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The role of professional associations in reducing maternal mortality worldwide
International Journal of Gynecology and Obstetrics 83 (2003) 94–102
Averting maternal death and disability
The role of professional associations in reducing maternal mortality worldwide J. Chamberlaina,*, R. McDonagha, A. Lalondeb, S. Arulkumaranc a
Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada b Society of ObstetriciansyGynecologists of Canada, Ottawa, Canada c University of London, St. George’s Hospital Medical School, London, UK Received 11 February 2003; accepted 13 April 2003
Abstract The death of hundreds of thousands of women due to pregnancy-related complications casts a shadow over the modern obstetrical world. This paper examines the potential roles and responsibilities of professional obstetrical and midwifery associations in addressing this tolerated tragedy of maternal deaths. We examine the successes and challenges of obstetrical and midwifery associations and encourage the growth and development of active associations to address maternal mortality within their own borders. Professional associations can play a vital role in the reduction of maternal mortality worldwide. Their roles include lobbying for women’s health and rights, setting standards of practice, raising awareness and team building. Associations from developed countries can influence and strengthen their colleagues within developing countries; for example, the FIGO Save the Mothers initiative. Professional associations should be encouraged to play an active role in reducing maternal mortality within their own country and abroad. 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. Keywords: Maternal mortality; Professional associations; Human rights
1. Introduction The ongoing tragedy of maternal mortality did not disappear as we entered the third millennium. It is estimated that 515 000 women die yearly from pregnancy-related complications w1x; the equiva*Corresponding author. St. Joseph’s Hospital, 301 James St. S. 2nd floor Fontbonne Building, Hamilton, Ontario, Canada L8N 4A6. Fax: q1-905-521-6089. E-mail address: [email protected] (J. Chamberlain).
lent of three jumbo jets crashing daily—loaded with pregnant women! While the medical causes of maternal mortality are well known, the social and political underpinnings of this human-health problem are complex and vary among and within countries. In light of modern medical advances (including the formal organization of many health care professionals) it is important to consider what, if any, role professional maternity health care associations might play in reducing maternal mortality.
0020-7292/03/$30.00 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0020-7292(03)00185-1
J. Chamberlain et al. / International Journal of Gynecology and Obstetrics 83 (2003) 94–102
The greatest killer of pregnant women is bleeding—usually postpartum hemorrhage. Of maternal deaths in developing countries, 25% are due to hemorrhage w2x. Sepsis accounts for 15% of maternal deaths followed by eclampsia (12%). Other significant contributors to maternal death are unsafe abortion practices (13%), hypertensive disorders of pregnancy (12%) and obstructed labor (8%) w2x. Treatments for these conditions are neither costly nor technically extravagant, yet many women are denied simple life saving treatments. The reasons are multiple and appear to have as much to do with health policy choices adopted by local governments as with financial constraints that place limits on health care delivery and access to medications. It must be remembered that the deficiencies in access and availability to health resources, which so profoundly impact maternal mortality, have effects far beyond maternal mortality alone. A clear example can be found in infant mortality, where the death of a mother very clearly impacts upon the survival of her child w3x. While immunization programs and treatment of diarrheal diseases have reduced infant mortality beyond the first week of life, similar improvements in early neonatal mortality (death within the first 7 days) have not materialized w4x. Poor antenatal care contributes to the persistently high rate of early neonatal mortality w4x. The joint statement by WHOyUNICEF w5x emphasizes the need for coordinated long-term efforts to reduce maternal mortality; efforts directed towards the community and family, as well as the health care system. Further, national legislative policies are also urged. The statement goes on to say that medical practice relating to pregnancy care should be regulated with protocols and guidelines for maternal care at each level of the healthcare system. Education and training curricula, along with national standards should be developed for all levels of health care workers w6x. What role might professional obstetrical associations play within countries with high maternal mortality? How might they act on the recommendations endorsed by the WHOyUNOCEF joint statement? We will investigate the potential for such professional organizations to assist in reduc-
95
ing maternal mortality, especially within those countries where the problem is epidemic. Further, we will discuss how professional obstetrical associations can be strong stimulants to support change within these countries. 2. History’s lessons Of the variety of research methodologies available that might be applied to investigate maternal mortality, the randomized controlled trial is neither feasible nor ethical. But observational methods, both prospective and retrospective, though less rigorous, are particularly suited to address questions of public health. Data that stem from these methodological approaches provide some anecdotal evidence in support of the role for professional obstetrical and midwifery associations in reducing maternal mortality. Nineteenth century Sweden was ahead of its time when it adopted national policies that encouraged professional midwifery practice and endorsed the development of practice standards. Subsequent to these initiatives, Sweden boasted one of the lowest maternal mortality ratios (MMR) in Europe at that time (230 maternal deaths per 100 000 live births vs. 500 per 100 000 in Europe in the mid1800s) w7x. This ratio remains significantly less than many countries today and it was achieved prior to establishment of safe anesthetic practice or the widespread use of antibiotics. Similar health improvements can be seen in developing countries that have embraced maternal mortality as a public health priority. In Sri Lanka, for example, the maternal mortality ratio plummeted from 1400 maternal deaths per 100 000 live births in 1940 to 95 per 100 000 live births by 1980. The dramatic reduction has been attributed to the expansion of professional maternity care and family planning across the country between 1940 and 1999 w8x. China, Cuba and Malaysia have each demonstrated similar reductions in their maternal mortality ratios by implementing similar national policies w9x. Such examples suggest that reductions in maternal mortality may be achieved once a country recognizes the problem as a national priority (i.e. to adopt a social health policy that places maternal mortality high on the political
J. Chamberlain et al. / International Journal of Gynecology and Obstetrics 83 (2003) 94–102
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Table 1 The maternal mortality ratio and its relationship to the presenceyabsence of a professional obstetrical association within 127 countriesa Maternal mortality ratio (number of deaths per 100 000 live births)
Number of countries WITH a professional obstetrical association (% of total)
-300 300–999 )1000 Total number of countries
70 20 3 93
a
(75%) (21.5%) (3.5%) (100%)
Number of countries WITHOUT a professional obstetrical association (% of total) 11 16 7 34
(32.5%) (47%) (20.5%) (100%)
Countries in which the maternal mortality ratio (MMR) is unknown or unavailable were not included in this table.
