IGO s ission: apacity uilding or the. other-/ hild ealth round. orld. Prof. Dr. Dr.h.c.mult. Wolfgang Holzgreve. MBA, FACOG, FRCOG

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1 IGO s ission: apacity uilding or the mproveent of other-/ hild ealth round he orld Prof. Dr. Dr.h.c.mult. Wolfgang Holzgreve. MBA, FACOG, FRCOG Medical Director Univ. Bonn Medical Center FIGO Officer

2 Unicef Data Maternal Mortality Ratio Last update (per 100,000 live biths)

3 FIGO is a professional organization that brings together 124 obstetrical and gynecological associations from all over the world. 3

4 VISION Women of the World achieve the highest possible standards of Physical, Mental, Reproductive and Sexual Health and Wellbeing throughout their lives. 4

5 "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." WHO Constitution

6 Berlin, Germany Name: Born: Kevin 11 October 2010 in maternity hospital Weight: gms Length: 51 cms Apgar score at 5 mins: 9 Life expectancy: 82 years

7 Asmara, Eritrea Name: not yet given Born: mid-october 2010 at home Weight: unknown Length: unknown Apgar score at 5 mins: unknown WHO/Chris de Bode Life expectancy: 59 years

8 Risk of maternal death in pregnancy or childbirth 1 in 44 in Eritrea, Africa 1 in in Ireland, Europe

9 Health inequity Maternal and newborn health is one of the major inequities of the world 98 % of deaths in low income countries More deaths than the ones caused by HIV/AIDS

10 Photo: WHO 358,000 mothers

11 Why do mothers die? Foto: WHO Source Maternal Mortality in 2005: WHO UNICEF, UNFPA, World Bank

12 Maternal mortality in 1,500 births 1 in 30,000 births

13 Causes of maternal death Other direct causes 8% Indirect causes 20% Severe bleeding (haemorrhage) 25% Unsafe abortion 13% Obstructed labour 8% Eclampsia 12% Infections 15% a Total is more than 100% due to rounding. (World Health Report, 2005)

14 One million children die each year because their mothers have died. The risk of death for children under five years doubles if their mothers die in childbirth. WHO, World Health Report 2003, Geneva.

15 What can we do and how to make fast progress to improve children s health 10 Suggestions 1. Learn from other countries 2. Centralization and classification of care levels 3. Education of the mothers 4. Free pre- and postnatal care 5. Stimulate to hospital deliveries 6. Promote breast feeding 7. Equipment (monitors, incubators) and staff 8. Evidence based treatment 9. National networks 10. Free essential drugs Saugstad OD, Neonatology in press

16 MDGs World Bank MDG Global Monitoring Report 2009

17 MDG 1: Reduce the proportion of people living in extreme poverty by half between 1990 and 2015 Poverty rates fell rapidly in Asia but little or not at all in Africa. Income inequality is a barrier to progress in Latin America.

18 MDG 4: Reduce infant and child mortality rates by two-thirds between 1990 and 2015

19 MDG 5: Reduce maternal mortality ratios by three-quarters between 1990 and 2015

20 Global MM Hogan MC et al, Lancet 375, ,2010 WHO, UNICEF, UNFPA, World Bank Trends in MM,

21 Decline Global M M R Annual decline necessary to 5.5 % achieve MDG5 Hogan MC et al 1.3 % Lancet 375, , (1-1.5) 2010 WHO, UNICEF, UNFPA, % ( )

22 Countdown to 2015 MDG5 Though some progress is being made on reducing MM, but globally and in most countdown Countries, progress is not sufficient to achieve MDG5. Countdown headlines Women Deliver Washington June 2010

23 Hypothesis: We have to learn more systematically from positive (and negative) experiences Necessary to study scientifically Examples of successful changes

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26 Portugal - a successful reform without costs In 1989 perinatal care was reformed: closure of maternities with less than 1500 deliveries per year hospitals were classified in level I no deliveries II - low risk deliveries, intermediate care units III high risk deliveries, intensive care units A nationwide system of neonatal transport had begun in 1987

27 Portugal Closure of more than 150 public maternities where births had taken place before Hospitals with deliveries decreased from > 200 to 51. In spite of this the rate of in-hospital deliveries increased from 74% previously, to 99% after the reform Neto MT, Acta Paed 2006

28 Success examples of Safe motherhood and women s health In Honduras, reduction of the MMR, from 182 to 108 between Cut in milit. expend. Sri Lanka s nationwide healthcare system expansion and improved midwifery skills over 94 percent of its births occur in hospitals. MMR in Sri Lanka declined from ,500 deaths/ 100,000 live births deaths/ 100,000 live births deaths/ 100,000 live births deaths/ 100,000 live births.

29 KEY Maternal Care INDICATORS : Sri Lanka (Central Bank Report 2002 & Annual Health Bulletin 2007) Total deliveries 350,000 and 100% receive antenatal care Average 5 AN field visit per mother at home Post natal care 72% Average 2.7 post natal visits during first 10 days Pregnant mothers immunized with tetanus toxoid 100% 98% of births in institutions (State Hospitals 94%, Private 4%) > 98% Skilled assistance at deliveries (National Policy aims to have 100% institutional deliveries) 3/15/

30 Healthcare Organizational structure : Sri Lanka Administrative Services institutional Provincial National Teaching Hospitals Medical Officer of Health Specialist Non-specialist Provincial General Hospitals Base Hospitals (A & B) District Hospitals Peripheral Units Central Dispensaries / Maternity homes Curative services Public Health Nurse & Public Health Inspector Family Health Worker / Public Health Midwife Preventive services

31 Maternal Mortality in USA In the past several decades, a dramatic decrease. Since 1980, the rate of decline has slowed. In 2000, The maternal mortality rate of 9.8 per 100,000 live births was not significantly different from prior years Slight increase in 2010

32 Some countries, as Malaysia, Srilanka and Thailand have made progress with low-cost, highyield integrated services such as family planning, skilled birth attendants, access to emergency obstetric and neonatal care, management of STIs and HIV 32 prevention.

