Obstetrics and gynecology in global health: Lessons learned for advancing public health to achieve universal health care

Addressing global health inequities requires a comprehensive response from the world’s surgical, anesthesia, and obstetrics and gynecology (OB/GYN) communities. These health care professionals need to share evidence-based knowledge and experience and collaborate to develop training programs and initiatives that ensure sustained, functioning health care systems. The world has experienced significant improvements in health care for millions because of effective global public health programs. However, these improvements have exposed the significant burden of obstetrical and surgical disease facing most of the world’s population. Tremendous gaps exist in expertise, workforce, and infrastructure, all of which are essential to provide critical surgical, anesthesia, and modern OB/GYN care in low- and middle-income countries (LMICs).

International efforts are under way to address these gaps. In 2015, the 68th World Health Assembly (WHA) passed Resolution 68.15 to strengthen emergency and essential surgical care and anesthesia as a component of universal health care.¹ That same year, The World Bank released the third edition of Disease Control Priorities, highlighting surgical procedures as cost-effective health care interventions and advocating for universal coverage of emergency surgery.² Further evidence for the need to strengthen health care systems was provided by The Lancet Commission on Global Surgery (LCoGS), which reported that 5 billion people lack access to safe and affordable surgical and anesthesia care, recommending six core indicators to monitor the strength of surgical systems.³ Within this framework, the OB/GYN, surgery, and anesthesia global communities have a unique opportunity to develop a comprehensive partnership approach that provides the level of expertise needed to lead a coordinated public health response.

The Millennium Development Goals (MDGs) project, led by the United Nations (UN) from 2000 to 2015, included eight primary goals, ranging from halting the spread of the human immunodeficiency virus (HIV) to reducing neonatal and maternal mortality. Although the MDGs for neonatal and maternal health were not achieved, substantial progress was made, and the maternal mortality ratio (MMR) fell from 385 to 216 deaths per 100,000 live births.⁴

Upscaling high-quality obstetrical interventions continues to be part of the response to the new sustainable development goal (SDG) of eliminating preventable maternal and early neonatal mortality. The SDG now calls for reducing global MMRs from 216 per 100,000 live births in 2015 to less than 70 per 100,000 live births by 2030 (SDG 3.1). This objective will be achieved only by expanding comprehensive obstetrical, anesthesia, and surgical care to a level not offered by community workers, general physicians, or midwives. These interventions will require novel partnership approaches and evidence-based strategies that go beyond relief and vertical programs and work toward long-term, sustainable capacity development.⁵

OB/GYN services are linked to the environments that support the treatment of other surgical conditions, both requiring widely available anesthesia capabilities. Providing safe deliveries, including cesarean sections (C-sections), has been shown to be cost-effective.^6,7 Furthermore, investing in improving access to safe reproductive health care, including family planning and abortion, when coupled with obstetric surgical care powerfully synergize cost-effectiveness.⁸ The importance of providing these services is based not only on ethical grounds, but on sound economic policy.^6,9

The maternal health community benefits from many years of global prioritization on these issues with funding and programmatic momentum. Moving forward to address more comprehensively the surgical burden of disease requires the coalescence of a global health agenda, with a strong collaboration between OB/GYN, surgery, and anesthesia to lead the next generation of global public health interventions.

The LCoGS created a road map for the way forward and recommended a list of key indicators to assess the strength of surgical systems and provide a baseline for measuring improvement. The improved health outcomes measured by these indicators can be accomplished if surgery, OB/GYN, and anesthesia unite for a coordinated global effort of prospective data collection. Coordinating the collection and reporting of these indicators at the national level with The World Bank Development Indicators will provide the metrics for the global community to measure progress and to achieve the 2030 targets.

This article describes some of the major interventions that the global OB/GYN community has implemented to build long-term and sustainable capacity around the world. It identifies successful models for academic and professional society partnerships and highlights areas of collaboration to build surgical, obstetrical, and anesthesia capacity. Through strong partnerships to build OB/GYN residency programs, strengthen professional societies, and create certification programs, we are growing and mentoring leaders in research, clinical care, education, and policy development. The lessons learned from these interventions can be applied to other surgical specialties and pave the way forward in building capacity to provide sustainable, high-quality obstetrical, gynecological, surgical, and anesthesia care globally.

