The public health impact of training physicians to become obstetricians and gynecologists in Ghana

Growth model for international academic medicine partnerships: Qualitative analysis of Ghana postgraduate Ob/Gyn training program

This study aims to detail the capacity strengthening process of the Ghana Ob/Gyn postgraduate training program in order to inform a model by which international academic medicine partnerships can form, grow, and effectively tackle development challenges. A qualitative analysis with grounded theory methodological approach was utilized. Convenience and purposive sampling were used to select certified Ob/Gyn training program graduates. Interviews were conducted face-to-face in in Accra, Kumasi, Cape Coast, and Tamale, Ghana between June 21 to August 20, 2017. An additional data analysis of 48 semi-structured interviews previously collected for another study were examined for factors pertinent to graduate career development. Coded data were grouped according to themes and subthemes. Emerging themes demonstrated that graduates further complete the maternal care team and facilitate collaboration amongst healthcare workers. Themes also included graduates' pursuit of subspecialty training and research. Graduates cited the training program as key to their professional development. Graduates assume leadership roles in hospital management and operations, teaching, mentoring, interprofessional maternal care team, and knowledge-sharing. Graduates expressed eagerness to subspecialize and to advance their research training and skills. The results suggest a growth model of international academic medicine partnerships from basic obstetric training to advanced training. The model is developed for adaptability in other SSA countries and low-resource settings so that it may effectively strengthen health workforce capacity. We hope that this program can serve as a model for other partnerships in medical specialties.

"Once you get one maternal death, it's like the whole world is dropping on you": experiences of managing maternal mortality amongst obstetric care providers in Ghana

BACKGROUND

Maternal mortality has a significant global impact, especially in low-resource settings. Little prior research has been conducted on the potential effects of poor maternal outcomes on the personal and professional well-being of healthcare providers. This study explores the in-depth experiences and perspectives of obstetric providers in Ghana who work in a setting with frequent maternal mortalities.

METHODS

This is a qualitative study of semi-structured interviews conducted at the Komfo Anokye Teaching Hospital in Ghana. Participants were obstetric healthcare providers, defined as midwives, house officers currently rotating on the obstetrics/gynecology service, and obstetrician/gynecologists at any training or practice level (residents, fellows, and specialists). Interviews were audio-recorded, transcribed verbatim, and uploaded into NVivo for qualitative analysis. Using the Attride-Stirling qualitative model, an incremental and iterative process was used to code interviews with keyword phrases and develop a framework of organizing and global themes.

RESULTS

Interviews were conducted with 27 participants-15 midwives and 12 physicians (three obstetrician/gynecologist residents, six obstetrician/gynecologist specialists, and three house officers), with sample size determined by data saturation. Obstetric providers' experiences in a setting with frequent maternal mortalities were dependent on their level of preparedness to manage maternal mortalities and the workplace environment. Providers' level of preparedness was dependent on both the training they had received on the medical management of obstetric emergencies, as well as a lack of training on the mental health aspects of coping with maternal mortality. The impact of the workplace environment was dependent on systems failures and limited resources, blame from colleagues and supervisors, and a lack of support in the workplace. In turn, obstetric providers' experiences managing frequent maternal mortalities impacted their clinical care performance and mental health.

CONCLUSIONS

Maternal deaths have profound personal and professional impacts on the healthcare providers who manage them. A large need exists for additional institutional training and support for obstetric providers who manage maternal mortality, especially in low-resource settings like Ghana.

Orthopaedic and trauma care in low-resource settings: the burden and its challenges

BACKGROUND AND BURDEN

Trauma with its early and late consequences disproportionately effects those from poor countries. The availability of effective orthopaedic and trauma care varies significantly across the globe.

CHALLENGES

The balancing out of quality care is required to reach the health-related UN development goal set out in 2015. A multifactorial approach addressing local, national and international aspects is key to improving the discrepancy seen between high- and low-income countries.

Surgical subspecialists in West Africa: Workforce size, training opportunities, and contributing factors

BACKGROUND

The global burden of disease treatable by surgical subspecialists remains an outstanding area of need, and yet little is known about the subspecialist workforce worldwide, especially in sub-Saharan Africa. This study aims to quantify the subspecialty surgical workforce and number of subspecialty training programs in West Africa and to identify socioeconomic factors predicting the number of subspecialists in West African countries.

