A vision for FIGO

My first responsibility is to recognize the history of our organization as we collectively move forward, and the vision and commitment of our past presidents. Building an organization requires a strong foundation and when change is required to strengthen the organization, the wisdom and support of those strong leaders is a great benefit. I would like to thank all of you for your support in making today a reality, but in addition to my family, I particularly wish to thank the Society of Obstetricians and Gynecologists of Canada (SOGC) for their commitment to FIGO, to the partnerships they have built with member societies in low income countries, for initiatives such as the International ALARM train, the trainer program in emergency obstetric care. Dr. André Lalonde deserves special mention, since in addition to his role as co-chair of the FIGO committee for Safe Motherhood and Newborn Health and his SOGC leadership, he has also represented FIGO tirelessly on the new international partnership for Maternal Newborn Child Health (PMNCH) and with our partners in ICM, IPA and others, professional organizations are finally being recognized as important partners internationally in moving our common agenda forward. What is our common agenda? Why did we choose sexual and reproductive health as our specialty, unique in its public health foundation and in its ability to raise more controversial questions than any other field of medicine? In the 5 days since this Congress opened, on Sunday, November 6, 2006 at 5 pm, until the time we began the closing ceremonies, approximately 7000 women died around the world from pregnancy-related causes, and for every woman who died, 30 more, or 210,000 women, have suffered serious illness, injury or disability. At FIGO, we understand that global maternal mortality is a shameful reality requiring our urgent attention, with an estimated 500,000 women dying during pregnancy or childbirth every year, most in the poorest countries. It was a former FIGO President, Mahmoud Fathalla, who turned the spotlight on the social responsibilities of FIGO; with the Safe Motherhood initiative in 1997 highlighting this role in addition to providing professional development for obstetrician/gynecologists of the world. His statement is still true today: “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” Women who die during childbirth or who suffer serious complications frequently experience stillbirth or lose their newborn infants, compounding the tragedy. The importance of reproductive health to maternal and infant health, addressing HIV/AIDS epidemic, gender equality, human rights, and poverty reduction was recognized by the global community during the International Conference on Population and Development at Cairo in 1994, when 179 countries agreed to achieve universal access to sexual and reproductive health by 2015. It was expected that the program of action would be included in the Millennium Development Goals. The FIGO Pre-Congress Workshop on November 2–3, 2006 was focused on emerging issues in access to reproductive health. Health is not only a human right; it is an important contributor to economic development. This creates a compelling case for investing in reproductive health, especially since interventions are readily available and affordable. When the MDG's were adopted in 2000, the evidence for such links was ignored and the MDG's failed to include targets for universal access to reproductive health. Fortunately, many governments, non governmental organizations (NGOs) and other organizations, including FIGO, recognized this omission, and began to call for increased commitment, political and financial, to reproductive health services. After years of pressure from the global community, in October 2006 the United Nations General Assembly finally accepted the target of achieving universal access to reproductive health as a target for MDG #5 — to reduce maternal mortality by three-quarters by 2015. This was partnership in action. During the last 3 years, FIGO's new committee on safe motherhood and newborn health has initiated 12 projects to save the lives of women and their newborns. Building on the lessons learned from twinning in the previous Safe Motherhood projects, each of these involves a mentor country and requires involvement of the Ministry of Health in the member country. President A. Acosta has led an initiative on the Prevention of Post Partum Hemorrhage. I want to state explicitly that three year cycles at FIGO are a thing of the past. FIGO is now moving to sustainability and strategic thinking about our priorities. The partnership with ICM on postpartum hemorrhage has been very effective, but must remain a focus for some time yet. The POPPHI initiative will continue over the next 3 years, since postpartum hemorrhage is the most common cause of maternal mortality. It is also one of the more easily treatable causes. There is another easily preventable cause of maternal mortality that we need to work on together, that of unsafe abortion. Of the half a million deaths each year related to pregnancy, at least 13% are caused by unsafe abortion. Many of the FIGO member societies have asked for FIGO's support as they struggle with their efforts to prevent this tragedy. If we look at the evidence, it is clear that unsafe abortion is a problem that affects poor women in countries where abortion may be legal or illegal. How can we prevent these senseless deaths and disabilities? Can we come to a place of understanding, so that we can save women's lives literally and broadly? Women who resort to unsafe abortion are desperate, poor, uneducated, have no access to financial resources, have no power to negotiate in their sexual relationships, and, in fact, are often faced with non-consensual sex, or forced to use their bodies to feed their families. How does blaming women and prosecuting them solve this problem? Does society care less about the lives of poor women? The human cost also involves