Seeking culturally safe care: a qualitative systematic review of the healthcare experiences of women and girls who have undergone female genital mutilation/cutting

Objective To explore the experiences of accessing and receiving healthcare related to female genital mutilation/cutting (FGM/C) across the life course from the perspective of women and girls who have undergone FGM/C. Design A systematic review of qualitative research studies using a thematic synthesis approach. Methods Inclusion criteria were qualitative studies (including grey literature) of any design, from Organisation for Economic Co-operation and Development (OECD) countries, of any date and any language. Sixteen electronic databases were searched from inception to December 2017, supplemented by reference list searching. Papers were screened, selected and quality-appraised by two reviewers using established tools from the Joanna Briggs Institute. NVivo software was used to extract study characteristics and code study findings. An inductive thematic synthesis approach was undertaken to identify descriptive themes and interpret these into higher order analytical constructs. Confidence in the review findings was assessed using Grading of Recommendations, Assessment, Development and Evaluations-Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual). Results Fifty-seven papers (from 55 distinct studies) from 14 different OECD countries were included (50% published within the last 8 years). One-third of studies focused exclusively on maternity care experiences, whereas others covered a range of foci. No studies reported explicitly on girls’ experiences or on experiences of health service-led safeguarding interventions. Only three studies addressed psychological care. The synthesis developed 17 descriptive themes, organised into 5 analytical constructs. These related to communication, access to care, experiences of cultural dissonance/integrity, disempowering care experiences and positive care encounters. The themes illuminate significant challenges to obtaining timely and holistic care (especially for deinfibulation), and highlight different ways in which women may experience care as disrespectful, unsafe and disempowering. Key elements of ‘culturally safe care’ are identified. Conclusions This review has highlighted key knowledge gaps, especially around (1) girls’/unmarried women’s experiences and (2) the impact of recent safeguarding interventions. There is an ongoing need for community engagement, service development and staff training. PROSPERO registration number CRD420150300012015.


INTRODUCTION
Health services in higher income countries are said to be operating in a context of 'superdiversity', [1][2][3][4][5] Whereas in previous decades, in-migration was primarily from a limited number of countries traditionally linked through former colonial ties, contemporary migration involves groups from many diverse countries across the globe. Super-diversity poses significant challenges to host country health services, in terms of adapting services and providing culturally appropriate and accessible care to very many different migrant groups with widely different migration histories, languages, health needs and social vulnerabilities.
Female genital mutilation (or female genital cutting) -hereafter referred to as FGM/C -is practised in 30 countries across North and sub-Saharan Africa and in parts of the Middle East and Asia. 6 In an era of super-diverse migration, European and other high-income countries (e.g. USA, Canada, Australia and New Zealand) are becoming home to increasing numbers of women and girls who have experienced, or who may be at risk of, FGM/C (within Europe alone there are thought to be over half a million women and girls who are FGM/C survivors). 7 These women and girls come from highly diverse regions with different cultural traditions, contexts and beliefs associated with the practise of FGM/C, and where different types of FGM/C are practised. For example, in some communities (e.g. within Somalia, Somaliland, Sudan, Eritrea, Kenya) type 3 FGM/C is common involving infibulation (narrowing of the vaginal opening through the creation of a covering seal, formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris). In other communities however, type 1 (partial or total clitoridectomy) or type 2 (partial or total clitoridectomy and removal of the labia minora, with or without excision of the labia majora) are more common. 8 However, it should be noted that these typologies represent biomedical categories and that different communities have their own nomenclature. Moreover, the exact type of FGM/C a woman has experienced may depend to some extent on the skills and experience of the 'cutter' and women themselves may not always be aware of which type of FGM/C they have experienced.
FGM/C can involve immediate and long term psychological, sexual, relational and physical health sequelae. 9 Health problems may be particular severe for women with Type 3 FGM/C who who has been infibulated, which is often necessary for improving health and well-being as well as to allow intercourse or to facilitate childbirth". 8 Currently, deinfibulation is recommended for women and girls reporting medical or psychosexual symptoms related to type 3 FGM/C or upon request (i.e. personal choice). In addition, global guidelines specifically recommend that deinfibulation is undertaken to prevent obstetric complications, although the optimal timing for the procedure (antepartum or intrapartum) is unclear. 9-12 9,13-17 There are compelling clinical reasons however for preferring antepartum deinfibulation, including the fact that it can be performed under local anaesthetic in an out-patient setting, thus reducing costs and risks associated with any emergency procedures that may emerge during labour. 18 In addition, in destination countries where staff may be less familiar with type 3 FGM/C, planned antepartum or pre-marital deinfibulation ensures that it is performed by trained and experienced professionals. 15 In destination countries, it is essential, therefore, that care pathways are developed that are able to support women's potential psychological and sexual health needs, [9][10][11]19,20 as well as supporting decision making around deinfibulation. In addition, health professionals are called upon to play a key role in the prevention of FGM/C, through health education with affected communities and identification of girls who may be at risk. [20][21][22] However, as a cultural phenomenon associated with women's sexuality, gender norms and genital area, FGM/C is a sensitive topic that can be hard for women, communities and health professionals to openly discuss. [23][24][25] Recent studies of health sector involvement in the management of FGM/C in destination countries, show variable availability of specialist services and staff training. 21,26 Moreover, several systematic reviews indicate that health professionals may lack knowledge, confidence and competence in managing FGM/C. [27][28][29] In addition, there are on-going calls for greater community involvement in the development of appropriate services related to FGM/C. [30][31][32] Aim This paper reports the findings of a qualitative systematic review that aimed to explore the experiences of accessing and receiving FGM/C-related healthcare across the life course for women and girls who have undergone FGM/C. 33,34 The review was conceived from an ongoing partnership between an academic team (CE, RT, GH, JMc, JE), clinical experts (JA) and a community organisation working on FGM/C-related issues (VN). By undertaking the review we hoped to illuminate women's voices and experiences in order to inform the provision of FGM/C related healthcare.

Rationale
Several prior reviews have been undertaken in relation to this topic, however we felt a new review was warranted for several reasons. First, most existing reviews have focused upon women's maternity care experiences or maternity-focused interventions. [35][36][37][38][39] However, as indicated above, a key issue for services is the development of joined up care pathways that are able to offer women a range of holistic services at different time points. Hence, our review adopted a focus on the life course. Second, it is well known that migrants experience a range of barriers to accessing health services, [40][41][42][43][44] yet 'access to care' has not been a focus of prior reviews related to FGM/C. Third, several prior reviews have included studies from all over the world, thereby bringing together widely different cultural and health system contexts. [37][38][39] We felt that a review focused just on 'destination' countries, would provide findings that were more transferable to these specific contexts. 45,46 Finally, prior reviews have often limited their searches to English language papers or to published literature only. 35,36 By contrast, this review has included any language and a wide range of grey literature sources, and thus is able to offer an extremely comprehensive picture. 47,48 Theoretical perspective This review is informed by the theoretical construct of 'cultural safety'. 49 Cultural safety derives from critical social theory and argues that, traditional approaches to 'cultural awareness' or 'cultural competence' within healthcare fail to adequately take into account power relations which are historically unequal between migrant or indigenous groups and healthcare providers and services. 50 Within a cultural competence discourse for example, it is argued that "the power to define the norm and the onus for action to understand and know about another culture fall to the health professional/service" p.200. 49 As such, migrant groups remain represented as the 'other' and may be viewed within a deficit model -as a problem that needs to be fixed -rather F o r p e e r r e v i e w o n l y than as partners whose knowledge and values can contribute equally to a relationship or to service development initiatives. Culturally safe practice, by contrast, is predicated upon relationships of mutual trust and respect. It is a transformative and rights based approach, seeking to uphold the principles of respect, dignity, empowerment, safety and autonomy. 51 Cultural safety envisages the healthcare encounter as a negotiated and equal partnership in which trust plays a central role. The healthcare practitioner's role is to enable patients to say how a service can be adapted and to negotiate an agreed approach -a key aspect of shared decision making. 52 The converse of cultural safety is 'cultural risk' 53 in that culturally unsafe practices are defined as: "any actions that diminish, demean or disempower the cultural identity and well being of an individual or group" p7. 54 Cultural safety is not just a feature of individual practice however. It is argued that culturally safe practice must be institutionalised through organisational policies and structures so that it becomes part of mainstream healthcare provision rather than being dependent upon individual practitioners who may or may not adopt its values and approach. [55][56][57] This theoretical perspective is well suited to areas of healthcare involving stigmatised or sensitive topics, such as FGM/C, and where there is a strong need for community engagement in service development and shared decision making in care delivery.