METHODS

West African subspecialists and accredited fellowship training programs in 17 West African countries were quantified using membership data from the West African College of Surgeons and compared with publicly available workforce data from the United States, the United Kingdom, and East, Central, and Southern Africa. Spearman's coefficients were calculated to identify socioeconomic predictors of subspecialist surgical workforce.

RESULTS

Of 2,181 surgeons, 712 (32.6%) were surgical subspecialists. Three (18%) of 17 West African countries had greater than 11 subspecialists. There were 174 subspecialty training programs in the region, though 13 countries (76%) had no programs. The number of subspecialists correlated most strongly with the number of subspecialty training programs (r_S = 0.68, P = .003) but also correlated significantly with gross population and number of medical schools (r_S = 0.50-0.52, P ≤ .05).

CONCLUSION

Subspecialist surgeons represent one third of surgeons in West Africa, though most countries have fewer than 12 providers. The number of subspecialists is significantly correlated with the number of subspecialty training programs, and yet many West African countries lack accredited programs. These results suggest that investing in training programs is the most valuable potential strategy to address the shortage of surgical subspecialists in West Africa.

A model for global surgical training and capacity development: the Children's of Alabama-Viet Nam pediatric neurosurgery partnership

INTRODUCTION

Training capable and competent neurosurgeons to work in underserved regions of the world is an essential component of building global neurosurgical capacity. One strategy for achieving this goal is establishing longitudinal partnerships between institutions in low- and middle-income countries (LMICs) and their counterparts in high-income countries (HICs) utilizing a multi-component model. We describe the initial experience of the Children's of Alabama (COA) Global Surgery Program partnership with multiple Vietnamese neurosurgical centers.

METHODS

The training model developed by the COA Global Surgery Program utilizes three complementary and interdependent methods to expand neurosurgical capacity: in-country training, out-of-country training, and ongoing support and mentorship. Multiple Vietnamese hospital systems have participated in the partnership, including three hospitals in Hanoi and one hospital in Ho Chi Minh City.

RESULTS

During the 7 years of the partnership, the COA and Viet Nam teams have collaborated on expanding pediatric neurosurgical care in numerous areas of clinical need including five subspecialized areas of pediatric neurosurgery: cerebrovascular, epilepsy, neuroendoscopy for hydrocephalus management, craniofacial, and neuro-oncology.

CONCLUSION

Long-term partnerships between academic departments in LMICs and HICs focused on education and training are playing an increasingly important role in scaling up global surgical capacity. We believe that our multi-faceted approach consisting of in-country targeted hands-on training, out-of-country fellowship training at the mentor institution, and ongoing mentorship using telecollaboration and Internet-based tools is a viable and generalizable model for enhancing surgical capacity globally.

Development and launch of the first obstetrics and gynaecology master of medicine residency training programme in Botswana

BACKGROUND

Sub-Saharan Africa (SSA) faces a severe shortage of Obstetrician Gynaecologists (OBGYNs). While the Lancet Commission for Global Surgery recommends 20 OBGYNs per 100,000 population, Botswana has only 40 OBGYNs for a population of 2.3 million. We describe the development of the first OBGYN Master of Medicine (MMed) training programme in Botswana to address this human resource shortage.

METHODS

We developed a 4-year OBGYN MMed programme at the University of Botswana (UB) using the Kern's approach. In-line with UB MMed standards, the programme includes clinical apprenticeship training complemented by didactic and research requirements. We benchmarked curriculum content, learning outcomes, competencies, assessment strategies and research requirements with regional and international programmes. We engaged relevant local stakeholders and developed international collaborations to support in-country subspecialty training.

RESULTS

The OBGYN MMed curriculum was completed and approved by all relevant UB bodies within ten months during which time additional staff were recruited and programme financing was assured. The programme was advertised immediately; 26 candidates applied for four positions, and all selected candidates accepted. The programme was launched in January 2020 with government salary support of all residents. The clinical rotations and curricular development have been rolled out successfully. The first round of continuous assessment of residents was performed and internal programme evaluation was conducted. The national accreditation process was initiated.

CONCLUSION

Training OBGYNs in-country has many benefits to health systems in SSA. Curricula can be adjusted to local resource context yet achieve international standards through thoughtful design and purposeful collaborations.

Preferences and perspectives on vaginal breech delivery in Ghana

OBJECTIVE

To evaluate obstetrician/gynecologist and midwife perspectives and experiences with vaginal breech deliveries in Ghana.

