Dorothy Shaw

Drivers of maternity care in high-income countries: can health systems support woman-centred care?

In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all the facilitys women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by womens experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman-centred care and the best outcomes without high costs is required to provide an impetus for change.

Access to sexual and reproductive health for young people: Bridging the disconnect between rights and reality

Of the 1.5 billion young people globally, 78% live in Asia and Africa, the poorest regions of the world. The majority of young people infected with HIV are female and adolescent girls have a significant increased risk for maternal mortality and morbidity, such as fistula. Trends to delay marriage do not decrease the age of onset of sexual activity, but highlight the need for access to sexual and reproductive information, and skills and services to learn healthy sexuality and prevent unwanted pregnancy and sexually transmitted infections. Youth‐friendly services require confidentiality, privacy, and non‐judgmental attitudes, and rights of adolescents include the consideration of their evolving capacities to consent to services. Denial of young peoples sexuality and rights by conservative and traditional forces has lethal consequences, especially for women and girls. Countries have committed to these rights through numerous international instruments and many are making progress, but challenges at the community level are significant.

The worldwide epidemic of female obesity

The rapidly rising number of individuals who are overweight and obese has been called a worldwide epidemic of obesity with >35% of adults today considered to be overweight or obese. Women are more likely to be overweight and obese than their male counterparts, which has far-reaching effects on reproductive health and specifically pregnancy, with obese women facing an increased risk of gestational diabetes, preeclampsia, operative delivery, fetal macrosomia, and neonatal morbidity. The etiology of obesity is highly complex encompassing genetic, environmental, physiologic, cultural, political, and socioeconomic factors, making it challenging to develop effective interventions on both a local and global scale. This article describes the extent and the cost of the obesity epidemic, which, although historically seen as a disease of high-income countries, is now clearly a global epidemic that impacts low- and middle-income countries and indigenous groups who bear an ever-increasing burden of this disease.

Women's right to health and the Millennium Development Goals: Promoting partnerships to improve access

The Millennium Development Goals (MGD) represent a commitment of 189 member states that adopted them during the Millennium Summit in September 2000. This UN General Assembly recognized that gender equality and womens empowerment are both central to achieving sustainable development by means of combating poverty, hunger and disease. Neither reproductive nor sexual health was explicitly articulated in the original MDGs and indicators—a critical omission, as globally women are more disadvantaged than men. However, a clear link exists between all of the MDGs and the reproductive and sexual health of women, who cannot contribute to sustainable development, unless their right to health is met through improved access. The FIGO 2006 World Report on Womens Health addresses many issues critical to the success of the MDGs, with a focus on how partnerships have become a crucial vehicle to improve access to health for women.

Female Genital Cosmetic Surgery

OBJECTIVE To provide Canadian gynaecologists with evidence-based direction for female genital cosmetic surgery in response to increasing requests for, and availability of, vaginal and vulvar surgeries that fall well outside the traditional realm of medically-indicated reconstructions. EVIDENCE Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in 2011 and 2012 using appropriate controlled vocabulary and key words (female genital cosmetic surgery). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Recommendations 1. The obstetrician and gynaecologist should play an important role in helping women to understand their anatomy and to respect individual variations. (III-A) 2. For women who present with requests for vaginal cosmetic procedures, a complete medical, sexual, and gynaecologic history should be obtained and the absence of any major sexual or psychological dysfunction should be ascertained. Any possibility of coercion or exploitation should be ruled out. (III-B) 3. Counselling should be a priority for women requesting female genital cosmetic surgery. Topics should include normal variation and physiological changes over the lifespan, as well as the possibility of unintended consequences of cosmetic surgery to the genital area. The lack of evidence regarding outcomes and the lack of data on the impact of subsequent changes during pregnancy or menopause should also be discussed and considered part of the informed consent process. (III-L) 4. There is little evidence to support any of the female genital cosmetic surgeries in terms of improvement to sexual satisfaction or self-image. Physicians choosing to proceed with these cosmetic procedures should not promote these surgeries for the enhancement of sexual function and advertising of female genital cosmetic surgical procedures should be avoided (III-L) 5. Physicians who see adolescents requesting female genital cosmetic surgery require additional expertise in counselling adolescents. Such procedures should not be offered until complete maturity including genital maturity, and parental consent is not required at that time. (III-L) 6. Non-medical terms, including but not restricted to vaginal rejuvenation, clitoral resurfacing, and G-spot enhancement, should be recognized as marketing terms only, with no medical origin; therefore they cannot be scientifically evaluated. (III-L).

The FIGO initiative for the prevention of unsafe abortion.

Unsafe abortion is a recognized public health problem that contributes significantly to maternal mortality. At least 13% of maternal mortality is caused by unsafe abortion, mostly in poor and marginalized women. The International Federation of Gynecology and Obstetrics (FIGO) launched an initiative in 2007 to prevent unsafe abortion and its consequences, building on its work on other major causes of maternal mortality. A Working Group was identified with collaborators from many international organizations and terms of reference provided direction from the FIGO Executive Board as to possible evidence‐based interventions. A total of 54 member associations of FIGO, representing almost half its member societies, requested participation in the initiative, with 43 subsequently producing action plans that are country specific and involve the national government and multiple collaborators. Obstetrician/gynecologists have demonstrated the importance of the initiative by an unprecedented level of engagement in efforts to reduce maternal mortality and morbidity in country and by sharing experiences regionally.

