World Report On Women's Health 2015

3
Volume 131 Supplement 1 October 2015 ISSN 0020-7292
131
S1
International Journal of Gynecology & Obstetrics Vol. 131 (2015) S1 S74
International Journal of
GYNECOLOGY
OBSTETRICS
This edition of the World Report on Women's Health

has been produced with the generous support of
World Report on Womens Health 2015

The Unfinished Agenda of Womens Reproductive Health
ELSEVIER
Official publication of FIGO

The International Federation
of Gynecology and Obstetrics
Guest Editors: Chittaranjan Narahari Purandare,

Richard Adanu
GYNECOLOGY
& OBSTETRICS
Volume 131, Supplement 1 (2015)
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Supplement to
International Journal of Gynecology & Obstetrics
Volume 131, Supplement 1

Guest Editors: Chittaranjan Narahari Purandare, Richard Adanu
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GYNECOLOGY
& OBSTETRICS
CONTENTS
Volume 131, Supplement 1, October, 2015
EDITORIAL
C.N. Purandare, R.M.K. Adanu
India, Ghana
The unfinished agenda of womens reproductive health
S1
MATERNAL HEALTH
M. Mathai, T.R. Dilip, I. Jawad,
S. Yoshida
Switzerland, UK
Strengthening accountability to end preventable maternal deaths
C. Schneeberger, M. Mathai
Switzerland
Emergency obstetric care: Making the impossible possible through

task shifting
S3
Implementation of maternal death surveillance and response (MDSR) is key to strengthening

national governments accountability to end preventable maternal deaths.
S6
A review and discussion of the role of task shifting in emergency obstetric care for improving
maternal and newborn health.
P. von Dadelszen, L.A. Magee,

B.A. Payne, D.T. Dunsmuir,
S. Drebit, G.A. Dumont, S. Miller,
J. Norman, L. Pyne-Mercier,
A . H . S h e n n a n , F. D o n n a y,
Z.A. Bhutta, J.M. Ansermino
Canada, USA, UK, Pakistan
Moving beyond silos: How do we provide distributed personalized

medicine to pregnant women everywhere at scale? Insights from
PRE-EMPT
M. Hod, E. Hadar, L. Cabero-Roura

Israel, Spain
Prevention of type 2 diabetes among women with prior gestational

diabetes mellitus
S10
Providing mobile, health-supported, personalized maternalfetal and newborn risk identification and interventions offers the greatest opportunity to provide distributed individualized care at scale, and soon.
S16
Type 2 diabetes can be prevented. FIGO has a crucial role to play in implementing prevention,
detection, and treatment of diabetes in pregnancy for the future health of mothers and their
children.
N.C. Ngene, J. Moodley

South Africa
New drug regimens for HIV in pregnancy and a national strategic

plan to manage HIV: A South African perspective
S19
New drug regimens and a strategic plan for the management of HIV in South Africa have
reduced mother-to-child transmission of HIV to 2.4% and simultaneously decreased maternal
deaths attributable to HIV.
M. Robson, M. Murphy,
F. Byrne
Ireland
Quality assurance: The 10-Group Classification System (Robson

classification), induction of labor, and cesarean delivery
To develop and ensure quality assurance, standardized methodology and structure for audit
of labor and delivery are essential. The 10-Group Classification System (TGCS) should be
implemented universally.
S23
REPRODUCTIVE HEALTH
L. Denny, W. Prendiville
South Africa, France
Cancer of the cervix: Early detection and cost-effective solutions
R. Sankaranarayanan
France
HPV vaccination: The most pragmatic cervical cancer primary

prevention strategy
S28
Alternative methods of cervical cancer screening are feasible and effective; early detection for
prevention is cost-effective.
S33
Current evidence indicates that HPV vaccination is an effective cervical cancer prevention
approach. Implementing HPV vaccination in national immunization programs with high
coverage will reduce cervical cancer burden substantially in future.
S. Becker
Germany
A historic and scientific review of breast cancer: The next global

healthcare challenge
S36
Breast cancer is becoming the number one oncologic health issue in womens health.
Coordinated efforts are required to provide high-quality, interdisciplinary, standardized
careparticularly in countries with developing health systems.
J.L. Morris, H. Rushwan

UK
Adolescent sexual and reproductive health: The global challenges
N. Akseer, J.E. Lawn, W. Keenan,

A. Konstantopoulos, P. Cooper,
Z. Ismail, N. Thacker, S. Cabral,
Z.A. Bhutta
Canada, UK, USA, Greece,
South Africa, Malaysia, India,
Brazil, Pakistan,
Ending preventable newborn deaths in a generation
S. Miller, A. Lalonde
USA, Canada
The global epidemic of abuse and disrespect during childbirth: History,

evidence, interventions, and FIGOs motherbaby friendly birthing
facilities initiative
S40
Healthcare workers have the opportunity to provide solutions to the global challenges of
adolescent sexual and reproductive health that include early pregnancy and motherhood,
unmet contraceptive need, unsafe abortion, and HIV/AIDS and other sexually transmitted
infections.
S43
Millions of newborn deaths and stillbirths occur every year while cost-effective evidencebased interventions are available. To end all preventable deaths, the Every Newborn Action
Plan along with investment and immediate action are needed.
S49
Disrespectful/abusive/coercive care in maternity facilities has been indirectly and directly

associated with adverse outcomes; one approach to improving outcomes by professional
associations can be accrediting facilities as motherbaby friendly.
A.G. Mark, M. Wolf, A. Edelman,

L. Castleman
USA
What can obstetrician/gynecologists do to support abortion access?
A. Fandes, I.H. Shah

Brazil, USA
Evidence supporting broader access to safe legal abortion
R. Joshi, S. Khadilkar, M. Patel

India
Global trends in use of long-acting reversible and permanent methods

of contraception: Seeking a balance
S53
Obstetrician/gynecologists have a unique role in the fight against maternal mortality from unsafe
abortion. By providing care, supporting other providers, or being advocates we can improve
access for women.
S56
Decriminalization and expanded access to safe legal abortion do not increase the abortion rate but
rather decrease the associated complications and deaths, and facilitate the reduction in abortions
through postabortion information and provision of contraception services.
Use of permanent contraception is high and long-acting reversible methods show rising trends
globally. Improved training of healthcare providers on effective LARC methods and patient
awareness are needed to prevent unintended pregnancies.
S60
S. Elneil
UK
Global efforts for effective training in fistula surgery
S64
The implementation of FIGO and its partners competency-based training program has provided a
standardized approach to the management of obstetric fistula, contributing to the global
eradication of this condition.
LEADERSHIP AND MANAGEMENT

H. Bhushan, A. Bhardwaj
India
Task shifting: A key strategy in the multipronged approach to reduce

maternal mortality in India
S67
Task shifting from specialist to nonspecialist doctors was implemented in comprehensive

emergency obstetric care in India to ensure service delivery, improve maternal health outcomes,
and prevent maternal deaths.
D.J. Taylor
UK
The role of health professional organizations in improving maternal

and newborn health: The FIGO LOGIC experience
The FIGO LOGIC Initiative in Maternal and Newborn Health increased the organizational capacity,
credibility, reputation, and contribution to national policy among eight national health
professional associations in Africa and Asia.
S71
International Journal of Gynecology and Obstetrics 131 (2015) S1S2
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo
EDITORIAL
The unnished agenda of womens reproductive health
The 2015 FIGO World Report on Womens Health is published at a

special time in the history of health interventions. This year marks
the end of the Millennium Development Goal (MDG) era and ushers
us into the sphere of Universal Health Coverage (UHC). As we talk
about UHC it is vital that the emphasis that has been placed on
womens reproductive health over the years does not diminish. The
emphasis that WHO is placing on Sustainable Development Goals
(SDGs) post 2015 also emphasizes the need to preserve our achievements, while taking on new challenges. In the light of these global
developments, the 2015 World Report focuses on the unnished
agenda of womens reproductive health. The MDG era achieved
many successes and womens health was central to a number of the
goals. With the move to build on these successes by targeting UHC,
it is important to remember that successes in womens health over
the years are not equivalent to the elimination of womens reproductive health problems.
The 2015 World Report articles provide new perspectives on issues that are all too familiar. The Report is divided into three sections: maternal health, reproductive health, and leadership and
management.
Maternal morbidity and mortality continue to be major issues in
many countries. Even though maternal mortality has reduced globally,
there are still many places where women face unacceptable risks
of death whenever they go through pregnancy, labor, and delivery.
The papers in the rst chapter stress the need for all health services to
ensure that the results of maternal death reviews are acted upon
using the new maternal death surveillance and response (MDSR)
approach. The controversial issue of task sharing or task shifting to
ensure adequate coverage of obstetric services is also addressed. Mobile
health (mHealth) is a subject receiving much attention and one article
looks at the use of mHealth in providing personalized care to pregnant
women. Medical conditions in pregnancy, such as gestational diabetes,
have always been an area of concern in maternal health. With the
current emphasis on the prevention of noncommunicable diseases
(NCDs), it is important to understand how the presence of medical
conditions in pregnancy could lead to the increase in incidence of
NCDs in women. The prevention of type 2 diabetes in women who
have suffered from gestational diabetes is considered in one paper.
Womens reproductive health is a broad topic that looks at clinical
and social problems that affect women. Over the past decade there
have been a number of advances in cervical cancer prevention; however,
the world continues to see equal numbers of deaths due to cervical
cancer and maternal deaths every year. Many of these advances in the
management of cervical cancer are not available to many women in
the world and we need to look at cost-effective ways of delivering the
interventions. The papers in the reproductive health section also highlight the new challenges that are emerging as we make progress in the
areas of breast cancer and adolescent health. Despite the numerous
gains made in these two areas, the problems of nancial access to services and sociocultural barriers to services remain major obstacles to
achieving UHC.
The complications of unsafe abortion and restriction of access to safe
abortion services still need to be addressed through advocacy, policy
change, and service provision. Family planning services have been
clearly recognized as the link between womens reproductive health
and maternal health. It is now accepted that family planning services
that have unrestricted access and that provide the full range of modern
contraceptive methods are crucial in the campaign against maternal
mortality. FIGO continues to show its commitment to family planning
and is currently involved in the postpartum intrauterine contraceptive
device project, which will contribute to increasing the prevalence rate
of modern contraceptive methods. The global contraceptive prevalence
rate is still low even though there has been some improvement over the
years. It has been shown that the health of women as well as newborns
is improved by a three-year interval between pregnancies. The reproductive health section examines current advances in preventing
newborn deaths and also discusses the use of long-acting reversible
contraception. Disrespect and abuse of women in labor are at the intersection of maternal health and womens reproductive health. As
the clinical indicators of maternal health improve, we begin to
focus more on quality of care and this has raised the gender-related
issue of disrespect and abuse that women in labor tend to suffer at
the hands of both male and female care givers. As we aim for UHC,
we must be ready to tackle the way in which these lifesaving services
are delivered.
The rights of women and children must always be of concern in
our health services. Obstetric stulas lead to the exclusion of many
women from society and are also located at the intersection of
maternal health and womens reproductive health. Collaboration
between FIGO and other global agencies is improving the capacity
for surgical treatment of obstetric stula. This old problem still
lives with us and needs to be emphasized as the health community
moves beyond 2015.
The last section of the Report comprises two papers that highlight
the importance of the role of professional societies and international
agencies in ensuring that health targets are met. The need for effective
local management in ensuring the success of interventions designed at
a global level is also emphasized.
The primary message of the 2015 World Report on Womens Health
is that while we celebrate the successes of the MDG era, we must
http://dx.doi.org/10.1016/j.ijgo.2015.04.025
0020-7292/ 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
S2
Editorial
remember that there are some challenges that we could not overcome.
We need to strategize to nd new approaches or to persist with the
proven interventions that we have been implementing.
Chittaranjan Narahari Purandare

