- Email: [email protected]
JOGC and FIGO 2015
EDITORIAL
JOGC and FIGO 2015 Timothy Rowe, MB BS, FRCSC Editor-in-Chief
W
e are very pleased to present this theme issue on International Women’s Health, published to coincide with the FIGO World Congress. We are equally pleased, and proud, that the Congress this year is being held in Vancouver; the world is on JOGC’s doorstep. As with previous issues coinciding with the FIGO World Congress, we have invited submissions on multiple aspects of women’s health from authors with widely distributed locations and broadly distributed focus. Previous theme issues have included varying perspectives on the UN Millennium Development Goals (MDGs). But the MDGs were developed with 2015 as the finish line, and they will expire in December. Sadly, and perhaps predictably, the targets of the key MDG related to women’s health (MDG5: to reduce global maternal mortality by three quarters between 1990 and 2015, and to achieve universal access to reproductive health) have not been reached. Nevertheless, it can be said that substantial progress towards the goals has been made, and, as the MDGs expire, global efforts to improve global quality of life will take a new shape. The MDGs are being replaced by the 17 Sustainable Development Goals (SDGs), which comprise 169 targets; devising measures to monitor progress towards these is a work in progress. In this issue of the journal, Lindsay Edouard and Stan Bernstein have once again provided a report on global reproductive health in the context of the MDGs.1 In their report they note that reproductive health was slow to be included as a priority in the MDGs, and that in the SDGs the laudable and critical goal of reducing maternal mortality has been subsumed under a single health-related goal. Because the SDGs are so important, it will be critical to devise metrics promptly for tracking progress and to establish relevant monitoring methods.2 The SDGs are slated to expire in 2030, and that is only 15 years away. In a related article, Wylam Faught and colleagues point out that women’s lives are more than childbirth,3 even though measuring childbirth outcomes seems to be used as a
proxy for women’s lives by some. Dr Faught and colleagues stress the need for all countries to recognize, at least, the importance of having comprehensive and accessible surgical care available for women and girls, in order to permit sustainable progress in global women’s health. Access to surgical care is indeed often seen as a luxury in low-resource settings, but it should not be. As noted by Sikolia Wanyonyi and Francis G. Muriithi, the lack of readily accessible surgical capacity in low-resource settings can mean that vaginal birth after Caesarean section, seen as a desirable option in settings with abundant resources, may be a riskier undertaking than elective repeat Caesarean section.4 Nevertheless, any Caesarean section requires safe and effective anaesthesia, and providing this can also be a significant challenge in some low-resource settings. As Angela Enright and colleagues point out, unsafe anaesthesia contributes to maternal mortality in many lowand middle-income countries.5 In response, they describe an approach to helping anaesthesia providers in these settings (who may not be physicians) manage obstetric anaesthetic emergencies. The course they describe is called SAFE OB, and it has been taught in many countries in Africa, Asia, and Latin America with beneficial results. This is a laudable response to a modifiable risk. From another perspective, Anne Bardsley and Mark Hanson discuss the importance of nutrition in the health of populations and particularly in the health of pregnant women and their offspring.6 As they note, poor maternal nutrition not only affects fetal and childhood growth, but also changes the trajectory of development so that affected individuals react adversely to environmental influences throughout their lives. They summarize FIGO’s Recommendations on Adolescent, Preconception and Maternal Nutrition, which emphasize the need for collaboration between health care professionals, public health professionals, and policy developers in their promotion. This is essential advice. J Obstet Gynaecol Can 2015;37(10):859–861
OCTOBER JOGC OCTOBRE 2015 l 859
Editorial
Preeclampsia and the hypertensive disorders of pregnancy remain among the leading causes of global maternal mortality, and Peter von Dadelszen and his team have written here before about the lessons they learned for health services in low- and middle-income countries from their PRE-EMPT project.7 More specific information is provided by Maria Laura Costa about the challenge of counselling women about reducing the risk of recurrent preeclampsia.8 In her review, she discusses the potential value of lifestyle and dietary changes and the use of a range of medication, noting in each case the uncertainty about potential benefit. Our clinical challenges persist.
and how knowledge of these can be used to modify the approach of local caregivers to improving maternal outcomes.14 Peace Byamukama Natakunda and colleagues describe their study of knowledge, attitudes, and practices in relation to voluntary blood donation in non-urban Uganda, and identify how these may compromise maternal survival in cases of postpartum hemorrhage.15 Lacey English and colleagues describe their findings in a study of ethanol use in pregnant women in Southwestern Uganda, and report that alcohol use is common because of the perception that there are few alcohol-related harms.16 They suggest some appropriate responses.
