Circumcision is the excision of the foreskin of the penis. Male circumcision is one of the most frequently performed surgical procedures across the world, with an estimated one-third of men being circumcised globally and approximately 10% in Europe (Morris et al, 2016). Although there is some evidence of therapeutic benefit (Alkhenizan and Elabd, 2016) and male circumcision is promoted by the World Health Organization (WHO) for HIV prevention in sub-Saharan Africa (Awori et al, 2017), it is predominantly performed in infanthood for non-therapeutic reasons within the Jewish and Muslim faiths (Morris et al, 2016). Globally, 97% of male circumcisions are performed for cultural or religious reasons (Genin, 2017). The reasons that different communities practice infant male circumcision has been described in the British Journal of Midwifery previously (Harbinson, 2015). The ethics of this practice are contentious and highly emotive and will not be addressed in detail here (Evans, 2011; Earp, 2013). Opponents of non-therapeutic male circumcision have argued that it should be deferred until the boy can make an independent decision (Di Pietro et al, 2017; Myers and Earp, 2020). However, parents may consider circumcision a necessary component of their son's religious upbringing (Ventura et al, 2020). Given that such deep-rooted religious traditions are unlikely to be swayed by ethical arguments or reports of harm, the authors believe there is a need to focus on ensuring that infant male circumcisions are performed as safely as possible (Anwer et al, 2017).
Globally, the three most common techniques for newborn male circumcision use a clamp or the Plastibell device, which are equally effective, with the procedure typically taking less than 10 minutes to perform (Omole et al, 2020). Providers should use an anaesthetic block to provide adequate pain relief (Sharara-Chami et al, 2017; Rossi et al, 2021).
Infant male circumcision generally has low reported complication rates, with the most common being minor bleeding occurring in between 0.5% (Jimoh et al, 2016) and 3.9% of cases (Heras et al, 2018). The complication rate for circumcisions using the Plastibell device is lowest when the procedure is performed at a younger age; follow-up of over 2000 infant boys under 3 months of age in Lagos found a complication rate of 1.1%, most commonly bleeding (Jimoh et al, 2016). A Plastibell circumcision service in Pakistan for older infant boys reported a complication rate of 4.1%, with the most common being failure of the bell to shed and minor bleeding (Moosa et al, 2021). Other reported minor complications include poor cosmetic appearance, infection, postprocedural adhesions or skin bridges. More serious and rare complications include complete or partial degloving of the penile skin, iatrogenic urethrocutaneous fistula, amputations of the penis and death (Colon-Sanchez et al, 2020; Omole et al, 2020). Being older at circumcision, lack of operator experience and poor setting sterility are associated with increased risk of complications (Ventura et al, 2020; Zeitler and Rayala, 2021). In Italy, it was reported that four boys died as a result of circumcision performed by unqualified operators in unhygienic conditions (Ventura et al, 2020).
In the UK, non-therapeutic infant male circumcision for religious or cultural reasons is not generally provided by the NHS. The vast majority of these procedures are undertaken by private providers in community settings (British Medical Association, 2019). There have been reports of unsafe practices, such as poor surgical technique as a result of lack of training and poor hygiene, by some unregulated private providers, with consequences ranging in severity from infection that is treatable with antibiotics to severe surgical errors requiring plastic surgical repair to amputation of the penis and even infant death. (Paranthaman et al, 2011; BBC News, 2012).
The aim of this article is to discuss how a voluntary quality assurance process can be used by midwives to support families and reduce the risk from harm associated with poor practice.
The Greater Manchester quality assurance process
Greater Manchester is an area of England with a diverse ethnic population and it has seen an increase in the number of males born into communities that practice non-therapeutic circumcision over the past decade (Office for National Statistics, 2020). In 2011, a quality assurance process was implemented for private providers of infant male circumcision in Greater Manchester with the aim of minimising complications and helping parents identify safe providers (Figure 1). The quality assurance process involves annual assessment against expected standards of care for non-therapeutic infant male circumcision for boys less than 12 months of age in the community (Table 1). The quality assurance standards are updated annually in light of recommendations from the British Association of Paediatric Surgeons (2016), the British Medical Association (2019), the Care Quality Commission (2019) and the General Medical Council (2020). In Greater Manchester, information about the programme is included in the maternity red book and parents are signposted to providers who meet the quality assurance standards via the programme website. This website also includes other information about safe circumcision practice to support parental choice. Providers that do not meet the standards are provided with guidance on how to improve their practice, with continued quality improvement engagement throughout the annual cycle. The process was developed through engagement with local providers, healthcare staff and community and faith groups (Whittaker et al, 2014).
