Scaling Preservice Training in Comprehensive Contraception and Abortion Care and Research across Ethiopia

Content

Reviewed and Harmonized Curricula

The curriculum review focused on ensuring that the FP/CAC components were competency-based. Competency-based education (CBE) prioritizes clear learning outcomes, and the methods of teaching and assessment are developed in alignment with these outcomes. To assure CBE, core competencies need to be defined.

One of the first activities UM-CIRHT undertook was the collection of all the medical school curricula, followed by a thorough revision of the FP/CAC areas to standardize, strengthen, and clarify competencies and learning objectives. This was accomplished as a group, with representatives from each partner school participating in the harmonization, revision, and integration of the medical school curriculum. Representatives from the FMOH’s human resources directorate also joined the discussion.

Faculty Curriculum Training

The midwifery curriculum review took a different approach. One midwifery faculty leader shared, “Midwives mainly focus on attending deliveries as well as giving immediate newborn care for the babies. If there were more of them in every health facility, in addition to delivery work, they could counsel and advise on family planning services. With UM-CIRHT’s assistance, we can share experiences and skills, creating benchmarks and best practices. I think that will help us motivate students and allow them to bring innovative ideas [for] bridging the gaps in health care that we may find.”

For the midwifery curriculum, the FMOH already had a standard curriculum that included FP/CAC. The baseline assessment revealed gaps in the awareness and delivery of those FP/CAC competencies, and how the schools chose to implement these topics varied significantly. To address this, the project used an approach similar to that used with the medical schools, focusing on revision of the syllabi and course materials.

When the UM-CIRHT project started, only three of the partner schools had active OBGYN residency programs: Addis Ababa University, Jimma University, and the University of Gondar. During the course of the project, UM-CIRHT supported five other partner schools in formulating their OBGYN residency curricula, meaning only one partner school did not have an OBGYN residency program by the end of the five-year project.

Created Course Syllabi

Once the curriculum was revised to address the gaps that had been identified, UM-CIRHT brought faculty from each partner school together through central workshops to develop course syllabi for both FP and CAC. These syllabi became the core reference documents used across the schools to ensure standardization. Figure 5 shows the FP/CAC educational sessions for each program (OBGYN, midwifery, MD) as defined by its course syllabus.

Figure 5.

FP/CAC Sessions for Partner Schools as Defined in the Course Syllabi

Developed New Learning Materials through a Faculty “Boot Camp”

The next step was to address the identified gap of access to adequate supporting educational materials. UM-CIRHT decided to use videos, a flexible and cost-effective medium for educating large numbers of students that also supports self-learning. Videos also enable faculty with the means to implement new and innovative ways of teaching, like using a flipped-classroom model. In order to provide materials relevant to the local context, a small group offaculty participated in an intensive workshop, or “boot camp,” in November 2016 to produce their own video lectures; UM-CIRHT invited OBGYN faculty from each of the partner medical schools to the three-day event. Faculty came prepared with draft lecture slides, which went through a rapid peer review and then were recorded on video. The boot camp covered the concept of the flipped classroom, as well as principles of e-learning and instructional design, cognitive processes in multimedia learning, editorial and visual style guides, and production of engaging slide presentations and audio and video materials. During the boot camp, video lectures were created for different topics: short-acting methods of contraception, intrauterine devices (IUDs), contraceptive implants, postpartum family planning (PPFP), permanent and emergency methods of contraception, counseling, and CAC.

Boot camp attendees were able to develop skills in e-learning resource production, thereby enabling the continuation of locally produced multimedia resources. After postproduction editing, all resources developed at the boot camp were distributed to students at all partner schools and posted publicly on the UM-CIRHT website.

Curated Existing Supplemental Learning Materials

“Boot Camp” Presentation Preparation

Faculty and students requested paper and electronic resources to support the syllabi. Hard copies of textbooks were purchased and distributed to each school. Electronic resources were collected in partnership with library and information technology specialists, who searched for materials on various reproductive health topics. Materials collected included electronic midwifery textbooks from an in-country partner as well as Open Michigan at U-M and other collections of open educational resources or freely available materials. In total, over 2,000 materials were organized into six collections and distributed to the schools. As internet connectivity can be unreliable, UM-CIRHT supported each school in setting up a platform that enabled students to access electronic resources without internet access. The same materials were also posted on a public website maintained at U-M.

