- Email: [email protected]
I221 CHANGING CLINICAL PRACTICE OF HEALTHCARE PROVIDERS – QUALITATIVE STUDY FROM FIVE AFRICAN AND ASIAN COUNTRIES
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Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
from remission. Most of these patients with resistant disease will have multiple metastases to sites other than the lung and vagina (stage IV) as well as high FIGO scores (≥12) and many will have had inadequate initial chemotherapy. Salvage chemotherapy with platinum/etoposide-containing drug regimens, often in conjunction with surgical resection of sites of persistent tumor, will result in cure of most of these high-risk patients with resistant disease. The EMA-EP regimen, substituting etoposide and cisplatin for cyclophosphamide and vincristine in the EMA-CO protocol, is the most appropriate therapy for patients who have responded to EMACO but have plateauing low hCG levels or developed re-elevation of hCG levels after a complete response to EMA-CO. In patients who have clearly developed resistance to methotrexate-containing treatment protocols, drug combinations containing etoposide and a platinum agent along with bleomycin (BEP), ifosfamide (VIP, ICE), or paclitaxel (TP/TE) have been found to be effective. I218 DEVELOPMENT OF THE AFRICAN NPC NETWORKING D. Lusale Africa Network For Associate Clinicians (formerly Non Physician Clinician) – Who are the Associate Clinicians? The Associate Clinicians (AC) are health care professionals who include assistant medical officers, clinical officers, medical licentiate practitioner, clinical associates, health officer (surgery, obstetrics and gynaecology), physician assistant, surgical technician and tecnicos ´ de cirurgia. The title AC was adopted at a meeting held in Geneva at WHO in April 2012. These professionals possess competencies to diagnose and manage most common medical, maternal, child health and surgical conditions, including obstetrics and gynaecology and surgery practice. ACs train for 4 to 5 years post secondary education in established educational institutions and or 3 years post initial associate clinician training. ACs are registered and their practice is regulated by their national or sub-national regulatory authority. ACs are recognized in 48 of 54 African countries. When was it founded? The Africa Network for Non Physician Clinician Training was formed in July 2010, Lusaka, Zambia by members of the Community of Practice. The current membership comprises; Zambia, Malawi, Mozambique, Tanzania, Ethiopia, South Sudan, Burkina Faso, Sierra Leon and Liberia. AMDD (USA) has supported the Network so far. Goal: The network seeks to • Training, maternal, neonatal and other priority health services, • Promotion of professional identity of ACs, • Contribute relevant research activities in health. I219 SURGICAL MANAGEMENT OF POST PARTUM HAEMORRHAGE C.B. Lynch The surgical management of post partum haemorrhage aims at preventing the perils. Risk factors should have appropriate surveillance during labour. An appropriate surgeon with seniority and experience should perform high risk Caesarean sections. Accurate assessment of blood loss is imperative prior to surgery. The aim of surgery when severe post partum haemorrhage is diagnosed should be conservative. Therefore bimanual compression followed by the insertion of balloon for tamponade, the B-Lynch suture technique or modifications at laparotomy should be considered first. Because the majority of cases are attributable to atonic uterus, the compression technique has a high chance of success in the region of at least 80%. At laparotomy the B-Lynch surgical technique or its modifications have claimed success rate up to 90% with low morbidity and evidence of uterine conservation for further reproduction. Even
in cases of abnormal placentation, satisfactory results have been reported following prophylactic application. Illustrations of trauma management of the pelvic floor will be demonstrated. The use of selective arterial embolization, stepwise devasculisation, internal iliac (hypogastric arterial ligation), and complex pelvic surgery will be illustrated with the increase risk of morbidity. Peripartum abdominal hysterectomy either sub-total or total should be considered early but as a last resort after all conservative surgical management have been tried unsuccessfully. Secondary post partum haemorrhage; rarely require surgical intervention but if severe and surgery becomes necessary, the same protocol of surgical management should be followed. The cornerstone of the surgical management of post partum haemorrhage is timely intervention. I220 INCREASING POST ABORTION CONTRACEPTION AS PART OF AN INITIATIVE TO REDUCE UNSAFE ABORTIONS AT THE UNIVERSITY TEACHING HOSPITAL, LUSAKA, ZAMBIA S. Macha, M. Muyuni, S. Nkonde. MMed (OBGY) University of Zambia (UNZA), Zambia Background: Facility based data shows that in Zambia, unsafe abortion contributes 30% to maternal