others who are unable to be helped by a health care system unnecessarily burdened with very ill women suffering the consequences of preventable unsafe abortion. The evidence is clear. Restrictive laws on abortion have clearly been shown to increase maternal mortality. The highest abortion rates are in countries with no legal access to abortion and restricted access to contraception. The lowest abortion rates in the world are in countries, such as Belgium, where young people are educated, there is comprehensive sex education in schools, and there is access to free or low-cost contraception and abortion services. There has been substantial work on unsafe abortion through the FIGO Committee on Women's Sexual and Reproductive Rights, driven by input from our member societies, on a regional basis. The workshop in Pretoria early in 2006 identified unsafe abortion and HIV/AIDS as priorities for the ECSAOGS region. The report from that workshop was instrumental in the outcome of the Special Session of the Conference of African Union Ministers of Health in Mozambique in September 2006, focused on universal access to comprehensive sexual and reproductive health services in Africa. Thoriah Obaid, Executive Director of UNFPA had this to say: “Unsafe abortion is a huge cause of maternal deaths in Africa. The uterus of women is the only organ in the body which is subject to the penal code, to quote the great Fred Sai of Africa. In Cairo it was agreed that abortion should not be used as a means of family planning. In the same paragraph 8.25 all your nations agreed that where abortion was legal it should be safe. We need to honor this commitment we made in Cairo to provide safe abortion services to women. Only three countries in the world have laws that completely prohibit abortion [actually four after last week in Nicaragua] — and they are NOT in Africa. African countries have various indications for which abortion is legal, but women have no access to services.” I fully recognize that this is a very sensitive and controversial issue, but uncomfortable silence, lack of dialogue, and inaction in the face of the evidence is not acceptable. Working with FIGO member societies in partnership with our collaborating agencies will provide thoughtful avenues for progress. Addressing unmet need for contraceptive information and services, especially for adolescents, is essential. Using the opportunity provided by postabortal care to assist women non-judgmentally — the options are many. As gynecologists caring for women, doing nothing is not one of them. FIGO has made a commitment to the treatment and prevention of obstetric fistula and many saw a heart-rending video presented by Lord Patel at the opening ceremony of the XVII FIGO World Congress in Santiago, Chile in November 2003. As you have heard, we are beginning to see results of the partnership with UNFPA, AMREF and others, but this also is a long-term project. Training personnel in country to provide the complex care and surgery required is critical for sustainability. Addressing the root cause of obstetric fistula is an issue of sexual and reproductive rights. Obstetric fistula is a living nightmare for women who did not become maternal mortality statistics, and the causes are similar. Obstetric fistula is also preventable. FIGO has forged partnerships with professional organizations, with our collaborative agencies in the Women's Health Alliance with WHO, UNFPA, IPPF, WB, ICM, IPA, UNICEF. In addition, we have been fortunate to acquire support for project funding from donor agencies, including Swedish SIDA, Capacity (United States Agency for International Development, USAID), the Packard Foundation, Ipas, and industry. Transparent ethical relationships with industry are important and I would like to acknowledge a significant unrestricted grant from Schering from 2007, for presidential projects in maternal mortality prevention over the next 3 years. We have been fortunate in the past to receive a similar grant from Pharmacia, to support us in safe motherhood initiatives. At the opening ceremonies of the recent World AIDS conference in Toronto, Bill Gates, in speaking about vaginal microbicides, said, “A woman should not need her partner's permission to save her own life.” Saving women's lives from HIV infection has become an urgent global priority. The reproductive function of women and their biological susceptibilities, coupled with lack of empowerment in sexual relationships, have resulted in women being over-represented in people living (and dying) with AIDS. They are not in a position to negotiate condom use for prevention of sexually transmitted disease; their access to voluntary testing, diagnosis, and treatment is currently far from equal in most low income countries, especially sub-Saharan Africa. Monogamy is not preventing women from becoming infected, though ignorance means they are often blamed and stigmatized for being HIV positive; in India, 90% of women who were HIV positive at their first antenatal visit reported being monogamous. The majority of young people age 15–24 infected with HIV are women. The risk factors for HIV in women are poverty, disempowerment and sexual violence. It is reported that almost half of all sexual assaults occur in girls under the age of 15. We could easily focus all our limited resources on HIV/AIDS, but many other agencies are already heavily involved, and knowing that sexual violence is a key risk factor, I would like to suggest that a focus on providing services for victims of sexual violence may be a key role for us to play. FIGO could facilitate the development of standards and services for integrated services for sexual assault, as the Ethiopian society demonstrated during its WSRR project, and as has occurred throughout Brazil with leadership in FEBRASGO, from Professor Anibal Faundes and others. FIGO can partner with others in civil society to provide residential services for young victims of sexual abuse as the Bolivian Society has done. FIGO