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Priorities in obstetrics and gynaecology in the developing world
Ethics/education
Priorities in obstetrics and gynaecology in the developing world
Internationally agreed goals In 1994, representatives from more than 180 nations met at the International Conference on Population and Development (ICPD) in Cairo. Sexual and reproductive rights were enshrined as human rights and a holistic ‘programme of action’ was proposed with the following goals: • every sex act should be free of coercion and infection • every pregnancy should be intended • every birth should be healthy. In 2000, eight millennium development goals (MDGs) were adopted by 189 nations during the United Nations Millennium Summit. These MDGs are to be achieved by 2015 and respond to the world’s main development challenges: poverty reduction, education, maternal health, gender equality, combating child mortality, AIDS and other diseases. MDG 5 directly addresses the health needs of women (see Table 1). The goal of universal access to sexual and reproductive health services for women (target 5b) has recently been reinstated as a key target indicator for the achievement of MDG 5. The difference in maternal mortality between developing and developed countries shows the greatest disparity of all health indicators. The lifetime risk of maternal death in Afghanistan and Sierra Leone is estimated to be 1 in 8, in the UK this is 1 in 8200 and in Sweden it is 1 in 17,400. It is very clear that when it comes to the wellbeing of women in resource-poor countries, priorities span the spectrum of obstetrics and gynaecology (see Table 2).
Priya Agrawal Nynke van den Broek
Abstract Every minute of every day a woman in the developing world dies of an avoidable cause of death. For every woman dying there are at least another 20 women who are left with severe morbidity. These deaths can be prevented. The interventions required are clear, inexpensive and effective. Yet they are not universally available or accessible. The call for action has been made, yet the speed of progress is slow.
Keywords cervical cancer; infant mortality; maternal mortality; prevention; reproductive health
Introduction The burden of obstetric and gynaecological mortality and morbidity suffered by women in resource-poor countries was highlighted in a seminal paper by Rosenfield and Maine in 1985 with an urgent plea to ‘put the M back into MCH’ (maternal and child health). In addition, the Safe Motherhood Initiative was started in 1987 in Nairobi, which celebrated its 20th anniversary in London in 2007. Bang and colleagues brought gynaecological morbidity to international attention by the publication of extremely high prevalence rates in rural India: over 55% of women attending ‘health camps’ had one or more gynaecological complaint but only 8% had ever had a gynaecological examination. This illustrated the need for attention to the health of non-pregnant women and to tackle the ‘culture of silence’, which often prevents women from seeking healthcare for gynaecological problems. There has recently been increased attention to the shocking rates of maternal mortality in the developing world; however, the burden of obstetric and gynaecological morbidity remains largely undocumented and unquantified with few evaluations of the associated social and economic burdens to women and their families.
Focus on maternal and neonatal mortality – preventable deaths Five main killers cause 80% of maternal deaths worldwide: haemorrhage, sepsis, unsafe abortion, hypertensive disorders (pre-eclampsia and eclampsia) and ruptured uterus as a result of obstructed labour. These are complicated by pre-existing and co-existing illnesses such as anaemia (which is endemic in most parts of the developing world) and infections such as human immunodeficiency virus (HIV), malaria and tuberculosis. Maternal deaths are largely preventable. There are existing proven effective medical and surgical interventions that are
Millennium Development Goal 5 – addressing the health needs of women Target 5a – Reduce by three-quarters the maternal mortality ratio 5.1 5.2
Target 5b – Achieve universal access to reproductive health 5.3 Increase contraceptive prevalence rate 5.4 Reduce adolescent birth rate 5.5 Increase antenatal care coverage 5.6 Reduce unmet need for family planning
Priya Agrawal BMBCh MA MPH is a Specialist Registrar and Academic Clinical Fellow in Obstetrics & Gynaecology, St Mary’s Hospital, Manchester, UK. Nynke van den Broek PhD FRCOG is a Senior Clinical Lecturer, Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:7
Reduce the maternal mortality ratio Increase the number of births attended by skilled health personnel
Table 1
197
© 2009 Elsevier Ltd. All rights reserved.
