The FIGO Save the Mothers Initiative

For an obstetrician, no event is more tragic than a maternal death. Obstetricians in developed countries may end their professional career without witnessing a single maternal death. For obstetricians in the southern hemisphere, maternal deaths are not statistics. They are human faces seen in agony. They have names, and they haunt their memories. Global awareness of maternal mortality was raised by the International Conference on Safe Motherhood in Nairobi, Kenya, in 1987. The sponsor of the Conference was the World Health Organization (WHO). The United Nations Agency Group was constituted after the Conference, with WHO, the Population Fund (UNFPA), and the World Bank as its members. The group was then joined by UNICEF, the International Planned Parenthood Federation (IPPF), the Population Council, and Family Care International, which provided a secretariat. FIGO was conspicuous by its absence from the initiative. It was not that FIGO or obstetricians declined to participate, but their relevance was in doubt: there was a feeling that obstetricians were part of the problem rather than a part of the solution. Obstetricians were often thought to be chiefly interested in their professional privileges and in high technology, and unwilling to delegate responsibilities to other health professionals or play the constructive role of team leaders. While this may have been true of some, it was certainly not true of most. Obstetricians from developed and developing countries were very much concerned about this tragedy, and they knew that they could alleviate it. The International Safe Motherhood Initiative soon made it clear that obstetricians had an indispensable role in making motherhood safe for all women. Pregnancy and childbirth are risky, as there is no way to predict or prevent all their possible life-threatening complications. However, with the knowledge that we have, these complications can be detected and managed by appropriate obstetric interventions. The question was whether essential obstetric functions could be made available in low-resource settings, and whether obstetricians were willing to face the challenge. When confronted with these questions, FIGO answered both of them with a clear yes, if resources could be mobilized. An approach came from Dr. Nicholas Dodd, Chief of the Technical Branch of UNFPA, who wanted to start a needs assessment of essential and emergency obstetric care in some countries and felt that obstetricians should be involved in the exercise. FIGO's reaction was that needs assessments would be worth doing only if they were followed by an implementation phase and a proper evaluation of the intervention. UNFPA agreed, and a draft proposal was developed that involved a partnership between obstetricians in developed and developing countries. The extensive paperwork, usually needed for grants from the UN System, was efficiently prepared with the help of the FIGO Secretariat, i.e. Ms. Chantal Pradier, Mr. Brian Thomas, and Ms. Rosa Tunberg. The grant proposal was processed through the UNFPA system, and finally approved on September 4, 1997, with $19 700 allocated for 1997, $251 450 for 1998, $55 000 for 1999, and $117 950 for 2000. The grant letter was signed, on behalf of UNFPA, by Mr. Sethuramiah L.N. Rao, Director of the Technical and Evaluation Division. At about the same time, preparations were going ahead for the FIGO World Congress in Copenhagen. Pharmaceutical companies were being asked to explore their interest in supporting Congress activities. Thanks to a preliminary approach by Prof. Jorgen Falck Larsen, President of the Congress, the pharmaceutical company Pharmacia (then about to merge with Upjohn) decided that if it received a sound scientific proposal with potential impact on women's health, it was willing to go beyond simple support of the Congress. A detailed plan was presented for a FIGO Save the Mothers Fund and Pharmacia accepted the plan and on May 13, 1997, the agreement was signed at the FIGO secretariat office in London. The donation was determined to be US $250 000 per year over 3 years, and it was to support research demonstration projects focused on reducing maternal mortality in developing countries. An additional support grant was approved, not to exceed 10% of the sum total of the research fund, to cover administrative costs. It must be stressed that Pharmacia–Upjohn did not have a commercial or profit-driven motive in this initiative. In the letter of agreement, the following statement was made: Pharmacia & Upjohn Inc (P&U) and FIGO are different organizations. P&U is a for-profit pharmaceutical firm. FIGO is a non-profit federation of medical societies. But both agree to work together in their mutual interest in alleviating the suffering of women in pregnancy and childbirth, particularly in developing countries. The agreement was signed on behalf of P&U by Dr. Shay Weibrich, Worldwide Director, and Dr. Lars Birgenson, Vice-President; and on behalf of FIGO by Dr. M.F. Fathalla, President, and Dr. Ho-Kei Ma, Secretary General. The FIGO Save the Mothers Fund was formally launched at the time of the FIGO Congress in Copenhagen in 1997, with strong enthusiasm among the world obstetric community. Shortly thereafter, thanks to the efforts of Dr. Ann Tinker, then Principal Health Specialist with the World Bank, the Bank became a third sponsor of the Fund. FIGO had the know-how and the commitment. Now that it had also the resources, and it was time to act. And FIGO did. The launch of the FIGO Save the Mothers Fund Project (soon after, renamed the FIGO Save the Mothers Initiative) provided the first concrete evidence of action by the very physicians who dedicate their lives to women's care; and FIGO, their international federation, was happy to add its own resources to ensure the success of the Initiative. A first meeting to operationally define the activities took place in London during February 1998; a number of FIGO representatives participated: Prof. G. Benagiano, Secretary General and Initiative Chair; Prof. M. Seppälä, President, Prof. M. Fathalla, Past-President; Prof. S. Arulkumaran, Treasurer; Profs D. Fairweather and Ho-kei