METHODS
This qualitative systematic review is reported following the ENTREQ guidelines. 58 The review was registered in Prospero 33 and the methods are documented in detail in a published protocol. 34

Search strategy
An exhaustive and sensitive three-step search strategy was designed by an experienced information scientist (JE). First, we searched 11 electronic databases using a combination of index terms and text-based queries. These were searched from inception to a cut-off date of 31-12-17. An example search strategy for Ovid MEDLINE is provided in Supplementary File 1.
Second, we searched for relevant grey literature drawing upon five key resources, Google, Google Scholar and suggestions from the project's expert advisory group (see Table 1 for all resources/databases that were searched). 59 63,64 Following the guidance of the Cochrane Qualitative Methods and Implementation Group 65 and the JBI, 47 reports and theses from the grey literature were appraised in the same way as published peer reviewed papers. 59,61,62 Studies were not excluded on the basis of quality, rather, the quality assessment was used to judge the relative contribution of each study to the overall synthesis, and to assess the methodological rigor of each study as part of a process of assessing confidence in the review findings. [66][67][68][69][70] The JBI-QARI tool was applied to each individual paper and an aggregate score for each was calculated. A criticism of 'scoring' qualitative critical appraisals is that it can be hard to distinguish between the poor conduct of a study and poor reporting, especially where journal word limits constrain the level of detail that can be reported. 71 In addition, there is no consensus regarding the relative importance of any one domain within an assessment tool over another, and, hence, whether they should all be given an equal weight or not. In view of these concerns, we chose to adopt a 'weighting system' used in previous studies by Higginbottom et al 72,73 in which papers were grouped into one of three 'bands' -high, medium or low -to enable a broad brush evaluation to be made of their relative quality -see Table 2. A study with a rigorous and robust scientific approach which meets most JBI benchmarks (perhaps 7 or more 'Yes') Medium Between 5-7 A study with some flaws but not seriously undermining the quality and scientific value of the research conducted (perhaps 5-7 'Yes') Low Under 5 A study with flaws and poor scientific value (perhaps below 5 of the benchmarks met) As an additional strategy for overcoming the potential limitations of solely relying upon a checklist to assess quality, we also assessed the 'richness' of the studies. This is an approach outlined by Popay et al, 74 Table 3) and categorized as either 'thick' or 'thin'.

Richness Operational Definition
Thick papers  Offer greater explanatory insights into the outcome of interest  Provide a clear account of the process by which the findings were produced-including the sample, its selection and its size, with any limitations or bias noted-along with clear methods of analysis  Present a developed and plausible interpretation of the analysis based on the data presented. Thin papers  Offer only limited insights  Lack a clear account of the process by which the findings were produced  Present an underdeveloped and weak interpretation of the analysis based on the data presented

Data extraction and assessment of relevance
Study characteristics were extracted by one author (RT) using a modified JBI template and double checked by CE. During this process, papers were categorized in terms of their relevance to the review question. This assessment was made in order to gain a better understanding of the nature of the body of evidence, and also to facilitate the coding process, as described further below. Study relevance was defined as high, medium or low as set out in Table 4. PDFs of all the included papers were imported into NVivo software and the 'findings/results' and 'discussion' sections were coded and analysed. 76

Study Relevance Definition
High (specific) FGM/C-specific healthcare (e.g. the study is focused on a specific aspect of care related directly to FGM/C, e.g. deinfibulation, childbirth for women who have had FGM/C, psychological care) Medium (direct) Other healthcare context (e.g. where the study focus is on the maternity care experience of a particular group more generally and where some of the findings relate to the experience of FGM/C) Low (indirect) Where the study focus is on general attitudes towards FGM/C and/or experiences and consequences of FGM -& where some FGM/C-related healthcare issues are reported, but are not the main focus of the paper as the latter comprise an aggregation of descriptive themes as well as descriptions of patterns or explanations that are inferred as part of the interpretative process. There is, as yet, relatively little guidance for, or experience with, applying CERQual to higher level analytical themes or theories. 84

Search outcome
The search outcomes are reported in detail in the PRISMA flowchart in Figure 1. Fifty seven papers met the inclusion criteria, representing 55 distinct studies. Fifty three papers were in the English language; two were published in German, 88,89 and two in Spanish. 90,91

Study characteristics
Due to the large numbers of studies in this review, a highly summarised description of key study characteristics and key methodological assessments is found in Canada, 100,103,110,118,119,133 Finland, 104 France, 105 Germany, 88,97 Netherlands, 131,141 New Zealand, 112, 115 Norway, 116,138 Spain, 90,91 Sweden, 23,99,106,120,142 Switzerland, 135,136 Scotland, 96,127,128 England 25,92-94, 101,111,114,117,121,123,125,126,129,130,134 and USA. 95,98,102, [107][108][109]113,122,132,137 The studies were a mixture of older and more recent research, with publication dates ranging from 1985 to 2017. However, 29 papers had been published since 2011, hence half of the papers reflected a more contemporary context. Over half of the included papers (n=33) were peer reviewed journal articles. 23 116,130 GP services, 121 identity, 100 pain/embodiment. 110 There were no studies that examined women's experiences of surgical reconstruction following FGM/C and no studies that examined experiences of health-service led safeguarding interventions.
The studies were primarily of adult women. Only one study included girls under the age of 18 years but did not report health-related experiences of this group. 23 There were no studies that focused specifically on healthcare issues related to FGM/C in older (post-child bearing) women.
Hence, although the aim of the review was to explore FGM/C across the life course, the studies all focused on generic issues relating to adult women and no further age-specific differentiation could be made. The majority of studies were with women from FGM/C practising countries in sub-Saharan Africa, and the majority of these included women specifically from countries in the Horn of Africa where type 3 FGM/C is most commonly practised. It is likely therefore, that the findings included in the review reflect issues that may be specific to these population groups and to the experience of type 3 FGM/C. Only three studies explicitly reported including women from Egypt/Middle East but did not differentiate these women's experience from the rest of the sample. 94

Methodological quality
Full details of assessments of methodological quality, richness (thick/thin) and relevance are provided in Supplementary File 4 (see Table 5 for a summary). Thirty papers were assessed as being of high quality, 23 A methodological weakness across many studies was lack of discussion of the underpinning philosophical standpoint (question one of the QARI tool), making it difficult to assess the congruency of the chosen methodology. Likewise, many studies did not describe any clear methodology (simply stating that they adopted a generic 'qualitative approach'). Such studies tended to have 'thin' or mainly descriptive findings, and it was difficult to judge the congruence of the methodology with the research question and the methods (questions two and three on the QARI tool). Finally, a limitation across many studies was lack of discussion of reflexivity (questions six and seven on the QARI tool). Given the sensitive nature of FGM/C (and sexuality or migrant healthcare) as a topic, the failure to explore the researcher's own theoretical standpoint or their role, professional background, ethnicity, experience of FGM/C or relationship to the participants is a significant weakness, making it hard to judge the dependability of the findings. 143

Thematic synthesis findings
The findings from 57 papers were synthesised into five analytical themes which represent a synthesis and interpretative analysis of 17 descriptive themes. Table 6 shows their interrelationship and provides one or two quotes to illustrate each descriptive theme. Hence, the description of themes below does not include quotes. Rather, each analytical theme is explained, followed by an elaboration of its constituent descriptive themes. Due to the large number of studies that contributed findings to each descriptive theme, rather than 'crowd' the text with multiple repetitive references to these individual studies, the reader is referred to a theme matrix   consultations. However, communication about FGM/C presented an additional layer of complexity related to the fact that FGM/C was seen by both women and healthcare providers as a deeply personal, private and sensitive issue touching upon a range of taboos associated with gender, culture and sexuality -all issues that in many societies are shrouded in secrecy and silence. When women encountered providers who were able to overcome taboos and cultural differences, it forged bonds of trust and facilitated an environment in which women were able to talk about their FGM/C and to explore options for care. However, the majority of studies reported challenges and problems with communication and interpretation which led to women being unable to talk about their problems or to explore appropriate treatment options, led them to avoid healthcare in general and generated a sense of mistrust in the system. This theme mainly related to maternity care interactions, but also to communication about cervical cancer screening. 121,127,131,139,140

Theme 1.1 Language barriers and interpretation challenges
The majority of studies (n=31) reported that for women who did not speak the host country language well, communication about FGM/C was hindered by language barriers and problems with accessing interpretation support that was appropriate for discussing highly sensitive and personal issues. Language barriers meant that women were unable to form a trusting relationship with their provider, express their needs adequately or understand information or advice. This led to frustration and increased anxiety, especially in a context where consultation times were often limited. 101,115 In some cases, women felt that they had had poor clinical experiences as a direct result of their inability to communicate about FGM/C. 23,115,127 In other examples, women avoided mentioning their FGM/C at all because they knew they lacked the language to explain. 114 silence. Women reported that FGM/C was rarely discussed within their own communities and likewise they found it hard to discuss it with health providers, especially if these (or the interpreters) were male. For this reason, women preferred the topic to be raised by health providers, however a commonly reported finding was that, even when women appropriately accessed relevant services (for example, GPs or antenatal services, 123,125,126 ) and might appreciate the general care offered, 91,104 healthcare providers often did not ask about FGM/C, even when the consultations were for pregnancy-related check-ups. The consequence was that FGM/C was sometimes not identified or discussed until women presented in the labour room, so opportunities for care planning or birth planning were missed. 96 In addition, some studies reported that women found communication to be easier when supported by a knowledgeable community advocate or confident peer. 96

Theme 1.3 Cultural (in)sensitivity
This theme was reported by 34 studies in which women described experiencing comments and questions from health providers that were perceived as clumsy, insensitive or intrusive. As a result, women reported feeling ashamed, scared or stigmatised. Such encounters inhibited women from talking about their FGM/C and in some cases, led to them avoiding examinations or healthcare services. 88,108 By contrast, culturally sensitive communication was greatly appreciated and enabled women to openly discuss their FGM/C and related questions. 105,123,128 Analytical theme 2 -Access to care: influenced by an interaction of multi-level community and health service processes The review found that access to care related to FGM/C was influenced by an interaction of factors operating at individual and community levels as well as at health system and service levels. At individual and community levels, studies showed that care seeking was influenced by cultural norms around health and sexuality, collective approaches to decision making and the what time period and where. However, the studies also showed that care-seeking choices were shaped by the types of services available and that outcomes were influenced by the extent to which the health system, health services and health practitioners were ready and able to provide the range of support that women may need at different points in their lives. The review showed that there were challenges within communities in terms of seeking care and finding the right services. However, even when services were appropriately accessed, care was sometimes haphazard and sub-optimal due to variable levels of staff expertise and inconsistent and unclear referral pathways, policies and procedures.

