This spreadsheet shows data for number of males using CIA data and estimates of number of circumcised males in all 237 countries and territories in the world, as well as basis for the estimate and MC percentage for each. (XLSX 29 kb)

This spreadsheet shows data for number of males using UN data for all but 45 countries and territories in the world and estimates of number of circumcised males in all but these 45, as well as basis for the estimate and MC percentage for each. (XLSX 31 kb)

Background: As countries scale up adult voluntary medical male circumcision (VMMC) for HIV prevention, they are looking ahead to long term sustainable strategies, including introduction of early infant male circumcision (EIMC). Although a number of devices for EIMC are prequalified by the World Health Organization, evaluation of additional devices can provide policy-makers and clinicians the information required to make informed decisions. We undertook a field evaluation of the safety and acceptability of the AccuCirc device in Kisumu County, Kenya. Methods: Procedures were performed by four trained clinicians in two public facilities. Participants were recruited from surrounding public health facilities through informational talks at antenatal clinics, maternity wards, and maternal neonatal child health clinics. Healthy infants ages 0-60 days, with no penile abnormality, without a family history of bleeding disorder, with current weight-for-age within -2 Z-scores of WHO growth standards, and whose mother was at least 16 years of age were eligible for EIMC. The procedure was performed after administration of a penile dorsal nerve block using 2% lidocaine and administration of Vitamin K. The mother was given post-operative instructions on wound care and asked to remain in the clinic with the baby for an observational period of one hour, during which a face-to-face questionnaire was administered. Results: Of 1259 babies screened, 704 were enrolled and circumcised. Median age of the infants was 16 days (IQR: 7-32.5) and of the mothers was 26 years (IQR: 22-30). Median time for the procedure was 19 minutes (IQR: 15-23). There were no serious adverse events (AE), and 20 (2.8%) moderate AEs, all of which were due to bleeding that required application of one to three sutures. There were 22 (3.8%) procedures in which the device did not fully incise the entire circumference of the foreskin and had to be completed using sterile scissors. 89.9% of mothers had knowledge of EIMC, but few (8.1%) had any knowledge of devices used for EIMC. Protection against HIV/AIDS was the most cited reason to circumcise a baby (65.3%), while the baby being ill (38.1%) and pain (34.4%) were the most cited barriers to uptake. 99% of mothers were "very satisfied" or "completely satisfied" with the procedure. Conclusions: This evaluation of the AccuCirc device is the largest to date and indicates that the device is safe and acceptable, achieving high levels of parental satisfaction. The AccuCirc device should be considered for WHO prequalification to increase options for safe and sustainable provision of EIMC.

Using a population-based survey we examined the behaviours, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to the establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high-risk sexual behaviours. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with the understanding that circumcised men are less likely to become infected with HIV.

BackgroundVoluntary medical male circumcision has been promoted in high HIV prevalence settings to prevent HIV acquisition in males. However, the uptake of circumcision in many sub-Saharan African settings remains low. While many studies have measured circumcision prevalence, understanding circumcision incidence and its predictors is vital to achieving ambitious circumcision prevalence targets.SettingRural KwaZulu-Natal, South Africa.MethodsWe measured circumcision incidence over the period 2009–2014 in a longitudinal population-based cohort with high HIV prevalence and low circumcision prevalence. Multivariable survival models with Weibull distributions were used to assess socio-demographic, behavioral and biological predictors of circumcision incidence.ResultsBetween 2009 and 2014, circumcision prevalence among males 15–49 years in the cohort increased from 3% to 24%. Among 6,203 males 15–49 years, 873 new circumcisions occurred over 13,678 person-years (incidence rate: 6.4/100 person-years, 95% CI 6.0–6.8). Circumcision incidence was substantially higher amongst young males: 15–19 year olds were twice as likely to circumcise as older males. In the survival model, shorter household distance to the nearest healthcare facility, knowledge of HIV status and biological HIV-negative status were associated with an increased likelihood of circumcision incidence.ConclusionsCircumcision prevalence among males in rural KwaZulu-Natal remains well below South Africa’s national 80% coverage target across age groups. In this population, distance to the nearest healthcare facility and knowledge of HIV status were important independent predictors of circumcision incidence. Mobile circumcision clinics and innovative HIV testing services may be important tools to help achieve circumcision targets.