Academic partnerships

Partnerships between OB/GYN departments in sub-Saharan Africa with academic OB/GYN departments in high-income countries are a feasible and resilient approach to building obstetric capacity in LMICs. These partnerships increase the capacity of faculties and departments to provide clinical service, education, and research in the African OB/GYN community. These model programs are informative and present opportunities for replication in surgery and anesthesia.

Ghana, for example, has used a university partnership approach to advance obstetric capacity development when faced with a health care workforce crisis. Until 1989, Ghana sent OB/GYN trainees to train in the U.K. with only three out of 30 specialists returning in a 20-year period. The residency program established in 1989 resulted from a collaboration between the local medical community, the Ministry of Health, and academic partners in the U.S., the U.K., and the West African College of Surgeons.¹⁰ As of July 2017, according to Frank W. J. Anderson, MD, MPH, a co-author of this article, the program has graduated 246 certified OB/GYNs, 238 of whom have remained in Ghana, providing clinical services, academic leadership, and contributing to governmental policymaking. Those physicians choosing faculty positions are conducting high-quality basic science and clinical research, and many are working in rural district hospitals, opening new facilities, and leading OB/GYN departments in four new medical schools in Ghana.^10,11 Subspecialty training in maternal-fetal medicine (MFM), gynecologic oncology, urogynecology, and reproductive health is now available.

This model of academic partnership is being replicated in Ghana in other specialties, including emergency medicine, family medicine, and otolaryngology, as well as in nonclinical departments. Notably, the “Charter for Collaboration” was created as part of the program implementation plan by partners in the U.S. and Ghana to foster an open dialogue on how to optimize the partnership. A concerted effort was made to ensure the priorities and concerns of both partners were integrated into the project’s development and implementation. A series of guiding principles were articulated by the group and featured in the charter, including trust, mutual respect, accountability, leadership, transparency, inclusion, communication, and sustainability.¹² Now, the charter serves the function as a guideline for new collaborative projects.¹²

The Ghana experience in training OB/GYNs and developing a model for partnerships provides a road map for numerous OB/GYN departments. At least four new OB/GYN partnerships have emerged and are actively training new OB/GYNs and other specialists.^13-17

The 1000+ OBGYNs Project is another collaborative effort, led by the department of OB/GYN at the University of Michigan, Ann Arbor, comprising a network of U.S. and African academic OB/GYN departments. The project was created after two global meetings of OB/GYN leadership in Rome, Italy, in 2012 and in Accra, Ghana, in 2014 and is poised to train more than 1,000 new OB/GYNs in the sub-Saharan region over the next decade.¹⁸ At these meetings, 10 critical components of OB/GYN training were identified to provide a base from which to replicate these partnerships (Figure 1).¹⁹ The educational programs will be supported by lectures, videos, textbooks, and curricula provided without cost. Online materials, together with the Global Library of Women’s Medicine, provide hundreds of OB/GYNs in sub-Saharan Africa with access to quality standardized material on the most prevalent issues in the region, as well as content related to general OB/GYN care, family planning, and cancer screening.²⁰

Figure 1. 10 critical components of comprehensive OB/GYN training programs

Critical components of comprehensive OB/GYN training, as identified during Rome (2010) and Accra (2014) meetings of the 1000+ OBGYNs Project partners

The Academic Model Providing Access to Healthcare (AMPATH) is an academic medical partnership between North American academic health centers and Moi University School of Medicine, Eldoret, Kenya.²¹ The partnership was initially focused on the department of internal medicine and progressed into a holistic HIV treatment program. A decade ago, the partnership expanded to include the University of Toronto, ON; Indiana University, Indianapolis; and Moi University to build capacity in OB/GYN. AMPATH leverages the tripartite academic mission of clinical care, research, and education. The focus has been prevention of maternal mortality and prevention and treatment of gynecologic malignancies. AMPATH has instituted numerous hospital-based training and protocol initiatives and has started a two-year training program in gynecologic oncology in Kenya. The program’s success has led to its expansion to a similar two-year in-country MFM fellowship in 2018.

The Human Resources for Health (HRH) program in Rwanda resulted from the Ministry of Health’s (MOH) vision to strengthen and sustain a specialized health workforce. With the help of the Clinton Health Access Initiative, an academic consortium was formed by U.S. universities, medical centers, and schools of nursing, dentistry, and public health to develop a seven-year partnership for sustained collaboration and the establishment of new medical residency programs.²² Since 2012, the program has deployed nearly 100 U.S. faculty members to Rwanda annually to partner with local faculty in clinical and academic teaching. A total of 19 OB/GYNs have participated in this program, including 11 MFM specialists who have provided training in high-risk obstetric management, curriculum development, teaching, and testing.