Table 1. Greater Manchester quality assurance standards for non-therapeutic community male infant circumcision
| Quality criteria | Minimum standard |
|---|---|
| Training | Practitioners should attend specific training on performing circumcision using their chosen technique. This must include neonatal resuscitation, administration of local anaesthetic by dorsal penile nerve block or ring and performing some circumcisions under supervision |
| Maintaining competence | Practitioners should perform a minimum of 20 circumcisions per year. Practitioners who have performed fewer than 20 circumcisions per year should undergo refresher training |
| Settings | Circumcisions must be performed in a clinical area registered with the Care Quality Commission for minor surgery with adequate infection control measures in place. The requirement for registration of premises with the Care Quality Commission was added in 2013 |
| Consent | Consent is to be sought from both parents. Consent needs to be obtained and documented even by telephone from the second parent and witnessed. A consent policy needs to be kept in the records. There is an exception to this rule if there is only a single parent |
| Pain relief | Local anaesthetic by dorsal penile nerve block or ring block should be used. These techniques reduce, but do not eliminate, the pain of circumcision, so treatment with systemic analgesics should also be used |
| Post-procedure observation | The infant should be observed by the practitioner for at least 30 minutes after bleeding from the circumcision site has stopped |
| Aftercare | The person who performed the circumcision is responsible for the post-operative care of the patient, and must ensure that the parents understand how to care for the wound and the infant following the procedure and under what circumstances they should seek medical advice. This advice should be provided verbally and in writing. The person who performed the circumcision should be available to answer questions or assess the infant in the week following the procedure. This information should be available in a range of languages |
| Follow-up appointment | A routine follow-up appointment should be offered to local families approximately 2 weeks after the circumcision. If this is not a practical option, follow up should be arranged with their GP |
| Safeguarding training | Practitioners must have completed level three safeguarding training. This requirement was changed from level two safeguarding training in 2014 |
| Audit | The process and outcomes of the procedures performed should be subject to annual audit.The audit must include:
|
| Complaints | All providers should provide a written copy of their complaints procedure and provide information for parents on how to make a complaint |
What difference has the quality assurance process made?
Compliance with quality assurance standards
The compliance of applicants with each quality assurance minimum standard was recorded and compared between 2011 and 2019 (the quality assurance panel did not take place in 2020 as a result of the COVID-19 pandemic). In 2011, nine providers applied for quality assurance and four met the required standards. Two providers failed to provide evidence that they were adequately trained in circumcision surgical technique and neonatal resuscitation. Two providers could not demonstrate that they performed enough procedures annually to maintain their competence. Four providers did not obtain consent from both parents before performing infant male circumcision. Three providers did not provide adequate aftercare advice to parents and five did not offer a follow-up appointment. Four providers had not completed level two safeguarding training. Four providers did not provide an audit of their outcomes, and three providers failed to provide a complaints procedure. In 2019, six providers applied for quality assurance, and all met the required standards. Details of standards met by the applicants can be seen in Tables 2 and 3.
