the most recent female births in the last five years preceding the survey. Some girls in the data are still susceptible to being circumcised. We acknowledge the possible influence of social desirability bias since questions on FGM/C—attitudes and experience—were self-reported. Besides, there is the possibility that some FGM/C were not reported due to laws and other factors, thereby leading to underreporting of the overall prevalence. Despite these limitations, the study depicts a nationally representative perspective of the phenomenon.

 Conclusion

The study produces useful insight into how education influences FGM/C which could aid in designing public health educative programs and interventions targeted at addressing FGM/C practices in Nigeria. Education influences FGM/C attitudes, however, women’s cutting experience can be a conduit for which FGM/C supportive attitudes persist. Promoting female education should be accompanied by strong political commitment toward enforcing laws on FGM/C practice. Law enforcement agencies, religious leaders and community/opinion leaders need to strengthen their collaborative efforts geared toward the fight against FGM/C in Nigeria. Furthermore, interventions designed to tackle FGM/C could be holistic to consider other socioeconomic and cultural factors such as wealth status, urbanization, religion and beliefs surrounding FGM/C. Programs could also consider community differences in its design to meet the needs of women from diverse communities.

 Supporting information Supporting tables and figure.

(DOCX)

 Inclusivity in global research.

(DOCX)

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Factors associated with female genital mutilation among women of reproductive age and girls aged 0–14 in Chad: a mixed-effects multilevel analysis of the 2014–2015 Chad demographic and health survey data. BMC Public Health. 2021;21(1):286. doi: 10.1186/s12889-021-10293-y 33541311 Waigwa S, Doos L, Bradbury-Jones C, Taylor J. Effectiveness of health education as an intervention designed to prevent female genital mutilation/cutting ({FGM/C)}: a systematic review. Reprod Heal. 2018;15(1). doi: 10.1186/s12978-018-0503-x 29650025 Asekun-Olarinmoye EO, Amusan OA. The impact of health education on attitudes towards female genital mutilation (FGM) in a rural Nigerian community. Eur J Contracept Reprod Heal Care. 2008; Doucet MH, Delamou A, Manet H, Groleau D. Erratum: Au-delà de la volonté: Les conditions d’empowerment nécessaires pour abandonner les mutilations génitales féminines à Conakry (Guinée), une ethnographie focalisée (Reprod Health (2020) 17 (61). Reproductive Health. 2020. Ahinkorah BO, Ameyaw EK, Seidu A-A, Yaya S. Predictors of female genital mutilation or cutting among daughters of women in Guinea, west Africa. Int J Transl Med Res Public Heal. 2021;5(1):4–13. Mberu B. Female genital mutilation/cutting in Nigeria: A scoping review. 2017 [cited 2021 Nov 28]; https://knowledgecommons.popcouncil.org/departments_sbsr-rh/597/ Adelekan B, Kareem YO, Abubakar Z, Bungudu K, Aderemi A, Goldson E, et al. Female genital mutilation and sexual behaviour by marital status among a nationally representative sample of Nigerian women. Reprod Health [Internet]. 2022 Dec 1 [cited 2022 Sep 11];19(1):1–9. Available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-022-01379-w 10.1371/journal.pgph.0000660.r001 Decision Letter 0 Davison Colleen M. Academic Editor 2022 Colleen M. Davison This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 0

15 Mar 2022

PGPH-D-21-01063

Circumcising daughters in Nigeria: To what extent does education influence mothers' FGM/C continuation attitudes?

PLOS Global Public Health

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Reviewer #1: This is a well written manuscript.

The background: should be reduced to about 2 pages. Summarize paragraphs 1 and 2 and present in a paragraph. Do the same in paragraphs 6 and 7. Doing this will bring out study rational clearly.

Methods: Summarize the Statistical analysis section.

Other sections are well described

Little language editing is needed

Reviewer #2: PLOS Global Public Health

ARTICLE: Circumcising daughters in Nigeria: To what extent does education influence mothers' FGM/C continuation attitudes? --Manuscript Draft-- Manuscript Number: PGPH-D-21-01063

Overall, I think this paper is quite important in highlighting the role of education in efforts to eradicate FGM. However, the authors need to go beyond presenting their results and offer a discussion with substance to be published. That is why I consider the recommendation REVISE & RESUBMIT.

