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V. What Were the Pillars for the Success of the Program?

1. Competency-Based Curriculum Integration

The program of integration in pre-service training is modeled after the competency-based curriculum of the Ryan Residency Training Program in Abortion and Family Planning in the United States, with adjustments made to fit the Ethiopian context.

SPHMMC students practicing on a PPIUD (postpartum IUD) model

SPHMMC students practicing on a PPIUD (postpartum IUD) model

There is an emphasis on practical skills above and beyond theory-driven approaches that used to be conducted through didactic lectures. Traditionally, there was a dearth of hands-on experience, and the time allotted for family planning rarely exceeded one to two lecture hours throughout a student’s time in the medical school. Due to the lack of a rigorous training in skills acquisition, the previous graduates from medical schools in Ethiopia were less interested in and less confident about delivering the much-needed RH services. It was evident that these physicians were not very involved in family planning service provision in the communities that they were assigned to.

What Is the Approach?

With particular focus on competency-based training, the curriculum incorporates a blend of the following methods to ensure that trainees will have all the necessary skills to deliver a full suite of RH services:

  • Didactic lectures, seminars, and tutorials that give students the evidence and theoretical base for FP/CAC and include relevant epidemiology during Clinical I and II years (CI and CII)
  • Case-based scenarios that illustrate a particular facet of FP and/or CAC
  • Simulation-based training on models that encourages the acquisition of skills such as long-acting reversible contraception (LARC) methods (e.g., IUD, birth control implant) and surgical abortion (e.g., Manual Vacuum Aspiration [MVA]) in their CII year
  • Dedicated time (one week) for interns to spend in the family planning unit during their OBGYN attachment, providing FP/CAC services for clients under supervision
  • Periodic objective assessment of acquired skills by tallying procedures observed and/or performed into a log book that is duly signed by a supervising resident or faculty member
  • Training on the legal aspects of abortion and counseling using the national training manual
  • Training in leadership, advocacy, and values clarification to improve attitude and professionalism (particular focus is given to this training)
  • Students assessments where FP/CAC is given due emphasis and included in the theoretical and practical examination/assessments, with at least two stations dedicated for FP/CAC in CI and CII OSCE (Objective Structured Clinical Exam)

“Previously there may have been a one-hour lecture, and then [we] memorize the information that we blurt out in an exam, and then we forget it. With this program, we have additional training and hands-on practice.”

Dr. Ahmed Ibrahim, Graduate of SPHMMC

The OBGYN residency curriculum at SPHMMC was designed to incorporate family planning and abortion training from the development phase of the program, with a one-month family planning rotation required each year over the first three years of residency. Incorporating family planning—based training has made the residents remarkably competent in providing comprehensive RH services and carrying out their clinical services with admirable professionalism. Because of this approach, it was possible to ensure the presence of at least one resident in the family planning unit every month and thus had the added benefit of assuring quality care for clients and patients who come to the unit seeking services. Additionally, the residents serve as mentors for the interns and medical students that rotate through the family planning unit. “Service and training integration in family planning and comprehensive abortion care has changed the mindsets of faculty. As students expand their skills, the faculty have been able to learn more and realize the importance of their leadership in providing comprehensive care to women,” says Dr. Malede Birara, former chair of OBGYN at SPHMMC.

SPHMMC student being assessed on IUD insertion at an OSCE station

SPHMMC student being assessed on IUD insertion at an OSCE station

When SPHMMC was about to launch the implementation of this integrated curriculum, the first batch of students had already started their internship years. Given that the opportune time for this would be with soon-to-be graduates, a package with a modified approach comprising the following was given as an intervention in collaboration with Ipas Ethiopia:

  • Two-day, intensive hands-on training on LARC and abortion care at the beginning of their rotation in OBGYN, and
  • One-week placement in the family planning unit

Assessment of the outcome of such a training package was done through a review of the log books that tallied the number of procedures the trainees performed before their graduation and the results of a self-administered survey. The overwhelming majority (96%) of the graduates indicated that the training they received was excellent/good, all the graduating class had inserted implants, and 93% had removed them. Potentially owing to the low uptake of IUDs by women, two-thirds inserted IUDs during their internship years and a quarter performed IUD removals.[18][21]

Results of the assessment of procedures observed and/or performed before and after the first FP/CAC training

Results of the assessment of procedures observed and/or performed before and after the first FP/CAC training

Subsequent to the graduation of the first class, more medical students have passed through the training, with the training being integrated starting in their CI attachments with both didactic and hands-on training mentioned above, which continues to increase the skill base of the students. Students speak passionately about the invaluable experience and confidence they are gaining with the integrated curriculum, which emphasizes hands-on training and simulations. The students and residents also agree that the counseling skills built through this program are crucial and that these skills are making them better doctors.

