WOMEN IN SURGERY - an overview of the evolving trends in Nigeria

Abstract

Background

Since 1974 when the first Nigerian female surgeon was produced, an increasing number of Nigerian females have qualified as surgeons and more are in the various residency training programmes in Nigeria to become surgeons.

Aim

To document the evolving trend of Nigerian females training as surgeons and their contribution to the surgical workforce.

Methodology

A questionnaire based survey of Nigerian females who are qualified surgeons and those in the surgical training programmes from June 2016 – September 2017.

Results

Sixty questionnaires were sent out, and 54(90%) responded, with 49(91%) completely answering the questionnaire. The age range of the respondents was between 29 -72 years, with a mean age of 37.5 ± 6.2 years. Twelve (22.2%) were registrars, 18(33.3%) were senior registrars, and 24(44.4%) were specialists. One respondent (1.85%) had an academic professorial chair. The reasons for the preferred choice of subspecialty included: genuine interest 44(89.8%), availability of mentors 20(40.8%), the availability of a structured programme 14(28.62%), lifestyle friendly programmes 7(14.3%), remuneration 6(12.2%), and the duration of the training 1(2.2%). Thirty three (67.4%) were married, 11(22.5%) were single and 5(10.2%) were divorced. Twenty six (78.8%) gave birth to children during their surgical training programmes, while 12(36.4%) and 5(15.2%) gave birth to children before and after their programmes respectively. Twelve (37.5%) of the respondents who gave birth during training, had disruption in their training. Four (8.2%) of the respondents, made a career switch from Surgery.

Conclusion

The evolving interest of female doctors in Surgery in Nigeria as highlighted in this study is a welcome development and should be encouraged and sustained by mentoring of aspiring female surgeons even from the medical schools.

Introduction

The surgical subspecialty in Nigeria had been for a long time dominated by males before the first female general surgeon, Dr Stella Adepero Adeoba1, came onto the scene at 1977 at the Lagos University Teaching Hospital, where she was appointed consultant general surgeon, having obtained the fellowship of the Royal College of Surgeons of England in 1973. Following was Dr Nene Obianyo2 with a fellowship from the same college in 1974. The latter became the first female professor of surgery in Nigeria, and continued in academics to become the first female Emeritus Professor of Paediatric Surgery in West Africa. These 2 were the pioneers that opened the door to the field of surgery for women in Nigeria. Ever since, the complexion of the surgical subspecialty training and workforce has been changing with an increasing number of females veering into even rarer fields like neurosurgery, orthopaedic surgery, cardiothoracic and urology. This may be due to the increasing number of medical schools and the increasing number of specialists’ training centres in Nigeria. Also, there is a global decrease of the male:female ratio of entrants into medical schools3,4,5,6,7,8,9. However, there are no studies to support this global trend in Nigeria. The minimum duration to qualify as a surgeon in Nigeria is 14 years: 6 years of medical school, 1 year internship, 1 year of mandatory national service and at least 6 years of surgical training. This excludes time spent in further sub-specialization.

This study was designed to document the trend of involvement of Nigerian female doctors in the surgical training and workforce in Nigeria.

Materials & Methods

This was a self-designed 3-page questionnaire based study, with an average completion time of 7 minutes using the Survey Monkey Application. It was conducted from June 1, 2016 to September 1, 2017. The first section of the questionnaire covered biodata of the respondent, while the other 2 sections covered details on residency training, family life and career.

It involved all females who are specialist surgeons and those currently in surgical training in Nigeria. The subspecialties included were: general surgery, paediatric surgery, urology, orthopaedics, cardiothoracic surgery, neurosurgery and plastic surgery.

The questionnaire was administered to 60 would be participants. The list of the participants was generated from the Postgraduate Medical Colleges’ list of registered surgical fellows, social media group platforms of the female surgical trainees, personal interaction with female trainees and surgeons encountered at postgraduate examinations and accreditation visits. The survey monkey web link of the questionnaire was sent via SMS, emails and their social media platforms. Also, printed hard copies were administered to some individually and the data were manually uploaded to the online application. Reminders were sent and the study was extended by 3 months to encourage more respondents.

Fifty four (90%) doctors responded and 49(91%) of them completed the questionnaire.

All the data which included their biodata, responses to questions on their residency training and family life were entered into a Microsoft Excel 2013 spreadsheet and analysed. Simple descriptive statistics (range, mean and standard deviation) were calculated for continuous variables; percentages and proportions were determined for categorical variables.

