Human Capacity Development and Maternal Mortality Reduction: Distribution and Population Coverage of Obstetricians and Gynecologists in Nigeria BY Agboghoroma C.O., Gharoro E. P.

INTRODUCTION Changes with Human Resource for Health is major contributory factor to high MMR in Developing countries Obstetricians &Gynecologists (ObGyn) are the highest cadre of maternal health care providers. Their presence in adequate number in developed countries has contributed to improved maternal health care and reduction in maternal deaths. There is scarcity of information on the number and distribution of ObGyn practitioners in the country

OBJECTIVE To determine the number and the spread of ObGyn in Nigeria. To evaluate the spread and correlation of ObGyn with maternal mortality in Nigeria.

METHODOLOGY Data were collected between July 2012 and December 2013 as part of National survey by the Society of Gynecology and Obstetrics of Nigeria (SOGON) to create the database of ObGyn engaged in the health sector in Nigeria. Information extracted and analyzed were gender, qualifications, place of work, primary employer, subspecialty interest and type of practice.

RESULT - 1 There were a total of 968 ObGyn in the country. Given an estimated national population of 175,651,197 in 2013, the ratio of ObGyn to the population is I /181,458. One hundred and twenty two (12.6%) were females. Lagos State have the highest number of ObGyn, 179 (18.5%), while Jigawa and Yobe States have the lowest number, 1 (0.1%) each. The South West zone of the country have located 315 (32.5%) ObGyn compared to the North West zone 71 (7.3%).

RESULT -2 The majority of ObGyn were certified in the country, 818 (84.5%) by the WACS while, 319 (33%) by the NPMCN. Only a few, 142 (14.7%) trained in foreign countries. Majority of the ObGyn are engaged by the Federal Government 452 (46.7%), while the States governments engaged 277 (28.7%), private sector 229 (23.7%) and NGO’s 10 (1%). 455 (47%) had subspecialty interest but only 53 (5.5%) had undergone appropriate training and acquired subspecialty certification.

Geo-Political Zones and States / Federal Capital Territory Obstetricians and Gynecologists Estimated Population (2013) Ratio of ObGyn to Population MaleFemaleTotal (%) South West Zone (32.5%)34,732,9961 in 110,263 Lagos (18.5%)11,401,7651 in 63,697 Osun32335(3.6%)4,274,8571 in 122,138 Ogun34034(3.5%)4,725,9071 in 138,997 Oyo32436(3.7%)7,080,5301 in 196,681 Ekiti14014(1.4%)2,980,3301 in 212,880 Ondo16117(1.8%)4,269,6071 in 251,153 South East Zone (16.9%)20,113,2061 in 122,641 Enugu47552(5.4%)4,031,4581 in 77,528 Ebonyi25227(2.8%)2,648,3141 in 98,085 Abia27229(3.0%)3,437,3351 in 118,528 Anambra37037(3.8%)5,082,4391 in 137,363 Imo18119(2.0%)4,913,6601 in 250,614 South South Zone (19.9%)26,229,4961 in 135,904 Edo47653(5.5%)3,906,0381 in 73,699 Delta37239(4.0%)5,144,9601 in 131,922 Rivers39847(4.9%)6,595,6581 in 140,333 Bayelsa14014(1.4%)2,088,1541 in 149,154 Cross-River20222(2.3%)3,544,1191 in 161,096 Akwa-Ibom17118(1.9%)4,950,5671 in 275,031 North Central Zone (18.6%)26,147,8541 in 145,266 Federal Capital Territory (9.6%)2,696,4021 in 29,631 Plateau21425(2.6%)3,873,6201 in 154,945 Kwara10717(1.8%)2,918,0841 in 171,652 Nasarawa11011(1.1%)2,306,2091 in 209,655 Kogi12113(1.3%)4,088,4611 in 314,497 Benue13215(1.5%)5,247,6231 in 349,841 Niger628(0.8%)5,017,4551 in 627,182 North East Zone39645(4.6%)23,825,6691 in 529,459 Borno14418(1.9%)5,291,9171 in 293,995 Gombe707(0.7%)2,958,8321 in 422,690 Taraba505(0.5%)2,811,2961 in 562,259 Bauchi9110(1.0%)5,903,3871 in 590,339 Adamawa303(0.3%)3,894,4431 in 1,298,148 Yobe112(0.2%)2,965,7921 in 1,482,896 North West Zone551671(7.3%)44,601,9761 in 628,197 Kaduna181028(2.9%)7,542,0931 in 269,360 Sokoto10111(1.1%)4,567,9101 in 415,264 Zamfara606(0.6%)4,102,1021 in 683,684 Kano13417(1.8%)11,844,2981 in 696,723 Kebbi213(0.3%)4,045,7441 in 1,348,581 Katsina505(0.5%)7,157,2861 in 1,431,457 Jigawa101(0.1%)5,342,5431 in 5,342,543 Total846(87.4%)122(12.6%)968(100%)175,651,1971 in 181,458