The training is not limited to skill and knowledge acquisition but also incorporates a leadership and advocacy training that has been delivered by a local institution, the Center for African Leadership Studies (CALS), in addition to the values clarification session they receive through the program. Overall, the training has demonstrated a visible difference in the caliber of medical graduates of SPHMMC, with most of them taking on a variety of leadership roles and spearheading reform initiatives in the institutions they are assigned to all over the country. “If I get a phone call from a graduate of SPHMMC, 90% of the time it is about improving the health system,” says Dr. Keseteberhan Admasu, current minister of health of Ethiopia.

What Happened after Graduation?

Postdeployment refresher training on FP/CAC and leadership was given in Addis Ababa a year after the first group of graduates had been practicing in their respective health facilities. This was an excellent platform for graduates to learn from each other by sharing their experiences on both the successes and the challenges they were facing, and it was used as an opportunity to interview 35 of the first 38 graduates of SPHMMC. Of that first class, 60% (21/35) were providing both safe abortion and contraception services, with a total of 71.4% (25/35) of graduates providing long-acting reversible contraception (LARC) and/or safe abortion services, while 11.4% (4/35) were delivering long-term contraception without safe abortion services due to moral and/or religious dilemma. Of the 28.6% (10/35) that were not providing any of these services, the majority attributed lack of necessary supplies and equipment as the number one barrier to service provision, showing there is still work to be done to improve access to family planning nationwide. Other barriers to providing abortion services cited included unsupportive environment, fear of stigma, and a need to refresh skills. The second batch of St. Paul’s graduates has subsequently participated in family planning refresher workshop and leadership training before deployment to their respective health facilities.

Dr. Kasim Ibrahim, a 26-year-old general practitioner who was among the first graduates of SPHMMC in 2013, was assigned as a medical director soon after he started working at Assaita Hospital in the Afar region. Upon assuming his leadership position, Dr. Kasim made it his life’s mission to improve the health care delivered to the population the hospital serves, with particular focus on maternal and child health.

Dr. Kasim in the renovated abortion clinic at Assaita Hospital FP/CAC training

Dr. Kasim in the renovated abortion clinic at Assaita Hospital FP/CAC training

The Afar region is one of the four underdeveloped, emerging regions in Ethiopia where most of the health indicators are very poor, marked by a huge lack of human resources for health and infrastructure. By marshaling resources from within the region and from the federal Ministry of Health and other donor agencies, the young and energetic Dr. Kasim indicates that maternal health is “a critical focus point” for him. Some of the changes he has brought about include introducing family planning and abortion care services to the hospital and improving the knowledge and attitude in the community served. Midwives in his facility are also trained to counsel all postpartum women on family planning. On average, around 10—20 contraceptive implants are inserted every month in an area where these issues are very sensitive. Both medical abortion and MVA are being provided currently, which were not available before he took over.

The abortion care room at Assaita Hospital has been completely renovated and fitted with the necessary equipment to support the optimal delivery of services. Additionally, Dr. Kasim oversees the training of health care providers in FP/CAC in the three adjoining health centers.

Dr. Kasim proudly states, “The family planning and leadership trainings I had in my days at SPHMMC have enabled me to lead the reform in the remotely located and underresourced district hospital in an organized manner.” He has a deep commitment to care for every woman and child and says, “I won’t stop providing care as long as I am alive!”