The global disposable circumcision stapler market is experiencing robust growth, driven by increasing prevalence of circumcision procedures, particularly in regions with high rates of newborn male circumcision. The market is projected to witness a Compound Annual Growth Rate (CAGR) of approximately 7% from 2025 to 2033, reaching an estimated market value of $350 million by 2033. This growth is fueled by several key factors: the preference for minimally invasive surgical techniques that offer faster healing times and reduced complications, the rising demand for advanced medical devices offering improved precision and efficacy, and the growing adoption of these devices in developing economies. Key players such as BD, Gore Medical, Johnson & Johnson, and Medtronic are driving innovation in the space, introducing devices with enhanced features and improved ergonomics. However, the market faces challenges like high costs associated with disposable devices and potential competition from reusable alternatives. Despite these challenges, the market's growth trajectory remains positive, underpinned by ongoing technological advancements, an increasing number of circumcision procedures performed annually, and a growing awareness among healthcare professionals regarding the benefits of using disposable circumcision staplers. The segment dominated by advanced staplers with enhanced features is expected to showcase substantial growth, while regional markets in North America and Europe are likely to maintain a significant share owing to high healthcare expenditure and a preference for advanced medical technologies. Continued market penetration in emerging economies, coupled with technological innovations, is anticipated to further propel the market's expansion during the forecast period. Specific regional data is unavailable and has been omitted, rather than using placeholder data.

Male circumcision (MC) is a key part of the package of interventions to prevent HIV, the biggest health challenge in sub-Saharan Africa.To estimate the male circumcision prevalence and to evaluate the progress towards meeting WHO targets in sub-Saharan Africa during the period 2010–2023.We carried out a systematic review and meta-analysis of studies published during the period 2010–2023. We searched PubMed, Scopus, Cochrane CENTRAL, Google Scholar, WHO and the Demographic and Health Survey for reports on MC prevalence in sub-Saharan Africa. MC prevalence was synthesized using inverse-variance heterogeneity models, heterogeneity using I2 statistics and publication bias using funnel plots.A total of 53 studies were included. The overall prevalence during the study period was 45.9% (95% CI 32.3–59.8), with a higher MC prevalence in Eastern (69.9%, 95%CI 49.9–86.8) compared to Southern African (33.3%, 95%CI 21.7–46.2). The overall prevalence was higher in urban (45.3%, 95%CI 27.7–63.4) compared to rural settings (42.6%, 95% 26.5–59.5). Male circumcision prevalence increased from 40.2% (95% CI 25.0–56.3) during 2010–2015 to 56.2% (95% CI 31.5–79.5) during 2016–2023. Three countries exceeded 80% MC coverage, namely, Ethiopia, Kenya and Tanzania.Overall, the current MC prevalence is below 50%, with higher prevalence in Eastern African countries and substantially lower prevalence in Southern Africa. Most of the priority countries need to do more to scale up medical male circumcision programs.

The data are internally documented.

ObjectivesTo ascertain clinical sequelae, client satisfaction and sexual behavior 2+ years after male circumcision using the ShangRing device.MethodsWe enrolled 199 men from the Kenya sites (Homa Bay district) participating in a 2012 study of the ShangRing device used in routine male circumcision services (N = 552). We enrolled men who had had the ShangRing placed successfully, and over-sampled men who had had an adverse event and/or were HIV-positive during the field study. In the present study, each participant was examined and interviewed by a study clinician, and penile photographs were taken to document longer-term cosmetic results and any abnormal findings.Results194 men were included in the analysis. The mean and median times between circumcision and the longer-term follow-up visit in this study were 31.8 and 32 months, respectively. Four men (2.1%) had signs/symptoms of a sexually transmitted infection (STI). Virtually all (99.5%) of the men were very satisfied with the appearance of their circumcised penis, and all would recommend a ShangRing circumcision to friends or family members. The most prevalent reported advantage of the circumcision was the ease of bathing and enhanced cleanliness of the penis (75.8%). 94.3% of the men did not cite a single negative feature of their circumcision. 87.5% of men reported more sexual pleasure post-MC, the most common reason being more prolonged intercourse. The majority of men (52.6%) reported one sexual partner post-MC, but more than a quarter of the men (28.1%) reported an increased number of partners post-MC. Less than half of the men (44.3%) reported using condoms half of the time or more, but the great majority of condom users stated that condom use was much easier post-MC, and 76.9% of users said they used condoms more after circumcision than before.ConclusionsThis study supports the safety and acceptability of ShangRing male circumcision during 2–3 years of follow-up. It should allay worries that the ShangRing procedure could lead to delayed complications later than the observation period of most clinical studies.Trial RegistrationClinicalTrials.gov NCT01567436

