NEONATAL MALE CIRCUMCISION AFTER DELISTING IN ONTARIO Survey of new parents Ruth E. Walton, MSc*
Canadian Family Physician A B S T R A C T OBJECTIVE To determine the prevalence of neonatal circumcision immediately following delisting of the procedure in Ontario and to examine parents' knowledge, attitudes, and behaviours regarding circumcision. DESIGN Cross-sectional survey. SETTING Perinatal tertiary care centre in southwestern Ontario. PARTICIPANTS Of the 151 mothers approached, three were excluded because they did not speak English and two declined participation; 112 of the 146 mothers of healthy male newborns responded for a response rate of 77%. MAIN OUTCOME MEASURES Circumcision status of infant and parents' knowledge, attitudes, and behaviour. RESULTS The circumcision rate before delisting had been 56.2%; in the months immediately after, the rate was 59.8% (95% confidence interval was 51%, 69%). Mothers of infants in the outcome groups did not differ significantly in any demographic feature other than education, where the group deciding against circumcision reported higher education levels (Wilcoxon nonparametric two-sample test: z = 2.29, P = 0.02). Mothers who chose circumcision listed medical (59%) and sociocultural considerations (40%) as most important in their decision. Father's circumcision status was strongly associated with the infant's (χ2[df 1] = 25.13, P = 0.0001). Although 74% discussed circumcision with their family physicians, many parents were not well informed about risks or benefits. Anaesthetic use during circumcision was reported by 29%, but 48% did not know whether any had been used. CONCLUSIONS The prevalence of neonatal circumcision did not change after delisting. Informed consent was often lacking. Sociocultural issues are important to some parents and need to be addressed in the consultation process. R É S U M É OBJECTIF Déterminer la prévalence de la circoncision néonatale immédiatement après la désassurance de cette intervention en Ontario et examiner les connaissances, les attitudes, et les comportements des parents concernant la circoncision.CONCEPTION Enquête transversale. CONTEXTE Centre tertiaire de périnatalogie du Sud-ouest de l'Ontario. PARTICIPANTES Des 151 mères contactées, trois furent exclues parce qu'elles ne parlaient pas l'anglais et deux autres ont décliné l'invitation à participer ; du groupe des 146 mères de nouveau-nés mâles en bonne santé, 112 ont participé à l'enquête pour un taux de réponses de 77 %. PRINCIPALES MESURES DES RÉSULTATS Nouveau-né circoncis et non-circoncis, ainsi que les connaissances, les attitudes, et les comportements des parents. RÉSULTATS Avant la désassurance, le taux de circoncision était de 56,2 % ; pour la période de trois mois suivant cette réforme, le taux fut de 59,8 % (intervalle de confiance à 95 %, 51 % et 69 %). Les mères des nouveau-nés du groupe des circoncis ne présentaient pas de différences significatives en termes de caractéristiques démographiques, sauf au niveau de l'éducation. Le groupe ayant décidé de ne pas faire circoncire avait un niveau d'éducation plus élevé (test non paramétrique à double échantillon de Wilcoxon : z = 2,29 ; p = 0,02). Les mères ayant choisi la circoncision ont établi en tête de liste les considérations médicales (59 %) et socioculturelles (40 %) pour justifier leur décision. On a également constaté une forte association entre la circoncision du père et celle de l'enfant (χ2[df 1] = 25,13 ; p = 0,0001). Même si 74 % ont discuté de la circoncision avec leur médecin de famille, de nombreux parents étaient mal informés des risques et des avantages. Pour la circoncision, 29 % des parents savaient qu'un anesthésique avait été utilisé alors que 48 % l'ignoraient. CONCLUSIONS Après la désassurance, la prévalence de la circoncision néonatale n'a pas changé. Le consentement éclairé était souvent absent. Pour certains parents, les aspects socioculturels sont importants et doivent faire partie du processus de consultation. *Ms Walton is a Research Associate in the Department of Epidemiology and Biostatistics at the University of Western Ontario in London. Dr Østbye is an Associate Professor in the Departments of Epidemiology and Biostatistics and of Family Medicine at the University of Western Ontario. Dr Campbell is an Associate Professor in the Departments of Epidemiology and Biostatistics, of Obstetrics and Gynaecology, and of Paediatrics at the University of Western Ontario.THE ISSUE of neonatal circumcision elicits strong opinions.[1-6] In Ontario, on April 1, 1994, circumcision for ritual, religious, cultural, or cosmetic reasons was deemed non-essential and delisted from the health insurance schedule of benefits. In London, Ontario, parents must now pay as much as $150 to have their newborns circumcised in hospital. This change in policy raises a number of questions. How will new parents and their physicians react to such a reversal of attitude toward a long-accepted practice? Non-religious circumcision began in North America as a preventive health procedure and evolved secondarily as a sociocultural tradition. Approximately 80% of boys in the United States and 40% of those born in Canada are circumcised as newborns.[7] Within Canada, prevalence varies across provinces, reflecting both sociocultural and health policy differences.[8] Southwestern Ontario hospitals reported proportions varying from a high of 56.2% to a low of 47.4% for the 1992-1993 fiscal year. Many studies and editorials promote neonatal circumcision,[9-13] and equally strong arguments oppose it.[14-18] The Canadian Paediatric Society reviewed the issue thoroughly and recommended, in an article published after delisting occurred, that neonatal circumcision not be performed routinely.[19] The pain of circumcision is an important issue.[20-22] Short hospital stays mean that circumcisions are often performed in the first days of life when mothers and infants are recovering from delivery, establishing family relationships, and initiating breastfeeding. Anesthetic use is not widespread,[21,22] but occasionally penile nerve block[23,24] and topical anesthetics, such as lidocaine and prilocaine cream,[25,26] are used. Parents' attitudes to circumcision are influenced by religion, culture, father's circumcision status, and the physician's attitude and advice. Many are not well informed about circumcision when they give consent for the procedure.[1,27,28] At the very least, they should be aware of the potential risks and disadvantages as well as the controversy about medical benefits.[29] This study evaluated circumcision practice in one tertiary care centre in southwestern Ontario just after the provincial health plan delisted the procedure. We addressed the following questions: Will parents choose circumcision for their newborn now that it is labeled a non-essential procedure and costs a substantial amount of money? What factors will influence their final decision? What advice will be given by their physicians?