Table 2. Applicants compliance with quality assurance quality standards in 2011
| Provider ID | Procedure training | Neonatal results | Perform >20 per year | Premises registered with Care Quality Commission for surgical procedures* | Dual consent | Local anaesthetic | Post-procedure analgesia advice |
|---|---|---|---|---|---|---|---|
| QA2011-01 | Y | Y | Y | N/A | Y | Y | Y |
| QA2011-02 | Y | Y | Y | N/A | Y | Y | Y |
| QA2011-03 | Y | Y | Y | N/A | Y | Y | Y |
| QA2011-04 | Y | Y | Y | N/A | Y | Y | Y |
| QA2011-05 | N | N | Y | N/A | N | Y | Y |
| QA2011-06 | N | N | N | N/A | N | Y | Y |
| QA2011-07 | Y | Y | Y | N/A | N | Y | Y |
| QA2011-08 | Y | Y | N | N/A | N | Y | Y |
| QA2011-09 | Y | Y | Y | N/A | Y | Y | Y |
| Post-procedure observation 30 minutes | Aftercare advice | Follow up offered | Safe guarding training level 2 | Audit | Complaints procedure available | Quality assured | |
| QA2011-01 | Y | Y | Y | Y | Y | Y | Y |
| QA2011-02 | Y | Y | Y | Y | Y | Y | Y |
| QA2011-03 | Y | Y | N | N | N | N | N |
| QA2011-04 | Y | Y | Y | Y | Y | Y | Y |
| QA2011-05 | Y | Y | N | Y | N | Y | N |
| QA2011-06 | Y | N | N | N | N | N | N |
| QA2011-07 | Y | N | N | N | N | Y | N |
| QA2011-08 | Y | N | N | N | Y | N | N |
| QA2011-09 | Y | Y | Y | Y | Y | Y | Y |
Table 3. Applicants compliance with quality assurance quality standards in 2019
| Provider ID | Procedure training | Neonatal results | Perform >20 per year | Premises registered with Care Quality Commission for surgical procedures* | Dual consent | Local anaesthetic | Post-procedure analgesia advice |
|---|---|---|---|---|---|---|---|
| QA2019-01 | Y | Y | y | Y | Y | Y | Y |
| QA2019-02 | Y | Y | Y | Y | Y | Y | Y |
| QA2019-03 | Y | Y | Y | Y | Y | Y | Y |
| QA2019-04 | Y | Y | Y | Y | Y | Y | Y |
| QA2019-05 | Y | Y | Y | Y | Y | Y | Y |
| QA2019-06 | Y | Y | Y | Y | Y | Y | Y |
| Post-procedure observation 30 minutes | Aftercare advice | Follow up offered | Safe guarding training level 2 | Audit | Complaints procedure available | Quality assured | |
| QA2019-01 | Y | Y | Y | Y | Y | Y | Y |
| QA2019-02 | Y | Y | Y | Y | Y | Y | Y |
| QA2019-03 | Y | Y | Y | Y | Y | Y | Y |
| QA2019-04 | Y | Y | Y | Y | Y | Y | Y |
| QA2019-05 | Y | Y | Y | Y | Y | Y | Y |
| QA2019-06 | Y | Y | Y | Y | Y | Y | Y |
Hospital admissions
An evaluation was performed by retrospective analysis of patient records for infant boys admitted to the main regional children's hospital in 2009 (the last year prior to introduction of the quality assurance process) and 2016 (the last year that the authors had access to patient records). The evaluation found that 27 infant boys were admitted in 2009 and 13 in 2016 suggesting that the number of serious complications reduced during a time when the population of infant males requiring non-therapeutic circumcision in Greater Manchester increased (Office for National Statistics, 2020). Bleeding was the most common complication in both years, occurring in 21 of the 27 admissions in 2009 (78%) and 12 of the 13 admissions in 2016 (92%). Infection was identified in four cases in 2009 (15%) and one case in 2016 (8%).
How do parents feel?
Both healthcare professionals and parents recognise the risks of non-therapeutic male circumcision being performed by unregulated private practitioners (Bhopal et al, 1998; Harbinson, 2015). This highlights the necessity for quality assurance of the procedure. Parents often rely on word of mouth and social media networks to identify providers to perform circumcision on an infant son (Whittaker et al, 2014). Many parents report feeling anxious about the process and would like more support from healthcare professionals, including midwives (Morris et al, 2017; Morgan et al, 2021). Parents may feel anxious about asking midwives for advice about finding good quality providers for fear of negative reactions and even censure (Bawadi et al, 2020). Non-judgemental conversations about what to look for in a provider and questions to ask will empower parents to make informed decisions about infant male circumcision providers (Anwer et al, 2017; Ventura et al, 2020). Key issues associated with safe practice are covered by the Greater Manchester quality assurance standards (Table 1). Of particular importance are training, maintaining competence and infection control practices, which have been shown to be associated with lower complication rates (Ventura et al, 2020; Zeitler and Rayala, 2021). Knowledge about pain relief, aftercare and follow up will also enable parents to understand what to expect and be prepared for any potential complications (Sharara-Chami et al, 2017; Altunkol et al, 2020; Omole et al, 2020; Ventura et al, 2020).
How do midwives feel?
Harbinson (2015) stated that midwives had little or no information for pregnant women and new mothers enquiring about infant male circumcision. The NHS website acknowledges that infant male circumcision is commonly practiced for religious or cultural reasons in many communities but offers no guidance for parents on how to identify a suitable provider. The Royal College of Midwives (2017) offers no guidance regarding male circumcision to its members. Articles on how to counsel parents considering infant male circumcision exist in the midwifery literature (for example, Mielke, 2013) but these typically focus on the health pros and cons of circumcision rather than on practical advice about identifying good quality provision.
