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Evaluating Impact of a Residency Training Program Rural Rotation on Obstetric Care in Rural Southeast Nigeria | OMICS International
ISSN: 2376-127X
Journal of Pregnancy and Child Health
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Evaluating Impact of a Residency Training Program Rural Rotation on Obstetric Care in Rural Southeast Nigeria

Odidika Ugochukwu Joannes Umeora1-3*, Eghosa Lucky-Emumwen2, Paul Olisaemeka Ezeonu1,3 and
Azubike Kanario Onyebuchi1,3
1Department of Obstetrics &Gynaecology, Federal Teaching Hospital, Abakaliki, Nigeria
2St.Vincent hospital, Ndubia-Igbeagu, Izzi Ebonyi State, Nigeria
3Department of Obstetrics &Gynaecology, Ebonyi State University, Abakaliki, Nigeria
Corresponding Author : Odidika Ugochukwu Joannes Umeora
Department of Obstetrics & Gynaecology
Federal Teaching Hospital, Abakaliki, Nigeria
Tel: 234 8039558074
Received December 09, 2014; Accepted March 23, 2015; Published March 25, 2015
Citation: Joannes Umeora OU, Lucky-Emumwen E, Ezeonu PO, Onyebuchi AK (2015) Evaluating Impact of a Residency Training Program Rural Rotation on Obstetric Care in Rural Southeast Nigeria. J Preg Child Health 2:141. doi: 10.4172/2376-127X.1000141
Copyright: © 2015 Joannes Umeora OU, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Context: Obstetric practice in rural Nigeria might be hindered by inadequately equipped and staffed care facilities. Resident doctors can increase medical capacity in rural settings.

Objective: To evaluate the impact of resident doctors on rotational postings on service delivery, Caesarean section rates and maternal mortality in a mission hospital in rural Nigeria.

Methods: A before and after evaluation of health services and indices at St Vincent catholic Hospital, Ndubia. Resident doctors commenced rotation at the rural hospital in November 2013. Health care services between Nov 2012 and October 2013 were compared with same services between November 2013 and October 2014. Analysis was by epi info statistical software version 7.1.4 of 2014 (DCD Atlanta USA).

Results: twelve residents have undergone rotation at the hospital in 12 months. There was an attendant increase in uptake of services in the hospital. Complications were better managed and though there were more emergency caesarean deliveries undertaken, the overall Caesarean section rate dropped. A reduction in maternal mortality ratio to 444/100,000 live births was recorded.

Conclusion: Maternal health indices are improved upon by increased medical staff capacity in obstetric care. A nationwide scale up is advocated.

