*Department of Surgery, Copperbelt University School of Medicine, Ndola, Zambia
†Department of Surgery, University of Zambia School of Medicine, Lusaka, Zambia
‡Department of Obstetrics and Gynecology, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
§Broadreach, Lusaka, Zambia
‖Department of Surgery, University Teaching Hospital, Lusaka, Zambia
¶Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC.
Correspondence to: Elizabeth M. Stringer, MD, MSc, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC (e-mail: firstname.lastname@example.org).
Funding was provided by the Centers for Disease Prevention & Control (CDC). We have not entered into an agreement with the funder that may have limited our ability to complete the research as planned. We had full control of all primary, data and the funder did not assist in (1) study design; (2) the collection, analysis, and interpretation of data; (3) the writing of the report; or (4) the decision to submit the article for publication.
All authors contributed substantially to the manuscript.
The authors have no conflicts of interest to disclose.
Received May 03, 2012
Accepted September 20, 2012
As early as 2001, ecological studies first suggested that countries with widespread coverage of male circumcision, such as those in West Africa, had lower burdens of HIV infection. 1–4 Subsequently, 3 large randomized trials in sub-Saharan Africa have conclusively shown that male circumcision (MC) reduces HIV acquisition among heterosexual men by up to 60%.5–7 Based on these findings, the World Health Organization (WHO) and UNAIDS recommended MC scale up as one component of a comprehensive HIV prevention strategy for settings of low MC prevalence and high HIV prevalence.8 Although adolescents and young adults are the primary targets for most prevention-oriented MC programs, to maximize long-term HIV prevention benefits, circumcision programs have also begun targeting male infants.
Neonatal male circumcision (NMC) (or circumcision within the first couple of months of life) is generally regarded as a cheaper, simpler, and safer procedure compared with circumcision of older boys and men 9,10. In industrialized-country settings, the procedure is commonly performed using 1 of 3 specialized devices (Mogen Clamp, Plastibell, or Gomco) designed to achieve hemostasis without sutures Complication rates among the 3 devices are similar,11 and choice among the devices is usually determined by provider preference.12–14 The WHO recommends all 3 of these methods in addition to the dorsal slit method for neonatal circumcision.15
Although NMC is rarely practiced in Zambia, the Ministry of Health of Zambia has ambitious plans to reach 80% of all male infants with NMC by 2020.16 We conducted an NMC study to determine the acceptability, feasibility, and safety of neonatal circumcision. The goal was to advise the Zambian Ministry of Health on the best method for national scale up. In this article, we report on device preference among different types of providers and safety.
PATIENTS AND METHODS
We conducted a prospective trial of NMC in 3 Lusaka sites: the University Teaching Hospital (UTH) and 2 public sector primary health care clinics. Neonatal vitamin K is not routinely used in our setting and was not administered to participants in our trial.
Recruitment and Training of NMC Providers
Before participant enrollment, we developed an NMC training package consisting of didactic lectures, practice on models of neonatal genitalia, and clinical practice. Nine physicians from the UTH were trained to serve as NMC supervisors for provider trainees enrolled in the study. During the study, these supervisors evaluated the competence of the trainees at set intervals, examined infants at review visits, and assessed adverse events.
Provider trainees included physicians, clinical officers, nurse midwives, and registered nurses. After completing informed consent to participate in the study of NMC provider training, providers were trained in groups consisting of 2 to 4 trainees depending on the availability of trainees. The individual methods were taught sequentially and in blocks. If a supervisor determined that a trainee was not competent in a given method after 10 procedures, then the provider would perform that particular method until competency, before moving on to another method. To ensure variation in the sequence of the 3 methods among trainees (assuming sequence could influence their competence and preferences among methods), the order of NMC methods for each provider was predetermined by an independent statistician. Providers were blinded to the sequence. Blinding the postoperative evaluations was not possible because the Plastibell technique involves a small plastic bell remaining on the penis for up to a week and the other two techniques did not.