Ma, former Secretary Generals; Ms. Chantal Pradier, Executive secretary; and Mr. Bryan Thomas, Assistant Secretary. The representative of Pharmacia–Upjohn, Dr. H. De Koning-Gans, was also present, together with a number of experts: Prof. A. Faundes, Dr. R. Hale, Prof. C. Hudson, Dr. A. Lalonde, and Prof. G. Lindmark. The scope of the meeting was to define the methodology and select the countries to be involved in the Initiative. FIGO determined to tap its strengths, and this decision produced the concept of 'twinning' of member societies, thus making experience gained in the developed world available to colleagues in the developing world—who, in turn, would use their local knowledge to ensure the success of the activities undertaken. It was agreed that, overall, the Initiative would have two components: a field of action and a field of research. The Initiative was to have two phases. After a first phase aimed at assessing the needs, a second phase would provide 'essential obstetric services' for women exposed to life-threatening complications. Are health facilities available? Are health facilities utilized? Are health facilities of sufficient quality? For Phase One, it was decided to use the publication 'Guidelines for Monitoring the Availability and Use of Obstetric Services' issued jointly by UNICEF, WHO, and UNFPA. One chapter contains standard indicators for assessing the availability and utilization of health facilities; by using these standard indicators, it is possible to gauge the level and accessibility of existing facilities, their utilization, and quality. Phase Two, in view of the limited availability of funding, would be conducted in only five countries. The purpose of the meeting was to choose five countries where needs assessments could be undertaken. Countries would be chosen on the basis of need. World Health Day, 7 April, 1998, would be dedicated to Safe Motherhood, providing a good opportunity to focus attention to the importance of the FIGO initiative. The issue of funding was specifically addressed. Contact had been made not only with the original donors, but with Anne Tinker, Principal Health Specialist at the World Bank, and eventually the Bank donated $100 000 to the Initiative. It was also mentioned that telecommunications companies may, at some point, be able to assist in the dissemination of information and provide practical assistance at the time of the demonstration projects. Develop the plan of activities; Make decisions on the selection of countries and country teams; Monitor and review progress; Approve periodic technical reports. Providing full secretarial and administrative support for the meetings of the Steering Committee; Serving as a liaison with the Research Team and Country Teams as appropriate; Making travel, meeting, and accommodation arrangements related to the Save The Mothers Fund as needed; Taking responsibility for all financial matters relating to the Save The Mothers Fund, including the disbursement of funds; Ensuring that all recipients of funds disbursed under the terms of the various grants acknowledge and adhere to the requirements of the grant providers; Preparing progress and financial reports to be submitted to FIGO's Executive Board and all funding institutions. High maternal mortality; The existence of an active society of obstetrics and gynecology; The demonstration of Government interest and commitment to improving women's health; An expression of interest from a FIGO member society of obstetricians and gynecologists in a developed country to work in the chosen region. After much deliberation of the relative merits of the applications received and the practicalities involved, the Committee agreed on the following: The Committee then agreed upon the following 'reserve' list: It was agreed that the FIGO Country Coordinators should be chosen from members of the Steering Committee. Their function would be to lead the Country Teams, to ensure that the individual demonstration projects remained on track, and to act as points of reference for the parties 'on the ground.' Their role would also involve reporting on developments to the Steering Committee. The following teams were agreed upon: The first task of the Country Teams—which were made up of physicians from the twinned societies—was to undertake a needs assessment within the country or region of their concern, using guidelines issued by the United Nations [1]. The Pharmacia & Upjohn grant was initially for operational research within the initiative. It was felt that one or more research students should synthesize data from various country teams to ensure uniformity. The University of Nottingham had confirmed its willingness to accept two or three fellows and the Faculty Head was prepared to provide input and assistance. Space as well as computer and e-mail facilities could be provided by the university. A credible focus of research would enable the Teams to use standardized systems for collating data. They would thus be able to document carefully the demonstration projects, assess their effectiveness and worth, and encourage their implementation in other areas/countries. It was also agreed that, within the country involved, an evaluation institute would be selected to validate the data and the value of each demonstration project. In summary, three research levels were envisaged: the most important was the local level, which retained ownership of the data and would be the ultimate beneficiaries; the second was to implement technical collaboration and support from the society of the developed country; and the third was to ensure the consolidation of the tasks undertaken in the different countries. Action immediately followed the first meeting, and in September 1998 a first assessment was made. During a meeting in London, each of the Country Team Coordinators gave a presentation based on their written reports, which were previously circulated. Each provided a detailed outline of how the individual project would be carried out and specified its financial requirements. An important overall comment stressed the need to closely collaborate with midwives' associations in the selected countries. In this respect, a