agenda) and if some elementary mechanisms are put in place to assist with maternity care. Further, the commonly held argument that there is a causal link between low Gross National Product (GNP) and high rates of maternal mortality, over-simplifies the problem. The Sri Lanka, China, Cuba and Malaysia examples demonstrate that high GNP levels are not necessary to achieve some reduction in maternal mortality. Developing countries need not await economic prosperity before they address their maternal mortality situation. Political commitment and organization of human health resources with available facilities is one step forward. In many areas of the world, traditional birth attendants (TBAs) are the immediate maternal health care giver. Studies have failed to reveal a reduction in maternal mortality following the introduction of TBAs within the health-care armamentarium w10x. TBAs often lack professional facilities to refer complicated patients. Unfortunately, in some situations, animosity and distrust have developed between TBAs and health care workers. This leads to further erosion of effective maternity care. Professional health care workers must extend a hand to TBAs and encourage them to refer complicated cases w11x. 3. A relationship between professional associations and maternal mortality? A potential relationship between a high rate of maternal mortality and the absence of a professional association of obstetricians is implied by the observation that 67% of countries without such
associations suffer a maternal mortality ratio in excess of 300 maternal deaths per 100 000 births. This is compared with countries with an association where only 25% of countries have a maternal mortality ratio of )300 maternal deaths per 100 000 live births. In fact, only three countries (3y93) having a professional association (Ethiopia, Sierra Leone and Nigeria) experience a MMR of greater than 1000 maternal deaths per 100 000 while seven countries without an association (7y 34) possess this high MMR ()100 000 deaths) w12x (see Table 1). Acknowledging that these observational data suggest only a potential connection between the presence of a professional association and MMR, nevertheless it is difficult to imagine how their presence within a developing country might not improve the local situation to at least some degree. Yet many countries may lack the ‘critical mass’ of care-providers necessary to develop and sustain such an association. 4. The role for professional associations The roles that professional associations might adopt within developing countries are numerous and each has the potential to reduce maternal mortality. The Federation of International Obstetricians and Gynecologists (FIGO) has registered professional obstetrical associations within 102 countries. FIGO was founded in 1942 and is governed by an international council. It has numerous committees that address women’s health issues (i.e. Gynecology Oncology Committee, Ethics Committee, and
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Fig. 1. Potential points of impact for a professional association on maternal mortality.
a Committee for Sexual and Reproductive Rights of Women). The Gynecology Oncology Committee produces strategies for staging and treatment of gynecological cancers which are distributed through national societies. The Ethics Committee examines various ethical problems and gives a broader outline with which the national societies can formulate their own ethical guidelines w13x. The recent past has witnessed several other committees including the Committee for Perinatal Health and the FIGO Save the Mothers Committee which attend to issues ranging from violence against women to hypertensive disorders in pregnancy. Other important international associations exist such as the International Confederation of Midwives. Their mission statement articulates goals to improve outcomes for women in their child-bearing years, their newborns and their families wherever they reside. The Confederation recognizes the vital role that continuing education plays in maintaining safe and up-to-date obstetrical practice. It urges member associations to require continuing education updates in keeping with the ethical
mandate for advancement of midwifery knowledge and practice as stated in the International Code of Ethics for Midwives w14x. Both the obstetrical and midwifery associations are important catalysts to work together in the promotion of women’s health care, especially pregnancy care. 5. What professional associations can do Professional associations can offer a unified voice for women’s health by lobbying, promoting and educating about the essentials of effective health care for women at the level of the general public, governments and international aid organizations (Fig. 1). These associations can be a strong unifier of services for women and promote cooperation among maternity health care workers. 5.1. Political lobbying The sphere of influence of many professional health care workers is broad and the lobbying audiences are, therefore, similarly broad. Potential
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targets include national Ministries of Health, their community and international donor programs. Professional associations can both mobilize the community in its collective concern regarding maternal mortality as well as educate the political decisionmakers that are charged with health resource allocation policy. Internationally, they can draw attention to the unacceptable rates of maternal mortality that might easily be reduced with relatively inexpensive international assistance. Above all, they can demonstrate leadership in ensuring quality care for all women within their country. National associations should be encouraged to carry out a national inventory of emergency obstetrical centers and generate a needs-assessment with the intent to present it to the national government. This needs-assessment will encourage governments to consider the magnitude of the maternal health problem and direct policy-makers to better plan and provide the needed services for delivery as well as upgrading existing facilities. These professional associations can both suggest governmental policy and vigorously endorse it. National associations that have international reputations could promote their agenda on an international scene with credibility. Specific deficiencies in the system could receive heightened attention (for example, the three-delay model of maternal mortality: delay in seeking care, delay in reaching care and delay in the provision of care) w15x. Maternal mortality is a multifactorial problem and thus the approach must cover the span of factors including women’s rights and empowerment, health, and basic education, transportation systems and health care attitudes and systems. As professionals, they can address the human rights issue and lobby their government for action and legislation. ‘Safe Maternity’ is increasingly being viewed as a basic human right worldwide. It is not a commodity for the privileged only. It has been over 50 years since the Universal Declaration of Human Rights (1948) that outlined basic human rights for all people. Those specific rights pertaining to safe motherhood include: 1. The right to life, survival and security of the person. 2. The rights relating to maternity and health.