NMC Provider Trainee Evaluations
The supervisors evaluated trainees using standard competency checklists (tailored to the procedure type being evaluated) after every 5 procedures. The trainees completed pretraining and posttraining questionnaires, to assess their knowledge, attitude, and previous experience with MC, and their NMC method preferences (posttraining only).
Informed Consent and Eligibility Screening
Parents of newborn boys were recruited for the study by peer educators in the postnatal wards of the 3 NMC sites and other public clinics. One or both parents (if available) or legal guardians of eligible infants completed an informed consent process before their infant's circumcision. All healthy male infants of gestational age >37 weeks at birth, aged 0–28 days, and between 2500 and 5000 g were considered eligible to be in the study. Infants with urethral or penile shaft abnormality, local infection, any current illness, or family history of bleeding disorder were excluded. Testing of mothers and infants for HIV was not offered in the study. However, all pregnant mothers are routinely tested for HIV under the Ministry of Health policy guidelines.
NMC Method Selection
Participating infants received a dorsal nerve block using 0.8 mL of 1% lignocaine for local anesthesia and were given up to 1 mL of an oral glucose solution, administered using a pacifier for analgesia during the procedure. Infants were then circumcised using 1 of the 3 NMC methods being trained (Mogen, Gomco, or Plastibell). The method performed on a given infant was determined based on which method was being practiced by the attending provider trainee at the time of the procedure, as previously described. For each circumcision performed, information such as provider, location, type of procedure used, procedure start, and end time, and individual infant characteristics as well as parental characteristics were recorded on standard clinic forms.
Study staff performed a detailed physical exam on all infants at 1 and 6 weeks after the procedure using standardized follow-up forms to guide their examinations. At infants' 6-week visits, parents completed a satisfaction survey during which they were asked to rate their level of satisfaction with the procedure outcome using a scale between 0 and 100, where 0 = not at all satisfied and 100 = completely satisfied. Study participants who missed their scheduled visits were followed up at home.
Evaluation of Adverse Events
Any observed complication was referred to study staff and recorded on an adverse events form. We categorized adverse events as mild, moderate, or severe based on criteria previously defined by the WHO.15 Mild bleeding episodes were defined as requiring pressure to control, moderate events required placement of a suture, and severe events were those requiring transfusion. We defined mild infections as requiring local cleaning, a moderate one as needing application of topical antibiotic ointment, and severe ones as requiring systemic antibiotics. A surgical revision was always classified as a severe cosmetic adverse event.
Descriptive statistics were used to summarize provider, parental, and infant characteristics. Differences in provider, parent, and infant characteristics between the 3 NMC methods were compared using the nonparametric Kruskal–Wallis test for continuous variables and the Pearson χ2 test for categorical variables. Providers ranked the 3 methods according to preference and ease of use, and the method with the highest rank was tallied. Mean parent satisfaction scores and procedure times were compared across the 3 circumcision methods, first using a 1-way analysis of variance model. Pairwise differences were evaluated using the Tukey HSD test to control for multiple comparisons.
The classification of the adverse event status for each participant was conducted in two ways. First, participants with missing follow-up data were treated as missing at random and removed from the denominator of all calculations. A separate sensitivity analysis classifying these missing patients as having an adverse event provided a conservative estimate of the upper bound for the percentage of adverse events. Adverse events were also tabulated by infant characteristics (such as HIV exposure status, age at procedure, and birth and procedure weight) and provider characteristics, including provider type. Although the study was not powered to detect any specific differences in adverse events between the 3 circumcision methods, a safety analysis was performed for the descriptive comparison of the methods. Data were summarized in terms of percentage of infants experiencing an adverse event at each follow-up visit. Separate comparisons between categorizations of adverse events and between each circumcision method were made using Fisher exact test. All statistical analyses were performed using SAS version 9.1.3 (SAS Institute, Inc, Cary, NC).
Our sample size was predetermined and based on convenience. Our goal was to train 15–20 providers, who would perform at least 10 circumcisions in each of 3 methods, for a total of approximately 600 circumcisions (200 per method). Enrollment of infants ended once all health care providers had completed at least 30 procedures and reached competency. Some providers completed >30 procedures; all procedures were included in the analysis.