deaths despite a “liberal law”. In 2009, the Government of the Republic of Zambia launched the guidelines to reduce unsafe abortions, following a four prong approach, which coincides with the FIGO initiative on prevention of unsafe abortions. Post Abortion Contraception is one of the strategies that Zambia’s Action Plan to reduce unsafe abortions adopted. Objective: To review the Post Abortion Contraception Uptake (PACU) over a three year period (2009–2011) at the University Teaching Hospital (UTH), Lusaka, Zambia. Methods: Review of all records on Post Abortion contraception at the University Teaching Hospital, Lusaka, from January 1st 2009 to December 31s 2011. All patients who had undergone Manual Vacuum Aspiration (MVA) or Medical Abortion (MA) were considered in the period under study. The primary outcomes were the PACU and Contraceptive Methods offered. Results: There was an increase in rate from 25% in 2009 to 69.3% in 2011. PACU for Pregnancy Termination was 92% compared to 67% for Post Abortion Care in 2011. The preferred contraceptive methods were injectables (44%), combined oral pill (22%) and condoms (23%), in 2011. The IUCD was accepted by just 0.6%, but acceptance of the LNg releasing IUS, introduced in 2012, has been very good. Conclusion: An initiative to increase post-abortion contraception at the (UTH), Lusaka, Zambia obtained a three fold increase since it was launched in 2009. Scaling up Post Abortion Contraception to the rest of the country is the next task. I221 CHANGING CLINICAL PRACTICE OF HEALTHCARE PROVIDERS – QUALITATIVE STUDY FROM FIVE AFRICAN AND ASIAN COUNTRIES B. Madaj. Maternal and Newborn Health Unit at the Liverpool School of Tropical Medicine, United Kingdom Background: As part of the evaluation of the impact of the Making it Happen Programme in 5 countries in Africa and Asia, healthcare providers trained using the LSS EOC&NC package were invited to participate in a qualitative study to explore the effects of the training on their behaviour, attitudes and clinical practice. Methods: A total of 288 in-depth interviews and focus groups discussions with healthcare providers, as well as key informant interviews with representatives of healthcare facilities, ministries and international organisations, were conducted in Bangladesh, India, Kenya, Sierra Leone and Zimbabwe. Data were collected at 3, 6 and 12 months after the training and subsequently processed using NVIVO9 and framework analysis.
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
Results: Based on the respondents’ accounts, the training had a number of positive effects. These included improved competence and confidence following training, but also changes in attitudes and behaviour. In particular, updating of procedures and practices, applying a more structured approach to managing patients and better teamwork were highlighted in all countries. Additionally, healthcare providers identified a number of barriers to implementing the skills and knowledge, including shortage of staff, equipment and infrastructure. Conclusions: Multidisciplinary training using a competency based package (the LSS EOC&NC training package) has a universal appeal in various settings in resource-poor countries. Healthcare providers across the board reported being able to benefit from the training and apply the newly acquired skills into practice. I222 COMMUNITY-BASED ACCESS TO INJECTABLE CONTRACEPTION (CBA2I) TOOLKIT DEVELOPMENT AND ADAPTATION B.N. Maggwa. FHI 360 Project Director, PROGRESS Project The Community-Based Access to Injectable Contraceptives (CBA2I) Toolkit, within the Knowledge for Health (K4Health) platform, is designed to strengthen the capacity of agencies and organizations to plan, implement, evaluate, promote, and scale up CBA2I programs and to advocate for changes to national policy and service delivery guidelines. The K4Health Toolkit platform is implemented by the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs and funded by the U.S. Agency for International Development. FHI 360 maintains and regularly updates the CBA2I Toolkit, which includes: resources on the global evidence to support the practice CBA2I; country experiences with CBA2I; advocacy tools for gaining buy-in and changing policy; curricula, job aids, and other materials for piloting, implementing and scaling up programs; and links to organizations that are global leaders in CBA2I. Contained in the toolkit are more than 200 resources and tools, strategically selected and vetted by technical experts in the field. Since its launch in July 2011, the CBA2I Toolkit has had more than 3,500 visits, from 112 countries. FHI 360 makes a concerted effort to track how these tools have helped policy-makers and program managers determine whether and how to implement CBA2I in their countries. Since its inception, the materials from the Toolkit have contributed to the design and implementation of CBA2I programs in Guinea, Liberia, Senegal, Uganda, and Zambia