The criteria for inclusion are as follows: (1) women aged >18 years; (2) identify as having FGM/C (type 1-4); (3) reside in South Australia; and (4) have accessed maternity, gynecological, and sexual health services in South Australia in the past 5 years.

The criteria for exclusion are as follows: (1) women aged <18 years; (2) have not experienced FGM/C; (3) do not reside in South Australia; (4) have not accessed maternity, gynecological, and sexual health services in South Australia; and (5) are unable to provide informed consent. Please note that the ability of women to speak or understand the English language will not be a requirement in this research, as qualified interpreters will be used. Interpreters with experience in translating in health care settings from South Australian Health–approved interpreting services will be used in this study.

The criteria for inclusion are as follows: (1) registered midwives and nurses, (2) working in clinical practice in South Australia, and (3) have cared for or will care for women with FGM/C.

The criteria for exclusion are as follows: (1) not a registered midwife or nurse, and (2) not working in clinical practice in South Australia.

FGM/C is recognized as a violation of the human rights of girls and women globally [22]. The practice is a deeply embedded sociocultural tradition among practicing communities, posing many challenges to its eradication, as women can be both the victims and perpetrators of FGM/C [15]. Women with FGM/C are more likely to experience sexual intimate partner violence than women who have not had the procedure [25,26]. It is well documented that storytelling triggers several concerns for victims of abuse, particularly, reliving the psychological trauma and resurfacing of suppressed memories [7,27]. Anticipating these issues, the researchers will take steps to address these and minimize any distress for participants.

The following steps will be followed during recruitment

Participants will be provided with an opportunity to discuss any concerns at the end of their participation.

Women will have the choice of attending an interview in person at UniSA City East campus or via telephone at a prearranged date and time.

Semistructured interviews will be used to explore the views and experiences of women with FGM/C who have accessed or are currently accessing maternity, gynecological, and/or sexual health services in South Australia for this phase. Semistructured questions will be asked by the researcher using examples identified from previous studies that have investigated the views and experiences of women with FGM/C [16,28]. The questions will be asked in a flexible manner and adapted, omitted, or elaborated on to correspond to the individual needs of each participant.

At the end of the interview, the principal researcher will provide participants with an opportunity to check and confirm responses and that these are a true representation of their views and experiences. If there is anything women would like to clarify or omit, they can do so. No further changes will be possible once data analysis or publication is conducted.

Data saturation will be attained when no new themes are identified [29,30]. Data saturation will be guided by the Hennink et al [30] framework. These researchers reported that data saturation could be achieved with 10 interviews but recommended that researchers should conduct a further 3 interviews to ensure that no new themes arise.

The investigators acknowledge that some women will not want to reveal that they have had FGM/C but may still want to share their views and experiences accessing maternity, gynecological, and sexual health services. Women who wish to remain anonymous will have the option to complete a web-based questionnaire on the study’s webpage. The web-based questions will be the same semistructured questions used in the face-to-face interviews. Women will be able to review their answers before submission.

The interview data will be manually transcribed by the principal researcher using the manual transcription function on the NVivo 12 (QRS International) software within 24-48 hours. No data will be saved on the cloud function of the program. A second researcher will check the accuracy of the scripts transcribed verbatim.

Constant comparative method (CCM) will be used to analyze data and generate codes from themes [31,32]. CCM uses a systematic process for analyzing interviews by constantly comparing the data, from “incident to incident, concepts emerging from further incidents in new data, and concept to concept” [32] to generate a theory. This approach enables researchers to identify gaps that require more exploration in future interviews. CCM has been used extensively in grounded theory research and can also be used effectively within other qualitative research [31,32].

Themes will be generated using the 6 steps for reflexive thematic analysis by Braun and Clarke [33] (Figure 2). Any discrepancies or disagreements will be resolved through open discussions with the research team.

Women in the face-to-face and telephone interviews will be given an Aus $50 (US $37) gift card to reimburse their time and travel or parking costs.