Ethics/education
r elatively inexpensive. However, such interventions are not universally available and accessible for women. The simple procedure of manual vacuum aspiration (MVA) for removing retained products of conception – which can be done using local anaesthesia – can prevent deaths from severe sepsis or unsafe abortion. The availability of blood for transfusion would prevent the deaths of at least one-quarter of women who otherwise die of haemorrhage due to the non-availability of blood products. Training in and availability of partograms and access to a safe Caesarean section when needed would prevent many of the complications of obstructed labour such as uterine rupture leading to maternal and neonatal death or urogenital fistulae (estimated incidence of 1–2 per 1000 deliveries worldwide). Lack of specialised surgical and rehabilitation services for women with fistulae results in such women living as outcasts of society in abject poverty. The health of the neonate is closely related to that of the mother. Adequate intrapartum care could help prevent an estimated 3.2 million stillbirths a year, of which at least one in three occurs during delivery. If interventions were in place to ensure good maternal health most of the 4 million deaths in the first month of life could also be prevented. Inability of the woman to ‘produce’ a live-born baby in many cultures is unacceptable and another reason for social exclusion and serious psychological morbidity. Provision of skilled birth attendance and timely access to essential (or emergency) obstetric care (EOC) when an obstetric complication occurs, coupled with newborn care, are key strategies that if implemented will reduce maternal and neonatal mortality and morbidity. A skilled birth attendant is defined as someone with the midwifery skills necessary to manage normal deliveries and diagnose, stabilise and refer obstetric complications. Two levels of EOC can be distinguished: basic EOC and comprehensive EOC. Table 3 highlights the defining characters of basic and comprehensive EOC. As Lord Crisp’s report ‘Scaling up, saving lives’ identifies, there is a global shortage of health workers ‘that are the cornerstone and drivers of health systems’. This shortage in human
Facts that cannot be ignored Maternal mortality • Every minute at least one woman dies from avoidable complications related to pregnancy or childbirth – this equates to over 536,000 women a year Maternal morbidity • For every woman who dies in childbirth, an estimated 20 more suffer injury, infection or disease - approximately 10 million women each year • An estimated 2 million women remain untreated for obstetric fistulae in developing countries and at least 50,000–100,000 new cases occur each year Infant mortality • Every year over 4 million babies die in the first 4 weeks of life; 3 million of these deaths occur in the first week of life and over 3.2 million babies are stillborn • Obstetric complications are responsible in up to 60% of cases • The neonatal deaths alone account for over 40% of all deaths under 5 years (MDG 4) • An estimated 1 million children are left motherless each year. These children are 10 times more likely to die within 2 years of their mothers’ death Cervical cancer • Every 2 minutes at least one woman dies from cervical cancer - this translates into 500,000 new cases and 275,000 deaths due to cervical cancer each year, 85% of which occur in developing countries Unsafe abortions and unmet need for contraception • About 18 million unsafe abortions are carried out in developing countries every year, resulting in 70,000 maternal deaths. Many of these deaths could be prevented if information on family planning and contraceptives were available and put into practice Adolescents – early marriage, early childbirth, early death • In many developing countries, 40–60% of girls are married before the age of 20 years • Girls aged 10–14 years are five times more likely to die in pregnancy and childbirth than women aged 20–24 years
Basic and Comprehensive Essential (or Emergency) Obstetric Care
Feminisation of HIV/AIDs • Women account for nearly half the 40 million people living with HIV worldwide • Young women constitute over 60% of 15–24 year olds living with HIV/AIDS STIs and associated infertility • Around 333 million new cases of curable STIs worldwide each year leading to a high proportion of infertility • Undiagnosed and untreated syphilis in pregnancy leads to poor pregnancy outcome MDG, millennium development goal; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; STIs, sexually transmitted infections.