can break down the barriers to access to voluntary testing and treatment for HIV by speaking openly about it and by using partnerships with government and others to address the real problem of stigma, which is a problem even among people working in health care facilities. Saving women's lives. Working together. I look forward to input from our member societies and collaborating agencies as to how we can help countries address these issues in the context of their specific needs. The solutions are best determined with those living the challenges real time. HIV/AIDS is a preventable cause of death. Partnerships with health professionals, law-enforcement agencies, parliamentarians, lawyers, and communities are essential in order to bring about the changes required to save women's lives from HIV/AIDS resulting from sexual violence. Every 2 minutes a woman dies of cervical cancer. It is the most common cause of death in women in Latin America. It is also mostly preventable, especially with the recent major breakthrough of HPV vaccine. The FIGO study group on cervical cancer and HPV vaccine has just published an important report that will be a priority area of action for FIGO over the next 3 years and beyond. Now that HPV vaccine is available, it is imperative that it becomes accessible, especially in low and middle income countries. In addition, simplified cervical cancer screening and treatment is both possible and an urgent priority. Access issues are problematic, and not only in low income countries, since marginalized women in all countries, as well as women from cultures unfamiliar with screening for cervical cancer, are found to have significantly higher rates of this preventable disease. Pelvic examination is not even understood by women in many poor rural communities. We need to work together with communities to determine optimal approaches. Our work in advocacy is not only because it is a socially just behavior, based on international human rights law. Through our role on the MNCH partnership, the FIGO committees for SMNH, WSRR, and gynecologic oncology, we are in a position to influence governments to provide access to reproductive health services so that they will become self-sustaining economically. Governments listen to economic arguments. Strengthening the role of FIGO member countries through partnerships is the way forward. Bangladesh has shown leadership in training midwives in recognition of their responsibility in addressing the barrier to access caused by lack of trained skilled personnel. The Recommendation on Women and Health of the UN Committee on the Elimination of Discrimination against Women [1] explains that neglecting health care that only women need, such as maternity care, including treatment for pregnant women with HIV/AIDS, emergency contraception, abortion and, for example, early diagnosis and treatment of cervical cancer, is a form of discrimination that governments are obligated to remedy. The year 2009 is the 30th anniversary of the Convention for the Elimination of Discrimination Against Women. In 2009, the FIGO Congress will be in Cape Town, South Africa, ably hosted by Professor Lindeque and his team at the SASOG. This presents us with a significant opportunity: How can we increase the profile of FIGO even further in ways that are meaningful to the lives of women? Women are our partners, our mothers, sisters, daughters and ourselves. Empowerment of women is essential to achieve any of the MDG's, and the sole focus of the third of eight goals and 2009 will be a milestone year to assess progress. While young women must be educated, reaching the Millennium Development Goals requires that young men are educated differently and we must address their own special needs and issues so that all adolescents become educated, healthy, economically empowered and capable of making autonomous decisions in life. Youth now make up half the world's population — about 130 billion. They do not have access to reproductive health information and services in many countries which is compromising a limited opportunity to ensure they have the best chance of contributing to their country's economic success. Can gynecologists play a role here? Many already do. Empowerment of women and ensuring that they enjoy their human rights is critical in saving women's lives. At the Pre-Congress Workshop in 2003 on our professional and ethical responsibilities in women's sexual and reproductive rights, President Shirish Sheth said, “If we do not attend to this now, when do we do it? If not we, who else?” [2] Since then, FIGO has made progress, is recognized at the international level as a serious partner providing real opportunity to build and grow to meet the needs of women through our member societies. This includes the development of a web portal, led by Professor Luis Cabero-Roura, designed to provide leading edge professional development opportunities. Cervical cancer, maternal mortality from unsafe abortion, and sexual violence in the HIV/AIDS pandemic: All are areas where FIGO has an opportunity at this time to make a difference, with evidence based information, willing volunteers and partnerships that continue to strengthen. All are controversial, and some will be more applicable to some member countries than others. All will require consultation in moving forward. All are too important to ignore. Denial of sexual and reproductive rights is a preventable cause of death. The causes are power, politics, and poverty. The deadly reluctance to discuss sexual behavior and related health issues factually must be overcome. Thank you for honoring me with the privilege to lead FIGO at such a critical time in the evolution of our organization. I hope to have the opportunity to hear from many of you over the next 3 years and look forward to seeing you in Cape Town. Together, in partnership, we will be saving and improving the lives of women and children. Isn't that our common agenda?

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