Theme 2.1 Influence of cultural norms
Women's care seeking in relation to FGM/C was strongly influenced by wider cultural norms around sexuality and health, including cultural norms on the importance of pre-marital virginity, avoiding male health providers and lack of familiarity with preventive care-seeking. These factors often led women to avoid seeking care unless symptomatic or pregnant. Thirty five studies contributed to this theme.
Women reported that strong cultural imperatives valuing premarital chastity and virginity, meant that they would avoid procedures requiring gynaecological examinations (e.g. pap smears 109, 126,131,140 ), and, especially for those with type 3 FGM/C, the general norm was to avoid seeking deinfibulation prior to marriage and pregnancy due to the cultural pressure to maintain chastity, prove their virginity and to remain 'closed' for their husbands. 109,115,116,123,132,135 This norm was so strong that some studies reported younger women wishing that they could undergo deinfibulation, experiencing unpleasant symptoms and being aware of services, but feeling unable to resist community pressure. 116,117,130 Some exceptions to this norm were reported, but mainly in the context of needing help for particularly difficult or painful symptoms. 123 Care seeking in relation to mental health issues associated with FGM/C was infrequently reported and a few studies suggested that this may also be linked to cultural norms in which

Theme 2.2 Influence of husbands and the family
Nineteen studies reported that access to care in terms of healthcare decision making, especially among Somali women, was strongly influenced by the views and advice of the wider family and peer group. In the maternity context, this had an impact on decision making around uptake of antenatal care and caesarean section. 100, 107,109,113,117,123,142 The family also influenced decision making around FGM/C specifically. For example, as mentioned above, women considering premarital deinfibulation reported that they might avoid informing their direct family members as they were aware that they would otherwise come under strong pressure to change their mind due to fears over their future marital prospects. 129,130 For married women with type 3 FGM, studies indicated that the views of husbands were of paramount importance and that women generally felt that they needed their husband's permission to undergo deinfibulation (outside of the context of delivery). 130

Theme 2.3 Knowledge and information about FGM/C services
Women's knowledge of, and familiarity with, health services was variable. In some cases, women lacked familiarity with the host country health system and this impeded their ability to access care in general. In other cases, women reported being quite familiar with maternity and primary care services, but lacked knowledge and information of FGM/C-specific specialist services (especially non-maternity related services such as counselling) and where and when it may be appropriate to seek help. 117,126,127 One study from the UK suggested that this might be a particular issue for women living in low prevalence areas. 125

Theme 2.4 'Hit & miss' care
When accessing healthcare, women reported that (i) the identification of FGM/C and (ii) provision of appropriate treatment or referrals could be a "hit and miss" process, depending upon individual provider characteristics and practices -rather than being a result of standardised organisational systems and processes. For example, many studies cited situations where opportunities to identify FGM/C during a consultation were missed, which was attributed to providers lacking awareness of FGM (or related specialist services) and hence failing to ask the right questions, or to undertake an examination, or to make timely referrals. 126 Maternity services were more likely to have knowledgeable providers and responsive reporting and follow up systems, but even here, women described situations where they felt their FGM/C had been mismanaged due to lack of awareness and lack of appropriate referrals. 91,121,126,129 The most common issue was failure to have been asked about FGM/C so that it was not included in birth planning discussions and was identified only once labour had started. 111 This theme, was reported in 38 studies, across different countries and time periods.
Analytical theme 3 -Cultural and bodily dissonance: striving for cultural and bodily integrity This analytical theme refers to changes in and challenges to, women's sense of cultural and bodily identity and integrity as a result of their experiences associated with FGM/C in the host country, and particularly through their encounters with the healthcare system (manifested, for example, during experiences of clinical examinations, childbirth, deinfibulation and reinfibulation). The theme describes women's responses to experiences of dissonance, whereby their decision making and actions can be understood as a desire to maintain a sense of cultural and bodily integrity. This theme highlights differences in, and changes to, cultural meanings and values related to FGM/C and how these differences and changes influence the way that women and health professionals define health issues, make decisions around FGM/C care and experience that care. When mutual interpersonal cultural understanding was not achieved, women perceived sub-optimal care and distrusted the health system and their health providers. If women felt understood, they felt safe and reassured, resulting in a sense of bodily and emotional integrity.

Theme 3.1 Moving from normal to different
Some women described becoming aware of FGM/C as something that is 'different' only once they moved to another culture. At this point, some started to become aware of the suffering and symptoms that their FGM/C may have caused them. They started to question and to resist previously taken for granted aspects of their culture and to feel uncomfortable with their own bodies and sexual identity. 139 However women also reported feeling shame and anger at being health professionals, and felt that their culture was misunderstood. 92,93,105,129 This experience of dissonance made some women feel reluctant to mention FGM/C to health providers or caused them to feel extremely uncomfortable during healthcare consultations, thereby limiting the opportunity to discuss the issues more openly and to achieve greater mutual understanding. 99,107,139 This theme was very common -reported in 40 studies. The experience of dissonance and quest for integrity was also seen in views and experiences around deinfibulation and was reported by 28 studies. As noted above, for cultural reasons, 'being opened' medically was seen as necessary primarily after marriage and primarily in the context of pregnancy and childbirth -rather than before. 118,119 There were no studies that explicitly or exclusively focused on the views or experiences of unmarried women, but some studies reported examples of unmarried women where the need to maintain cultural and bodily integrity outweighed the experience of physical pain or discomfort, even when women knew about the option to seek surgical deinfibulation. [115][116][117] There were few reported exceptions to this rule, although one study suggested that for some women, finding out about the option for surgical deinfibulation was empowering and deinfibulation was subsequently seen as a way of asserting control over their bodies and lives. 129  Most studies reported that women preferred to be 'opened' during labour to avoid the pain and trauma of being cut twice. 107,110,116,123,130,135

Theme 4.4 Feeling unsafe and vulnerable
Many studies (n=46) reported care encounters where women felt unsafe and vulnerable, primarily when they were treated by providers who they perceived to be inexperienced in dealing with FGM/C, and when they faced language barriers or were unable to express their own preferences. Such encounters often led to perceived poor quality care or poor clinical outcomes. 101 The consequences ranged from providers failing to recognise, identify or discuss FGM/C, 96 to situations where women felt their care had been adversely affected as a direct result of poor provider skills (for example having unnecessary caesarean sections or extensive perineal tearing). 23,25,88,91,96,115,120,123,126,137,138 Women endured such situations feeling unsafe and highly vulnerable, often describing painful and traumatic experiences. 139  given information and awareness about FGM/C-related services, and involving women and affected communities in FGM service development).

CONFIDENCE IN THE REVIEW FINDINGS
Confidence in review findings (as assessed by GRADE CERQual) ranged from high to medium and there was strong consistency in the findings across countries, population groups and clinical contexts (see Table 6 for the final CERQual assessment for each theme and Supplementary File 6 for the full details of the CERQual evaluation).

FGM/C
The review shows that FGM/C -literally and symbolically -embodies complex processes of cultural change and cultural interaction that are occurring as a result of globalisation, migration and super-diversity. These processes manifest themselves very concretely in healthcare in terms of influencing how individuals seek care, how care is delivered and experienced by all involved, and how services are configured. 2,145,146 This review has shown that, when obtaining care for FGM/C-related issues in a host country, women face common challenges that affect many groups of migrants, but that these are exacerbated. 44,73,[147][148][149][150] Silence, secrecy, stigma and lack of familiarity with FGM/C within the system combine and act as obstacles to identifying FGM/C or to providing women with appropriate care. The care for FGM/C described in this review exemplifies the challenges of achieving 'cultural safety' in health services. Many of the experiences reported in the review describe a situation of physical but also cultural 'vulnerability' or 'risk' whereby women felt physically unsafe but also disrespected in terms of their cultural identity and bodily integrity.
Many of the themes in this review referred specifically to maternity care contexts, and there are striking similarities with themes identified in studies across the world, that highlight disrespect and abuse in maternal healthcare. 35,36,151 However, as this review shows, the same challenges also appear to exist for women with FGM/C in primary care and other health settings. 152-154 . This review has also shown that, in some circumstances, women and providers can overcome

RECOMMENDATIONS FOR CULTURALLY SAFE CARE
The review recommendations fall into three overlapping areas.