INTRODUCTION.

1. Line 66 FGM/C has no health benefit. It is however a clear violation of girls and women’s human rights 67 as it inflicts irreversible and devastating complications such as sexual dysfunction, obstetric 68 complications and psychological trauma among survivors [5],

Authors could reference specific studies done on psychological aspects of FGM/C in Nigeria and elsewhere. See:

Berg, R. C., Denison, E. M. L., & Fretheim, A. (2010). Psychological, social and sexual consequences of female genital mutilation/cutting (FGM/C): a systematic review of quantitative studies. Norwegian Knowledge Centre for the Health Services.

Omigbodun, O., Bella-Awusah, T., Groleau, D., Abdulmalik, J., Emma-Echiegu, N., Adedokun, B., & Omigbodun, A. (2020). Perceptions of the psychological experiences surrounding female genital mutilation/cutting (FGM/C) among the Izzi in Southeast Nigeria. Transcultural psychiatry, 57(1), 212-227.

Omigbodun, O., Bella-Awusah, T., Emma-Echiegu, N., Abdulmalik, J., Omigbodun, A., Doucet, M. H., & Groleau, D. (2021). Escaping Social Rejection, Gaining Total Capital: The Complex Psychological Experience of Female Genital Mutilation/Cutting (FGM/C) Among The Izzi in Southeast Nigeria. BMC Reproductive Health

Mulongo, P., Hollins Martin, C., & McAndrew, S. (2014). The psychological impact of female genital mutilation/cutting (FGM/C) on girls/women’s mental health: a narrative literature review. Journal of Reproductive and Infant Psychology, 32(5), 469-485.

2. Line 84 SDG target 5.3

What does SDG mean?

3. Line 102 Social and behavioural change towards FGM/C has been a major tool to suppressing the practice.

Need to be more specific here. What kind of change are you referring to?

4. Line 125 A plausible pathway linking maternal education to daughter’s circumcision is through attitudes 126 towards FGM/C.

This statement needs to be substantiated in term of the rational as well as supporting references. What about daughter’s education?

5. Line 131 The study produces useful insight on how education influence FGM/C which could 132 aid in designing public health educative programs and interventions targeted at addressing FGM/C 133 practices in Nigeria.

This sentence goes in the conclusion section not the introduction.

METHODS

6. I cannot comment that section as I am a qualitative researcher.

DISCUSSION

1. The interaction between low education level, positive attitude towards FGM and religion as predictors of FGM practice point to the need to discuss the implications of these variables for public health action; in particular, how girls and women can be educated on the deleterious effect of FGM even if they do not access higher level of education.

2. How can religious leader, in particular Muslim leaders, play an education role to help end FGM?

3. How can other types of education on FGM for mothers, fathers and daughter impact the attitude towards FGM?

4. One of my main problem is that the discussion section is underdeveloped when it comes to discussing the results in the light of the literature especially relating to the interaction of the roles played by education, attitudes (personal and cultural) and personal experience of the mother with own FGM. It seems a bit simplistic to focus the discussion only on anti-FGM policy. While policies and anti FGM laws are important they are not enough. Authors data suggest that attitudes, level of education and personal experience with FGM are key. Some qualitative studies have investigated these factors in different countries and should be discussed to enrich and substantiate the discussion section. For example, the mother’s personal experience with FGM was very important in determining attitude of some parents, who refuse to cut their daughter in a context of universal practice of FGM in Guinea. See:

Doucet, M. H., Delamou, A., Manet, H., & Groleau, D. (2020). Beyond will: the empowerment conditions needed to abandon female genital mutilation in Conakry (Guinea), a focused ethnography. BMC Reproductive health, 17(1), 1-15.

5. Authors should suggest the aspects of sociocultural dimension that would need to be studied in relation to these variables. For example, do future studies need to be comparing women with same level of education (high vs low), attitudes towards FGM (for vs against FGM vs ambivalent), self-experience of FGM (positive, negative, traumatic) to see what sociocultural process and context come into play to influence their decision not to cut their daughters. I this context looking at ‘positive deviants’ proved to be heuristic in understanding sociocultural process that come into play and could guide future strategies to eradicate FGM.