Ultrasound is an essential diagnostic tool for OB/GYN. MFM specialists provide ongoing training in ultrasound diagnosis, and more than 90 percent of admitted patients at the partnership sites receive an ultrasound in the triage unit. Furthermore, the number of OB/GYN residents has increased by 45 percent in Rwanda, and quality improvement measures, such as guidelines development and maternal mortality conferences, have been initiated.²³ The partnerships facilitate research capacity, clinical teaching, and the development of Rwandan specialists to address the specialized health care workforce shortage.

Professional society partnerships

After completion of residency training, physicians need ongoing medical education and access to professional associations to maintain their knowledge base and provide quality care, sustain the specialty, and inform policy development. Unlike high-income countries (HICs) where these institutions and their infrastructure exist, many LMICs have yet to create their own national societies, or have young and nascent programs.

The effort to build workforce capacity is best achieved starting at the education level, then continuing through participation in lifelong learning opportunities. Certification programs lead to the creation of an objectively assessed professional status, which is critical for public confidence. Ongoing maintenance of certification allows for peer learning and participation in continuing education while in practice. The content of the training must be informed by the local context, academic curriculum, and professional associations and defined by best clinical evidence.

A process for certification of specialists in OB/GYN is in development in Ethiopia. In 2005, a new health care strategic plan was created to increase the number of trained medical physicians annually from 120 to 3,000, and the national government increased the number of OB/GYN residency programs from three to 12. The Ethiopian Society of Obstetricians and Gynecologists (ESOG) was well-suited to define the quality of medical training and standards for providers. Together with consultation from the American College of Obstetricians and Gynecologists (ACOG) and with endorsement from the MOH, ESOG launched a national harmonized residency curriculum in July 2017. The project has ambitious goals to expand collaboration between universities in the areas of education, research, and service, not only focusing on technical capabilities and quality assurance, but also on leadership, social accountability, and advocacy. The curriculum development resulted from the ESOG-ACOG partnership, a supportive government, and collaboration between experts and residency program directors. This model has been successful, and other national associations are considering replicating it.

Similarly, the Federation of Central American Associations and Societies of Obstetrics and Gynecology (FECASOG) and ACOG partnered in 2003 to strengthen residency training in Central America. The Comité de Acreditatión FECASOG-ACOG (CAFA) created a residency accreditation committee and an in-service examination for residents and a certification exam for graduates, allowing them to become fellows. ACOG fellows assisted the programs seeking accreditation, facilitating and mentoring local leaders to institutionalize regular quality assurance measures. Residency programs received feedback and accreditation. An annual examination process was developed for administration to OB/GYNs in six countries across Central America. CAFA examinees receive a detailed report on their performance relative to peers nationally and internationally, and CAFA members get an in-depth review and track performance at the individual, program, and national level over time.

Professional societies have great potential to play a significant role in promoting national policies, establishing national standards, developing quality assurance and outcome measures, and monitoring health care indicators. Professional associations are well-positioned to influence national policy and advocate for prioritization of improved health services and strengthening of surgical systems.²⁴ The ability of professional societies to assume this leadership role relies on their overall organizational capacity, their ability to identify gaps and solutions, and the ongoing development of a vibrant professional cadre. OB/GYN societies have recognized the need for comprehensive education that includes nontechnical skills. Leveraging the experience of mature OB/GYN associations, partnerships between established and newer professional societies promote credibility with policymakers and facilitate advocacy for comprehensive training, thereby expanding the role of physicians as drivers of change.

Quite often, physicians without training or experience find themselves in leadership roles that use these skill sets.²⁵ Training future specialists in the importance of nontechnical skills and teamwork among surgery, obstetrics, and anesthesia is key in the provision of safe surgery. Professional OB/GYN societies are able to assume a leadership role in the development of these skills for practicing physicians and those in training.

A substantial proportion of intraoperative adverse events are due to surgeons’ poor behavior and a lack of communication.²⁶ An example of an association actively enhancing communication skills is the Society of Obstetricians and Gynaecologists of Canada, which has long been involved in organizational capacity development through the International Federation of Gynecology and Obstetrics’ (FIGO) Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) program. The LOGIC program has developed a toolkit for professional associations to strengthen capacity or institute organizational change. The toolkit focuses on the areas of culture, organizational capacity, performance, external relations, and function.