Overcoming barriers: community engagement for knowledge and awareness
The review showed that there is a need for communities to be more aware of FGM/C related services and of potential interventions. However, it also highlighted the challenges that women may have in discussing FGM/C within their family or community and with a health provider.
This finding highlights a need for ongoing community involvement and engagement to raise awareness of services and provide support to women who may wish to access help (especially for unmarried or non-pregnant women). 30,31 The review suggests that service models which involve community advocates or community liaison workers may be particularly helpful in encouraging women to access care and to overcome communication difficulties with providers.
Similar models have been found to be effective in other areas of healthcare. [159][160][161][162][163] Breaking the silence: communication, continuity and shared decision making Given the communication challenges around FGM/C, the review findings strongly suggest that the onus of 'breaking the silence' may lie with the healthcare provider, with women stating that they expected and wanted health professionals to raise the issue. It may be appropriate for services to consider routinizing questions around FGM/C in key clinical settings, as has been done for other 'sensitive' clinical issues such as domestic violence or HIV. [164][165][166][167] However, the review also highlighted that providers may lack the confidence or cultural competence to raise the subject in an appropriate and respectful way, potentially missing opportunities to identify FGM/C in a timely manner but also missing opportunities to discuss prevention/safeguarding.
Communication challenges can be addressed through staff and interpreter training. 168 However, for such a sensitive topic, the review strongly suggests that respectful open discussions are more likely to happen in a context of a trusting relationship, and that such relationships are facilitated through models such as continuity of care and shared decision making. [152][153][154]169 Given the particular global concern for women's (and their babies') well-being related to timing of deinfibulation surgery (for women with type 3 FGM/C), the review findings strongly suggest that women appreciate, and would benefit from, more discussion, information and advice -at

Getting care pathways right: clear systems and holistic services
The review suggests that women sometimes receive sub-optimal care due to their FGM/C being missed or because of a lack of appropriate referral and reporting pathways. Some countries have made great strides to develop clear processes in this area (e.g. UK), but in others, service provision remains ad-hoc. 21 As per WHO guidelines, 9,20 the review affirms the ongoing need to develop holistic care pathways. 13,26,[170][171][172][173] The review findings suggest that women have better experiences in places where there are specialist services with confident and competent staff, and that women in lower prevalence or rural areas may be at a particular disadvantage. Hence, it is important for regions to develop service models that can address these inequalities.
In addition, the review has highlighted the ongoing need for the availability of mental health assessment and support where required. In particular, the review showed that for some women affected by FGM/C, childbirth and other clinical interventions could be traumatising, triggering flashbacks of their original cutting, creating profound anxiety and distress, and potentially leading to poor care experiences or avoidance of services. 174,175 The reviews were unable to illuminate in any further depth, how such women might best be identified or treated, or which women might be most at risk. This is an important agenda for future research. 13,39,[176][177][178][179][180] However, most maternity care services have well established processes in place for dealing with highly anxious women or women who have experienced trauma. It would seem important for services to ensure that these interventions are also available for women affected by FGM/C. 35,181

STRENGTHS AND LIMITATIONS
The review has several strengths. First, it adopted an exceptionally comprehensive and exhaustive search and we are confident that the majority of relevant papers were identified.
Second, it has focused exclusively on OECD countries, and its findings are, therefore, highly relevant to health service development in most destination countries.

COMPETING INTERESTS
None declared.

PROVENANCE AND PEER REVIEW
Not commissioned. No additional data available.

DATA SHARING STATEMENT
No additional data are available.

22
("non-UK-born" or "born outside the UK" or "length of residence in the UK" or (("not 2887 lawful*" or "not legal*" or unlawful* or illegal* or unauthori#ed* or "not authori#ed" or uncertain or insecure or legal* or legitimate* or permit* or visa* or irregular* or refused or undocumented) adj3 (residen* or student* or worker* or employee* or unemployed or immigrant* or imigrat* or migrant* or migrat*))).mp. 23 (("non-UK-born" or "born outside the UK" or "length of residence in the UK" or (("not lawful*" or "not legal*" or unlawful* or illegal* or unauthori#ed* or "not authori#ed" or uncertain or insecure or legal* or legitimate* or permit* or visa* or irregular* or refused or undocumented) adj3 (residen* or student* or worker* or employee* or unemployed or immigrant* or imigrat* or migrant* or migrat*))) adj3 (female* or wom#n or girl* or child* or adolescen*) emirat*" or UAE or "saudi arabia*" or palestin* or india* or indonesia* or malaysia* or pakistan*).ti,ab. 33 (egypt* or yemen* or sudan* or ethiopi* or somali* or djibouti* or eritrea* or kenya* or uganda* or tanzania* or camero?n* or chad* or niger* or benin* or togo* or ghana* or burkin* or ivory coast* or cote d'ivoire or liberia* or guinea* or sierra leone or leonean* or gambia* or senegal* or mauritan* or mali or malian* or "sara subgroup" or ngama).ti,ab. 259558 34 ((africa* or "middle east*" or asia* or iran* or iraq* or israel* or oman* or "united arab emirat*" or UAE or "saudi arabia*" or palestin* or india* or indonesia* or malaysia* or pakistan* or egypt* or yemen* or sudan* or ethiopi* or somali* or djibouti* or eritrea* or kenya* or uganda* or tanzania* or camero?n* or chad* or niger* or benin* or togo* or ghana* or burkin* or ivory coast* or cote d'ivoire or liberia* or guinea* or sierra leone or leonean* or gambia* or senegal* or mauritan* or mali or malian* or "sara subgroup" or ngama) adj3 (female* or wom#n or girl* or child* or adolescen*)).mp. 50 ((pregnan* or birth* or childbirth* or matern* or gyn#e* or obstetric* or menstru* or labo#r* or vulv* or vagina* or uter*) adj3 (poor* or adverse or complicat* or difficult* or disorder* or dysfunction* or disease* or pain* or risk* or danger* or problem* or issue* or concern* or infect* or inflamm*)).ti,ab. 60 ((pelvic* or back* or urolog* or urogenit* or urinat* or genit* or abdomin*) adj3 (poor* or adverse or complicat* or difficult* or disorder* or dysfunction* or disease* or pain* or risk* or danger* or problem* or issue* or concern* or infect* or inflamm*) adj3 (female* or wom#n or girl* or child* or adolescen*) exp United Kingdom/ or ("united kingdom" or "great britain" or britain or england or scotland or wales or "northern ireland" or british or english or scottish or welsh or "northern irish" or hebrid* or "isle of man" High Thin Journal Low

High Confidence
Three out of four domains have no or only minor concerns. Lack of reflexivity as a methodological limitation is less of a concern for this finding as it is not such a highly sensitive topic.

Being opened: complexities around deinfibulation
For women with type III FGM/C, decision making around 'being opened' (deinfibulation) was influenced by cultural norms and medical imperatives. Some younger women specifically sought out medical deinfibulation before marriage as a way of asserting control over their bodies and lives, but the majority of women considered medical deinfibulation only in the context of pregnancy, and the majority preferred the procedure to be carried out during labour (rather than antenatally) to avoid additional cutting and pain.

Being exposed and humiliated
Many studies reported women feeling exposed, objectified and 'on display' during healthcare encounters -due to the health provider's reactions to their FGM/C. They reported feeling a lack of concern for their privacy or dignity and felt humiliated and stigmatised. These experiences led them to lose trust in the health provider and 'the system' more generally. 8 Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

10
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.

10-11
Risk of bias in individual studies 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.

9
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means).

10-11
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I 2 ) for each meta-analysis.

& 31
Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.

RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.

12
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.

12-16
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).

& 13-16
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
n/a Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency.

22-32
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15).
n/a DISCUSSION Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).

31-34
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).

34-35
Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research.

ABSTRACT OBJECTIVE
To explore the experiences of accessing and receiving healthcare related to female genital mutilation/cutting (FGM/C) across the life course, from the perspective of women and girls who have undergone FGM/C.

DESIGN
A systematic review of qualitative research studies, using a thematic synthesis approach.

METHODS
Inclusion criteria were qualitative studies (including grey literature) of any design, from OECD countries, of any date and any language. Sixteen electronic databases were searched from inception to December 2017, supplemented by reference list searching. Papers were screened, selected and quality appraised by two reviewers using established tools from the Joanna Briggs Institute (JBI). NVivo software was utilised to extract study characteristics and code study findings. An inductive thematic synthesis approach was undertaken to identify descriptive themes and interpret these into higher order analytical constructs. Confidence in the review findings was assessed using GRADE-CERQual.

