André B. Lalonde

Global Strategy for Women’s and Children’s Health

With the Olympics and the G8 and G20 Summits well behind us, the world’s spotlight has shifted away from Canada. In late September, all eyes were on New York, where the United Nations held a major summit meeting to review progress towards the Millennium Development Goals (MDGs), eight highly ambitious goals to address some of the world’s most pressing issues. Although the MDGs have seen progress on many fronts, the target that has seen the least progress is MDG 5, the goal of reducing maternal mortality by three quarters by 2015. Ten years have passed since the Millennium Development Goals were established, and yet nearly half a million women continue to die each year from complications related to pregnancy and childbirth.

Prevention and treatment of postpartum hemorrhage in low‐resource settings

This statement does not change the 2 previous statements on management of the third stage of labor (both available at http://www.figo. org/projects/prevent/pph): ICM/FIGO Joint Statement – Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage [1]; and ICM/FIGO Joint Statement – Prevention and Treatment of Postpartum Haemorrhage: New Advances for Low Resource Settings [2]. The following guideline provides a comprehensive document regarding best practice for the prevention and treatment of postpartum hemorrhage (PPH) in low-resource settings. FIGO is actively contributing to the global effort to reducematernal death and disability around the world. Its mission statement reflects a commitment to the promotion of health, human rights, and wellbeing of all women—especially those at greatest risk for death and disability associated with childbearing. FIGO promotes evidence-based interventions that, when applied with informed consent, can reduce the incidence of maternal morbidity and mortality. This statement reflects the best available evidence, drawn from scientific literature and expert opinion, on the prevention and treatment of PPH in low-resource settings. Approximately 30% (in some countries, over 50%) of direct maternal deaths worldwide are due to hemorrhage, mostly in the postpartum period [3]. Most maternal deaths due to PPH occur in lowincome countries in settings (both hospital and community) where there are no birth attendants or where birth attendants lack the necessary skills or equipment to prevent and manage PPH and shock. The Millennium Development Goal of reducing the maternal mortality ratio by 75% by 2015 will remain beyond our reach unless we prioritize the prevention and treatment of PPH in low-resource areas [4]. FIGO endorses international recommendations that emphasize the provision of skilled birth attendants and improved obstetric services as central to efforts to reduce maternal and neonatal mortality. Such policies reflect what should be a basic right for every woman. Addressing PPH will require a combination of approaches to expand access to skilled care and, at the same time, extend life-saving interventions

A Research‐Oriented System for McGill Obstetrical and Neonatal Data (Mond)

In April, 1977, a proposal was made to collect research-oriented perinatal data, including data for both mother and baby, for all deliveries in the hospital and all postnatal referrals. The intention was to develop a system for the Royal Victoria Hospital (RVH), with about 3 500 cases per year, with the aim of later extending the system to other hospitals affiliated with McGill University. The Medical Records department was not in a position to get involved in the computerization, but was willing to cooperate with chart handling. Extensive discussions among a neonatologist, an obstetrician, an information officer and an engineer followed, and a coding manual and code sheet were ready by January 1978. Complete data have been entered for the RVH for 1978 and 1979. The coding manual was considerably revised during 1979, and the data for 1980 and 1981 have been entered with the new format. Starting in April 1980, data have also been coded and entered for Lasalle General Hospital, a community hospital with about 1600 deliveries per year.

Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage

To review the clinical aspects of postpartum hemorrhage (PPH) and provide guidelines to assist clinicians in the prevention and management of PPH. These guidelines are an update from the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline on PPH, published in April 2000.

SOGC CLINICAL PRACTICE GUIDELINESActive management of the third stage of labour: Prevention and treatment of postpartum hemorrhage: No. 235 October 2009 (Replaces No. 88, April 2000)☆

To review the clinical aspects of postpartum hemorrhage (PPH) and provide guidelines to assist clinicians in the prevention and management of PPH. These guidelines are an update from the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline on PPH, published in April 2000.

