Behind the Research: Theresa Rager on Ghana's Successful OB/GYN Postgraduate Training Program

To get started, tell us about this unique program and why it was started in the first place.

In the late 1980s, Ghana faced one of the highest maternal mortality rates in the world, with estimates ranging from 500 to 700 maternal deaths per 100,000 live births. In stark contrast, the average maternal mortality rate in the United States at the time was less than 15 per 100,000 live births. In short, a Ghanaian mother was approximately 33 times more likely to die during childbirth than her U.S. counterpart. This challenge was exacerbated by a growing scarcity of OB/GYN specialists: Physicians who had gone abroad to pursue their training chose higher-paying positions in foreign countries due to the absence of recognized residency training programs in Ghana.

In 1986, the Ghana postgraduate Ob/Gyn training program began as a collaboration between health, medical education, and development stakeholders to address the obstetrician workforce gap in Ghana, including my co-author and CGHE member Dr. Tim Johnson. In 1989, the group launched an OB/GYN residency program on two campuses: the University of Ghana Medical School and the Kwame Nkrumah University of Science and Technology School of Medical Sciences. At its founding, the goal of this UM-Ghana ObGyn postgraduate training program was to build a cadre of ObGyns who could address the need for comprehensive obstetric care in Ghana. And, more than thirty years later, our data indicates that this program was wildly successful due in large part to the longstanding, bidirectional partnership between the Government of Ghana, a consortium of Ghanaian medical schools, and external supporting partners.  

As you analyzed interviews with program stakeholders, what narratives emerged that struck you as representative of the program’s success and its remaining challenges?

For me, the most exciting narrative that emerged from our interview data was that graduates were working to improve obstetric care at every level across the country. Our interviewers spoke with graduates who were clinicians, educators, mentors, researchers, or subspecialists and found they were all deeply passionate about strengthening the ObGyn healthcare workforce, increasing the obstetric and gynecologic capacity, and improving direct patient care in Ghana. Their responses indicated that graduates of the program who remain in academia are training the next generation of ObGyns—which exponentially increases the availability of ObGyn care in Ghana. Additionally, graduates of the program who pursue research and subspecialty training are bringing new technologies and skill sets to the country. We truly see the three pillars of academic medicine—clinical care, education, and research—sustained.

In the paper, you describe the program as a growth model, where participants are able to pursue advanced subspecialty training, potentially progressing from generalist OB/GYN knowledge to a wide range of sub-specialities including gynecologic oncology, reproductive endocrinology and infertility, family planning, among others. Tell us about why this kind of training matters to patients and health systems at large.

In any context, subspecialty training allows for individuals to develop advanced skills and expertise so they can focus their practice to managing complex conditions. While generalist OB/GYNs are able to provide a wide range of sexual and reproductive healthcare services to women across the lifespan, subspecialists are able to add depth to this comprehensive care. Subspecialty training allows physicians to develop specialized, advanced expertise to better treat more complex conditions such as gynecologic malignancies, infertility, high risk obstetric conditions, complex family planning, urogynecologic conditions, etc. By building these advanced training opportunities in Ghana, the national health system is able to better address the complex health needs of its people.

Several references are made to the importance of women mentors for women interviewees. What role did this approach have in the success of the program in retaining women OB/GYNs in Ghana?

Many of the women interviewees spoke to the importance of further recruiting and retaining women into the field. They expressed to us that, as women physicians, they were expected to manage professional and family lives seamlessly. Finding mentors among fellow physicians who had encountered similar challenges instilled in them the belief that pursuing this career path was indeed attainable. In doing so, they actively promoted greater educational opportunities for women and advanced gender equity within the field.

How has the program been received by leaders and stakeholders of the national health system in Ghana over the course of its 30 years?

This program is unique because representatives of the Government of Ghana, including the Ministry of Health, have been key drivers of the initiative since its founding. Unlike many other initiatives which are driven by external stakeholders from higher income countries, this program has been so successful because it was built with government buy-in and expertise from the very beginning.

Other countries have taken note of this initiative, with Ghanaian program leadership actively supporting the implementation of similar programs in peer health systems, such as those in Ethiopia, Cameroon, and Sierra Leone. An early advocate for this program was Dr. Tedros Adhanom Ghebreyesus, who, while serving as Ethiopia’s Minister of Health, successfully implemented the program in his own country. Dr. Tedros also collaborated with his Ghanaian counterparts to champion this approach across the African continent. Together, they have extended their support to other African nations, including Cameroon and Sierra Leone, as these countries explore the possibility of integrating the program into their respective healthcare systems.

One of the primary objectives of this paper was to shed light on this remarkable program in order to inspire other countries to consider adopting this educational model. By doing so, they can enhance the capabilities of their healthcare workforce and expand the scope of available obstetric care services.

Above all, our study provides data that reinforces what our Ghanaian collaborators are already aware of and actively pursuing: improving the accessibility of subspecialty care, expanding research opportunities, and further strengthening the academic medicine framework established by the postgraduate program.