Indian College of Obstetrics and Gynaecology and Purandare Hospital,
Mumbai, India
E-mail address: dr.c.n.purandare@gmail.com.
Conict of interest
Professor Purandare is President Elect of FIGO (20122015).
Professor Adanu is the Editor of the International Journal of Gynecology
and Obstetrics (IJGO).
Richard M.K. Adanu

School of Public Health, University of Ghana, Legon, Ghana

MATERNAL HEALTH
Strengthening accountability to end preventable maternal deaths

Matthews Mathai a,, Thandassery R. Dilip a, Issrah Jawad b, Sachiyo Yoshida a
a
b
World Health Organization, Geneva, Switzerland

North West London NHS Trust, London, UK
a r t i c l e
i n f o
Keywords:
Accountability
Low- and middle-income countries
Maternal deaths
Population surveillance
Quality Improvement
a b s t r a c t
The present paper describes the ongoing efforts to revitalize the accountability of national governments toward
preventable maternal deaths. Maternal death reviews are included in the national health policies of the majority
of countries contributing 95% of global maternal deaths. However in actual practice, the extent of implementation
and follow-up of recommended actions on lessons learnt from maternal death reviews is inadequate. This paper
describes and discusses the role of the Maternal Death Surveillance and Response (MDSR) system in strengthening
accountability and ending preventable maternal deaths. MDSR provides a surveillance tool for timely information
on where, when, and why maternal deaths occur, builds on maternal death reviews, and includes the missing
response component for improving quality of care and preventing maternal deaths.
2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. This
is an open access article under the CC BY-NC-ND license
1. Introduction
Over the last two decades, there have been increasing global efforts
to improve maternal health. Although the estimated number of 289 000
maternal deaths for 2013 is 45% less than the estimated number of
maternal deaths that occurred in 1990, it remains unacceptably high
[1]. The majority of these deaths continue to occur in low- and
middle-income countries, with 62% occurring in Sub-Saharan Africa.
Most maternal deaths result from preventable causes [26]. However,
to end preventable maternal deaths, there is a need for better information to understand and address the real causes of why women die
during and following pregnancy and childbirth.
Information about maternal death is ideally captured through
national civil registration and vital statistics systems. It requires both a
well-functioning health information system to record deaths and accurate coding to ensure that all the relevant cases are captured. Even countries with well-established systems can have gross inaccuracies in their
data. In the UK, the independent condential enquiry into maternal
deaths found 60% more cases than the national registration system [7].
Across 60% of the world, where there is no reliable civil registration
system, there is little or no data about maternal deaths [1]. Estimates of
maternal mortality in these countries are generated through household
surveys and through statistical modelling [1]. Although these estimates,
despite their wide ranges of uncertainty, ag the severity of the
Corresponding author at: Department of Maternal, Newborn, Child and Adolescent
Health, World Health Organization, 1211 Geneva 27, Switzerland. Tel.: + 41 22 791
3210; fax: +41 22 791 4853.
E-mail address: mathaim@who.int (M. Mathai).
problem, they do not provide sufcient information for targeted action

to end preventable maternal deaths. Without quality information on
where, when, and why maternal deaths occur, we cannot begin to tackle
the real causes of maternal mortality. Better information is an essential
requirement for better health, as highlighted by the Commission on
Information and Accountability for womens and childrens health
(CoIA) [8].
2. Beyond the numbers and beyond
WHO recognizes the contribution of maternal death reviews (MDR)
in improving maternal health and has promoted its use in countries.
WHOs Beyond the Numbers provides guidance on the different
methods for review of maternal deaths and morbidity [9]. This widely
disseminated document has been used in MDR implementation in
several countries [36,10]. FIGO sees MDR as a potential means of improving maternal and newborn health clinical practice and ultimately
inuencing national policies [11]. FIGO has supported national health
professional organizations to develop their MDR systems as well as
establishing other clinical audit systems [6,11].
However, there has been wide variability in uptake and quality of
the MDR process across the world. While some of the positive experiences have been documented [35,12,13], there are many countries
where the MDR process ends with the review and there is no further
follow-up action based on the ndings of the review [5,6,10].
A new approach was therefore required to ensure more robust
collection and use of information for action. This new approach, the
Maternal Death Surveillance and Response (MDSR), was introduced
by WHO in 2012.
S4
M. Mathai et al. / International Journal of Gynecology and Obstetrics 131 (2015) S3S5
3. What is MDSR?
The overall goals of MDSR are to provide information that can effectively guide actions to end preventable maternal mortality in health facilities and in the community [14]. It also seeks to ensure that every
maternal death is counted, consequently permitting an assessment of
the true magnitude of maternal mortality. With this more accurate
data, we can undertake a true evaluation of the impact of interventions
in maternal health.
MDSR is a form of continuous surveillance linking the health information system and quality improvement processes from local to national
levels. There are several steps that ensure that a maternal death is
reported and recorded. The cause of death is then noted and other determinants identied. Finally, the preventable factors are highlighted and
recommendations produced for action (Fig. 1).
MDSR builds on existing MDR programs and underlines the need to
respond to every maternal death. A maternal death is a relatively rare
event, but the information that a mother has died is critical. The surveillance aspect of MDSR approaches maternal death in the same way as
other systems that collect data on rare but important conditions. It
aims to ensure that there is a xed procedure for capturing these deaths,
within 2448 hours, regardless of whether they occur at facilities or in
the community. A key feature of this is zero reporting, which is the
active process of notifying suspected maternal deaths, whether or not
any have occurred [14].
The response component of MDSR focuses on the action portion. It is
the key step that is often missed in existing MDRs. Maternal deaths are
comprehensively reviewed by committees, which include family and
community members, to establish the circumstances surrounding the
death and recommendations are produced. These recommendations
are then followed up to ensure accountability. Annually, a national
report is produced with country-wide priorities that are shared with
stakeholders. This aspect of MDSR is what makes maternal death visible
at local and national level. It provides information at local, health facility,
and district levels for action to prevent deaths. It sensitizes communities
and facility health workers and, because it connects actions to results, it
permits measurement of impact.
Successful MDSR provides real-time and nationally owned information on maternal mortality measurements and helps strengthen national
civil registration and vital statistics and quality improvement.
4. Update on current MDSR work
WHO leads an international MDSR Working Group comprising UN
and bilateral agencies, professional organizations, academic institutions,
and advocacy groups. MDSR has been introduced globally over the past
two years. Seventy-ve low- and middle-income countries have
assessed their overall progress in workshops organized in the six
WHO regions as a follow up to the CoIA recommendations [8]. These
workshops facilitated regional learning and provided opportunities for
MDSR Cycle
Respond and
monitor response
Analyse and make

recommendations
M&E
Identify and
notify deaths
Review maternal
deaths
Fig. 1. Maternal Death Surveillance and Response (MDSR) system. Reproduced with
permission from WHO [14].
planning strategic actions. Country assessments were undertaken to

identify challenges to the institutionalization of the MDSR process.
MDRs were reportedly implemented as a vertical program and recommended follow-up actions are not always acted on. Technical assistance
on implementation of MDSR was requested by almost all countries.
Signicant country support is still needed to strengthen implementation of the MDSR program.
The MDSR Working Group has published a technical guide to
support MDSR implementation in countries [14]. The guide introduces
the newer concepts of surveillance and response to death reviews. It
also provides a tool for assessing the existing death review process
and assisting the adaptation of national MDR guidelines. Training tools
have been developed by partners and are being tested in project implementation areas. The rst global training of trainer workshops were
held in 2013 to orient experts on the new concept and approach, and
similar workshops have been held in national and regional meetings
of professional societies.
Implementation of MDSR varies across countries. Among the 71
high-priority countries responding to the WHO Global Maternal, Newborn, Child and Adolescent Health (MNCAH) policy survey 20132014
[15], 34 countries (an increase of 79% since 2009) had a policy on
notication of all maternal deaths to a central authority within
24 hours of the event, and 53 countries (an increase of 66% since
2009) had a policy requiring all maternal deaths to be reviewed
(Table 1). Policy support to perform health facility-based maternal
death review was reported in 55 countries, while processes to perform
community maternal death reviews were in place in 30 countries.
However, in many countries these routine reviews at facility and community level are conned to subnational or subregional level and are
not part of the essential MDSR cycle where national level surveillance
and response are key components. The limited information on MDSR
implementation available in the WHO Global MNCAH policy indicator
survey showed that only 20 high-priority countries have a national
panel/committee in place to review maternal deaths every quarter
each year. Therefore, while countries are adopting the MDSR approach
Table 1
Existence of national policy on maternal death notication and review in 71 high-priority
countries.a
(A) Policy requiring all maternal deaths to be notied within 24 hours to a
central authority
Afghanistan, Angola, Azerbaijan, Benin, Bolivia, Botswana, Comoros, Congo, Cte
d'Ivoire, Egypt, Equatorial Guinea, Gabon, Gambia, Guatemala, Indonesia, Iraq,
Kenya, Kyrgyzstan, Lesotho, Liberia, Malawi, Mexico, Morocco, Nigeria, Rwanda,
Sao Tome and Principe, Senegal, Sierra Leone, Swaziland, Tajikistan, Togo,
Uganda, Uzbekistan, Zimbabwe
(B) Policy requiring all maternal deaths to be reviewed
Afghanistan, Angola, Azerbaijan, Benin, Bolivia, Botswana, Brazil, Cambodia,
Cameroon, Comoros, Congo, Cte d'Ivoire, Djibouti, Democratic Republic of the
Congo, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana,
Guatemala, India, Indonesia, Iraq, Kenya, Lao PDR, Lesotho, Liberia, Malawi, Mali,
Mexico, Morocco, Mozambique, Nigeria, Pakistan, Papua New Guinea,
Philippines, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, South Africa,
Sudan, Swaziland, Tajikistan, Togo, Uganda, United Republic of Tanzania,
Uzbekistan, Vietnam, Zambia, Zimbabwe
(C) Health facility-based death review/audit process in place
Afghanistan, Angola, Azerbaijan, Benin, Bolivia, Botswana, Brazil, Burkina Faso,
Burundi, Cambodia, Cameroon, Comoros, Congo, Cte d'Ivoire, Democratic
Republic of the Congo, Djibouti, Egypt, Eritrea, Ethiopia, Gabon, Gambia, Ghana,
Guatemala, India, Indonesia, Iraq, Kenya, Lao PDR, Lesotho, Liberia, Madagascar,
Malawi, Mali, Mexico, Morocco, Mozambique, Niger, Nigeria, Pakistan, Papua
New Guinea, Philippines, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone,
South Africa, Sudan, Swaziland, Togo, Uganda, United Republic of Tanzania,
Uzbekistan, Vietnam, Zambia, Zimbabwe
(D) Community maternal death review/audit in place
Bolivia, Brazil, Burkina Faso, Cambodia, Chad, Comoros, Congo, Egypt, Eritrea,
Ethiopia, Ghana, Guatemala, India, Indonesia, Kenya, Lao PDR, Madagascar,
Malawi, Mali, Mexico, Morocco, Pakistan, Papua New Guinea, Philippines,
Rwanda, Sao Tome and Principe, Sudan, Vietnam, Zambia, Zimbabwe
a
Of the 75 high-priority countries where 95% of the global maternal and child deaths
occur, data were not available for China, DPR Korea, Peru, and Turkmenistan.
M. Mathai et al. / International Journal of Gynecology and Obstetrics 131 (2015) S3S5
into policy, there is paucity of information on the actual implementation