by Ministries of Health and numerous organizations such as Save the Children, International Rescue Committee, ChildFund International and FHI 360. I223 REACHING 200 MILLION HARD TO REACH WOMEN WITH QUALITY FAMILY PLANNING SERVICES: THE ROLE OF COMMUNITY HEALTH WORKERS B.N. Maggwa. MD Director PROGRESS Project FHI360 The presentation will share experiences with task-shifting and sharing from select countries to show how these can inform countries poised to follow-up on the widely recognized actions at the London Summit on Family Planning hosted by the UK Government and the Bill & Melinda Gates Foundation. The Summit re-energized global commitments to improve access to FP in the world’s poorest countries. More than 220 million women in developing countries want to avoid pregnancy but are not using a modern method of contraption. At the Summit, partners pledged $4.6 billion dollars to give at least 120 million of these women access to contraceptives by 2020. What is required now is for programs to develop innovative strategies to translate this commitment into actions. One important tool is task sharing. Task-shifting and sharing will be a key strategy for addressing the critical human resource shortages rampant in countries with
S217
the greatest unmet need. Although many countries are beginning to implement this strategy in their FP programs, it remains controversial on many aspects. Many Professional Associations are not comfortable allowing lower cadre professionals and non-clinical providers to provide clinical FP methods. There are wide variations in the selection criteria, classification, training, certification and remuneration of community health workers making it difficult to standardize recommendations and practices across countries and programs. Most evidence generated in this area does not meet the strict GRADE criteria used by WHO to develop medical eligibility criteria. These concerns are delaying adoption and scale-up of this key intervention. I224 WOMEN’S HEALTH IN CRISIS SITUATIONS J. Mahmood Women face many challenges in disasters and conflicts. Sexual and reproductive health needs are often the least met and there is a tendency to overlook these special needs in crises situations. The session will share the particular challenges women face in crises, good practices and tools like the Minimal Initial Service Package (MISP) to address reproductive health needs from preventing and treatment of sexual violence, reduce maternal mortality and morbidity, prevent unwanted pregnancies and reduce the transmission of HIV and AIDS. Case studies from disasters rising from acute natural hazards and conflict situations – from Haiti, Indonesia, Myanmar and Puntland highlight the different challenges and successes from tailored interventions by non Governmental organizations MERCY Malaysia and Medecin du Monde. How can technology and science enhance access and minimal standards of care for women in crises? SMS and other social media platforms are beginning to emerge as important means of supporting health care workers in remote settings and the MAMA project started by Womens Refugee Commission is one example. Innovation in provision of obstetric and gynaecological services is required and how can the FIGO community contribute to this? New models of funding and opportunities such as the humanitarian innovation fund will be shared with the audience. I225 STANDARDS OF CARE IN WOMEN’S HEALTH SERVICES; REPORT OF AN EBCOG WORKING PARTY T. Mahmood. President Elect: European Board & College of Obstetrics & Gynaecology (EBCOG) There exists a huge variation in standards of care which is offered in women’s health services across the European Union. This is reflected in huge variation in Caesarean Section rates, maternal death rates and perinatal mortality rates. In some countries women even do not have access to early pregnancy screening tests. It is unfortunate that such an inequality in access to women’s health services continues to exist in 21st century. These variations in standards of care not only affect care of women during pregnancy, labour and postnatally but has also been reported in other health services such as reproductive medicine, access to abortion and evidence based care for gynaecological cancers across member states. As this inequality continues to persist, it directly affects the environment in which future generations of our specialists are being trained in different countries. The Council of the European Board and Council of Obstetrics and Gynaecology agreed to set up a working party in 2010 to oversee the development of core standards of care which could also be closely linked to training standards. This led to production of a working party report entitled “Standards of Care for Women’s Health in Europe” (Obstetrics and Neonatal Services (Vol 1) to be followed by our second report dealing with standards in Gynaecological Services in 2013. In this presentation I will focus on clinical standards of care in maternity services in EU and how they can be closely aligned to postgraduate