The study protocol and informed consent documents underwent continuing ethical review from the relevant Institutional Review Boards at the University of Zambia, the University of Alabama at Birmingham, and the US Centers for Disease Control and Prevention (ClinicalTrials.gov registration: NCT01115335).
Between October 27, 2009, and March 24, 2011, we enrolled 17 providers into our study, each of whom performed at least 30 circumcisions (10 of each method). Six hundred sixty-one infants were enrolled, and 21 (3.2%) were excluded due to ineligibility after enrolling. Infants were excluded from the study if they were older than 28 days, had an infection or illness at the time of the procedure, or if they had pustules or blisters on their body. These infants did not undergo circumcision (Fig. 1). The total number of circumcisions performed was 640. Six of the 17 providers (35%) were male, 5 were doctors, 3 were clinical officers, and 9 were nurses or midwives. Of the doctors, 1 was a surgeon. None of the providers had previous experience performing neonatal circumcision, but 5 had experience with adult circumcision. Six providers were trained in Plastibell first, 6 providers performed Mogen first, and 5 providers were trained in Gomco methods first.
Infant and Parent Characteristics
Ninety-nine percent (635/640) had a 1-week follow-up visit, and 98% (630/640) were seen at 6 weeks after procedure. The median age of the infants at time of circumcision was 11 days (interquartile range [IQR]: 7–18 days). Approximately 11% were <48 hours at the time of the procedure. The median birthweight was 3.2 kg (IQR: 2.9–3.5 kg), and the median weight at the time of the procedure was 3.6 kg (IQR: 3.2–4.0 kg). Of the 624, 149 (23.3%) were exposed to HIV, and 17.2% were delivered by cesarean section. None of these infant characteristics differed by circumcision method (Table 1). Parental characteristics are described in Table 2. The median age of infants' mothers was 28 years (IQR: 24–32 years) and 34 years (IQR: 30–38 years) for the fathers. The majority of mothers reported being married (92.6%). Seventy percent had a household income greater than US $200 per month. More than half of all fathers (51.0%) were circumcised. Overall 10.7% of the mothers and 11.3% of the fathers were Muslim. Infants circumcised by the Mogen group were more likely to have a Muslim mother (P = 0.001) and have a Muslim father (P < 0.001).
For the 613 mothers and 64 fathers who completed a satisfaction survey, mean satisfaction score for mothers and fathers was 96.4 (SD = 7.5) and 95.9 (SD = 8.2), respectively, based on a scale from 0 (very dissatisfied) to 100 (very satisfied). Parental satisfaction scores did not differ significantly by method, and no pairwise differences between any two methods was found.
Provider Preferences and Procedures
Eleven of the 17 providers (65%) preferred the Mogen clamp to the Gomco or the Plastibell. The majority of providers (15/17, 88%) also found that the Mogen clamp was the easiest to perform. The mean duration of the procedures differed significantly by method and was 11.5 minutes (SD = ±6.7) for the Mogen clamp, 13.9 minutes for the Gomco (SD = ±6.3), and 11.9 minutes for the Plastibell (SD = ±4.0) (P < 0.001). Tukey-adjusted pairwise comparisons indicated that the duration of the Gomco procedure was 2.4 minutes longer [95% confidence interval (CI): 1.1 to 3.8 minutes] compared with the Mogen and 2.0 minutes longer (95% CI: 0.7 to 3.4 minutes) compared with the Plastibell procedures. The mean number of procedures to competency was 10.3 (SD = ±3.3) for Gomco, 10.3 (SD = ±3.7) for Plastibell, and 8.9 (SD = ±2.9) for the Mogen clamp. All providers were competent in each circumcision method by fifteen procedures. In general, nurses took longer to train than the other providers, but this was not statistically significant.