including the response to recommendations arising from death reviews.
5. Conclusion
Most countries with high maternal mortality have weak civil registration systems. Consequently, many maternal deaths and the reasons
behind these deaths remain unrecorded and unreported, particularly
when women die at home. Preventing maternal deaths can be effective
only if accurate information is available to support targeted responses.
MDSR makes each maternal death a notiable event, and ensures that
communities and facilities report and respond to each death in their
efforts to end preventable maternal deaths.
Countries are adopting the MDSR approach into policy. MDSR implementation in countries should also move rapidly beyond pilot testing
and should be scaled up to achieve results. This will involve training of
more health workers at subnational levels to correctly identify and
notify all maternal deaths, conduct death reviews, analyze and report
on ndings, and ensure a continued commitment of supervisors
and administrators to respond to these ndings. To translate policy
into action, a more qualitative approach to improving the response to
the recommendations arising from the death reviews is required, as
are monitoring and evaluation of the process. Partnerships are key to
building a pool of technical experts who are committed to supporting
MDSR implementation in countries.
Global efforts in maternal mortality and morbidity are also focusing
on the important role of quality of care. In the past, the focus has been on
increasing the coverage of key interventions, for example skilled care at
birth. However, increasing coverage of interventions has not translated
into reductions in maternal mortality. Poor quality of care in health
facilities has been highlighted as a possible explanation for this discrepancy [5]. WHO and the Partnership for Maternal, Newborn and Child
Health have published a global core set of indicators for reporting on
quality of care in facilities providing maternal, newborn, and child
health services [16]. Performance of MDR is one of the recommended
core indicators. Use of these indicators in monitoring quality of
care and implementing the MDSR approach will contribute to more
effective coverage of lifesaving interventions and greater accountability
for maternal health, thus contributing to the end of preventable
maternal mortality.
Conict of interest
The authors have no conicts of interest.
S5
References
[1] World Health Organization, UNICEF, UNFPA, The World Bank, United Nations
Population Division. Trends in Maternal Mortality: 1990 to 2013. Geneva: WHO;
2014. http://www.who.int/reproductivehealth/publications/monitoring/maternalmortality-2013/en/.
[2] Say L, Chou D, Gemmill A, Tunalp O, Moller AB, Daniels J, et al. Global causes of
maternal death: a WHO systematic analysis. Lancet 2014;2(6):e32333.
[3] Moodley J, Pattinson RC, Fawcus S, Schoon MG, Moran N, Shweni PM. The condential enquiry into maternal deaths in South Africa: a case study. BJOG 2014;
121(Suppl. 4):5360.
[4] Hodorogea S, Friptu V. The Moldovan experience of maternal death reviews. BJOG
2014;121(Suppl. 4):815.
[5] Paily VP, Ambujam K, Rajasekharan Nair V, Thomas B. Condential Review of
Maternal Deaths in Kerala: a country case study. BJOG 2014;121(Suppl. 4):616.
[6] De Brouwere V, Delvaux T, Leke RJ. Achievements and lessons learnt from facilitybased maternal death reviews in Cameroon. BJOG 2014;121(Suppl. 4):714.
[7] Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al.
Saving Mothers Lives: Reviewing maternal deaths to make motherhood safer:
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the United Kingdom. BJOG 2011;118(Suppl. 1):1203.
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6770.
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MDR%20Guidelines%20nal%202014.pdf.
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pdf?ua=1. Published 2014. Accessed September 18, 2014.
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of maternal, newborn and child care in health facilities. http://apps.who.int/iris/
bitstream/10665/128206/1/9789241507417_eng.pdf. Published 2014. Accessed
September 18, 2014.

MATERNAL HEALTH
Emergency obstetric care: Making the impossible possible through

task shifting
Caroline Schneeberger, Matthews Mathai
Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
a r t i c l e
i n f o
Keywords:
Cesarean delivery
Emergency obstetric care
Maternal mortality
Nonphysician clinician
Task shifting
a b s t r a c t
Task shiftingmoving tasks to healthcare workers with a shorter trainingfor emergency obstetric care (EmOC)
can potentially improve access to lifesaving interventions and thereby contribute to reducing maternal and neonatal morbidity and mortality. The present paper reviews studies on task shifting for the provision of EmOC. Most
studies were performed in Sub-Saharan Africa and South Asia and focused primarily on task shifting for the performance of cesarean deliveries. Cesarean delivery rates increased following EmOC training without signicant
increase in adverse outcomes. The paper discusses the advantages and disadvantages of task shifting in EmOC
and the role of this approach in improving maternal and newborn health in the short and long term.
1. Introduction
The majority of global maternal deaths occur in Sub-Saharan Africa
(62%) and Southern Asia (24%) due to preventable and treatable complications such as hemorrhage, hypertensive disorders, prolonged and
obstructed labor, and sepsis [14].
Skilled health workers are needed to provide lifesaving essential interventions to prevent and treat complications [3,4]. Shortage of skilled
health workers remains a major obstacle to achieving Millennium
Development Goals 4 and 5 [2,3] In rural areas where mortality and morbidity rates are the highest and healthcare workers are most needed, the
number of available healthcare workers is the lowest [5]. Lack of nances
for training programs, loss of personnel to HIV/AIDS and other associated
diseases, and the brain drain from rural to urban areas and from lowincome to high-income countries, all contribute to this shortage [6,7].
Task shiftingthe process whereby specic tasks are moved, where
appropriate, to health workers with shorter qualications and shorter
trainingsis one approach to addressing the problem of insufcient
workforce. Applying task shifting to basic and comprehensive emergency
obstetric care (EmOC) could improve access to lifesaving interventions
and thereby reduce maternal and neonatal morbidity and mortality [3,4].
Task shifting has been happening over decades, either consciously or
unconsciously, and is not a recent intervention [8]. Recent studies of interest (published from 2003) cover the safety aspects of task shifting by
looking at provider performance and patient outcomes, advantages and
Corresponding author at: Department of Maternal, Newborn, Child and Adolescent
Health, World Health Organization, 1211 Geneva 27, Switzerland. Tel.: +41 22 791
3210; fax: +41 22 791 4853.
E-mail address: mathaim@who.int (M. Mathai).
disadvantages including provider and user experiences, and barriers to

and facilitators of task shifting.
Most studies discussed in the present paper that address task
shifting in EmOC were performed in Sub-Saharan Africa and South
Asia. Some studies compared nonphysician clinicians with doctors,
while others compared doctors with different levels of training, for
example, generalist doctors with specialists. Terms used to describe different physician and nonphysician healthcare workers vary between
studies and countries, similarly duration of training. It is difcult to
judge the competence and clinical practice level of a healthcare worker
based on job title alone. Other factors inuence performance such as
availability of equipment, skills of other co-workers, workload, feedback, leadership, and access to clinical guidelines [9].
2. Safety
A major concern of task shifting is the quality and safety of interventions performed by health workers with less training. Several recent
studies report on the outcomes of tasks or interventions performed by
different types of health workers, including health workers who only
received a limited amount of training. Most studies on performer outcomes focus on cesarean deliveries and other obstetrical surgeries.
Some studies report on anesthesia and neonatal resuscitation.
In Malawi, where nonphysician clinicians (clinical ofcers with
three years of training) performed 90% of surgeries, no major differences were found between postoperative outcomes such as maternal
death, wound infection, and need for reoperation for emergency obstetric surgeries, mainly cesareans, performed by nonphysician clinicians
and physicians [10].
C. Schneeberger, M. Mathai / International Journal of Gynecology and Obstetrics 131 (2015) S6S9
Nonphysician clinicians in Ethiopia often perform the bulk of emergency obstetric procedures including cesarean deliveries, manual removal
of placenta, and uterine evacuations. Outcomes (maternal death, fetal
death, and length of hospital stay) of surgeries performed by nonphysician clinicians were comparable to those performed by physicians [5].
Nyamtema et al. [11] reported on a three-month training program to
create teams providing EmOC (assistant medical ofcers) and anesthesia (nurses, midwives, or clinical ofcers) in Tanzania. The performance
of the EmOC teams was considered acceptable since only one severe
complication occurred out of 278 major obstetric surgeries in the
training period and the stillbirth rate was reduced in the training period.
Also in Tanzania, McCord et al. [12] found no signicant differences in outcomes, risk indicators, or quality of complicated deliveries
and/or major obstetric surgeries performed by assistant medical ofcers (nonphysician clinicians who receive an additional two years of
training) and medical ofcers (doctors).
In contrast with the other papers, Hounton et al. [13] found a significant difference in newborn case fatality rates (CFR) per thousand live
births among obstetricians (CFR 99), general practitioners (CFR 125)
and clinical ofcers (CFR 198) who received additional surgical training
in Burkina Faso. No signicant differences were found in maternal case
fatality rates. The indication for and relevance of cesarean delivery, the
clinical conditions of mother and fetus on arrival, and delays before
performing the procedure were not taken into account [13].
Overall, most recent studies indicate that the quality of emergency
obstetric surgeries is not at risk when performed by a less-skilled health
worker. This is conrmed by a meta-analysis performed by Wilson et al.
[14], which included some older studies comparing the outcomes of
cesarean delivery performed by clinical ofcers with those performed
by medical doctors. Surgeries done by clinical ofcers were more likely
to be associated with wound infection (odds ratio [OR] 1.58; 95% CI,
1.01 2.47) and wound dehiscence (OR 1.89; 95% CI, 1.21 2.95)
compared with medical doctors, but no signicant differences were
found for the other outcomes.
In Malawi, a prospective study showed that a cesarean delivery supported by nonphysician clinicians with no formal training in anesthesiology was associated with an increased maternal mortality (adjusted
OR 2.9; 95% CI, 1.6 5.1) compared with cesarean delivery supported
by nonphysician clinicians with a formal training in anesthesiology [15].
Approximately 5% 10% of all neonates born need simple stimulation (drying and rubbing) to help them breathe, 3% 6% require basic resuscitation (bag-and-mask ventilation), and only less than 1% advanced
resuscitation (chest compressions, drugs) [16]. The meta-analysis of observational before-and-after studies by Wall et al. [16] reported a 30% reduction in intrapartum-related neonatal mortality after introduction of
training in neonatal resuscitation, and that a broad range of healthcare
workers including nonphysician clinicians, traditional birth attendants,
and community health workers can perform neonatal resuscitation [16].
Finally, two studies used clinical vignettes covering topics such as
postpartum infection management and acute complications of labor
to assess clinical competence of obstetric care providers. In Mali,
physicians (78.6 13.4) had higher clinical competence scores (out
of 100) compared with obstetric nurses (57.8 11.2) and midwives
(66.4 14.7). However, obstetric nurses and midwives had slightly
higher scores for neonatal care compared with physicians. Health
workers working in rural referral centers scored lower than those
working in urban centers [9].
Of the 233 skilled birth attendants in India assessed for their EmOC
skills, only 14% were competent at initial assessment, 58% were able to
make a correct clinical diagnosis, and 20% were competent at providing
appropriate rst-line care [17].
3. Advantages and disadvantages of task shifting
Pereira et al. [7] performed a retrospective study underscoring the
large contribution of nonphysician clinicians in meeting unmet need;
S7
85% of all cesareans deliveries were performed by nonphysician clinicians. Unfortunately, the percentage of cesareans performed overall
(2.2% 2.8%) was still far below the recommended 5% level [4].
Nyamtema et al. [11] found a 300% increase in the cesarean delivery
rate after training and introducing EmOC teams. De Brouwere et al.
[18] evaluated a task-shifting policy introduced in Senegal whereby district surgical teams including an anesthetist, general practitioner, and
surgical assistant were trained to perform emergency obstetric surgery
in district hospitals. Introducing a district team was regarded to save
lives and reduce referral costs. The cesarean delivery rate remained
below 1%; far below the UN recommended rate of 5% 15% [4].
Utz et al. [19] used questionnaires to identify which EmOC skills
are provided by cadres in Bangladesh, India, Nepal, and Pakistan.
Most cadres performed newborn resuscitation and administered
parenteral antibiotics and oxytocics. Doctors often performed manual
removal of the placenta, removal of retained products of conception,
and assisted vaginal delivery. The authors concluded that lives can be
saved when cadres are trained to provide more EmOC skills. A more
recent study showed that EmOC signal functions (vacuum extraction,
removal of retained products) are performed in a limited number of
EmOC facilities mainly because of inadequate knowledge and skills
and missing supplies [20].
Spitzer et al. [21] investigated the effect of a ve-day EmOC program
on maternal and neonatal morbidity and mortality for health professionals in Kenya. They found an increase in administration of oxytocin
and management of postpartum hemorrhage resulting in a decreased
postpartum hemorrhage rate after introducing the training.
A qualitative study by Cumbi et al. [6] in Mozambique reported that
surgically trained nonphysician clinicians or technico de cirurgia were
considered essential to provide lifesaving surgical services in rural areas.
Their work contributed to avoiding unnecessary referrals leading to
lower costs and reduced workload of the referral hospitals.
An important reported advantage of training nonphysician clinicians
in Mozambique is that unlike medical doctors who leave within three
years, 88% of the nonphysician clinicians continue to work in the same
hospital after seven years [22].
A cost-effectiveness analysis showed that the average cost per cesarean delivery when performed by an obstetrician, a nonspecialist
doctor, or a clinical ofcer was US $513, US $207, and US $ 193, respectively. Although task shifting is cost-effective, the costs are still fairly
high because lower than expected numbers of cesarean deliveries are
performed by trained health workers in their facilities [13].
De Brouwere et al. [18] reported from Senegal that because anesthetists are trained only to provide anesthesia, they did not have enough
work because of the low volume of cesarean deliveries performed in district hospitals. The authors suggest that training nonphysician clinicians
as part of the district team to perform other surgical interventions would
increase cost-effectiveness by using the available anesthesiologist(s).
Nyamtema et al. [11] reported that due to short training periods and
the large groups of trainees, only some trainees were able to perform
more complicated procedures such as vacuum delivery or intubation
for general anesthesia.
Cumbi et al. [6] reported that the knowledge of nonphysician clinicians related to therapeutic management was insufcient. Chilopora
et al. [10] noted that clinical ofcers have proper manual skills but
may miss essential diagnostic accuracy; however, they concluded that
more research is needed to compare these skills with those of medical
ofcers.
Kouanda et al. [23] reviewed the medical records of 300 low-risk
women who underwent intrapartum cesarean delivery in Burkina
Faso and concluded that clinical ofcers performed more unnecessary cesarean deliveries than obstetrician-gynecologists (OR 4.46;
95% CI, 1.44 13.77).
A more recent study of interviews with 54 nonphysician clinicians
providing EmOC who had received a 30-month advanced clinical
and leadership training in Malawi, reported that trainees were able
S8
to make positive changes in their practice after nishing training in

