Medical male circumcision: do women in Swaziland welcome it for their sons and at what age?

Key findings:
Women were highly knowledgeable about the health benefits of medical circumcision, although knowledge of the comparative risks and benefits of early infant male circumcision (EIMC) and adult circumcision was poor. All the women said they would have their sons circumcised, but there was significant variation in the age at which they felt it would be most appropriate.

‘Male circumcision is surgical removal of the foreskin – the retractable fold of tissue that covers the head of the penis. The inner part of the foreskin is highly susceptible to HIV infections. Trained health professionals can safely remove the foreskin of infants, adolescents and adults. This procedure is called male medical circumcision.’ World Health Organization: Voluntary medical male circumcision for HIV prevention. Factsheet: 2012

Context
Swaziland has the highest prevalence of HIV in the world, with 26% of the adult population infected. Medical male circumcision (MMC) reduces the risk of men contracting HIV through heterosexual sex by around 60%. Historically, Swaziland has had one of the lowest rates of circumcision in the sub-Saharan African region, with 8.2% of males aged 15-49 circumcised countrywide. In 2009, the Government of Swaziland introduced a five-year strategy to increase MMC with the aim of reaching 80% of males, including newborns, by 2015. It is estimated that achieving this target would reduce the HIV incidence in Swaziland by 70% by 2025, preventing 64,000 new infections.

Why this study?
EIMC provides an opportunity to dramatically reduce the incidence of HIV in a safe and cost effective way. EIMC is circumcision in the first 8 weeks of life. It has several advantages over adult circumcision, including faster healing, fewer complications and lower cost. Understanding the knowledge, motivation and willingness of parents to circumcise their sons is essential for improving take-up of EIMC. While current evidence from elsewhere in Africa suggests that EIMC is generally very acceptable to parents and grandparents, this study is the first detailed insight into opinions on EIMC in Swaziland. Specifically, it highlights the main issues that might either encourage or discourage women and mothers when considering EIMC for their sons.

The findings fall into 6 main themes:

  1. most appropriate age for MMC
  2. fear of pain and complications
  3. cultural beliefs
  4. importance of family in decision making
  5. religion
  6. access to services

What we did
In this qualitative study we interviewed 14 women aged 18-44 who were attending the outpatient department of Good Shepherd Hospital (GSH). GSH is a rural district hospital in the Lubombo region and is developing the first integrated, comprehensive MMC service for HIV prevention in Swaziland.

Topics covered in the interviews include:
• existing knowledge of MMC;
• acceptability in the community of medical circumcision (both generally and for infants);
• willingness to have a son circumcised; and
• barriers and facilitators to medical circumcision, including religious and cultural beliefs.

The interview was also used as an opportunity to educate women about the risks and benefits of medical circumcision for infants.

While current evidence from elsewhere in Africa suggests that EIMC is generally very acceptable to parents and grandparents, this study is the first detailed insight into opinions on EIMC in Swaziland. Specifically, it highlights the main issues that might either encourage or discourage women and mothers when considering EIMC for their sons.
1: Most appropriate age for MMC
Early infancy: Those who favoured circumcision in early infancy usually felt the first 6 months to 1 year of life was the best time. These women gave various reasons, including the fact that babies would not be fearful before the procedure, nor would they be self-conscious or suffer discrimination from other children. The wound healing process would also be faster as young babies are less active than older children. Another view was that early infant male circumcision would encourage women to give birth in hospital: ‘What they encourage…is that you don’t have to deliver at home but at the hospital so you can get all the services they do to a newborn baby.’

Childhood: Some women felt that medical circumcision was best done in childhood to protect their son before they had sex for the first time. ‘When this child is older, like my brothers they are refusing now, so you can’t take them, you can’t force them to do it without them deciding if they do want to go. Whereas when this child is still young, you can do it, just for the sake of his life.’ Several participants said it would be important for their son to understand the reasons why circumcision is necessary and to be old enough to benefit from pre-operative counselling.

Adolescence: The ability of a son to make his own decision about circumcision was frequently mentioned as a reason to wait until adolescence. It is also the time that boys might become sexually active. However, participants made the point that an uncircumcised son might grow up asking questions about why his mother had not chosen to protect him, especially if he becomes infected with HIV.