This dataset is about book subjects. It has 2 rows and is filtered where the books is A surgical temptation : the demonization of the foreskin and the rise of circumcision in Britain. It features 10 columns including number of authors, number of books, earliest publication date, and latest publication date.

BackgroundThe World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS promote MC (male circumcision) as a key HIV prevention strategy where HIV prevalence and incidence are high and MC prevalence is low. In Zimbabwe, to achieve the 1.26 million circumcisions needed to be performed by 2015 to achieve optimal MC coverage, a new approach was needed. The primary objective of the current trial was to assess the performance (safety, procedure time, and cost) of the PrePex device compared to forceps-guided surgical circumcision.Methods and FindingsThis Phase II, randomized, open-label trial in Zimbabwe involved healthy, non-circumcised adult male volunteers who were randomly assigned to the PrePex device (n = 160) or surgical arm (n = 80). Three doctors and 4 nurses, all certified on both circumcision methods, performed the procedures. The PrePex device procedure involves a plastic ring with a rubber O-ring that necrotizes the foreskin to facilitate easy and minimally invasive removal. Total procedure time was the primary endpoint. Adverse event (AE) data were also gathered for 90 days post-procedure. All 80 participants in the surgical arm and 158 participants in the PrePex arm achieved complete circumcision. The total procedure time for the PrePex device was approximately one-third of the total surgical procedure (4.8 minutes, Standard Deviation [SD]: 1.2 versus 14.6 minutes; SD: 4.2; p

Introduction: Voluntary male medical circumcision (VMMC) reduces HIV acquisition by up to 60%. Kenya has successfully scaled up VMMC to an estimated 91% of eligible men and boys in certain regions. Given that funding toward VMMC is expected to decline in the coming years, it is important to identify what models of care are most appropriate and efficient as new cohorts of men become eligible for VMMC. To this end, we compared the costs of facility-based VMMC and one within a rapid results initiative (RRI), a public health service scheduled during school holidays to perform many procedures over a short period.

Methods: We employed activity-based micro-costing to estimate the costs, from the implementer perspective, of facility-based VMMC and RRI-based VMMC conducted between October 2017 and September 2018 at 41 sites in Kisumu County, Kenya supported by the Family AIDS Care & Education Services (FACES). We conducted site visits and reviewed financial ledger and programmat...

The global circumcision suture device market is experiencing robust growth, driven by increasing demand for minimally invasive surgical procedures and a rising prevalence of circumcision globally. The market, estimated at $150 million in 2025, is projected to exhibit a compound annual growth rate (CAGR) of 7% from 2025 to 2033, reaching approximately $250 million by 2033. This growth is fueled by several factors, including advancements in suture technology resulting in faster healing times, reduced pain, and improved cosmetic outcomes. The increasing adoption of advanced surgical techniques in both hospital and clinic settings further propels market expansion. Segment-wise, Type 12 and Type 18 circumcision suture devices currently dominate the market, accounting for over 60% of total sales, owing to their established presence and widespread acceptance amongst medical practitioners. However, the introduction of innovative Type 26 and Type 30 devices offering enhanced features like biodegradability and ease of use is anticipated to fuel segment growth in the coming years. Geographical analysis reveals a significant market share held by North America and Europe, due to higher healthcare expenditure and better healthcare infrastructure. However, the Asia-Pacific region is poised for significant growth, driven by rising disposable incomes and increasing awareness of advanced surgical options. Restraints to market growth include the high cost of advanced suture devices and the availability of alternative procedures. Despite these restraints, the market is expected to witness continuous expansion. The growing number of medical device manufacturers focusing on product innovation and the penetration of advanced suture devices into emerging markets will support sustained growth. The rising preference for outpatient procedures and a growing focus on patient comfort are further boosting the demand. Key players are adopting strategic collaborations, mergers and acquisitions, and technological advancements to strengthen their market position and cater to the diverse needs of the healthcare sector. Companies like Geyi Medical Instrument, Zhonghuan Medical Technology, and Henry Schein are prominent players driving innovation and expansion within the global market. The focus on developing cost-effective and user-friendly devices will be crucial for capturing a larger market share in developing economies.

