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The FIGO Save the Mothers Initiative
International Journal of Gynecology and Obstetrics 86 (2004) 283–293
The FIGO Save the Mothers Initiative G. Benagianoa,*, M.F. Fathallab, A. Lalondec, B. Thomasd a
Professor and Dean, First Postgraduate School of Gynecology and Obstetrics, University ‘‘La Sapienza,’’ Rome, Italy, and former Secretary General of FIGO b Professor of Obstetrics and Gynaecology, Assiut University, Egypt, and Past President of FIGO c Executive Vice-President, Society of Gynecologists and Obstetricians of Canada, and Manager, the FIGO Save the Mothers Initiative d Administrative Director, FIGO, UK
1. Introduction For an obstetrician, no event is more tragic than a maternal death. Obstetricians in developed countries may end their professional career without witnessing a single maternal death. For obstetricians in the southern hemisphere, maternal deaths are not statistics. They are human faces seen in agony. They have names, and they haunt their memories. Global awareness of maternal mortality was raised by the International Conference on Safe Motherhood in Nairobi, Kenya, in 1987. The sponsor of the Conference was the World Health Organization (WHO). The United Nations Agency Group was constituted after the Conference, with WHO, the Population Fund (UNFPA), and the World Bank as its members. The group was then joined by UNICEF, the International Planned Parenthood Federation (IPPF), the Population Council, and Family Care International, which provided a secretariat. FIGO was conspicuous by its absence from the initiative. It was not that FIGO or obstetricians declined to participate, but their relevance was in doubt: there was a feeling that obstetricians were part of the problem rather than a part of the solution. Obstetricians were often thought to be *Corresponding author. Tel.: q39-06-490398; fax: q39-064997-2514. E-mail address: [email protected] (G. Benagiano).
chiefly interested in their professional privileges and in high technology, and unwilling to delegate responsibilities to other health professionals or play the constructive role of team leaders. While this may have been true of some, it was certainly not true of most. Obstetricians from developed and developing countries were very much concerned about this tragedy, and they knew that they could alleviate it. The International Safe Motherhood Initiative soon made it clear that obstetricians had an indispensable role in making motherhood safe for all women. Pregnancy and childbirth are risky, as there is no way to predict or prevent all their possible life-threatening complications. However, with the knowledge that we have, these complications can be detected and managed by appropriate obstetric interventions. The question was whether essential obstetric functions could be made available in low-resource settings, and whether obstetricians were willing to face the challenge. When confronted with these questions, FIGO answered both of them with a clear yes, if resources could be mobilized. 2. The beginning An approach came from Dr. Nicholas Dodd, Chief of the Technical Branch of UNFPA, who
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wanted to start a needs assessment of essential and emergency obstetric care in some countries and felt that obstetricians should be involved in the exercise. FIGO’s reaction was that needs assessments would be worth doing only if they were followed by an implementation phase and a proper evaluation of the intervention. UNFPA agreed, and a draft proposal was developed that involved a partnership between obstetricians in developed and developing countries. The extensive paperwork, usually needed for grants from the UN System, was efficiently prepared with the help of the FIGO Secretariat, i.e. Ms. Chantal Pradier, Mr. Brian Thomas, and Ms. Rosa Tunberg. The grant proposal was processed through the UNFPA system, and finally approved on September 4, 1997, with $19 700 allocated for 1997, $251 450 for 1998, $55 000 for 1999, and $117 950 for 2000. The grant letter was signed, on behalf of UNFPA, by Mr. Sethuramiah L.N. Rao, Director of the Technical and Evaluation Division. At about the same time, preparations were going ahead for the FIGO World Congress in Copenhagen. Pharmaceutical companies were being asked to explore their interest in supporting Congress activities. Thanks to a preliminary approach by Prof. Jorgen Falck Larsen, President of the Congress, the pharmaceutical company Pharmacia (then about to merge with Upjohn) decided that if it received a sound scientific proposal with potential impact on women’s health, it was willing to go beyond simple support of the Congress. A detailed plan was presented for a FIGO Save the Mothers Fund and Pharmacia accepted the plan and on May 13, 1997, the agreement was signed at the FIGO secretariat office in London. The donation was determined to be US $250 000 per year over 3 years, and it was to support research demonstration projects focused on reducing maternal mortality in developing countries. An additional support grant was approved, not to exceed 10% of the sum total of the research fund, to cover administrative costs. It must be stressed that Pharmacia–Upjohn did not have a commercial or profit-driven motive in this initiative. In the letter of agreement, the following statement was made: Pharmacia & Upjohn Inc (P&U) and FIGO are different organizations. P&U is a for-profit pharmaceutical firm.
FIGO is a non-profit federation of medical societies. But both agree to work together in their mutual interest in alleviating the suffering of women in pregnancy and childbirth, particularly in developing countries.
The agreement was signed on behalf of P&U by Dr. Shay Weibrich, Worldwide Director, and Dr. Lars Birgenson, Vice-President; and on behalf of FIGO by Dr. M.F. Fathalla, President, and Dr. HoKei Ma, Secretary General. The FIGO Save the Mothers Fund was formally launched at the time of the FIGO Congress in Copenhagen in 1997, with strong enthusiasm among the world obstetric community. Shortly thereafter, thanks to the efforts of Dr. Ann Tinker, then Principal Health Specialist with the World Bank, the Bank became a third sponsor of the Fund. FIGO had the know-how and the commitment. Now that it had also the resources, and it was time to act. And FIGO did. 3. The initiative in action The launch of the FIGO Save the Mothers Fund Project (soon after, renamed the FIGO Save the Mothers Initiative) provided the first concrete evidence of action by the very physicians who dedicate their lives to women’s care; and FIGO, their international federation, was happy to add its own resources to ensure the success of the Initiative. A first meeting to operationally define the activities took place in London during February 1998; a number of FIGO representatives participated: Prof. G. Benagiano, Secretary General and Initia¨ ¨ President, Prof. M. tive Chair; Prof. M. Seppala, Fathalla, Past-President; Prof. S. Arulkumaran, Treasurer; Profs D. Fairweather and Ho-kei Ma, former Secretary Generals; Ms. Chantal Pradier, Executive secretary; and Mr. Bryan Thomas, Assistant Secretary. The representative of Pharmacia–Upjohn, Dr. H. De Koning-Gans, was also present, together with a number of experts: Prof. A. Faundes, Dr. R. Hale, Prof. C. Hudson, Dr. A. Lalonde, and Prof. G. Lindmark. The scope of the meeting was to define the methodology and select the countries to be involved in the Initiative. FIGO determined to tap its strengths, and this decision produced the con-
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cept of ‘twinning’ of member societies, thus making experience gained in the developed world available to colleagues in the developing world— who, in turn, would use their local knowledge to ensure the success of the activities undertaken. It was agreed that, overall, the Initiative would have two components: a field of action and a field of research. 3.1. The field of action The Initiative was to have two phases. After a first phase aimed at assessing the needs, a second phase would provide ‘essential obstetric services’ for women exposed to life-threatening complications. The need-assessment phase would consider three points: ● Are health facilities available? ● Are health facilities utilized? ● Are health facilities of sufficient quality? For Phase One, it was decided to use the publication ‘Guidelines for Monitoring the Availability and Use of Obstetric Services’ issued jointly by UNICEF, WHO, and UNFPA. One chapter contains standard indicators for assessing the availability and utilization of health facilities; by using these standard indicators, it is possible to gauge the level and accessibility of existing facilities, their utilization, and quality. Phase Two, in view of the limited availability of funding, would be conducted in only five countries. The purpose of the meeting was to choose five countries where needs assessments could be undertaken. Countries would be chosen on the basis of need. World Health Day, 7 April, 1998, would be dedicated to Safe Motherhood, providing a good opportunity to focus attention to the importance of the FIGO initiative. The issue of funding was specifically addressed. Contact had been made not only with the original donors, but with Anne Tinker, Principal Health Specialist at the World Bank, and eventually the Bank donated $100 000 to the Initiative. It was also mentioned that telecommunications companies may, at some point, be able to assist in the