33 Continuum of care Pre pregnancy Pregnancy Birth Neonatal Infancy Contracept. Nutrition Antenatal Care S B A Access to EOC Post natal care Newborn care and NICU Immunization STIs Unsafe abortion 33

34 Skilled birth attendant

35 Maternal deaths per 100,000 live births 2000 The presence of a skilled attendant at delivery is key to maternal and newborn survival Y Linear (Y) % skilled attendant at delivery

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37 Controlled cord traction

38 External bimanual uterine massage

39 Internal bimanual uterine massage

40 Post partum haemorrhage

41 anterior posterior

42 Our hypothesis: Minimum requirements Adequate number of skilled birth attendants Minimum standards for normal deliveries (e.g. minimum facility size ( ca. 500/year), 24h/7days service, emergency obstetric services, possibility of blood transfusions) Quality leadership ( Capacity building of professional health care workers, esp. medical doctors)

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44 Maternal mortality in Eritrea 1995: 998/ : 752/ : 450/1 000 (Germany 4) ( NGO Archemed, formerly Hammer Forum active since 1992)

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46 Deliveries: Centralisation of obstetric services Asmara: to in past 4 years Decrease: Mat. Mort. 45% Newb. Mort. 80% Keren: Plan for deliveries, currently Zones Anseba, Gash-Barka, Norther Red Sea, population 2 Mio.

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48 Reduction of maternal mortality by Having skilled attendant at all deliveries Easy access to emergency obstetric care Using a referral system to ensure safe transportation to life-saving EmOC in time All three points are equally important

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53 Misoprostol (Cytotec) for Induction of Labor in Term Pregnancies DV Surbek, H Bösiger, I Hösli, N Pavic, F Stoz, W Holzgreve University Hospital, Department of Obstetrics and Gynecology Basel, Switzerland Am J Obstet Gynecol 1997; 177:

54 Birthing hut : Labor for 10 days and 10 nights Lewis G

55 ICM/FIGO s 2 nd Joint Statement Summary Call to Action Advocate for every woman to have skilled attendant at birth Advocate perinatal centers Ensure that all birth attendants have the necessary training Call upon regulators to approve Misoprostol for PPH Prevention and Treatment Incorporate recommendations into current guidelines, competencies and curricula

56 Role of the International Federation of Gynaecology and Obstetrics (FIGO)

57 FIGO pursues its mission through Advocacy and partnership Programmatic activities, Capacity strengthening of member associations Education and training. 57

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59 Family Planning/Year prevents 187m Unintended pregnancies 105 m Abortions UN Population division 2007 Women deliver, June 2010 Averts 15 m Injuries and

60 Estimated annual numbers of unsafe abortions Total = 19 million (68,000 maternal deaths = 13 %) Africa 4.2 million Latin America and Caribbean 3.7 million Europe 0.5 million Asia 10.5 million (WHO, 2004)

61 Contraceptive Prevalence Global, 62 % Northern Europe 73 % North America 70 % South America 58% Sub-Saharan Africa 17% Mexico 71% Population Reference Bureau 2010-UNFPA State of World Population 2010

62 FIGO Collaboration with faith-based organizations (FBO) is vital to overcome resistance to implementation of means of protecting and advancing reproductive and sexual health rights and accelerating achieving health-related MDGs.

63 Adolescent Pregnancy 40%of women in Africa get married before age of 15. Risk of death for adolescent pregnant women is five times more than the risk for women in their twenties.

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66 10 Mio. $ Gates grant for capacity building in 8 countries

67 Annual review meeting FIGO- Gates initiative Addis Ababa, October 27-29, 2010

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70 FGM/C m. World wide. > 91 m. In Africa alone. 3 m. New cases/year. WHO-UNFPA-UNICEF Serour GI. Int. J Gyn. Obst, (2):93-6

71 The global scale of the problem The practice is most prevalent in 28 countries in Africa and some countries in Asia and the Middle East As a result of migration, a growing number of girls in Europe, North America, Australia and New Zealand are also affected

72 Health consequences Immediate/short-term Intense pain and/or haemorrhage that can lead to shock during and after the procedure (haemorrhage can also lead to anaemia), sometimes leading to death Wound infection, including tetanus Damage to adjoining organs Urine retention from swelling and/or blockage of the urethra

73 Demographic and Health surveys data show that the medicalization of FGM/C has increased substantially in recent years. -Serour G. I Int. J. Obst & Gyn. 109(2) 93-96

74 FIGO s response The 1994 Montreal FIGO General Assembly Resolution on FGM encourages FIGO s societies to urge national governments to sign up to international human rights agreements condemning the practice and to support the work of national authorities, NGOs and intergovernmental organisations working to eliminate it The FIGO Committee for the Ethical Aspects of Human Reproduction and Women s Health has two statements opposing FGM, the most recent concerning medicalisation FIGO continues to recommend that individual obstetricians and gynecologists explain and educate about the consequences of FGM, while supporting community members opposing its continuation

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76 but rich countries are failing their promises too (Martines et al., Lancet, 2005)

77 Every Minute 380 women become pregnant 190 women face unplanned or unwanted pregnancy

78 Every Minute 110 women experience pregnancy related complications 40 women have an unsafe abortion 1 woman dies while giving birth

79 Ban Ki-moon Secretary General of UN announced Sept. 22, 2010 that UN will spend 40 billion $ to save women and children The money comes from Governments and private donors. We know how we can save lives of women and children. 16 million women and children can be saved within 2015

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