“My passion to give women-centered care comes from the training I received as a medical student at SPHMMC, which has made me a confident professional and [one who can] even pass my knowledge and skills to providers in hospitals I am assigned in as well as to satellite health centers.” says Dr. Ayantu Tesfaye, also of the first batch of SPHMMC graduates. Dr. Ayantu is posted in Ambo Hospital in the Oromia region, the largest and most populous region in the nation, where she is providing a variety of reproductive health care services, including FP/CAC services, as a result of the program in integrated FP/CAC training at SPHMMC. Since her placement as a general practitioner, the hospital has seen a substantial growth in the use of long-acting reversible contraceptive (LARC) methods. A mean of 15%—17% of women who delivered at the hospital received IUDs, and 191 IUDs or implants were inserted over a period of six months, from July to December of 2014, which was a huge leap from the previous years’ data. “By providing family planning for a woman and preventing unintended pregnancies, my goal is to help [create] happy families. I am proud of serving my own people by choice.”

“Saving a mother is everything to her child, so saving a mother is like saving the world of the newborn. If the mother dies, the future of her child dies with it.”

Dr. Kasim Ibrahim, Graduate of SPHMMC

Dr. Ayantu also provides mentorship and supervision in FP/CAC and HIV treatment for the surrounding health centers. She led an outreach program in March 2015 in Shenen, one of the satellite health centers, during which 170 IUDs were inserted. In the other four health centers, after training the health professionals and carrying out health education for patients, the use of long-acting family planning methods compared to short-term family planning methods had increased substantially. “The changes I observe in these satellite facilities are my motivations to keep working there.” She presented her work as a physician and mentor for the satellite centers in increasing the uptake of LARC, on a preformed panel at the 2016 International Conference on Family Planning (ICFP) in Indonesia, which was lauded highly by the audience.

Dr. Ayantu teaching students at Ambo Hospital about IUDs

Dr. Ayantu teaching students at Ambo Hospital about IUDs

“Integration of family planning and abortion training into pre-service education is a feasible approach that sustainably improves the competency of medical students to provide those services,” said Dr. Delayehu Bekele, one of SPHMMC’s OBGYN faculty when he presented about the program at the 2016 ICFP in Indonesia.

The value of the partnership was not one sided. Supported by different programs at the U-M, medical students and residents as well as public health students from the U-M have been traveling to St. Paul’s to engage in different clinical and research activities, pair up with their counterpart students, and be mentored by faculty from SPHMMC and U-M. This helped them gain global health experience, honed their clinical and research skills, enhanced cultural competencies, and broadened their horizons through learning about the different health systems within developing countries like Ethiopia and exploring potential areas of meaningful engagement for their future careers.

2. Faculty Development Initiatives

“The training we acquired as interns of SPHMMC has enabled us to be competent doctors, to provide quality FP and CAC service and pass our knowledge and skills to hospitals we are assigned [to] as well as to satellite health centers.”

Dr. Ayantu Tesfaye, Graduate of SPHMMC

The SPHMMC OBGYN department had only two faculty members when the SPHMMC—U-M collaboration started (the department chair, Dr. Abdulfetah Abdulkadir, and Dr. Lia Tadesse who was working mainly as vice provost) and five when the OBGYN residency was launched in 2012. The strong partnership between U-M and SPHMMC, especially in the areas of faculty development and the potential for growth, has played an instrumental role in drawing many more faculty to SPHMMC. The presence of such committed faculty with the support of their U-M colleagues has been crucial to the successful implementation of the curriculum integration. The OBGYN department has markedly increased its capacity for the 2015—16 academic year, with 16 full-time faculty members training 63 residents, 70 interns, and 180 medical students in their clinical years, with a steep increase in the intake capacity from 7 residents in the first year (2012) to 31 residents admitted in September 2015. The 7 residents who began their training in 2012 graduated in July 2016 and became full-fledged OBGYNs, and they will continue as faculty at SPHMMC, further increasing their numbers. SPHMMC now has the highest number of OBGYNs of any public hospital in Ethiopia.

Cohort/YearGraduating InternsCurrent Residents
1st3830
2nd2514
3rd7412
4th657
Total20263

Since this program started, University of Michigan faculty have been traveling to Addis Ababa to train and support the teaching faculty at St. Paul’s to enhance their skills in delivering competency-based education in reproductive health. U-M OBGYN faculty including Dr. Senait Fisseha, Dr. Carrie Bell, Dr. Jason Bell, Dr. Diana Curran, Dr Beth Skinner, Dr. Suzie As-Sanie, Dr. Carolyn Johnston, Dr. John Randolph, Dr. Tariq Shah and many others have been able to transfer knowledge and skills to their counterparts at St. Paul’s and to their residents through hands-on advanced skills training in different areas, including ultrasounds, simulations in immediate postpartum IUDs (PPIUDs), surgical abortion, and laparoscopic tubal ligation. Experienced faculty, such as Dr. Patricia Mullan, have also traveled to SPHMMC to give workshops on medical education and pedagogy and thus enhancing the teaching skills of the faculty.

