Participants.

Both purposive and convenience sampling were used to recruit participants. Inclusion criteria included graduation from the Ob/Gyn postgraduate training program and membership and/or fellowship in the Ghana College of Physicians and Surgeons or the West African College of Surgeons since 1989. There were no exclusion criteria for this study. A roster of the 245 certified Ob/Gyn graduates with information about location, current practice setting, gender, and contact information was obtained from the Ghana College of Physicians and Surgeons and Ghana Medical Board. The roster was reviewed and information verified via department chairs or participants. Convenience sampling occurred at the university teaching hospitals in Accra and Kumasi, where many Ob/Gyns are employed or are completing fellowship training. Verbal announcements regarding study participation were made at daily morning meetings. Interested participants were scheduled for interviews on a first-come basis. To attain a more diverse sample population, purposive sampling was later utilized to recruit Ob/Gyns working outside of the teaching hospitals, including those working in non-academic settings, rural settings or other parts of the country, and recent graduates. These Ob/Gyns were contacted via information provided on the roster and other departmental resources. Through phone calls and emails, interviewees in district and private hospitals in various regions of Ghana were recruited. MK and YB then traveled to these hospitals to conduct in-person interviews. For both sampling methodologies, department chairs, administrative assistants, chief residents and other department employees assisted with participant recruitment.

Interviews.

Both Ghanaian and U.S. researchers (MK, YB, AS, TJ, FA) from the University of Michigan, Korle Bu Teaching Hospital, and Komfo Anokye Teaching Hospital together developed a 50-question interview guide for the purposes of a qualitative study evaluating the retention and experience of graduates [19]. Consensus for the interview guide was obtained by iterative review by the authors. If consensus was unable to be obtained, decisions were made by senior investigators FA and TJ. It was not pilot tested. The guide was centered on three topics: (1) motivations for retention, practice type and location (2) role of community, social, and economic factors in retention, and practice location consideration (3) how and why the in-country training programs shaped and strengthened obstetric capacity. Interview questions from topics 1 and 2 guided this study’s analysis of the previously-collected qualitative data and are provided in Table 1.

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Table 1. Interview questions pertaining to graduate retention and career development.

Selected questions from interview guide that contributed to this additional data analysis and model development.

https://doi.org/10.1371/journal.pgph.0000546.t001

A total of 48 in-depth, semi-structured interviews were conducted face-to-face at the hospitals by MK and YB between June 21—August 20, 2017. Participants were provided with an explanation of the purpose and goals of the study and informed that there was no incentive for participation. Then, verbal consent was obtained and audio recorded to conduct and record the interview for all participants. All interviews were conducted in English by 1 of 2 researchers and were audio recorded. The average interview length was 31 minutes. Repeat interviews were not conducted. Participants were recruited and interviewed from the graduate roster until data saturation was reached. Saturation was determined by MK and YB’s reflexive analysis during the interview process.

Analysis.

Data was analyzed using a grounded theory methodological approach. Audio recordings were transcribed verbatim, de-identified, reviewed, and imported into NVivo 12 by the MK and YB. Only the researchers had access to the transcripts and were not returned to participants for comments. Field notes were not used in this analysis. Each interview transcript was coded and analyzed by TR to examine factors contributing to graduate career development. A codebook was developed for data pertaining to the research questions. Patterns emerged from the coded data and were grouped according to specific aims. Patterns and groupings were reviewed by TR and FA until concurrence was reached. Based on groupings, themes and subthemes were derived from the data. Coded items were reviewed in the original transcripts to ensure contextual integrity.

Reflexivity.

Members of the research team maintained reflexivity throughout the study design, data collection, and analysis processes. Both Ghanaian and U.S. authors were critically involved in the study design. U.S. authors (TR, MK, YB, TJ, FA) maintained awareness of possible bias due to their prior assumptions and experience outside of Ghana. Both interviewers (MK and YB) were female, trained in conducting interviews through their graduate studies, and were completing public health and medical training at the time of the study. They are not Ghanaian and are not practicing Ob/Gyns. Participants were aware of the interviewers’ credentials. Interviewers had no prior relationship with the participants. MK and YB regularly met with Ghanaian and Ob/Gyn members of the research team throughout the data collection process to discuss themes, saturation, and contextual interpretation. Members of the research team were also mindful of potential desirability bias as interviewees were graduates of the Ob/Gyn postgraduate training program and interviewers served as representatives of the program. Authors most closely involved in data collection, transcription, coding, and analysis met closely with the wider research team to discuss emerging themes and codes thereby utilizing insights of those handling the data and those with a wider perspective and contextual insights.