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
from remission. Most of these patients with resistant disease will have multiple metastases to sites other than the lung and vagina (stage IV) as well as high FIGO scores (≥12) and many will have had inadequate initial chemotherapy. Salvage chemotherapy with platinum/etoposide-containing drug regimens, often in conjunction with surgical resection of sites of persistent tumor, will result in cure of most of these high-risk patients with resistant disease. The EMA-EP regimen, substituting etoposide and cisplatin for cyclophosphamide and vincristine in the EMA-CO protocol, is the most appropriate therapy for patients who have responded to EMACO but have plateauing low hCG levels or developed re-elevation of hCG levels after a complete response to EMA-CO. In patients who have clearly developed resistance to methotrexate-containing treatment protocols, drug combinations containing etoposide and a platinum agent along with bleomycin (BEP), ifosfamide (VIP, ICE), or paclitaxel (TP/TE) have been found to be effective. I218 DEVELOPMENT OF THE AFRICAN NPC NETWORKING D. Lusale Africa Network For Associate Clinicians (formerly Non Physician Clinician) – Who are the Associate Clinicians? The Associate Clinicians (AC) are health care professionals who include assistant medical officers, clinical officers, medical licentiate practitioner, clinical associates, health officer (surgery, obstetrics and gynaecology), physician assistant, surgical technician and tecnicos ´ de cirurgia. The title AC was adopted at a meeting held in Geneva at WHO in April 2012. These professionals possess competencies to diagnose and manage most common medical, maternal, child health and surgical conditions, including obstetrics and gynaecology and surgery practice. ACs train for 4 to 5 years post secondary education in established educational institutions and or 3 years post initial associate clinician training. ACs are registered and their practice is regulated by their national or sub-national regulatory authority. ACs are recognized in 48 of 54 African countries. When was it founded? The Africa Network for Non Physician Clinician Training was formed in July 2010, Lusaka, Zambia by members of the Community of Practice. The current membership comprises; Zambia, Malawi, Mozambique, Tanzania, Ethiopia, South Sudan, Burkina Faso, Sierra Leon and Liberia. AMDD (USA) has supported the Network so far. Goal: The network seeks to • Training, maternal, neonatal and other priority health services, • Promotion of professional identity of ACs, • Contribute relevant research activities in health. I219 SURGICAL MANAGEMENT OF POST PARTUM HAEMORRHAGE C.B. Lynch The surgical management of post partum haemorrhage aims at preventing the perils. Risk factors should have appropriate surveillance during labour. An appropriate surgeon with seniority and experience should perform high risk Caesarean sections. Accurate assessment of blood loss is imperative prior to surgery. The aim of surgery when severe post partum haemorrhage is diagnosed should be conservative. Therefore bimanual compression followed by the insertion of balloon for tamponade, the B-Lynch suture technique or modifications at laparotomy should be considered first. Because the majority of cases are attributable to atonic uterus, the compression technique has a high chance of success in the region of at least 80%. At laparotomy the B-Lynch surgical technique or its modifications have claimed success rate up to 90% with low morbidity and evidence of uterine conservation for further reproduction. Even
in cases of abnormal placentation, satisfactory results have been reported following prophylactic application. Illustrations of trauma management of the pelvic floor will be demonstrated. The use of selective arterial embolization, stepwise devasculisation, internal iliac (hypogastric arterial ligation), and complex pelvic surgery will be illustrated with the increase risk of morbidity. Peripartum abdominal hysterectomy either sub-total or total should be considered early but as a last resort after all conservative surgical management have been tried unsuccessfully. Secondary post partum haemorrhage; rarely require surgical intervention but if severe and surgery becomes necessary, the same protocol of surgical management should be followed. The cornerstone of the surgical management of post partum haemorrhage is timely intervention. I220 INCREASING POST ABORTION CONTRACEPTION AS PART OF AN INITIATIVE TO REDUCE UNSAFE ABORTIONS AT THE UNIVERSITY TEACHING HOSPITAL, LUSAKA, ZAMBIA S. Macha, M. Muyuni, S. Nkonde. MMed (OBGY) University of Zambia (UNZA), Zambia Background: Facility based data shows that in Zambia, unsafe abortion contributes 30% to maternal deaths despite a “liberal law”. In 2009, the Government of the Republic of Zambia launched the