role of the Team Coordinator was to ensure that all available human resources were used. The meeting clearly indicated that expectations had been fulfilled and the overall project was on target. It was therefore decided to give the go ahead signal to working partners and encourage them to order equipment immediately. All projects were approved in principle, but subject to clarification and binding amendments. Revised proposals that incorporated the responses to the various amendments and clarifications sought by the Steering Committee were to be submitted. Over the following years, a number of meetings took place to properly monitor progress, identify problems, and suggest solutions. Already in 1999 one point became clear: the original time frame envisaged was totally unrealistic and needed to be extended. This, however, implied not only redirecting existing funds from research to implementation, but searching for additional financial resources. FIGO will be forever grateful to Pharmacia Corporation (the new name Pharmacia–Upjohn was adopted in 2000) for coming to the support of the Save the Mothers Initiative with an additional sum of $300 000. A detailed description of individual projects has been published recently [2–5]; articles describing the FIGO initiative have also appeared recently [6,7]. These provide full accounts of the projects, which are here only briefly summarized. To guide its work, FIGO adopted the 'three delay' model, first described by the Mailman School of Public Health at Columbia University in the United States of America [8]. It "provides guidance and tools for the design and evaluation of maternal mortality programs," with the aim of identifying solutions to the causes of delay. These are defined as: delay in deciding to seek care; delay in reaching a treatment facility; and delay in receiving adequate treatment at the facility. As already explained, after an initial needs assessment, customized projects were developed to remedy the deficiencies identified in each of the projects areas. All were designed to ensure that the activities would be low cost, replicable in other regions, and fully sustainable locally once the international involvement was phased out. Central America was selected because in Guatemala, El Salvador, Honduras, and Nicaragua maternal mortality rates are approximately 200 per 100 000, with a lifetime risk of pregnancy-related deaths between 1 in 65 and 1 in 100 [9], compared with a rate in the United States of 7 per 100 000 live births and a lifetime risk of death from complications of pregnancy and childbirth of 1 in 3500 [10]. The Central America–USA demonstration projects took place in the following rural provinces of the four countries: Sonsonate in El Salvador, Sololá in Guatemala, Santa Rosa de Copán in Honduras, and Matagalpa in Nicaragua. They involved several interventions and objectives, including the implementation of training courses in the management of emergency obstetric care, on the one hand, and of improved relationships between the National Obstetric and Gynecology societies and the Ministries of Health, on the other. Given that most institutions providing total care were located in urban areas and were privately owned, it became immediately evident that the capacity to provide basic care in obstetric emergencies was virtually nonexistent. For these reasons, most of the rural population, i.e., an population, had very limited to obstetric care during pregnancy and at The scope of the project then focused assessing and improving obstetric emergency care, developing systems for maternal systems and at and and identifying to prevent maternal of field in the management of emergency obstetric care, including the of and with in obstetric emergency care, based on the work undertaken by These then the of the in the that all health care would be a for active management with during the third phase of in all the institutions providing childbirth a and data system, including a detailed of all maternal with with and a more maternal mortality maternal mortality to causes and related to each with the aim of providing to ensure health in the for at health and to ensure proper with evaluation meetings to local and health and At first the were to no in the number of maternal as involved had that projects would provide within three However, more carefully at the it became that as a of the improved system, more maternal deaths were being made with data and the that the would need to for five to if it was to a in maternal the developed by the project clearly that most maternal deaths were not being important was that of maternal deaths of which are to following at and that only in In all the need for emergency obstetric care was approximately During the a was to approximately The most important of the activities in Central America was the training of all health care in the health care received initial training and all health care facilities in each of the four provinces can provide basic emergency obstetric to maternal mortality in is than in most with a of deaths per 100 000 live The for a in this rate is because of the limited availability of health In in the country a of deaths during pregnancy is complications by In order to and this the of Obstetricians and and The of and joined in The project was the of The where the and two health are The initial needs assessment, conducted in 1998, determined that obstetric indicators for the were among the in the A number of were identified including a or absence of at all to in working and of of essential medical equipment and absence of absence of an of emergency obstetric care in the was for 1999 at more than to some in an need for emergency obstetric care of and for of emergency obstetric care were an standard and not provided the at the For this the aim of the was to in emergency obstetric care through adequate and emergency obstetric care was by existing facilities through the of and physicians and other from and Health in emergency obstetric care; Providing new and with the for a of for in a of and to a new for obstetric and that had been at the to the and had been for over two During the all the obstetric and the were