In reducing maternal morbidity and mortality and improving perinatal outcomes, improving the quality of clinical services is the usual target in countries such as Canada. But in other countries, improving the organization of services for obstetrical and neonatal care and analyzing the available data about outcomes carefully may be just as important, or even more so. In this issue Marina P. Shuvalova and colleagues provide a detailed overview of how maternity care is provided in Russia.9 They describe the three-level organization of specialized care and the challenges they have faced in increasing accessibility and the quality of care. Since 2012, Russia has been registering births according to WHO recommendations, allowing improved data assessment and leading to greater potential for international collaboration in research. In another contribution, Rohit Ramaswamy and colleagues describe how in tertiary care hospitals in Ghana a composite model for change has been used to improve maternal and neonatal outcomes.10 It is encouraging to learn that in testing in one of the largest hospitals in Ghana, this model appeared to be capable of taking clinical conditions, limited resources, and organizational issues into account in developing strategies that will lead to reduced maternal and neonatal outcomes in a low-resource setting. In a parallel review, Heather Scott and Akinyele Dairo examine the level of maternal death surveillance and response, a key strategy to reduce maternal mortality, in East and Southern Africa.11 As is the case in many developing areas, progress is being made, but much more needs to be done.
With each FIGO theme issue, we recognize that providers of reproductive health care can learn from each other, regardless of their location. In this vein, it is heartening to read that there is a strong desire among residency program directors and senior residents in Canada to strengthen postgraduate education in global women’s health. As Heather Millar and colleagues report, the respondents to their survey felt that current coverage of global women’s health in Canadian residency programs is insufficient, and they expressed interest in developing a national educational model.17 A plan for this will be presented at the FIGO World Congress in Vancouver. I have no doubt that future FIGO theme issues of JOGC will show the fruits of this effort.
We are pleased to include four short reports of research carried out in Africa, three of these under the umbrella of the MicroResearch initiative.12 Catherine Arkell and colleagues report on their examination of gender equity in MicroResearch workshop participation in East Africa and opportunities for leadership.13 What they found was genuinely encouraging. Florence Beinempaka and colleagues describe their exploration of traditional rituals and customs for pregnant women in Southwest Uganda, 860 l OCTOBER JOGC OCTOBRE 2015
I wish to thank all of the authors who have contributed to this issue, and I trust that you, our readers, will find these articles both stimulating and informative. REFERENCES 1. Edouard L, Bernstein S. Sexual and reproductive health at 2015 and beyond: a global perspective. J Obstet Gynaecol Can 2015;37(10):872–9. 2. Lu Y, Nakicenovic N, Visbeck M, Stevance A-S. Five priorities for the UN Sustainable Development Goals. Nature 2015;520:432–3. 3. Faught W, Gill R, Ng-Kamstra J. Women’s health and surgical care: moving from maternal health to comprehensive surgical systems. J Obstet Gynaecol Can 2015;37(10):894–6. 4. Wanyonyi S, Muriithi FG. Vaginal birth after Caesarean section in low resource settings: the clinical and ethical dilemma. J Obstet Gynaecol Can 2015;37(10):922–6. 5. Enright A, Grady K, Evans F. A new approach to teaching obstetric anaesthesia in low resource areas. J Obstet Gynaecol Can 2015;37(10):880–4. 6. Bardsley A, Hanson M. Developing a global maternal nutrition guideline. J Obstet Gynaecol Can 2015;37(10):885–6. 7. von Dadelszen P, Firoz T, Donnay F, Gordon R, Hofmeyr GJ, Lalani S, et al. Preeclampsia in low and middle income countries - health services lessons learned from the PRE-EMPT (PRE-Eclampsia-Eclampsia Monitoring, Prevention and Treatment) project. J Obstet Gynaecol Can 2012;34:917–26. 8. Costa ML. Preeclampsia: reflections on how to counsel about preventing recurrence. J Obstet Gynaecol Can 2015;37(10):887–93.