OB/GYN societies have recognized the need for comprehensive education inclusive of advocacy. FIGO is the international coordinator of many global OB/GYN professional development projects. FIGO’s strategy to achieve SDG 5 on gender equality and empowerment of women involves an advocacy and education strategy to eliminate gender violence and ensure universal access to sexual and reproductive health. Advocacy actions prompt policymakers and regulators to further the recognition, promotion, and protection of girls’ and women’s human rights.

In addition, an essential component of women’s health advocacy is education of women to take ownership of their health, and education of professionals to integrate a human rights framework into projects and policies. As part of the training, regular workshops take place in several countries to raise awareness on providing human rights-based health care assistance to women. Furthermore, FIGO is in the process of publishing a handbook titled Women’s Health and Human Rights: Mapping Possible Contributions to the United Nations Selected Bodies for More Conductive Legislation, Regulations and Policies at Country Levels.

Standardization of surgical methods is essential for comparison of surgical outcomes and meta-analysis.²⁷ To address the need for evidence-based and standardized procedures, FIGO initiated the All-African Surgical Database project focusing on C-section, hysterectomy, and basic endoscopy. FIGO partnered with the New European Surgical Academy (NESA) and the International Society for Gynecologic Endoscopy to standardize and transfer evidence-based surgical knowledge to LMICs. The Université Cheikh Anta Diop, Dakar, Senegal, provides the platform for training, which includes lectures, workshops, and live operations. Furthermore, NESA and the Institute of Numerical Mathematics in Russia have partnered to establish a standardization of surgical methods with a detailed collection of surgical steps that allow for comparison between different surgeons and institutions.²⁸ The All-African Surgical Database project is the first of this type, and its model can be applied to different disciplines and localities with high potential to measure and improve surgical outcomes worldwide.

Other professional clinical and certifying organizations have been critical in expanding clinical and research expertise across the globe. The Royal College of Obstetricians provides extensive clinical and certification support, as outlined in its strategy document.²⁹ The Association of Professors in Gynecology and Obstetrics, through its global health committee, contributes faculty development resources, scholarships, and educational materials for the international OB/GYN community.³⁰ The Council on Resident Education in Obstetrics and Gynecology offers scholarships for the residency director program “school,”³¹ whereas the Society for Maternal and Fetal Medicine has created capacity-building fellowships through its global health committee, which seeks to improve outcomes for pregnant women in resource-limited areas of the world.³² The International Urogynecological Association has extended its mission to assist in training OB/GYNs and others in pelvic surgery and fistula repair.³³

Bringing obstetrical, anesthetic, and surgical capacity together

Efforts to reduce maternal and neonatal mortality have traditionally been a central part of the global health agenda as reflected by the MDG and SDG frameworks. Consequently, most LMICs have integrated initiatives to reduce maternal mortality into core elements of national strategic health plans. These programs have succeeded to the extent to which emergency care, capacity building of community health workers and midwives, and decentralization of services to increase facility-based deliveries can be effective. However, universal access to comprehensive, modern obstetrics and essential and emergency surgery by qualified specialists and anesthesia is still lacking. The LCoGS proposed a framework to assist countries in creating national surgical, obstetrical, and anesthetic plans (NSOAP) which, when implemented, would comprehensively address the need for universal, safe, and affordable surgery, anesthesia, and obstetrical services.³ The NSOAP originally set forth five domains for improvement of access and quality: service delivery, infrastructure, workforce, information management, and financing.3 A sixth domain, governance, has subsequently been recommended (see Figure 2). Leveraging the success around programs to reduce maternal and neonatal mortality, to expand obstetric, anesthesia, and surgical capacity is key to improving health outcomes.

Figure 2. NSOAP’s six domains of surgical systems development

Monitoring and evaluation through a common set of health indicators, with a consistent method of data collection is another key area of collaboration between the maternal health and the surgical communities. One LCoGS indicator focuses on tracking surgical volume, with a target of 5,000 surgical procedures per 100,000 population by 2030.³ Data on C-section volumes are widely collected, and these reporting systems could be expanded to report more broadly on other surgical procedures.