RESULTS
Fifty seven papers (from 55 distinct studies) from 14 different OECD countries were included (50% published within the last eight years). One third of studies focused exclusively on maternity care experiences, whereas others covered a range of foci. No studies reported explicitly on girls' experiences or on experiences of health-service led safeguarding interventions. Only three studies addressed psychological care. The synthesis developed 17 descriptive themes, organised into five analytical constructs. These related to: communication; access to care; experiences of cultural dissonance/integrity; disempowering care experiences and positive care encounters. The themes illuminate significant challenges to obtaining timely and holistic care (especially for deinfibulation), and highlight different ways in which women may experience care as disrespectful, unsafe and disempowering. Key elements of 'culturally safe care' are identified.

CONCLUSIONS
This review has highlighted key knowledge gaps, especially around (i) girls'/unmarried women's experiences, and, (ii) the impact of recent safeguarding interventions. There is an ongoing need for community engagement, service development and staff training.

STRENGTHS AND LIMITATIONS OF THIS STUDY
 This is the first review that goes beyond a maternity care focus to examine women's/girls' experiences of FGM/C-related healthcare across the life course, enabling new insights into care-seeking and care-access, especially around deinfibulation.  This is an exceptionally comprehensive review, due to its wide focus and its inclusion of grey literature and papers in any language.  The review has used a theoretical model of 'cultural safety' to inform its analytical approach and has assessed confidence in its findings using GRADE-CERQual.  The review process has been informed by strong community involvement and input from a multi-disciplinary expert advisory group at every stage.  Methodological limitations of the included studies make it difficult to develop findings that reflect nuances of experience related to ethnic group, nationality, age or type of FGM/C.

KEYWORDS
Female genital mutilation, female genital cutting, deinfibulation, qualitative systematic review, thematic synthesis, CERQual  and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris). In other communities however, type 1 (partial or total clitoridectomy) or type 2 (partial or total clitoridectomy and removal of the labia minora, with or without excision of the labia majora) are more common. 8 However, it should be noted that these typologies represent biomedical categories and that different communities have their own nomenclature. Moreover, the exact type of FGM/C a woman has experienced may depend to some extent on the skills and experience of the 'cutter' and women themselves may not always be aware of which type of FGM/C they have experienced.
FGM/C can involve immediate and long term psychological, sexual, relational and physical health sequelae. 9 Health problems may be particular severe for women with Type 3 FGM/C who require a degree of deinfibulation in order to have sexual intercourse and to give birth. being as well as to allow intercourse or to facilitate childbirth". 8 Currently, deinfibulation is recommended for women and girls reporting medical or psychosexual symptoms related to type 3 FGM/C or upon request (i.e. personal choice). In addition, global guidelines specifically recommend that deinfibulation is undertaken to prevent obstetric complications, although the optimal timing for the procedure (antepartum or intrapartum) is unclear. 9-12 9,13-17 There are compelling clinical reasons however for preferring antepartum deinfibulation, including the fact that it can be performed under local anaesthetic in an out-patient setting, thus reducing costs and risks associated with any emergency procedures that may emerge during labour. 18 In addition, in destination countries where staff may be less familiar with type 3 FGM/C, planned antepartum or pre-marital deinfibulation ensures that it is performed by trained and experienced professionals. 15 In destination countries, it is essential, therefore, that care pathways are developed that are able to support women's potential psychological and sexual health needs, [9][10][11]19,20 as well as supporting decision making around deinfibulation. In addition, health professionals are called upon to play a key role in the prevention of FGM/C, through health education with affected communities and identification of girls who may be at risk. [20][21][22] However, as a cultural phenomenon associated with women's sexuality, gender norms and genital area, FGM/C is a sensitive topic that can be hard for women, communities and health professionals to openly discuss. [23][24][25] Recent studies of health sector involvement in the management of FGM/C in destination countries, show variable availability of specialist services and staff training. 21,26 Moreover, several systematic reviews indicate that health professionals may lack knowledge, confidence and competence in managing FGM/C. [27][28][29][30] In addition, there are on-going calls for greater community involvement in the development of appropriate services related to FGM/C. [31][32][33] Aim This paper reports the findings of a qualitative systematic review that aimed to explore the experiences of accessing and receiving FGM/C-related healthcare across the life course for women and girls who have undergone FGM/C. 34

Rationale
Several prior reviews have been undertaken in relation to this topic, however we felt a new review was warranted for several reasons. First, most existing reviews have focused upon women's maternity care experiences or maternity-focused interventions. [35][36][37][38][39][40][41] However, as indicated above, a key issue for services is the development of joined up care pathways that are able to offer women a range of holistic services at different time points. Hence, our review adopted a focus on the life course. Second, it is well known that migrants experience a range of barriers to accessing health services, [42][43][44][45][46] yet 'access to care' has not been a focus of prior reviews related to FGM/C. Third, several prior reviews have included studies from all over the world, thereby bringing together widely different cultural and health system contexts. [37][38][39] We felt that a review focused just on 'destination' countries, would provide findings that were more transferable to these specific contexts. 47,48 Finally, prior reviews have often limited their searches to English language papers or to published literature only. 35,36 By contrast, this review has included any language and a wide range of grey literature sources, and thus is able to offer an extremely comprehensive picture. 49,50 Theoretical perspective This review is broadly informed by the theoretical construct of 'cultural safety'. 51 Cultural safety derives from critical social theory and argues that, traditional approaches to 'cultural awareness' or 'cultural competence' within healthcare fail to adequately take into account power relations which are historically unequal between migrant or indigenous groups and healthcare providers and services. 52 Within a cultural competence discourse for example, it is argued that "the power to define the norm and the onus for action to understand and know about another culture fall to the health professional/service" p.200. 51 As such, migrant groups remain represented as the 'other' and may be viewed within a deficit model -as a problem that needs to be fixed -rather than as partners whose knowledge and values can contribute equally to a relationship or to service development initiatives. Culturally safe practice, by contrast, is predicated upon relationships of mutual trust and respect. It is a transformative and rights based approach, seeking to uphold the principles of respect, dignity, empowerment, safety and autonomy. 53 Cultural safety envisages the healthcare encounter as a negotiated and equal partnership in which trust plays a central role. The healthcare practitioner's role is to enable patients to say how a service can be adapted and to negotiate an agreed approach -a key aspect of shared decision making. 54 The converse of cultural  56 Cultural safety is not just a feature of individual practice however. It is argued that culturally safe practice must be institutionalised through organisational policies and structures so that it becomes part of mainstream healthcare provision rather than being dependent upon individual practitioners who may or may not adopt its values and approach. [57][58][59] This theoretical perspective is well suited to areas of healthcare involving stigmatised or sensitive topics, such as FGM/C, and where there is a strong need for community engagement in service development and shared decision making in care delivery.
To date, reflexive consideration of the use of theory in qualitative systematic reviews has received minimal attention. Indeed, some authors have referred to the conceptual process of meta-synthesis as a 'black box' 60 and recent research has highlighted the poor reporting of the interpretive work of synthesis. 61 Yet, as noted by Guba and Lincoln (1994), 62 there is no such thing as 'theory-free' research. Some authors report using a 'framework synthesis' approach in which the review is designed to test or expand a pre-existing theoretical framework (which is used as the basis of an initial coding framework to develop key themes). 63 In contrast to this relatively deductive approach, in the present review, the concept of Cultural Safety was used in three ways to support an interpretive inductive approach. Firstly, it acted as one of a variety of 'lenses' and perspectives (along with other aspects of our identities and backgrounds) through which we interpreted the findings of the research studies. 64 As such, it represented what Maxwell (2013) 65:39 has termed an 'idea context' or 'spotlight' for the review process in which a theory can help to identify themes that might otherwise be overlooked. Second, as the review progressed, we felt that concepts related to Cultural Safety remained a 'good fit' for helping us to understand and position the review findings within the wider literature. 66 Hence, we drew upon some of its ideas to inform and structure the Discussion and Recommendations. Finally, we were aware that a common criticism of systematic reviews is their failure to be policy relevant or transferable. 67

METHODS
This qualitative systematic review is reported following the ENTREQ guidelines. 68 The review was registered in Prospero 69 Table   1 for all resources/databases that were searched). 70-73 Finally, we hand searched the reference lists of related systematic reviews and of all the included studies. All retrieved datasets were downloaded into group sets within an EndNote library and duplicates were removed.

Screening and selection
The review included studies from any date and any language that met the following inclusion  Studies were not excluded on the basis of quality, rather, the quality assessment was used to judge the relative contribution of each study to the overall synthesis, and to assess the methodological rigor of each study as part of a process of assessing confidence in the review findings. 77-81 The JBI-QARI tool was applied to each individual paper and an aggregate score for each was calculated. A criticism of 'scoring' qualitative critical appraisals is that it can be hard to distinguish between the poor conduct of a study and poor reporting, especially where journal word limits constrain the level of detail that can be reported. 82 In addition, there is no consensus regarding the relative importance of any one domain within an assessment tool over another, and, hence, whether they should all be given an equal weight or not. In view of these concerns, we chose to adopt a 'weighting system' used in previous studies by Higginbottom et al 83,84 in which papers were grouped into one of three 'bands' -high, medium or low -to enable a broad brush evaluation to be made of their relative quality -see Table 2.  Table 3) and categorized as either 'thick' or 'thin'.