METHODS

Respondents completed a survey on their experiences, training, comfort levels, and decision making about vaginal breech deliveries. Comparisons were made across obstetricians/gynecologists and midwives. Multiple logistic regression explored predictors of comfort performing vaginal breech deliveries.

RESULTS

Respondents comprised 93 (36.5%) obstetricians/gynecologists and 162 (63.5%) midwives. Most believed that some breech fetuses should be delivered vaginally, with higher agreement from obstetricians/gynecologists than from midwives (n = 86, 97.7% versus n = 207, 80.8%, P = 0.001). Midwives were more likely to strongly agree that training was adequate for obstetricians/gynecologists (n = 65, 55.6% versus n = 8, 9.8%, P < 0.001) and midwives (n = 60, 49.6% versus n = 6, 7.4%, P < 0.001). Most (n = 192, 94%) respondents wanted more experience and/or training. Despite most providers performing only one ot five breech vaginal deliveries yearly, 77.4% (n = 199) were comfortable performing them and 79.5% (n = 202) were comfortable supervising them. Significant predictors of comfort performing vaginal breech delivery were perceived adequacy of training (odds ratio 8.74, 95% CI 3.39-22.52) and belief that vaginal breech deliveries should be performed (odds ratio 4.28, 95% CI 1.33-13.72).

CONCLUSION

Respondents were more likely to feel comfortable performing breech vaginal deliveries if they felt that their training was adequate. Vaginal breech deliveries can only be offered as safe alternatives to cesarean delivery if training and experience are maintained in low-resource settings.

Gynecologic Oncology Sub-Specialty Training in Ghana: A Model for Sustainable Impact on Gynecologic Cancer Care in Sub-Saharan Africa

African women have double the risk of dying from cancer than women in high-income countries. In Ghana, most women with gynecological malignancies present with advanced-stage disease when treatment is less effective. Barriers to improved cancer outcomes include the availability of cancer screening, affordability of treatment, and access to gynecologic oncology specialists. In response to a paucity of gynecologic oncology providers, an in-country fellowship training program was established at Komfo Anokye Teaching Hospital (KATH) in 2013. Historically, Ghanaian resident physicians were sent to other countries for fellowship training and were unlikely to repatriate. The establishment of an in-country training program not only addresses the challenge of "brain drain," but also builds local capacity in gynecologic oncology education and emphasizes culturally relevant and accessible healthcare. The four-years gynecologic oncology fellowship program at KATH was developed as part of a longitudinal multi-decade partnership between the University of Michigan and academic medical centers in Ghana. The fellowship trains obstetricians and gynecologists to provide subspecialist clinical and surgical care to patients with gynecologic malignancies. Fellows collaborate with the radiation, oncology and pathology departments, participate in monthly inter-institutional tumor board meetings, conduct research, advise on health policy issues, and train subsequent cohorts. This fellowship is representative of emerging twenty-first-century trends in which subspecialty training programs in low-income countries are strengthened by international collaborations. Providing specialized training in gynecologic oncology can help develop and maintain resources that will improve clinical outcomes for women in low-resources settings.

Embedding international medical student electives within a 30-year partnership: the Ghana-Michigan collaboration

BACKGROUND

Global health experiences are an increasingly popular component of medical student curricula. There is little research on the impact of international medical electives embedded within long-standing, sustainable partnerships. Our research explores the University of Michigan medical student elective experience in Ghana within the context of the Ghana-Michigan collaborative.

METHODS

Study participants are University of Michigan medical students who completed an international elective in Ghana between March 2006 and June 2017. Post-elective reports were completed by students, including a description of the experience, highlights, disappointments, and the impact of the experience on interest in future international work and future practice of medicine. A retrospective thematic analysis of reports was carried out using NVivo 12 (QSR International, Melbourne, Australia).

RESULTS

A total of 57 reports were analyzed. Benefits of the elective experience included building cross-cultural relationships, exposure to different healthcare environments, hands-on clinical and surgical experience, and exposure to different patient populations. Ninety-five percent of students planned to engage in additional international work in the future. Students felt that the long-standing bidirectional exchange allowed them to build cross-cultural relationships and be incorporated as a trusted part of the local clinical team. The partnership modeled collaboration, and many students found inspiration for the direction of their own careers.