Another indicator of a strong surgical system is tracking of perioperative mortality.³ Countries have been reporting maternal mortality ratio for several years, and, as a result, many have started systems for quality improvement review around mortality cases. These review and reporting systems could go beyond obstetrics and expand to cover perioperative mortality from all surgical procedures. By leveraging existing structures, surgery and anesthesia can leapfrog many years of slow and costly institutional reform by learning from the advances achieved by the maternal health community.

Another key area of synergy between NSOAP and maternal health planning is the sharing of infrastructure and workforce resources. Most maternal health plans dedicate resources to decentralization of comprehensive emergency obstetric and newborn care (CEMONC) services to ensure the provision of C-sections at the district- or health-center level. This endeavor will require significant investment in functional and well-equipped operating theaters, as well as qualified personnel. For example, Tanzania’s national health strategy includes upgrading all district hospitals and 50 percent of the health centers to provide CEMONC. This move has resulted in significant upgrading or construction of operating rooms to provide C-sections. The incremental infrastructure required to convert a CEMONC-ready facility to one that provides all other emergency and essential surgical procedures expected at the district level is minimal. The expansion of surgical services should be tied to expansion in the workforce of qualified anesthesia and surgery providers.

Zambia has been a leader in NSOAP. Facing a workforce shortage, weak infrastructure, and poor referral systems that resulted in high mortality, morbidity, and financial catastrophe for patients led the MOH to prioritize access to surgery as an essential component of universal health care. In May 2017, the Zambian MOH drafted, budgeted, and signed the world’s first NSOAP to be integrated into Zambia’s National Health Strategic Plan.³⁴ By coordinating and leveraging existing momentum around maternal and neonatal health, surgery and anesthesia can accelerate progress in implementing NSOAP, with the overarching goal of decreasing the global burden of disease preventable with timely accessible surgery.

Conclusion

Improving health for all requires expansion of public health interventions to include obstetrics, surgery, and anesthesia. Consequently, a professional class of surgeons, OB/GYNs, and anesthesiologists will need to define and maintain quality standards, provide leadership and supervision, and promote growth of their medical fields. To achieve these outcomes, strong university and hospital-based training programs must exist in every country. In many LMICs, the ability to train, certify, and maintain the programs, institutions, and infrastructure that define surgical professions is weak and cannot be initiated again without significant inputs from experienced academic and professional society partners. Leaders in OB/GYN, surgery, and anesthesia who participate in functioning departments and supportive policy environments have a unique opportunity to share their expertise for replication in LMICs.

Established departments anywhere in the world can initiate a process for mutually beneficial partnerships to strengthen research, service, and education. Success in these partnerships has been demonstrated by OB/GYN in Ghana, Ethiopia, and Kenya, among other locations, and serves as a template for any specialty to work in global health. Creating the appropriate context for academic partnerships is a critical first step in sharing expertise across the world. A long-term capacity-building context also is critical. When authentic partnerships are created, the goals, barriers, and opportunities must be clearly defined.¹² The examples described previously did not include short-term clinical interventions, surgical camps, or one-week training workshops. The sustainably successful interventions are those that lead to benefits for faculty and students on both sides. In this context, efforts to improve research, education, and service can all occur within the overall goal of long-term capacity building, professional and leadership development, and measurably improved clinical outcomes.

As the number of professionals increases, certification and ongoing continuing medical education are critical components that must be strengthened or, in many cases, created for each country. Professional associations ensure their members meet high professional and ethical standards while promoting collegiality, mentoring, and lifelong learning. Creating professional association partnerships in surgery, anesthesia, and OB/GYN to achieve this goal must be initiated in tandem with academic partnerships. By creating partnerships between strong, longstanding professional associations in HICs with nascent societies in LMICs, the sustainable infrastructure for creating quality, consistent, and properly staffed surgical, obstetrical, and anesthesia services can be developed.

This article discusses only some of the initiatives the global OB/GYN community has led to build long-term and sustainable capacity around the world (see Table 1). By developing residency programs, strengthening professional societies, and creating certification programs, the field of OB/GYN is growing and mentoring leaders in research, clinical care, training, and policy development. The lessons learned from these endeavors can be applied to all surgical specialties and anesthesia. Furthermore, the opportunity to leverage ongoing national efforts in maternal health with NSOAP is compelling. As public health interventions are expanded to include global surgery, anesthesia, and modern, comprehensive obstetrics and gynecology, these disciplines must support each other and partner to achieve the SDGs and the global goal of strengthening universal health coverage.

Table 1. Key Lessons learned in OB/GYN to build global capacity

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