performing a vacuum extraction or neonatal resuscitation. The effect
of the training on maternal and neonatal mortality was not evaluated
[24].
4. Barriers and facilitators
To make optimal use of task shifting it is important to have insight
into the barriers and facilitators.
The main barriers identied in Senegal were resistance from senior
academic clinicians, lack of career progression, and limited program
coordination. These resulted in only six out of 11 teams functioning
ve years after the start of the program and long delays between completion of training and opening of operating theatres. An increased
intervention rate was observed at the time a complete team was
in place; however, the rates dropped synchronously when team
members were absent. The lack of continuity is an important issue imperiling the ability of task-shifting policies to achieve their goal and
meet obstetric need [18].
Mavalankar et al. [25] evaluated the experiences of 14 medical ofcers (doctors with a ve-year degree) in India who received training
in Life Saving Anaesthetic Skills (LSAS) for EmOC. Being posted at a
healthcare facility without a specialist anesthesiologist and/or nonperforming or uncooperative EmOC provider, led to a higher likelihood of
not using the anesthetic skills learned. Trained medical ofcers experienced difculties combining their EmOC duties with their other duties.
Resuscitation training was highly valued and also applied to newborns.
Evans et al. [26] reported important barriers to providing EmOC,
especially cesarean delivery, after nishing a 16-week comprehensive
EmOC training of 17 nonspecialist doctors in India. To start with, these ofcers were assigned to the training by the government (not volunteers).
Some of them were not allowed to perform cesarean delivery during
their training. Anesthetists were not present or refused to work with
these trainees. Infrastructure (operating theatre, equipment) was often
missing, and blood services were limited. The authors concluded that
training medical ofcers in comprehensive EmOC is only one piece of
the puzzle and that training cannot occur in a vacuum [26].
In Uganda, those in favor of task shifting argue that nonphysician
clinicians already perform tasks of higher-trained health workers;
those against argue that nonphysician clinicians are incompetent,
overworked, and more expensive compared with trained health
workers. Opponents of task shifting argue that, Consumers of health
services were either uninformed or ignorant about the competencies
of the health providers and/or had no other options. They were also
ignorant about their legal rights otherwise the cost compensating
patients would be high [27].
Cumbi et al. [6] identied that the interaction of nonphysician clinicians, especially with medical doctors, is problematic. This may be because nonphysician clinicians are seen king because they perform
lifesaving surgery. The doctor is only prescribing medicines. This attitude may stir resistance from doctors to further implement task shifting
and/or working with nonphysician clinicians.
Colvin et al. [28] noted that legal protections and liabilities and
the regulatory framework for task shifting should be designed to accommodate new task-shifted practices and stressed that managing
inter-professionally is important.
5. Discussion
The increased numbers of health workers providing lifesaving EmOC
interventions is a major advantage of task shifting in EmOC. In some
countries, the bulk of cesarean deliveries and other obstetric operations
is currently performed by nonphysician clinicians [6,22].
However, improving access to EmOC and increasing intervention
coverage rates may not directly lead to reductions in maternal and neonatal mortality and morbidity. The quality of the intervention provided
is at least as important as coverage rates to improve maternal and newborn health. Although current studies do not show major differences in
patient outcomes with task shifting, other important problems have
been identied that could potentially undermine the positive effects of
task shifting [14].
Task shifting is currently seen as a vertical approach focusing on
training of selected cadres to perform one specic procedure. Focusing
on training nonphysician clinicians to perform cesarean deliveries without addressing other issues in the health system could lead to new and
different problems; for example, a nonphysician clinician available to
perform a cesarean but no anesthesiologist or operating theatre.
Although 75% of surgical procedures, including cesarean delivery, in
most low-resource countries are at low levels of complexity and do not
require fully-trained doctors, decision making, for example, on whether
or not to perform a cesarean is thought to be more complex and may not
be satisfactorily addressed by task shifting [18,23].
The duration and location of the training and the limited emphasis
on keeping skilled health workers skilled are other issues to be considered. Training should be in places with sufcient number of births
and complications. Often these are in large referral hospitals where infrastructure and supporting resources are likely to be different from
those of the trainees. In these centers, trainees on short-term courses
may have to compete for learning opportunities with specialist trainees
on longer-term training courses in the same institution. In addition,
health workers may receive only a one-time training, with no additional
refresher courses on offer.
Finally, there is a paucity of information on the perspectives of
women and their families on task shifting in EmOC. It is important to
share information on the potential benets and harms of task shifting
with women, their families, and communities and take their preferences into account while making policy decisions that affect their lives.
While EmOC is needed for management of complications, it is
also important to remember that investing in providing good quality
essential care during pregnancy and childbirth will reduce the risk of
major complications, and thus the need for many EmOC interventions.
This would also make task shifting in EmOC an interim solution while
working toward long-term health system strengthening.
Conict of interest
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MATERNAL HEALTH
Moving beyond silos: How do we provide distributed personalized

medicine to pregnant women everywhere at scale? Insights
from PRE-EMPT
Peter von Dadelszen a,e,, Laura A. Magee a,b,e, Beth A. Payne a,e, Dustin T. Dunsmuir c,e, Sharla Drebit a,e,
Guy A. Dumont d,e, Suellen Miller f, Jane Norman g, Lee Pyne-Mercier h,i, Andrew H. Shennan j, France Donnay h,
Zulqar A. Bhutta k,l, J. Mark Ansermino c,e
a
Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
Department of Medicine, University of British Columbia, Vancouver, BC, Canada
c
Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
d
Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada
e
Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
f
Department of Obstetrics, Gynecology and Reproductive Sciences and Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA
g
University of Edinburgh/MRC Centre for Reproductive Health, The Queens Medical Research Institute, University of Edinburgh, UK
h
Family Health Team, Bill & Melinda Gates Foundation, USA
i
Department of Global Health, University of Washington, Seattle, WA, USA
j
Division of Womens Health, Kings College London, London, UK
k
Centre for Global Child Health, Hospital for Sick Children, University of Toronto, Toronto, Canada
l
Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
b
a r t i c l e
Keywords:
Maternal health
Mobile health
Newborn health
Outcome prediction
PRE-EMPT
Stillbirth
i n f o
a b s t r a c t
While we believe that pre-eclampsia mattersbecause it remains a leading cause of maternal and perinatal morbidity and mortality worldwidewe are convinced that the time has come to look beyond single clinical entities
(e.g. pre-eclampsia, postpartum hemorrhage, obstetric sepsis) and to look for an integrated approach that will
provide evidence-based personalized care to women wherever they encounter the health system. Accurate outcome prediction models are a powerful way to identify individuals at incrementally increased (and decreased)
risks associated with a given condition. Integrating models with decision algorithms into mobile health
(mHealth) applications could support community and rst level facility healthcare providers to identify those
women, fetuses, and newborns most at need of facility-based care, and to initiate lifesaving interventions in
their communities prior to transportation. In our opinion, this offers the greatest opportunity to provide distributed individualized care at scale, and soon.
1. Background
hypertension, we are convinced that the time has come to look beyond
single clinical entities (e.g. pre-eclampsia, postpartum hemorrhage
[PPH], obstetric sepsis) to look for an integrated approach that will provide evidence-based personalized care to women wherever they encounter the health system. In our view, only an integrated approach
(across disease entities and between community and facility) will overcome all three delays in triage, transport, and treatment that make individual women vulnerable to maternal mortality [5].
PRE-EMPT (PRE-eclampsia-Eclampsia Monitoring, Prevention and