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dissemination of information and provide practical assistance at the time of the demonstration projects. The meeting also defined the responsibilities of the Steering Committee, which were to: ● Develop the plan of activities; ● Make decisions on the selection of countries and country teams; ● Monitor and review progress; ● Approve periodic technical reports. The role of the Secretariat was also identified as: ● Providing full secretarial and administrative support for the meetings of the Steering Committee; ● Serving as a liaison with the Research Team and Country Teams as appropriate; ● Making travel, meeting, and accommodation arrangements related to the Save The Mothers Fund as needed; ● Taking responsibility for all financial matters relating to the Save The Mothers Fund, including the disbursement of funds; ● Ensuring that all recipients of funds disbursed under the terms of the various grants acknowledge and adhere to the requirements of the grant providers; ● Preparing progress and financial reports to be submitted to FIGO’s Executive Board and all funding institutions. The meeting then defined how the project areas were to be chosen; it was agreed that they should be chosen on the basis of: ● High maternal mortality; ● The existence of an active society of obstetrics and gynecology; ● The demonstration of Government interest and commitment to improving women’s health; ● An expression of interest from a FIGO member society of obstetricians and gynecologists in a developed country to work in the chosen region. After much deliberation of the relative merits of the applications received and the practicalities involved, the Committee agreed on the following:
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Country
To be twinned with:
Canada Italy Sweden UK UK USA
Uganda Mozambique Ethiopia Nepal Pakistan Central American group
Swedeny Ethiopia
The Committee then agreed upon the following ‘reserve’ list: To be twinned with:
Australia France Germany Netherlands
Papua, New Guinea Burkina FasoyMali Guinea Angola
It was agreed that the FIGO Country Coordinators should be chosen from members of the Steering Committee. Their function would be to lead the Country Teams, to ensure that the individual demonstration projects remained on track, and to act as points of reference for the parties ‘on the ground.’ Their role would also involve reporting on developments to the Steering Committee. The following teams were agreed upon: Country Team: Canaday Uganda
Names: Coordinator: Developed country society representative: Developed country society representatives: Local government:
Researcher: Italyy Mozambique
Coordinator: Developed country society representatives:
Andre´ Lalonde Andre´ Lalonde Dr. Pius Okong Dr. Florence Mirembe Peter Cadamer (Planning Div. Ministry of Finance) Linda Bartlett (Canada) ´ Anibal Faundes Prof. Bellati Dr. Todaro
Developing country society representative: To be identified later Local government: Ministry of Health representative (to be nominated) Researcher: To be identified
Gunilla Lindmark Viveca Odlind ¨ Bo Moller
Developing country society representatives: Eyob Tadesse Solomon Kumbi Local government: To be identified Researcher: To be identified UKy Pakistan
Country
Coordinator: Developed country society representatives:
Coordinator: Developed country society representatives:
Naren Patel Chris Hudson Rudi Pitroff
Developing country society representatives: Shafiq Ahmed Rashid Latif Khan Sadaaqi Jafarey Local government: To be identified Researcher: To be identified USAy Central America
Coordinator: Ralph Hale Developed country society representative: Luis Curet Developing country society representative: Jorge Gonzalez (El Salvador) Local government: To be identified Researcher: To be identified
The first task of the Country Teams—which were made up of physicians from the twinned societies—was to undertake a needs assessment within the country or region of their concern, using guidelines issued by the United Nations w1x. 3.2. The research component The Pharmacia & Upjohn grant was initially for operational research within the initiative. It was felt that one or more research students should synthesize data from various country teams to ensure uniformity. The University of Nottingham had confirmed its willingness to accept two or three fellows and the Faculty Head was prepared to provide input and assistance. Space as well as computer and e-mail facilities could be provided by the university. A credible focus of research would enable the Teams to use standardized systems for collating data. They would thus be able to document carefully the demonstration projects, assess their effectiveness and worth, and encourage their implementation in other areasycountries. It was also agreed that, within the country involved, an
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evaluation institute would be selected to validate the data and the value of each demonstration project. In summary, three research levels were envisaged: the most important was the local level, which retained ownership of the data and would be the ultimate beneficiaries; the second was to implement technical collaboration and support from the society of the developed country; and the third was to ensure the consolidation of the tasks undertaken in the different countries. Action immediately followed the first meeting, and in September 1998 a first assessment was made. During a meeting in London, each of the Country Team Coordinators gave a presentation based on their written reports, which were previously circulated. Each provided a detailed outline of how the individual project would be carried out and specified its financial requirements. An important overall comment stressed the need to closely collaborate with midwives’ associations in the selected countries. In this respect, a role of the Team Coordinator was to ensure that all available human resources were used. The meeting clearly indicated that expectations had been fulfilled and the overall project was on target. It was therefore decided to give the go ahead signal to working partners and encourage them to order equipment immediately. All projects were approved in principle, but subject to clarification and binding amendments. Revised proposals that incorporated the responses to the various amendments and clarifications sought by the Steering Committee were to be submitted. Over the following years, a number of meetings took place to properly monitor progress, identify problems, and suggest solutions. Already in 1999 one point became clear: the original time frame envisaged was totally unrealistic and needed to be extended. This, however, implied not only redirecting existing funds from research to implementation, but searching for additional financial resources. FIGO will be forever grateful to Pharmacia Corporation (the new name Pharmacia– Upjohn was adopted in 2000) for coming to the support of the Save the Mothers Initiative with an additional sum of $300 000.
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4. A description of the projects A detailed description of individual projects has been published recently w2–5x; articles describing the FIGO initiative have also appeared recently w6,7x. These provide full accounts of the projects, which are here only briefly summarized. To guide its work, FIGO adopted the ‘three delay’ model, first described by the Mailman School of Public Health at Columbia University in the United States of America w8x. It ‘‘provides guidance and tools for the design and evaluation of maternal mortality programs,’’ with the aim of identifying solutions to the causes of delay. These are defined as: delay in deciding to seek care; delay in reaching a treatment facility; and delay in receiving adequate treatment at the facility. As already explained, after an initial needs assessment, customized projects were developed to remedy the deficiencies identified in each of the projects areas. All were designed to ensure that the activities would be low cost, replicable in other regions, and fully sustainable locally once the international involvement was phased out. 4.1. The Central America–USA experience w2x Central America was selected because in Guatemala, El Salvador, Honduras, and Nicaragua maternal mortality rates are approximately 200 per 100 000, with a lifetime risk of pregnancy-related deaths between 1 in 65 and 1 in 100 w9x, compared with a rate in the United States of 7 per 100 000 live births and a lifetime risk of death from complications of pregnancy and childbirth of 1 in 3500 w10x. The Central America–USA demonstration projects took place in the following rural provinces of the four countries: Sonsonate in El Salvador, Solo´ in Hondula´ in Guatemala, Santa Rosa de Copan ras, and Matagalpa in Nicaragua. They involved several interventions and objectives, including the implementation of training courses in the management of emergency obstetric care, on the one hand, and of improved relationships between the National Obstetric and Gynecology societies and the Ministries of Health, on the other.
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Given that most institutions providing total care were located in urban areas and were privately owned, it became immediately evident that the capacity to provide basic care in obstetric emergencies was virtually nonexistent. For these reasons, most of the rural population, i.e., an indigent population, had very limited access to obstetric care during pregnancy and at delivery. The scope of the project then focused around assessing and improving obstetric emergency care, developing monitoring systems for maternal mortality, establishing monitoring systems and committees at community and district hospital levels, and identifying strategies to effectively prevent maternal deaths. The following interventions were implemented: ● Training of field coordinators in the management of emergency obstetric care, including the development of ad hoc instructors and course manuals with updates in obstetric emergency care, based on the work undertaken by T.F. Baskett w11x. These coordinators then trained the remainder of the staff in the entire province thereby ensuring that all health care personnel would be adequately trained. ● Introducing a routine protocol for active management with oxytocin during the third phase of labor in all the institutions providing childbirth services. ● Establishing a prospective and systematic data gathering system, including a detailed study of all maternal deaths, with ‘verbal autopsies’ (interviews with family and community members), thereby determining a more realistic maternal mortality rate. ● Creating provincial maternal mortality committees to better understand causes and factors related to each death, with the aim of providing education to ensure better prevention. ● Training health providers in the manual endometrial vacuum aspiration for incomplete abortions. ● Installing radiotelephones at health centers and tertiary hospitals to ensure proper communication with tertiary hospitals.