CPI: 2022=100: Weights: Health: Outpatient Care: Circumcision Cost data was reported at 0.002 % in 2023. This stayed constant from the previous number of 0.002 % for 2022. CPI: 2022=100: Weights: Health: Outpatient Care: Circumcision Cost data is updated yearly, averaging 0.002 % from Dec 2022 (Median) to 2023, with 2 observations. The data reached an all-time high of 0.002 % in 2023 and a record low of 0.002 % in 2023. CPI: 2022=100: Weights: Health: Outpatient Care: Circumcision Cost data remains active status in CEIC and is reported by Statistics Indonesia. The data is categorized under Indonesia Premium Database’s Inflation – Table ID.IA010: Consumer Price Index: 2022=100: Weights.

Description: This data set contains information on adults aged 25 years and older: biographical data, media, communication and norms, knowledge and perceptions of HIV/AIDS, male circumcision, sexual debut, partners and partner characteristics, condoms, vulnerability, HIV testing, alcohol and substance use, general perceptions about government, health and violence in the community. The data set contains 516 variables and 10501 cases. Abstract: South Africa continues to have the largest number of people living with HIV/AIDS in the World. This study intends to understand the determinants that lead South Africans to be vulnerable and susceptible to HIV. This is the third in a series of household surveys conducted by Human Sciences Research Council (HSRC), that allow for tracking of HIV and associated determinants over time using a slightly same methodology used in 2002 and 2005 survey, making it the third national-level repeat survey. The 2002 and 2005 surveys included individuals aged 2+ years living in South Africa while 2008 survey included individuals of all ages living in South Africa, including infants younger than 2 years of age. The interval of three years since 2002 allows for an exploration of shifts over time against a complex of demographic and other variables, as well as allowing for investigation of the new areas. The survey provides the first nationally representative HIV incidence estimates. The study key objectives were to: determine the prevalence of HIV infection in South Africa; examine the incidence of HIV infection in South Africa; assess the relationship between behavioural factors and HIV infection in South Africa; describe trends in HIV prevalence, HIV incidence, and risk behaviour in South Africa over the period 2002-2008; investigate the link between social, values, and cultural determinants and HIV infection in South Africa; assess the type and frequency of exposure to major national behavioural change communication programmes and assess their relationship to HIV prevention, AIDS treatment, care, and support; describe male circumcision practices in South Africa and assess its acceptability as a method of HIV prevention; collect data on the health conditions of South Africans; and contribute to the analysis of the impact of HIV/AIDS on society. In the 13440 valid households or visiting points, 10856 agreed to participate in the survey, 23369 individuals (no more than 4 per household, including infants under 2 years) were eligible to be interviewed, and 20826 individuals completed the interview. Of the 23369 eligible individuals, 15031 agreed to provide a blood specimen for HIV testing and were anonymously linked to the behavioural questionnaires. the household response rate was 80.8%, the individual response rate was 89.1% and the overall response rate for HIV testing was 64.3%.

This table is a collation of returns I received from hospital trusts showing their number of child circumcisions in 2011 with age and whether therapeutically coded or not. I think it is a useful snapshot of practice across England - it shows how circumcisions were performed in age groups 0-4, 5-9 and 10-17 and how many were explicitly coded as non medically necessary. Note regarding non therapeutic circumcision (NTC) that this is frequently performed in the NHS as an outpatient operation so the figures for NTC ops in this table are only a partial picture (there are some 130 or so Hospital trusts so they don't even represent all the inpatient operations). Not all trusts replied to my questions and not all gave responses in the same format, hence the partial picture. Aside the issue of non therapeutic circumcisions on unconsenting subjects the data also suggests a potentially significant issue of the false coding of unnecessary circumcisions as necessary. Note for example that Su Anna Boddy of BAPS (a member of working group which formulated the 2007 policy on foreskin conditions) has stated publicly that therapeutic circumcision is 'virtually never' necessary in a child under five. BAPS also state that non-retractability (developmental phimosis) can be normal even in the late teens. Danish and Japanese researchers have both shown in fact that full natural retraction tends to happen sometime after the tenth birthday. So with that knowledge, and also the huge variation in numbers we can assume that many of the therapeutic operations shown here were not therapeutic, particularly as most were coded with the ICD 10 diagnosis code N47X (Redundant prepuce, phimosis and paraphimosis). Detailed returns from individual hospitals are available on request (covering mainly 2009 and 2011 - some a longer period). I won't upload everything as it's just too much.