Richness Operational Definition
Thick papers  Offer greater explanatory insights into the outcome of interest  Provide a clear account of the process by which the findings were produced-including the sample, its selection and its size, with any limitations or bias noted-along with clear methods of analysis  Present a developed and plausible interpretation of the analysis based on the data presented. Thin papers  Offer only limited insights  Lack a clear account of the process by which the findings were produced  Present an underdeveloped and weak interpretation of the analysis based on the data presented

Data extraction and assessment of relevance
Study characteristics were extracted by one author (RT) using a modified JBI template and double checked by CE. During this process, papers were categorized in terms of their relevance to the review question. This assessment was made in order to gain a better understanding of the nature of the body of evidence, and also to facilitate the coding process, as described further below. Study relevance was defined as high, medium or low as set out in Table 4. PDFs of all the included papers were imported into NVivo software and the 'findings/results' and 'discussion' sections were coded and analysed. 87

Study Relevance Definition
High (specific) FGM/C-specific healthcare (e.g. the study is focused on a specific aspect of care related directly to FGM/C, e.g. deinfibulation, childbirth for women who have had FGM/C, psychological care) Medium (direct) Other healthcare context (e.g. where the study focus is on the maternity care experience of a particular group more generally and where some of the findings relate to the experience of FGM/C) Low (indirect) Where the study focus is on general attitudes towards FGM/C and/or experiences and consequences of FGM -& where some FGM/C-related healthcare issues are reported, but are not the main focus of the paper

Data analysis and synthesis
The review adopted a thematic synthesis approach as outlined by Thomas and Harden 88 involving four iterative stages: (i) in-depth reading of the whole papers, (ii) inductive line by independently. The codes were then reviewed and compared. Where reviewers had identified and coded the same issue, a code for that issue was agreed for use in coding subsequent papers. A standardised name was identified for the code and a description was produced.
Where reviewers had applied slightly different codes to a concept indicating a different interpretation of meaning, they discussed it and either agreed a shared code (based on a shared understanding of meaning) or created two different codes to reflect two different meanings. The initial set of codes were 'free nodes'. These were compared, analysed and discussed by the whole team. Where meanings appeared to relate to a similar concept, these were grouped into broad descriptive themes and sub-themes. This process created a codebook which was applied to the remaining papers and expanded, refined and modified as appropriate (by identifying new codes and new themes or by merging and re-naming existing codes and themes). The codebook ensured that definitions of codes and themes were explicit and could be easily shared across the team and discussed. More detail on this process is given in Supplementary File 3, using the analytical theme of 'Communication is Key' (see below) as an exemplar. Analytical themes were evolved through an in-depth process of comparing and contrasting the meanings of the descriptive themes, analysing these in relation to how they were, or were not, able to illuminate the review questions, and inferring broader phenomena, categories of meaning or social processes that they related to. 102,103

Patient and public involvement
Public involvement was an integral part of the review process and was achieved in three ways. Firstly, the review was conceived and co-constructed from an ongoing partnership

Rigor within the analytical process
To ensure rigor of the analytical process, the team sought to identify and understand possible 'disconfirming' cases that might challenge emerging interpretations, 104 and to explore possible sub-group or contextual differences. These processes were aided by the creation of a theme matrix (see Supplementary File 4), in which each theme was mapped to its constituent studies. This helped the team to see clearly how common the theme was amongst the studies, what kind of study contexts or samples the theme related to, and to explore why it may have been present in some studies but not in others. In addition, as described above, the whole team and wider project advisory group contributed to the evolution of the synthesis, through reading of key papers and providing feedback on the emerging interpretations.

Assessment of confidence in the review findings (CERQual)
Assessment of confidence in the findings of the review was undertaken using the CERQual (Confidence in Evidence from Reviews of Qualitative Research) approach. 76,77,105-111 Akin to GRADE, CERQual uses assessments of 'concerns' within four distinct domains (methodological limitations, relevance, coherence and adequacy of data) applied to each individual review finding. The CERQual assessment was applied to the descriptive rather than analytical themes, as the latter comprise an aggregation of descriptive themes as well as descriptions of patterns or explanations that are inferred as part of the interpretative process.
There is, as yet, relatively little guidance for, or experience with, applying CERQual to higher level analytical themes or theories. 108

Search outcome
The search outcomes are reported in detail in the PRISMA flowchart in Figure 1.

Study characteristics
Due to the large numbers of studies in this review, a highly summarised description of key study characteristics and key methodological assessments is found in Table 5. Full details are provided in Supplementary Files 5 and 6.   Canada, 123,126,131,137,138,149 Finland, 127 131 There were no studies that examined women's experiences of surgical reconstruction following FGM/C and no studies that examined experiences of health-service led safeguarding interventions.
The studies were primarily of adult women. Only one study included girls under the age of 18 years but did not report health-related experiences of this group. 23 There were no studies that focused specifically on healthcare issues related to FGM/C in older (post-child bearing) women. Hence, although the aim of the review was to explore FGM/C across the life course, the studies all focused on generic issues relating to adult women and no further age-specific differentiation could be made. The majority of studies were with women from FGM/C practising countries in sub-Saharan Africa, and the majority of these included women specifically from countries in the Horn of Africa where type 3 FGM/C is most commonly practised. It is likely therefore, that the findings included in the review reflect issues that may be specific to these population groups and to the experience of type 3 FGM/C. Only three studies explicitly reported including women from Egypt/Middle East but did not differentiate these women's experience from the rest of the sample. 118,129,148

Methodological quality
Full details of assessments of methodological quality, richness (thick/thin) and relevance are provided in Supplementary File 6 (see Table 5 for a summary). Thirty papers were assessed as being of high quality, 23,[89][90][91][92][93][94][95][96][97][98][99][100][101]115,116,125,127,130,131,136,137,140,141,[144][145][146][147]149,152 21 as medium quality, 25,112,114,117,[119][120][121][122][123][124]126,128,129,[133][134][135]142,143,150,151,153 and six as low quality. 113,118,132,138,139,148 A methodological weakness across many studies was lack of discussion of the underpinning philosophical standpoint (question one of the QARI tool), making it difficult to assess the congruency of the chosen methodology. Likewise, many studies did not describe any clear methodology (simply stating that they adopted a generic 'qualitative approach'). Such studies tended to have 'thin' or mainly descriptive findings, and it was difficult to judge the congruence of the methodology with the research question and the methods (questions two and three on the QARI tool). Finally, a limitation across many studies was lack of discussion of reflexivity (questions six and seven on the QARI tool). Given the sensitive nature of FGM/C (and sexuality or migrant healthcare) as a topic, the failure to explore the researcher's own theoretical standpoint or their role, professional background, ethnicity, experience of FGM/C or relationship to the participants is a significant weakness, making it hard to judge the dependability of the findings. 154

Thematic synthesis findings
The findings from 57 papers were synthesised into five analytical themes which represent a synthesis and interpretative analysis of 17 descriptive themes.

Theme 1.1 Language barriers and interpretation challenges
The majority of studies (n=31) reported that for women who did not speak the host country language well, communication about FGM/C was hindered by language barriers and problems with accessing interpretation support that was appropriate for discussing highly sensitive and personal issues. Language barriers meant that women were unable to form a trusting relationship with their provider, express their needs adequately or understand information or advice. This led to frustration and increased anxiety, especially in a context where consultation times were often limited. 124,135 In some cases, women felt that they had had poor clinical experiences as a direct result of their inability to communicate about FGM/C. 23,135,144 In other examples, women avoided mentioning their FGM/C at all because they knew they lacked the language to explain. 134,135,150 Analytical theme 2 -Access to care: influenced by an interaction of multi-level community and health service processes The review found that access to care related to FGM/C was influenced by an interaction of factors operating at individual and community levels as well as at health system and service levels. At individual and community levels, studies showed that care seeking was influenced by cultural norms around health and sexuality, collective approaches to decision making and However, the studies also showed that care-seeking choices were shaped by the types of services available and that outcomes were influenced by the extent to which the health system, health services and health practitioners were ready and able to provide the range of support that women may need at different points in their lives.
The review showed that there were challenges within communities in terms of seeking care and finding the right services. However, even when services were appropriately accessed, care was sometimes haphazard and sub-optimal due to variable levels of staff expertise and inconsistent and unclear referral pathways, policies and procedures.