Delivery

Built Capacity and Awareness for Competency-Based Education

The various capacity-building workshops and trainings were intended for faculty who teach undergraduate medical students to acquaint them with the revised OBGYN curriculum and prepare them to use the teaching and assessment methods included in the curriculum. Similar workshops were provided for midwifery faculty to enhance FP/CAC teaching.

Overall, the goal was for faculty participants to be able to:

• understand the principles of CBE
• revise course syllabi
• examine effective ways of lecturing
• discuss the variety of teaching methods that can be employed in clinical training
• demonstrate clinical skills teaching in a simulated setting
• develop good exam items for knowledge assessment
• assess skills, particularly using objective structured clinical examination (OSCE)
• apply the new medical eligibility criteria for family planning
• apply new recommendations in abortion care delivery
• demonstrate insertion of postpartum IUDs

Introduced Simulation-Based Training

The project also focused on the role of simulation-based training in advancing skills in the provision of contraception and pregnancy termination. UM-CIRHT exposed faculty and the school leadership to a multitude of trainings in teaching clinical skills, including delivery of contraception and pregnancy termination, using simulation; such instruction had been limited at most medical schools in Ethiopia before this. While skills laboratory teaching was indicated in the original curricula, in reality, the quality and frequency with which they were utilized were low to nonexistent in some schools. There were multiple reasons for this, such as lack of availability of space, equipment, and time in the course schedule, as well as a need for technical skill support for faculty. UM-CIRHT trained faculty in the rationale for simulation-based teaching and in how to integrate it into the curriculum, use simulators to teach skills, and give feedback and assess student practice. UM-CIRHT supported the setup and renovation of simulation labs, as well as the training of simulation lab technicians to better facilitate skills teaching using equipment such as mannequins. Learning guides were also adapted to include skills in delivery of contraception and pregnancy termination, and standards were developed for effective clinical skills teaching, including tools for faculty self-assessment.

Integrated Interactive Teaching Methods

Many of the faculty had never been trained in effective teaching skills, which is important to ensure information is presented in a manner conducive to learning. The UM-CIRHT education team therefore invested time in training faculty in teaching skills such as writing and facilitating case studies as well as those used in a clinical setting. Prior to the intervention, most classes were structured as didactic presentations, which is less engaging than other methods and does not accommodate multiple learning styles. In addition to the simulation-based training, other methods introduced included case-based learning and the flipped-classroom model. After participating in the training sessions, each school received at least two follow-up visits from the education team to monitor the translation of training into practice.

Simulation Lab Training at Addis Ababa University and Hawassa University

Introduced Peer-Assisted Learning

Peer-assisted learning (PAL) is a form of academic support in which students mentor other students. The student mentors are trained in facilitation, coaching techniques, and general mentoring principles and meet regularly with mentees for study support sessions. The PAL scheme benefits students struggling with certain class content as well as the mentors by reinforcing course material and developing learning and creative skills. Mentors are undergraduate volunteers who have strong academic records and good communication skills. The education team introduced a pilot for PAL as a part of curriculum implementation at Addis Ababa University.

Workshop on Improving Clinical Skills Teaching at Debre Tabor University

The Case of Bahir Dar University

The OBGYN chair of Bahir Dar University highlighted the changes brought about by UM-CIRHT’s partnership in teaching FP/CAC skills. In a presentation at the International Conference on Family Planning in November 2018, he recounted that the concept of simulation-based training was nascent in Ethiopian medical schools and that before the project there was no simulation center at his medical school. As a result of this project, the leadership at Bahir Dar dedicated space for a simulation center, renovating and equipping it with necessary FP/CAC simulators:

Assessment

Standardized Student Logbooks

As part of the effort to inculcate hands-on training in FP/CAC, the education team encouraged the use of standardized logbooks across the partner schools. For medical and midwifery students, they collaborated with the FMOH; for OBGYN residents, they worked with the Ethiopian Society of Obstetrics and Gynecology (ESOG). Students used their logbooks to record procedures they observed and/or performed during their FP clinical rotations. The logbooks were used for skills teaching, formed the basis of trainees’ progressive assessments for FP/CAC, and were duly signed by supervising residents and/or attending physicians.

Integrated New Learner Assessment Methods

Aligning assessment methods with teaching objectives is a main component of CBE. The education team conducted multiple training sessions on appropriate assessment methods and tools and how to develop and apply the methods, including context-dependent multiple-choice examination and OSCE. OSCE testing is performance based and allows for the standardized assessment of a wide range of clinical skills. The education team members presented material on student assessment and worked with faculty to set up written and OSCE exams in real time. More than 75% of the faculty were subsequently trained in student assessment, and eight out of nine medical schools and six out of eight midwifery schools successfully introduced OSCE as an assessment method.