3. Rights to non-discrimination and due respect for difference. 4. Rights related to information and education relevant to women’s health protection during pregnancy and childbirth. 5. Right to equality and privacy. 6. Right to freedom of thought. 7. Right to choose whether or not to marry. 8. Right to choose whether or not to have children. 9. Right to benefit from scientific progress. 10. Freedom from torture and ill treatment. w16x These rights are derived from international human rights agreements. It is the responsibility of individual countries to create laws that protect and care for women’s basic human rights. These responsibilities include passing laws to prohibit female genital mutilation and early marriage while ensuring property and child rights for women. There needs to be proactive legislation that encourages access to quality health care for women w16x. Tools are being developed to assist professional medical personnel to address their country’s decision-makers around these basic foundational rights for women. 5.2. Standard setting The role that professional associations might play in quality assurance is significant. In many developing countries, there is not only a shortage of health care workers, but the quality of services they render is less than adequate thereby adding to an already complex problem. Inadequate care fails not only the individual women but erodes public confidence in the ‘system’. This may cause some to seek alternative sources of (potentially riskier) care such as traditional healers or traditional birth attendants. Standards of care and protocol setting can lead to improvements in the quality of care and a greater level of confidence (and utilization) in the ‘system’. Professional associations can highlight areas of needed improvement wfor example, access to essential lifesaving medications for emergency obstetric care (EmOC)x and by addressing high case fatality rates within certain regions and facil-
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Fig. 2. Active interventions by professional associations.
ities (see Fig. 2). These associations are able to assist in the development of standard setting especially in the context of local resource availability. 5.3. Promotion of self assessments and audits The professional association can assist its membership with quality of care assessments in their own practices and facilitate self-assessments such that the professional can review their own practice patterns and outcomes. The Royal College of Physicians and Surgeons of Canada now has a self-assessment program that allows physicians to both document their continuing medical education and demonstrate its impact on their own practice patterns. This self-assessment diary is mandatory for all specialists to maintain their certification with the Royal College w17x. Other resources for evaluating quality of care have been published and are available to national associations w18x. Monitoring and assessment tools have been developed to assist the health care professional in the planning and monitoring of maternal mortality w19–21x. The Making Pregnancy Safer Initiative, led by the WHO, is committed to national organizations in the annual review of progress made towards reducing maternal morbidity and mortality w22x. 5.4. Continuing medical education for members Professional associations can be active in continuing medical education—emphasizing best practices based on scientific evidence and avoiding harmful practices.
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Organization and dissemination of educational opportunities is another role for the associations. An example is the international Advances in Labor and Reducing Mortality (ALARM) program that has been developed through a partnership of the obstetrical associations of Canada, Uganda, Guatemala and Haiti. The program addresses the educational needs of health care providers concerning safe motherhood. It is designed to update the health care providers on labor and high-risk situations during delivery. It includes training of association members as trainers so that the program can be disseminated widely. The program is based on World Health Organization (WHO) guidelines, the Cochrane Database and internationally accepted guidelines. 5.5. Awareness-raising and team building Professional associations can play a role in public education around women’s health issues. They can also liaise between social scientists and health care providers in order to generate an effective outreach to the community. Health care professionals can augment the access to health information for their patients and the general public. This can be done through having patient information booklets in their offices and public places. The association may assist these professionals in both printing and having primary access to literature. The associations can also work with other organizations to produce and update medical publications. In this way, they will support the improvement of both the quality and dissemination of information. Professional associations can stimulate better teamwork within the health care system. The hierarchical structure in many countries fosters a cold and distant relationship between the midwives and doctors. This can be addressed and improved through educational programs for physicians centering on a team approach to care. Professional associations can promote the use of maternal mortality audits to assess barriers and breakdowns within the maternal health care system and recommend changes to improve the access and availability of care for pregnant women.
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Associations of obstetricians in developing countries should open their membership to include nurses, midwives and other health care workers with the shared goal of improving maternal mortality. This would foster a multidisciplinary approach towards a complex problem. Obstetricians need to become more communitybased within developing countries and assist the community to better manage their health care centers and district hospitals. Through community visits and genuine involvement, the obstetrician can play an important role in improving the quality of care and services available. They may be able to offer insight into problems of transport and supply of materials as well as offering continuing education for those in isolation. However, these clinicians bring only some of the requisite skills to attend to the problem. By adopting a wider membership, professional associations can recognize and capitalize on the expertise that many bring to a common task towards improving maternal health in their country. 6. The international response to maternal mortality worldwide What are the responsibilities and potentials for professional health care associations within developed countries to assist their colleagues in developing countries? All health professional associations have an ethical obligation to promote women’s health within their country and to assist other associations in their effort to do so. Looking at the international scene, development assistance for all purposes (economic and social including health) was $47.6 billion (US) in 1997. The goals set out by the International Conference on Population and Development (ICPD) (1994) in Cairo has an annual budget of $5.7 billion (US) per year w23x. The agenda of the ICPD included the reduction of maternal mortality by 75% (compared with 1990 levels), universal access to family planning and 90% of all deliveries attended by skilled professionals. These goals are to be achieved by the year 2015. The last 20 years of development assistance has demonstrated that instead of simply dropping money into developing countries, investment of time and energy into