Theme 2.1 Influence of cultural norms
Women's care seeking in relation to FGM/C was strongly influenced by wider cultural norms around sexuality and health, including cultural norms on the importance of pre-marital virginity, avoiding male health providers and lack of familiarity with preventive care-seeking.
These factors often led women to avoid seeking care unless symptomatic or pregnant. Thirty five studies contributed to this theme.
Women reported that strong cultural imperatives valuing premarital chastity and virginity, meant that they would avoid procedures requiring gynaecological examinations (e.g. pap smears 101,130,143,147 ), and, especially for those with type 3 FGM/C, the general norm was to avoid seeking deinfibulation prior to marriage and pregnancy due to the cultural pressure to maintain chastity, prove their virginity and to remain 'closed' for their husbands. 95

Theme 2.3 Knowledge and information about FGM/C services
Women's knowledge of, and familiarity with, health services was variable. In some cases, women lacked familiarity with the host country health system and this impeded their ability to access care in general. In other cases, women reported being quite familiar with maternity and primary care services, but lacked knowledge and information of FGM/C-specific specialist services (especially non-maternity related services such as counselling) and where and when it may be appropriate to seek help. 93,143,144 One study from the UK suggested that this might be a particular issue for women living in low prevalence areas. 142

Theme 2.4 'Hit & miss' care
When accessing healthcare, women reported that (i) the identification of FGM/C and (ii) provision of appropriate treatment or referrals could be a "hit and miss" process, depending upon individual provider characteristics and practices -rather than being a result of standardised organisational systems and processes. For example, many studies cited situations where opportunities to identify FGM/C during a consultation were missed, which was attributed to providers lacking awareness of FGM (or related specialist services) and hence failing to ask the right questions, or to undertake an examination, or to make timely referrals. 143 Maternity services were more likely to have knowledgeable providers and responsive reporting and follow up systems, but even here, women described situations where

Theme 3.3 Being opened: complexities of deinfibulation for women with type 3 FGM
The experience of dissonance and quest for integrity was also seen in views and experiences around deinfibulation and was reported by 28 studies. As noted above, for cultural reasons, 'being opened' medically was seen as necessary primarily after marriage and primarily in the context of pregnancy and childbirth -rather than before. 137

Theme 4.4 Feeling unsafe and vulnerable
Many studies (n=46) reported care encounters where women felt unsafe and vulnerable, primarily when they were treated by providers who they perceived to be inexperienced in dealing with FGM/C, and when they faced language barriers or were unable to express their own preferences. Such encounters often led to perceived poor quality care or poor clinical outcomes. 124 The consequences ranged from providers failing to recognise, identify or discuss FGM/C, 89 to situations where women felt their care had been adversely affected as a direct result of poor provider skills (for example having unnecessary caesarean sections or extensive perineal tearing). 23 Analytical theme 5 -Positive care encounters As seen above, the synthesis has revealed many reports of poor care and difficult experiences in relation to FGM/C. However, many studies reported a mixture of experiences, including both good and poor care. High quality care was conceptualised by women as care that is safe, respectful, culturally sensitive and compassionate. The essential process underpinning the experience of 'good' care was having a sense of trust -both in the individual provider and also in the 'system' as a whole. Trust was essential for, and developed from, positive care experiences. Positive experiences were associated with the development of a good relationship with health professionals who were perceived to be clinically knowledgeable and culturally sensitive, facilitating open communication and a sense of being in safe hands. Trust in the 'system' was linked to women's appreciation of the availability and accessibility of services (compared with their home countries) but particularly when services were perceived to be prepared to be responsive to community needs (e.g. provision of appropriate interpretation services) and to manage issues relating to FGM/C (e.g. by having specialist services or specialist providers).

CONFIDENCE IN THE REVIEW FINDINGS
Confidence in review findings (as assessed by GRADE CERQual) ranged from high to medium and there was strong consistency in the findings across countries, population groups and clinical contexts (see Table 6 for the final CERQual assessment for each theme and Supplementary File 7 for the full details of the CERQual evaluation).

FGM/C
The review shows that FGM/C -literally and symbolically -embodies complex processes of cultural change and cultural interaction that are occurring as a result of globalisation, migration and super-diversity. These processes manifest themselves very concretely in healthcare in terms of influencing how individuals seek care, how care is delivered and experienced by all involved, and how services are configured. 2,156,157 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   34 This review has shown that, when obtaining care for FGM/C-related issues in a host country, women face common challenges that affect many groups of migrants, but that these are exacerbated. 46,84,[158][159][160][161] Silence, secrecy, stigma and lack of familiarity with FGM/C within the system combine and act as obstacles to identifying FGM/C or to providing women with appropriate care. The care for FGM/C described in this review exemplifies the challenges of achieving 'cultural safety' in health services. Many of the experiences reported in the review describe a situation of physical but also cultural 'vulnerability' or 'risk' whereby women felt physically unsafe but also disrespected in terms of their cultural identity and bodily integrity and un-involved in their care. Many of the themes in this review referred specifically to maternity care contexts, and there are striking similarities with themes identified in studies across the world, that highlight disrespect and abuse in maternal healthcare. 35,36,162 However, as this review shows, the same challenges also appear to exist for women with FGM/C in primary care and other health settings. [163][164][165] .

RECOMMENDATIONS FOR CULTURALLY SAFE CARE
As per the model in Figure 2, the review recommendations fall into four overlapping areas.

Overcoming barriers: information, awareness and community engagement
The review showed that there is a need for communities to be more aware of FGM/C related services and of potential interventions. However, it also highlighted the challenges that women may have in discussing FGM/C within their family or community and with a health provider. This finding highlights a need for ongoing community involvement and engagement to raise awareness of services and provide support to women who may wish to access help (especially for unmarried or non-pregnant women). 31,32 The review suggests that service models which involve community advocates or community liaison workers may be particularly helpful in encouraging women to access care and to overcome communication difficulties with providers. Similar models have been found to be effective in other areas of healthcare. [170][171][172][173][174]

Breaking the silence: open communication and shared decision making
Given the communication challenges around FGM/C, the review findings strongly suggest that the onus of 'breaking the silence' may lie with the healthcare provider, with women stating that they expected and wanted health professionals to raise the issue. It may be appropriate for services to consider routinizing questions around FGM/C in key clinical settings, as has been done for other 'sensitive' clinical issues such as domestic violence or HIV. [175][176][177][178] In addition, given the particular global concern for women's (and their babies') well-being related to timing of deinfibulation surgery (for women with type 3 FGM/C), the review findings strongly suggest that women appreciate, and would benefit from, more discussion, information and advice -at different stages in their life (before and after marriage) and both pre-and post-deinfibulation.

Provider competence and confidence
The review highlighted that providers may lack the confidence or cultural competence to raise the subject of FGM/C in an appropriate and respectful way, potentially missing opportunities to identify FGM/C in a timely manner but also missing opportunities to discuss prevention/safeguarding. 30 Communication challenges can be addressed through staff and  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   36 interpreter training. 179 Likewise, the review showed that providers would benefit from additional training in associated clinical skills such as deinfibulation. The evidence base for best practice in health worker training around FGM/C is still weak, 180 however, as per WHO guidelines, 20 it is suggested that basic training around FGM/C should be embedded in preservice curricula for all health professionals, as well as being offered as continuous professional development for providers in more specialised roles.

Getting the model of care right: appropriate systems, services and care pathways
The review suggests that women sometimes receive sub-optimal care due to their FGM/C being missed or because of a lack of appropriate referral and reporting pathways. Some countries have made great strides to develop clear processes in this area (e.g. UK), but in others, service provision remains ad-hoc. 21 As per WHO guidelines, 9,20 the review affirms the ongoing need to develop holistic care pathways. 13,26,[181][182][183][184] The review findings suggest that women have better experiences in places where there are specialist services with confident and competent staff, and that women in lower prevalence or rural areas may be at a particular disadvantage. Hence, it is important for regions to develop service models that can address these inequalities. In addition, the review strongly suggests that respectful open discussions about FGM/C are more likely to happen in a context of a trusting relationship, and that such relationships are facilitated through service models that implement continuity of care approaches and shared decision making. [163][164][165]185 The review has highlighted the ongoing need for the availability of mental health assessment and support where required. In particular, the review showed that for some women affected by FGM/C, childbirth and other clinical interventions could be traumatising, triggering flashbacks of their original cutting, creating profound anxiety and distress, and potentially leading to poor care experiences or avoidance of services. 186,187 The review was unable to illuminate in any further depth, how such women might best be identified or treated, or which women might be most at risk. This is an important agenda for future research. 13,39,[188][189][190][191][192] However, most maternity care services have well established processes in place for dealing with highly anxious women or women who have experienced trauma. It would seem important for services to ensure that these interventions are also available for women affected by FGM/C. 35,193 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 37

STRENGTHS AND LIMITATIONS
As mentioned above (under 'Rationale'), previous reviews have primarily focused on care experiences within maternity contexts. 35,36,40,41 Our findings on care experiences resonate strongly with these existing reviews. However, we feel that our review has been able to expand upon current knowledge in several ways. First, it adopted an exceptionally comprehensive and exhaustive search and we are confident that the majority of relevant papers were identified. The inclusion of grey literature as well as studies in other languages significantly broadened the evidence base (for example, the existing reviews on maternity contexts included between four and 16 papers, whereas this review included 57). 35,36 It is our contention that this wider evidence base, as well as the broader review focus on all aspects of the lifecourse has enabled a more nuanced understanding to emerge around FGM/C related health experiences. In particular, our review has identified new findings around: (i) factors that influence care-seeking and access to care (as well as the care experience itself), (ii) decision making around deinfibulation surgery, (iii) community perspectives on positive care experiences and suggestions for service improvement, and, (iv) being able to demonstrate the importance of primary care as well as maternity contexts for discussing and identifying FGM/C. The theme matrix presented in Supplementary File 4 provides a visual means for exploring in more detail how the wider evidence base has contributed to particular review findings and, thus, how it has enabled new or more nuanced themes to be identified.
Another strength of the review is its exclusive focus on OECD countries which ensures that its findings are highly relevant to health service development in most destination countries.
The main limitation of the review is that the findings inevitably reflect the methodological limitations of its included studies. Many papers displayed a homogenising tendency in terms of the affected communities as well as FGM/C types. For example, in papers that had mixed community samples, there was little attempt to explore cultural differences in relation to FGM/C. Likewise, it was not always clear which type of FGM/C was being studied. In research with Somali or Sudanese communities, the assumption can reasonably be made that their focus was FGM/C type 3. However, in studies with mixed samples, there was very little differentiation on the basis of FGM/C type. As a result, there is limited specific knowledge on the needs or experiences of women with other FGM/C types.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 38

