Women and girls living with female genital mutilation (FGM) are more likely to experience psychological problems than women without FGM. As well as psychological support, this population may need additional care when seeking surgical interventions to correct complications of FGM. Recent WHO guidelines recommend cognitive behavioral therapy for women and girls experiencing anxiety disorders, depression, or posttraumatic stress disorder. The guidelines also suggest that preoperative counselling

10 In the present paper, we first providethemethodologyusedinthedevelopmentandrankingof PICOquestions(Step1)andthendetailthecommonmethodology for each of the systematic reviews and each qualitative evidence synthesis(Step2). | Step 1: Methodology for the development and ranking of PICO questionsThe goal of this step was to develop an evidence-based and expert informed list of the key questions that would help inform a set of recommendations for healthcare workers who work with women andgirlslivingwithFGM.Thisprocesshadthreephases:(1)scanning existingliteraturetoidentifycriticalissuesandknowledgegapsand developing of PICO questions; (2) ranking and prioritizing the PICO questionsthroughanexpert-ledprocess;and(3)selectingandfinalizingthePICOquestions. | Phase 1: Scan of existing guidelines and development of PICO questionsWe identified existing guidelines and a recent publication 12 that summarized the available guidance on the clinical care of women living with FGM. From this publication, we identified and framed

Deinfibulation can prevent or treat gynecological and obstetric complications in women living with type III female genital mutilation (FGM), and subsequently improve childbirth outcomes. Recently published WHO guidelines recommend use of deinfibulation in both circumstances. However, to really impact practice, evidencebased guidance needs to be matched with evidence-based implementation strategies. This qualitative evidence synthesis provides information on the factors that facilitate or act as barriers to use of deinfibulation, and the context and conditions that are necessary for implementing the procedure, including healthcare providers' knowledge and experience, the service delivery environment, as well as broader health system contexts. This information is of great value for policy makers and others considering this as an option for better clinical care of women living with | SUMMARY OF THE EVIDENCESix studies were included in the qualitative synthesis (more detailed methods in Stein et al. 4 ). All identified studies were conducted in the following high-income countries: France (n=1), 5 Norway (n=2), 6,7 Sweden (n=2), 8,9 and the UK (n=1), 3 and included immigrant women and healthcare providers as participants. Two studies specifically explored women's experience of deinfibulation, three explored healthcare providers' experiences of caring for women with FGM during pregnancy and childbirth, and in one the focus was on women's motivations for clitoral repair.

Background In settings with high prevalence of female genital mutilation (FGM), the health sector could play a bigger role in its prevention and care of women and girls who have undergone this harmful practice. However, ministries of health lack clear policies, strategic plans or dedicated funding to implement anti-FGM interventions. Along with limited relevant knowledge and skills to prevent the practice of FGM and care for girls and women living with FGM, health providers have limited interpersonal communication skills and self-efficacy, while some may have supportive attitudes towards FGM and its medicalization. We propose to test the effectiveness of a health system strengthening intervention that includes training antenatal care (ANC) providers on person-centred communication (PCC) for FGM prevention. Methods This will be a two-level, hybrid, effectiveness-implementation research study using a cluster randomized trial design in Guinea, Kenya and Somalia conducted over a 6 months period. In each country, within pre-selected regions/counties, 60 ANC clinics will be randomized to intervention and control arms. At baseline, all clinics will receive the level one intervention involving provision of FGM-related clinical guidelines and handbook as well as anti-FGM policies and posters. At month 3, intervention clinics will receive the level two intervention comprising of a training for ANC providers on PCC to challenge their FGM-related attitudes and build their communication skills to effectively provide FGM prevention counselling. A process evaluation will be conducted to understand ‘how’ and ‘why’ the intervention package achieves intended results. Multi-level regression modelling will be used for quantitative data analysis while qualitative data will be assessed using thematic content analysis to determine the effectiveness, feasibility and acceptability of the different intervention levels. Discussion The proposed study will strengthen the knowledge base regarding how to effectively involve health providers in FGM prevention and care. Trial registration Trial registration and date: PACTR201906696419769 (June 3rd, 2019).

Providing information and education to women and girls living with female genital mutilation(FGM)couldbeanimportantinfluenceontheirhealthcare-seekingbehavior. Healthcare providers also need adequate knowledge and skills to provide good qualitycaretothispopulation.RecentWHOguidelinesonmanaginghealthcomplicationsfromFGMcontainbestpracticestatementsforhealtheducationandinformation interventions for women and providers. This qualitative evidence synthesis summarizes the values and preferences of girls and women living with FGM, and healthcareproviders,togetherwithotherevidenceonthecontextandconditionsof