Treatment), a Bill & Melinda Gates Foundation-funded initiative, is
designed to develop, test, and introduce new knowledge to reduce the
unacceptable maternal, perinatal, family, societal, and global impacts of
pre-eclampsia, and the other hypertensive disorders of pregnancy [1,2].
At the time of publication, we will be ve of seven years into the initiative.
We believe that pre-eclampsia matters because it remains a leading cause of maternal and perinatal morbidity and mortality worldwide [3,4]. However, in parallel with our current focus on pregnancy
2. Outcome prediction: The key to distributed personalized medicine
Corresponding author at: Rm V3-339, 950 West 28th Avenue, Vancouver, BC V5Z 4H4,
Canada. Tel.: +1 604 875 3054; fax: +1 604 875 3212.
E-mail address: pvd@cw.bc.ca (P. von Dadelszen).
In our opinion, major advances in maternal, fetal, and newborn

health can be achieved through making outcome prediction models
available to women, parents, their families, and all levels of healthcare
P. von Dadelszen et al. / International Journal of Gynecology and Obstetrics 131 (2015) S10S15
MgSO4
antihypertensives
Within the scope of our activities, we have developed and validated

two outcome prediction models, the PIERS (Pre-eclampsia Integrated
Estimate of RiSk) models that identify those pregnant women with
pre-eclampsia who are most likely to develop life-threatening complications. Both models have accurate ability to identify women at low
risk of developing imminent complications.
The fullPIERS model, which includes demographics, symptoms [13],
pulse oximetry [14], and maternal laboratory tests [15,16], identies
clinical relevant risk categories (area under the curve of the receiver
operator characteristic [AUC ROC] 0 88 [95% CI, 0 84 0 92])
[17,18]. Currently, fullPIERS is undergoing external validation; a preliminary validation exercise is reassuring [19].
The validated miniPIERS model is solely demographics-, symptom-,
and sign-based and can be administered by (1) community healthcare
providers (cHCPs ) in the home and at primary health centers; and
(2) facility-based practitioners as they initially triage women admitted
with pregnancy hypertension prior to the availability of laboratory results (or in lieu of laboratory results in some less-developed settings)
(AUC ROC 0.77 [95% CI, 0.74 0.80]) [20].
The PIERS on the Move (POM) smart phone app integrates
miniPIERS and clinical decision algorithms to support cHCPs (e.g. Lady
Health Workers in Pakistan) as they provide prenatal care, diagnose
pre-eclampsia, and initiate lifesaving therapies in the womans home
prior to urgent transfer to an effective facility [2123] (Fig. 2). When
using the miniPIERS model alone, and if we choose a 25% probability
for developing an adverse outcome as a threshold for high risk, we
identify 65% of women who will go on to suffer a severe complication.
Through the POM project we have learnt that, by adding pulse oximetry,
using the same 25% risk threshold, we improve the prediction rate to
85% of women who will go on to suffer a severe complication [22].
Currently, the POM app is being tested at scale in the CommunityLevel Interventions for Pre-eclampsia (CLIP) Trials in Nigeria,
Mozambique, Pakistan, and India with pulse oximetry limited to
NHS
welfare reforms
John Snow
(1) To be able to identify, from within a population with such conditions, the specic individuals who are likely to become critically
unwell prior to their clinical decompensation (e.g. development
of seizures or sepsis) so that they can receive early interventions
(e.g. MgSO4 or antibiotics) and, if they are still in the community,
so that they can be transported rapidly for denitive, facilitybased care. For use in resource-constrained settings at the community level, such outcome prediction models can include only
demographics, symptoms, and signs (augmented by low-cost,
noninvasive, robust but accurate sensors to measure blood
pressure, temperature, or pulse oximetry) while ndings from

laboratory tests could also be added as predictors for use at the
facility level.
(2) To develop clinical algorithms that respond to levels of risk using
predictive modelling techniques that incorporate guidance from
the WHO, other organizations that promulgate expert guidelines,
and large robust clinical data sets, tailored to the various settings
(i.e. community vs primary health center vs inpatient facility in
resource-constrained vs well-resourced settings).
blood transfusion
oxytocics
antibiotics
workers. At a time of improvements in general conditions for women, in

absolute numbers, the ongoing British Condential Enquiries into Maternal Deaths provide evidence that the introduction of the National
Health Service with free maternity care and, soon thereafter, reproductive choice was associated with a rapid decline in the number of maternal deaths attributed to the hypertensive disorders of pregnancy,
primarily pre-eclampsia and eclampsia (Fig. 1). The accelerating pattern
of maternity care (four-weekly visits until 28 weeks, fortnightly to
36 weeks, and weekly thereafter) was designed in Edinburgh largely
for the identication of pre-eclampsia to afford the opportunity
for timely delivery [6]. Since the rst triennial report (195254), preeclampsia- and eclampsia-related deaths have fallen by approximately
90%. Over 90% of that fall was achieved prior to the introduction of
either effective antihypertensives for the management of pregnancy
hypertension [7] or the use in the UK of magnesium sulfate (MgSO4)
for eclampsia prevention and treatment following the Collaborative
Eclampsia and Magpie Trials, respectively [8,9]. Similar data exist for
Sri Lanka following the introduction of comprehensive maternity care,
including vital registration, registration of midwives, prenatal coverage
(health center- and home-based), and facility strengthening [10].
Therefore, the process of individualized risk assessment through prenatal care is an effective tool for reducing adverse pregnancy outcomes, especially when included in a package of health service enhancements.
Accurate outcome prediction models are a powerful way to identify
individuals at incrementally increased (and decreased) risks associated
with a given condition [11]. By stratifying the population into true risk
groups, interventions and timely delivery can be targeted to those most
in need so that maximum benet is achieved in a resource-constrained
setting. For mothers, fetuses, and newborns, examples of such conditions
could be pre-eclampsia, decreased fetal movements, or sepsis, respectively. Approximately half of maternal deaths occur in the home [12], so it is
critical to develop a distributed model of diagnosis and risk assessment.
To do so, there are two challenges that need to be addressed:
S11
Fig. 1. Modied from Why mothers die 20002002. Report on condential enquiries into maternal deaths in the United Kingdom. London: CEMACH; 2004. The dotted line represents the
probable rate of decline without the introduction of the National Health Service (NHS). Vertical lines represent important dates in the evolution of health care in the UK relevant to
maternity outcomes.
S12
Fig. 2. PIERS on the Move mHealth application screenshots (Nigerian version of pictograms).
Mozambique and Pakistan (http://pre-empt.cfri.ca/treatment/clip-trial;

accessed November 10, 2014). Within the context of the CLIP Trial, hypertensive women identied within their community to be at greatest risk of
maternal complications receive 10 g intramuscular MgSO4 and, with severe hypertension, oral 750 mg methyldopa prior to urgent referral to a
referral facility (i.e. completed referral within four hours). In CLIP intervention clusters, all women identied as being hypertensive are referred
to facilities within 24 hours as none is without risk and many will have
disease evolution to more severe disease.
3. Translational biomarkers at point of care
It is clear that the identication of angiogenic imbalance, especially
decreased maternal serum placental growth factor (PlGF) concentrations, strengthens the ability to identify women with pre-eclampsia
when clinical uncertainty exists [24,25]. From the PELICAN Study, it appears that PlGF has the additional benet of being able to discriminate
between women who are most unwell with pre-eclampsia from those
who are least unwell [24]. There is ongoing research to investigate
how PlGF might strengthen the PIERS models. However, the largest
diagnostic benet of PlGF appears to be prior to 35 + 0 weeks of pregnancy, whereas the majority of pre-eclampsia (and associated maternal
deaths) arises nearer to, or at, term. In addition, to be most useful in less
developed settings, a low cost, whole blood point-of-care diagnostic
platform, as in HIV management, for example [26], is required. Finally,
low maternal serum PlGF is not specic to pre-eclampsia, but is observed in women with small-for-dates fetuses due to placental dysfunction (but not constitutionally small fetuses) [27].
Low PlGF appears to identify a pregnancy complicated by placental
dysfunction and/or failure. This last point may be important in terms
of the generalizability of PlGF to obstetric populations at scale.
4. Looking beyond hypertension to hypotension: Labor and

the puerperium
We are condent that the PIERS model and POM app can guide individualized care and improve outcomes for women with pregnancy
hypertension; however, pregnancy hypertension only accounts for approximately 15% of maternal deaths [4].
In temporal order, the other leading causes of direct maternal mortality are prolonged labor, PPH, and puerperal sepsis [4]. To us, a priority
is to develop (an) outcome prediction model(s) comparable to the
PIERS models so that women vulnerable to labor, postpartum, and
puerperal complications can be identied before they clinically
decompensate. We anticipate that all such models will include pulse
oximetrythe fth vital sign [28].
Women thus identied could have lifesaving therapy initiated in the
community or at rst level facility (e.g. antibiotics or a heat stable
uterotonic), and be referred urgently for evidence-based denitive
care at a higher level. Such an approach would have the added benet
of being able to detect deteriorating maternal health due to intercurrent
communicable (e.g. HIV, malaria, tuberculosis) and noncommunicable
(e.g. acquired valvular heart disease), in addition to direct obstetric
causes of maternal death.
To this end, we have developed a modied blood pressure device
(Microlife 3AS1-2; Microlife, Widnau, Switzerland) specically for use
in low- and middle-income countries (LMICs), which fulls WHO requirements for suitability for use in low-resource settings [29]. The device has been validated for use in both non-pregnant and pregnant
populations (including both women with pre-eclampsia and low
blood pressure), according to the British Hypertension Society protocol
[29,30]. It has been evaluated in a feasibility study in Sub-Saharan Africa
(Tanzania, Zambia, and Zimbabwe) and shown to be acceptable, feasible, and resulted in increased referrals to higher level institutions for
suspected hypertensive disorders by cHCPs.
We have determined the normal range of conventional vital signs as
well as shock index, which is the ratio of heart rate to systolic blood
pressure. Thereafter, we retrospectively analyzed datasets of women
with PPH (one dataset in the UK and another large dataset of women
in four African low-resource settings) to evaluate the predictive value
of conventional vital signs and shock index. The shock index was
shown to be a more consistent predictor of adverse clinical outcomes
than conventional vital signs. Currently, we are evaluating our retrospectively determined thresholds for the shock index, relating to increased risk of adverse outcome. Based on these results, we expect
that the shock index will be used as a trigger for action to help guide
cHCPs and staff at rst level facilities.
A trafc light early warning system has been incorporated into the device, to alert users to abnormalities in blood pressure and pulse, using
these developed shock index thresholds along with well-recognized
thresholds to indicate hypertension in pregnancy. For the shock index
(SI), a green light (SI threshold b 0.9) would provide reassurance, an
amber light (SI 0.9 and 1.7) indicates need for intervention, and a red
light (SI 1.7) indicates the need for urgent referral to higher level facilities. These thresholds are being validated prospectively.
5. Stillbirth and newborn health
While the focus of the present paper is maternal health, we believe
that the greatest advantage can be obtained through integration of maternal, fetal, and newborn health silos. In brief, stillbirth remains an underrecognized and under-investigated scourge [31]. The daily toll of lost
wanted fetuses is unacceptable; however, we consider that it should be
possible to combine maternal awareness of fetal well-being (e.g. fetal
movements), mHealth-supported fetal heart screening and, quite probably, the point-of-care use of a biomarker such as PlGF to identify individual fetuses at increased risk of stillbirth prior to the occurrence of that
devastating complication. Such an outcome prediction model could be integrated into a maternal fetal newborn mHealth platform.
In addition, pulse oximetry has been shown to be an effective
screening tool for congenital heart disease and early newborn sepsis
[32,33]. Integration of pulse oximetry into a community-based newborn
outcome prediction model such as the TRIPS score might enable cHCPs
and staff at rst level facilities to deliver effective newborn screening,
risk identication, and initiation of lifesaving therapies in the home
S13
prior to transfer [34,35]. In time, this approach could be extended to