Total Number of Residents and Interns
SPHMMC OBGYN in 2016 by the Numbers
16 Faculty
63 Residents
70 Interns
180 Clinical Students

At the same time, St. Paul’s faculty have made several planned trips to the University of Michigan under observer status to learn, among other things, different clinical skills; the structure of educational programs for medical students, residents, and fellows; and the flow of patient-centered care services, research programs, and administration. Two senior residents from SPHMMC also had the opportunity to gain exposure to OBGYN practices and education in a developed-world setting during a four-week visit to the U-M. This visit broadened their perspectives on high-end obstetrics and gynecology care and supplemented their in-country training.

This has fostered a long-standing partnership between the two institutions, and there is now a very strong ongoing faculty exchange program between U-M and SPHMMC that continues to grow.

Laparoscopy skills training by U-M faculty member Dr. Skinner at SPHMMC, Addis Ababa

Laparoscopy skills training by U-M faculty member Dr. Skinner at SPHMMC, Addis Ababa

The leadership training given through this program was not limited to students; faculty also had the opportunity to participate in the training. With additional funding from American International Health Alliance’s (AIHA) Twinning Center, Dr. Balkachew Nigatu, SPHMMC’s OBGYN residency program director, received three sequential training courses for program directors through the American College of Obstetricians and Gynecologists (ACOG) in the United States and received certification as a residency director from the CREOG-ACOG (the Council on Resident Education in Obstetrics and Gynecology of the ACOG). This certification training is in addition to the consistent mentoring he receives from Dr. Diana Curran, the U-M OBGYN residency director. His training has not only improved SPHMMC’s OBGYN residency program, but as a master trainer, he is impacting the other residency programs at SPHMMC and will be leading a cascade of trainings for all OBGYN Residency Directors in the various medical schools in Ethiopia. His leadership in the program has helped cultivate a culture of learning, mentoring, and role modeling within the faculty. Dr. Thomas Mekuria, one of the first residents at SPHMMC, says, “You can talk to your [faculty] mentor at any time. You can go into the surgical theater and do procedures with them and also consult with them on any cases. That’s different from the traditional way of teaching in our country because it used to be very distant.”

Systematic and sustainable capacity building in research has also been one of the stalwarts of this program, whereby the research capacity of the faculty and residents has been enriched through periodic training by regularly visiting U-M faculty, who give workshops on research methodology and provide one-on-one mentoring. Dr. Vanessa Dalton, an OBGYN faculty member, together with Sarah Rominiski, a senior research associate, have been supporting and mentoring the residents in their research projects. The research support runs the whole gamut, from helping residents come up with research questions and carrying them through drafting a research protocol, to guiding them toward conducting the particular research projects and focusing on the identified core thematic areas. Of note, three out of the seven in the first batch of residents have selected FP/CAC research projects, and one of the residents has presented his work as a poster at the 2016 ICFP in Indonesia. Professor Richard Adanu, dean of the University of Ghana School of Public Health and editor of the International Journal of Obstetrics and Gynecology (IJOG), has also been conducting hands-on research workshops and mentorships, thus forging South—South collaboration for research capacity building. The impact has been demonstrated by the phenomenal research output, with five original articles authored or coauthored by SPHMMC OBGYN faculty published in peer-reviewed medical journals. All seven final-year residents have completed their studies and presented their work. “The research work of the graduating residents which I reviewed was very impressive, and a few of them can easily get their work published in an international journal,” says Prof. Richard Adanu.

“You can talk to your [faculty] mentor at any time. You can go into the surgical theater and do procedures with them and also consult with them on any cases. That’s different from the traditional way of teaching in our country because it used to be very distant.”

