be well nourished than older mothers. In spite of a widespread assumption that young mothers are less likely to get adequate prenatal and obstetric care, recent evidence suggests that this is not the case (Abou-Zahr and Wardlaw, 2003). However, evidence from some sub-Saharan African countries suggests that young mothers may be less likely to deliver with a skilled attendant (Magadi, Agwanda, Obare, and Raffa, 2004). Regardless of whether there is an intrinsically higher risk of death associated with young age, the physical toll of early parenthood can have significant consequences later in life, including infertility and complications in later pregnancies.

Female genital cutting is one factor that contributes to the level of maternal morbidity and mortality in a number of countries. Female genital cutting—an operation that involves the partial or total removal of female external genitalia—is a rite of passage that is traditionally carried out during childhood in some societies and during adolescence in others. In either case, the consequences continue during adolescence and adulthood. Female genital cutting is not a worldwide practice, but is confined largely to a band of countries stretching across the upper half of Africa also including some countries of the Middle East. Prevalence of the practice is as high as 97 percent in Egypt and 98 percent in Somalia and Djibouti, and it falls to 5 percent in Uganda and the Democratic Republic of Congo (Carr, 1997; Creel, 2001; Toubia and Izett, 1998). (We are not aware of regional or global estimates of female genital cutting.) The practice can have immediate health consequences (such as infection and hemorrhage) and, particularly for those who have the more extreme forms, can lead to later obstetrical complications and eventual reduced fertility as well as psychological difficulties and reduced sexual pleasure (Shell-Duncan and Hernlund, 2001).

A gradual recognition of the magnitude and consequences of this practice, a redefinition of it as a human rights issue, and a strong policy push for elimination followed the 1994 International Conference on Population and Development and the 1995 Fourth World Conference on Women. Declines in the practice are now apparent in a few countries, and there are some indications that its harmful effects are increasingly being recognized by affected populations and that disapproval of the practice is increasing. In a study based on DHS data from eight countries, women ages 20-24 in six of the countries were more likely to oppose female genital cutting than women ages 45-49 (Creel, 2001). Another study in Egypt suggests a 10 percentage point decline in prevalence from one generation to the next, around the time of the International Conference on Population and Development (El-Gibaly et al., 2002).

Despite an emerging international consensus on the issue, few sustained national-level policy initiatives have been implemented to date. However, nongovernmental organizations and community-led efforts appear to have made some progress, by breaking the silence around the issue and mobiliz-



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