Assessed the Current FP/CAC Service Capacity

At the outset, the teaching hospitals affiliated with each partner school had different levels of service provision due to constraints on physical capacity, provider competence, or simple gaps in attention. Most hospitals offered FP services, but they were dispersed throughout the OBGYN wards as part of general service provisions. This meant the client population was not always aware of the availability of the services.

A team from UM-CIRHT worked with each school to provide a baseline assessment of the types of services offered and the facilities to support those services. Their first area of inquiry was determining whether there was available space for waiting, counseling, and procedures, as well as signage that clearly identified the availability of FP/CAC. They also considered basic sanitation needs like having a clean water supply, handwashing facilities, and toilets.

They also assessed the services themselves. This included looking at patient flow and medical records. The needs the team considered ran across the spectrum of FP: all temporary and permanent methods of contraception as well as first- and second-trimester abortions, including medical and surgical abortions. Their analysis also considered the waiting time for clients seeking a safe abortion in the first or second trimester.

The team examined staffing for specific FP services and which staff provided them. They looked at the respective roles of residents, interns, nurses, midwives, OBGYN faculty, and other permanent staff for FP/CAC. Among their questions were the following: What were the length and content of students’ rotations through the clinics and procedures? How were those rotations logged and supervised? More broadly, the assessment looked at how services were being offered as a part of antenatal care, postpartum care, and general health care for women and girls.

Once the assessment was completed, the gaps were noted and a work plan was established jointly by representatives from the partner school and UM-CIRHT. This was used to promote changes such as the renovation of the physical environment, training to fill knowledge and practice gaps, and the introduction of new processes to monitor progress.

Michu Clinics, Clockwise from Top Left: Mekelle University, Addis Ababa University, Hawassa University, Haramaya University, and Bahir Dar University

Addressed Stigma of Abortion through VCAT Training

Facilities and technical skills were not the only barriers to women accessing safe abortion and family planning care. Like many other countries, providers had to contend with the stress and stigma associated with the provision of these services, which some considered controversial, affecting their attitudes. VCAT workshops were conducted for providers (and in some cases, every worker who came into contact with patients, including guards and cleaning staff). These workshops ensured that providers had a thorough knowledge of their rights and responsibilities as health workers but also asked participants to think critically about their own values and prejudices regarding abortion care.

VCAT Training

Promoted Ethical and Legal Aspects of Safe Abortion

After facilitating multiple VCAT workshops for various partner schools, the UM-CIRHT service team was unsatisfied with the overall response to the presentation of the material, which seemed to only have had a small effect on changing attitudes toward safe abortion.

They decided to shift the perspective of the content to ethics while keeping the overall aims of encouraging compassionate, patient-centered care and emphasizing reproductive justice. The revised presentation delved into providers’ responsibilities to patients and society in general as advocates of policies that further the agenda of providing quality, evidence-based care to promote healthy lives for women.

Promoted Patient Feedback and Education

For certain communications-related work, UM-CIRHT contracted with an outside vendor to understand the patient experience in the Michu clinics. The process began with handing out patient satisfaction surveys in the clinics to get feedback on what parts of the client experience were positive and what could be improved. The next steps were physical improvements, like developing recognizable branding and accessibility as well as redesigning clinical interiors and staff uniforms to be brighter and more pleasant. UM-CIRHT also contracted with another company to produce short educational videos in Amharic about implants and IUDs to be played in the waiting rooms of the Michu clinics.

Stimulated Quality Improvement Committees and Projects

Quality improvement (QI) activities were deemed necessary to sustain developments in resident and student training and to continually stress aspects of service delivery, including patient satisfaction and adherence to contraception. The service team worked with each partner school to create QI committees, interdisciplinary groups of health care workers in FP/CAC that included OBGYN faculty, residents, midwives, and nurses. The QI committee at each partner school conducted a comprehensive baseline audit developed by UM-CIRHT to identify gaps in FP/CAC service quality. The audit consisted of 300 questions on process, patient care, outcome indicators, and other factors. The same audit was used at each location so monitoring would be consistent across sites. While each partner school audit produced different findings, there were some similarities across the schools: lack of availability of safe first-trimester abortion and PPFP services, long wait times for second-trimester abortion services, small or obscure FP clinic locations, and a lack of formal rotation in FP clinics for trainees.