● Establishing evaluation meetings to brief local and national health authorities and Obstetricsy Gynecology Society representatives. At first the coordinators were surprised to see no significant reduction in the number of maternal deaths, as everyone involved had originally believed that projects would provide positive results within three years. However, looking more carefully at the situation, it became apparent that as a result of the improved surveillance system, more maternal deaths were being identified. This made any comparison with historical data impossible and forced the realization that the intervention would need to continue for five to six years if it was to demonstrate a decrease in maternal mortality. Indeed, the surveillance system developed by the project clearly demonstrated that most maternal deaths were not being reported. Another important finding was that 74% of maternal deaths (approximately two-thirds of which are due to postpartum hemorrhage) occur following delivery at home, and that only 22% occur in hospitals. In all areas, the unmet need for emergency obstetric care was approximately 80%. During the study period a slight decrease was observed, to approximately 70%. The most important achievement of the activities in Central America was the training of almost all health care providers in the targeted provinces. Overall, 929 health care personnel received initial training and 502, follow-up training. Today, all health care facilities in each of the four provinces can provide basic emergency obstetric care. 4.2. The Ethiopia–Sweden experience w3x According to WHO estimates w12x maternal mortality in Ethiopia is higher than in most subSaharan African countries, with a ratio of 1800 deaths per 100 000 live births. The prospect for a rapid decline in this rate is poor, because of the limited availability of health services. In addition, in the country a major cause of deaths occurring during pregnancy is complications caused by illegal abortion. In order to try and modify this dire situation, the Ethiopian Society of Obstetricians and Gynecolo-
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gists (ESOG) and The Swedish Society of Obstetrics and Gynaecology joined forces in 1998. The main project area was Ambo, the principal town of The West Showa Zone, where the Zonal Hospital and two health centers are located. The initial needs assessment, conducted in 1998, determined that obstetric indicators for the Zone were among the lowest in the country. A number of serious problems were identified w3x, including a shortage or even absence of trained manpower at all levels, forced to practice in non-conducive working environments; poor administration and lack of accountability; shortages of essential drugs, supplies, medical equipment and absence of blood transfusion services; absence of an effective referral system. Coverage of emergency obstetric care in the West Showa Zone was calculated for 1999 at slightly more than 6%, raising to some 7.5% in 2001. This indicates an unmet need for emergency obstetric care of 91% and for cesarean sections of 97%. Moreover, emergency obstetric care services were deemed below an acceptable standard and not provided around the clock, even at the Zonal Hospital. For this reason, the main aim of the intervention was to increase coverage in emergency obstetric care through training, accurate record keeping, securing adequate staff, and creating costeffective community-based integrated emergency obstetric care services. This was accomplished by upgrading existing facilities through the provision of equipment, supplies and materials. The intervention included: ● Training physicians and other service providers from Ambo Hospital, Shenen and Ijaji Health Centers in emergency obstetric care; ● Providing new equipment, materials and supplies; ● Entering into agreements with the Ethiopian Red Cross Society for a regular supply of blood for transfusion in Ambo Hospital; ● Securing a dependable supply of water and electricity to a new block for obstetric and gynecological services that had been built at the Ambo Hospital prior to the intervention, and had been standing idle for over two years. Dur-
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ing the intervention period, all the obstetric and gynecologic services—including the operating theatre were moved to the new block; ● Encouraging community participation through a regular dialogue with community leaders and extending invitations to the local population to attend graduation ceremonies of trainees. Before the intervention, obstetric performance of Ambo Hospital was very poor, as documented by the number of referrals to Addis Ababa hospitals. However, as soon as the implementation phase began, the total number of deliveries at Ambo Hospital increased from a baseline of 709 in 1998 to 991 in 2001 (an increase of almost 40%). Particularly significant was the increase in cases with obstetric complications—from 128 in 1998 to 432 in 2001 (an increase of approximately 238%). The leading cause of hospitalization in the area is obstructed labor, accounting for 39% of all complications. Obstetric hemorrhage comes next, accounting for 24% of all admissions. An important achievement has been that instrumental deliveries increased from 6% in 1998 to 23% in 2001. Particularly noteworthy was the almost six-fold increase in the cesarean section rate at Ambo Hospital, which improved from a base line level of 3.8% in 1998 to 17.3% in 2001. Case fatality rates, calculated taking into account direct maternal deaths, decreased from 7.2% in 1998 to 4.6% in 2001. There was an improvement in record keeping after the first round of training, not only in Ambo Hospital, but also in the two health centers. Record keeping was assigned to midwives in all facilities, and it was improved by regular supervision. The two health centers in the intervention area (at Shenen and Ijaji) have been upgraded regarding staff training and provision of equipment and supplies. Regular supervision was implemented to ensure access to basic emergency obstetric care services by the community. The availability of high quality emergency obstetric care in all the involved project sites is currently demonstrated by a significant decline in referrals to Addis Ababa. Annual deliveries at the Shenen Health Center have increased from 38 in 1999 to 76 in 2001, and at the Ijaji Health Center from 206 to 362.
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4.3. The Mozambique–Italy experience According to the Demographic and Health Survey, the maternal mortality rate in Mozambique was between 500 and 1500 per 100 000 live births, in 1997. In the same period the cesarean delivery rate was 2.7%, with a range from 7.3% in urban areas to 1.4% in rural areas. To identify the principal determinants of maternal mortality in Mozambique, the Ministry of Health conducted an analysis of 90 in-hospital maternal deaths in 7 provinces between January 1, 1997, and June 30, 1998. Of these deaths, 75 were attributed to direct obstetric causes. It soon was recognized that the major obstacle to improvement was the almost complete lack of medical practitioners qualified to provide obstetric care. Therefore, improving the country’s ability to train physicians in general, and obstetricians in particular, became a top long-term priority. The activities in Mozambique (coordinated by ´ Prof. Anibal Faundes, from Brazil) were focused on the city of Maputo. During an initial needs assessment conducted in April 1999 in six Rural Hospitals and two General Hospitals, reasons for the inability to provide comprehensive emergency obstetric care were identified: ● Low number of trained personnel; ● Scarcity of drugs; ● Lack of surgical materials and equipment. Although the floods that devastated Mozambique in 2000 affected the project areas and completely disturbed all normal activities, interventions ¸ and Mapuwere planned for the areas of Manhica to. The intervention developed for the area aimed at upgrading three selected hospitals to allow them to become comprehensive emergency obstetric care units, through: ● Training non-physicians (surgical technicians); ● Supplementing the equipment of the EOC units in the selected Districts; ● Improving the diagnosis and management of obstetric complications; ● Improving the interpersonal communication and counseling skills of health providers; ● Improving data collection systems.
As a result of the interventions the number of centers offering basic emergency obstetric care in the Mavalane district doubled, from two in 1998 to four in 2000; in the Manhica district, the number increased from one in 1998 to five in 2000. By December 2001, emergency obstetric care had become available 24 hours per day in Xinavane, part of the day in Mavalane, and intermit¸ with the aim of a 24-h provision tently at Manhica, in all three centers by the end of the project activities. This improvement resulted in an increase in the number of complications treated at Mavalane and Manhica Hospitals. In Mavalane, total deliveries in 1998–99 were 4289, with 1816 complications and 14 cesarean deliveries. In 1999–2000, whereas the total number of deliveries was 3822, the number of complications treated rose to 2065 and the number of cesarean deliveries to 39. The model of intervention used in the FIGO project was adopted as a model for basic and comprehensive emergency care at the national level. As a result, a 5-year plan was developed based on the Mozambique project’s model, taking into account the difficulties, mistakes, and problems that had arisen during the demonstration project. All the lessons learned were incorporated into the national strategy for the reduction of maternal and perinatal mortality in Mozambique—which essentially means the application of Save the Mothers Initiative concepts throughout the country. Work continues to ensure the sustainability of the effort even in the difficult situation faced by Mozambique. 4.4. The Pakistan–United Kingdom experience w4x Pakistan is one of the world’s poorest countries. Although population growth has slowed in recent years and the use of contraceptives is more widespread, maternal mortality remains at least 350 per 100 000 live births w12x; given the problems existing in data collection, however, it is more than likely that this estimate could be less than accurate. The FIGO-supported intervention took place in the District of Kasur, outside Lahore, which, it was believed, was representative of the semi-urban and rural nature of many of the country’s communities. Although the area would not rank as ‘very poor’
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by Pakistani standards, it was considered representative of the country: prior to the commencement of activities, the provision of emergency obstetric care was virtually nonexistent. Three Rural Health Centers (RHCs)—essentially, ‘cottage hospitals’ with only modest in-patient facilities, each serving about six Basic Health Units (BHUs), or primary care facilities—were targeted w4x. The interventions were aimed at:
● The number of births in the project facilities increased from 1124 to 1918 (an increase of almost 71%); ● By the middle of 2002, more than 80% of all women living in the area of intervention who required a cesarean delivery received it at the target centers; ● Good liaison and interaction with government authorities were established at all levels.