cover the leading causes of mortality in children under ve years old:
diarrhea and pneumonia [36].
6. Long-term maternal health: Pregnancy as a risk identier for
noncommunicable diseases
In addition to the peripartum advantages offered to women by such
an integrated mHealth platform, there is an opportunity to intervene to
the benet of womens long-term health. While there is increasing recognition of the role of pre-eclampsia as a risk identier for premature
cardiovascular disease [37], as is well recognized for gestational diabetes and type 2 diabetes [38], what is less well recognized is the association of a whole range of placental complications of pregnancy with
cardiovascular disease [39,40].
Using data from the Scottish health dataset, Smith et al. [39] identied that maternal risk of ischemic heart disease admission or death was
associated with delivering a baby in the lowest birth weight quintile (i.e.
b20th percentile) for gestational age (adjusted hazard ratio [aHR] 1.9
[95% CI, 1.5 2.4]), preterm delivery (b37 + 0 weeks; aHR 1.8 [95%
CI, 1.3 2.5]), and pre-eclampsia (aHR 2.0 [95% CI, 1.5 2.5]). These
associations were additive as women with all three characteristics had
a seven-fold greater risk of ischemic heart disease admission or death
(95% CI, 3.3 14.5) than normotensive women delivering appropriately grown babies at term [39]. These data conform to other datasets,
linking pregnancy outcomes with noncommunicable diseases [37,40].
This may be very important in the context of less developed countries.
In most countries, health provision for mothers is dissociated from pediatric care after birth, although it is usually mothers who bring their children for that care.
Given the ability to use pregnancy to identify women with increased
cardiovascular and endocrine risks, there exists an opportunity to
use childhood immunization infrastructures to support targeted
ongoing surveillance of blood pressure, urine, and glucose for women
who have had complicated pregnancies. Such an approach would be facilitated by a maternal newborn child mHealth platform that
maintains the link between women and their children to coordinate
clinical care.
7. Community versus facility focus
Our experience with the PIERS models informs us that it is possible
to identify those who would most benet from focused and timely
facility-based care. There is a compelling argument that all pregnant
women should receive woman-friendly facility-based intrapartum
care, despite many health systems remaining challenged to provide sufcient resources to offer such care to all pregnant and laboring women.
At present, there is a pressing need to determine whether or not
community-level risk stratication can accurately identify and promote
access for those women who require urgent transfer to and management and delivery in a facility under routine conditions. We are more
condent that facility-based risk stratication will support personnel
to respond to individualized risks and to prioritize the care of those
women in greatest need.
Through an integrated mHealth-supported approach, which includes elements such as diagnostic and decision algorithms, prenatal
visit booking, and text reminders, we will be able to offer personalized risk assessment to women in their homes or primary health
centers. This would provide an evidence-based, portable continuum
of care from home to hospital that can be used by all level of
healthcare workers. Our view is all levels, across this continuum
from home to hospital, need strengthening in parallel, achieving complementarity between the community and facilities and prioritizing
facility resources to those women, fetuses, and newborns who will
most benet.
S14
8. Community engagement
Clearly, none of this will be effective without engaging communities
to gain buy-in, especially around the uptake of innovations [4143].
Many societies hold a conservative and limiting view of womens autonomy and value within their family and community. Individuals such as
community leaders, faith leaders, traditional and political leaders,
volunteers, and traditional birth attendants should be engaged in the
process of implementing any mHealth-supported approach that introduces new technologies and task shifting to community members.
[2]
[3]
[4]
[5]
[6]
9. Integration with existing health system strategies

As with communities, so must those who wish to innovate across the
maternal fetal newborn continuum engage with, and take into account, existing health system strategies and interventions [4245]. In
our view, to be attractive to those who fund health delivery, whether
governments, multilaterals, nongovernmental organizations, or the private sector, strategies for mHealth-supported individualized care must
be integrated into existing and evolving health systems, and be comprehensive enough to be attractive to implementers. Attempting to create a
parallel platform will be counterproductive in the long term, as it will be
unsustainable by design. Engagement with decision makers and
thought leaders from the initial design phase of an intervention will improve ownership and the likelihood of implementation at scale. Again, it
is our opinion that trials and implementation projects of mHealth-based
interventions require health economic analyses that clearly show to
those who make often difcult decisions what the return will be on
the resources invested. As a benchmark for comparison, in 2001 US
dollars, it cost $12 942, $1179, and $263 to avoid one seizure of
eclampsia using MgSO4 in high-, middle- and low-income countries,
respectively, limiting its use to women with severe pre-eclampsia [46].
10. Summary
As a group of investigators coming from apparently disparate
academic foci in obstetrics, maternal medicine, midwifery, newborn
medicine, pediatric anesthesia, infectious diseases medicine, and electrical and computer engineering, we are of a joint view that we can accelerate progress toward Millennium Development Goals 4 and 5
through integrated efforts that take us out of our silos. In our opinion,
the use of scientically robust outcome prediction models integrated
with decision and intervention algorithms into mHealth applications
offer the greatest opportunity to provide distributed individualized
care at scale, and, if resources can be found to undertake the remaining
work quickly, soon.
Acknowledgments
We acknowledge the intellectual input of the global PRE-EMPT initiative into the evolution of our thoughts over the past ve years. The
PRE-EMPT initiative and the shock index project are funded by the Bill
& Melinda Gates Foundation. The fullPIERS modelling and PIERS on
the Move projects are funded by the Canadian Institutes for Health Research and Saving Lives at Birth, respectively. PvD, LAM, GAD, and JMA
receive salary support from the Child and Family Research Institute.
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
Conict of interest
[26]
J. Mark Ansermino and Guy A. Dumont are cofounders and shareholders of LionsGate Technologies.
[27]
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9996 women with pre-eclampsia from 33 countries: economic evaluation of the
Magpie Trial. BJOG 2006;113(2):14451.

MATERNAL HEALTH
Prevention of type 2 diabetes among women with prior gestational

diabetes mellitus
Moshe Hod a, Eran Hadar a, Luis Cabero-Roura b,
a
b
Helen Schneider Hospital for Women, Rabin Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Department of Obstetrics, Hospital Universitari ValldHebron, Universitat Autonoma, Barcelona, Spain
a r t i c l e
i n f o
Keywords:
Gestational diabetes mellitus
Prevention
Type 2 diabetes
a b s t r a c t
The morbidity and mortality rates related to diabetes are constantly rising, as well as those for other
noncommunicable diseases. The epidemic is spreading throughout the world, in both low- and high-resource
countries. Prevention is a key aspect in the battle against the disease and obstetricians play a critical role in the
ght. Prevention starts in uterofor the diabetic mother, her infant, and future generations. The postpartum
period should not be neglected because it provides another window of opportunity to address prevention.
Data on the prevention of type 2 diabetes among women diagnosed with gestational diabetes are discussed.
1. Introduction
Type 2 diabetes is a silent epidemic of increasing proportions, which
is coupled with risk factors such as increasing age, obesity, inadequate
nutrition, and a sedentary lifestyle [1]. It is one of the most important
chronic noncommunicable diseases along with cancer, and cardiovascular and respiratory diseases. The diabetes-related death toll was
3.4 million in 2004, and it will be the seventh cause of death in 2030
[2]. This holds true for both high- and low-resource countries [3], with
more than 80% of deaths associated with diabetes occurring in lowand middle-income countries [4].
Urgent steps to stop this epidemic are overdue. Focus should be
given to detection and treatment of diabetes, in all its formskeeping
in mind that the prevalence of gestational diabetes mellitus (GDM)
peaks at 15% 25% in certain populationsand prevention, which
starts in utero [5], although the postpartum period is also crucial.
Among women diagnosed with GDM there is a higher risk of developing type 2 diabetes in the future. This risk was the rst outcome measure used to dene the hyperglycemia threshold in pregnancy, more
than 50 years ago [6]. The cumulative risk of type 2 diabetes after
GDM is wide rangingfrom 2.5% to as high as 70% at follow-up ranging
from 6 weeks to 28 years after delivery [7]. Women with prior GDM
constitute a high-risk group, which make them candidates for interventions to reduce the prevalence of type 2 diabetes. This may be a
key component for the long-term well-being of women and their offspringboth as children and as adults [8]as well as for future
generations, through in utero environmental modication [9].
Corresponding author at: Hospital Vall Hebron, Passeig Vall de Hebron 115, 08035
Barcelona, Spain. Tel.: +34 934893085.
E-mail address: lcaberor@sego.es (L. Cabero-Roura).
The present review discusses the current data on available interventions, and considers the further studies and policy implementations that
can be encouraged to reduce the incidence of type 2 diabetes in the
postpartum period.
2. What is the evidence base for interventions?
Numerous trials have shown the efcacy of various interventions to
prevent type 2 diabetes in high-risk populations [1013]. However, the
focus for these trials was high-risk patients identied according to
impaired fasting glucose (IFG) or impaired glucose tolerance (IGT).
There is limitedalbeit generally positiveevidence of the efcacy of
these interventions among other high-risk groups, including those
with prior GDM [14]. Available data support three main modalities of intervention: breastfeeding, lifestyle modication, and pharmacological
treatment [15].
2.1. Breastfeeding
In contrast to other interventions, breastfeeding has an advantage for
both the mother and child [16,17]. Several studies have shown
breastfeeding to be a risk modier that may be benecial in the prevention of type 2 diabetes [18,19]. Breastfeeding duration and intensity are
also important, with exclusive breastfeeding more important than partial
breastfeeding, and a suggested duration of at least 39 months [2022].
2.2. Lifestyle modication
Lifestyle modication may include diet and nutritional counseling,
weight reduction, and physical activity. This may be delivered by
M. Hod et al. / International Journal of Gynecology and Obstetrics 131 (2015) S16S18
doctors, nurses, and diabetic educatorsin person, by phone, or via the

internetat various levels of intensity and oversight.
The largest trial on prevention of type 2 diabetes was conducted by
the Diabetes Prevention Program (DPP). In that study [23], 3234 patients at high risk for diabetes were randomized to a standard care
group versus two possible interventions groupslifestyle modications
and metforminwith an approximately three-year follow-up. Importantly, the initial inclusion denition for diabetes risk was based on
IFG and IGT. Results from the study demonstrated that lifestyle modication was signicantly more potent in preventing type 2 diabetes compared with metformin, with risk reduction at 58% and 31%, respectively.
Similar trends have been demonstrated by other randomized trials
[2426].
In an ancillary analysis of the DPP trial [27], the focus was on the subgroup of women with prior GDM as the risk-dening parameter, along
with the initial risk of IFG/IGT. Overall, 350 women with prior GDM
were included and were compared with 416 women with a prior live
birth without GDM. Results of the study demonstrated that there was
an approximately 70% risk of developing type 2 diabetes among the
women with prior GDM who were randomized to the control group;
and that among those with a history of GDM, both lifestyle modication
and metformin achieved a risk reduction of approximately 50%
compared with the control group.
In another trial, Prez-Ferre at al. [28] randomized 237 women with
prior GDM into two groups: Mediterranean diet as a lifestyle intervention, including monitored physical activity, compared with a conventional follow-up group. The study demonstrated a risk reduction of
approximately 25% for the lifestyle intervention group.
Although this risk reduction has not been consistent in all studies
[29], lifestyle modications have been shown to be cost-effective and
cost saving [30].
2.3. Pharmacological treatment
As mentioned previously, the DPP study demonstrated the efcacy
of metformin in reducing the progression to type 2 diabetes among
women with prior GDM [27].To date, it is still the largest study that
has shown a pharmacological intervention that effectively reduces the
risk of diabetes among women with prior GDM.
In smaller trials, other medications have also been tested
(troglitazone, pioglitazone, and acarbose). Buchanan et al. [31] studied
the effect of troglitazone versus placebo among 266 Hispanic women
with prior GDM. The study concluded that treatment signicantly reduced the rate of postpartum type 2 diabetes by approximately 45%.
However, troglitazone was withdrawn from production because of hepatotoxicity. In an observational follow-up study of the same population
[32], pioglitazone was given for three years to 89 women. Similarly, this
was also shown to be effective in lowering progression rates to type 2
diabetes via an insulin-sensitizing effect and preservation of the functionality of beta cells.
Acarbose has also been studied for type 2 diabetes prevention [26];
however, the study population was not selected for prior GDM as a
risk factor and instead IGT was the selected inclusion criteria. In the
study, 1429 patients were randomized to placebo or acarbose groups.
The results demonstrated a 25% risk reduction in progression to type 2
diabetes in the acarbose group (relative hazard 0.75; 95% CI, 0.630.90).
3. Are these interventions being implemented?
Aside from questions surrounding the efcacy of possible interventions, the cardinal issue is that of implementation. Being aware of the
risk, the possible interventions, and knowing their efcacy is not always
enough [33,34]. Multiple organizations have published recommendations on postpartum follow-up and care of women with prior GDM,
most of which include recommendations on postpartum diabetes
S17
screening but with only vague suggestions as to referral for preventive

