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.

Potentially under-recognized late-stage physical and psychosexual complications of non-therapeutic neonatal penile circumcision: a qualitative and quantitative analysis of self-reports from an online community forum.

The removal of non-pathogenic foreskin from the penis of healthy neonates and infants for non-religious reasons is routinely practiced in many parts of the world. High level data from well-designed randomized controlled trials of circumcision in neonates and infants does not guide clinical practice. Reliable counts of immediate and short term circumcision complications are difficult to estimate. Emerging evidence suggests routine neonatal circumcision could lead to long term psychological, physical, and sexual complications in some men. The stigma associated with discussing circumcision complications creates a prevalence paradox where the presence of significant circumcision complications is higher than reported. Prior to the Internet, there were very few forums for men from diverse communities, who were troubled about their circumcision status, to discuss and compare stories. To investigate the long term consequences of circumcision, we reviewed 135 posts from 109 individual users participating in a circumcision grief subsection of Reddit, an internet discussion board. We identified three major categories of complications: physical such as pain during erections and lost sensitivity, psychological such as anxiety and violation of autonomy, and sexual such as feeling that the sexual experience was negatively altered or being unable to complete a sexual experience. We also identified a "discovery process" where some men described coming into awareness of their circumcision status. These findings suggest that neonatal circumcision can have significant adverse consequences for adult men. The removal of normal foreskin tissue should be limited to adult men who choose the procedure for cosmetic reasons or when medically indicated.

Lessons Learned Serving on a Long-Standing Maternal Mortality Review Committee.

The maternal mortality ratio in the United States is increasing; understanding the significance of this change and developing effective responses requires a granular analysis of the contributing factors that a well-informed maternal mortality review committee can provide. Data collection and analysis, clinical factors, preventability, social determinants of health, and racial inequities combine to affect this outcome, and each factor must be considered individually and in combination to recommend a robust response. Obstetrician-gynecologists formed the State of Michigan's Maternal Mortality Review Committee (the Committee) in 1950 to identify gaps in care that needed to be systematically addressed at the time. In the early years, the Committee witnessed a reduction in the number of maternal deaths; over time, prioritization of maternal mortality decreased, yet the Committee witnessed changing patterns of death, varied data collection and evaluation processes, delayed reviews, and unimplemented recommendations. The calculation of the maternal mortality ratio was not informed by the outcomes of Committee reviews. Today, the Committee, with increased support from the Michigan Department of Health & Human Services, can clearly identify and report preventable pregnancy-related mortality along with its causes and is close to achieving a near real-time surveillance system that allows the development of timely clinical and policy recommendations and interventions. The Committee's adaptations in response to the rise in maternal mortality have resulted in several lessons learned that may be helpful for currently operating committees and in the formation of new ones.

Completing the Maternal Care Team: OB/GYN Expertise at Rural District Hospitals in Ghana, a Qualitative Study.

Introduction To provide a qualitative perspective on the changes that occurred after newly placed OB/GYNs began working at district hospitals in Ashanti, Ghana. Methods Structured interviews of healthcare professionals were conducted at eight district hospitals located throughout the Ashanti district of Ghana, four with and four without a full-time OB/GYN on staff. Individuals interviewed include: medical superintendents, medical officers, district hospital administrators, OB/GYNs (where applicable), and nurse-midwives. Interviews were transcribed verbatim and content analysis was performed to identify common themes. Characteristics quotes were identified to illustrate principal interview themes. Quotes were verified in context by researchers for accuracy. Results Interviews with providers revealed four areas most impacted by an OB/GYN's leadership and expertise at district hospitals: patient referral patterns, obstetric protocol and training, facility management and organization, and hospital reputation. Discussion OB/GYNs are uniquely positioned to add clinical capacity and care quality to established maternal care teams at district hospitals-empowering district hospitals as reliable care centers throughout rural Ghana for women's health. Coordinated efforts between government, donors and OBGYN training institutions to provide complete obstetric teams is the next step to achieve the global goal of eliminating preventable maternal mortality by 2030.

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.

Community-based surveillance of maternal deaths in rural Ghana.