● Restoring structural facilities and upgrading the operating and delivery rooms within the RHCs; ● Ensuring that RHC ambulances were functional; ● Negotiating the filling of established health personnel positions, and offering in-service training in emergency obstetric care to existing medical and paramedical staff; ● Undertaking a comprehensive educational program for local people, including men and civic dignitaries (customarily, the decision makers) and ‘dayas’ (traditional birth attendants); ● Providing blood transfusion equipment.
The traditional cultural resistance shown by women to the idea of being examined or treated by male doctors has all but disappeared.
The registers of all three RHCs (once operational) were audited for both vaginal deliveries and all interventions (including cesarean deliveries) carried out in the presence complications, to evaluate which complications were potentially life-threatening, if untreated. Specific attention was given to an evaluation of the impact that the new services might have throughout the area. Therefore, the village of origin of all women presenting at hospitals in Lahore for delivery, or for treatment of a pregnancy-related emergency, was also recorded. This ensured that, for the population of the study area, the total number of deliveries, treated complications, and cesarean deliveries were recorded, irrespective of whether they had taken place within the area or outside of it. As a result of the interventions between July 2001 and June 2002: ● The number of cesarean deliveries increased to 369, from 248 for the corresponding period the preceding year (an increase of 48%); ● 1179 complications were treated compared with 1,076 (an increase of almost 10%);
4.5. The Uganda–Canada experience w5x Uganda is unquestionably another of the poorest countries in the world. Maternal mortality is estimated at 510 per 100 000 live births. The number of births per 1000 women between the ages of 15 and 19 years is 180, and the prevalence rate of active contraception practices is only approximately 15%. Trained health personnel attend only 38% of all births w13x. For these reasons, it seemed natural to select Uganda as one of the countries where the work of the FIGO initiative should begin. Because of the size and rural nature of its population, the presence of a hospital with the capacity to become a referral hospital, and its lack of other public health projects, the District of Kiboga was selected. Maternal mortality rates in the district had been estimated at 650 per 100 000 live births, even higher than the national average. As was the case for all other projects, an initial needs assessment was carried out and the main challenges to the provision of emergency obstetric care services in the district were identified. They included w5x: ● Delays in transportation for women trying to reach a health center; ● Lack of radio or telephone communication between the community dispensaries and the referral hospital; ● Lack of trained midwives; ● Lack of community health workers; ● Lack of basic equipment and supplies in some community dispensaries.
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Several interventions were planned to make emergency obstetric services available to the women of the District and reduce maternal morbidity and mortality w5x: ● Increasing the skilled attendants’ coverage and capabilities related to basic and comprehensive emergency obstetric care; ● Opening eight new Dispensary Maternity Units; ● Recruiting 14 midwives to ensure 24-h coverage; ● Recruiting a midwife-coordinator to coordinate the project’s seminar series for midwives, collect the project data, and organize the bimonthly visits of Canadian andyor Ugandan volunteer obstetricians; ● Upgrading health facilities by providing basic equipment, supplies and medication; ● Identifying and addressing social and cultural barriers to maternal care by educating, through a partnership with the Department of Women and Gender Studies at Makerere University, women and their families on issues related to pregnancy, delivery and possible complications during birth; ● Addressing the lack of emergency communication and transportation facilities in the district to ensure the timely transfer of women to health facilities. After 18 months of continuing work, a number of improvements were noticed: ● One comprehensive emergency obstetric care facility was fully functional, with two other facilities providing basic care; ● The number of births in the project’s health facilities increased from 17% in 1998, to 23% in 1999, although it decreased slightly to 21% in 2000; ● ‘Met need’ for treatment of women with obstetric complications in emergency obstetric care facilities increased from 8.5% in 1998, to 34% in 1999 and 38% in year 2000; ● ‘Met need’ for cesarean sections increased from 1.3% in 1998 to 2.2% in 1999 and to 2.7% in the year 2000. The number of antenatal cases seen and treated by midwives at Kiboga District increased by more than 40%.
Despite the success of the interventions, in all the basic emergency obstetric care and dispensary maternity units, the number of births to women attending antenatal clinics has consistently remained less than 10%, as most deliveries still take place in the home. The overall ‘unmet need’ remains at more than 60% and the ‘unmet need’ for cesarean sections is still between 2.32 and 12.3%. 5. The future The original five projects are coming to their natural conclusion. Overall, FIGO can be proud of what was achieved with such limited means, especially because it was the first time that the Federation had engaged itself in field activities. The job, however, is far from being completed. The FIGO Save the Mothers Initiative has clearly demonstrated that ObstetriciansyGynecologists and other allied health professionals have important contributions to make to global, national, and regional efforts to improve women’s reproductive health and, most specifically, to ensure safe and healthy pregnancies for all women. FIGO and the national ObstetricianyGynecologist associations from countries in both the southern and northern hemispheres can assume leadership of safe motherhood initiatives whether in the fields of advocacy, promotion, program design, management, and evaluation, and other professional endeavors of technical support. In the next few years, FIGO will have to move forward again. FIGO will need to organize an overarching committee that will coordinate the efforts and followup of the FIGO Save the Mothers Initiative and the Postpartum Hemorrhage Initiative, and to provide effective representation at the international level for the new Partnership for Safe Motherhood and Newborn Health (PSMNH). FIGO will need to devote resources to follow up on the numerous opportunities available jointly with UN agencies, UNFPA, UNICEF, WHO, and the World Bank. Secretariat support at the FIGO Headquarters would be a key initiative to fulfill the mandate of FIGO, i.e. to continue to be recognized as the leading, technical agency in the reduction of
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maternal mortality and morbidity and the promotion of sexual and reproductive rights. The future of the FIGO Save the Mothers program will need a large consensus to be developed within the FIGO organization. FIGO may request developedydeveloping countries to submit possible north–south and south–south collaborations. Once the survey of these possible projects occurs, FIGO will need to put together a team to solicit international and national donors to support these initiatives. The partnership between developed and developing country associations is crucial to scale up the ability of smaller associations to respond to the needs of women in their countries. Our force is in partnerships between countries, health care providers, and national governments. FIGO needs to revisit the FIGOyWHO Alliance to make it a more active partnership and see the partnership’s effects on individual countries. FIGO will need to establish a working group with WHO to ensure that all WHO projects in any country would involve the individual countries’ ObstetricianyGynecologist associations as well as FIGO. References
w2 x
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w7 x w8 x
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w1x United Nations Children Fund (UNICEF), World Health Organization (WHO), United Nations Population Fund (UNFPA). Guidelines to monitoring the availability and
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use of obstetric services. New York: UNICEF, WHO, UNFPA, 1997. Curet LB, Foster-Rosales A, Hale R, Kestler E, Medina C, Aetamirano L, et al. FIGO Save the Mothers Initiative: the Central America and USA collaboration. Int J Gynecol Obstet 2003;80:213 –221. Mekbib T, Kassaye E, Getachew A, Tadesse T, Debebe A. FIGO Save the Mothers Initiative: the Ethiopia–Sweden collaboration, Int J Gynecol Obstet 2003;81:93– 102. Lodhi S, Zaman F, Sohail R, et al. FIGO Save the Mothers Initiative: the Pakistan–United Kingdom collaboration, Int J Gynecol Obstet; in press. Lalonde AB, Okong P, Mugasa A, Perron L. FIGO Save the Mothers Initiative: the Uganda–Canada collaboration. Int J Gynecol Obstet 2003;80:204 –212. Benagiano G, Thomas B. Saving mothers lives: the FIGO save the mothers initiative. Int J Gynecol Obstet 2003;80:198 –203. Benagiano G, Thomas B. Safe Motherhood: the FIGO Initiative. Int J Gynecol Obstet 2003;82:263 –274. Maine D, Azakalin MD, Ward VM, Kamara A. The Design and Evaluation of Maternal Mortality Programs. New York: Columbia School of Public Health, 1997. AbouZahr C, Royston E. Maternal mortality: a global fact book. Geneva: WHO, 1991. US Centers for Disease Control and Prevention. Maternal mortality—United States, 1987–1996. Morbid Mortal Wkly Rep 1998;47:705 –707. Baskett TF. Essential management of obstetric emergencies. New York: Wiley, 1985. WHO. Maternal mortality in 1995: estimates developed by WHO, UNICEF, UNFPA. Geneva: WHO, 2001. UNFPA. The state of the world population 2000: live together, worlds apart. UNFPA, 2000.