Mother–Baby Friendly Birthing Facilities Initiative

Guidelines for mother–baby friendly birthing facilities have been developed by the FIGO Safe Motherhood and Newborn Health (SMNH) Committee in collaboration with colleagues from the International Confederation of Midwives, White Ribbon Alliance, the International Pediatrics Association, and the World Health Organization (WHO) [1]. FIGO announces the launch of this new initiative to promote active involvement by professional associations, governments, nongovernmental organizations, and civil society to improve quality of care and reduce abuse, neglect, and extortion of childbearing women in facilities. This initiative was approved by the FIGO Executive Board in July 2014 and will use 10 criteria and 10 sets of indicators to help to assure that women and families are treated with respect and dignity, as well as afforded evidencebased maternity care in facilities. This initiative was inspired by the WHO/UNICEF Baby Friendly Initiative and was grounded philosophically and ethically in the Charter on the Universal Rights of Childbearing Women [2,3]. The organizational authors of this initiative are well aware that while global maternal health experts are urging facility-based delivery with skilled attendance, maternal mortality is not decreasing as rapidly as expected. The authors, along with other global maternal health experts, posit that one reason for the slow progress may be the lack of accountability and adherence to globally recognized, evidence-based practices applied rapidly and with attention to quality [4,5]. In recent surveys and qualitative observational studies, providers have been seen yelling at and slapping childbearing women, and coercing them to pay bribes or fees when no fees are due. This in turn has led many women to avoid facility-based delivery [6–8]. Further, lowquality or absent care has been associatedwith higher rates ofmortality and morbidity [4]. Adherence to the indicators developed jointly by the participating maternal, pediatric, grass-roots, and interdisciplinary organizations should result in development of trust, security, and perceptions of quality among childbearing women and their families. This should lead to higher rates of facility-based deliveries with better outcomes. The 10 criteria for a mother–baby friendly birthing facility include: mobility and positions of preference for labor and birth; privacy; choice of birth partner; nondiscriminatory policies for the treatment of women with HIV, youth, minorities, etc; no physical, verbal, emotional, or financial abuse; affordable or free maternity care; no practices used routinely that are not evidence-based; nonpharmacological and/or pharmacological pain relief as required; and promotes immediate skin-to-skin mother–baby care and breastfeeding.

The Role of Health Professional Associations in the Promotion of Global Women's Health

Health professional associations, especially those from countries with the highest maternal death burden, have vital roles to play in improving maternal and newborn health and in achieving the Millennium Development Goals 4 and 5. Possessing the knowledge, skills, and influence to positively impact practice at the service delivery level, they can also advocate for change at the policy level and lobby for higher priority and greater investment in the maternal and newborn health field at the national level. The ability of professional associations to assume this leadership is nevertheless contingent on their institutional capacities to achieve planned goals and objectives in support of their organizational mission and strategic priorities. Since 1998, the Society of Obstetricians and Gynaecologists of Canada (SOGC) has been supporting the capacity development efforts of peer professional associations in low-resource countries. SOGCs work in this specific area has led it to develop and pilot an Organization Capacity Improvement Framework (OCIF) that guides professional associations, incrementally, in successive cycles of capacity development. Building on capacity developed within previous capacity-building cycles, this article summarizes and reports on the recent outcomes of the Asociación de Gynecoloígia y Obstetricia de Guatemalas (AGOG) organizational development efforts and the impact they have had in positioning the association as an important contributor in national efforts to improve maternal and newborn health outcomes in the country.

FIGO Saving Mothers and Newborns Initiative 2006–2011

Reduction in maternal mortality is a key Millennium Development Goal (MDG 5). In an effort to contribute toward achievement of MDG 5, FIGOs Safe Motherhood and Newborn Health Committee worked with associations of obstetricians, gynecologists, and midwives in 10 low‐ and middle‐income countries between 2006 and 2011. Contributions were made by professional associations in high‐income countries through a structured north–south mentoring program. Each project focused on identified needs within each country and resulted in varied approaches and targets, ranging from clinical training, protocol development, and implementation of clinical audit through to legislative and policy change. Significant and largely sustainable results were achieved, particularly in relation to the relatively small‐scale funding available. This resulted in direct improvements to maternal and newborn health outcomes. The capacity of both FIGO and national professional associations was also substantially strengthened in project design, management, and implementation, leading to opportunities to further support international development efforts in the future.

A report on the FIGO Saving Mothers and Newborns Project.

In collaboration with member national professional associations, the International Federation of Gynecology and Obstetrics (FIGO) has been conducting a Saving Mothers and Newborns Project in 10 low- and middle-resource countries. The project aims to achieve the objectives set out in Millennium Development Goals 4 and 5 related to child survival and maternal mortality and to develop organizational capacity among member associations. Projects are developed in response to the needs of the local country, through a twinning of professional associations between high- and low-resource countries.

Safe motherhood and newborn health: FIGO initiatives 2006–2010

Through international partnerships, FIGO has been delivering safe motherhood and newborn health (SMNH) projects in a number of low‐income countries. The projects aim to achieve the objectives set out in the ICPD Programme of Action and the Millennium Development Goals 4 and 5, which are related to child survival and maternal mortality. Each project is developed in response to the needs of the intervention region and can be organized around the following themes: provision of maternal and newborn health care services to underserved and hard‐to‐reach areas; improvement and provision of quality basic emergency obstetric care; establishment of functional clinical and perinatal audits; development of new maternal and newborn health care protocols; community education and sensitization to womens rights in sexual and reproductive health; and reducing the risk of unsafe abortion.