CEOC
• Parenteral antibiotics • Parenteral oxytocics • Parenteral anti-convulsants • Manual removal of a retained placenta • Removal of retained products of conception (MVA) • Assisted vaginal delivery (vacuum extraction)
All six BEOC functions plus: • Caesarean Section • Blood transfusion
BEOC, basic essential (or emergency) obstetric care; CEOC, comprehensive essential (or emergency) obstetric care; MVA, manual vacuum aspiration.
Table 2
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:7
BEOC
Table 3
198
© 2009 Elsevier Ltd. All rights reserved.
Ethics/education
resource has been identified as one of the most critical constraints to achieving health and development goals such as MDG 5.
Sexual and reproductive health To achieve the ICPD goals, equal attention needs to be given to the reproductive health of the non-pregnant, non-lactating woman in the developing world. Millions of premature deaths, illnesses and injuries could be avoided by helping women prevent unwanted pregnancies and obtain prompt treatment for reproductive health problems. Women should have free access to a variety of family planning methods. Moreover, political will is needed to ensure women are empowered by education and financial independence so as to prevent customs such as early marriage, to enable better health-seeking behaviour and to ensure women have access to the services they need; services they have a basic and universally accepted human right to have.
Focus on cervical cancer – a preventable disease Cervical cancer disproportionately affects the poorest, most vulnerable women. It is the most common cancer in women in sub-Saharan Africa and the leading cause of cancer death among women in the developing world. Without further preventative measures, deaths from cervical cancer are predicted to jump four-fold to over 1 million a year by 2050 as a result of the explosion in human papillomavirus infection rates across the world. Healthcare providers in developing countries regularly see women with advanced, incurable cervical cancer. At this late stage, there is little they can do to save women’s lives. Palliative care provisions (analgesia or simple antibiotics to reduce foul discharge) are not available, let alone radical surgery or radiotherapy. There are multiple reasons why cervical cancer is more common in the developing world. There are no effective national screening programmes and awareness of cervical cancer prevention methods, even amongst healthcare workers, is low. In addition, HIV infection increases susceptibility to the disease. Cervical cancer is a preventable disease by early detection. The UK’s cytology programme saves 2000 lives every year. However, these programmes are not feasible in developing countries as they do not have the resources or the infrastructure required for recall systems. The single-visit visual inspection method simply requires visual inspection of the cervix with dilute vinegar and if necessary immediate treatment with a freezing technique. This method does not require electricity, running water or anaesthetic and it can be provided by trained nurses. Randomised controlled trials in South Africa and India have shown the technique to be safe, acceptable and effective and modelling studies have shown it to reduce the burden of cervical cancer. In fact, one visit between the ages of 30 and 45 years will reduce the lifetime risk by around 35%. There is a clear need to scale up such screening programs. It is hoped that with the advent of a new vaccine for cervical cancer this disease will receive renewed attention inclusive of the needs of women in developing countries.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:7
Think and act In the 10 minutes it has taken you to read this article, at least 25 women and children have died of avoidable causes and even greater morbidity has occurred. As respected individuals of a profession that promises to help others and do no harm, is turning the page and doing nothing justifiable? ◆
Further reading Bang RA, Bang AT, Baitule M, Choudhary Y, Sarmukaddam S, Tale O. High prevalence of gynaecological diseases in rural Indian women. Lancet 1989; 1: 85–88. Program for Appropriate Technology in Health (PATH). Reproductive health. Also available at: http://www.path.org/reproductive-health. php (accessed 15 Mar 09). Rosenfield A, Maine D. Maternal mortality – a neglected tragedy. Where is the M in MCH? Lancet 1985; 2: 83–85. Crisp N. Global Health Partnerships – The UK contribution to health in developing countries. Publishers COI, February 2007. World Health Organization. Reproductive Health Library. http://www. who.int/rhl/en/ (accessed 15 Mar 09). The Lancet.com Collections. Neonatal survival series. Lancet 2005; 365: 891–900, 977–988, 1087–1098, 1189–1197. The Lancet.com Collections. Maternal survival series. Women deliver. Lancet 2007; 370: 1283–1392.