Learning point:
The preferred age cited by women for male medical circumcision ranged widely from babies, to toddlers, through to older children and adolescents. This highlights the need for flexible services that provide medical circumcision at all ages rather than only at discreet points in a male’s life.
2: Fear of pain and complications
Although all participants said they would want their son to be circumcised, fear of complications and pain were cited as the main barriers. There was some contention about whether the wound would heal more, or less, quickly in infancy and whether the procedure would be more, or less, painful.

Pain: Some women felt circumcision would be more painful in adulthood due to erections. There were other concerns over the pain of stitches for infants. However, these women were reassured by an information leaflet that EIMC was generally safer and easier than circumcising an adult and that the procedure uses local anaesthetic and no stitches. ‘I didn’t know that they first inject the baby and then they don’t stitch the baby, I was afraid of the stitches.’

Complications: Excessive bleeding was a particular concern in considering circumcision for infants. However, the women acknowledged that the likelihood of death from medical circumcision was very remote.

Scarring: Some mentioned worries about scarring or injury that would lead to sexual dysfunction in later life: ‘They say that sometimes they cut at the wrong place so you get scarred for life, injured for life and then you have problems using your penis.’

Infertility: There were views expressed that medical circumcision was equivalent to castration, resulting in infertility. ‘What if I circumcise my one and only child and he doesn’t get any children?’

Learning points:
Women were reassured and more positive about EIMC after reading an information leaflet. Therefore, culturally-sensitive education materials on EIMC should be widely distributed. Existing services such as antenatal clinics and maternity wards should be used as an opportunity to reach and educate mothers about EIMC.
3: Cultural beliefs
Tradition: The fact that there is no tradition of circumcision in Swaziland was suggested as a barrier to MMC.

Popular myths: Particular cultural beliefs were raised about the removed foreskin being burned as a medicinal spice by traditional healers. The myth may have been triggered by a storyline in a popular television drama. Fear among children of being kidnapped when they go to be circumcised was also raised.

‘Some children are told about circumcisions at school and they are told there is going to be free transport, so what worries them most is what if the transport doesn’t return them, it takes them away for good, maybe for ritual purposes, so they are afraid to do it.’

Learning point:
It will be important to address these specific concerns in educational materials and to provide a high-quality and demonstrably safe service to allay fears.
4: The importance of family in decision-making
The role of different family members appears to be important in the decision to circumcise a son in Swaziland.

• It is common for women to consult the father of the child who would make the final decision. The father’s decision may depend on whether the father himself is circumcised.
• Sometimes, the mother was described as not having much power in the decision, with the father and grandparents having the final say.
• Others suggested that the decision is a collaborative one, related to the importance of family in Swazi culture: ‘A child in a family doesn’t just belong to one in Swaziland, when you are talking about someone’s life everybody has to participate.’

Learning point:
Men are particularly influential in the decision to circumcise a child, so should be targeted, perhaps through their own interaction with medical circumcision and reproductive health services.

5: Religion
Acceptability in the church: Christianity is the most common religion in Swaziland and Christian beliefs are firmly embedded in society. There were contradictory views among the women, however, with some arguing that circumcision was ‘ungodly’ and others saying it was acceptable in the church.

Learning point:
The influence of religion on women’s views about the acceptability of EIMC were variable, indicating that the perceived stance of their church on circumcision could serve as a barrier or an enabler.
6: Access to services
The distance from people’s homes to hospital services was seen as a barrier to considering MMC. ‘It can be best if the health workers can go into the communities…rather than them [the child and their parents] coming to the hospital as it can cost a lot of money and transport.’

Learning point:
One of the strengths of this study is its focus on rural inhabitants who make up 75% of the Swazi population. Good Shepherd Hospital serves a population living in very remote areas that may benefit most from outreach or community-based services.

 

This brief is based on a COMDIS-HSD study that assesses the knowledge and attitudes around early infant male circumcision among women attending a rural hospital in Swaziland, Southern Africa.

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