OBJECTIVE: To examine the feasibility and effectiveness of community-based maternal mortality surveillance in rural Ghana, where most information on maternal deaths usually comes from retrospective surveys and hospital records. METHODS: In 2013, community-based surveillance volunteers used a modified reproductive age mortality survey (RAMOS 4+2) to interview family members of women of reproductive age (13-49 years) who died in Bosomtwe district in the previous five years. The survey comprised four yes-no questions and two supplementary questions. Verbal autopsies were done if there was a positive answer to at least one yes-no question. A mortality review committee established the cause of death. FINDINGS: Survey results were available for 357 women of reproductive age who died in the district. A positive response to at least one yes-no question was recorded for respondents reporting on the deaths of 132 women. These women had either a maternal death or died within one year of termination of pregnancy. Review of 108 available verbal autopsies found that 64 women had a maternal or late maternal death and 36 died of causes unrelated to childbearing. The most common causes of death were haemorrhage (15) and abortion (14). The resulting maternal mortality ratio was 357 per 100 000 live births, compared with 128 per 100 000 live births derived from hospital records. CONCLUSION: The community-based mortality survey was effective for ascertaining maternal deaths and identified many deaths not included in hospital records. National surveys could provide the information needed to end preventable maternal mortality by 2030.

Maternal Deaths Due to Sepsis in the State of Michigan, 1999-2006.

OBJECTIVE: To identify maternal deaths due to sepsis in the state of Michigan, review the events leading to diagnosis, and evaluate treatment to identify areas for improvement. METHODS: A case series was collected for maternal deaths due to sepsis from a cohort of maternal deaths in the state of Michigan. The study period was 1999-2006 and included deaths during pregnancy and up to 42 days postpartum. Cases were identified using Maternal Mortality Surveillance records from the Michigan Department of Community Health. Each case was reviewed by all authors. RESULTS: Maternal sepsis was the cause of death in 15% (22/151) of pregnancy-related deaths. Of 22 deaths, 13 women presented to the hospital with sepsis, two developed sepsis during hospitalization, and seven developed sepsis at home without admission to the hospital for care. Review of available hospital records (n=15) revealed delays in initial appropriate antibiotic treatment occurred in 73% (11/15) of patients. Delay in escalation of care also occurred and was identified in 53% (8/15) of patients. CONCLUSION: Common elements in these deaths illustrate three key delays that may have contributed to the deaths: in recognition of sepsis, in administration of appropriate antibiotics, and in escalation of care. LEVEL OF EVIDENCE: III.

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

OBJECTIVES: We assessed the public health effect of creating and sustaining obstetrics and gynecology postgraduate training in Ghana, established in 1989 to reverse low repatriation of physicians trained abroad. METHODS: All 85 certified graduates of 2 Ghanaian university-based postgraduate training programs from program initiation in 1989 through June 2010 were identified and eligible for this study. Of these, 7 were unable to be contacted, inaccessible, declined participation, or deceased. RESULTS: Of the graduates, 83 provide clinical services in Ghana and work in 33 sites in 8 of 10 regions; 15% were the first obstetrician and gynecologist at their facility, 25% hold clinical leadership positions, 50% practice in teaching hospitals, and 14% serve as academic faculty. CONCLUSIONS: Creating capacity for university-based postgraduate training in obstetrics and gynecology is effective and sustainable for a comprehensive global approach to reduce maternal and neonatal morbidity and mortality. Policies to support training and research capacity in obstetrics and gynecology are an integral part of a long-term national plan for maternal health.

Fistula awareness among sisters of women with fistula.

OBJECTIVE: To determine whether sisters of women with obstetric fistula (OF) were aware of their sisters' condition, in order to inform the development of survey questions that adapt the sister-based method to fistula rate estimation. METHODS: Twelve women with OF and 20 of their sisters were interviewed using semi-structured questionnaires in rural Uganda in 2007. Topics included fistula awareness and perceptions of causality. RESULTS: Eleven women had vesicovaginal fistula and 1 had rectovaginal fistula. Three were primiparous at time of fistula occurrence; 6 had a parity of 6 or more. Nineteen sisters were aware their sister had OF; 12 became aware at the time of occurrence. The majority of participants (fistula patients and their sisters) associated OF with mistakes made by hospital personnel or problems during procedures. CONCLUSION: Sisters were generally aware of OF within their family. Larger studies are needed to assess the validity and reliability of the sister-based method in capturing fistula through household surveys. In the present study, there was a widespread perception among fistula patients and their sisters that fistula is caused by medical procedures. More research is needed to understand this perception, and program development efforts are required to improve patient perceptions of hospital care.