Residents; Mortality; Rural; Obstetrics; Complications
From all indications the maternal health targetof the Millennium development goals (MDGs) would not be achieved by Nigeria when 2015 ends in some months’ time. Maternal health indices remain poor in the country. This has not been for lack of Government policies but effective implementation and nationwide coverage seem to be lacking. A maternal mortality ratio of 545/100,000 live births in the country [1] depicts dysfunctionality in the health care system while singlehandedly contributing 14% to global maternal deaths is embarrassing [2].
In Nigeria, access to quality health care and utilization of existing facilities and services are poor. The skewed distribution of health care institutions and personnel in favour of urban areas sustain the inequity in health care delivery between urban and rural populations in the country where majority inhabit the rural areas. It means the hard to reach populations remain unreachable. Several studies out of Nigeria have also shown that the health seeking pattern of rural populace differ from their urban counterparts with poorer utilization of the health services and patronage of unorthodox health services [2-5].
The Nigeria Demographic and Health Survey clearly showed that on the average, only 38% of mothers have their deliveries supervised by skilled birth attendants, with women in the urban areas more likely to utilize services of skilled birth attendants than those in the rural areas [1]. The prevalence of traditional birth attendants, spiritualists, herbalists, charlatans providing unorthodox care within the rural communities as well as rife superstitious beliefs and myths within such communities, further hinder access to modern health care services [5]. Other barriers identified included cost, attitude of medical staff and perceived poor service quality and dearth of trained staff in the modern facilities in such rural settings [3,4].
Teaching Hospitals in Nigeria were primarily established to provide facilities for training of medical students and resident doctors, medical services and research. They serve as referral centers to primary and secondary health facilities within their catchment areas. There have been calls at different for a and by stakeholders that such teaching hospitals be granted oversight functions over the lower level health facilities within their localities. This if well planned, implemented and sustained may improve care at those settings and remove undue burden from the tertiary centers.
The Federal Teaching Hospital, Abakaliki (FETHA) recently developed and entered into partnership with some rural hospitals in Ebonyi State signing a memorandum of understanding to allow obstetrics and gynecology (Ob/Gyn) resident doctors rotate at intervals through such hospitals. This paper is conceived to evaluate the impact of this programme on the health care delivery in one of the rural hospitals.
Materials and Methods
Study background
The Igbo ethnic nationality is the predominant inhabitants of southeast Nigeria, others being the Yoruba, Hausa, fulani, Efik, ibibio nationalities amongst others. Ebonyi State is one of the five States in Southeast Nigeria and is the youngest having been created in 1996, from the predominantly rural areas of existing Enugu and Abia States. Abakaliki, the administrative capital of the state is about the only urban settlement in the state which also has one semi urban community. The rest are rural and majority of the population live here.
By the 2007 census figures in Nigeria, Ebonyi state has a population of over 2.7 million [6]. Majority of these engage in subsistent farming, petty trading and civil service as their occupation. Literacy level generally is low while poverty is prevalent among this population who are also predominantly Christians. Muslims, animists and traditional religionists are also found. Traditional superstitious beliefs and myths exist to explain certain disease conditions. Some obstetric complications are deemed to be amenable only to unorthodox medical intervention. Maternal health indices are poor.
The Federal Teaching Hospital Abakaliki (FETHA) was established in December 2011 following the merger between the defunct Federal medical center and Ebonyi State University Teaching Hospital. It is accredited by both the National postgraduate medical college of Nigeria and the West African Postgraduate College for residency training in different clinical specialties including Obstetrics and Gynaecology. The Obstetrics and Gynaecology department has over 80 residents at different levels of training. Resident doctors are currently required by one of the accrediting bodies to have experience in rural clinical settings. Hence FETHA in 2013 entered into a memorandum of understanding with the St. Vincent hospital, Ndubia, Ibague and other rural mission hospitals pursuant to that purpose.
St Vincent hospital, Ndubia (SVHN) is a Catholic mission hospital located in the rural area of Izzi local administrative unit of Ebonyi State, about 30 kilometers from Abakaliki with good access road. It offers primary, secondary, and occasionally tertiary level care service to the community and its environs. The Obstetric unit has 30 beds and is staffed by a specialist Obstetrician/Gynecologist and three general duty medical officers. Obstetric services (including primary Caesarean section, manual removal of placenta amongst others) are rendered on a routine basis by the medical officers, who could at any timecall in the Specialist for cases needing specialized or further care. The Specialist lived 30 minutes away from the centre. Occasionally such cases were referred to the tertiary care center about 35kilometers away.The annual delivery rate on the average is 1000. Antenatal clinic is rather very busy following the free maternal health services obtainable at the centre.
The memorandum of understanding between the two hospitals stipulates that FETHA sends two resident doctors (a senior registrar and a registrar) to SVHN on a two monthly rotation. This boosts the Obstetric staff capacity of SVHN while providing a setting for rural experience for the residents. The residents are resident in the hospital’s staff quarter and come directly under the supervision of the Specialist Obstetrician/Gynecologist. They are disposed to the labour and delivery ward, maternity ward and antenatal and gynecological clinics. The programme took off in November 2013. Before undertaking the rural posting, a registrar must have satisfactorily completed a threemonth rotation each in the labour ward and Gynecological emergency units in addition to having worked directly under a consultant as a member of the team for a minimum of three months also. Theseprepare the resident for clinical challenges he/she might face at the peripheral centers during the rotation a rural setting.
Study design
This is a descriptive analysis of before and after data collected from the SVHN from November 1st 2012 to October 2014. The interval between November 2012 and October 2013 was compared to the subsequent one year interval of November 2013 to October 2014. Records were pulled from the central records department as well as the antenatal clinic, labour ward and operating theatre. Items of interest included number of antenatal clients served, labour and deliveries attended, complications resolved, referrals made and surgeries performed by the obstetric staff. Also information on maternal mortality was collected and analyzed. The Health Research and Ethics committee of FETHA granted an expedited approval for the study. Analysis was by Epi info statistical package version 7.1.4. (CDC Atlanta, USA 2014) and presented in simple frequency tables.