Once the gaps were identified, the service team organized and facilitated on-site workshops for each partner QI committee to review the baseline audit findings, prioritize gap areas, set goals, and develop intervention plans for QI project implementation. Some of the QI projects addressed in-service provider training in FP/CAC, assigning residents and interns to FP/CAC services, creating policy guidelines and standards of service, and renovating existing building space to establish an FP/CAC outpatient clinic. Using the PDCA (plan, do, check, act) cycle framework, the QI committees tested and assessed their interventions by adhering to data-collection routines, reviewing the collected data at bimonthly committee meetings, and working with the service team during regular supportive UM-CIRHT supervision visits.

Seminars and trainings focused on specific clinical issues as well as on patient-centered care with attention to counseling, communication, and patient satisfaction. Creating basic management tools like documentation practices and supply-chain management were also a part of the QI effort. QI committees at each site were responsible for implementing tools, identifying gaps in service provision, and creating QI projects to address those gaps.

Michu Clinic at Hawassa University with New Uniforms and Signage

The Case of Adama Hospital Medical College

Each partner school experienced tangible results specific to its own context. In the case of Adama Hospital Medical College (AHMC), the Michu clinic was established with routine rotations for residents, interns, nurses, and midwives. The hospital dedicated nine beds specifically for second-trimester abortion, and PPFP saw a dramatic increase, rising to 30% uptake for women in the immediate postpartum phase. This was all accomplished despite significant challenges, including systemic problems like infrastructure issues, which influenced FP/CAC provision, and difficulties with money allocation when trying to distribute project funds, leading to delays in activities. Additional challenges faced at AHMC were a consistent shortage of staff, compounded by high staff turnover rates, which impacted service availability. Initial attempts at in-service training were stymied by per-diem and compensation issues.

Lessons learned from the QI experience at AHMC underscore the benefits of institutional QI projects, which can improve infrastructure and access to services, as well as the quality of care provided. This in turn can increase the number of clients, which increases opportunities for preservice training exposure. One of the most important factors that helped AHMC achieve its success was the institutional and facility ownership of the project. A UM-CIRHT employee commented, “The bold action of the college management, especially the provost, to hand over their offices to establish the Michu clinic in the hospital demonstrated an unprecedented commitment. This significantly minimized the prevailing space shortage for provision of RH services.” Not only did the staff and departments working in FP/CAC value the initiative, but the heads of the college and hospital did as well, which had a positive effect on access to these services. The process was another factor that led to AHMC’s positive outcomes—by applying an evidence-based, participatory approach to QI, it was possible to increase service access and quality in a relatively short time span. Looking ahead, continued ownership and on-site support on all levels will be crucial to ensure the sustainability of these outcomes.

Renovation and Use of Adama’s Michu Clinic

Conducted Baseline Assessment of Research Needs

The research program began in early 2015 with a preliminary needs assessment of the then eight partner medical schools in Ethiopia. The baseline assessment revealed that OBGYN faculty lacked both protected time for research and dedicated research funding and had only limited knowledge and skills in conducting research. The faculty identified these as major factors contributing to the dearth of research activity and culture.

Built a Network of Research Advisors

The research endeavor required creating a group of experienced research investigators who would be able to provide training, coaching, and peer feedback to faculty investigators at the partner schools. This included the members of the in-country and Michigan-based research team for UM-CIRHT, as well as others from their professional networks in Ethiopia and Michigan. The in-country advisors were able to easily travel to the partner schools to support research training. This in-country team was initially just the research director, who developed a scope of work and a road map for the implementation of the research program with the partner schools based on the findings of the baseline assessment. The team grew to include two research coordinators who provided on-site supportive supervision to the research teams at the partner schools during various stages of the research life cycle. The research coordinators facilitated the day-to-day work of the research teams at partner schools through the following activities:

• coordinating a series of on-site research methodology workshops taught by identified expert trainers within the partner schools, in-country, or through UM-CIRHT contacts
• providing periodic on-site supportive supervision for research project implementation
• serving as liaisons with other members of the UM-CIRHT research team
• advising on the budgets of the pilot research grants
• facilitating transfers of approved funds for the pilot research grants

Facilitated Inspirational Talks by Local Successful Researchers

UM-CIRHT invited faculty at each respective school with a track record of conducting and publishing scholarly work in peer-reviewed journals to speak to junior faculty. These busy clinicians with established research careers spoke candidly to the faculty and delivered a series of talks on site in a workshop format. The inspirational talks were aimed at reinvigorating research, demystifying research conduct, and sharing practical tips, including time-management skills. Anecdotally, these talks have inspired other faculty who until then had only been peripherally exposed to research.