Traditional preparations used as uterotonics in Sub-Saharan Africa and their pharmacologic effects.

BACKGROUND: Little is known about the use of traditional preparations for uterotonic effects at or near delivery in Sub-Saharan Africa. OBJECTIVE: To describe (1) use of traditional preparations in Sub-Saharan Africa intended to have uterotonic effects at or near birth; and (2) results of pharmacologic investigations of the uterotonic properties of such preparations. SEARCH STRATEGY: Structured review of 13 databases. SELECTION CRITERIA: Articles describing use of traditional preparations in Sub-Saharan Africa with primary data, published in English between January 1, 1980 and June 30, 2010. DATA COLLECTION AND ANALYSIS: Full-text review using standard spreadsheet templates. MAIN RESULTS: Objective 1 analysis identified 208 plant species used for uterotonic effects at or near delivery. The most common use was labor induction/augmentation (n=185). Other uses were to expel the placenta, shorten the third stage of labor, manage retained placenta (n=61), and prevent/manage postpartum hemorrhage (n=20). Objective 2 analysis identified 82 species with uterotonic activity confirmed through pharmacologic evaluation. Studies also identified potentiating/inhibiting effects of extracts on pharmaceutical uterotonics. CONCLUSION: Numerous plants are used for uterotonic effects in Sub-Saharan Africa; uterotonic activity has been confirmed in many through pharmacologic evaluation. Such use may increase the risk of adverse outcomes. Further research is needed on the uterotonic efficacy of traditional preparations and on interventions to address use during labor.

Improving maternal mortality reporting at the community level with a 4-question modified reproductive age mortality survey (RAMOS).

OBJECTIVE: To investigate the identification of maternal deaths at the community level using the reproductive age mortality survey (RAMOS) in all households in which a women of reproductive age (WRA) died and to determine the most concise subset of questions for identifying a pregnancy-related death for further investigation. METHODS: A full RAMOS survey was conducted with the families of 46 deceased WRA who died between 2005 and July 2009 and was compared with the cause of death confirmed by the maternal mortality review committee to establish the number of maternal mortalities. The positive predictive value (PPV) of each RAMOS question for identifying a maternal death was determined. RESULTS: Compared with years of voluntary reporting, active surveillance for maternal deaths doubled their identification. In addition, 4 questions from the full RAMOS have the highest PPV for a maternal death including the question: "Was she pregnant within the last 6weeks?" which had a 100% PPV and a 100% negative predictive value. CONCLUSION: Active identification of maternal mortality at the community level by using a 4-question modified RAMOS that is systematically administered in the local language by health workers can increase understanding of the extent of maternal mortality in rural Ghana.

Factors related to retention of postgraduate trainees in obstetrics-gynecology at the Korle-Bu Teaching Hospital in Ghana.

PURPOSE: The retention of health care workers in developing countries is a key component to reducing the current health care workforce crisis. The availability of postgraduate medical training in developing countries could be an appropriate adjunctive solution. The authors investigated factors that led obstetrics-gynecology (ob/gyn) residents at a university-based academic training program at the Korle-Bu Teaching Hospital (Accra, Ghana) to stay in Ghana for training and explored why the residents expect to stay in (or leave) Ghana after training. METHOD: In July 2006, the authors surveyed 20 residents and conducted semistructured interviews with a subset of 9 residents. RESULTS: Nineteen respondents (95%) reported they would have left Ghana if postgraduate training had not been available, 16 (80%) reported that becoming an ob/gyn specialist was important to them, 15 (75%) indicated that the program trained them to practice in Ghana, and 17 (85%) were certain they would stay in Ghana after completing the program. Both quantitative and qualitative data supported the idea that three factors contribute to the retention of ob/gyn physicians in Ghana: (1) the presence of a postgraduate training program in Ghana, (2) residents' commitment to serve the people of Ghana, and (3) residents' feelings that physicians can "make it" economically in Ghana. CONCLUSIONS: Postgraduate training is an important contributor to the retention of physicians in country. Partnerships between academic health centers in developed and developing countries provide opportunities to address the global health care crisis in a significant and sustainable way.