to the new through a with and to the local to of the obstetric of was very as by the number of to However, as soon as the implementation phase the total number of at from a of in 1998 to in of was the in with obstetric in 1998 to in of approximately The of in the is for of all complications. Obstetric for of all An important has been that from in 1998 to in was the in the rate at which improved from a level of in 1998 to in maternal from in 1998 to in was an in after the first of not only in but also in the two health was to in all facilities, and it was improved by The two health in the and have been training and of equipment and was to ensure to basic emergency obstetric care by the community. The availability of high emergency obstetric care in all the involved project is by a in to at the Health have from in 1999 to in and at the Health from to to the and Health the maternal mortality rate in was between and per 100 000 live in In the same the rate was with a from in urban areas to in rural areas. To identify the of maternal mortality in the of Health conducted an of maternal deaths in 7 provinces between 1997, and these were to obstetric It soon was that the to was the of medical to provide obstetric improving the to physicians in and obstetricians in became a number of of of and the equipment of the in the selected the and management of obstetric the and of health providers; data As a of the interventions the number of basic emergency obstetric care in the from two in 1998 to four in in the the number from one in 1998 to five in 2000. emergency obstetric care had available per in part of the in and at with the aim of a in all three by the end of the project activities. in an in the number of complications at and In total in were with complications and In the total number of was the number of complications to and the number of to The of in the FIGO project was adopted as a for basic and emergency care at the As a a plan was developed based on the model, the and that had during the demonstration project. All the were incorporated the for the of maternal and mortality in the of Save the Mothers Initiative the to ensure the of the in the by is one of the countries. has in and the use of is more maternal mortality at per 100 000 live births the existing in data however, it is more than that this could be than The took place in the of it was was representative of the and rural of of the the would not as by it was representative of the to the of the of emergency obstetric care was virtually nonexistent. Health with only facilities, each about Health or care facilities and the and within the Ensuring that were the of health and training in emergency obstetric care to existing medical and a for local including and the decision and Providing The of all three were for both and all interventions carried out in the to which complications were if attention was to an evaluation of the impact that the new have the the of of all women at in for or for treatment of a pregnancy-related was also that, for the of the the total number of and were of whether they had place within the or of it. The number of to from for the the year of complications were compared with of The number of births in the project facilities from to of the of more than of all women in the of who a received it at the liaison and with were at all The by women to the of being or by has all but is of the countries in the mortality is at per 100 000 live The number of births per women between the of and is and the rate of active is only approximately health only of all births in for women to a health of or between the and the of of health of basic equipment and in some the and related to basic and emergency obstetric care; new to ensure a to the for the project and the of health facilities by providing basic and and and to maternal care by through a partnership with the of and at women and their on related to and possible complications during the of emergency and facilities in the to ensure the of women to health One emergency obstetric care was fully with two other facilities providing basic care; The number of births in the health facilities from in 1998, to in 1999, it to in for treatment of women with obstetric complications in emergency obstetric care facilities from in 1998, to in 1999 and in year for from in 1998 to in 1999 and to in the year 2000. The number of seen and by at by more than the success of the in all the basic emergency obstetric care and the number of births to women has remained than as most place in the The overall at more than and the for is between and The original five projects are coming to their FIGO can be of was with limited because it was the first time that the Federation had in field activities. The however, is from being The FIGO Save the Mothers Initiative has clearly that and other health professionals have important to to and efforts to women's health most to ensure safe and for all women. FIGO and the associations from countries in both the southern and can of safe motherhood whether in the of and and other professional of technical In the years, FIGO will have to FIGO will need to an that will the efforts and of the FIGO Save the Mothers Initiative and the and to provide at the international level for the new for Safe Motherhood and Health FIGO will need to resources to up on the available jointly with UN UNFPA, UNICEF, WHO, and the World support at the FIGO would be a initiative to the of FIGO, i.e. to to be as the technical in the of maternal mortality and and the of and The of the FIGO Save the Mothers will need a to be developed within the FIGO FIGO may countries to possible and the of these possible projects FIGO will need to together a team to international and to support these The partnership between developed and developing country associations is to up the of associations to to the needs of women in their countries. is in between health care and FIGO needs to the to it a more active partnership and the on individual countries. FIGO will need to a working group with to ensure that all projects in country would involve the individual associations as well as

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