Dr. Thomas Mekuria, one of the first SPHMMC OBGYN residents

Faculty and residents at SPHMMC have had numerous opportunities to network with the OBGYN and family planning community nationally and globally. Several have presented their work in international conferences, which include the International Federation of Gynecology and Obstetrics (FIGO) and International Conference on Family Planning (ICFP).

Along with strengthening the residency and medical student training, the OBGYN department has recently launched a Reproductive Health Fellowship program. This is a two-year subspecialty fellowship program on advanced training in clinical practice, education, and research in family planning, abortion, and other aspects of reproductive health that aims to produce leaders and advocates in family planning and abortion. In addition, through the collaboration with U-M, the department has also commenced fellowships in maternal-fetal medicine, gynecologic oncology, and infertility.

Dr. Timothy Johnson, OBGYN professor and chair of U-M department of OBGYN, with SPHMMC OBGYN faculty (Drs. Balkachew, Mustefa, and Malede), Addis Ababa

Dr. Timothy Johnson, OBGYN professor and chair of U-M department of OBGYN, with SPHMMC OBGYN faculty (Drs. Balkachew, Mustefa, and Malede), Addis Ababa

The department, in collaboration with U-M faculty and the Ethiopian Society of OBGYNs (ESOG), is charged with organizing a Continuing Medical Education (CME) lecture series in family planning, safe abortion, and maternal health. These CME series are running almost every year and are well attended by OBGYNs and other RH providers from all over the country.

“The integrated curriculum at SPHMMC was not started with [an] external push. We were fortunate enough to have dedicated [though few at the beginning], passionate faculty who modeled appropriate behavior. This has helped in starting it right and ensuring continuity. Mind you, every faculty member was on board from the outset—that is the pillar for the success at SPHMMC, with the tremendous guidance of U-M faculty.”

Dr. Balkachew Nigatu, OBGYN faculty and residency director at SPHMMC

Building capabilities through developing open educational resources (OER) was another area supported by faculty and staff from the department of the learning health sciences (formerly the department of medical education) and information and communications technology [ICT] at the U-M. SPHMMC faculty and residents have created new, freely available OER designed specifically for their learners and have adapted some resources from previous OER developed by Ghanaian colleagues as well. Some of the materials produced include demonstrations on long-acting contraceptives like implants and IUDs. Setting up a learning resource room with computers, books, and online journals for OBGYN residents and medical students, and developing a robust network infrastructure with capabilities for video conferencing to facilitate remote teaching, was also supported by the program. “The technology collaboration which started with the creation and delivery of OER for OBGYN has grown to ensure that there is proper ICT infrastructure and digital tools for better training and patient care,” says Kathleen Omollo, who was leading this support from the U-M.

3. Service and Systems Improvement

Michu Clinic

In general, family planning and safe abortion services were traditionally considered primary care and so very little attention was given to those services in tertiary centers like SPHMMC. When this program started, the family planning unit was a very small room at the back of the outpatient clinic that was not properly catering to the needs of women.

OBGYN Learning Resource Room at SPHMMC

OBGYN Learning Resource Room at SPHMMC

With the goal of improving the quality and accessibility of family planning and abortion services at SPHMMC as part of the integrated training program and with the greater vision of making it a National Center of Excellence (CoE) in family planning and abortion training and service, the college leadership and the OBGYN department championed the development of a new RH center.

Inauguration of the Michu Clinic at SPHMMC

Inauguration of the Michu Clinic at SPHMMC

Thus a newly redesigned, woman-friendly reproductive health unit has been inaugurated at SPHMMC in early January 2016. This spacious center is named Michu Clinic; “Michu” is an Amharic word for “comfortable,” that also pays tribute to the partnership with the University of Michigan. The new clinic supports SPHMMC’s efforts to meet the nation’s growing family planning demands and reflects a commitment to improved access to quality care that puts patients first. With a visible and convenient location at the front of the SPHMMC campus, this center is providing a full-range of services in one place, including counseling, family planning procedures, and safe abortion. Senior OBGYN faculty are assigned in the clinic through rotations to lead, supervise, and teach the team of residents, interns, and nurses assigned there. This center is expected to increase the uptake of these services and pave the way to the realization of SPHMMC’s goal of becoming a Center of Excellence in reproductive health in Ethiopia and the region.