Theme 1.1: Decision-making and management.

As graduates assume leadership roles on maternal care teams, they are exercising decision-making and management skills consistent with evidence-based, modern comprehensive obstetric care.

“Because you learn first of all decision making. It is very key. It’s not just doing procedures or operations. But decision making, to arrive to do or not to do a procedure for a patient.” [22051721]

“That places you in the cadre of being a leader. So it’s not something you read, it’s something you practice. So the way you coordinate your affairs, in saving a life and all that, makes you a leader.” [11140004]

Theme 1.2: Operational changes.

Additionally, many graduates have utilized their expertise and leadership to induce operational changes that improve care or address patient needs. These changes include projects such as updating clinical flow, creating specialty clinics, introducing new protocols, or reorganizing care teams.

“We have introduced other systems like the introduction of triage to obstetric practice that has also helped us reshape the process of care. We have also introduced an obstetrical emergency unit, which again did not exist before.” [12051913]

Theme 1.3: Teaching and mentorship.

The majority of interviewees described a passion for teaching and mentoring medical students, junior colleagues, and other health professionals. Through such efforts, many felt that they increased the skills and development of those around them to the benefit of both their colleagues and patients. Such teaching experiences take place in teaching institutions, with patients, and in the community through outreach programs.

“You also become a resource to train other people like the nurses and the midwives that work under you and other junior colleagues that you work with. You are able to transfer some of your skills and knowledge to them. So at the end of the day, you kind of replicate yourself and you make a lot more impact than you would as a [medical officer].” [12191504]

“You get to mentor people. You think strategically, so the whole department is under you, so you need to plan as to different ways, the personnel planning, the career development of your staff, because some of them may not, they want to develop their career, but they may not know how. So they may choose a course that may not be beneficial to them. So if you get to know or they come to you, then you’ll be able to guide them as to how to do it.” [12180111]

For women Ob/Gyns, mentoring opportunities were particularly important. Interviewees were passionate about mentoring young women to encourage their pursuit of a career in obstetrics and gynecology and to increase the female representation in the field.

“I became a role model for others to say that, "Yes, it is possible, it is doable." And so after me, we had four girls joining the OB-GYN program. Three of them have completed and the other one is yet to complete and there are other ladies who also want to. When they come and they see the way I go about it, they say, "Oh, then we can do it." I say, "Yes, you can do it. So come do it".” [12180111]

“right now in this department I have seven medical officers, and five of them are females. And they are all writing the exam to go to school. So I’m proud of that, because they all keep telling me that they are doing it because they’ve seen that I’ve been able to do it. So, it’s fulfilling.” [31081301]

Theme 1.4: Maternal care team collaboration.

When asked to describe their work with midwives, graduates praised their colleagues for their knowledge, skills, and shared collaborative practice. Obstetricians considered midwives essential members of the maternal care team and patient advocates.

“In obs and gynae we can’t do anything without our midwives…So there is no obstetric care without the midwife, and the midwives form an important part of that obstetric care team.” [12191504]

As midwives are often first line of contact, obstetricians rely on strong professional relationships and communication to coordinate care.

“Then they have our mobile phone numbers, as well, both within and without the hospital, so if there are issues, they just call you. "I have this case, what should I do?" "I have this case I want to refer" they refer them. It’s been a lot of collaboration in all that.” [12110210]

Additionally, obstetricians noted the vast knowledge and skills of midwives. Interviewees expressed immense respect and gratitude for midwives who taught them during their training.

“You should have a good relationship with them, very good, very, very good relationship with them because irrespective of where you are, some of them were midwives before you became a specialist. Some of them have seen a lot. You see. You will fine tune it, but even when you’re doing that it has to be respectfully you see, respect for them, they will respect you.” [22050324]

Theme 1.5: Knowledge-sharing.

As leaders and collaborators, graduates are seeking and disseminating knowledge within Ghana, across SSA, and around the world. Interviewees were refreshed by and encouraged to exchange ideas with colleagues, collaborate on cases, or interact with people from different disciplines and countries.

“You are here with other colleagues so sharing ideas because like no two cases are the same so sharing ideas, learning from others, others learning from you as well because eventually you stop working, but even before you stop working you should have handed over all the knowledge that you have.” [22050324]

Obstetricians explained that innovation and creativity were fostered through knowledge sharing. By seeing how other hospitals, countries, or regions conduct care, new ideas and protocols can be implemented.

“It’s good that we do the training and collaboration…because it helps us to see what is being done elsewhere. But I think everybody must come back and then it will help keep our mothers alive. Our mortalities are very high in this country, we need to reduce it.” [12200213]