JOGC and FIGO 2015
9. Shuvalova MP, Yarotskaya EL, Pismenskaya TV, Dolgushina NV, Baibarina EN, Sukhikh GT. Maternity care in Russia: issues, achievements, and potential. J Obstet Gynaecol Can 2015;37(10):865–71. 10. Ramaswamy R, Iracane S, Srofenyoh E, Bryce F, Floyd L, Kallam B, et al. Transforming maternal and neonatal outcomes in tertiary hospitals in Ghana: an integrated approach for systems change. J Obstet Gynaecol Can 2015;37(10):905–14. 11. Scott H, Dairo A. Maternal death surveillance and response in East and Southern Africa. J Obstet Gynaecol Can 2015;37(10):915–21. 12. MacDonald NE , Bortolussi R, Kabakyenga J, Pemba S, Estambale B, Kollmann KHM, et al. MicroResearch: finding sustainable local health solutions in East Africa through small local research studies. J Epidemiol Glob Health 2014;4:185–93. 13. Arkell C, MacPhail C, Abdalla S, Grant E, Ashaba S, Bii LC, et al. MicroResearch in East Africa: opportunities for addressing gender inequity. J Obstet Gynaecol Can 2015;37(10):897–8.
14. Beinempaka F, Tibanyendera B, Atwine F, Kyomuhangi T, Kabakyenga J, MacDonald NE. Traditional rituals and customs for pregnant women in selected villages in Southwest Uganda. J Obstet Gynaecol Can 2015;37(10):899–900. 15. Natukunda PB, Agaba E, Wabuyi P, Bortolussi R, McBride E. Knowledge, attitudes, and practices about regular, voluntary non-remunerated blood donation in peri-urban and rural communities in Mbarara District, South Western Uganda, and its impact on maternal health. J Obstet Gynaecol Can 2015;37(10):903–4. 16. English L, Mugyenyi GR, Ngonzi J, Kiwanuka G, Nightingale I, Koren G, et al. Prevalence of ethanol use among pregnant women in Southwestern Uganda. J Obstet Gynaecol Can 2015;37(10):901–2. 17. Millar HC, Randle EA, Scott HM, Shaw D, Kent N, Nakajima AK, et al. Global women’s health education in Canadian obstetrics and gynaecology residency programs: a survey of program directors and senior residents. J Obstet Gynaecol Can 2015;37(10):927–35.
OCTOBER JOGC OCTOBRE 2015 l 861
JOGC and FIGO 2015 Timothy Rowe, MB BS, FRCSC Editor-in-Chief
W
e are very pleased to present this theme issue on International Women’s Health, published to coincide with the FIGO World Congress. We are equally pleased, and proud, that the Congress this year is being held in Vancouver; the world is on JOGC’s doorstep. As with previous issues coinciding with the FIGO World Congress, we have invited submissions on multiple aspects of women’s health from authors with widely distributed locations and broadly distributed focus. Previous theme issues have included varying perspectives on the UN Millennium Development Goals (MDGs). But the MDGs were developed with 2015 as the finish line, and they will expire in December. Sadly, and perhaps predictably, the targets of the key MDG related to women’s health (MDG5: to reduce global maternal mortality by three quarters between 1990 and 2015, and to achieve universal access to reproductive health) have not been reached. Nevertheless, it can be said that substantial progress towards the goals has been made, and, as the MDGs expire, global efforts to improve global quality of life will take a new shape. The MDGs are being replaced by the 17 Sustainable Development Goals (SDGs), which comprise 169 targets; devising measures to monitor progress towards these is a work in progress. In this issue of the journal, Lindsay Edouard and Stan Bernstein have once again provided a report on global reproductive health in the context of the MDGs.1 In their report they note that reproductive health was slow to be included as a priority in the MDGs, and that in the SDGs the laudable and critical goal of reducing maternal mortality has been subsumed under a single health-related goal. Because the SDGs are so important, it will be critical to devise metrics promptly for tracking progress and to establish relevant monitoring methods.2 The SDGs are slated to expire in 2030, and that is only 15 years away. In a related article, Wylam Faught and colleagues point out that women’s lives are more than childbirth,3 even though measuring childbirth outcomes seems to be used as a
proxy for women’s lives by some. Dr Faught and colleagues stress the need for all countries to recognize, at least, the importance of having comprehensive and accessible surgical care available for women and girls, in order to permit sustainable progress in global women’s health. Access to surgical care is indeed often seen as a luxury in low-resource settings, but it should not be. As noted by Sikolia Wanyonyi and Francis G. Muriithi, the lack of readily accessible surgical capacity in low-resource settings can mean that vaginal birth after Caesarean section, seen as a desirable option in settings with abundant resources, may be a riskier undertaking than elective repeat Caesarean section.4 Nevertheless, any Caesarean section requires safe and effective anaesthesia, and providing this can also be a significant challenge