The FIGO Save the Mothers Initiative G. Benagianoa,*, M.F. Fathallab, A. Lalondec, B. Thomasd a
Professor and Dean, First Postgraduate School of Gynecology and Obstetrics, University ‘‘La Sapienza,’’ Rome, Italy, and former Secretary General of FIGO b Professor of Obstetrics and Gynaecology, Assiut University, Egypt, and Past President of FIGO c Executive Vice-President, Society of Gynecologists and Obstetricians of Canada, and Manager, the FIGO Save the Mothers Initiative d Administrative Director, FIGO, UK
1. Introduction For an obstetrician, no event is more tragic than a maternal death. Obstetricians in developed countries may end their professional career without witnessing a single maternal death. For obstetricians in the southern hemisphere, maternal deaths are not statistics. They are human faces seen in agony. They have names, and they haunt their memories. Global awareness of maternal mortality was raised by the International Conference on Safe Motherhood in Nairobi, Kenya, in 1987. The sponsor of the Conference was the World Health Organization (WHO). The United Nations Agency Group was constituted after the Conference, with WHO, the Population Fund (UNFPA), and the World Bank as its members. The group was then joined by UNICEF, the International Planned Parenthood Federation (IPPF), the Population Council, and Family Care International, which provided a secretariat. FIGO was conspicuous by its absence from the initiative. It was not that FIGO or obstetricians declined to participate, but their relevance was in doubt: there was a feeling that obstetricians were part of the problem rather than a part of the solution. Obstetricians were often thought to be *Corresponding author. Tel.: q39-06-490398; fax: q39-064997-2514. E-mail address: [email protected] (G. Benagiano).
chiefly interested in their professional privileges and in high technology, and unwilling to delegate responsibilities to other health professionals or play the constructive role of team leaders. While this may have been true of some, it was certainly not true of most. Obstetricians from developed and developing countries were very much concerned about this tragedy, and they knew that they could alleviate it. The International Safe Motherhood Initiative soon made it clear that obstetricians had an indispensable role in making motherhood safe for all women. Pregnancy and childbirth are risky, as there is no way to predict or prevent all their possible life-threatening complications. However, with the knowledge that we have, these complications can be detected and managed by appropriate obstetric interventions. The question was whether essential obstetric functions could be made available in low-resource settings, and whether obstetricians were willing to face the challenge. When confronted with these questions, FIGO answered both of them with a clear yes, if resources could be mobilized. 2. The beginning An approach came from Dr. Nicholas Dodd, Chief of the Technical Branch of UNFPA, who
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wanted to start a needs assessment of essential and emergency obstetric care in some countries and felt that obstetricians should be involved in the exercise. FIGO’s reaction was that needs assessments would be worth doing only if they were followed by an implementation phase and a proper evaluation of the intervention. UNFPA agreed, and a draft proposal was developed that involved a partnership between obstetricians in developed and developing countries. The extensive paperwork, usually needed for grants from the UN System, was efficiently prepared with the help of the FIGO Secretariat, i.e. Ms. Chantal Pradier, Mr. Brian Thomas, and Ms. Rosa Tunberg. The grant proposal was processed through the UNFPA system, and finally approved on September 4, 1997, with $19 700 allocated for 1997, $251 450 for 1998, $55 000 for 1999, and $117 950 for 2000. The grant letter was signed, on behalf of UNFPA, by Mr. Sethuramiah L.N. Rao, Director of the Technical and Evaluation Division. At about the same time, preparations were going ahead for the FIGO World Congress in Copenhagen. Pharmaceutical companies were being asked to explore their interest in supporting Congress activities. Thanks to a preliminary approach by Prof. Jorgen Falck Larsen, President of the Congress, the pharmaceutical company Pharmacia (then about to merge with Upjohn) decided that if it received a sound scientific proposal with potential impact on women’s health, it was willing to go beyond simple support of the Congress. A detailed plan was presented for a FIGO Save the Mothers Fund and Pharmacia accepted the plan and on May 13, 1997, the agreement was signed at the FIGO secretariat office in London. The donation was determined to be US $250 000 per year over 3 years, and it was to support research demonstration projects focused on reducing maternal mortality in developing countries. An additional support grant was approved, not to exceed 10% of the sum total of the research fund, to cover administrative costs. It must be stressed that Pharmacia–Upjohn did not have a commercial or profit-driven motive in this initiative. In the letter of agreement, the following statement was made: Pharmacia & Upjohn Inc (P&U) and FIGO are different organizations. P&U is a for-profit pharmaceutical firm.
FIGO is a non-profit federation of medical societies. But both agree to work together in their mutual interest in alleviating the suffering of women in pregnancy and childbirth, particularly in developing countries.
The agreement was signed on behalf of P&U by Dr. Shay Weibrich, Worldwide Director, and Dr. Lars Birgenson, Vice-President; and on behalf of FIGO by Dr. M.F. Fathalla, President, and Dr. HoKei Ma, Secretary General. The FIGO Save the Mothers Fund was formally launched at the time of the FIGO Congress in Copenhagen in 1997, with strong enthusiasm among the world obstetric community. Shortly thereafter, thanks to the efforts of Dr. Ann Tinker, then Principal Health Specialist with the World Bank, the Bank became a third sponsor of the Fund. FIGO had the know-how and the commitment. Now that it had also the resources, and it was time to act. And FIGO did. 3. The initiative in action The launch of the FIGO Save the Mothers Fund Project (soon after, renamed the FIGO Save the Mothers Initiative) provided the first concrete evidence of action by the very physicians who dedicate their lives to women’s care; and FIGO, their international federation, was happy to add its own resources to ensure the success of the Initiative. A first meeting to operationally define the activities took place in London during February 1998; a number of FIGO representatives participated: Prof. G. Benagiano, Secretary General and Initia¨ ¨ President, Prof. M. tive Chair; Prof. M. Seppala, Fathalla, Past-President; Prof. S. Arulkumaran, Treasurer; Profs D. Fairweather and Ho-kei Ma, former Secretary Generals; Ms. Chantal Pradier, Executive secretary; and Mr. Bryan Thomas, Assistant Secretary. The representative of Pharmacia–Upjohn, Dr. H. De Koning-Gans, was also present, together with a number of experts: Prof. A. Faundes, Dr. R. Hale, Prof. C. Hudson, Dr. A. Lalonde, and Prof. G. Lindmark. The scope of the meeting was to define the methodology and select the countries to be involved in the Initiative. FIGO determined to tap its strengths, and this decision produced the con-
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cept of ‘twinning’ of member societies, thus making experience gained in the developed world available to colleagues in the developing world— who, in turn, would use their local knowledge to ensure the success of the activities undertaken. It was agreed that, overall, the Initiative would have two components: a field of action and a field of research. 3.1. The field of action The Initiative was to have two phases. After a first phase aimed at assessing the needs, a second phase would provide ‘essential obstetric services’ for women exposed to life-threatening complications. The need-assessment phase would consider three points: ● Are health facilities available? ● Are health facilities utilized? ● Are health facilities of sufficient quality? For Phase One, it was decided to use the publication ‘Guidelines for Monitoring the Availability and Use of Obstetric Services’ issued jointly by UNICEF, WHO, and UNFPA. One chapter contains standard indicators for assessing the availability and utilization of health facilities; by using these standard indicators, it is possible to gauge the level and accessibility of existing facilities, their utilization, and quality. Phase Two, in view of the limited availability of funding, would be conducted in only five countries. The purpose of the meeting was to choose five countries where needs assessments could be undertaken. Countries would be chosen on the basis of need. World Health Day, 7 April, 1998, would be dedicated to Safe Motherhood, providing a good opportunity to focus attention to the importance of the FIGO initiative. The issue of funding was specifically addressed. Contact had been made not only with the original donors, but with Anne Tinker, Principal Health Specialist at the World Bank, and eventually the Bank donated $100 000 to the Initiative. It was also mentioned that telecommunications companies may, at some point, be able to assist in the
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dissemination of information and provide practical assistance at the time of the demonstration projects. The meeting also defined the responsibilities of the Steering Committee, which were to: ● Develop the plan of activities; ● Make decisions on the selection of countries and country teams; ● Monitor and review progress; ● Approve periodic technical reports. The role of the Secretariat was also identified as: ● Providing full secretarial and administrative support for the meetings of the Steering Committee; ● Serving as a liaison with the Research Team and Country Teams as appropriate; ● Making travel, meeting, and accommodation arrangements related to the Save The Mothers Fund as needed; ● Taking responsibility for all financial matters relating to the Save The Mothers Fund, including the disbursement of funds; ● Ensuring that all recipients of funds disbursed under the terms of the various grants acknowledge and adhere to the requirements of the grant providers; ● Preparing progress and financial reports to be submitted to FIGO’s Executive Board and all funding institutions. The meeting then defined how the project areas were to be chosen; it was agreed that they should be chosen on the basis of: ● High maternal mortality; ● The existence of an active society of obstetrics and gynecology; ● The demonstration of Government interest and commitment to improving women’s health; ● An expression of interest from a FIGO member society of obstetricians and gynecologists in a developed country to work in the chosen region. After much deliberation of the relative merits of the applications received and the practicalities involved, the Committee agreed on the following:
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Country
To be twinned with:
Canada Italy Sweden UK UK USA
Uganda Mozambique Ethiopia Nepal Pakistan Central American group
Swedeny Ethiopia
The Committee then agreed upon the following ‘reserve’ list: To be twinned with:
Australia France Germany Netherlands
Papua, New Guinea Burkina FasoyMali Guinea Angola
It was agreed that the FIGO Country Coordinators should be chosen from members of the Steering Committee. Their function would be to lead the Country Teams, to ensure that the individual demonstration projects remained on track, and to act as points of reference for the parties ‘on the ground.’ Their role would also involve reporting on developments to the Steering Committee. The following teams were agreed upon: Country Team: Canaday Uganda
Names: Coordinator: Developed country society representative: Developed country society representatives: Local government:
Researcher: Italyy Mozambique
Coordinator: Developed country society representatives:
Andre´ Lalonde Andre´ Lalonde Dr. Pius Okong Dr. Florence Mirembe Peter Cadamer (Planning Div. Ministry of Finance) Linda Bartlett (Canada) ´ Anibal Faundes Prof. Bellati Dr. Todaro
Developing country society representative: To be identified later Local government: Ministry of Health representative (to be nominated) Researcher: To be identified
Gunilla Lindmark Viveca Odlind ¨ Bo Moller
Developing country society representatives: Eyob Tadesse Solomon Kumbi Local government: To be identified Researcher: To be identified UKy Pakistan
Country
Coordinator: Developed country society representatives:
Coordinator: Developed country society representatives:
Naren Patel Chris Hudson Rudi Pitroff
Developing country society representatives: Shafiq Ahmed Rashid Latif Khan Sadaaqi Jafarey Local government: To be identified Researcher: To be identified USAy Central America
Coordinator: Ralph Hale Developed country society representative: Luis Curet Developing country society representative: Jorge Gonzalez (El Salvador) Local government: To be identified Researcher: To be identified
The first task of the Country Teams—which were made up of physicians from the twinned societies—was to undertake a needs assessment within the country or region of their concern, using guidelines issued by the United Nations w1x. 3.2. The research component The Pharmacia & Upjohn grant was initially for operational research within the initiative. It was felt that one or more research students should synthesize data from various country teams to ensure uniformity. The University of Nottingham had confirmed its willingness to accept two or three fellows and the Faculty Head was prepared to provide input and assistance. Space as well as computer and e-mail facilities could be provided by the university. A credible focus of research would enable the Teams to use standardized systems for collating data. They would thus be able to document carefully the demonstration projects, assess their effectiveness and worth, and encourage their implementation in other areasycountries. It was also agreed that, within the country involved, an
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evaluation institute would be selected to validate the data and the value of each demonstration project. In summary, three research levels were envisaged: the most important was the local level, which retained ownership of the data and would be the ultimate beneficiaries; the second was to implement technical collaboration and support from the society of the developed country; and the third was to ensure the consolidation of the tasks undertaken in the different countries. Action immediately followed the first meeting, and in September 1998 a first assessment was made. During a meeting in London, each of the Country Team Coordinators gave a presentation based on their written reports, which were previously circulated. Each provided a detailed outline of how the individual project would be carried out and specified its financial requirements. An important overall comment stressed the need to closely collaborate with midwives’ associations in the selected countries. In this respect, a role of the Team Coordinator was to ensure that all available human resources were used. The meeting clearly indicated that expectations had been fulfilled and the overall project was on target. It was therefore decided to give the go ahead signal to working partners and encourage them to order equipment immediately. All projects were approved in principle, but subject to clarification and binding amendments. Revised proposals that incorporated the responses to the various amendments and clarifications sought by the Steering Committee were to be submitted. Over the following years, a number of meetings took place to properly monitor progress, identify problems, and suggest solutions. Already in 1999 one point became clear: the original time frame envisaged was totally unrealistic and needed to be extended. This, however, implied not only redirecting existing funds from research to implementation, but searching for additional financial resources. FIGO will be forever grateful to Pharmacia Corporation (the new name Pharmacia– Upjohn was adopted in 2000) for coming to the support of the Save the Mothers Initiative with an additional sum of $300 000.
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4. A description of the projects A detailed description of individual projects has been published recently w2–5x; articles describing the FIGO initiative have also appeared recently w6,7x. These provide full accounts of the projects, which are here only briefly summarized. To guide its work, FIGO adopted the ‘three delay’ model, first described by the Mailman School of Public Health at Columbia University in the United States of America w8x. It ‘‘provides guidance and tools for the design and evaluation of maternal mortality programs,’’ with the aim of identifying solutions to the causes of delay. These are defined as: delay in deciding to seek care; delay in reaching a treatment facility; and delay in receiving adequate treatment at the facility. As already explained, after an initial needs assessment, customized projects were developed to remedy the deficiencies identified in each of the projects areas. All were designed to ensure that the activities would be low cost, replicable in other regions, and fully sustainable locally once the international involvement was phased out. 4.1. The Central America–USA experience w2x Central America was selected because in Guatemala, El Salvador, Honduras, and Nicaragua maternal mortality rates are approximately 200 per 100 000, with a lifetime risk of pregnancy-related deaths between 1 in 65 and 1 in 100 w9x, compared with a rate in the United States of 7 per 100 000 live births and a lifetime risk of death from complications of pregnancy and childbirth of 1 in 3500 w10x. The Central America–USA demonstration projects took place in the following rural provinces of the four countries: Sonsonate in El Salvador, Solo´ in Hondula´ in Guatemala, Santa Rosa de Copan ras, and Matagalpa in Nicaragua. They involved several interventions and objectives, including the implementation of training courses in the management of emergency obstetric care, on the one hand, and of improved relationships between the National Obstetric and Gynecology societies and the Ministries of Health, on the other.
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Given that most institutions providing total care were located in urban areas and were privately owned, it became immediately evident that the capacity to provide basic care in obstetric emergencies was virtually nonexistent. For these reasons, most of the rural population, i.e., an indigent population, had very limited access to obstetric care during pregnancy and at delivery. The scope of the project then focused around assessing and improving obstetric emergency care, developing monitoring systems for maternal mortality, establishing monitoring systems and committees at community and district hospital levels, and identifying strategies to effectively prevent maternal deaths. The following interventions were implemented: ● Training of field coordinators in the management of emergency obstetric care, including the development of ad hoc instructors and course manuals with updates in obstetric emergency care, based on the work undertaken by T.F. Baskett w11x. These coordinators then trained the remainder of the staff in the entire province thereby ensuring that all health care personnel would be adequately trained. ● Introducing a routine protocol for active management with oxytocin during the third phase of labor in all the institutions providing childbirth services. ● Establishing a prospective and systematic data gathering system, including a detailed study of all maternal deaths, with ‘verbal autopsies’ (interviews with family and community members), thereby determining a more realistic maternal mortality rate. ● Creating provincial maternal mortality committees to better understand causes and factors related to each death, with the aim of providing education to ensure better prevention. ● Training health providers in the manual endometrial vacuum aspiration for incomplete abortions. ● Installing radiotelephones at health centers and tertiary hospitals to ensure proper communication with tertiary hospitals.