therapy [3537].
Adherence to these guidelines is insufcient and the percentage of
women screened with any assessment for glycemic status ranges from
18% to 67% [15]. Nonadherence to these recommendations implies
that many physicians and women do not understand the increased
risk for type 2 diabetes. Although there are no studies that have properly
evaluated this, we can safely assume that if screening guidelines are not
being met then neither are preventive measures.
A postpartum continuum of prenatal care for women with GDM
marks a critical missed opportunity for research, clinical practice and
policy statements [38]. Parameters that may block implementation of
screening and preventive efforts, that therefore need to be addressed,
include tiredness and fatigue, childcare duties and lack of access to
childcare services, work commitments, psychosocial barriers, lack of environmental support, cultural barriers, lack of motivation, and nancial
and time constraints.
4. Conclusion
Type 2 diabetes can be reduced among populations at high risk,
including among women who have previously been diagnosed with
GDM. Future studies should focus on this specic population of
women, with or without IFG/IGT and other concomitant risk factors
such obesity, and family history. Guidelines for screening should be better employed, as well as providing encouragement to adopt appropriate
preventive measures. A comprehensive approach to diabetes prevention should include provision of lifestyle interventions, breastfeeding
support, and appropriate pharmacological treatment. The most important issue is not to abandon the diabetic pregnant woman once she
has delivered, but to continue care and follow-up for her and her
childrens future health.
The FIGO GDM initiative seeks to produce, disseminate, and implement evidence-based standards of care protocols for women with GDM.
Conict of interest
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MATERNAL HEALTH
New drug regimens for HIV in pregnancy and a national strategic plan to
manage HIV: A South African perspective
Nnabuike C. Ngene a, Jagidesa Moodley b,
a
b
Department of Obstetrics and Gynecology, Edendale Hospital, Pietermaritzburg, and University of KwaZulu-Natal, Durban, South Africa
Womens Health and HIV Research Group, University of KwaZulu-Natal, Durban, South Africa
a r t i c l e
i n f o
Keywords:
Antiretroviral
HIV
Mother-to-child transmission
Pregnancy
South Africa
Strategic planning
a b s t r a c t
In South Africa, new drug regimens (WHO treatment Option B) used to manage HIV infection in pregnancy and
the national strategic plan on HIV have resulted in improved health outcomes. Among these outcomes are reductions in the following: mother-to-child transmission (MTCT) of HIV to 2.4%; maternal deaths attributable to HIV;
and adverse reactions due to antiretroviral therapy (ART). The present article describes these new drug regimens
and the national strategic HIV management plan, as well as their challenges and the implications of improved
health outcomes. Such outcomes imply that further decreases in MTCT of HIV, and HIV attributable maternal
deaths are possible if potential challenges are addressed and treatment option B+ offered. A condential enquiry
into each case of MTCT is advocated to reduce vertical transmission rates to zero levels.
1. Introduction
In 2012, approximately 35.3 (32.238.8) million people, 70% of
whom were women, were living with HIV infection worldwide; SubSaharan Africa accounts for 71% of this gure [1]. In the same year, an
estimated 6.1 million people were living in South Africa with HIV infection; this constitutes an overall prevalence rate of 17.9%, making South
Africa the country with the highest number of people infected with
this retroviral disease [2]. This has translated to a high burden of HIV
infection among pregnant women. To lessen this burden, new drug
regimens and strategies have been introduced internationally and
across nations. For instance, in 2001 the United Nations developed the
four-pronged framework for the prevention of mother-to-child transmission (MTCT) of HIV. The components of this framework are primary
prevention of HIV infection; prevention of unplanned pregnancies;
prevention of MTCT; and the provision of appropriate care, treatment,
and support to HIV-infected mothers, their children, and families [3].
In an attempt to improve care, South Africa has developed management
guidelines and health policies that have repeatedly been revised based
on emerging evidence and the resources available to the country.
The new antiretroviral drug regimens [4] and national strategic plan
[5] for the management of HIV in pregnancy in South Africa are leading
to improved health outcomes. Notably, the national prevalence of HIV
in pregnancy has declined from 30% in 2010 to 29.5% in 2012 [2]. Data
on the number of HIV-exposed infants who tested polymerase chain
Corresponding author at: Womens Health and HIV Research Group, University of
KwaZulu-Natal, Durban, South Africa. Tel.: +27 31 260 4675.
E-mail address: jmog@ukzn.ac.za (J. Moodley).
reaction (PCR) positive at approximately two months of age show that

the rate of MTCT has also declined from 9.6% in 2008 to 4.4% in 2010
[6] and to 2.4% in 2013 [7]. The 2013 interim Saving Mothers report
has shown that the institutional maternal mortality ratio in South
Africa has decreased from 176.2 per 100 000 live births in 20082010
to 146.7 per 100 000 live births in 2012. The decline in maternal deaths
is attributable to a reduction in the number of deaths resulting from
nonpregnancy-related infections, primarily HIV [8]. Similarly, maternal
deaths resulting from an adverse reaction to antiretroviral therapy
(ART)nevirapine (NVP) in particularhave also declined [9].
The present article describes South Africas new drug regimen and
national strategic plan used for the management of HIV in pregnancy,
their outcomes and challenges, and the implications of further reductions in MTCT rates.
2. WHO treatment options for prevention of mother-to-child
transmission of HIV
Different ART options have been used for prevention of mother-tochild transmission (PMTCT) of HIV [10]. In 2012, WHO introduced
three management categories: option A, option B, and option B+ [11].
2.1. Option A
Triple antiretroviral drugs (ARVs) are started following diagnosis
and continued for life (life-long) if the pregnant woman has a CD4
count less than or equal to 350 cells/mm3. Pregnant women with a
CD4 count greater than 350 cells/mm3 receive zidovudine (AZT) from
S20
N.C. Ngene, J. Moodley / International Journal of Gynecology and Obstetrics 131 (2015) S19S22
14 weeks of gestation in the prenatal period; single-dose NVP, AZT, and

lamivudine (3TC) during labor; and AZT plus 3TC for seven days postpartum. The infants of these mothers receive daily NVP for an extra
week following cessation of breastfeeding, or for 46 weeks (if not
being breastfed or if the mother is on life-long ARVs).
2.2. Option B
Life-long triple ARVs are started following diagnosis in women with
CD4 less than or equal to 350 cells/mm3. In women with CD4 greater
than 350 cells/mm3, triple ARVs are commenced from 14 weeks of
gestation throughout the prenatal period and stopped after childbirth
(if not breastfeeding), or continued up to one week after cessation of
breastfeeding. The infants of these mothers receive daily NVP or AZT
until they are 46 months old irrespective of infant feeding practices.
2.3. Option B+
Every pregnant woman diagnosed with HIV infection is commenced
on life-long triple ARVs irrespective of CD4 count. The infants of these
mothers receive daily NVP or AZT until they are 46 months old regardless of infant feeding practices.
2.4. Rational behind the different treatment options
Treatment options A, B, and B+ were suggested by WHO for the following reasons: the global plan to eliminate new cases of HIV infection
in children by 2015 and the need to keep infected mothers alive;
attempt to reduce HIV transmission among discordant couples; operational challenges associated with option A and option B; some countries
proposing their wish to adopt option B +; initiative to simplify ARV
regimen to be exactly the same as the national rst-line ART for nonpregnant adults and avoid the need to unnecessarily change ARV during
a pregnancy; data suggesting that efavirenz is safe in pregnancy; and increasing affordability of ARVs [11]. It has also been established that NVP
causes adverse reactions, especially hepatotoxicity, at baseline CD4
counts of greater than 250 cells/mm3 and greater than 400 cells/mm3
in women [12] and men [13], respectively. In addition, an increasing incidence of cases of hepatic failure and Stevens-Johnson syndrome has
been detected in pregnant patients on NVP [9]. The availability of a single pill containing a xed-dose combination of tenofovir, lamivudine,
and efavirenz has simplied the ARV regimen and efciency [11].
2.5. Probability of vertical HIV transmission with the use of different