building up their human resources is essential, particularly if the goals of reproductive health care are going to be achieved. Skilled health care attendants (i.e. physicians and nurse-midwives) are essential and leadership is needed to stimulate high standards of care and encourage ongoing progress. At the present rate of 53% attendance of skilled attendants at deliveries in developing countries, the goal of 90% attendance (by 2015) is a distant dream w24x. 7. Professional associations making a difference There are examples of professional associations that affect, within their own countries, the health care offered to women, and other examples of professional associations assisting other countries. Consider the Association of ObstetriciansyGynecologists of Uganda (AOGU). This association met infrequently before 1996 and the extent of its meetings was to present scientific work authored by members of the association. In 1998, the AOGU was joined in a partnership with the Society of Obstetricians and Gynecologists of Canada (SOGC). The two associations worked together to secure funding from the FIGO Save the Mothers project in order to carry out a maternal mortality reduction program in a rural Ugandan district. Members from the both the Canadian and Ugandan Associations, volunteered to work in the district and were welcomed by the community and health care team. The Ugandan Association has become very active in influencing its own Ministry of Health and has been carrying out numerous community interventions and continuing medical education courses which focus on maternal mortality and reproductive health. With the assistance of the Canadian Society wthrough a grant by the Canadian International Development Agency (CIDA)x, the Ugandan Association now has its own office, secretary, library and internet access. The establishment of an infrastructure was an important step to see the Association move forward. The Society of Obstetricians and Gynecologists of Canada (SOGC) have also partnered with obstetrical associations in Haiti and Guatemala. Another example is in Sri Lanka where the maternal mortality which was 2100 deaths per
J. Chamberlain et al. / International Journal of Gynecology and Obstetrics 83 (2003) 94–102
100 000 live births in 1881 was reduced to 60 per 100 000 live births in 1995 w25x. This was mainly attributed to public health measures in controlling malaria, availability of antibiotics and blood transfusion and decline in fertility w26x. A special committee investigated maternal deaths from 1960 and a family health bureau was established in 1968. Health education programs were initiated by the Ministry of Education in conjunction with United Nations Fund for population Activities. The professional organization wrote evidence based standards and protocols for the management of complications and circulated it widely. The needs assessment by UNICEF formed the stimulus for discussion with the Ministry of Health for further improvement. These findings and recommendations were unreservedly supported by the professional association which invariably forms that catalyst for the Ministry to implement the recommendations. The professional organization plays a key role in enhancing further improvement. On an international scene, the Federation of International Gynecologists and Obstetricians (FIGO) has been instrumental in uniting associations worldwide in the fight to reduce maternal mortality. The FIGO Save the Mothers Fund was a program which linked associations from a developed and developing country to carry out a project to reduce maternal mortality within the developing country w27x. 8. Conclusion An organized cooperative effort is needed to reduce maternal mortality. Only then, will we start to see a difference in these horrendous 18th century rates of women dying from pregnancy-related complications. Maternal mortality is a tolerated tragedy—tolerated because often very little is done to prevent it. Professional health care organizations targeted at women’s health care need to be developed, mentored and motivated into action in order to achieve quality and effective care for women worldwide. No woman should die from a preventable pregnancy-related complication. Worldwide, the resources are available. It would seem that Coca Cola has done a better job of marketing its product
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than has been done for safe motherhood. We have seen Coke available in the remotest villages of Africa. The villages are frequently visited and stocked on a regular basis. The Coke container may differ in various places but the end product is the same. What about Safe Mother—Safe Baby, Everywhere? References w1x Maternal mortality in 1995: estimates developed by WHO, UNICEF, UNFPA. WHO, 2001. (p. 2). w2x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. WHO, 1999. (p. 13). w3x Strong MA. The health of adults in the developing world: the view from Bangladesh. Health Transition Rev 1992;2(2):215 –224. w4x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 18). w5x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 22). w6x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank Statement. Geneva: WHO, 1999. (p. 23). w7x Hogberg U, Wall S, Brostrom G. The impact of early medical technology on maternal mortality in late 19th century Sweden. Int J Gynecol Obstet 1986;24(4):251 – 261. w8x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 20). w9x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 21). w10x Tinker A, Koblinksy M. Making motherhood safe. Washington, DC: World Bank, 1993. w11x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 26). w12x Maternal mortality in 1995: estimates developed by WHO, UNICEF, UNFPA. Geneva: WHO, 2001. p. 42 – 47. w13x Federation of International Gynecologists and Obstetricians (FIGO). FIGO ethics committee guidelines are available at http:yywww.figo.org. w14x International Confederation of Midwives Mission Statement. w15x Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social Sci Med 1994;38:8. w16x Cook R, Dickens BM, Wilson AF, Scarrow SE. Advancing safe motherhood through human rights. Geneva: WHO, 2001. (p. 2).
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w17x Royal College of Physicians and Surgeons of Canada, Continuing Professional Development for Maintenance of Certification Program. 2000. (http:yywww.mainport.org). w18x Hutton L, Matthews Z, Stones RW. A framework for the evaluation of quality of care in maternity services. Highfield: University of Southampton. 2000. w19x Guidelines for monitoring the availability and use of obstetric services. New York: UNICEF, WHO, UNFPA, 1997. w20x Safe motherhood needs assessment. Part VI: maternal death review guidelines. WHO, Geneva, 1997 (unpublished document available on request from Reproductive Health and Research, WHO, 1211 Geneva 27, Switzerland). w21x Graham W, Wagaarachichi P, Penney G, McCaw-Binns A, Antwi K, Hall M. Criteria for the clinical audit of
w22x w23x w24x
w25x w26x w27x
the quality of hospital-based obstetric care in developing countries. Bull WHO 2000;78(5):614 –620. Making pregnancy safer: a health sector strategy for reducing maternal and perinatal morbidity and mortality (WHOyRHRy00.6), Geneva: WHO, p. 16. The state of the world population 1999: 6 billion a time for choice. New York: UNFPA, 1999. (p. 56). United Nations. Report on the Ad Hoc Committee of the Whole of the Twenty-first Special Session of the General Assembly (AyS-21y5yAdd. 1). New York: United Nations, 1999. Maternal mortality in 1995: estimates developed by WHO, UNICEF, UNFPA. Geneva: WHO, 2001. (p. 46). Seneviratne H, Rajapaksa L. Safe motherhood in Sri Lanka: a 100-year march. Int J Gynecol Obstet 2000;70(1):113 –124. Benagiano G, Thomas B. Saving Mother’s lives: the FIGO Save the Mothers Initiative. Int J Gynecol Obstet 2003;80:198 –203.
