PREFERRED METHODS OF MALE NEONATAL CIRCUMCISION AMONG MOTHERS IN LAGOS NIGERIA

Abstract

Background

Although male neonatal circumcision is routinely done in many parts of Africa for cultural reasons, little is known about the reasons for neonatal circumcisions in metropolitan settings.

Objectives

To elucidate from mothers reasons and preferred methods for circumcising male children in Lagos

Setting

Lagos University Teaching Hospital, Lagos, Nigeria.

Patients, Materials and Method:

One thousand and two consecutive mothers of male children were interviewed through a questionnaire-based survey to determine the reasons why their male children were circumcised and their preferred method.

Results:

A thousand and two mothers were interviewed. One thousand, seven hundred and seventy five (1775) male children from these mothers, comprising 59.7% of the children and all of whom had been circumcised in Lagos were the subjects of this study. The Plastibell kit method was preferred by 415 mothers (41.5%) of mothers while the open surgical dissection method was employed in 15%. The Gomco method was only requested by 16 mothers (1.6%). Six hundred and six mothers (60.6%) mothers circumcised their children for traditional reasons while 20.8% believed it fulfilled their religious obligations.

Conclusion

Most male children in Lagos were circumcised for traditional and religious reasons. The Plastibell kit is the method of choice for male circumcision among mothers in Lagos.

Introduction

Male neonatal circumcision in most developed countries is controversial1,2,3,4. While some workers support the procedure, claiming it is protective against the transmission of the Human Immunodeficiency Virus (HIV) in heterosexual males, among other reasons, others insist it does not confer any benefits5,6,7. In many parts of sub-Saharan Africa however, the practice of male neonatal circumcision is universal. Paediatric Surgeons are therefore regularly confronted with the request to circumcise male neonates, with mothers sometimes asking for a particular method or another.

There are few medical indications for this procedure and most mothers circumcise their sons based on socio-cultural and religious reasons8. Although there are many options available to perform the procedure, only a few are available to most mothers in the African continent. We wondered if loosening cultural ties and higher maternal education in metropolitan settings have not diminished the universal desire for male circumcision in our community. We therefore sought to determine the reasons why mothers circumcise male children in our metropolitan setting, and methods preferred by mothers for this procedure.

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PATIENTS AND METHODS

A questionnaire–based survey was carried out at the Lagos University Teaching Hospital, Lagos (LUTH) to determine the reasons why mothers circumcised their children and their preferred circumcision methods. One thousand and two consecutive consenting mothers of circumcised male children were recruited into the study from the Paediatric Surgery Outpatients’, General Paediatric Outpatients’, Antenatal and Postnatal Clinics of the Lagos University Teaching Hospital, Lagos, Nigeria. Information about maternal age, educational status, total number of children, number of circumcised male children, the reason why the male children were circumcised and the preferred circumcision methods, if any, were documented. These questionnaires were administered by Residents and House Officers in the Paediatric Surgery Unit. Excluded were mothers with medical and paramedical occupational backgrounds. The data was analyzed using SPSS® version 13 software package (SPSS^® Inc., Chicago IL, USA) for windows to derive frequencies, mean and standard deviation. Chi-square analysis and the independent sample t-test were used to evaluate associations between the categorical and continuous variables and, unless otherwise stated, P-values < 0.05 were considered to be statistically significant.

RESULTS

A thousand and two mothers with 2975 children were interviewed. Of these, 1775(59.7%) were males all of whom had been circumcised in Lagos. The maternal mean age was 34.1±8.2 years

Maternal education

Four hundred and forty five mothers (44.5%) had tertiary education while 268 (26.7%) mothers had completed secondary school. Eighty five (8.5%) mothers had only primary education while 11(1%) mothers did not go to school at all. One hundred and ninety two mothers (19.2%) did not disclose their educational status. The median number of children by the mothers was 3 (range 1 – 9) while the median number of male children that were circumcised was 2 (range 0 – 6). Figure 1 shows the distribution of the number of children circumcised per mother.