199
© 2009 Elsevier Ltd. All rights reserved.
Priorities in obstetrics and gynaecology in the developing world
Internationally agreed goals In 1994, representatives from more than 180 nations met at the International Conference on Population and Development (ICPD) in Cairo. Sexual and reproductive rights were enshrined as human rights and a holistic ‘programme of action’ was proposed with the following goals: • every sex act should be free of coercion and infection • every pregnancy should be intended • every birth should be healthy. In 2000, eight millennium development goals (MDGs) were adopted by 189 nations during the United Nations Millennium Summit. These MDGs are to be achieved by 2015 and respond to the world’s main development challenges: poverty reduction, education, maternal health, gender equality, combating child mortality, AIDS and other diseases. MDG 5 directly addresses the health needs of women (see Table 1). The goal of universal access to sexual and reproductive health services for women (target 5b) has recently been reinstated as a key target indicator for the achievement of MDG 5. The difference in maternal mortality between developing and developed countries shows the greatest disparity of all health indicators. The lifetime risk of maternal death in Afghanistan and Sierra Leone is estimated to be 1 in 8, in the UK this is 1 in 8200 and in Sweden it is 1 in 17,400. It is very clear that when it comes to the wellbeing of women in resource-poor countries, priorities span the spectrum of obstetrics and gynaecology (see Table 2).
Priya Agrawal Nynke van den Broek
Abstract Every minute of every day a woman in the developing world dies of an avoidable cause of death. For every woman dying there are at least another 20 women who are left with severe morbidity. These deaths can be prevented. The interventions required are clear, inexpensive and effective. Yet they are not universally available or accessible. The call for action has been made, yet the speed of progress is slow.
Keywords cervical cancer; infant mortality; maternal mortality; prevention; reproductive health
Introduction The burden of obstetric and gynaecological mortality and morbidity suffered by women in resource-poor countries was highlighted in a seminal paper by Rosenfield and Maine in 1985 with an urgent plea to ‘put the M back into MCH’ (maternal and child health). In addition, the Safe Motherhood Initiative was started in 1987 in Nairobi, which celebrated its 20th anniversary in London in 2007. Bang and colleagues brought gynaecological morbidity to international attention by the publication of extremely high prevalence rates in rural India: over 55% of women attending ‘health camps’ had one or more gynaecological complaint but only 8% had ever had a gynaecological examination. This illustrated the need for attention to the health of non-pregnant women and to tackle the ‘culture of silence’, which often prevents women from seeking healthcare for gynaecological problems. There has recently been increased attention to the shocking rates of maternal mortality in the developing world; however, the burden of obstetric and gynaecological morbidity remains largely undocumented and unquantified with few evaluations of the associated social and economic burdens to women and their families.
Focus on maternal and neonatal mortality – preventable deaths Five main killers cause 80% of maternal deaths worldwide: haemorrhage, sepsis, unsafe abortion, hypertensive disorders (pre-eclampsia and eclampsia) and ruptured uterus as a result of obstructed labour. These are complicated by pre-existing and co-existing illnesses such as anaemia (which is endemic in most parts of the developing world) and infections such as human immunodeficiency virus (HIV), malaria and tuberculosis. Maternal deaths are largely preventable. There are existing proven effective medical and surgical interventions that are
Millennium Development Goal 5 – addressing the health needs of women Target 5a – Reduce by three-quarters the maternal mortality ratio 5.1 5.2
Target 5b – Achieve universal access to reproductive health 5.3 Increase contraceptive prevalence rate 5.4 Reduce adolescent birth rate 5.5 Increase antenatal care coverage 5.6 Reduce unmet need for family planning
Priya Agrawal BMBCh MA MPH is a Specialist Registrar and Academic Clinical Fellow in Obstetrics & Gynaecology, St Mary’s Hospital, Manchester, UK. Nynke van den Broek PhD FRCOG is a Senior Clinical Lecturer, Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:7
Reduce the maternal mortality ratio Increase the number of births attended by skilled health personnel
Table 1
197
© 2009 Elsevier Ltd. All rights reserved.