Averting maternal death and disability
The role of professional associations in reducing maternal mortality worldwide J. Chamberlaina,*, R. McDonagha, A. Lalondeb, S. Arulkumaranc a
Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada b Society of ObstetriciansyGynecologists of Canada, Ottawa, Canada c University of London, St. George’s Hospital Medical School, London, UK Received 11 February 2003; accepted 13 April 2003
Abstract The death of hundreds of thousands of women due to pregnancy-related complications casts a shadow over the modern obstetrical world. This paper examines the potential roles and responsibilities of professional obstetrical and midwifery associations in addressing this tolerated tragedy of maternal deaths. We examine the successes and challenges of obstetrical and midwifery associations and encourage the growth and development of active associations to address maternal mortality within their own borders. Professional associations can play a vital role in the reduction of maternal mortality worldwide. Their roles include lobbying for women’s health and rights, setting standards of practice, raising awareness and team building. Associations from developed countries can influence and strengthen their colleagues within developing countries; for example, the FIGO Save the Mothers initiative. Professional associations should be encouraged to play an active role in reducing maternal mortality within their own country and abroad. 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. Keywords: Maternal mortality; Professional associations; Human rights
1. Introduction The ongoing tragedy of maternal mortality did not disappear as we entered the third millennium. It is estimated that 515 000 women die yearly from pregnancy-related complications w1x; the equiva*Corresponding author. St. Joseph’s Hospital, 301 James St. S. 2nd floor Fontbonne Building, Hamilton, Ontario, Canada L8N 4A6. Fax: q1-905-521-6089. E-mail address: [email protected] (J. Chamberlain).
lent of three jumbo jets crashing daily—loaded with pregnant women! While the medical causes of maternal mortality are well known, the social and political underpinnings of this human-health problem are complex and vary among and within countries. In light of modern medical advances (including the formal organization of many health care professionals) it is important to consider what, if any, role professional maternity health care associations might play in reducing maternal mortality.
0020-7292/03/$30.00 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0020-7292(03)00185-1
J. Chamberlain et al. / International Journal of Gynecology and Obstetrics 83 (2003) 94–102
The greatest killer of pregnant women is bleeding—usually postpartum hemorrhage. Of maternal deaths in developing countries, 25% are due to hemorrhage w2x. Sepsis accounts for 15% of maternal deaths followed by eclampsia (12%). Other significant contributors to maternal death are unsafe abortion practices (13%), hypertensive disorders of pregnancy (12%) and obstructed labor (8%) w2x. Treatments for these conditions are neither costly nor technically extravagant, yet many women are denied simple life saving treatments. The reasons are multiple and appear to have as much to do with health policy choices adopted by local governments as with financial constraints that place limits on health care delivery and access to medications. It must be remembered that the deficiencies in access and availability to health resources, which so profoundly impact maternal mortality, have effects far beyond maternal mortality alone. A clear example can be found in infant mortality, where the death of a mother very clearly impacts upon the survival of her child w3x. While immunization programs and treatment of diarrheal diseases have reduced infant mortality beyond the first week of life, similar improvements in early neonatal mortality (death within the first 7 days) have not materialized w4x. Poor antenatal care contributes to the persistently high rate of early neonatal mortality w4x. The joint statement by WHOyUNICEF w5x emphasizes the need for coordinated long-term efforts to reduce maternal mortality; efforts directed towards the community and family, as well as the health care system. Further, national legislative policies are also urged. The statement goes on to say that medical practice relating to pregnancy care should be regulated with protocols and guidelines for maternal care at each level of the healthcare system. Education and training curricula, along with national standards should be developed for all levels of health care workers w6x. What role might professional obstetrical associations play within countries with high maternal mortality? How might they act on the recommendations endorsed by the WHOyUNOCEF joint statement? We will investigate the potential for such professional organizations to assist in reduc-
95
ing maternal mortality, especially within those countries where the problem is epidemic. Further, we will discuss how professional obstetrical associations can be strong stimulants to support change within these countries. 2. History’s lessons Of the variety of research methodologies available that might be applied to investigate maternal mortality, the randomized controlled trial is neither feasible nor ethical. But observational methods, both prospective and retrospective, though less rigorous, are particularly suited to address questions of public health. Data that stem from these methodological approaches provide some anecdotal evidence in support of the role for professional obstetrical and midwifery associations in reducing maternal mortality. Nineteenth century Sweden was ahead of its time when it adopted national policies that encouraged professional midwifery practice and endorsed the development of practice standards. Subsequent to these initiatives, Sweden boasted one of the lowest maternal mortality ratios (MMR) in Europe at that time (230 maternal deaths per 100 000 live births vs. 500 per 100 000 in Europe in the mid1800s) w7x. This ratio remains significantly less than many countries today and it was achieved prior to establishment of safe anesthetic practice or the widespread use of antibiotics. Similar health improvements can be seen in developing countries that have embraced maternal mortality as a public health priority. In Sri Lanka, for example, the maternal mortality ratio plummeted from 1400 maternal deaths per 100 000 live births in 1940 to 95 per 100 000 live births by 1980. The dramatic reduction has been attributed to the expansion of professional maternity care and family planning across the country between 1940 and 1999 w8x. China, Cuba and Malaysia have each demonstrated similar reductions in their maternal mortality ratios by implementing similar national policies w9x. Such examples suggest that reductions in maternal mortality may be achieved once a country recognizes the problem as a national priority (i.e. to adopt a social health policy that places maternal mortality high on the political
J. Chamberlain et al. / International Journal of Gynecology and Obstetrics 83 (2003) 94–102
96
Table 1 The maternal mortality ratio and its relationship to the presenceyabsence of a professional obstetrical association within 127 countriesa Maternal mortality ratio (number of deaths per 100 000 live births)
Number of countries WITH a professional obstetrical association (% of total)
-300 300–999 )1000 Total number of countries
70 20 3 93
a
(75%) (21.5%) (3.5%) (100%)
Number of countries WITHOUT a professional obstetrical association (% of total) 11 16 7 34
(32.5%) (47%) (20.5%) (100%)
Countries in which the maternal mortality ratio (MMR) is unknown or unavailable were not included in this table.