Maternal mortality: an enduring epidemic.

Women continue to die from pregnancy-related causes at an alarming rate. Maternal mortality was first called a neglected epidemic in 1985, but to date, no significant improvements have been realized. Great disparity exists as lifetime risk of dying from pregnancy is 1 in 26 in Africa, 1 in 7300 in high-income areas. The UN Millennium Development Goals call for a 75% reduction in maternal mortality by 2015, which will only be realized when priority setting, funding, and program implementation can create conditions for appropriate human resources, infrastructure, and patient education for high-quality obstetric care.

Obstetric fistula in low-income countries.

OBJECTIVE: To identify, survey, and systematically review the current knowledge regarding obstetric fistula as a public health problem in low-income countries from the peer-reviewed literature. METHODS: The Medline and Science Citation Index databases were searched to identify public health articles on obstetric fistula in low-income countries. Quantitative evidence-based papers were reviewed. RESULTS: Thirty-three articles met the criteria for inclusion: 18 hospital-based reviews; 6 on risk factors/prevention; 4 on prevalence/incidence measurement; 3 on consequences of obstetric fistula; and 2 on community-based assessments. CONCLUSION: Obstetric fistula has received increased international attention as a public health problem, but reliable research on the burden of disease and interventions is lacking.

Perceptions of pregnancy complications in Haiti.

OBJECTIVE: To determine the incidence of perceived pregnancy complications and associated factors. METHODS: During a census, 450 women identified themselves as pregnant and 388 were interviewed postpartum. RESULTS: Complications were reported by 58.6%. Bleeding post-delivery was the most frequent complication (42.5%), followed by great pain (33.8%), bleeding during pregnancy (20.1%), and fever post-delivery (11.6%). Prenatal care at either a dispensary or a clinic was associated with reports of bleeding during pregnancy (odds ratio [OR] 9.06; 95% confidence interval [CI], 1.71-48.00 and OR 7.58; 95% CI, 1.53-37.48, respectively). Women who visited a doctor were less likely to report bleeding during pregnancy (OR 0.20; 95% CI, 0.08-0.55) or fever post-delivery (P=0.015). Herb use was associated with reported bleeding during pregnancy (OR 2.22; 95% CI, 1.12-4.40) and great pain (OR 1.94; 95% CI, 1.05-3.58). CONCLUSION: The perceived pregnancy complication rate in Haiti is high and is associated with access to health care. The association between use of herbs and pregnancy complications warrants investigation.

Who will be there when women deliver? Assuring retention of obstetric providers.

The Safe Motherhood Initiative has highlighted the need for improved health services with skilled attendants at delivery and the provision of emergency obstetric care. "Brain drain" has hampered this process and has been particularly prevalent in Ghana. Between 1993 and 2000, 68% of Ghanaian trained medical school graduates left the country. In 1989, postgraduate training in obstetrics and gynecology was established in Ghana, and as of November 2006, 37 of the 38 specialists who have completed the program have stayed in the country, most working in the public sector providing health care and serving as faculty. Interviews with graduates in 2002 found that the first and single-most important factor related to retention was the actual presence of a training program leading to specialty qualification in obstetrics and gynecology by the West African College of Surgeons. Economic and social factors also played major roles in a graduates' decision to stay in Ghana to practice. This model deserves replication in other countries that have a commitment to sustainable development, human resource and health services capacity building, and maternal mortality reduction. A network of University partnerships between departments of obstetrics and gynecology in developed and developing countries throughout the world sharing internet resources, clinical information, training curriculum and assessment techniques could be created. Grand rounds could be shared through teleconferencing, and faculty exchanges would build capacity for all faculty and enrich both institutions. Through new partnerships, creating opportunity for medical school graduates to become obstetrician-gynecologists may reduce brain drain and maternal mortality.