Ethics/education
r elatively inexpensive. However, such interventions are not universally available and accessible for women. The simple procedure of manual vacuum aspiration (MVA) for removing retained products of conception – which can be done using local anaesthesia – can prevent deaths from severe sepsis or unsafe abortion. The availability of blood for transfusion would prevent the deaths of at least one-quarter of women who otherwise die of haemorrhage due to the non-availability of blood products. Training in and availability of partograms and access to a safe Caesarean section when needed would prevent many of the complications of obstructed labour such as uterine rupture leading to maternal and neonatal death or urogenital fistulae (estimated incidence of 1–2 per 1000 deliveries worldwide). Lack of specialised surgical and rehabilitation services for women with fistulae results in such women living as outcasts of society in abject poverty. The health of the neonate is closely related to that of the mother. Adequate intrapartum care could help prevent an estimated 3.2 million stillbirths a year, of which at least one in three occurs during delivery. If interventions were in place to ensure good maternal health most of the 4 million deaths in the first month of life could also be prevented. Inability of the woman to ‘produce’ a live-born baby in many cultures is unacceptable and another reason for social exclusion and serious psychological morbidity. Provision of skilled birth attendance and timely access to essential (or emergency) obstetric care (EOC) when an obstetric complication occurs, coupled with newborn care, are key strategies that if implemented will reduce maternal and neonatal mortality and morbidity. A skilled birth attendant is defined as someone with the midwifery skills necessary to manage normal deliveries and diagnose, stabilise and refer obstetric complications. Two levels of EOC can be distinguished: basic EOC and comprehensive EOC. Table 3 highlights the defining characters of basic and comprehensive EOC. As Lord Crisp’s report ‘Scaling up, saving lives’ identifies, there is a global shortage of health workers ‘that are the cornerstone and drivers of health systems’. This shortage in human
Facts that cannot be ignored Maternal mortality • Every minute at least one woman dies from avoidable complications related to pregnancy or childbirth – this equates to over 536,000 women a year Maternal morbidity • For every woman who dies in childbirth, an estimated 20 more suffer injury, infection or disease - approximately 10 million women each year • An estimated 2 million women remain untreated for obstetric fistulae in developing countries and at least 50,000–100,000 new cases occur each year Infant mortality • Every year over 4 million babies die in the first 4 weeks of life; 3 million of these deaths occur in the first week of life and over 3.2 million babies are stillborn • Obstetric complications are responsible in up to 60% of cases • The neonatal deaths alone account for over 40% of all deaths under 5 years (MDG 4) • An estimated 1 million children are left motherless each year. These children are 10 times more likely to die within 2 years of their mothers’ death Cervical cancer • Every 2 minutes at least one woman dies from cervical cancer - this translates into 500,000 new cases and 275,000 deaths due to cervical cancer each year, 85% of which occur in developing countries Unsafe abortions and unmet need for contraception • About 18 million unsafe abortions are carried out in developing countries every year, resulting in 70,000 maternal deaths. Many of these deaths could be prevented if information on family planning and contraceptives were available and put into practice Adolescents – early marriage, early childbirth, early death • In many developing countries, 40–60% of girls are married before the age of 20 years • Girls aged 10–14 years are five times more likely to die in pregnancy and childbirth than women aged 20–24 years
Basic and Comprehensive Essential (or Emergency) Obstetric Care
Feminisation of HIV/AIDs • Women account for nearly half the 40 million people living with HIV worldwide • Young women constitute over 60% of 15–24 year olds living with HIV/AIDS STIs and associated infertility • Around 333 million new cases of curable STIs worldwide each year leading to a high proportion of infertility • Undiagnosed and untreated syphilis in pregnancy leads to poor pregnancy outcome MDG, millennium development goal; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; STIs, sexually transmitted infections.