agenda) and if some elementary mechanisms are put in place to assist with maternity care. Further, the commonly held argument that there is a causal link between low Gross National Product (GNP) and high rates of maternal mortality, over-simplifies the problem. The Sri Lanka, China, Cuba and Malaysia examples demonstrate that high GNP levels are not necessary to achieve some reduction in maternal mortality. Developing countries need not await economic prosperity before they address their maternal mortality situation. Political commitment and organization of human health resources with available facilities is one step forward. In many areas of the world, traditional birth attendants (TBAs) are the immediate maternal health care giver. Studies have failed to reveal a reduction in maternal mortality following the introduction of TBAs within the health-care armamentarium w10x. TBAs often lack professional facilities to refer complicated patients. Unfortunately, in some situations, animosity and distrust have developed between TBAs and health care workers. This leads to further erosion of effective maternity care. Professional health care workers must extend a hand to TBAs and encourage them to refer complicated cases w11x. 3. A relationship between professional associations and maternal mortality? A potential relationship between a high rate of maternal mortality and the absence of a professional association of obstetricians is implied by the observation that 67% of countries without such
associations suffer a maternal mortality ratio in excess of 300 maternal deaths per 100 000 births. This is compared with countries with an association where only 25% of countries have a maternal mortality ratio of )300 maternal deaths per 100 000 live births. In fact, only three countries (3y93) having a professional association (Ethiopia, Sierra Leone and Nigeria) experience a MMR of greater than 1000 maternal deaths per 100 000 while seven countries without an association (7y 34) possess this high MMR ()100 000 deaths) w12x (see Table 1). Acknowledging that these observational data suggest only a potential connection between the presence of a professional association and MMR, nevertheless it is difficult to imagine how their presence within a developing country might not improve the local situation to at least some degree. Yet many countries may lack the ‘critical mass’ of care-providers necessary to develop and sustain such an association. 4. The role for professional associations The roles that professional associations might adopt within developing countries are numerous and each has the potential to reduce maternal mortality. The Federation of International Obstetricians and Gynecologists (FIGO) has registered professional obstetrical associations within 102 countries. FIGO was founded in 1942 and is governed by an international council. It has numerous committees that address women’s health issues (i.e. Gynecology Oncology Committee, Ethics Committee, and
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Fig. 1. Potential points of impact for a professional association on maternal mortality.
a Committee for Sexual and Reproductive Rights of Women). The Gynecology Oncology Committee produces strategies for staging and treatment of gynecological cancers which are distributed through national societies. The Ethics Committee examines various ethical problems and gives a broader outline with which the national societies can formulate their own ethical guidelines w13x. The recent past has witnessed several other committees including the Committee for Perinatal Health and the FIGO Save the Mothers Committee which attend to issues ranging from violence against women to hypertensive disorders in pregnancy. Other important international associations exist such as the International Confederation of Midwives. Their mission statement articulates goals to improve outcomes for women in their child-bearing years, their newborns and their families wherever they reside. The Confederation recognizes the vital role that continuing education plays in maintaining safe and up-to-date obstetrical practice. It urges member associations to require continuing education updates in keeping with the ethical
mandate for advancement of midwifery knowledge and practice as stated in the International Code of Ethics for Midwives w14x. Both the obstetrical and midwifery associations are important catalysts to work together in the promotion of women’s health care, especially pregnancy care. 5. What professional associations can do Professional associations can offer a unified voice for women’s health by lobbying, promoting and educating about the essentials of effective health care for women at the level of the general public, governments and international aid organizations (Fig. 1). These associations can be a strong unifier of services for women and promote cooperation among maternity health care workers. 5.1. Political lobbying The sphere of influence of many professional health care workers is broad and the lobbying audiences are, therefore, similarly broad. Potential
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targets include national Ministries of Health, their community and international donor programs. Professional associations can both mobilize the community in its collective concern regarding maternal mortality as well as educate the political decisionmakers that are charged with health resource allocation policy. Internationally, they can draw attention to the unacceptable rates of maternal mortality that might easily be reduced with relatively inexpensive international assistance. Above all, they can demonstrate leadership in ensuring quality care for all women within their country. National associations should be encouraged to carry out a national inventory of emergency obstetrical centers and generate a needs-assessment with the intent to present it to the national government. This needs-assessment will encourage governments to consider the magnitude of the maternal health problem and direct policy-makers to better plan and provide the needed services for delivery as well as upgrading existing facilities. These professional associations can both suggest governmental policy and vigorously endorse it. National associations that have international reputations could promote their agenda on an international scene with credibility. Specific deficiencies in the system could receive heightened attention (for example, the three-delay model of maternal mortality: delay in seeking care, delay in reaching care and delay in the provision of care) w15x. Maternal mortality is a multifactorial problem and thus the approach must cover the span of factors including women’s rights and empowerment, health, and basic education, transportation systems and health care attitudes and systems. As professionals, they can address the human rights issue and lobby their government for action and legislation. ‘Safe Maternity’ is increasingly being viewed as a basic human right worldwide. It is not a commodity for the privileged only. It has been over 50 years since the Universal Declaration of Human Rights (1948) that outlined basic human rights for all people. Those specific rights pertaining to safe motherhood include: 1. The right to life, survival and security of the person. 2. The rights relating to maternity and health.