Through the program in partnership with U-M, SPHMMC has gone from being an institution that gave very limited services in family planning and safe abortion to providing comprehensive services including long-acting reversible contraception (LARC), interval IUDs and postpartum IUDs, birth control implants, and permanent sterilization to comprehensive abortion care, including second-trimester pregnancy termination services. The uptake of family planning and abortion services since the inception of the program has shown a marked rise.

The reception lobby of Michu Clinic at SPHMMC

The reception lobby of Michu Clinic at SPHMMC

Before the start of the program in 2012, second-trimester abortion services were not available at all, but after the program’s inception four years ago, 262 safe second-trimester terminations were provided over a one-year period (July 2014—July 2015), averaging 22 a month. IUD insertions more than tripled, with total contraceptive users rising to 2995 over the same one-year time frame and then to 5071 over the 18-month period spanning July 2014 to December 2015. Post-abortion family planning integration has doubled from 40% to 81%, and immediate postpartum family planning has grown from less than 1% at the initiation of the program to 21% during the past year.

Quality Improvement

When faculty from St. Paul’s were doing observerships at the University of Michigan, they were learning not only new clinical knowledge and skills but also approaches of building a better health system, and they were inspired to bring a number of changes back to St. Paul’s that did not require many resources. One of the biggest changes they made, which is now a hallmark of SPHMMC, is for OBGYN physician consultants to be on call, in-house, 24/7 as opposed to the previous policy of being “on call” to give advice mostly via telephone during off-hours and weekends and to only occasionally be called in when complications arose. This has brought a significant improvement to both the quality of care and the quality of training delivered.

ABORTION AND CONTRACEPTION SERVICES PROVIDED AT SPHMMC (2010–2016)
 PeriodNumber of Safe Abortions (SA)Number of Safe Second Trimester AbortionsPost Abortion Contraception Provided (%)Total LARC* Method Users
Baseline Period20100029%Data Not Available
Beginning of IntegrationJuly 2012–June 201329040%233
Building the ResourcesJuly 2013–June 201421310226%1028
July 2014–June 201531426281%1736
July 2015–June 201631415884%2588
*LARC: Long Acting Reversible Contraceptives (Including Implants and IUDs)

As part of its quality improvement (QI) initiatives, the OBGYN department has also put into practice a monthly family planning and abortion audit, which includes presentations and discussions that delve into the challenges of reproductive health service provision and accomplishments within the field, charting the way to better health service delivery.

TeamSTEPPS® training is an evidence-based set of tools aimed at optimizing patient outcomes by improving communication and teamwork skills among multidisciplinary teams of health care professionals. This training series was conducted by Dr. Sue Ann Bell, a faculty member from the nursing school at the U-M, for nurse and physician RH providers at SPHMMC, and it has improved the team approach in the care delivered. “The integration is likely to empower midlevel staff as well when they see family planning being part of the training, as they can see its importance,” says Dr. Feiruz Surur, chair of the OBGYN department at SPHMMC.

In addition, each OBGYN resident is expected to identify gaps in service delivery and plan and implement a QI miniproject to ameliorate the identified gap and improve quality of care. Accordingly, some of the QI miniprojects included preparing a family planning counseling checklist; guides to be used by antenatal care (ANC) and postnatal care (PNC) providers; preparing patient educational materials to be distributed by ANC and PNC providers, which included family planning information; and preparing a system to provide family planning commodities 24/7, just like emergency drugs. In addition to improving the quality of care, this process is expected to improve residents’ problem identification and solving skills, enabling them to become stellar future leaders.

4. Supportive College Leadership

One of the pillars of the success of this program is the supportive SPHMMC leadership, beginning with Provost Dr. Mesfin Araya and Vice Provosts Dr. Lia and Dr. Tola, who created an environment that enabled the department to flourish and provided all the necessary administrative support to further boost the OBGYN department’s growth in volume and quality and strengthened the partnership with U-M. This strong leadership in the beginning, and the visionary and bold leadership team that took over, led by Provost Dr. Zerihun, has directly impacted the success of the department by facilitating the recruitment of able OBGYN faculty from every corner of the country, reinforcing a culture of collegiality within the staff and faculty, and availing space and necessary equipment to expand reproductive health services within the premises of St. Paul’s Hospital.