Awarded Pilot Research Grants to Local Faculty Investigators

In June 2015, UM-CIRHT launched a pilot research grant program that was open to all OBGYN faculty at the partner schools. In February 2017, a second round of pilot research grants was opened to the midwifery faculty at the partner schools. Both followed an iterative, transparent process to award competitive pilot grants based on clearly stipulated selection criteria with scientific and public health merit. Teams had to be multidisciplinary, involving coinvestigators from other clinical departments or sciences. During the selection process, principal investigators (PIs) incorporated input from seasoned investigators across medical, midwifery, and public health schools and the FMOH. Once selected, UM-CIRHT paired the PIs with mentors from U-M who were experienced research investigators. These research projects were used as examples in hands-on activities throughout the faculty research workshops.

Research Training at the University of Gondar

Facilitated Research Training and Coaching throughout the Research Life Cycle

UM-CIRHT organized a series of research workshops to inspire a positive research culture and strengthen the capacity of local faculty. The workshops followed the full life cycle of a research project (see figure 6) with the aim of equipping junior faculty with the skills necessary to lead such a project from the initial selection of a research question through to the publication of the results in a scientific journal. All faculty in OBGYN and midwifery were able to attend, not just those faculties selected for the pilot research grants.

Milestones in the Research Life Cycle

Step 1. Frame the Research Question

At each site, experienced researchers led hands-on workshops in framing appropriate research questions. Through didactics and interaction sessions, participants discussed the importance of a well-defined research question(s) before moving to the next phases of conduct. Faculty—and, in some cases, residents too—formed teams and critiqued the merits of research questions through a priori–defined criteria. Specifically, trainers emphasized the FINER (feasible, interesting, novel, ethical, relevant) criteria of judging the merits of good research questions with adaptation to include that of the National Institutes of Health (NIH) for research grants (significance, approach, innovation). These exercises helped faculty develop and submit research questions of interest for potential funding and laid the groundwork for the selection process.

Figure 6.

Research Milestones to Build a Cadre of Independent Investigators at Partner Schools

Step 2. Develop the Research Protocol

The objective of the research protocol workshop was to enable investigators to turn their research question into fully formed research proposals based on their specific aims. By the end of the workshop, faculty had developed draft proposal documents that had the majorelements ofresearch protocols, including research methods and data-analysis plans. As in the other research workshops, these sessions lasted four to five days and were highly interactive, structured with the workshop leader(s) functioning as facilitators. Participation was open to all faculty, including those who may not have had their research topics selected. Feedback from faculty, coinvestigators, and other research team members confirmed that the sessions had been valuable and, more important, useful.

Following the workshop, the research teams were given approximately one month to further revise and refine their research protocols. They were expected to interact with their team members, adapt their protocols, and seek advice on their research design and data-analysis plans with local biostatistics experts in their respective schools of public health. They also worked on their proposed budget plans.

Once those revisions were made, local defense sessions were held at each of the partner schools with the objective of strengthening the proposals to make them more competitive. Local public health or epidemiology faculty led the sessions and provided rankings against a set of preformed criteria, as well as giving constructive feedback on methodology. Each presentation lasted 20 minutes. Site coordinators facilitated the defenses with support from the UM-CIRHT research team. Scoring at local defense sessions determined which ones proceeded to the national research protocol defense. OBGYN and midwifery each had their own local and national defenses.

For the national defense, research proposals were presented over two days. The judges were experts in reproductive health and/or had methodological or statistical expertise and were selected from the faculty of universities across the country and experts from the FMOH Department of Maternal, Newborn, and Child Health. The judges scored each of the presentations using set criteria and also provided feedback on the protocols. One stakeholder from the FMOH commented, “If there is a policy intent ofthe research, engaging the ministry in selection of topics can focus it more on monitoring and generating evidence that can be applied nationally.” The FMOH representatives provided a perspective to align the selected projects with topics of national interest and relevance. In fact, the FMOH input directly inspired the creation of two of the research projects.