Maternal Reasons for circumcision

The reason for circumcision of male children was tradition in 606 mothers (60.6%) while 208 mothers (20.8%) circumcised their male children due to religious beliefs. Medical indications accounted for 35 (3.5%) mothers who circumcised their male children. The medical indications were not known to the mothers but they had all been referred to different hospitals for circumcision by Medical personnel soon after birth. Twenty five mothers (2.5%) circumcised their sons because the mothers thought circumcision improves the perineal hygiene while thirty-four mothers (3.4%) circumcised their sons because they preferred the cosmetic appearance of a circumcised penis to the uncircumcised one. Other reasons are as shown in Fig. 2. Educational status of mothers did not statistically significantly influence the reasons for circumcision.

Preferred Circumcision Methods

Four hundred and fifteen mothers (41.5%) preferred the Plastibell device to be used to circumcise their sons while 150 mothers (15%) preferred the open method without the use of any specialized devise. One hundred and sixty-three mothers (16.2%) preferred the operator to choose whichever method appropriate for the procedure while 16mothers (1.6%) preferred the Gomco method of circumcision to be performed on their male children. Two hundred and fifty-eight (25.7%) mothers had no preference for any method of circumcision and thus did not mention what method of circumcision they preferred.

Conclusions

In conclusion, male neonatal circumcision is requested by mothers based on traditional and religious beliefs, and this is regardless of maternal educational status. The Plastibell method is the preferred method by most mothers. Safe use of this popular method should be taught to all doctors and nurses who may wish to perform neonatal male circumcision.

Discussion

Male circumcision is deeply entrenched in the traditional beliefs of most African societies including West Africa9. As a result, almost all male children born in West Africa will be circumcised some time in their lifetime. This is in contrast to what obtains in some parts of the world where male circumcision is on the decline as more people now question its benefits10. This study aimed to determine the reasons why mothers present their children for circumcision and the preferred method to carry out the procedure in a cosmopolitan setting.

Lagos is the largest city in Africa with an estimated population of 18 million people. It is largely urban and cosmopolitan. LUTH is one of two teaching hospitals in the state, although there are a few Specialist hospitals (both public and private) in the city.

The mean age of the mothers interviewed was 34.1±6.2 years, reflecting the relatively young population of Nigerians, including Lagos dwellers. National population estimates suggests that more than half of the population is below 30 years 11. A large proportion of the mothers (71.2%) had at least Secondary education or more. Consequently, one would have expected the responses of the mothers to be influenced by their level of education. However, our study did not suggest this. Rather, mothers appeared to be still strongly rooted in traditional beliefs about male circumcision. There were similar responses across the different categories of levels of education, indicating a strong adherence to age-old traditions as far as circumcision is concerned. This may be as a result of the fact that unless the mother has been exposed to medical or related fields, the level of knowledge about circumcision may not be different across the levels of education. The major reason for circumcision by mothers was the traditional belief and religion. This confirms previous studies on the indications for circumcision 12. In Southern Nigeria, most mothers present their male babies for circumcision in the neonatal period irrespective of whether there is a medical indication or not. Refusal by trained medical personnel to perform the circumcision usually results in such mothers seeking help from paramedical staff and even local “circumcisionists” with attendant, needless complications 12,13. Therefore, in our sub-region, the contention is not whether to perform circumcision or not but rather, that the circumcision should be performed safely without any harm to the male child.

This study has shown a preference, by mothers, for the Plastibell® method. This may be as a result of the fact that this method is easily available and it is performed by both doctors and nurses. It is also appealing to mothers who call it the “ring method” and many of whom think it is fashionable, oblivious of its many attendant complications in untrained hands14. The open method of circumcision is performed by medical doctors with a bias for surgery because of the technicality and dexterity involved. The possibility of penile amputation and urethrocutaneous fistula makes other health professionals to avoid this method. The Gomco® method on the other hand is usually performed by Specialists Paediatric Surgeons and Urologists. It is thus not widely patronized by mothers.

Limitations of this study include the fact that the mothers in the study group might not have represented all the segments of the population in Lagos as not all mothers have ready access to tertiary care. Similarly, the influence of the fathers on choice and reasons of circumcision was not explored. Mothers with exposure to medical or paramedical training were not included but this could form subjects of further studies

Figure 1.

Number of children circumcised per mother

Figure 2.

Indications for circumcision