Applying Human Rights to Improve Access to Reproductive Health Services

Universal access to reproductive health is a target of Millennium Development Goal (MDG) 5B, and along with MDG 5A to reduce maternal mortality by three‐quarters, progress is currently too slow for most countries to achieve these targets by 2015. Critical to success are increased and sustainable numbers of skilled healthcare workers and financing of essential medicines by governments, who have made political commitments in United Nations forums to renew their efforts to reduce maternal mortality. National essential medicine lists are not reflective of medicines available free or at cost in facilities or in the community. The WHO Essential Medicines List indicates medicines required for maternal and newborn health including the full range of contraceptives and emergency contraception, but there is no consistent monitoring of implementation of national lists through procurement and supply even for basic essential drugs. Health advocates are using human rights mechanisms to ensure governments honor their legal commitments to ensure access to services essential for reproductive health. Maternal mortality is recognized as a human rights violation by the United Nations and constitutional and human rights are being used, and could be used more effectively, to improve maternity services and to ensure access to drugs essential for reproductive health.

Abortion and human rights

Abortion has been a reality in womens lives since the beginning of recorded history, typically with a high risk of fatal consequences, until the last century when evolutions in the field of medicine, including techniques of safe abortion and effective methods of family planning, could have ended the need to seek unsafe abortion. The context of womens lives globally is an important but often ignored variable, increasingly recognised in evolving human rights especially related to gender and reproduction. International and regional human rights instruments are being invoked where national laws result in violations of human rights such as health and life. The individual right to conscientious objection must be respected and better understood, and is not absolute. Health professional organisations have a role to play in clarifying responsibilities consistent with national laws and respecting reproductive rights. Seeking common ground using evidence rather than polarised opinion can assist the future focus.

Today's evidence, tomorrow's agenda: Implementation of strategies to improve global reproductive health

The Alliance for Womens Health deliberated on critical gaps and emerging issues related to womens health, focusing on contraception, safe abortion care, HIV, and cervical cancer prevention. Despite the health, socioeconomic, and development benefits of family planning, up to 222 million women have an unmet need for modern contraception. The number of unsafe abortions increased globally, 98% of which occurred in low‐resource countries. Fragmentation of services for HIV and cervical cancer prevention and treatment fail to maximize opportunities to reach women within reproductive, maternal, and child health services. The FIGO 2012 PreCongress Workshop elaborated the role of societies of obstetricians‐gynecologists in implementation of actions to increase access to modern methods of contraception to help individuals meet family planning intentions. Human rights principles underpin the imperative to ensure equitable access to a wide range of modern methods of contraception. The role of task shifting/sharing in different models of service delivery was elaborated. Actions from the International Conference on Population and Development on safe abortion care and integration of effective contraception were reaffirmed. A call was made to increase access to integrated HIV and cervical cancer prevention, screening, and management. Cross‐cutting strategic approaches to accelerate progress include evidence‐based information to stakeholders and continued education in these areas at all levels of training. A call was made to advocate for a budget line item for sexual and reproductive health, including family planning and engaging the demand side of family planning, while involving men to enhance uptake and continuation.

Universal access to reproductive health: Opportunities to prevent unsafe abortion and address related critical gaps

When the Millennium Development Goals (MDGs) were adopted in 2000 they failed to include targets for universal access to reproductive health, despite this having been articulated and agreed to during the International Conference on Population and Development (ICPD), held in Cairo in 1994, and the ICPDs Programme of Action [1]. Fortunately, many governments, nongovernmental organizations (NGOs), andother organizations—including the International Federation of Gynecology and Obstetrics (FIGO)—recognized this omission, and began to call for increased commitment, political andfinancial, to reproductive health services. The MDGs are all interrelated, but 3 of them—MDGs 4, 5, and 6— are recognized as specific to health, and the original MDG 5 was to reduce maternal mortality by three-quarters between 1990 and 2015 [2]. Its indicators included maternal mortality ratio and proportion of births attended by skilled health personnel. Based on the evidence, obstetricians and gynecologists and other health experts were well aware that such reductions in maternal mortality were unattainable by 2015 without addressing other related issues, such as unmet contraceptive need and adolescent reproductive health. In addition, HIV/AIDS in Sub-Saharan Africa has become a major contributor to maternal mortality in addition to child mortality from vertical transmission, thus linking all of the health MDGs. After years of pressure from the global community, in 2006 the United Nations General Assembly finally accepted the target of achieving, by 2015, universal access to reproductive health as an additional component ofMDG 5, now known as Target 5b. The indicators for Target 5B include contraceptive prevalence rate; adolescent birth rate; antenatal care coverage (at least one visit and at least 4 visits); and unmet need for family planning [3]. Unsafe abortion is a problem almost entirely restricted to the most marginalized women in the world and has been the most neglected of the causes of maternal mortality, despite contributing to at least 13% of deaths [4,5]. Additionally, an estimated 5 million women are hospitalized each year for treatment of abortion-related complications, such as hemorrhage and sepsis [4,5]. During the FIGO triennium that culminated in the XIX FIGOWorld Congress in 2009, an Initiative to Prevent Unsafe Abortion and its Consequences was approved by the FIGO Executive Board at a retreat in 2007, initiated by the president of FIGO. The Working Group and terms of reference were decided and the Chair of the Working Group as unanimously agreed by the FIGO Executive Board was Anibal Faúndes. The Initiative has involved many collaborating agencies internationally and nationally to support action plans in FIGOmember association countries or territories that were alignedwith the national governments. In recognition of the contribution of unsafe abortion to