The average scores from all the judges were summed up to rank the research projects. After the defense, the strongest projects were selected for pilot grant support from UM-CIRHT. The PIs were expected to revise the protocols based on input from the judges. The UM-CIRHT research team was in regular contact with the PIs via phone, email, and in-person meetings to ensure that the feedback was incorporated into their proposals. In parallel with these revisions, the research team evaluated the budget proposals of each of the selected projects against their justifications.

Step 3. Secure Ethical Review Approval

The PIs submitted their revised protocols to their respective institutional review boards (IRB) for ethical approval. This was an essential step to ensure adherence to human-subject research guidelines, and no funding was released without such ethical clearance.

Step 4. Design the Survey Instrument

Almost all the research projects selected for pilot grant support involved primary data collection (with a few retrospective chart reviews) and as such needed support through the development of research instruments. Even if the proposals submitted initially had some data-capturing elements, they may not have been well developed.

The survey instrument workshop helped the teams refine their tools. While this was an iterative process, the two- to three-day workshop led by local public health experts helped inculcate fundamental tool-development principles and practical hands-on skills in each of the teams. Quantitative and qualitative research tools were covered during these sessions, since some teams had both methods included in their projects. For two of the multicenter studies, besides the local workshop and individual mentors’ input, the forum at the Program on Women’s Healthcare Effectiveness Research (PWHER) group within the U-M OBGYN department provided substantial feedback on the survey instruments, as well as focus group and in-depth interview guides. These revised tools were used to help collect the primary data in an analyzable format. Once survey instruments were fully developed, teams converted them into appropriate data- collecting formats and translated the documents into local languages. While most used paper for collecting their data, a few teams had developed electronic data-capturing tools and were able to collect their data directly on tablets.

Data Collection in a Village near Mekelle

Step 5. Collect the Data

Research teams recruited data collectors and trained them on the projects and data-collection procedures. Recruitment and deployment of data collectors varied across the teams and schools. The UM-CIRHT research team and site coordinators served in supporting roles when teams came upon issues, such as difficulties determining benchmark payment rates for data collectors and identifying research coordinators.

Step 6. Manage and Analyze Data

Once the teams had reached their target sample size, they completed workshops in data management and analysis taught by statisticians versed in analytic frameworks—preferably public health experts and biostatisticians whenever possible. The workshops ran for three to five days, the duration dependent on the time the research team members were able to dedicate and the complexity of the analyses.

The objective of these workshops was to help teams clean up data and create analytic data files so they could run appropriate statistical analyses on their own. The workshops covered various types of data-analysis methods and when to use them, as well as commonly used statistical packages and quantitative-analysis software. By the end of the workshop, teams were each expected to have clean analytical data sets, an updated data-analysis plan, and preliminary inputs for the results section of their respective manuscripts.

Step 7. Prepare Abstracts

Authors created abstracts to summarize the research questions, methods, and resulting findings. The abstracts were later adapted to be proposals for research conferences or journal opportunities, depending on the scope.

UM-CIRHT identified relevant scientific conferences and encouraged PIs to prepare the abstracts and submit their scholarly work for presentation, creating a platform for interaction with global leaders in the field. With a priori–set criteria, faculty and residents were able to present their work in the form of oral and/or poster presentations at various national and international conferences in reproductive health.

Step 8. Develop Manuscripts

Research teams were encouraged to draft manuscripts structured according to a target journal they selected. Although the PIs were responsible for overseeing the manuscript drafting, all the coauthors were expected to intellectually contribute to the write-up in an iterative manner.

In many of the partner schools, faculty reported limited experience with developing full-length biomedical journal articles to submit to peer-reviewed journals. To support the research writing, UM-CIRHT partnered with U-M Pre-Publication Support Services (PREPSS), which has extensive experience supporting manuscript writing and publishing for authors from numerous low- and middle-income countries. This support included a four-day intensive hands-on writing workshop for all OBGYN PIs. PIs submitted their draft manuscripts prior to the on-site workshop to help gauge the training pace and common pitfalls that the authors were likely to encounter. By the end of the workshop, participants were expected to have a more refined manuscript and receive and respond to feedback from peer reviewers. As a follow-up to the workshop, PREPSS provided personalized manuscript development support to the PIs. The support included one-on-one consultations for peer-review and copyediting support.

Scientific Writing Workshop

Step 9. Submit to Target Journal

The PREPSS support included guidance on selecting a target journal and tailoring the manuscript to specific journal requirements, as well as templates for letters for corresponding with journal editors.