Results

Fifty four (90%) of the 60 doctors recruited responded to this survey, and 49(91%) of the respondents completed the questionnaire. Twelve (22.2%) of the respondents were registrars, 18(33.3%) were senior registrars and 24(44.4%) were specialists. Of the respondents, 9.1% were employed in a University or College of Medicine and 1(1.85%) had an academic professorial chair.

The age range of the respondents was between 29 – 72 years with a mean age of 37.5 ± 6.2 years 60% of the respondents were ≤ 37 years old (Fig. 1).

Fig. 1. Age of respondents in years.

The majority 41(76%) of the respondents were indigenes of the southern part of Nigeria while the rest 13(24%) are from the northern part of Nigeria. Also, the majority 46(85%) of respondents had or were currently having their surgical residency training in the southern part of Nigeria. Lagos State alone accounted for 21(38.9%) of these.

The Postgraduate College examination passed by the respondents at the Primary level was 75.5%, 22.5% and 2.0% for the West African College of Surgeons (WACS), the National Postgraduate Medical College in Nigeria (NPMCN) and the Royal College of Surgeons respectively. The pass rate for the Part 1 examinations was 79.6% and 44.9% for the WACS and NPMCN respectively. The pass rate for the Part 2 examinations was 90.9%, 18.2% and 4.6% for the WACS, NPMCN and the Royal College of Surgeons respectively. For the respondents who passed the Part 2 examinations, at the time they passed, 61.5% did not involve writing a dissertation.

The reasons for the preferred choice of subspecialty included one or more of the following: genuine interest in 89.8%, the availability of mentors in 40.8%), availability of a structured training programme in the specialty in 28.6%, lifestyle friendly specialties in 14.3%, remuneration in 12.2% and relatively short duration of training in 2.0% (Fig. 2).

Fig. 2. Reasons for choice of specialties.

Thirty three (67.4%) of the respondents were married, 11(22.5%) were single and 5(10.2%) were divorced as shown in Fig. 3.

Fig. 3. Marital status of respondents.

Amongst the married respondents, 15(46.9%) got married before residency, 15(46.9%) got married during their surgical training programme while 2(6.35%) got married after.

Twenty six (78.8%) of the respondents gave birth to children during their surgical training while 12(36.4%) and 5(15.2%) gave birth to children before and after the programme respectively (Fig. 4).

Fig. 4. Timing of childbearing among the respondents.

Twelve (37.5%) of the respondents who gave birth to children during their surgical training admitted to experiencing some adverse effects of childbearing on their training programme: an increase in the duration of their training in 9(75%) respondents, strained relationship with their trainers in 4(33.3%), flexibility in attending outside postings/rotations in 4(33.3%), and eventual change of choice of subspecialty in 1(8.3%).

Four (8.2%) of the respondents admitted to a career switch from surgery: 2(66.7%) to internal medicine, 1(33.3%) to non-medical careers and 1 person did not respond to this question. The main reason for the switch was a change in location/environment.

Discussion

Traditionally, surgery was seen as a male dominated specialty in Medicine and there were few female surgeons in the past in Nigeria. The first female General Surgeon in Nigeria was Dr Adeoba1 who became a Consultant Surgeon at the Lagos University Teaching Hospital (LUTH) in 1977.

Hitherto, surgeons had their training abroad10 but with the establishment of the West African College of Surgeons and the National Postgraduate Medical College of Nigeria11, most surgeons subsequently trained locally. In 2015, there were 47 and 43 surgical training centres accredited by WACS and NPMCN respectively in Nigeria12,13

This questionnaire-based study will add to the growing body of literature with respect to the trends and contribution of females to the surgical workforce in Nigeria.

The results indicated that there were more females in surgery in their 3^rd decade and constituted 60% of the study population as against the older ones in their 4^th decade and above. There was only one female with an academic chair in surgery in our study; this was not far-fetched from what obtained in the USA14. Few (9.1%) of the respondents who were already specialists were employed in a College of Medicine. This in consequence could have affected the inflow of younger females into academic surgery, since there were few female mentors or role models.