A workgroup collaborative will be established to develop the education and training program. The group will consist of women with FGM/C, health advocates, community leaders, and FGM/C clinical experts. The findings from phase 1 will inform the content of the program. The education program will be divided into 2 modules: module 1 (e-learning) and module 2 (face-to-face training).

Module 1, an e-learning module, will cover the theoretical aspects of FGM/C, including, but not limited to the following:

Module 2 will be a 1-hour face-to-face interactive training session delivered at various clinical sites around South Australia. The session will provide participants with a summary of the information learned in module 1, a chance to discuss questions and any aspects of the course further, and an opportunity to consolidate their understanding of the theory. Phase 1 will inform the development of case studies that review the health needs and care of women with FGM/C in the antenatal, intrapartum, and postpartum periods based on the experiences of women. The training will involve group work and will be facilitated by the principal researcher. The content will include conducting sensitive history taking, effective documentation, use of interpreters, deinfibulation counseling, and physical examinations.

KAP changes among midwives and nurses will be measured using 3 questionnaires: (1) a multiple-choice questionnaire to measure knowledge, (2) a 5-point-Likert scale survey to measure attitude, and (3) a survey to measure practice. The questionnaires will be developed based on previously validated questions identified in the literature that have evaluated FGM/C education for health professionals [34]. Knowledge will be measured via a multiple-choice questionnaire designed from the content of the program. Multiple-choice questionnaires are a convenient and effective assessment tool that has been extensively used in research to test knowledge [35-38].

Midwives’ and nurses’ attitudes toward FGM/C will be measured using 5-point Likert scales, adapted from 3 previous studies that have evaluated the implementation of education and training on FGM/C for health professionals [36,39,40]. Participants will be given a series of statements from which they will be required to select the extent to which they agree or disagree with each (ie, strongly agree, agree, neutral, disagree, and strongly disagree).

Information on the experience (practice) of midwives and nurses caring and supporting women with FGM/C will be collected through a survey that covers midwives’ and nurses’ experiences with FGM/C history taking, physical examinations, reinfibulation, mandatory reporting, and care plans.

Participants’ demographics, such as age, qualifications, years of clinical practice, and area of expertise, will be collected only once via a survey that will be completed on the web before commencing module 1.

Content validity of the FGM/C education program and data collection tools will be conducted by an expert panel of clinicians, FGM/C experts, and nursing and midwifery academics. Feedback will be sought on the content, wording, and structure of the education program and questionnaires and instructions to participants. Any disagreements among the members of the expert panel will be addressed through discussion and changes to the content until a consensus is reached [41].

Test-retest reliability will be used to measure the reliability of the validated questionnaire [42]. Midwife or nurse volunteers will be invited to complete the questionnaires at the same time and then 2 weeks later. Correlations between the scores at both time points will be measured, and the instruments will be determined to be reliable or not. Reliability refers to the consistency of the tool that measures the same trait in the same person and situation at different points in time [42]. Instruments that are reliable guarantee the accuracy and replicability of the results in future studies by reducing random error and bias [43].

The education program (including questionnaires) will be piloted with a sample of 10 midwives and nurses who will not be involved in the study. These participants will be asked to complete an evaluation form to inform the researchers if any changes need to be made. The information that will be sought includes the relevance of the module to practice, navigation of the module, ease of access to the content, relevance of questionnaires, and time it took to complete.

Owing to the lack of previous data on the effect of FGM/C education on practicing midwives’ and nurses’ knowledge and attitudes, sample size calculation was conducted to detect a standardized medium effect (d=0.5). Reflective of the pre- and posttest design, a paired sample size calculation was conducted using the SAS/STAT version 14.2 software at a significance level of 0.05 and power of 0.9. Using a two-sided test and allowing for 20% loss to follow-up, a sample size of 55 nurses or midwives will be required to complete phase 3.