guidelines to reduce unsafe abortions, following a four prong approach, which coincides with the FIGO initiative on prevention of unsafe abortions. Post Abortion Contraception is one of the strategies that Zambia’s Action Plan to reduce unsafe abortions adopted. Objective: To review the Post Abortion Contraception Uptake (PACU) over a three year period (2009–2011) at the University Teaching Hospital (UTH), Lusaka, Zambia. Methods: Review of all records on Post Abortion contraception at the University Teaching Hospital, Lusaka, from January 1st 2009 to December 31s 2011. All patients who had undergone Manual Vacuum Aspiration (MVA) or Medical Abortion (MA) were considered in the period under study. The primary outcomes were the PACU and Contraceptive Methods offered. Results: There was an increase in rate from 25% in 2009 to 69.3% in 2011. PACU for Pregnancy Termination was 92% compared to 67% for Post Abortion Care in 2011. The preferred contraceptive methods were injectables (44%), combined oral pill (22%) and condoms (23%), in 2011. The IUCD was accepted by just 0.6%, but acceptance of the LNg releasing IUS, introduced in 2012, has been very good. Conclusion: An initiative to increase post-abortion contraception at the (UTH), Lusaka, Zambia obtained a three fold increase since it was launched in 2009. Scaling up Post Abortion Contraception to the rest of the country is the next task. I221 CHANGING CLINICAL PRACTICE OF HEALTHCARE PROVIDERS – QUALITATIVE STUDY FROM FIVE AFRICAN AND ASIAN COUNTRIES B. Madaj. Maternal and Newborn Health Unit at the Liverpool School of Tropical Medicine, United Kingdom Background: As part of the evaluation of the impact of the Making it Happen Programme in 5 countries in Africa and Asia, healthcare providers trained using the LSS EOC&NC package were invited to participate in a qualitative study to explore the effects of the training on their behaviour, attitudes and clinical practice. Methods: A total of 288 in-depth interviews and focus groups discussions with healthcare providers, as well as key informant interviews with representatives of healthcare facilities, ministries and international organisations, were conducted in Bangladesh, India, Kenya, Sierra Leone and Zimbabwe. Data were collected at 3, 6 and 12 months after the training and subsequently processed using NVIVO9 and framework analysis.
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
Results: Based on the respondents’ accounts, the training had a number of positive effects. These included improved competence and confidence following training, but also changes in attitudes and behaviour. In particular, updating of procedures and practices, applying a more structured approach to managing patients and better teamwork were highlighted in all countries. Additionally, healthcare providers identified a number of barriers to implementing the skills and knowledge, including shortage of staff, equipment and infrastructure. Conclusions: Multidisciplinary training using a competency based package (the LSS EOC&NC training package) has a universal appeal in various settings in resource-poor countries. Healthcare providers across the board reported being able to benefit from the training and apply the newly acquired skills into practice. I222 COMMUNITY-BASED ACCESS TO INJECTABLE CONTRACEPTION (CBA2I) TOOLKIT DEVELOPMENT AND ADAPTATION B.N. Maggwa. FHI 360 Project Director, PROGRESS Project The Community-Based Access to Injectable Contraceptives (CBA2I) Toolkit, within the Knowledge for Health (K4Health) platform, is designed to strengthen the capacity of agencies and organizations to plan, implement, evaluate, promote, and scale up CBA2I programs and to advocate for changes to national policy and service delivery guidelines. The K4Health Toolkit platform is implemented by the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs and funded by the U.S. Agency for International Development. FHI 360 maintains and regularly updates the CBA2I Toolkit, which includes: resources on the global evidence to support the practice CBA2I; country experiences with CBA2I; advocacy tools for gaining buy-in and changing policy; curricula, job aids, and other materials for piloting, implementing and scaling up programs; and links to organizations that are global leaders in CBA2I. Contained in the toolkit are more than 200 resources and tools, strategically selected and vetted by technical experts in the field. Since its launch in July 2011, the CBA2I Toolkit has had more than 3,500 visits, from 112 countries. FHI 360 makes a concerted effort to track how these tools have helped policy-makers and program managers determine whether and how to implement CBA2I in their countries. Since its inception, the materials from the Toolkit have contributed to the design and implementation of CBA2I programs in Guinea, Liberia, Senegal, Uganda, and Zambia by Ministries of Health and numerous organizations such as Save the Children, International