3. Rights to non-discrimination and due respect for difference. 4. Rights related to information and education relevant to women’s health protection during pregnancy and childbirth. 5. Right to equality and privacy. 6. Right to freedom of thought. 7. Right to choose whether or not to marry. 8. Right to choose whether or not to have children. 9. Right to benefit from scientific progress. 10. Freedom from torture and ill treatment. w16x These rights are derived from international human rights agreements. It is the responsibility of individual countries to create laws that protect and care for women’s basic human rights. These responsibilities include passing laws to prohibit female genital mutilation and early marriage while ensuring property and child rights for women. There needs to be proactive legislation that encourages access to quality health care for women w16x. Tools are being developed to assist professional medical personnel to address their country’s decision-makers around these basic foundational rights for women. 5.2. Standard setting The role that professional associations might play in quality assurance is significant. In many developing countries, there is not only a shortage of health care workers, but the quality of services they render is less than adequate thereby adding to an already complex problem. Inadequate care fails not only the individual women but erodes public confidence in the ‘system’. This may cause some to seek alternative sources of (potentially riskier) care such as traditional healers or traditional birth attendants. Standards of care and protocol setting can lead to improvements in the quality of care and a greater level of confidence (and utilization) in the ‘system’. Professional associations can highlight areas of needed improvement wfor example, access to essential lifesaving medications for emergency obstetric care (EmOC)x and by addressing high case fatality rates within certain regions and facil-
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Fig. 2. Active interventions by professional associations.
ities (see Fig. 2). These associations are able to assist in the development of standard setting especially in the context of local resource availability. 5.3. Promotion of self assessments and audits The professional association can assist its membership with quality of care assessments in their own practices and facilitate self-assessments such that the professional can review their own practice patterns and outcomes. The Royal College of Physicians and Surgeons of Canada now has a self-assessment program that allows physicians to both document their continuing medical education and demonstrate its impact on their own practice patterns. This self-assessment diary is mandatory for all specialists to maintain their certification with the Royal College w17x. Other resources for evaluating quality of care have been published and are available to national associations w18x. Monitoring and assessment tools have been developed to assist the health care professional in the planning and monitoring of maternal mortality w19–21x. The Making Pregnancy Safer Initiative, led by the WHO, is committed to national organizations in the annual review of progress made towards reducing maternal morbidity and mortality w22x. 5.4. Continuing medical education for members Professional associations can be active in continuing medical education—emphasizing best practices based on scientific evidence and avoiding harmful practices.
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Organization and dissemination of educational opportunities is another role for the associations. An example is the international Advances in Labor and Reducing Mortality (ALARM) program that has been developed through a partnership of the obstetrical associations of Canada, Uganda, Guatemala and Haiti. The program addresses the educational needs of health care providers concerning safe motherhood. It is designed to update the health care providers on labor and high-risk situations during delivery. It includes training of association members as trainers so that the program can be disseminated widely. The program is based on World Health Organization (WHO) guidelines, the Cochrane Database and internationally accepted guidelines. 5.5. Awareness-raising and team building Professional associations can play a role in public education around women’s health issues. They can also liaise between social scientists and health care providers in order to generate an effective outreach to the community. Health care professionals can augment the access to health information for their patients and the general public. This can be done through having patient information booklets in their offices and public places. The association may assist these professionals in both printing and having primary access to literature. The associations can also work with other organizations to produce and update medical publications. In this way, they will support the improvement of both the quality and dissemination of information. Professional associations can stimulate better teamwork within the health care system. The hierarchical structure in many countries fosters a cold and distant relationship between the midwives and doctors. This can be addressed and improved through educational programs for physicians centering on a team approach to care. Professional associations can promote the use of maternal mortality audits to assess barriers and breakdowns within the maternal health care system and recommend changes to improve the access and availability of care for pregnant women.
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Associations of obstetricians in developing countries should open their membership to include nurses, midwives and other health care workers with the shared goal of improving maternal mortality. This would foster a multidisciplinary approach towards a complex problem. Obstetricians need to become more communitybased within developing countries and assist the community to better manage their health care centers and district hospitals. Through community visits and genuine involvement, the obstetrician can play an important role in improving the quality of care and services available. They may be able to offer insight into problems of transport and supply of materials as well as offering continuing education for those in isolation. However, these clinicians bring only some of the requisite skills to attend to the problem. By adopting a wider membership, professional associations can recognize and capitalize on the expertise that many bring to a common task towards improving maternal health in their country. 6. The international response to maternal mortality worldwide What are the responsibilities and potentials for professional health care associations within developed countries to assist their colleagues in developing countries? All health professional associations have an ethical obligation to promote women’s health within their country and to assist other associations in their effort to do so. Looking at the international scene, development assistance for all purposes (economic and social including health) was $47.6 billion (US) in 1997. The goals set out by the International Conference on Population and Development (ICPD) (1994) in Cairo has an annual budget of $5.7 billion (US) per year w23x. The agenda of the ICPD included the reduction of maternal mortality by 75% (compared with 1990 levels), universal access to family planning and 90% of all deliveries attended by skilled professionals. These goals are to be achieved by the year 2015. The last 20 years of development assistance has demonstrated that instead of simply dropping money into developing countries, investment of time and energy into
