National Consultancy to investigate and document the clinical complications of Female Genital Mutilation (FGM) during labor and delivery

Background and Study Justification:

Female Genital Mutilation (FGM) in Liberia is a deeply entrenched cultural practice historically tied to the Sande secret societies, with prevalence rates among women aged 15–49 estimated between 31.8% and 38.2%. While the practice remains a significant human rights and public health challenge, recent years have marked a pivotal shift in the country's approach. In February 2023, the National Council of Chiefs and Elders of Liberia (NACCEL) made a historic declaration to ban FGM nationwide, following an earlier three-year moratorium. Despite this traditional decree, Liberia still lacks a comprehensive national law that explicitly criminalizes the practice; however, an Anti-FGM Bill has been drafted to provide a permanent legal framework. Efforts to sustain this progress focus on "alternative rites of passage," which preserve cultural initiations while excluding the physical "cutting" and provide former practitioners (known as Zoes) with alternative livelihoods to replace the income once generated by traditional ceremonies.

Female genital mutilation (FGM) results in a range of immediate and long-term physical, psychological, and obstetric health complications. These procedures, which involve the partial or total removal of external female genitalia, offer no health benefits and interfere with natural bodily functions.

The immediate aftermath of FGM is characterized by acute physical trauma. The most common complications occurring during or shortly after the procedure include:

1. Severe Pain and Hemorrhage: Victims often experience extreme pain and excessive bleeding, which can lead to shock.
2. Physical Injury: Damage to nearby genital tissue, urine retention, and genital tissue swelling are frequently reported.
3. Infection: Open sores and the use of unsterile instruments significantly increase the risk of sepsis, tetanus, and the transmission of blood-borne pathogens such as HIV and Hepatitis B or C.

Women who have undergone FGM face chronic health issues that persist throughout their lives. Long-term consequences include recurrent urinary tract infections, painful menstruation, and the formation of cysts or keloid scars. Obstetric complications are particularly severe; women with FGM are at a significantly higher risk for prolonged labor, obstetric hemorrhage, and extensive perineal tearing during childbirth. These issues are even more pronounced in Type III FGM (infibulation), which requires the vaginal opening to be cut open (de-infibulation) for sexual intercourse and delivery.

The psychological toll of FGM is profound, often manifesting as long-term mental health disorders. Research indicates that a vast majority of survivors report symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD). Specific symptoms such as nightmares, low self-esteem, and an aversion to sexual activity—often due to dyspareunia (painful intercourse)—further impact the quality of life and interpersonal relationships. These psychological effects may be intensified by the "double burden" of trauma from the procedure and potential isolation or discrimination in communities where FGM is not the norm.

Purpose of consultancy:

The purpose of this study is to investigate and document the clinical complications of Female Genital Mutilation (FGM) during labor and delivery, establishing a robust evidence base for FGM eradication advocacy.

The specific objectives include the following:

• To quantify the incidence and severity of obstetric complications—such as prolonged labor, postpartum hemorrhage, and perineal tearing—among women with a history of FGM.
• To analyze the relationship between specific types of FGM (Type I, II, or III) and the nature of complications encountered during the second stage of labor.
• To identify and map the geographic distribution of FGM-related delivery complications across Liberia to pinpoint the county with the highest clinical burden.

To propose evidence-based clinical protocols and legislative recommendations aimed at mitigating birth complications and strengthening the legal framework for the eradication of FGM.

Scope of work: (Description of services, activities, or outputs)

This study spans six counties, specifically targeting the major referral hospitals that serve the majority of the national population and handle over two-thirds of delivery referrals. These sites were selected based on high FGM prevalence and high delivery volumes. Furthermore, the selection aligns with the 2026–2030 Country Programme and ensures regional representation that reflects the nation’s cultural and socio-economic diversity. The designated counties and hospitals are as follows:

The study will use quantitative methods to systematically identify and document FGM-related complications across six selected referral hospitals in six counties. The study will focus on women of reproductive age (15–49 years) who are currently pregnant, in active labor, or requiring skilled delivery assistance or C-section.

Expected results:

1. Inception Report
2. Study Protocol approval
3. Monitoring Report
4. Report on data collection
5. Report from Workshop to present the study findings
6. Final Study Report

Duration and working schedule:

Place where services are to be delivered:

Although the study covers six target county hospitals—Gbarpolu, Montserrado, Rivercess, Bong, Lofa, and Grand Gedeh—the consultant will be stationed in Monrovia, with field travel conducted as necessary.

Delivery dates and how work will be delivered (e.g., electronic, hardcopy, etc.):

The study will be conducted over 150 days, from August to November 30, 2026.

Monitoring and progress control, including reporting requirements, periodicity format, and deadline:

The consultant will be managed by the Specialist for Data and Evidence, who will provide day-to-day oversight of the process. In close collaboration with the Specialist, the consultant will receive the necessary support to ensure smooth execution of the assignment.

According to the established timeline, all deliverables will undergo an initial review by the Data and Evidence Specialist before being submitted to the Deputy Representative for input and approval.

Supervisory arrangements:

The consultant will be under the supervision of the Data and Evidence Specialist.

Expected travel:

The consultant is expected to travel to the field and selected hospitals periodically to train and observe the data collection process.

Required expertise, qualifications, and competencies, including language requirements:

The consultant must meet the following criteria:

• Must have a qualified health professional (Nurse, Midwife, Medical Doctor) or must be a health professional with 5 to 10 years of clinical practice
• Proven experience in the conduct of research in a similar context
• Excellent writing and organizational skills in workshop facilitation
• Excellent analytical skills and a high capacity to synthesize information.
• Fluency in English

Roles and responsibilities of the Ministry of Health

Given the critical importance of this study to the Ministry of Health's (MOH) efforts to identify the root causes of maternal and neonatal mortality and to implement the 365-Day Maternal and Neonatal Death Reduction Strategy, the MOH will be actively engaged in all phases of the research. This involvement will ensure findings are evidence-based and reflective of the reality at the study sites.

Specifically, the MOH will:

• Coordinate closely with UNFPA across all aspects of the study to foster institutional ownership and promote the strategic use of data.
• Facilitate and secure all necessary ethical and administrative approvals.
• Collaborate directly on the recruitment of consultants and study participants through relevant MOH units.
• Participate in field monitoring activities at designated study sites.
• Review and approve the study protocol, methodology, and data collection tools.
• Participate in the review and approval of the study data, analysis, and final report.

The UNFPA Liberia Country Office (CO) will provide efficient and responsive administrative support services to ensure timely delivery