Male circumcision is a relatively safe procedure associated with a host of health benefits, including reductions in the risk of some STIs, genital ulcer disease, urinary tract infections and female-to-male HIV infection. Promotion of newborn circumcision is one long-term strategy for prevention of HIV transmission. However, a recent survey of Thailand’s hospitals indicates that the country’s health system, despite having the requisite medical infrastructure, may not be prepared to implement newborn circumcision as a public health intervention.1 Among facilities thought to be able to provide newborn circumcision, just 31% of private and 2% of public hospitals had actually performed the procedure in the last year. Only a minority of responding health professionals considered newborn circumcision safe (39%) and agreed that their hospital should offer the procedure (29%), although half reported wanting to be trained to perform it.

Data come from a 2011 survey of all hospitals in Thailand that were capable of providing obstetric services and hence considered potentially able to perform circumcision. Each hospital was sent a questionnaire requesting information about the facility’s characteristics and its provision of newborn circumcision in the previous year; specific topics included the type of staff who performed the procedure, the reasons for performing it and the surgical techniques used. A second questionnaire was to be completed by a doctor or nurse familiar with delivery and postpartum care; it asked about the difficulty of providing newborn circumcision, the safety of the procedure, desire for training in newborn circumcision and opinions on whether the procedure should be performed in the respondent’s hospital and how it should be paid for.

Staff at just over half (55%) of hospitals responded to the survey. Of the 747 participating facilities, 85% were government hospitals and 15% were private hospitals, representing 68% of public and 27% of private facilities in the country. Only 6% of the hospitals (31% of private and 2% of public facilities) had provided newborn circumcision in 2010.

At the 46 facilities where newborn circumcision was available, the procedure was typically provided in response to parents’ request (38 hospitals); less commonly, respondents reported that circumcision was performed for medical indications (12 hospitals) or on a physician’s advice (five hospitals). At three-quarters of institutions, pediatric or general surgeons usually performed the procedure. Five of the 11 public facilities, and all but one of the 35 private hospitals, reported that patients paid the full cost of the newborn circumcision. Health professionals at public hospitals typically used free-hand surgical techniques, whereas private hospital surgeons tended to use specialized tools.

A total of 562 health professionals responded to the second questionnaire; 65% were nurses and 35% physicians. Overall, just 39% agreed that newborn circumcision was safe; physicians and private facility employees were more likely to agree with this statement than were nurses and public employees. Fewer than a third (29%) of respondents agreed that their hospital should offer newborn circumcision, but about half of all doctors (53%) and nurses (50%) reported wanting to be trained to perform the procedure. Respondents generally felt that if newborn circumcision were to be promoted as a public health measure, the decision to circumcise should rest with parents (55%); however, 33% believed the procedure should be performed only when medically indicated. Forty-three percent believed that the service should be free of charge, while the same proportion felt that the parents should bear some or all of the cost. (The remainder said that other individuals should pay or that they did not know who should do so.)

The authors conclude that although the use of newborn circumcision for HIV prevention is appropriate for Thailand for a variety of reasons—including the primarily heterosexual nature of the country’s HIV epidemic, the availability of qualified medical staff and well-equipped hospitals, and a lack of cultural proscriptions against circumcision—further steps are needed before the procedure can be promoted. In addition to suggesting that currently practicing doctors and nurses be offered training on how to perform newborn circumcision and provide postsurgical care, they recommend that newborn circumcision be incorporated into medical and nursing school curricula and that government stakeholders be educated about the potential benefits of the procedure. Until these and other preparatory steps are taken, the authors state, "a promising approach to disease prevention will not be implemented in the country."—H. Ball

REFERENCE

1. Srithanaviboonchai K et al., Capability of Thailand to implement newborn male circumcision: a nation-wide survey, AIDS Care, 2014, 26(1):20–25.