CONCLUSIONS

Embedding clinical rotations within a well-established, sustained partnerships provides valuable experiences for trainees by modeling reciprocity, program management by local physicians, and cultural humility-all of which can help prepare learners to ethically engage in balanced, long-term partnerships in the future.

Estimating obstetric and gynecologic surgical rate: A benchmark of surgical capacity building in Ghana

OBJECTIVE

To estimate the annual rate of obstetric and gynecologic (ObGyn) operations performed in Ghana and establish a baseline for tracking the expansion of Ghana's surgical capacity.

METHODS

Data were obtained for ObGyn operations performed in Ghana between 2014 and 2015 from a nationally representative sample of hospitals and scaled up for national estimates. Operations were classified as "essential" or "other" according to The World Bank's Disease Control Priorities Project. Data were used to calculate cesarean-to-total-operation ratio (CTR) and estimate the rate of cesarean deliveries based on the number of live births in 2014.

RESULTS

A total of 90 044 (95% uncertainty interval [UI] 69 461-110 628) ObGyn operations were performed nationally over the 1-year period, yielding an annual national ObGyn operation rate of 881/100 000 females aged 12 years and over (95% UI 679-1082). Eighty-seven percent were essential procedures, 80% of which were cesarean deliveries. District hospitals performed 71% of ObGyn operations. The national rate of cesarean deliveries was 7.2% and the CTR was 0.27.

CONCLUSION

The cesarean delivery rate of 7.2% suggests inadequate access to obstetric care. The CTR of 0.27 suggests inadequate overall surgical capacity. These measures, along with estimates of distribution of procedures by hospital level, provide useful baseline data to support surgical capacity building efforts in Ghana and similar countries.

Postgraduate Medical Education in Sub-Saharan Africa: A Scoping Review Spanning 26 Years and Lessons Learned

BACKGROUND

Investments in training physician specialists through postgraduate medical education (PGME) are critical for Sub-Saharan Africa, given the increasing burden of non-communicable diseases.

OBJECTIVES

The objectives of this scoping review were to (1) understand the breadth of publications on PGME from Sub-Saharan Africa, and (2) conduct a thematic analysis of lessons learned by specific training programs.

METHODS

We conducted a literature search of 7 databases for PGME literature published between January 1991 and December 2016. Two reviewers independently reviewed titles and abstracts for inclusion. Full-text articles were then reviewed, and bibliometric data were extracted to create a profile of PGME-related publications. Two authors coded the manuscripts to identify articles written about specific PGME programs. These were analyzed for lessons learned.

RESULTS

We identified 813 publications that reported on postgraduate medical education in Sub-Saharan Africa. Most articles were published between 2005 and 2016. Nations leading in publication were South Africa and Nigeria, followed by Ethiopia, Uganda, Kenya, Ghana, and Malawi. The largest number of articles related to general surgery training, followed by family medicine, emergency medicine, and anesthesiology. Thematic analysis revealed advantages of training programs for health facilities, challenges related to teaching, resourcing, and standardizing of training, and lessons learned related to international partnerships, faculty engagement, and research support for trainees.

CONCLUSIONS

PGME in Sub-Saharan Africa has evolved over the past 26 years. Future growth will require strategic support to scale programs, support new specialties, trainees, and teachers, and leverage best practice models to sustain PGME programs.

A Comprehensive Evaluation of Obstetrics and Gynecology Residencies' Global Health Training Programs

OBJECTIVE

To compile a comprehensive summary of obstetrics and gynecology global health training programs and to describe program type, global distribution of work, effect, and reciprocity within programs.

METHODS

This cross-sectional observational study identified all U.S. obstetrics and gynecology residencies with global health training programs, described residency and program characteristics, and evaluated the publications resulting from them. Eligible articles included those published in 2011-2016 about work done in a global health training location by global health training faculty. All eligible articles were evaluated for academic effect. The inclusion of host country authors on articles served as a proxy for reciprocity. Article content was assessed to evaluate whether programs addressed Millennium Development Goals.

RESULTS

Among 245 obstetrics and gynecology residencies, 196 (80%) had global health training programs. Location and faculty members were identified for 67 (34%) programs, of which 26 (39%) had global health training faculty who had published articles meeting inclusion criteria. Of 698 articles reviewed, 78% addressed at least one Millennium Development Goal, including 39% that addressed improving maternal health (Millennium Development Goal 5). Approximately half (48%) of authors were from host countries.

