Evaluation of a project to reduce morbidity and mortality from traditional male circumcision in Umlamli, Eastern Cape, South Africa:Outcome mapping

Background: Traditional circumcision is common among the amaXhosa in Umlamli, Eastern Cape. Circumcision is associated with high morbidity and mortality. The need to reduce complications was identified as a priority by the local community. The aim was to design, implement and evaluate a project to improve the safety of traditional circumcision.Method: A safe circumcision team was established and comprised health workers, community leaders and traditional surgeons. Outcome mapping involved three stages: intentional design, outcome, and performance monitoring and evaluation. The eight boundary partners were the initiates, parents, community leaders, traditional surgeons, the District Health Services, the provincial Department of Health, the emergency services and the police. Outcomes, progress markers and strategies were designed for each boundary partner. The team kept an outcome and strategy journal and evaluated hospital admissions, genital amputations and mortality.Results: Ninety-two initiates were circumcised, with two admissions for minor complications, compared to 10 admissions, two amputations and two deaths previously. More than 70% of the outcome measures were achieved in all boundary partners, except emergency services and the Department of Health. The key aspects were: the use of outcome mapping, the participatory process, a lower age limit, closure of illegal schools,  consolidation of accredited schools, training workshops for traditional surgeons, private treatment room for initiates, assistance with medical materials, pre-circumcision examination, certificates of fitness.Conclusion: This study has shown the value of community-orientated primary care initiatives to address local health problems. Key lessons were identified and the project could easily be replicated in communities facing similar challenges