General characteristics of study participants
Overall, 240 obstetrics and gynecology residents from the twelve higher learning institutions and from different years of training responded to the questions sent out via Google Forms. Of the respondents, 85.8% were males and residents from all years of training are represented and the percentage residents included from each year of study are comparable (Table 1).. Nearly 75% of the respondents were from five institutions; namely, St. Paul’s Hospital Millennium Medical College, Hawassa University, Addis Abeba University (Tikur Anbesa Hospital), Gondar University and Jimma University. These institutions also enroll most of the residents in Ethiopia.
Eleven chief residents and eight Obstetrics and gynecology residency program directors were involved in the two the focus group discussion. Additional focus group was not required as there was repetition of ideas, perspectives during the two focus group discussions.
Immediate impact of COVID–19 on clinical service delivery and teaching learning
It is known that obstetrics and gynecology residents are involved routine clinical services in the respective training hospitals. Regarding their engagement in routine OPD services during COVID–19 pandemic, regular ANC and high risk clinics are “slightly” reduced in most cases; however the percent reduction in gynecology OPD and family planning services is much higher (Figure 1a).. Their involvement in emergency OPD activities remained unaffected during the study period. The level of involvement was not statistically significant by year of training as well (p>0.5) (data not shown). When we look at the family planning services, there was a “slight” to “severe” reduction in the residents’ involvement in both emergency and non-emergency contraception provision (Figure 1b)..
The obstetrics and gynecology residents’ engagement in routine labor and delivery (both spontaneous vaginal and cesarean deliveries) activities remained unaffected for the majority of the residents during the COVID–19 period and it was not statistically different by year of training (Table 2).
During April and May of the COVID–19 pandemic period; it was reported that there was a “slight” reduction in residents’ involvement in the diagnostic procedures and the pattern of involvement did not change by year of training. The reduction in their involvement in minor gynecologic procedures and gynecologic screening activities ranges from “slight” to “severe” (Table 3).. The reduction in the engagement on minor diagnostic and therapeutic procedures was not significantly different (p>0.05).
Engagement of the obstetrics and gynecology residents in emergency procedures remained unaffected. Majority of the residents in all years of training reported that gynecologic emergency service provision remained the same compared to the pre-COVID–19 period (Table 4).. However, their exposure to benign gynecologic conditions was reduced across the different years of training. Overall, the level of exposure to major benign gynecologic and oncologic surgeries reached to severe reduction to complete suppression for the majority of the residents without statistically significant difference among residents in different years of training.
The level of residents’ exposure (involvement) to the care of people experienced gender based violence and provision of comprehensive abortion care ranged from no change (“not affected at all”) to “slight” reduction” (Table 5).. However, near to 14% of them reported that they were not involved (“not relevant”) in the care of victims of gender-based violence. However, there was “severe reduction” to “complete suppression” in terms of exposure to infertility service provision for the majority of the obstetrics and gynecology residents in Ethiopia during the COVID–19 period.
On top of learning through service provision, the obstetrics and gynecology residents were expected to have other teaching learning activities and they were asked about the level of reduction in the specific teaching learning experiences. In general, there was “some” to “complete interruption” in the various teaching learning activities for the significant majority of the residents in all the training institutions. “Complete interruption” was reported in didactic lectures, demonstration of medical procedures and surgical techniques, management sessions and seminars and in teaching rounds in all the institutions by 67.1%, 59.2%, 71.3%, and 64.2% of residents respectively (Table 6)..
After COVID–19 was reported in Ethiopia, the immediate changes in the teaching hospitals included decrease over all case load (patients avoided coming to the hospital for fear of exposure) but at the same time the number of emergency case (both obstetric and gynecologic) increased as many of the district hospitals almost stopped providing services (many are designated as COVID–19 treatment centers). Moreover, the flow of labor and delivery cases either remained unaffected or increased in most instances in this period. Besides, institutions have experienced delayed presentation of laboring mothers with complications such as ruptured uterus, obstructed labor and eclampsia with a magnitude never seen same time before. The focus group participants expressed that home deliveries were increasing even if it is not supported by data.
"By the way, we experienced increased number of deliveries and emergency CS during the last months as the nearby health centers and one of other general hospital had interrupted services. The only nearby general hospital was designated as COVID–19 treatment center.” (CR7)
The number of antenatal and post-natal care case remained unaffected with the same reason of lack of services in other centers. As a result of increased number of cases, institutions offered prolonged appointment for low risk mothers or back referrals to other facilities providing the service.
Residents’ exposure to skill training was reduced as a result of the decrease in number of patient visits and cessation of service provision to benign conditions (cold cases) by the hospitals. Didactic teaching learning, morning sessions, seminars, case presentation, management session were interrupted for fear of exposure and to limit the spread of the virus within the institutions. Both minor and major gynecologic procedures such as laparoscopy, uro-gynecology were not performed during the COVID–19 period in many of the hospitals for fear of spreading the virus. The impacts of such measures were maximal for senior residents as they are expected to perform major procedures before graduation. Rotations at other departments and community services which were an essential element of the residency training were interrupted during this period which specifically has a bearing on specialized skill training for senior residents.