in some low-resource settings. As Angela Enright and colleagues point out, unsafe anaesthesia contributes to maternal mortality in many lowand middle-income countries.5 In response, they describe an approach to helping anaesthesia providers in these settings (who may not be physicians) manage obstetric anaesthetic emergencies. The course they describe is called SAFE OB, and it has been taught in many countries in Africa, Asia, and Latin America with beneficial results. This is a laudable response to a modifiable risk. From another perspective, Anne Bardsley and Mark Hanson discuss the importance of nutrition in the health of populations and particularly in the health of pregnant women and their offspring.6 As they note, poor maternal nutrition not only affects fetal and childhood growth, but also changes the trajectory of development so that affected individuals react adversely to environmental influences throughout their lives. They summarize FIGO’s Recommendations on Adolescent, Preconception and Maternal Nutrition, which emphasize the need for collaboration between health care professionals, public health professionals, and policy developers in their promotion. This is essential advice. J Obstet Gynaecol Can 2015;37(10):859–861
OCTOBER JOGC OCTOBRE 2015 l 859
Editorial
Preeclampsia and the hypertensive disorders of pregnancy remain among the leading causes of global maternal mortality, and Peter von Dadelszen and his team have written here before about the lessons they learned for health services in low- and middle-income countries from their PRE-EMPT project.7 More specific information is provided by Maria Laura Costa about the challenge of counselling women about reducing the risk of recurrent preeclampsia.8 In her review, she discusses the potential value of lifestyle and dietary changes and the use of a range of medication, noting in each case the uncertainty about potential benefit. Our clinical challenges persist.
and how knowledge of these can be used to modify the approach of local caregivers to improving maternal outcomes.14 Peace Byamukama Natakunda and colleagues describe their study of knowledge, attitudes, and practices in relation to voluntary blood donation in non-urban Uganda, and identify how these may compromise maternal survival in cases of postpartum hemorrhage.15 Lacey English and colleagues describe their findings in a study of ethanol use in pregnant women in Southwestern Uganda, and report that alcohol use is common because of the perception that there are few alcohol-related harms.16 They suggest some appropriate responses.
In reducing maternal morbidity and mortality and improving perinatal outcomes, improving the quality of clinical services is the usual target in countries such as Canada. But in other countries, improving the organization of services for obstetrical and neonatal care and analyzing the available data about outcomes carefully may be just as important, or even more so. In this issue Marina P. Shuvalova and colleagues provide a detailed overview of how maternity care is provided in Russia.9 They describe the three-level organization of specialized care and the challenges they have faced in increasing accessibility and the quality of care. Since 2012, Russia has been registering births according to WHO recommendations, allowing improved data assessment and leading to greater potential for international collaboration in research. In another contribution, Rohit Ramaswamy and colleagues describe how in tertiary care hospitals in Ghana a composite model for change has been used to improve maternal and neonatal outcomes.10 It is encouraging to learn that in testing in one of the largest hospitals in Ghana, this model appeared to be capable of taking clinical conditions, limited resources, and organizational issues into account in developing strategies that will lead to reduced maternal and neonatal outcomes in a low-resource setting. In a parallel review, Heather Scott and Akinyele Dairo examine the level of maternal death surveillance and response, a key strategy to reduce maternal mortality, in East and Southern Africa.11 As is the case in many developing areas, progress is being made, but much more needs to be done.
With each FIGO theme issue, we recognize that providers of reproductive health care can learn from each other, regardless of their location. In this vein, it is heartening to read that there is a strong desire among residency program directors and senior residents in Canada to strengthen postgraduate education in global women’s health. As Heather Millar and colleagues report, the respondents to their survey felt that current coverage of global women’s health in Canadian residency programs is insufficient, and they expressed interest in developing a national educational model.17 A plan for this will be presented at the FIGO World Congress in Vancouver. I have no doubt that future FIGO theme issues of JOGC will show the fruits of this effort.