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Abstract

The 2003 Nigeria Demographic and Health Survey (2003 NDHS) is the third national Demographic and Health Survey conducted in Nigeria. The 2003 NDHS is based on a nationally representative sample of over 7,000 households. All women age 15-49 in these households and all men age 15-59 in a subsample of one-third of the households were individually interviewed. The survey provides up-to-date information on the population and health situation in Nigeria.

The 2003 NDHS was designed to provide estimates for key indicators such as fertility, contraceptive use, infant and child mortality, immunization levels, use of family planning, maternal and child health, breastfeeding practices, nutritional status of mothers and young children, use of mosquito nets, female genital cutting, marriage, sexual activity, and awareness and behaviour regarding AIDS and other sexually transmitted infections in Nigeria.

MAIN RESULTS

• FERTILITY

Fertility Levels, Trends, and Preferences. The total fertility rate (TFR) in Nigeria is 5.7. This means that at current fertility levels, the average Nigerian woman who is at the beginning of her childbearing years will give birth to 5.7 children by the end of her lifetime. Compared with previous national surveys, the 2003 survey shows a modest decline in fertility over the last two decades: from a TFR of 6.3 in the 1981-82 National Fertility Survey (NFS) to 6.0 in the 1990 NDHS to 5.7 in the 2003 NDHS. However, the 2003 NDHS rate of 5.7 is significantly higher than the 1999 NDHS rate of 5.2. Analysis has shown that the 1999 survey underestimated the true levels of fertility in Nigeria.

On average, rural women will have one more child than urban women (6.1 and 4.9, respectively). Fertility varies considerably by region of residence, with lower rates in the south and higher rates in the north. Fertility also has a strong negative correlation with a woman's educational attainment.

Most Nigerians, irrespective of their number of living children, want large families. The ideal number of children is 6.7 for all women and 7.3 for currently married women. Nigerian men want even more children than women. The ideal number of children for all men is 8.6 and for currently married men is 10.6. Clearly, one reason for the slow decline in Nigerian fertility is the desire for large families.

• FAMILY PLANNING

Knowledge of Family Planning Methods. About eight in ten women and nine in ten men know at least one modern method of family planning. The pill, injectables, and the male condom are the most widely known modern methods among both women and men. Mass media is an important source of information on family planning. Radio is the most frequent source of family planning messages: 40 percent of women and 56 percent of men say they heard a radio message about family planning during the months preceding the survey. However, more than half of women (56 percent) and 41 percent men were not exposed to family planning messages from a mass media source.

Current Use. A total of 13 percent of currently married women are using a method of family planning, including 8 percent who are using a modern method. The most common modern methods are the pill, injectables, and the male condom (2 percent each). Urban women are more than twice as likely as rural women to use a method of contraception (20 percent versus 9 percent). Contraceptive use varies significantly by region. For example, one-third of married women in the South West use a method of contraception compared with just 4 percent of women in the North East and 5 percent of women in the North West.

• CHILD HEALTH

Mortality. The 2003 NDHS survey estimates infant mortality to be 100 per 1,000 live births for the 1999-2003 period. This infant mortality rate is significantly higher than the estimates from both the 1990 and 1999 NDHS surveys; the earlier surveys underestimated mortality levels in certain regions of the country, which in turn biased downward the national estimates. Thus, the higher rate from the 2003 NDHS is more likely due to better data quality than an actual increase in mortality risk overall.