CONCLUSION

Most obstetrics and gynecology residencies are offering global health training. The majority of programmatic work addresses Millennium Development Goals and thus is aligned with global health priorities. The effect and reciprocity of global health training programs varies across institutions. Residencies could benefit from internal analysis of their global health training programs to evaluate whether knowledge gained is being disseminated and to ensure equitable partnerships and the creation of sustainable, influential initiatives.

Ethical issues in global health engagement

With an increasing number of clinicians participating in global health work, such engagement is now more than ever in need of critical ethical scrutiny. Exemplary initiatives in research, academics and publication, and other special considerations, provide potential approaches for overcoming ethical challenges in global health work. These methods demonstrate that successful global health work includes a commitment to foundational ethical principles such as trust, honesty, open communication and transparency, sustainability, capacity building, and appreciation for multiple perspectives - principles that surpass the traditional considerations of clinical practice. From this perspective, successful interventions to reduce neonatal and perinatal mortality must be strategically focused on building in-country capacity and sustainability.

Post-Ebola situational assessment of opportunities for capacity building at the national obstetrics and gynecology referral hospital in Sierra Leone

OBJECTIVE

To describe a site assessment of the Princess Christian Maternity Hospital (PCMH; Freetown, Sierra Leone), the national referral center for reproductive, maternal, newborn, child and adolescent health (RMNCAH) services and logical site for focused efforts to train and expand the RMNCAH workforce in Sierra Leone.

METHODS

In April 2016, a mixed-methods assessment approach was used involving facility observation and staff interviews using the WHO's Service Availability and Readiness Assessment (SARA) tool. Quantitative and qualitative data were obtained.

RESULTS

PCMH had 150 inpatient beds and provided care for more than 4600 deliveries in 2015. The number of maternal deaths increased at a rate of approximately 40% per month from January 2015 to June 2016 (P=0.005). Key factors requiring attention were identified in the categories of infrastructure and supplies, RMNCAH services, and human resources.

CONCLUSION

SARA provided a framework for identifying strengths and weaknesses in infrastructure and supplies, RMNCAH services, and human resources. The process described might serve as a model for evaluating obstetrics and gynecology training facilities in low- and middle-income countries. Human resources are currently insufficient for the volume and complexity of patients at PCMH. Numerous opportunities exist for strengthening healthcare services and capacity building in Sierra Leone.

Strengthening care and research for women's cancers in Sub-Saharan Africa

•The burden of gynecologic cancers in low resource settings is overwhelming.•Areas with the highest needs have few human resources and limited infrastructure.•Cancer specialists can best help by leveraging ongoing work to assist local leaders.

Global Health Ethics: The Case of Maternal and Neonatal Survival

Through their Sustainable Development Goals the United Nations recognizes the moral significance of health, stating that the elimination of maternal and early neonatal mortality are health outcomes that should be available to all women in the world. Complete prevention requires addition of a skill set for maternal care teams that is a magnitude greater than what we have today. As universities, individuals, institutions and NGO's engage in initiatives to end preventable maternal and neonatal mortality, an expanded context of ethical imperatives becomes increasingly important. Besides the traditional principles of non-maleficence, beneficence, autonomy, and social justice, imbalances between high and low income countries and cultural relativity give rise to broader ethical imperatives: mutual respect, trust, open communication, accountability, transparency, leadership capacity building and sustainability. The elimination of disparities in other women's issues, HIV, malaria, tuberculosis, chronic non-infectious diseases, can all be more effectively addressed through a lens of ethical global health engagement.

Medical Education and Training: Building In-Country Capacity at All Levels

Poorly trained workers and limited workforce capacity contribute immensely to barriers in cancer control in low- and middle-income countries (LMICs). Because of an increasing disease burden and the gap in trained personnel, it is critical that LMICs must develop appropriate in-country training programs at all levels to adequately address their cancer-related outcomes. The training in LMICs of cancer health personnel should address priority cancer diseases in the specific country by developing caregivers, trainers, researchers, and administrators at all levels of health care and all cadres of staff, from the community level to the national level. The Academic Model of Providing Access to Health care is a representative model of how a public tertiary hospital like the Moi Teaching and Referral Hospital in an LMIC setting can leverage its resources, collaborate with partners from high-resource countries, and assist in the development of a training center to spearhead a sustainable education program.