6. Line 375. our findings deviate from the conclusions by De Cao and Giulia [23] who focused on the impact of the 376 Universal Primary Education programme on daughter’s circumcision and FGM/C attitudes.

What do you mean here? Please clarify.

7. Also, what are the implications of these results for global public health?

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Reviewer #1: Yes: Amelia Ngozi Odo, Ph.D.

Reviewer #2: No

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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.

 10.1371/journal.pgph.0000660.r002 Author response to Decision Letter 0 Submission Version 1

10 Jun 2022

Submitted filename: Response to Reviewers.docx

 10.1371/journal.pgph.0000660.r003 Decision Letter 1 Davison Colleen M. Academic Editor 2022 Colleen M. Davison This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 1

5 Sep 2022

PGPH-D-21-01063R1

Circumcising daughters in Nigeria: To what extent does education influence mothers' FGM/C continuation attitudes?

PLOS Global Public Health

Dear Dr. Ackah,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’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.

Please submit your revised manuscript by Oct 05 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 globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Colleen M. Davison

Academic Editor

PLOS Global Public Health

Journal Requirements:

1. Please amend your online Financial Disclosure statement. If you did not receive any funding for this study, please simply state: “The authors received no specific funding for this work.”

2. 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.

Additional Editor Comments (if provided):

The third reviewer (brought on after the first revision) has a few minor edits that the authors should address.

[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

Reviewer #3: (No Response)

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2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. 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 #3: Yes

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

PLOS Global Public Health 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

Reviewer #3: Yes

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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: I am satisfied with the revision

Reviewer #3: General comment: Thank you very much for the opportunity to review this manuscript. Overall, the study provides fascinating insights into the link and associative effects between education, FGM/C continuation attitudes, and daughters’ circumcision in Nigeria. The findings have important implications for policy and programmatic interventions for reducing the high prevalence of FGM/C in Nigeria and other West African countries with similar socio-demographic characteristics. I have a few suggestions, comments, and questions that the authors may want to consider in strengthening the manuscript. They are as summarized below:

Methods: Line 161-162: The authors stated that the study considered “youngest daughters who were only born in the last five years preceding the 2018 DHS”. Although this may reflect the most recent prevalence of the practice in Nigeria, in other countries such as The Gambia, the recent DHS reported that while the younger population of children between 0 to 14 years reveals a lower number of 51 percent, 27 percent of children between the age of 0 and 4 years old have been subjected to FGM/C. So, the practice of FGM/C could even happen as soon as the child is born usually at home and not reported by parents for fear of the law, which may not be captured in the most recent DHS.

Results: Line 304-305: There were also higher odds of 2.50 of being circumcised if the mother was in union compared to those whose mothers were not in union. What could be the probable explanation (s) for this finding?

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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.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Amelia Ngozi Odo

Reviewer #3: Yes: Mat Lowe

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[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.

 10.1371/journal.pgph.0000660.r004 Author response to Decision Letter 1 Submission Version 2

16 Sep 2022

Submitted filename: Response to Reviewers 2.docx

 10.1371/journal.pgph.0000660.r005 Decision Letter 2 Robinson Julia Staff Editor 2022 Julia Robinson This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 2

25 Oct 2022

Circumcising daughters in Nigeria: To what extent does education influence mothers' FGM/C continuation attitudes?

PGPH-D-21-01063R2

Dear Miss Ackah,

We are pleased to inform you that your manuscript 'Circumcising daughters in Nigeria: To what extent does education influence mothers' FGM/C continuation attitudes?' has been provisionally accepted for publication in PLOS Global Public Health.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

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 globalpubhealth@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.

Best regards,

Julia Robinson

Staff Editor

PLOS Global Public Health

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Reviewer Comments (if any, and for reference):

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 #3: All comments have been addressed

**********

2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #3: Yes

**********

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

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. 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 #3: Yes

**********

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

PLOS Global Public Health 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 #3: 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 #3: (No Response)

**********

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.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Mat Lowe

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