"OPD’s are closed; some procedures are not done especially; oncology, urogynecology surgeries are interrupted and similar procedures are not done whose impact is maximal on the final year ones (residents) as they need essential surgical skills in these areas. There is no plan up to now as to how to make up for the lost time for the final year residents” (CR2)
As part of the resident training, final year residents are expected to carry out an independent research which is hampered by the COVID–19 pandemic. Residents expressed difficulty of getting cases in the hospital to have interviews and conducting prospective studies is becoming unrealistic.
Alternative approaches adopted for teaching learning and clinical services
To avoid gathering of people in one room, many of the traditional teaching such as face-to-face discussions, seminars, lectures are avoided during this period. Hence, institutions should resort to new ways of continuing the teaching learning. Residents and program directors expressed the need to maximize the utilization of various technologies. Despite the interest to use various platforms, Zoom video conferencing and Telegram application are the commonly mentioned platforms used to hold discussions, make presentations, and conduct management sessions and exchange documents among residents. However, very few institutions use these platforms and there is a wife variation in the application. In some institutions, the senior faculty (consultants) send assignments via telegram which is found to be convenient as there is a possibility to share bigger files compared to others platforms.
“We use Zoom application to have a biweekly case presentation, weekly intern case presentation, and we just started management session today and it was a good experience; many were able to participate, slides can be shared easily. We are also using telegram group for all residents at different level to share articles to just continue the teaching learning aspect…” (CR9)
Other adaptive methods used include having more frequent morning sessions using smaller group of residents and seniors so that everyone has the chance to take part. Assigning some residents to various centers not far from the teaching hospital minimized overcrowding and disease transmission and as the same time increased changes of practicing during this period. Moreover, assigning smaller number of residents at a time on major operation days limit the exposure to the disease.
Some hospitals were considering admitting limited number of elective (cold) cases for the purpose of continuing the skill training especially for the final year students but in the end there was a need to have bigger number of elective operations in the form of a campaign to address the backlog. The recent (toward the end of April, 2020) reduction in the number of reported cases prompted this action according to some of the focus group participants. Making use of the gynecology wards which are less occupied for post-natal mothers also provided opportunities for more physical distancing.
"We decided limited elective surgeries to be performed to increase the skill exposure for residents- mainly for the teaching purpose starting from last week. We are also planning to continue the skill training for the final year residents by admitting more gynecologic patients…” (CR1)
Institutional readiness to fulfil their training mandate in times of COVID–19 pandemic
The COVID–19 pandemic has exposed the training hospitals capacity to balance between continuing the training of health professionals while minimizing the risk of being hotspots for the disease spread and transmission. The reality on the ground showed that the hospitals did not position themselves to address the above two at the same time. One of the program directors explained that many of the important requirements for the hospitals to be centers for resident training were not fulfilled. A month or so after the first case of COVID–19 is reported in Ethiopia, institutions lack guidance on how to continue the teaching learning especially on skill training aspect. One hundred three (42.4%) of the residents believe that the impact of COVID–19 on their training was “severe” (data not shown).
“We have witnessed that we could acquire sophisticated equipment and made institutional arrangements within a very short period of time in response to COVID–19 pandemic. If we had fulfilled the standards of our own hospitals to be teaching centers from the outset, many of such materials and arrangements would have been in place already….” (DP8)
Training on personal protection was provided to 44.9% of the residents, but the personal protection equipment (PPE) was availed for only 26.3% of them. Residents and other staff members in hospitals were provided with limited trainings on COVID–19 but the focus was mainly on infection prevention and basic skills in application of PPE and how to support on another in applying those PPEs. Not many institutions provided training in the care of mothers in labor and delivery in the context of COVID–19 pandemic. Tailored training was not provided for almost 80% percent of the residents in all the institutions.
The focus group participants also expressed concerns about measures taken to prevent exposure of health personnel to COVID–19 which were mostly inadequate. Among others, reducing the number of residents in morning meetings (only duty residents and seniors) and those assigned in the wards; working in shifts, conducting rounds away from the patient, avoiding more than one attendant for an admitted patient, reducing the number of clinicians in the wards at a given time, and availing more space in the wards for admitted patients were some of the measures taken. However, lack of personal protection equipment was a common problem expressed by almost all participants in all institution which made the other preventive measures futile.
“…If an infected (obstetric) case is comes to our hospital most of the residents are at risk of exposure due to the lack of PPE. Maternity, labor ward and ORs are connected and a single case of COVID–19 could infect many in the areas as they are brought to the wards straight from the ambulance…” (CR1)
On the other side, the institutions’ capacity to utilize the available technologies such as e-learning platforms, video conferencing to deliver lectures, conduct seminar presentation, management session and even virtual simulation was challenged by the poor internet connection or networking infrastructure as expressed by residents and program directors in many of the teaching hospitals.
Residents needed also to be provided psychological support in the process as many might have worries and confusions as to how to go about the next steps in their career as obstetricians and gynecologists if the required skills were not acquired during their training period and as the same time they are reluctant to accept the need to push back the training program.
"I wouldn’t agree in the pushing back of the program without testing the effectiveness of some adaptive measures we are thinking of doing. We don’t know when this (COVID–19) ends and I wouldn’t agree to push back the program for another one year if the situation stays like this for the next one year. We have to evaluate those measures before making the decision…” (CR5)