We are pleased to include four short reports of research carried out in Africa, three of these under the umbrella of the MicroResearch initiative.12 Catherine Arkell and colleagues report on their examination of gender equity in MicroResearch workshop participation in East Africa and opportunities for leadership.13 What they found was genuinely encouraging. Florence Beinempaka and colleagues describe their exploration of traditional rituals and customs for pregnant women in Southwest Uganda, 860 l OCTOBER JOGC OCTOBRE 2015
I wish to thank all of the authors who have contributed to this issue, and I trust that you, our readers, will find these articles both stimulating and informative. REFERENCES 1. Edouard L, Bernstein S. Sexual and reproductive health at 2015 and beyond: a global perspective. J Obstet Gynaecol Can 2015;37(10):872–9. 2. Lu Y, Nakicenovic N, Visbeck M, Stevance A-S. Five priorities for the UN Sustainable Development Goals. Nature 2015;520:432–3. 3. Faught W, Gill R, Ng-Kamstra J. Women’s health and surgical care: moving from maternal health to comprehensive surgical systems. J Obstet Gynaecol Can 2015;37(10):894–6. 4. Wanyonyi S, Muriithi FG. Vaginal birth after Caesarean section in low resource settings: the clinical and ethical dilemma. J Obstet Gynaecol Can 2015;37(10):922–6. 5. Enright A, Grady K, Evans F. A new approach to teaching obstetric anaesthesia in low resource areas. J Obstet Gynaecol Can 2015;37(10):880–4. 6. Bardsley A, Hanson M. Developing a global maternal nutrition guideline. J Obstet Gynaecol Can 2015;37(10):885–6. 7. von Dadelszen P, Firoz T, Donnay F, Gordon R, Hofmeyr GJ, Lalani S, et al. Preeclampsia in low and middle income countries - health services lessons learned from the PRE-EMPT (PRE-Eclampsia-Eclampsia Monitoring, Prevention and Treatment) project. J Obstet Gynaecol Can 2012;34:917–26. 8. Costa ML. Preeclampsia: reflections on how to counsel about preventing recurrence. J Obstet Gynaecol Can 2015;37(10):887–93.
JOGC and FIGO 2015
9. Shuvalova MP, Yarotskaya EL, Pismenskaya TV, Dolgushina NV, Baibarina EN, Sukhikh GT. Maternity care in Russia: issues, achievements, and potential. J Obstet Gynaecol Can 2015;37(10):865–71. 10. Ramaswamy R, Iracane S, Srofenyoh E, Bryce F, Floyd L, Kallam B, et al. Transforming maternal and neonatal outcomes in tertiary hospitals in Ghana: an integrated approach for systems change. J Obstet Gynaecol Can 2015;37(10):905–14. 11. Scott H, Dairo A. Maternal death surveillance and response in East and Southern Africa. J Obstet Gynaecol Can 2015;37(10):915–21. 12. MacDonald NE , Bortolussi R, Kabakyenga J, Pemba S, Estambale B, Kollmann KHM, et al. MicroResearch: finding sustainable local health solutions in East Africa through small local research studies. J Epidemiol Glob Health 2014;4:185–93. 13. Arkell C, MacPhail C, Abdalla S, Grant E, Ashaba S, Bii LC, et al. MicroResearch in East Africa: opportunities for addressing gender inequity. J Obstet Gynaecol Can 2015;37(10):897–8.
14. Beinempaka F, Tibanyendera B, Atwine F, Kyomuhangi T, Kabakyenga J, MacDonald NE. Traditional rituals and customs for pregnant women in selected villages in Southwest Uganda. J Obstet Gynaecol Can 2015;37(10):899–900. 15. Natukunda PB, Agaba E, Wabuyi P, Bortolussi R, McBride E. Knowledge, attitudes, and practices about regular, voluntary non-remunerated blood donation in peri-urban and rural communities in Mbarara District, South Western Uganda, and its impact on maternal health. J Obstet Gynaecol Can 2015;37(10):903–4. 16. English L, Mugyenyi GR, Ngonzi J, Kiwanuka G, Nightingale I, Koren G, et al. Prevalence of ethanol use among pregnant women in Southwestern Uganda. J Obstet Gynaecol Can 2015;37(10):901–2. 17. Millar HC, Randle EA, Scott HM, Shaw D, Kent N, Nakajima AK, et al. Global women’s health education in Canadian obstetrics and gynaecology residency programs: a survey of program directors and senior residents. J Obstet Gynaecol Can 2015;37(10):927–35.
OCTOBER JOGC OCTOBRE 2015 l 861