building up their human resources is essential, particularly if the goals of reproductive health care are going to be achieved. Skilled health care attendants (i.e. physicians and nurse-midwives) are essential and leadership is needed to stimulate high standards of care and encourage ongoing progress. At the present rate of 53% attendance of skilled attendants at deliveries in developing countries, the goal of 90% attendance (by 2015) is a distant dream w24x. 7. Professional associations making a difference There are examples of professional associations that affect, within their own countries, the health care offered to women, and other examples of professional associations assisting other countries. Consider the Association of ObstetriciansyGynecologists of Uganda (AOGU). This association met infrequently before 1996 and the extent of its meetings was to present scientific work authored by members of the association. In 1998, the AOGU was joined in a partnership with the Society of Obstetricians and Gynecologists of Canada (SOGC). The two associations worked together to secure funding from the FIGO Save the Mothers project in order to carry out a maternal mortality reduction program in a rural Ugandan district. Members from the both the Canadian and Ugandan Associations, volunteered to work in the district and were welcomed by the community and health care team. The Ugandan Association has become very active in influencing its own Ministry of Health and has been carrying out numerous community interventions and continuing medical education courses which focus on maternal mortality and reproductive health. With the assistance of the Canadian Society wthrough a grant by the Canadian International Development Agency (CIDA)x, the Ugandan Association now has its own office, secretary, library and internet access. The establishment of an infrastructure was an important step to see the Association move forward. The Society of Obstetricians and Gynecologists of Canada (SOGC) have also partnered with obstetrical associations in Haiti and Guatemala. Another example is in Sri Lanka where the maternal mortality which was 2100 deaths per
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100 000 live births in 1881 was reduced to 60 per 100 000 live births in 1995 w25x. This was mainly attributed to public health measures in controlling malaria, availability of antibiotics and blood transfusion and decline in fertility w26x. A special committee investigated maternal deaths from 1960 and a family health bureau was established in 1968. Health education programs were initiated by the Ministry of Education in conjunction with United Nations Fund for population Activities. The professional organization wrote evidence based standards and protocols for the management of complications and circulated it widely. The needs assessment by UNICEF formed the stimulus for discussion with the Ministry of Health for further improvement. These findings and recommendations were unreservedly supported by the professional association which invariably forms that catalyst for the Ministry to implement the recommendations. The professional organization plays a key role in enhancing further improvement. On an international scene, the Federation of International Gynecologists and Obstetricians (FIGO) has been instrumental in uniting associations worldwide in the fight to reduce maternal mortality. The FIGO Save the Mothers Fund was a program which linked associations from a developed and developing country to carry out a project to reduce maternal mortality within the developing country w27x. 8. Conclusion An organized cooperative effort is needed to reduce maternal mortality. Only then, will we start to see a difference in these horrendous 18th century rates of women dying from pregnancy-related complications. Maternal mortality is a tolerated tragedy—tolerated because often very little is done to prevent it. Professional health care organizations targeted at women’s health care need to be developed, mentored and motivated into action in order to achieve quality and effective care for women worldwide. No woman should die from a preventable pregnancy-related complication. Worldwide, the resources are available. It would seem that Coca Cola has done a better job of marketing its product
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than has been done for safe motherhood. We have seen Coke available in the remotest villages of Africa. The villages are frequently visited and stocked on a regular basis. The Coke container may differ in various places but the end product is the same. What about Safe Mother—Safe Baby, Everywhere? References w1x Maternal mortality in 1995: estimates developed by WHO, UNICEF, UNFPA. WHO, 2001. (p. 2). w2x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. WHO, 1999. (p. 13). w3x Strong MA. The health of adults in the developing world: the view from Bangladesh. Health Transition Rev 1992;2(2):215 –224. w4x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 18). w5x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 22). w6x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank Statement. Geneva: WHO, 1999. (p. 23). w7x Hogberg U, Wall S, Brostrom G. The impact of early medical technology on maternal mortality in late 19th century Sweden. Int J Gynecol Obstet 1986;24(4):251 – 261. w8x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 20). w9x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 21). w10x Tinker A, Koblinksy M. Making motherhood safe. Washington, DC: World Bank, 1993. w11x Reduction of maternal mortality. A joint WHOy UNFPAyUNICEFyWorld Bank statement. Geneva: WHO, 1999. (p. 26). w12x Maternal mortality in 1995: estimates developed by WHO, UNICEF, UNFPA. Geneva: WHO, 2001. p. 42 – 47. w13x Federation of International Gynecologists and Obstetricians (FIGO). FIGO ethics committee guidelines are available at http:yywww.figo.org. w14x International Confederation of Midwives Mission Statement. w15x Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social Sci Med 1994;38:8. w16x Cook R, Dickens BM, Wilson AF, Scarrow SE. Advancing safe motherhood through human rights. Geneva: WHO, 2001. (p. 2).
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w17x Royal College of Physicians and Surgeons of Canada, Continuing Professional Development for Maintenance of Certification Program. 2000. (http:yywww.mainport.org). w18x Hutton L, Matthews Z, Stones RW. A framework for the evaluation of quality of care in maternity services. Highfield: University of Southampton. 2000. w19x Guidelines for monitoring the availability and use of obstetric services. New York: UNICEF, WHO, UNFPA, 1997. w20x Safe motherhood needs assessment. Part VI: maternal death review guidelines. WHO, Geneva, 1997 (unpublished document available on request from Reproductive Health and Research, WHO, 1211 Geneva 27, Switzerland). w21x Graham W, Wagaarachichi P, Penney G, McCaw-Binns A, Antwi K, Hall M. Criteria for the clinical audit of
w22x w23x w24x
w25x w26x w27x
the quality of hospital-based obstetric care in developing countries. Bull WHO 2000;78(5):614 –620. Making pregnancy safer: a health sector strategy for reducing maternal and perinatal morbidity and mortality (WHOyRHRy00.6), Geneva: WHO, p. 16. The state of the world population 1999: 6 billion a time for choice. New York: UNFPA, 1999. (p. 56). United Nations. Report on the Ad Hoc Committee of the Whole of the Twenty-first Special Session of the General Assembly (AyS-21y5yAdd. 1). New York: United Nations, 1999. Maternal mortality in 1995: estimates developed by WHO, UNICEF, UNFPA. Geneva: WHO, 2001. (p. 46). Seneviratne H, Rajapaksa L. Safe motherhood in Sri Lanka: a 100-year march. Int J Gynecol Obstet 2000;70(1):113 –124. Benagiano G, Thomas B. Saving Mother’s lives: the FIGO Save the Mothers Initiative. Int J Gynecol Obstet 2003;80:198 –203.