title: Determinants of morbidity associated with infant male circumcision: community-level population-based study in rural Ghana.
abstract: Male circumcision services have expanded throughout Africa as part of a long-term HIV prevention strategy. We assessed the effect of type of service provider (formal and informal) and hygiene practices on circumcision-related morbidities in rural Ghana.
  
  
  
  Population-based, cross-sectional study conducted between May and December 2012 involving 2850 circumcised infant males aged under 12 weeks. Multivariable logistic regression models were adjusted for maternal age, maternal education, income, birthweight and site of circumcision.
  
  
  
  A total of 2850 (90.7%) infant males were circumcised. Overall, the risk of experiencing a morbidity (defined as complications occurring during or after the circumcision procedure as reported by the primary caregiver) was 8.1% (230). Risk was not significantly increased if the circumcision was performed by informal providers (121, 7.2%) vs. formal health service providers (109, 9.8%) [adjusted odds ratio (aOR) 1.11, 95% CI 0.80-1.47, P = 0.456]. Poor hygiene practices were associated with significantly increased risk of morbidity: no handwashing [148 (11.7%)] (aOR 1.78, 95% CI 1.27-2.52, P = 0.001); not cleaning circumcision instruments [174 (10.6%)] (aOR 1.80, 95% CI 1.27-2.54, P = 0.001); and uncleaned penile area [190 (10.0%)] (aOR 1.84, 95% CI 1.25-2.70, P = 0.002).
  
  
  
  The risk of morbidity after infant male circumcision in rural Ghana is high, chiefly due to poor hygiene practices. Governmental and non-governmental organisations need to improve training of circumcision providers in hygiene practices in sub-Saharan Africa.
authors.affiliation: School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.|Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.
authors.forename: Thomas
authors.initials: T
authors.lastname: Gyan
authors.affiliation: School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.
authors.forename: Kimberley
authors.initials: K
authors.lastname: McAuley
authors.affiliation: School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.
authors.forename: Natalie A
authors.initials: NA
authors.lastname: Strobel
authors.affiliation: Engender Health, New York, USA.
authors.forename: Caitlin
authors.initials: C
authors.lastname: Shannon
authors.affiliation: School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
authors.forename: Sam
authors.initials: S
authors.lastname: Newton
authors.affiliation: Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Tawiah-Agyemang
authors.affiliation: Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.
authors.forename: Seeba
authors.initials: S
authors.lastname: Amenga-Etego
authors.affiliation: Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.|Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Seth
authors.initials: S
authors.lastname: Owusu-Agyei
authors.affiliation: Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Betty
authors.initials: B
authors.lastname: Kirkwood
authors.affiliation: School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.
authors.forename: Karen M
authors.initials: KM
authors.lastname: Edmond
mesh_terms: D000328:Adult; D002944:Circumcision, Male / Q000009:adverse effects*; D003430:Cross-Sectional Studies; D005869:Ghana; D015658:HIV Infections / Q000517:prevention & control*; D006235:Hand Disinfection; D006282:Health Personnel; D006801:Humans; D006920:Hygiene; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D009017:Morbidity; D016017:Odds Ratio; D010413:Penis / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology*; D012111:Residence Characteristics; D012307:Risk Factors; D012424:Rural Population; D013525:Surgical Instruments; D055815:Young Adult
keywords: Ghana; circumcision; community level; determinants; infant; male; morbidity