Midwives are trusted professionals providing support, advice and information for women throughout pregnancy, labour and the postnatal period (International Confederation of Midwives, 2018). During this time, midwives work very closely, and often intensely, with women and their families, building trusting relationships. Midwives' communication skills are pivotal in engaging women and, where appropriate, referring them to safe and accessible services (Gibbon, 2010). For many women, accessing a midwife may be their first encounter with health services, opening a gateway to evidence-based public health information relevant to their families (Royal College of Midwives, 2017). The Greater Manchester quality assurance process enables midwives to provide vital information to mothers and their families surrounding the safe practice of male circumcision, equipping midwives to have informative, open and honest conversations regarding male circumcision and good quality provision. Midwives can use the programme's website to guide non-judgemental conversations about what is required for safe infant male circumcision. Parents should be advised that although infant male circumcision is generally safe, as with all surgical procedures, there is a small risk of complications; the most common being bleeding (Jimoh et al, 2016; Omole et al, 2020). Parents should be advised that the risk of complications is lower if the procedure is performed by a trained provider, operating in sterile conditions who provides adequate pain relief for their son (Sharara-Chami et al, 2017; Altunkol et al, 2020; Omole et al, 2020; Ventura et al, 2020). The website lists providers that meet these criteria. The Greater Manchester quality assurance process is a tool to support midwives in their roles as trusted health practitioners and increase trust in health professionals. It enables the subject of male circumcision to be discussed without feelings of judgment and prejudice.
Limitations of the quality assurance process and future developments
Engagement with the quality assurance process is entirely voluntary, and the quality assurance panel has no power to prevent providers who do not engage with the process or who do not meet the quality assurance standards from continuing to practice. Improvements with the quality assurance standards may reflect better recording of their practices by providers rather than actual improvements in the quality of care offered to patients. The main barrier to making engagement with the quality assurance process mandatory is that there is no legal obligation in the UK for those that perform these operations to have any medical qualification or be registered with any professional body (British Medical Association, 2019).
Data collection from primary care, emergency department and hospital admissions to evaluate the impact of such programmes that aim to prevent complications from infant male circumcisions performed by community private providers face a number of barriers. These include access, incomplete recording and the fact that there is no hospital episode statistics code specific to complications from non-therapeutic circumcision. In future, recording the name of the community provider in hospital records would enable quality improvement feedback to individual providers and verification of their self-recorded outcome audits. This would allow more transparent monitoring of practitioner safety. In 2013, Denmark began a register collecting data on all non-therapeutic male childhood circumcisions performed in the country (Ploug and Holm, 2017). The register enables complication rates to be calculated accurately (Van Howe et al, 2019). In contrast, there is no routine data collection regarding circumcision in the UK, either on the prevalence or on the presentation of complications to hospitals, meaning the number of infant male circumcisions performed and the complication rate is currently impossible to calculate accurately for the UK (Fox et al, 2019).
Conclusions
Infant male circumcision is common. The development of the Greater Manchester quality assurance process was associated with a reduction in the number of hospital admissions of infant males resulting from complications from non-therapeutic circumcision. Participating providers have demonstrated increased compliance with the Greater Manchester quality assurance standards over time, indicating quality improvement in practice.
Midwives are ideally placed to deliver non-judgemental conversations to empower parents to identify safely operating infant male circumcision providers. Parents should be advised to seek operators that have been trained in the procedure, who operate in sterile conditions and who will provide adequate pain relief to their infant.
Midwives can use voluntary quality assurance signposting to steer parents towards providers operating safely and away from providers who do not meet minimum standards. This will reduce the risk of harm from poor practice.
Key points
- Parents want more support in finding safe providers for non-therapeutic male circumcision.
- Midwives need reliable information to be able to help parent choose wisely.
- Lack of training and experience and poor infection control are associated with higher risk of harm from infant male circumcision.
- Using qualified providers that have met quality assurance criteria would reduce exposure of infant males to poor provision associated with higher risk of harm.
- Access to a list of quality assured providers can enable midwives to steer parents towards providers operating safely, thereby reducing the risk of harm from poor practice.
Reflective questions
- What proportion of your patients intend to practice male infant circumcision?
- Would your patients feel comfortable asking you for advice about male infant circumcision without fear of judgment?
- What advice is available in your area to help parents find good quality providers of male infant circumcision?
- What advice would you give parents on what to look out for when choosing a provider for male infant circumcision?