M E T H O D S The survey was approved by the Health Sciences Review Board for Research Involving Human Subjects at the University of Western Ontario in London.Women who gave birth to healthy male infants at the study hospital were approached during their hospital stay and asked to take part in the survey. Any who did not speak English, were under 18 years of age, or were giving the child up for adoption were excluded. For multiple births, mothers answered questions as they pertained to the oldest male newborn. The questionnaire was pretested on a small sample of women. In London, while most pregnant women with no high-risk factors see their family physicians for prenatal care, obstetricians perform most deliveries. In London, only 20% to 25% of deliveries are attended by family physicians (personal communication from Dr L Reynolds on Oct 4, 1996). Sample size calculation indicated that 120 participants were necessary to estimate the prevalence with a boundary on the error of estimation of 10%. A 30-day period from May 16 to June 15, 1994, was designated for accumulating the required sample. Questionnaires were mailed to participants 2 weeks after the births. Respondents who did not return the first questionnaire were sent a second copy. Women reported the circumcision status of their infant, his gestation, relevant medical history, family demographics, place and time of circumcision if it occurred, and whether anesthetic was used during the procedure, by completing a checklist and fill-in-the-blank questions. Respondents' knowledge of the procedure was assessed by answers to 11 true-or-false statements. Attitudes to sociocultural issues were measured by Likert scale questions. Mothers' discussions with physicians were evaluated using a checklist. Mothers answered as proxy for questions concerning fathers. (Copies of the questionnaire are available on request from the authors.) Descriptive analyses comparing the outcome groups included Student's t, χ2, and Wilcoxon non-parametric rank order tests. A stepwise logistic regression analysis evaluated a model with nine predictors of neonatal circumcision.[30] A 0.15 level of significance was chosen to determine the relative importance of variables.[31] Data management and statistical analyses were performed using Statistical Analysis System version 6.07 for Sun OS (UNIX) and Epi Info version 5.01 for MS-DOS.
R E S U L T S Of the 151 mothers approached, three were excluded because they did not speak English and two declined participation. The response rate was 76.7%; 112 of 146 women returned the survey. Hospital records indicated no significant differences between respondents and nonrespondents with respect to age, residence, or circumcision outcome. Information about religious affiliation or education level of nonrespondents was unavailable. Most respondents resided in London; 30% were from other communities or rural areas.Of 112 newborns, 67 (59.8%) were circumcised. A comparison of this proportion with that of the hospital's 1992-1993 fiscal year's proportion of 56.2% indicated that there was no reduction in neonatal circumcisions at the study hospital in the months immediately following delisting (95% CI: 51%, 69%). None of the 112 newborns were reported to have any medical contraindications to circumcision. There was no association between circumcision choice and city versus rural residence, and no statistical difference in the ages of parents in the outcome groups. Mothers who chose not to circumcise reported higher education levels than those choosing circumcision (Wilcoxon non parametric two-sample test: z = 2.29, P = 0.02). There was no difference between groups with respect to whether mother or father made the decision, and 89% of respondents reported that both made the decision. There were no infants of Jewish or Muslim religion reported in either outcome group and no significant association with other religious affiliation (ie, none, Catholic, Protestant, or other) and outcome (χ2[df 3] = 3.8, P = 0.28). Reasons parents gave for their decisions reflected current controversies about circumcision (Table 1). While 58% of parents choosing circumcision did so because they believed that it was medically beneficial, more than one-third chose it for sociocultural reasons, the most common being that the baby should be like his father or siblings. Most (81%) of those who decided against circumcision reported that the medical risks or disadvantages were most important to their decision. The two groups differed significantly in terms of whether their most important reason was medical or sociocultural (χ2[df 1] =7.21, P = 0.007). Of the 110 fathers whose circumcision status was known, 70.9% had been circumcised (92% as newborns). Fathers' circumcision status was strongly associated with infants' (χ2[df 1] = 25.13, P = 0.0001; odds ratio = 11.09, 95% CI: 4.1, 29.7). Mothers' agreement with statements addressing sociocultural issues was assessed in light of fathers' and infants' circumcision status (Table 2). There was little variability across groups with respect to beliefs that children might be teased about different body appearance, and almost all agreed that children can be taught to accept such differences. In the group where fathers and infants were both circumcised, 49% of mothers perceived that teasing would be a serious problem, while agreement in all other combinations of concordance and discordance was 40% or less. The greatest variation occurred in responses to statements that "a boy's body should be like his father's (or brother's)." Most of those who chose circumcision agreed with those statements; agreement