Asignaturas del Quinto Curso

1. Maternity is a social function and not a disease. Societies have an obligation to protect women’s right to life when they go through the risky business of this social function that ensures the survival of our species. Maternal health care is not only important for avoiding maternal mortality and morbidity, but is also crucial for reducing the high burden of perinatal mortality and morbidity.

2. Worldwide, each year, about 287,000 women die – over 786 daily, exceeding one every two minutes – because of pregnancy and childbirth, an average maternal mortality ratio (MMR) of 251/100,000 live births. Of these deaths, 99% occur in resource poor countries. The woman’s lifetime risk of death due to pregnancy is 1/31 in Sub-Saharan Africa compared to 1/4300 in industrialised regions of the world.

3. Reduction of maternal mortality is one of the UN Millennium Development Goals; the goal set for MMR is75% reduction by the year 2015. Without a concerted effort, this goal will not be achieved, especially in Sub-Saharan Africa and South Asia.

4. Hemorrhage is the leading cause of maternal death during pregnancy, accounting for more than one third of all casualties.

5. The majority of maternal deaths occur during labour. In most circumstances, pregnant women die because they deliver without the benefit of any skilled birth attendants.

6. The training of traditional birth attendants (TBAs) has proven to be inefficient on its own to reduce maternal mortality. The management of life-threatening complications in pregnancy and childbirth needs services which cannot normally be provided by TBAs.

7. Maternal deaths are nearly always related to three delays in implementing appropriate care: a delay in the recognition of life- threatening complications, a delay in transfer to a medical setting and a delay in access to proper obstetrical treatment.

8. The minimum rate of caesarean section to prevent avoidable maternal death is estimated to be around 5%. However, in countries with high maternal mortality, the rate of caesarean section is often less than 1%, due to a lack of health facilities and trained personnel.

9. Contributing factors to maternal mortality are early age at marriage, pregnancy occurring too early (before 18), too close (with less than two years intervals), too late (after 40), too frequently, illiteracy, malnutrition, lack of access to proper contraception and undue trust in the contraceptive value of breastfeeding.

10. About 180 million pregnancies occur each year. Half of these are unplanned, half of these unplanned pregnancies will end in induced abortion, 48% of which, around 22 million, are unsafe abortions, responsible for 70,000 annual deaths and 5 million disabilities, amounting to over 24% of all maternal deaths overall, but more in some countries. When countries have introduced legislation to permit abortion for non-medical reasons, the overall mortality and morbidity from the procedure has fallen dramatically, without any significant increase in the number of induced abortions.

Recommendations

1. Women’s mortality related to pregnancy remains unacceptably high, particularly in resource poor areas. Prevention of maternal death should be considered worldwide as a public health priority. Obstetric professional societies should publicise the tragedy of maternal mortality as a violation of women’s rights, and not just as a health problem. In advocating for safe motherhood as a human right, the health professions should collaborate with human rights advocates. 2. Since the main reason for maternal death is an avoidable delay in implementing proper emergency care during complicated labour, efforts should be made to provide all pregnant women with skilled birth attendants during delivery.

3. To achieve universal coverage of maternity services, obstetricians should play the role of team leaders, and delegate appropriate responsibility to other categories of trained and supervised health care providers.

4. Antenatal and intranatal care should be organised so that every woman with an obstetric life threatening complication would be transferred without delay to a medical centre providing the human and technical resources required for emergency obstetrical care, including caesarean section and blood transfusion.

5. Where abortion is not against the law, every woman should have the right, after appropriate counselling, to have access to medication or surgical abortion. The health care service has an obligation to provide such services as safely as possible. Proper medical and humane treatment should be made available to women who have undergone an unsafe abortion.

6. Family planning services and information should be made available for the timing and spacing of births.

7. The review of cases of maternal deaths should probe deeply into the underlying causes, beyond the clinical diagnosis.

8. Reduction of maternal mortality also depends on nonmedical policies such as development of suitable transportation means and roads accessible by vehicle and financial needs for underprivileged women, particularly within rural communities and in remote areas.

9. Obstetricians should lead the way in demonstrating how emergency obstetric care can be provided in a cost effective way in low resource settings. North to South and South to South collaborative efforts are needed to advance cost-effective strategies

See the FIGO Safe Motherhood and Newborn Health Committee guidelines Prevention and Treatment of Postpartum Hemorrhage in Low-Resource Settings (International Journal of Gynecology and Obstetrics 117 (2012) 108–18).

London, March 2012 (updated)

ETHICAL GUIDELINES ON OBSTETRIC FISTULA