● Establishing evaluation meetings to brief local and national health authorities and Obstetricsy Gynecology Society representatives. At first the coordinators were surprised to see no significant reduction in the number of maternal deaths, as everyone involved had originally believed that projects would provide positive results within three years. However, looking more carefully at the situation, it became apparent that as a result of the improved surveillance system, more maternal deaths were being identified. This made any comparison with historical data impossible and forced the realization that the intervention would need to continue for five to six years if it was to demonstrate a decrease in maternal mortality. Indeed, the surveillance system developed by the project clearly demonstrated that most maternal deaths were not being reported. Another important finding was that 74% of maternal deaths (approximately two-thirds of which are due to postpartum hemorrhage) occur following delivery at home, and that only 22% occur in hospitals. In all areas, the unmet need for emergency obstetric care was approximately 80%. During the study period a slight decrease was observed, to approximately 70%. The most important achievement of the activities in Central America was the training of almost all health care providers in the targeted provinces. Overall, 929 health care personnel received initial training and 502, follow-up training. Today, all health care facilities in each of the four provinces can provide basic emergency obstetric care. 4.2. The Ethiopia–Sweden experience w3x According to WHO estimates w12x maternal mortality in Ethiopia is higher than in most subSaharan African countries, with a ratio of 1800 deaths per 100 000 live births. The prospect for a rapid decline in this rate is poor, because of the limited availability of health services. In addition, in the country a major cause of deaths occurring during pregnancy is complications caused by illegal abortion. In order to try and modify this dire situation, the Ethiopian Society of Obstetricians and Gynecolo-
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gists (ESOG) and The Swedish Society of Obstetrics and Gynaecology joined forces in 1998. The main project area was Ambo, the principal town of The West Showa Zone, where the Zonal Hospital and two health centers are located. The initial needs assessment, conducted in 1998, determined that obstetric indicators for the Zone were among the lowest in the country. A number of serious problems were identified w3x, including a shortage or even absence of trained manpower at all levels, forced to practice in non-conducive working environments; poor administration and lack of accountability; shortages of essential drugs, supplies, medical equipment and absence of blood transfusion services; absence of an effective referral system. Coverage of emergency obstetric care in the West Showa Zone was calculated for 1999 at slightly more than 6%, raising to some 7.5% in 2001. This indicates an unmet need for emergency obstetric care of 91% and for cesarean sections of 97%. Moreover, emergency obstetric care services were deemed below an acceptable standard and not provided around the clock, even at the Zonal Hospital. For this reason, the main aim of the intervention was to increase coverage in emergency obstetric care through training, accurate record keeping, securing adequate staff, and creating costeffective community-based integrated emergency obstetric care services. This was accomplished by upgrading existing facilities through the provision of equipment, supplies and materials. The intervention included: ● Training physicians and other service providers from Ambo Hospital, Shenen and Ijaji Health Centers in emergency obstetric care; ● Providing new equipment, materials and supplies; ● Entering into agreements with the Ethiopian Red Cross Society for a regular supply of blood for transfusion in Ambo Hospital; ● Securing a dependable supply of water and electricity to a new block for obstetric and gynecological services that had been built at the Ambo Hospital prior to the intervention, and had been standing idle for over two years. Dur-
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ing the intervention period, all the obstetric and gynecologic services—including the operating theatre were moved to the new block; ● Encouraging community participation through a regular dialogue with community leaders and extending invitations to the local population to attend graduation ceremonies of trainees. Before the intervention, obstetric performance of Ambo Hospital was very poor, as documented by the number of referrals to Addis Ababa hospitals. However, as soon as the implementation phase began, the total number of deliveries at Ambo Hospital increased from a baseline of 709 in 1998 to 991 in 2001 (an increase of almost 40%). Particularly significant was the increase in cases with obstetric complications—from 128 in 1998 to 432 in 2001 (an increase of approximately 238%). The leading cause of hospitalization in the area is obstructed labor, accounting for 39% of all complications. Obstetric hemorrhage comes next, accounting for 24% of all admissions. An important achievement has been that instrumental deliveries increased from 6% in 1998 to 23% in 2001. Particularly noteworthy was the almost six-fold increase in the cesarean section rate at Ambo Hospital, which improved from a base line level of 3.8% in 1998 to 17.3% in 2001. Case fatality rates, calculated taking into account direct maternal deaths, decreased from 7.2% in 1998 to 4.6% in 2001. There was an improvement in record keeping after the first round of training, not only in Ambo Hospital, but also in the two health centers. Record keeping was assigned to midwives in all facilities, and it was improved by regular supervision. The two health centers in the intervention area (at Shenen and Ijaji) have been upgraded regarding staff training and provision of equipment and supplies. Regular supervision was implemented to ensure access to basic emergency obstetric care services by the community. The availability of high quality emergency obstetric care in all the involved project sites is currently demonstrated by a significant decline in referrals to Addis Ababa. Annual deliveries at the Shenen Health Center have increased from 38 in 1999 to 76 in 2001, and at the Ijaji Health Center from 206 to 362.
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4.3. The Mozambique–Italy experience According to the Demographic and Health Survey, the maternal mortality rate in Mozambique was between 500 and 1500 per 100 000 live births, in 1997. In the same period the cesarean delivery rate was 2.7%, with a range from 7.3% in urban areas to 1.4% in rural areas. To identify the principal determinants of maternal mortality in Mozambique, the Ministry of Health conducted an analysis of 90 in-hospital maternal deaths in 7 provinces between January 1, 1997, and June 30, 1998. Of these deaths, 75 were attributed to direct obstetric causes. It soon was recognized that the major obstacle to improvement was the almost complete lack of medical practitioners qualified to provide obstetric care. Therefore, improving the country’s ability to train physicians in general, and obstetricians in particular, became a top long-term priority. The activities in Mozambique (coordinated by ´ Prof. Anibal Faundes, from Brazil) were focused on the city of Maputo. During an initial needs assessment conducted in April 1999 in six Rural Hospitals and two General Hospitals, reasons for the inability to provide comprehensive emergency obstetric care were identified: ● Low number of trained personnel; ● Scarcity of drugs; ● Lack of surgical materials and equipment. Although the floods that devastated Mozambique in 2000 affected the project areas and completely disturbed all normal activities, interventions ¸ and Mapuwere planned for the areas of Manhica to. The intervention developed for the area aimed at upgrading three selected hospitals to allow them to become comprehensive emergency obstetric care units, through: ● Training non-physicians (surgical technicians); ● Supplementing the equipment of the EOC units in the selected Districts; ● Improving the diagnosis and management of obstetric complications; ● Improving the interpersonal communication and counseling skills of health providers; ● Improving data collection systems.
As a result of the interventions the number of centers offering basic emergency obstetric care in the Mavalane district doubled, from two in 1998 to four in 2000; in the Manhica district, the number increased from one in 1998 to five in 2000. By December 2001, emergency obstetric care had become available 24 hours per day in Xinavane, part of the day in Mavalane, and intermit¸ with the aim of a 24-h provision tently at Manhica, in all three centers by the end of the project activities. This improvement resulted in an increase in the number of complications treated at Mavalane and Manhica Hospitals. In Mavalane, total deliveries in 1998–99 were 4289, with 1816 complications and 14 cesarean deliveries. In 1999–2000, whereas the total number of deliveries was 3822, the number of complications treated rose to 2065 and the number of cesarean deliveries to 39. The model of intervention used in the FIGO project was adopted as a model for basic and comprehensive emergency care at the national level. As a result, a 5-year plan was developed based on the Mozambique project’s model, taking into account the difficulties, mistakes, and problems that had arisen during the demonstration project. All the lessons learned were incorporated into the national strategy for the reduction of maternal and perinatal mortality in Mozambique—which essentially means the application of Save the Mothers Initiative concepts throughout the country. Work continues to ensure the sustainability of the effort even in the difficult situation faced by Mozambique. 4.4. The Pakistan–United Kingdom experience w4x Pakistan is one of the world’s poorest countries. Although population growth has slowed in recent years and the use of contraceptives is more widespread, maternal mortality remains at least 350 per 100 000 live births w12x; given the problems existing in data collection, however, it is more than likely that this estimate could be less than accurate. The FIGO-supported intervention took place in the District of Kasur, outside Lahore, which, it was believed, was representative of the semi-urban and rural nature of many of the country’s communities. Although the area would not rank as ‘very poor’
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by Pakistani standards, it was considered representative of the country: prior to the commencement of activities, the provision of emergency obstetric care was virtually nonexistent. Three Rural Health Centers (RHCs)—essentially, ‘cottage hospitals’ with only modest in-patient facilities, each serving about six Basic Health Units (BHUs), or primary care facilities—were targeted w4x. The interventions were aimed at:
● The number of births in the project facilities increased from 1124 to 1918 (an increase of almost 71%); ● By the middle of 2002, more than 80% of all women living in the area of intervention who required a cesarean delivery received it at the target centers; ● Good liaison and interaction with government authorities were established at all levels.