The overall adverse event rate was 4.9% (31/630, 95% CI: 3.% to 6.9%). When patients missing a follow-up visit were classified as having an adverse event, the overall adverse event rate was 6.34% (41/640, 95% CI: 4.6% to 8.6%). The 31 documented adverse events included 5 (16%) that were mild adverse events, 10 (32%) that were moderate events, and 16 (52%) that were severe events. All of the mild events were bleeding events requiring pressure to stop. The 10 moderate complications included bleeding needing either Surgicel (Ethicon, Somerville, New Jersey) or a suture to attenuate. The 16 severe complications included 11 cosmetic issues requiring revisions, 1 retained Plastibell that required removal in the theater, 3 infections requiring intravenous antibiotics and hospitalization, and 1 transfusion for bleeding in a patient who was delayed on the way to the tertiary hospital. The overall adverse event rate did not differ by method (P = 0.609). There were more cosmetic complications with the Mogen clamp compared with the other methods (Table 3).
In this prospective study, one of the largest to date of neonatal circumcision in Africa,17 and the only operational study of its kind, we show that neonatal circumcision can be provided by a variety of health care providers with relatively low complication rates (4.9%). We also found that most providers preferred the Mogen clamp over the Gomco and Plastibell techniques. We observed that providers were more likely to remove insufficient skin with the Mogen clamp, prompting surgical revision. However, this was not statistically significant given the small sample size of our study and the infrequent occurrence of these events.
Our complication rates were relatively low but higher than rates of other studies from the United States. Between 1963 and 1972, Gee and Ansell12 retrospectively analyzed almost 6000 infants who had been circumcised in the United States; approximately half of the infants had been circumcised with the Gomco method and half with the Plastibell method. The overall complication rate was 0.2% with no significant difference between the two different methods. Another study of NMC from Israel also report very low complication rates at 0.003% with almost all related to hemorrhage, cosmetic, and penile trauma, which is consistent with our causes of morbidity.14 A few studies in Africa have reported complication rates as high as 20%.18 Our complication rates may be slightly higher than those observed in other studies, given that we classified any postprocedure bleeding as an adverse event—even if it was mild. We also categorized any surgical revision for redundant foreskin as a severe adverse event, whereas other studies have typically excluded cosmetic events. In addition, because our study involved newly trained providers (as opposed to providers who had performed hundreds of procedures), we think it is safe to assume that our complication rates represent the upper limit of what could be expected in real practice. As providers perform more circumcisions and become more skilled, complication rates are likely to decline further.9
A recognized weakness of our study is that we did not perform individual infant randomization but rather chose to assign the providers to different orders of the procedures. Individual randomization would have interfered with analysis of the provider training because skill development is most easily achieved through repetition of the same technique a number of times in a short time frame. One result of our study design was imbalance between allocations groups. For example, more infants of Asian descent were included in the Mogen method group compared with the other methods, a result of patient clustering. We believe that this can be attributed to similar groups of mothers being brought to the clinic together on a given day by one woman from the community.
In our study, all types of providers preferred the Mogen clamp. This method has many benefits: one size can be used for all clients, the instrument consists of only one piece (versus the Gomco clamp that contains several pieces which much fit together); and it can be sterilized for reuse, which may reduce on cost. Our safety outcomes were not significantly different between physicians and nurses, although we had relatively few complications. Given the limited number of physicians (the physician:patient ratio is 1:14,000 and WHO recommendation is 1:5000), this method will lend itself to easier scale up using mid-level providers. In general, we found that it did take longer for nurses to achieve competency compared with the other types of trainees.
As Southern African countries turn their attention to scaling up early infant circumcision services for future prevention of male HIV acquisition, strategic decisions must be made regarding which method(s) to employ and which types of providers to train. We recommend that countries adopt and focus on a single NMC method, to ensure standardization in provider proficiency, to streamline training and procurement, and to minimize complications. Finally, given that the relatively high complication rates for NMC—particularly when compared with industrialized country settings—carefully monitoring of adverse events is urgently needed, and systems to ensure ongoing clinical mentorship and training should be implemented.
The authors would like to acknowledge all the patients who participated in the study and the dedicated providers. The authors would also like to acknowledge Richard Levine for initial help in training.
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