EVIDENCE GAPS AND FUTURE RESEARCH
The review has identified five key gaps in the evidence base around FGM/C, all of which are priority areas for future research. First, there were very few studies that focused specifically on mental health needs. Second, there is a lack of studies on girls' or unmarried/non-pregnant women's experiences around FGM. Important areas for future investigation amongst this group are care seeking and decision making (especially around deinfibulation timing). Third, there is a lack of knowledge on potential health needs or experiences of older women, hence this is an area that may require further investigation. Fourth, there were no in-depth evaluations of interventions or services which means that development of models of 'good care' (e.g. 134,194 ) still need to be inferred rather than being based upon sound evidence.
Further mapping and evaluation of models of care would be beneficial to understand better their differential impact on accessibility, outcomes, cost and patient satisfaction. Finally, there was no research that specifically explored women's/girls' experiences of healthcare professional's involvement in implementation of legal safe guarding or prevention interventions, which, in some countries (such as the UK), are inserting new complexities into the patient-professional relationship and reportedly undermining trust. 32,33,[195][196][197] CONCLUSION This review has identified key challenges but also opportunities for the development of culturally safe and accessible services to improve care for women affected by FGM/C.
Future research should involve communities to evaluate existing models of care in order to inform best practice.

ACKNOWLEDGEMENTS
We would like to thank all those who have contributed time and valuable insights to this project. We would particularly like to thank all those who gave up their day to attend the national stakeholder consultation event. Special thanks go to Carol McCormick (FGM/C specialist midwife) for her support and input at the start of this project. We gratefully acknowledge the invaluable contributions of our project advisory group:  Kinsi Clarke, Nottingham and Nottinghamshire Refugee Forum, co-founder of Nottingham FGM survivor's group  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59

COMPETING INTERESTS
None declared.

PROVENANCE AND PEER REVIEW
Not commissioned. No additional data available.

Example of the Analytical Theme of 'Communication is Key'
Below, we describe the analytical process involved in the thematic synthesis, using the Analytical Theme 1 ('Communication is Key') as an exemplar.
The open codes were then reviewed and compared. Where reviewers had identified and coded the same issue, a code for that issue was agreed for use in coding subsequent papers. A standardised name was identified for the code and a description was produced. Where reviewers had applied slightly different codes to a concept indicating a different interpretation of meaning, they discussed it and either agreed a shared code (based on a shared understanding of meaning) or created two different codes to reflect two different potential meanings. As can be seen above, the initial set of open codes were 'free nodes'. These initial sets of codes were regularly examined through team discussion. The codes were then expanded, merged or refined. For example, after coding additional papers, it became clear that the initial combined open code 1 ('interpretation problems') was very broad, so it was decided to code more closely to identify what specific aspects of interpretation were considered challenging. After re-reading the original papers, two refined codes were created, so that there were a total of three codes related to interpretation (all the index papers were re-coded using the refined framework).

Moderate confidence
Two of the four domains have only moderate confidence. Many studies do report on this theme, but there are some concerns on their quality and some of the findings are ambiguous.
Analytical theme 2: access to care: influenced by an interaction of multi-level community and health service processes

Influence of cultural norms
Women's care seeking in relation to FGM/C was strongly influenced by wider cultural norms around sexuality and health, including cultural norms on the importance of pre-marital virginity, avoiding male health providers and lack of familiarity with preventive careseeking. These factors led women to avoid seeking care unless symptomatic or pregnant.

Moderate confidence
Moderate confidence due to moderate concerns regarding methodological quality, coherence and relevance.

Knowledge and information about FGM/C services
Women's knowledge of, and familiarity with, health services was variable. In some cases, women lacked familiarity with the host country health system and this impeded their ability to access care in general. In other cases, women reported being aware of maternity and primary care services. However, there was a particular lack of knowledge and information of FGM/C-related specialist services n=34 1,3-5,7,10-

High Confidence
Three out of four domains have no or only minor concerns. Lack of reflexivity as a methodological limitation is less of a concern for this finding as it is not such a highly sensitive topic. Minor concerns regarding methodological limitations Thirty five of the studies are rated as high or medium quality. Five are low quality. However, many studies failed to report issues relating to reflexivity.

No concerns regarding coherence
Minor concerns regarding adequacy The majority of studies in the review present rich data on this theme. Eight studies provide only thin data where detailed information is not given.

No concerns regarding relevance
The studies represented mixed contexts, 13 countries and a range of population groups. Eighteen out of 40 studies had an exclusively Somali sample.

High Confidence
All domains report no or only minor concerns.

Moderate confidence
Moderate confidence due to moderate concerns regarding methodological quality and coherence.

Being opened: complexities around deinfibulation
For women with type III FGM/C, decision making around 'being opened' (deinfibulation) was influenced by cultural norms and medical imperatives. Some younger women specifically sought out medical deinfibulation before marriage as a way of asserting control over their bodies and lives, but the majority of women considered medical deinfibulation n= 28 3 only in the context of pregnancy, and the majority preferred the procedure to be carried out during labour (rather than antenatally) to avoid additional cutting and pain.
stemming from poor or no reporting of theoretical perspective and methodology, and poor analysis or presentation of participant voices. There are serious concerns with two papers because of no ethics description (n=1) and very weak methodology (n=1).
the findings were less specific, but generally still consistent with the theme.
explanatory insights or in-depth descriptions of women's views.
practise type III FGM/C. However, there is little in-depth exploration of any potential differences between different ethnic groups.

Being changed: complexities around re-infibulation
For women with type III FGM/C, 'being opened' (deinfibulation) was reported as a process involving significant emotional, physical, social and relational adjustments as their bodies became changed. Some women felt ambivalent about these changes and sometimes wanted to be closed again (reinfibulated) to varying degrees, feeling upset if their requests were denied by health providers.

Minor concerns regarding adequacy
There are 19 papers reporting on this theme with the majority contributing rich data (n=16). Three studies present thin data.

Moderate concerns regarding relevance
The data is well spread across the included studies, representing 11 countries, involving diverse participants groups with FGM/C III. However, there is little in-depth exploration of any potential differences between different ethnic groups.

Moderate confidence
Moderate confidence due to moderate concerns regarding methodological quality and relevance.

Being exposed and humiliated
Many studies reported women feeling exposed, objectified and 'on display' during healthcare encountersdue to the health provider's reactions to their FGM/C. They reported feeling a lack of concern for their privacy or dignity and felt humiliated and stigmatised. These experiences led n=40 1,3,4,7,9,10,1

Being judged and stereotyped
Women reported feeling judged and discriminated against within some of their healthcare encounters. They reported feeling that health providers made negative assumptions about them and provided sub-optimal care based on racial, religious or other stereotypes and misconceptions about their culture in general as well as about FGM/C. Such experiences caused distress, anger and avoidance of the health provider or service. are only minor concerns regarding coherence, adequacy and relevance.

No concerns regarding coherence
No concerns regarding adequacy This theme has a high number of studies contributing to it (n=46). The majority of these provide rich or indepth data (n=42) in relation to this finding.

No concerns regarding relevance
Studies involve mixed participant groups, and across a range of health contexts, topics and countries.

High Confidence
There are a few studies with serious methodological concerns, and some concern regarding the lack of reflexivity. However the data is very rich and consistent across contexts, hence there are no concerns regarding adequacy, coherence or relevance.
Analytical theme 5: positive care encounters 5.1 Trusting and appreciating providers and the system Women appreciated the good medical services available in the host country. Women also expressed great appreciation for providers who made them feel safe and respected. Such providers were described as knowledgeable and experienced, who treated women with respect, who understood their individual needs and who involved them in their care. Women described these n= 34 3 relation to a range of health care contexts.

Voicing healthcare needs and preferences
Women's recommendations for good quality safe FGM/C related care and services they could trust included: (i) interpersonal provider characteristics and behaviours (such as providers being willing and able to talk about FGM/C, providers being skilled and knowledgeable around FGM/C, providers offering culturally sensitive and respectful care) and (ii) service organisation issues (such as having specialist services for FGM/C, being given information and awareness about FGM/C-related services, and involving women and affected communities in FGM service development  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60  9 Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

11
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.

11-12
Risk of bias in individual studies 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.

10
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means).

11-12
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I 2 ) for each meta-analysis. Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).

RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.

13
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.

14-18
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).

20&14-18
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
n/a Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency.

20-33
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15).
n/a DISCUSSION Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).