was lower in all other groups. Of all respondents, 74% said that they had discussed circumcision with the family doctor, and this did not differ across outcome groups. The influence of the family doctor was important to outcome, though numbers were insufficient to allow for statistical analysis. In 42% of responses mothers reported that their doctor was neutral about circumcision. Of those who chose circumcision, 47% thought that their doctor favoured it and 12% thought that the doctor was negative about it. In contrast, none of the mothers who decided against circumcision reported that their doctor favoured it. Only 16% of parents who chose circumcision and 7% of those who did not had discussed it with a pediatrician. Family or friends were considered a source of influence by 77% of parents who chose circumcision compared with only 44% of those who did not. Many parents who chose circumcision were not well informed before making their decision. Some did not discuss it with their doctor at all (21%), or only minimally after delivery (21%) to give consent for the procedure. Approximately half of the mothers who chose circumcision were informed about the most commonly occurring complications, such as infection (55%) or excessive bleeding (54%). The issue of pain was mentioned to 37% (Table 3). Discussion about the function of a normal foreskin and any disadvantages of circumcision was uncommon. The most commonly discussed benefits related to ease of cleansing (48%) and the avoidance of more complicated surgery later (49%). Most of the 67 circumcisions were performed in hospital before discharge (two in the outpatient department): during the first day for 46% of the infants, on the second day for 36%, and from the third to the ninth day for 18%. Twenty-nine percent of mothers reported that an anesthetic was used during the procedure; 23% answered that none was used, but many mothers (48%) answered that they "didn't know." Seven variables were selected as key predictors of circumcision outcome and entered into a stepwise logistic regression (Table 4). Variables significantly associated with circumcision related to fathers' and siblings' circumcision status and beliefs that the baby should be like them. Physician advice that was negative to circumcision was significantly predictive that the baby would not be circumcised. The effect of mothers' education (community college or less versus university or postgraduate), and a cumulative score of knowledge about circumcision remained in the model at significance levels of P < 0.135 and P < 0.134, respectively.
D I S C U S S I O N The prevalence of neonatal circumcision did not change at the study hospital immediately following delisting of the procedure. Parents in this population chose circumcision for medical or sociocultural reasons. Although the $150 fee was a substantial amount, for most parents the desire to have the circumcision done superseded concerns about the expense.The strong association between fathers' and infants' circumcision status was confirmed in this study. The high prevalence of circumcision in the fathers reflects the trend of 20 to 40 years ago; the fact that more than half of the healthy male newborns at this hospital are still being circumcised reflects both the social culture that has developed and the continued belief that neonatal circumcision is a medically beneficial procedure. Whether the rate will decline over time remains to be seen. The sociocultural concerns of parents considering a break in the circumcision tradition of their family or peer group need to be addressed. In spite of the fact that most mothers agreed that children can be taught to accept differences in appearance, many of those choosing circumcision did so for sociocultural rather than medical or religious reasons. Physicians and public health educators could offer parents more support, reassurance, and advice on how to address these social issues with relatives, peers, and the boys themselves. Many who chose circumcision had acquired their beliefs about the medical benefits of circumcision from family and friends rather than from their doctors. Though most of the women reportedly did discuss it with their doctors, the level of knowledge acquired often did not meet the criteria for informed consent Although many physicians presented a neutral view to parents, those who expressed opinions did influence outcomes. Circumcision was performed in a few cases even though a doctor reportedly expressed a negative opinion; it was carried out in all situations where a doctor had recommended it. Most infants underwent circumcision without pain relief even though most mothers agreed that the circumcision was painful. Many parents rely on physicians to guide the direction of the discussion, perhaps reasoning that, if pain relief is not mentioned, it is not an important issue for infants. Limitations
While some outcomes of the study could be validated by hospital records, some, such as mothers' answers to questions regarding anesthetic use during circumcision, could not be confirmed. However, since mothers would have had to give consent for the procedure and anesthetic use specifically, the responses were assumed to be accurate. Conclusions
Many parents did not receive adequate, current information about circumcision and anesthetic options. Physicians could provide guidance by addressing the sociocultural concerns that are important to many parents. Acknowledgments
Correspondence to: Ms Ruth E Walton, Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON N6J 5C1. References
^Top |
){kind=link}
){kind=link}
){kind=link}
){kind=link}