Maternal health gains from low-resource training model

Ghana’s obstetrics and gynaecology (ObGyn) training, development and retention programme over the past 30 years has demonstrated the strengths and barriers of speciality training in low-resource settings and has the potential to serve as a model for international academic medicine partnerships. It can be adapted to other low-resource settings, a study has found.

The research, ‘Growth model for international academic medicine partnerships: Qualitative analysis of Ghana postgraduate Ob/Gyn training programme’, was published in PLOS Global Public Health in January 2023.

The authors, Theresa Rager, Melani Kekulawala, Yael Braunschweiga, Ali Samba, Tim Johnson and Frank Anderson, said the programme filled the gap in obstetric capacity by completing the maternal care team in hospitals and was able to provide the required care.

Reacting to the study, Dr Chris Barasa, ObGyn and health system strengthening expert of the non-governmental health organisation Amref Health Africa, based in Kenya, told University World News: “I resonate well with the findings in this paper.”

He said his professional journey as an undergraduate got him posted to a busy maternity hospital and he was expected to head the unit.

Barasa said he was later posted as a medical superintendent – a year into being a medical officer without any leadership or management training – adding that, “I had to separately enrol for a masters in business administration to manage this.

“I moved out of government employment as I lacked support to execute my mandate as a clinician and leader and joined the NGO world, after which I went back to school to study towards an MSc in public health,” he said.

However, driven by the desire to undertake a sub-specialisation in gynaecology oncology, Basara said, he went back to undertake a masters in ObGyn as a self-sponsored student.

Driving SDGs

The study said the programme has laid “the foundation to promote decent work for graduates, leading to gender equity for both graduates and patients, and ultimately improved health and well-being, particularly maternal, newborn and child health”.

The Ghana postgraduate ObGyn training programme began in 1986 as a collaboration between health, education and development stakeholders to address the obstetrician workforce and provides training for Ghanaian medical school graduates (medical officers) at two Ghanaian institutions (University of Ghana Medical School and Kwame Nkrumah University of Science and Technology) to mitigate the effect of ObGyns travelling abroad for training and remaining abroad to practise.

According to the authors, “since 1989, the programme has trained and retained over 250 certified ObGyns” which, they said, can be adapted to other low-resource settings, adding that, “the programme has demonstrated efficacy in increasing national maternal health and obstetric capacity and is on the brink of drastically increasing women’s health capacity, reducing preventable maternal mortality, and driving Sustainable Development Goals (SDG) progress with the growth of the ObGyn generalist population and the projected growth of the subspecialist population”.

SDG 3, which is about good health and well-being, is also about the training and development of health professionals who can support populations to be healthy.

Data for the study was collected in Ghana between June and August 2017 and was reviewed for an additional analysis in June and July 2020. The researchers used Consolidated Criteria for Reporting Qualitative Research (COREQ) to ensure robust qualitative methodology. In addition, both purposive and convenience sampling were used to recruit participants.

“In building the postgraduate training programme, medical officers were recruited to train in-country, obtain obstetric skills, and become certified as ObGyn specialists capable of integrating into the health system.

“The novel and growing ObGyn population in Ghana allows for the filling of maternal care team roles and collaborations, opportunity for subspecialisation, and space for conducting research,” the authors said.

Empowering graduates

They said establishing graduates as practising ObGyns allows them to “flourish as leaders and collaborators. Graduates are proving to be leaders of the maternal care team by exercising decision-making and management skills to serve as team and-or department managers”.

“As such, graduates are creating operational changes to improve protocols and establish new clinics. Through their teaching, graduates are practising academic medicine, and thereby promoting programme sustainability.

“Additionally, women ObGyns are serving as mentors and role models capable of recruiting more women into the speciality,” the study said.

The authors said their results “suggest that, as the number of ObGyn trainees and, subsequently, certified ObGyn practitioners increases, the demand for obstetric and gynaecologic care will be met.

“Within this structure, midwives can service uncomplicated cases and refer complex cases so that all cases are addressed with skill and competence.”

In addition, by bolstering the maternal care team through leadership and collaboration, preventable maternal mortality can be reduced, the study said, adding that results suggest a model by which postgraduate training programmes strengthen the healthcare workforce, expand specialisation and increase national capacity.

From what the study said, “an opportunity to increase capacity must be first identified. Here, the postgraduate training programme discovered medical officers were eager to specialise in Ghana but lacked the opportunity”.

It was for this reason that an opportunity presented itself for ObGyn specialists eager to complete sub-specialisation training to expand ObGyn care within Ghana.

Curriculum change

In order for Sub-Saharan African medical institutions to actualise the three pillars of academic medicine, ObGyn programmes need to integrate subspeciality and research training and practicums into their curriculums.

By creating an environment that allows for such advancement, comprehensive women’s health services can become more widely available and contribute to improving women and children’s health outcomes.

The study said processes like postgraduate and subspeciality training are successful if there is an initial investment and partnership that creates space for the process to exist, be self-sustained and be high impact.

“Building programmes allows infrastructure for retention, improved healthcare quality and access, a broader spectrum of care, and research platforms. Many development initiatives attempt to fill gaps with projects because processes for comprehensive, national approaches are not in place,” the authors said.

They suggested a model for the establishment and growth of long-term, sustainable programmes that mitigate development gaps that necessitate filling by international aid.

When considered as prospective, gap-mitigation efforts rather than a retrospective tackling of development challenges, training programmes can truly avert preventable maternal mortality and improve women’s health, the study concluded.