The rural infant mortality rate (121 per 1,000) is considerably higher than the urban rate (81 per 1,000), due in large part to the difference in neonatal mortality rates. As in other countries, low maternal education, a low position on the household wealth index, and shorter birth intervals are strongly associated with increased mortality risk. The under-five mortality rate for the 1999-2003 period was 201 per 1,000.

Vaccinations. Only 13 percent of Nigerian children age 12-23 months can be considered fully vaccinated, that is, have received BCG, measles, and three doses each of DPT and polio vaccine (excluding the polio vaccine given at birth). This is the lowest vaccination rate among African countries in which DHS surveys have been conducted since 1998. Less than half of children have received each of the recommended vaccinations, with the exception of polio 1 (67 percent) and polio 2 (52 percent). More than three times as many urban children as rural children are fully vaccinated (25 percent and 7 percent, respectively). WHO guidelines are that children should complete the schedule of recommended vaccinations by 12 months of age. In Nigeria, however, only 11 percent of children age 12-23 months received all of the recommended vaccinations before their first birthday.

• WOMEN'S HEALTH

Breastfeeding. Breastfeeding is almost universal in Nigeria, with 97 percent of children born in the five years preceding the survey having been breastfed. However, just one-third of children were given breast milk within one hour of birth (32 percent), and less than two-thirds were given breast milk within 24 hours of birth (63 percent). Overall, the median duration of any breastfeeding is 18.6 months, while the median duration of exclusive breastfeeding is only half a month.

Complementary Feeding. At age 6-9 months, the recommended age for introducing complementary foods, three-quarters of breast-feeding infants received solid or semisolid foods during the day or night preceding the interview; 56 percent received food made from grains, 25 percent received meat, fish, shellfish, poultry or eggs, and 24 percent received fruits or vegetables. Fruits and vegetables rich in vitamin A were consumed by 20 percent of breastfeeding infants age 6-9 months.

Maternal Care. Almost two-thirds of mothers in Nigeria (63 percent) received some antenatal care (ANC) for their most recent live birth in the five years preceding the survey. While one-fifth of mothers (21 percent) received ANC from a doctor, almost four in ten women received care from nurses or midwives (37 percent). Almost half of women (47 percent) made the minimum number of four recommended visits, but most of the women who received antenatal care did not get care within the first three months of pregnancy.

In terms of content of care, slightly more than half of women who received antenatal care said that they were informed of potential pregnancy complications (55 percent). Fifty-eight percent of women received iron tablets; almost two-thirds had a urine or blood sample taken; and 81 percent had their blood pressure measured. Almost half (47 percent) received no tetanus toxoid injections during their most recent birth.

WOMEN'S CHARACTERISTICS AND STATUS

Across all maternal care indicators, rural women are disadvantaged compared with urban women, and there are marked regional differences among women. Overall, women in the south, particularly the South East and South West, received better care than women in the north, especially women in the North East and North West.

Female Circumcision. Almost one-fifth of Nigerian women are circumcised, but the data suggest that the practice is declining. The oldest women are more than twice as likely as the youngest women to have been circumcised (28 percent versus 13 percent). Prevalence is highest among the Yoruba (61 percent) and Igbo (45 percent), who traditionally reside in the South West and South East. Half of the circumcised respondents could not identify the type of procedure performed. Among those women who could identify the type of procedure, the most common type of circumcision involved cutting and removal of flesh (44 percent of all circumcised women). Four percent of women reported that their vaginas were sewn closed during circumcision.

MALARIA CONTROL PROGRAM INDICATORS

Nets. Although malaria is a major public health concern in Nigeria, only 12 percent of households report owning at least one mosquito net. Even fewer, 2 percent of households, own an insecticide treated net (ITN). Rural households are almost three times as likely as urban households to own at least one mosquito net. Overall, 6 percent of children under age five sleep under a mosquito net, including 1 percent of children who sleep under an ITN. Five percent of pregnant women slept under a mosquito net the night before the survey, one-fifth of them under an ITN.

Use of Antimalarials. Overall, 20 percent of women reported that they took an antimalarial for prevention of malaria during their last pregnancy in the five years preceding the survey. Another 17 percent reported that they took an unknown drug, and 4 percent took paracetamol or herbs to prevent malaria. Only 1 percent received intermittent preventative treatment (IPT)-or preventive treatment with sulfadoxine-pyrimethamine (Fansidar/SP) during an antenatal care visit. Among pregnant women who took an antimalarial, more than half (58 percent) used Daraprim, which has been found to be ineffective as a chemoprophylaxis during pregnancy. Additionally, 39 percent used chloroquine, which was the chemoprophylactic drug of choice until the introduction of IPT in Nigeria in 2001.