Step 10. Publish in Journal

As part of the research process, the UM-CIRHT team, PREPSS, and mentors stressed to PIs that the journal article process is often iterative—that the target journal may reject the paper and investigators will need to find alternative outlets. When a journal article is accepted from a journal, there are multiple rounds of feedback with the editor and reviewers for revisions to content and layout. PIs were coached through this process up to the point of final publication.

The Case of Hawassa University

The research capacity–building efforts paid dividends early on, as evidenced by the excitement of faculty who were motivated to carry out further research and consider the physician-scientist track. An OBGYN faculty member at Hawassa University commented about the impact of this research support:

Journal Article Published by Research Investigator at Hawassa University

Journal article cover page used under a Creative Commons Attribution 4.0 International License.

This faculty member was the first PI to publish his work in a peer-reviewed journal.[8] After that accomplishment, this investigator started a follow-up research project and applied for an internal grant for Hawassa University faculty.

Conducted Targeted Workshops for Education, Service, and Research Objectives

As mentioned in the earlier sections, each of the program areas included workshops and coaching for faculty. For the education program, these workshops focused on curriculum review and design, CBE, OSCE, simulation-based training, and exam blueprint preparation and item development. For the service program, topics included various short-acting, long-acting, and permanent methods of contraception; medical and surgical abortion for first- and second-trimester pregnancies; VCAT; ethical and legal aspects of abortion; client-centered counseling; and compassionate and respectful care. For the research program, workshop topics included information literacy, data analysis, and writing. A full list of topics is provided in figure 15.

Stimulated Leadership Coaching to Develop Institutional Change Agents

The culture change goals envisioned at the partner schools required strong change management. Almost all leaders at the helm of the OBGYN and midwifery and nursing departments agreed on the relevance of the project and their schools’ goals. However, the implementation required that the entire school’s leadership be brought on board and exposed to training on how to become a change agent. Core faculty at all levels of educational leadership from the partner schools received training and continuous remote mentoring. The leadership training included workshops and team and individualized coaching. UM-CIRHT partnered with an Ethiopian company to facilitate the process, which was intended to help faculty in leadership positions initiate and sustain change within their institution—and within themselves. Faculty were given tools to overcome institutional and individual resistance and introduce initiatives for improving academia overall. Workshop participants came up with project ideas that they committed to lead in their respective departments, including improving teaching, transforming the work climate, and setting standards for clinical service. Each partner school created four to five groups, each made up of several individuals.

Brokered Experience-Sharing Visits between Peer Institutions

Once embarking on these change-management goals in FP/CAC at their institutions, it was valuable for the partner school faculty to connect with peers who had completed similar projects at other institutions. Faculty completed experience-sharing visits for multidirectional knowledge exchange within and between countries. Faculty described these opportunities as “precious” for their own professional development. These visits included the following:

• a trip by the faculty champions to the University of British Columbia’s Women’s Hospital and Comprehensive Abortion and Reproductive Education (CARE) Program Women’s Health Centre
• a multischool educational workshop at Debre Tabor University that included 45 participants across the partner schools
• a visit focused on PPFP hosted by Adama Hospital Medical College for providers from Bahir Dar University and Mekelle University
• an attachment for OBGYN residents and midwifery students at University of Mekelle with affiliate hospitals

Contributed to Global Dialogue at Renowned RH Academic Conferences

The goal of the research program was to generate evidence to improve education, service, and knowledge about FP/CAC. In order to enhance that research, UM-CIRHT coached and supported faculty at national and international academic conferences. This included participating in renowned conferences focused on RH and in increasing RH imprint at other mainstream health conferences. Through its website, blog, and social media, UM-CIRHT promoted the partner schools’ presence at these events, which helped make the faculty work more visible. These conferences included the following:

• October 2015—21st World Congress of Gynecology and Obstetrics organized by the International Federation of Gynecology and Obstetrics (FIGO) in Vancouver, Canada
• January 2016—4th International Conference on Family Planning (ICFP) in Nusa Dua, Indonesia
• January 2016—3rd International Congress on Women’s Health and Unsafe Abortion (IWAC) in Bangkok, Thailand
• May 2016—4th global conference of Women Deliver in Copenhagen, Denmark
• November–December 2016—Africa Regional Conference on Abortion in Addis Ababa, Ethiopia
• March 2017—6th annual conference of Ethiopia Public Health Officers Association (PHOA-E) in Addis Ababa, Ethiopia
• April 2017—53rd Annual Medical Conference of the Ethiopian Medical Association (EMA) in Addis Ababa, Ethiopia
• April 2017—five-kilometer walk/run celebrating the theme “Family Planning for Prosperity” sponsored by the Ethiopian Medical Association (EMA) in Addis Ababa, Ethiopia
• May 2017—25th annual celebration of the Ethiopian Midwives Association (EMWA) in Addis Ababa, Ethiopia
• June 2017—31st congress of the International Confederation of Midwives (ICM) in Toronto, Canada
• March 2018—9th Annual Consortium of Universities for Global Health (CUGH) Conference in New York, US
• May 2018—26th International Day of the Midwife conference organized by the Ethiopian Midwives Association (EMWA) in Addis Ababa, Ethiopia
• October 2018—22nd World Congress of Gynecology and Obstetrics organized by the International Federation of Gynecology and Obstetrics (FIGO) in Rio de Janeiro, Brazil
• November 2018—5th International Conference on Family Planning (ICFP) in Kigali, Rwanda

Ethiopian colleagues attending the International Conference on Family Planning in Kigali, Rwanda, November 2018

Convened Video Conferences to Connect U-M Mentors with Partner School Faculty

Video conferencing was a useful interface for webinars, online meetings, and journal club group discussions with faculty and residents from the partner schools. Journal club topics included contraception, safe abortion, new developments in RH research and care, and evidence-based medicine (EBM). EBM involves the careful and systematic application of rules of evidence to a study to assess its validity, importance, and usefulness in clinical practice and decision-making. Prior to the webinar and journal club sessions, participants were assigned papers and specific sections to read and critique in advance. During the discussion, each presenter walked the participants through the selected paper and analyzed each aspect of the study in an interactive manner.

Journal Club, Started at the University of Michigan with Participants from Six Ethiopian Campuses

Standardized Data Collection

The M&E team developed templates to standardize data collection across all the partner schools. Templates were created for each program area and were originally developed as documents or spreadsheets, though they were later adapted into an online database.

In the area of education, data were gathered every six months. Indicators included the following:

• frequency of FP/CAC core syllabus use for OBGYN and midwifery
• number of teaching hours for didactics and simulation in FP/CAC
• number of hours and procedures in the Michu clinic
• learner outcomes in written, OSCE, and other assessments

Prior to graduation, students completed a pregraduation assessment that tested for competencies in FP/CAC services.

In the area of clinical services, data were collected monthly by the site coordinator. Custom data-collection forms were created to expand upon the national RH indicators already required by the FMOH on paper and through its electronic health management information system (HMIS). Indicators related to clinical services included the following:

• number of patients who had received FP/CAC services by which method
• number of deliveries
• PPFP uptake
• number of patients who received safe abortion or postabortion care
• postabortion family planning (PAFP) uptake

In the area of research, data were collected every two to three months. A short form was developed to track the status of each of the research projects. The template captured the progress in the research cycle, related funding, publications, and conferences.

The M&E team conducted periodic data audits to validate the data reported in the forms. For the service data, this included comparing the forms against the written service logbooks and electronic health record systems. In some cases, one-on-one follow-up with faculty was required for the research and education data.

Provided On-Site Quarterly Supervision

A representative from the M&E team made a quarterly site visit to each partner school. During the site visit, they met with the faculty champions, site coordinators, and other leaders to make sure the agreed-on activities were proceeding as planned, to acknowledge good practices, to identify challenges and discuss possible solutions, and to listen to feedback for improvement in coordination with UM-CIRHT and internal coordination within the partner school. In between visits, the M&E team did routine follow-up via email with the site coordinators at each of the partner schools.

Conducted Stakeholder Interviews

In October 2017, two members of UM-CIRHT conducted an assessment visit to the partner schools. Over a three-week visit, the team interviewed 95 individuals. The stakeholders approached for the final evaluation were leaders of the college or university in roles such as provost, dean, vice president, chief executive director (CED), chief academic and research director (CARD), and department head of OBGYN, nursing, or midwifery schools, as well as faculty in these departments who acted as former or current faculty champions for the project. Of those interviewed, 43% were in a leadership role and 57% in a faculty role. Of respondents, 72% (68 interviewees) were from medical school leadership or OBGYN departments and 28% (27 interviewees) from midwifery school leadership or faculty.