Most of the respondents to up to 76% were indigenes from the southern part of the country: south - west, southeast and south-south geopolitical zones while the northcentral zone accounted for 20.4%, the northeast and the northwest zones each accounted for 1.85% of the respondents (Table 1). It was also observed that most of the respondents had their training in training centres that were located in the southern region (85.2%). Lagos state, the former capital of Nigeria and also its economic and commercial hub15, had four surgical training centres located at Lagos University Teaching Hospital, National Orthopaedic Hospital, Lagos State University Teaching Hospital and the Federal Medical Centre Ebute Metta; 38.9% of the female respondents had or are still in training there. This may be a reflection of the entry of and higher influence of western education into southern Nigeria during the British Colonial Era16. Thus the presence of these institutions may have contributed to encouraging the local indigenes to acquire tertiary education and specialist training.

Table 1. Distribution of respondents according to their geopolitical zones of origin in Nigeria.

Geopolitical Region	Frequency	Percentage
Northeast	1	1.85%
Northwest	1	1.85%
Northcentral	11	20.37%
Southeast	8	14.82%
Southwest	23	42.61%
Southsouth	10	18.52%

The results indicate that there was a higher pass rate of 75.5%, 79.6% and 90.9% in the WACS examination at all levels of training: Primaries, Parts 1 and 2 respectively. Is this due to a preference of the WACS over the NPMCN examinations? This study did not address this. However, the study showed that the absence of a dissertation at the exit Part 2 examination until recently could have been responsible for this preference for the WACS examination at this level. Dissertations have recently been introduced as a compulsory requirement for the Part 2 WACS examinations. Thus, this disparity may be less obvious in a future assessment of this parameter. A further study may be needed to assess the reasons for the disparity of the pass rates between the WACS and NPMCN examinations at the Primary and Part 1 levels.

It was interesting to note that of all the subspecialties, plastic surgery was the most preferred in 30.6%, distantly followed by paediatric surgery in 18.4% of the respondents. In a similar study in the USA, general surgery topped the list, probably because this subspecialty was becoming more lifestyle friendly4. There was also a noticeable growing interest in and entry of females into the technically male dominated subspecialties of orthopaedic surgery, cardiothoracic surgery, neurosurgery and urology.

A previous study in our environment had recorded that the overriding factors in the determinants in choice of specialty training were job security, financial remuneration, and examination requirements17. Genuine interest and availability of mentors were the strongest reasons that guided the choice of their specialties as shown in Fig. 2. In a similar study, Thakur et al18 concluded that mentor guidance is an important influence in the choice of surgical subspecialty.

It is pertinent to discuss other major factors that influenced the decision of the respondents to specialise in surgery in Nigeria: lifestyle and family life. From this study, the majority of the respondents were married. The study however did not determine if the respondents who were single or divorced were due to the demands of the surgical training programme and career. This is in contrast to what obtained in a study in USA, where the number of single female surgeons was quite high19.

Closely on the heels of marriage is childbearing. Of great concern is childbearing during the surgical training programme. This study showed that most respondents had children during their surgical training. Eleven respondents postponed childbearing at some point during their training due to several reasons such as stage of training, lack of family support structure, health reasons, financial reasons, and specialty of training. This result on childbearing is in contrast to that obtained in a study conducted in the USA where a few had babies during their surgical training programme20. Their study showed that 15% of the women surveyed had children during their surgical training programme. One reason for this high childbearing rate during the surgical training in this study was the extended family system still practised in Nigeria21. Here, all hands would be on deck to assist at the announcement of a pregnancy and delivery. It is an informal but a traditionally required arrangement that offers a strong family support mechanism for young parents to adjust to the demands of their growing families. It offers assistance with care of the mother, baby and the home during pregnancy, delivery and thereafter. It is usually done by experienced and trustworthy family members like grandmothers and aunties who would also help in transferring desired cultural and family values to their young children21,22,23. In consequence, the female surgeon was probably able to focus better on her training and career path since the home front was being managed by reliable hands. However, it was not known for how long this family support system would last. There is an evolving preference for the nuclear family structure, urbanisation, and a gradual loss of our traditional and cultural values that strongly guide our society24,25. Therefore it is important that more concrete measures are put in place to cater for females who choose to get pregnant during their training. Nine of the respondents who had children during the training programme admitted to adverse effects such as increase in duration of their training, non-flexibility of outside rotations and strained relationship with their trainers; one respondent changed her preferred choice of specialty.

The limitations of this study were the exclusion of women in ophthalmology, othorhinolaryngology and obstetrics & gynaecology as well as the questionnaire nature of the study with inherent subjectivity.

Conclusions

The evolving interest of female doctors in Surgery in Nigeria as highlighted in this study is a welcome development and should be encouraged and sustained by mentoring of aspiring female surgeons even from the medical schools.