Among children

As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of men's VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate men's movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.

Abstract

The 2008 Sierra Leone Demographic and Health Survey (SLDHS) is the first DHS survey to be held in Sierra Leone. Teams visited 353 sample points across Sierra Leone and collected data from a nationally representative sample of 7,374 women age 15-49 and 3,280 men age 15-59. The primary purpose of the 2008 SLDHS is to provide policy-makers and planners with detailed information on Demography and health.

This is the first Demographic and Health Survey conducted in Sierra Leone and was carried out by Statistics Sierra Leone (SSL) in collaboration with the Ministry of Health and Sanitation. The 2008 SLDHS was funded by the Sierra Leone government, UNFPA, UNDP, UNICEF, DFID, USAID, and The World Bank. WHO, WFP and UNHCR provided logistical support. ICF Macro, an ICF International Company, provided technical support for the survey through the MEASURE DHS project. MEASURE DHS is sponsored by the United States Agency for International Development (USAID) to assist countries worldwide in obtaining information on key population and health indicators.

The purpose of the SLDHS is to collect national- and regional-level data on fertility and contraceptive use, marriage and sexual activity, fertility preferences, breastfeeding practices, nutritional status of women and young children, childhood and adult mortality, maternal and child health, female genital cutting, awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections, adult health, and other issues. The survey obtained detailed information on these topics from women of reproductive age and, for certain topics, from men as well. The 2008 SLDHS was carried out from late April 2008 to late June 2008, using a nationally representative sample of 7,758 households.

The survey results are intended to assist policymakers and planners in assessing the current health and population programmes and in designing new strategies for improving reproductive health and health services in Sierra Leone.

MAIN RESULTS

FERTILITY

Survey results indicate that there has been little or no decline in the total fertility rate over the past two decades, from 5.7 children per woman in 1980-85 to 5.1 children per woman for the three years preceding the 2008 SLDHS (approximately 2004-07). Fertility is lower in urban areas than in rural areas (3.8 and 5.8 children per woman, respectively). Regional variations in fertility are marked, ranging from 3.4 births per woman in the Western Region (where the capital, Freetown, is located) to almost six births per woman in the Northern and Eastern regions. Women with no education give birth to almost twice as many children as women who have been to secondary school (5.8 births, compared with 3.1 births). Fertility is also closely associated with household wealth, ranging from 3.2 births among women in the highest wealth quintile to 6.3 births among women in the lowest wealth quintile, a difference of more than three births. Research has demonstrated that children born too close to a previous birth are at increased risk of dying. In Sierra Leone, only 18 percent of births occur within 24 months of a previous birth. The interval between births is relatively long; the median interval is 36 months.

FAMILY PLANNING

The vast majority of Sierra Leonean women and men know of at least one method of contraception. Contraceptive pills and injectables are known to about 60 percent of currently married women and 49 percent of married men. Male condoms are known to 58 percent of married women and 80 percent of men. A higher proportion of respondents reported knowing a modern method of family planning than a traditional method.

About one in five (21 percent) currently married women has used a contraceptive method at some time-19 percent have used a modern method and 6 percent have used a traditional method. However, only about one in twelve currently married women (8 percent) is currently using a contraceptive method. Modern methods account for almost all contraceptive use, with 7 percent of married women reporting use of a modern method, compared with only 1 percent using a traditional method. Injectables and the pill are the most widely used methods (3 and 2 percent of married women, respectively), followed by LAM and male condoms (less than 1 percent each).