Rescue Committee, ChildFund International and FHI 360. I223 REACHING 200 MILLION HARD TO REACH WOMEN WITH QUALITY FAMILY PLANNING SERVICES: THE ROLE OF COMMUNITY HEALTH WORKERS B.N. Maggwa. MD Director PROGRESS Project FHI360 The presentation will share experiences with task-shifting and sharing from select countries to show how these can inform countries poised to follow-up on the widely recognized actions at the London Summit on Family Planning hosted by the UK Government and the Bill & Melinda Gates Foundation. The Summit re-energized global commitments to improve access to FP in the world’s poorest countries. More than 220 million women in developing countries want to avoid pregnancy but are not using a modern method of contraption. At the Summit, partners pledged $4.6 billion dollars to give at least 120 million of these women access to contraceptives by 2020. What is required now is for programs to develop innovative strategies to translate this commitment into actions. One important tool is task sharing. Task-shifting and sharing will be a key strategy for addressing the critical human resource shortages rampant in countries with
S217
the greatest unmet need. Although many countries are beginning to implement this strategy in their FP programs, it remains controversial on many aspects. Many Professional Associations are not comfortable allowing lower cadre professionals and non-clinical providers to provide clinical FP methods. There are wide variations in the selection criteria, classification, training, certification and remuneration of community health workers making it difficult to standardize recommendations and practices across countries and programs. Most evidence generated in this area does not meet the strict GRADE criteria used by WHO to develop medical eligibility criteria. These concerns are delaying adoption and scale-up of this key intervention. I224 WOMEN’S HEALTH IN CRISIS SITUATIONS J. Mahmood Women face many challenges in disasters and conflicts. Sexual and reproductive health needs are often the least met and there is a tendency to overlook these special needs in crises situations. The session will share the particular challenges women face in crises, good practices and tools like the Minimal Initial Service Package (MISP) to address reproductive health needs from preventing and treatment of sexual violence, reduce maternal mortality and morbidity, prevent unwanted pregnancies and reduce the transmission of HIV and AIDS. Case studies from disasters rising from acute natural hazards and conflict situations – from Haiti, Indonesia, Myanmar and Puntland highlight the different challenges and successes from tailored interventions by non Governmental organizations MERCY Malaysia and Medecin du Monde. How can technology and science enhance access and minimal standards of care for women in crises? SMS and other social media platforms are beginning to emerge as important means of supporting health care workers in remote settings and the MAMA project started by Womens Refugee Commission is one example. Innovation in provision of obstetric and gynaecological services is required and how can the FIGO community contribute to this? New models of funding and opportunities such as the humanitarian innovation fund will be shared with the audience. I225 STANDARDS OF CARE IN WOMEN’S HEALTH SERVICES; REPORT OF AN EBCOG WORKING PARTY T. Mahmood. President Elect: European Board & College of Obstetrics & Gynaecology (EBCOG) There exists a huge variation in standards of care which is offered in women’s health services across the European Union. This is reflected in huge variation in Caesarean Section rates, maternal death rates and perinatal mortality rates. In some countries women even do not have access to early pregnancy screening tests. It is unfortunate that such an inequality in access to women’s health services continues to exist in 21st century. These variations in standards of care not only affect care of women during pregnancy, labour and postnatally but has also been reported in other health services such as reproductive medicine, access to abortion and evidence based care for gynaecological cancers across member states. As this inequality continues to persist, it directly affects the environment in which future generations of our specialists are being trained in different countries. The Council of the European Board and Council of Obstetrics and Gynaecology agreed to set up a working party in 2010 to oversee the development of core standards of care which could also be closely linked to training standards. This led to production of a working party report entitled “Standards of Care for Women’s Health in Europe” (Obstetrics and Neonatal Services (Vol 1) to be followed by our second report dealing with standards in Gynaecological Services in 2013. In this presentation I will focus on clinical standards of care in maternity services in EU and how they can be closely aligned to postgraduate