● Restoring structural facilities and upgrading the operating and delivery rooms within the RHCs; ● Ensuring that RHC ambulances were functional; ● Negotiating the filling of established health personnel positions, and offering in-service training in emergency obstetric care to existing medical and paramedical staff; ● Undertaking a comprehensive educational program for local people, including men and civic dignitaries (customarily, the decision makers) and ‘dayas’ (traditional birth attendants); ● Providing blood transfusion equipment.
The traditional cultural resistance shown by women to the idea of being examined or treated by male doctors has all but disappeared.
The registers of all three RHCs (once operational) were audited for both vaginal deliveries and all interventions (including cesarean deliveries) carried out in the presence complications, to evaluate which complications were potentially life-threatening, if untreated. Specific attention was given to an evaluation of the impact that the new services might have throughout the area. Therefore, the village of origin of all women presenting at hospitals in Lahore for delivery, or for treatment of a pregnancy-related emergency, was also recorded. This ensured that, for the population of the study area, the total number of deliveries, treated complications, and cesarean deliveries were recorded, irrespective of whether they had taken place within the area or outside of it. As a result of the interventions between July 2001 and June 2002: ● The number of cesarean deliveries increased to 369, from 248 for the corresponding period the preceding year (an increase of 48%); ● 1179 complications were treated compared with 1,076 (an increase of almost 10%);
4.5. The Uganda–Canada experience w5x Uganda is unquestionably another of the poorest countries in the world. Maternal mortality is estimated at 510 per 100 000 live births. The number of births per 1000 women between the ages of 15 and 19 years is 180, and the prevalence rate of active contraception practices is only approximately 15%. Trained health personnel attend only 38% of all births w13x. For these reasons, it seemed natural to select Uganda as one of the countries where the work of the FIGO initiative should begin. Because of the size and rural nature of its population, the presence of a hospital with the capacity to become a referral hospital, and its lack of other public health projects, the District of Kiboga was selected. Maternal mortality rates in the district had been estimated at 650 per 100 000 live births, even higher than the national average. As was the case for all other projects, an initial needs assessment was carried out and the main challenges to the provision of emergency obstetric care services in the district were identified. They included w5x: ● Delays in transportation for women trying to reach a health center; ● Lack of radio or telephone communication between the community dispensaries and the referral hospital; ● Lack of trained midwives; ● Lack of community health workers; ● Lack of basic equipment and supplies in some community dispensaries.
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Several interventions were planned to make emergency obstetric services available to the women of the District and reduce maternal morbidity and mortality w5x: ● Increasing the skilled attendants’ coverage and capabilities related to basic and comprehensive emergency obstetric care; ● Opening eight new Dispensary Maternity Units; ● Recruiting 14 midwives to ensure 24-h coverage; ● Recruiting a midwife-coordinator to coordinate the project’s seminar series for midwives, collect the project data, and organize the bimonthly visits of Canadian andyor Ugandan volunteer obstetricians; ● Upgrading health facilities by providing basic equipment, supplies and medication; ● Identifying and addressing social and cultural barriers to maternal care by educating, through a partnership with the Department of Women and Gender Studies at Makerere University, women and their families on issues related to pregnancy, delivery and possible complications during birth; ● Addressing the lack of emergency communication and transportation facilities in the district to ensure the timely transfer of women to health facilities. After 18 months of continuing work, a number of improvements were noticed: ● One comprehensive emergency obstetric care facility was fully functional, with two other facilities providing basic care; ● The number of births in the project’s health facilities increased from 17% in 1998, to 23% in 1999, although it decreased slightly to 21% in 2000; ● ‘Met need’ for treatment of women with obstetric complications in emergency obstetric care facilities increased from 8.5% in 1998, to 34% in 1999 and 38% in year 2000; ● ‘Met need’ for cesarean sections increased from 1.3% in 1998 to 2.2% in 1999 and to 2.7% in the year 2000. The number of antenatal cases seen and treated by midwives at Kiboga District increased by more than 40%.
Despite the success of the interventions, in all the basic emergency obstetric care and dispensary maternity units, the number of births to women attending antenatal clinics has consistently remained less than 10%, as most deliveries still take place in the home. The overall ‘unmet need’ remains at more than 60% and the ‘unmet need’ for cesarean sections is still between 2.32 and 12.3%. 5. The future The original five projects are coming to their natural conclusion. Overall, FIGO can be proud of what was achieved with such limited means, especially because it was the first time that the Federation had engaged itself in field activities. The job, however, is far from being completed. The FIGO Save the Mothers Initiative has clearly demonstrated that ObstetriciansyGynecologists and other allied health professionals have important contributions to make to global, national, and regional efforts to improve women’s reproductive health and, most specifically, to ensure safe and healthy pregnancies for all women. FIGO and the national ObstetricianyGynecologist associations from countries in both the southern and northern hemispheres can assume leadership of safe motherhood initiatives whether in the fields of advocacy, promotion, program design, management, and evaluation, and other professional endeavors of technical support. In the next few years, FIGO will have to move forward again. FIGO will need to organize an overarching committee that will coordinate the efforts and followup of the FIGO Save the Mothers Initiative and the Postpartum Hemorrhage Initiative, and to provide effective representation at the international level for the new Partnership for Safe Motherhood and Newborn Health (PSMNH). FIGO will need to devote resources to follow up on the numerous opportunities available jointly with UN agencies, UNFPA, UNICEF, WHO, and the World Bank. Secretariat support at the FIGO Headquarters would be a key initiative to fulfill the mandate of FIGO, i.e. to continue to be recognized as the leading, technical agency in the reduction of
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maternal mortality and morbidity and the promotion of sexual and reproductive rights. The future of the FIGO Save the Mothers program will need a large consensus to be developed within the FIGO organization. FIGO may request developedydeveloping countries to submit possible north–south and south–south collaborations. Once the survey of these possible projects occurs, FIGO will need to put together a team to solicit international and national donors to support these initiatives. The partnership between developed and developing country associations is crucial to scale up the ability of smaller associations to respond to the needs of women in their countries. Our force is in partnerships between countries, health care providers, and national governments. FIGO needs to revisit the FIGOyWHO Alliance to make it a more active partnership and see the partnership’s effects on individual countries. FIGO will need to establish a working group with WHO to ensure that all WHO projects in any country would involve the individual countries’ ObstetricianyGynecologist associations as well as FIGO. References
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w1x United Nations Children Fund (UNICEF), World Health Organization (WHO), United Nations Population Fund (UNFPA). Guidelines to monitoring the availability and
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use of obstetric services. New York: UNICEF, WHO, UNFPA, 1997. Curet LB, Foster-Rosales A, Hale R, Kestler E, Medina C, Aetamirano L, et al. FIGO Save the Mothers Initiative: the Central America and USA collaboration. Int J Gynecol Obstet 2003;80:213 –221. Mekbib T, Kassaye E, Getachew A, Tadesse T, Debebe A. FIGO Save the Mothers Initiative: the Ethiopia–Sweden collaboration, Int J Gynecol Obstet 2003;81:93– 102. Lodhi S, Zaman F, Sohail R, et al. FIGO Save the Mothers Initiative: the Pakistan–United Kingdom collaboration, Int J Gynecol Obstet; in press. Lalonde AB, Okong P, Mugasa A, Perron L. FIGO Save the Mothers Initiative: the Uganda–Canada collaboration. Int J Gynecol Obstet 2003;80:204 –212. Benagiano G, Thomas B. Saving mothers lives: the FIGO save the mothers initiative. Int J Gynecol Obstet 2003;80:198 –203. Benagiano G, Thomas B. Safe Motherhood: the FIGO Initiative. Int J Gynecol Obstet 2003;82:263 –274. Maine D, Azakalin MD, Ward VM, Kamara A. The Design and Evaluation of Maternal Mortality Programs. New York: Columbia School of Public Health, 1997. AbouZahr C, Royston E. Maternal mortality: a global fact book. Geneva: WHO, 1991. US Centers for Disease Control and Prevention. Maternal mortality—United States, 1987–1996. Morbid Mortal Wkly Rep 1998;47:705 –707. Baskett TF. Essential management of obstetric emergencies. New York: Wiley, 1985. WHO. Maternal mortality in 1995: estimates developed by WHO, UNICEF, UNFPA. Geneva: WHO, 2001. UNFPA. The state of the world population 2000: live together, worlds apart. UNFPA, 2000.