CHILD HEALTH

Examination of levels of infant and child mortality is essential for assessing population and health policies and programmes. Infant and child mortality rates are also used as indices reflecting levels of poverty and deprivation in a population. The 2008 survey data show that over the past 15 years, infant and under-five mortality have decreased by 26 percent. Still, one in seven Sierra Leonean children dies before reaching age five. For the most recent five-year period before the survey (approximately calendar years 2003 to 2008), the infant mortality rate was 89 deaths per 1,000 live births and the under-five mortality rate was 140 deaths per 1,000 live births. The neonatal mortality rate was 36 deaths per 1,000 live births and the post-neonatal mortality rate was 53 deaths per 1,000 live births. The child mortality rate was 56 deaths per 1,000 children surviving to age one year. Mortality rates at all ages of childhood show a strong relationship with the length of the preceding birth interval. Under-five mortality is three times higher among children born less than two years after a preceding sibling (252 deaths per 1,000 births) than among children born four or more years after a previous child (deaths 81 per 1,000 births).

MATERNAL HEALTH

Almost nine in ten mothers (87 percent) in Sierra Leone receive antenatal care from a health professional (doctor, nurse, midwife, or MCH aid). Only 5 percent of mothers receive antenatal care from a traditional midwife or a community health worker; 7 percent of mothers do not receive any antenatal care.

In Sierra Leone, over half of mothers have four or more antenatal care (ANC) visits, about 20 percent have one to three ANC visits, and only 7 percent have no antenatal care at all. The survey shows that not all women in Sierra Leone receive antenatal care services early in pregnancy. Only 30 percent of mothers obtain antenatal care in the first three months of pregnancy, 41 percent make their first visit in the fourth or fifth month, and 17 percent in have their first visit in the sixth or seventh month. Only 1 percent of women have their first ANC visit in their eighth month of pregnancy or later.

BREASTFEEDING AND NUTRITION

Poor nutritional status is one of the most important health and welfare problems facing Sierra Leone today and particularly afflicts women and children. The data show that 36 percent of children under five are stunted (too short for their age) and 10 percent of children under five are wasted (too thin for their height). Overall, 21 percent of children are underweight, which may reflect stunting, wasting, or both. For women, at the national level 11 percent of women are considered to be thin (body mass index <18.5); however, only 4 percent of women are considered severely thin. At the other end of a spectrum, 20 percent of women age 15-49 are considered to be overweight (body mass index 25.025.9) and 9 percent are considered obese (body mass index =30.0).

HIV/AIDS

The HIV/AIDS pandemic is one of the most serious health concerns in the world today because of its high case-fatality rate and the lack of a cure. Awareness of AIDS is relatively high among Sierra Leonean adults age 15-49, with 69 percent of women and 83 percent of men saying that they have heard about AIDS. Nevertheless, only 14 percent of women and 25 percent of men are classified as having 'comprehensive knowledge' about AIDS, i.e., knowing that consistent use of condoms during sexual intercourse and having just one faithful, HIV-negative partner can reduce the chances of getting HIV/AIDS, knowing that a healthy-looking person can have HIV (the virus that causes AIDS), and knowing that HIV cannot be transmitted by sharing food/utensils with someone who has HIV/AIDS, or by mosquito bites.

Such a low level of knowledge about HIV/AIDS implies that a concerted effort is needed to address misconceptions about the transmission of HIV in Sierra Leone. Comprehensive knowledge is substantially lower among respondents with no education and those who live in the poorest households. Programmes could be targeted to populations in rural areas, and especially women in the Northern and Southern regions and men in the Eastern Region, where comprehensive knowledge is lowest. A composite indicator on stigma towards people who are HIV positive shows that only 5 percent of women and 15 percent of men age 15-49 expressed accepting attitudes towards persons living with HIV/AIDS.

FEMALE CIRCUMCISION

The 2008 SLDHS collected data on the practice of female circumcision (or female genital cutting) in Sierra Leone. Awareness of the practice is universally high. Almost all (99 percent) of Sierra Leonean women and 96 percent of men age 15-49 have heard of the practice. The prevalence of female circumcision is high (91 percent). Most women (82 percent) reported that the cutting involves the removal of flesh. The most radical procedure, infibulation-when vagina is sewn closed during the circumcision-is reported by only 3 percent of women. The survey results indicate that almost all of the women were circumcised by traditional practitioners (95 percent); only a small proportion of circumcisions were performed by a trained health professional (0.3 percent).

Among Sierra Leonean adults age 15-49 who have heard of female circumcision, more men than women oppose the practice (41 and 26 percent, respectively), which is similar to patterns in other West African countries.

Geographic coverage

The survey used a