So far six senior registrars and six registrars respectively have been posted to the rural mission hospital. Their impact has been felt mainly on three aspects: clinical service, policy and training.The greatest impact has been on clinical services to the rural communities. Table 1 shows the number of patients managed by obstetrics & gynecology residents in the in the interval November 2013 to October 2014 compared with the 12 months immediately preceding that interval when the Consultant was the only obstetrics/gynecology cadre staff available. The activities ranged from clinic consultation to emergency surgical operations. The emergency Caesarean section pattern is presented in Table 2.
Twelve elective caesarean sections were undertaken in the first period (2012-2013) as well as 109 emergency sections. This gave a Caesarean section rate of 16.5%. This figure fell to 12.4 percent in the subsequent year. Indications for elective Caesarean sections were mainly previous multiple Caesarean sections and malpresentation at term, these were same for both periods under comparison. Emergency Caesarean sections during the same period were mainly for cepahlo pelvic disproportion and obstructed labour. There were five maternal deaths giving a maternal mortality ratio of 444 per 100,000 live births between 2013 and 2014 compared with 546/100,000live births in the earlier year. Three of the maternal deaths followed ruptured uterus and one each from postpartum hemorrhage in aRhesus negative grand multiparaand ruptured ectopic gestation.
On their prompting, the hospital administration introduced weekly clinical reviews on Tuesdays where clinical cases of interest are presented to an audience comprising doctors, nurses and administrative staff are presented and discussed. They serve as clinical audit X-raying clinical and logistic challenges in management. Furthermore the obstetric theatre adjacent to the labour and delivery room is in the process of being remodeled and reactivated. They initiated the process.
On training, the residents undergo self hands-on training with little supervision from the specialist obstetrician/gynecologist. The senior registrars supervise the registrars and with them teach the general medical officers in the hospital. The medical officers have been instructed and taught minor emergency gynecological and obstetric surgeries including manual vacuum aspiration, marsupialization, laparotomy and partial salpingectomy for ectopic gestation as well as Caesarean section.
By far the most exciting data returned from this evaluation is the sharp decline in maternal death in the centre. Recording an MMR ratio of 444 per 100,000 live births in a rural setting is no mean feat by any standards down from 546/100,000 which is almost exact the National average of 545/100,000 [1] in the preceding year. This gain can be better conceptualized and appreciated when it is noted that less than a decade earlier, the centre recorded an MMR of 2659/100,000. Whereas many factors may be postulated to have been responsible for this positive decline in maternal deaths but the influence of the Government policy extending free maternal health services in 2007 cannot be over emphasized. A further gain was noted with the advent of Ob/Gyn residents into the setting as shown above. This singular achievement means that the rural mission hospital is in tune to achieving the Millennium development goal 4 relating to maternal death in a country which as a whole cannot lay such claim. This therefore calls for further critical evaluation of the processes and protocols at this mission hospital with a view to scaling up on a wider National basis. It must be noted that the resident doctors live within the hospital premises, sleep in in the hospital when on call and are available on a 24 hour basis. As such, complications are managed earlier and better by the residents than would have been the case where only general duty medical officers were available. Time is gained when such cases are promptly managed rather than inviting the Consultants as would have been the case with medical officers. The residents call in the Consultant only when the cases exceed their capabilities. It may also be argued that workers in a mission set up are bound and abide by the mission’s policy of compassion and empathy, and Godliness in dealing with individuals especially patients. However, a qualitative study may provide key information in this respect.
The impact of the residents in a year which culminated in the reduction in maternal death ratio is evident in the different aspects of clinical practice they were involved in. There was not just only an appreciable increase in number of patients accessing services at the hospital, but also a rise in the proportion seen by medical obstetric staff both in the clinic, labour rooms and theatre. Majority of complications attending labour was quickly evaluated and resolved. Before then, there might have been some delay in recognizing, assessing and managing such complications contributing to maternal deaths. Also evident was the reduction in Caesarean section rate from 16.5% before the programme to 12.4% when the resident doctors were on ground. The 16.5% rate was slightly above the WHO recommended rate of 10-15% for optimal outcome [7,8]. It means that most cases in the second part of the study were better triaged and actively managed to obviate unnecessary caesarean delivery. It is noted that before the intervention decision for Caesarean section was taken by the Consultant when available and by the senior medical officer most times. Among reasons given by some mothers in Ebonyi State for low uptake of maternal health services were perception of poor quality services in the hospitals and absence or inadequate medical staff available at all times. The resident doctors in this review seem to have breached these gaps resulting in increased patronage of the hospital and as such better maternal health indices as observed. The hospital delivery rate among booked women appreciated to 37.2% from 29.9% thus equating to the national average [9].
The weekly review also instituted serve as clinical audit, and is geared towards improved patients’ care by care providers. Clinical audit is an established process of quality improvement. It provides a platform for systematic assessment of practice and suggestions for improvements. During such reviews, good clinical practices are identified and encouraged, information flow and communication amongst staff is encouraged while problems are highlighted and solutions proffered [10]. This served to train the medical officers in the institution as well as the nurses and complimented the hands-on training of the medical officers.
Sub Saharan Africa bears a great burden of gynecologicaldiseases and obstetric complications [11]. These have resulted in poor maternal health indices, poor quality of life and decreased life expectancy. Life expectancy in Nigeria for females is currently 53.66 years [12]. The impact of Ob/Gyn residents in rural health care is evident in this review. An obvious limitation here was that this survey involved only one centre. Consequently we advocate for evaluation of other centers having similar rotations to provide more critical data for a National scale up. Furthermore, the there is also need to evaluate the experience garnered by these residents in terms of clinical management and surgical exposure from this same programme. In recent fora, accrediting postgraduate medical institutions and some authorities have voiced their concern on the dwindling exposure of surgical residents to hands on surgical experiences. This might provide a leeway out. As many as 53.9% of residents interviewed in a survey were not satisfied with their surgical exposure in training [13].
Resident doctors in Obstetrics and Gynaecology undergoing rural rotations in a mission hospital impact positively on maternal health indices in the rural community. A more in depth evaluation is advocated for possible nationwide scale up.



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