Qualifications Number(Percentag e) Specialization Certificate -FWACS818(84.5%) -FMCOG319(33.9%) -MRCOG/FRCOG, FACOGandother Foreign Certificates 142(14.7) Sub-specialization Certificate 53(5.5%) Management Training Certificate (including MA, MBA, MPA) 25(2.6%) Other Postgraduate Certificate (including MPH, M.Sc, Ph.D) 104(10.7%) Table 2: Qualifications of Obstetricians and Gynecologists (Obgyn) in Nigeria

Discussion -1 In the 1990s Nigeria and many developing countries suffered “brain drain” occasioned by movement of many specialists in the health sector to developed and richer countries. This trend is gradually being reversed [6,7].The finding of 968 ObGynin the country, with an average national coverage of 1 in 181,458 population in this report is similar to the national coverage of 1 in 173,200 population reported from Ghana in 2007 [12].This is an improvement over the national coverage of 1 in 407,000 population documented for Nigeria in 2007.

DISCUSSION-2 The increase in the number of ObGyn in Nigeria can be attributed to many factors which include increase in the number of specialist being produced annually by the West African College of Surgeons and the National Postgraduate Medical College. The increase in remuneration for health workers in Nigeria has also contributed in attracting and retaining health professionals in the country. The reported high coverage of ObGynin the Ghanaian health care system was also attributed to the impact of local postgraduate medical training programand improvement in the country’s economy

DISCUSSION-3 Though, the number of ObGyn in Nigeria can be said to be appreciable when compared to some developing nations, its distribution across the country is skewed against some states and geopolitical zones. Even within a state the cities and towns are disproportionately better served compared to the rural areas. Inequity in distribution of health facilities, personnel and services in most developing countries affects access to health care, contributing to maternal and perinatal mortality.

Discussion - 4 Though, the number of ObGyn in Nigeria can be said to be appreciable when compared to some developing nations, its distribution across the country is skewed against some states and geopolitical zones. Even within a state the cities and towns are disproportionately better served compared to the rural areas. Inequity in distribution of health facilities, personnel and services in most developing countries affects access to health care, contributing to maternal and perinatal mortality. The quality of care rendered in a facility is likely to be better where there is an ObGyn and this has the potential to attract patronage from the community

DISCUSSION -5 While many factors may contribute to maternal deaths, reports on maternal mortality from Nigeria shows that the level of maternal mortality ratio across the country closely mirrors the distribution of ObGyn. The North East geopolitical zone having one of the highest maternal mortality ratio of 1,549/100,000 live births also recorded the lowest ObGyn to population ratio of 1 in 628,197. While the South West geopolitical zone with a lower maternal mortality ratio of 165/100,000 live births has a higher ObGyn to population ratio of 1 in 110,263 [14].

DISCUSSION - 6 The low number of female ObGyn recorded in this study 122(12.6%) may be a reflection of the low level of educational attainment by females in Nigeria. The traditional Nigerian society favors male child education at the expense of the female child. This finding has implications especially in the northern part of the country where for religious and cultural reasons some women would not accept to be attended to by male health workers even in emergency situation.

DISCUSSION 7 Most ObGyn currently practicing in Nigeria are trained in the country and acquired the postgraduate certificatesof either the West African College of Surgeons and/or the National Postgraduate Medical College of Nigeria. Only 142(14.7%) holds foreign specialist certificates.The introduction of medical specialists training program in West Africa and Nigeria saved the country cost of sponsorship of its citizen to foreign countries. The local training program has ensured availability of a critical mass of specialists even in the face of on-going migration from Nigeria to neighboring countries, Europe and America

DISCUSSION 8 The need for improvement in standard and quality of care has led to the introduction of subspecialization in Obstetrics &Gynecology [16]. About half of the ObGyn indicated interest in sub-specialty practice but only 53(5.5%) have received sub-specialty training in reproductive medicine, fetomaternal medicine, gynecological oncology, urogynecology, reproductive health and family planning and endoscopy. It is expected that the local training program will in the future introduce subspecialization training [17].The need to acquire additional knowledge and develop other skills apart from medical practice motivated engagement in the study of other courses.

CONCLUSION The numbers of ObGyn are few in relation to the population and are not well distributed in the country. Post graduate medical training institutions should be supported to increase their capacity to train more specialists. Sub- specialization should be encouraged in order to improve on the quality of maternal health care. Efforts to improve maternal health and reduce the current high maternal mortality ratio in Nigeria should therefore include investment in training, engagement and equitable distribution of ObGyn. Government support for expansion of the postgraduate medical training program in the country will improve the ObGyn to population ratio and lead to better quality maternal health care and reduction in maternal mortality..

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