CEOC
• Parenteral antibiotics • Parenteral oxytocics • Parenteral anti-convulsants • Manual removal of a retained placenta • Removal of retained products of conception (MVA) • Assisted vaginal delivery (vacuum extraction)
All six BEOC functions plus: • Caesarean Section • Blood transfusion
BEOC, basic essential (or emergency) obstetric care; CEOC, comprehensive essential (or emergency) obstetric care; MVA, manual vacuum aspiration.
Table 2
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:7
BEOC
Table 3
198
© 2009 Elsevier Ltd. All rights reserved.
Ethics/education
resource has been identified as one of the most critical constraints to achieving health and development goals such as MDG 5.
Sexual and reproductive health To achieve the ICPD goals, equal attention needs to be given to the reproductive health of the non-pregnant, non-lactating woman in the developing world. Millions of premature deaths, illnesses and injuries could be avoided by helping women prevent unwanted pregnancies and obtain prompt treatment for reproductive health problems. Women should have free access to a variety of family planning methods. Moreover, political will is needed to ensure women are empowered by education and financial independence so as to prevent customs such as early marriage, to enable better health-seeking behaviour and to ensure women have access to the services they need; services they have a basic and universally accepted human right to have.
Focus on cervical cancer – a preventable disease Cervical cancer disproportionately affects the poorest, most vulnerable women. It is the most common cancer in women in sub-Saharan Africa and the leading cause of cancer death among women in the developing world. Without further preventative measures, deaths from cervical cancer are predicted to jump four-fold to over 1 million a year by 2050 as a result of the explosion in human papillomavirus infection rates across the world. Healthcare providers in developing countries regularly see women with advanced, incurable cervical cancer. At this late stage, there is little they can do to save women’s lives. Palliative care provisions (analgesia or simple antibiotics to reduce foul discharge) are not available, let alone radical surgery or radiotherapy. There are multiple reasons why cervical cancer is more common in the developing world. There are no effective national screening programmes and awareness of cervical cancer prevention methods, even amongst healthcare workers, is low. In addition, HIV infection increases susceptibility to the disease. Cervical cancer is a preventable disease by early detection. The UK’s cytology programme saves 2000 lives every year. However, these programmes are not feasible in developing countries as they do not have the resources or the infrastructure required for recall systems. The single-visit visual inspection method simply requires visual inspection of the cervix with dilute vinegar and if necessary immediate treatment with a freezing technique. This method does not require electricity, running water or anaesthetic and it can be provided by trained nurses. Randomised controlled trials in South Africa and India have shown the technique to be safe, acceptable and effective and modelling studies have shown it to reduce the burden of cervical cancer. In fact, one visit between the ages of 30 and 45 years will reduce the lifetime risk by around 35%. There is a clear need to scale up such screening programs. It is hoped that with the advent of a new vaccine for cervical cancer this disease will receive renewed attention inclusive of the needs of women in developing countries.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:7
Think and act In the 10 minutes it has taken you to read this article, at least 25 women and children have died of avoidable causes and even greater morbidity has occurred. As respected individuals of a profession that promises to help others and do no harm, is turning the page and doing nothing justifiable? ◆
Further reading Bang RA, Bang AT, Baitule M, Choudhary Y, Sarmukaddam S, Tale O. High prevalence of gynaecological diseases in rural Indian women. Lancet 1989; 1: 85–88. Program for Appropriate Technology in Health (PATH). Reproductive health. Also available at: http://www.path.org/reproductive-health. php (accessed 15 Mar 09). Rosenfield A, Maine D. Maternal mortality – a neglected tragedy. Where is the M in MCH? Lancet 1985; 2: 83–85. Crisp N. Global Health Partnerships – The UK contribution to health in developing countries. Publishers COI, February 2007. World Health Organization. Reproductive Health Library. http://www. who.int/rhl/en/ (accessed 15 Mar 09). The Lancet.com Collections. Neonatal survival series. Lancet 2005; 365: 891–900, 977–988, 1087–1098, 1189–1197. The Lancet.com Collections. Maternal survival series. Women deliver. Lancet 2007; 370: 1283–1392.
199
© 2009 Elsevier Ltd. All rights reserved.