treatment options
There is a scarcity of studies that assess transmission probabilities
when all aspects of each WHO treatment option are addressed in the
targeted population [14,15]. However, use of mathematical models,
such as Spectrum, shows the following MTCT probabilities: singledose NVP, 9.4%12.1%; WHO 2006 dual therapy, 2.3%5.3%; option A,
2%; option B, 0.9%2.9%; and option B+, less than 2% [15].
3. New PMTCT drug regimens in South Africa
The use of ARVs for PMTCT was rst introduced in South Africa as national policy in 2002. The regimen involved the administration of singledose NVP to both the mother (during labor) and her newborn (after
delivery). Since then, the PMTCT program was modied in 2005 and
2008, and option A was introduced in 2010 [16]. Thereafter, option B
was introduced in 2013 and constitutes current practice at the time of
writing the present article [4]. The current drug regimen in South
Africa is similar to WHO option B with the exception that South
African guidelines state that pregnant women with CD4 greater than
350 cell/mm3 are initiated on ART during the rst prenatal visit, even
before 14 weeks of gestation. This South African drug regimen is satisfactory (as option B) given the acceptable safety prole of efavirenz in
pregnancy, and that the longer the duration of ART before delivery
then the less chance of MTCT of HIV [17]. Table 1 provides a summary
of the ARV regimen used for PMTCT in South Africa. Further details on
the drug regimens used for PMTCT in South Africa are free to view online [4]. The purpose of the South African PMTCT guidelines is to ensure
that every possible preventable MTCT, using option B, is achieved.
4. South African national strategic plan on HIV
Strategic planning may be dened as the systematic and organized
process whereby an organization creates a document indicating the
way it plans to progress from its current situation to the desired future
situation [18]. Several approaches have been used to develop strategic
planning. A common classical method involves the following ve
processes: (1) establishing mission, vision, and values; (2) strategy formulation involving an analysis of internal and external environments,
SWOT (strengths, weaknesses, opportunities, and threats) matrix, strategic alternatives, areas and objectives; (3) operational planning;
(4) evaluation of results; and (5) strategy reformulation [18].
Table 1
Summary of antiretroviral therapy approved for prevention of mother-to-child transmission of HIV in South Africa in 2013.
Recipient Antiretroviral therapy
Mother
All pregnant women except those already known to be HIV infected undergo Provider Initiated Counselling and Testing during the rst prenatal visit. HIV-infected
women are then managed as outlined below.
Women who are HIV infected are started on xed-dose combination (FDC) of TDF, FTC/3TC, EFV the same day (in the absence of active psychiatric or renal disorder)
and reviewed in one week.
Women with contraindication to FDC (such as active psychiatric or renal disorder) are started on daily AZT (300 mg) the same day as long as the hemoglobin is
greater than 7 g/dL. Following a review in one week, they are placed on appropriate regimen.
Women on FDC with a baseline CD4 count less than or equal to 350 cell/mm3 or WHO clinical stage 3/4 disease, the treatment is continued life-long.
Women on FDC with a baseline CD4 count greater than 350 cell/mm3 or WHO clinical stage 1/2 disease, the treatment is continued throughout the prenatal and
intrapartum period until one week after complete cessation of breastfeeding.
Women having renal impairment with CD4 less than or equal to 350 cells/mm3 or WHO stage 3/4 are later commenced on FDC unless the serum creatinine is greater
than 85 mol/L, in which case they receive a renal-friendly regimen, AZT + 3TC + EFV for life (but ABC or d4T is used if AZT is contraindicated). With a CD4 count
greater than 350 cell/mm3 or WHO clinical stage 1/2 disease, the patient receives daily AZT prenatally, AZT 3 hourly plus sd NVP and sd TDF/FTC intrapartum.
Women having psychiatric disorder with CD4 less than or equal to 350 cells/mm3 or WHO stage 3/4 are commenced on life-long TDF + FTC + NVP (or LPV/RTV if
CD4 greater than 250 cells/mm3). With a CD4 count greater than 350 cell/mm3 or WHO clinical stage 1/2 disease, the patient receives: prenatally AZT daily;
intrapartum AZT 3 hourly plus sd NVP and sd TDF/FTC.
Women who test HIV positive for the rst time in labor are given sd NVP plus AZT 3 hourly and sd TDF + FTC.
Infants
Infants born to HIV-infected mothers receive daily NVP for at least six weeks or until one week after cessation of breastfeeding.a
Abbreviations: AZT, Zidovudine; d4T, stavudine; EFV, efavirenz; FTC, emtricitabine; LPV/RTV, lopinavir/ritonavir; NVP, nevirapine; sd, single dose; TDF, tenofovir; 3TC, lamivudine.
a
Mixed feeding is not a recommended infant feeding option.
In South Africa, the national strategic plan on HIV, sexually transmitted infections, and tuberculosis (20122016) is the current and
third strategic plan for the ght against HIV infections [5]. The vision,
goals and objectives, and core indicators of this strategic plan are
shown in Box 1.
The vision is adapted from the three zeros on HIV, which is a
20-year vision by UNAIDS [5]. The goals and objectives were drafted
based on evidence-based publications such as the Know Your
Epidemic (KYE) report [19]. Each strategic objective has multiple
subobjectives. Enablers that will ensure successful implementation of
the strategic plan include: effective communication; good governance
and functional institutional arrangements; research; and monitoring
and evaluation using core indicators. Costing and nancing are also
factored into the strategic plan, with estimated annual cost of 1668.07
and 2872.34 billion US dollars in 2012/13 and 2016/17, respectively
[5] (using an exchange rate of US 1$ = ZAR 11.2269).
Box 1
National strategic plan on HIV, sexually transmitted infections, and
tuberculosis 20122016 in South Africa.
Vision:
Zero new cases of HIV and TB infections.

Zero vertical transmissions of HIV.
Zero preventable mortality related to HIV and TB.
Zero discrimination related to HIV, TB, and STIs.
Broad goals:
Use combination of preventive measures to achieve at least
50% reduction in new HIV infection.
Ensure that not less than 80% of eligible HIV-infected patients are started on antiretroviral treatment, with at least
70% of them alive and on the treatment five years following
initiation of the therapy.
Decrease the number deaths from TB and new cases of TB
infection by 50%.
Provide an accessible and enabling legal framework that
promotes and protects the human right required to support
successful implementation of the national strategic plan.
Ensure that the self-reported stigma associated with TB and
HIV is reduced by at least 50%.
Strategic objectives:
Deal with the structural and social barriers related to HIV, TB,
and STI care, prevention, and impact.
Prevent new TB, HIV, and STI infections.
Maintain wellness and health.
Enhance access to justice and improve human rights
protection.
Core indicators:
Percentage of HIV-positive young men and women aged
1524 years.
Percentage of HIV-positive people in key populations such as
sex workers, etc.
Percentage and number of infants exposed to HIV whose HIV
test is positive at six weeks and 18 months of ages.
Incidence and prevalence of TB.
Adult mortality percentage attributable to TB and HIV.
Patterns of stigma.
Retention of patients on ART.
Abbreviations: TB, tuberculosis; STI, sexually transmitted infections; ART, antiretroviral therapy.
S21
The implementation of the strategic plan at every sector of the

country is based on the following principles: (1) all initiatives should
be vision led; (2) initiatives should be scalable and of high impact;
(3) activities should be evidence based; (4) the strategic plans should
be exible to accommodate necessary changes; (5) multisectoral teamwork that considers local practices is required for success; (6) through
partnership, the strategic plan should be promoted as having country
ownership by all individuals; and (7) the national strategic plan should
be rights based, ensuring human rights and gender equity [5].
In addition, important determinants of HIV infection were addressed
in the strategic plan. Social and behavioral determinants include sexual
debut, having multiple sexual partners, condom use, age-disparate coital relationships, substance and alcohol abuse, and knowledge of risk
perception. The biological determinants include MTCT, medical male
circumcision, prevention of different sexually transmitted infections,
and initiating treatment on eligible HIV-positive patients as a preventive measure. Structural determinants are issues of mobility and migration, norms and gender roles, and intimate partner violence/sexual
abuse. Further information on South Africas national strategic plan on
HIV is free to view online [5].
The rst evaluation of South Africas PMTCT program occurred in
2010 and a 3.5% rate of MTCT was reported [20]. The national strategic
plan on HIV has identied a need for a strategic plan on HIV for sex
workers [21]. In 2013, this then led to the development of a strategic
plan entitled the National Strategic Plan for HIV Prevention, Care
and Treatment for Sex Workers [21]. It is important to note that a
review of the HIV, tuberculosis, and PMTCT programs in South Africa
was carried out in 2013 and was reported in 2014 [22]. This was
aimed to assess the performance of different programs and suggest
measures for improvement. The review showed that MTCT based on
positive PCR at eight weeks of age decreased to 2.6%/2.7% in 2011/
2012 respectively [22].
5. Challenges associated with the South African 2013
PMTCT guidelines
In South Africa there are factors that occasionally prevent the complete implementation of the PMTCT guidelines, and as a result increase
the risk of MTCT. These factors include booking for prenatal care at a late
gestation, no monitoring of maternal viral load, failure to perform an
HIV test on exposed infants, and inadequate ARV prophylaxis [16].
Others factors include poor quality data collection and management,
failure to obtain any prenatal care, and inability to initiate ARVs at
every public healthcare facility in the country [6]. In addition, overcrowding of maternity units predispose mothers to HIV transmission
[23]. Gender-based violence and inadequate stafng of health facilities
are also issues of concern.
There are measures that may be valuable in addressing the aforementioned challenges in South Africa. For instance, intensication of
community health promotion will encourage citizens to avoid risky
practices. The newly introduced MomConnect mobile phone text
message services used to provide healthcare information to pregnant
women will also be valuable [24]. Ongoing in-service training of medical
staff will improve data management and adherence to the PMTCT
guidelines. It is envisaged that the rollout of the national health insurance scheme [25] will provide the infrastructure and human resources
required to promote health, as well as zero MTCT.
6. Conclusion
In South Africa, new drug regimens and the strategic plan on HIV
have resulted in improved health outcomes such as a reduction in
MTCT of HIV. This has been a major achievement. If the current challenges associated with implementation of the PMTCT guidelines are
tackled and treatment option B + adopted, it is hoped that complete
elimination of MTCT will be a reality. Condential enquiry into each
S22
case of MTCT should be undertaken to identify and address gaps militating against complete elimination of vertical transmission.
Conict of interest
References
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contentassets/documents/unaidspublication/2014/JC2559_local-epidemics_en.pdf.
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[5] South African National AIDS Council. National Strategic Plan on HIV, STIs and TB
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September 27, 2014.
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toxicity with continuous nevirapine in pregnancy: results from PACTG 1022. J Acquir
Immune Dec Syndr 2004;36(3):7726.
Bartlett JG, Gallant JE, Conradie F. Medical Management of HIV Infection. Durham,
NC, USA: TheraSim, Inc.; 2008.
Chi BH, Stringer JS, Moodley D. Antiretroviral drug regimens to prevent mother-tochild transmission of HIV: a review of scientic, program, and policy advances for
Sub-Saharan Africa. Curr HIV AIDS Rep 2013;10(2):12433.
Rollins N, Mahy M, Becquet R, Kuhn L, Creek T, Mofenson L. Estimates of peripartum and postnatal mother-to-child transmission probabilities of HIV for use in
Spectrum and other population-based models. Sex Transm Infect 2012;88(Suppl. 2):
i4451.
Ibeto M, Giddy J, Cox V. Closing the gaps: steps towards elimination of mother-tochild transmission of HIV. South Afr J HIV Med 2014;15(3):1089.
Van Schalkwyk M, Andersson MI, Zeier MD, La Grange M, Taljaard JJ, Theron GB. The
impact of revised PMTCT guidelines: a view from a public sector ARV clinic in Cape
Town, South Africa. J Acquir Immune Dec Syndr 2013;63(2):2348.
Perera F, Peiro M. Strategic planning in healthcare organizations. Rev Esp Cardiol
(Engl Ed) 2012;65(8):74954.
South African National AIDS Council. Know Your Epidemic, Know Your Response:
Summary Report 2011. Published 2011. http://www.sanac.org.za/resources/cat_
view/7-publications/9-reports. Accessed September 27, 2014.
Goga A, Dinh T, Jackson DJ, for the SAPMTCTE study group. Evaluation of the Effectiveness of the National Prevention of Mother-to-Child Transmission (PMTCT)
Programme Measured at Six Weeks Postpartum in South Africa, 2010. South
African Medical Research Council, National Department of Health of South Africa
and PEPFAR/US Centers for Disease Control and Prevention; 2012. http://www.hst.
org.za/sites/default/les/pmtcteffectiveness.pdf. Accessed September 27, 2014.
South African National AIDS Council. National Strategic Plan for HIV Prevention,
Care and Treatment for Sex Workers. Published 2013. http://www.sanac.org.za/
resources/cat_view/7-publications/9-reports. Accessed September 27, 2014.
National Department of Health South Africa. Joint Review of HIV, TB and PMTCT
Programmes in South Africa. Published April 2014. http://www.hst.org.za/sites/
default/les/WHO-nal-report-of-joint-hiv-tb-pmtct-main_April2014.pdf. Accessed
September 27, 2014.
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an overcrowded hospital. South Afr J HIV Med 2014;15(2):668.
Western Cape Government. New Project Connects Expectant Moms to Government
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2014.
Matsoso M, Fryatt R. National Health Insurance: The rst 16 months. S Afr Med J
2013;103(3):1568.

MATERNAL HEALTH
Quality assurance: The 10-Group Classication System

(Robson classication), induction of labor, and cesarean delivery
Michael Robson , Martina Murphy, Fionnuala Byrne
National Maternity Hospital, Dublin, Ireland
a r t i c l e
i n f o
Keywords:
10-Group Classication System (TGCS)
Audit
Cesarean delivery
Induction of labor
Quality assurance
Robson classication
a b s t r a c t
Quality assurance in labor and delivery is needed. The method must be simple and consistent, and be of universal
value. It needs to be clinically relevant, robust, and prospective, and must incorporate epidemiological variables.
The 10-Group Classication System (TGCS) is a simple method providing a common starting point for further detailed analysis within which all perinatal events and outcomes can be measured and compared. The system is
demonstrated in the present paper using data for 2013 from the National Maternity Hospital in Dublin, Ireland.
Interpretation of the classication can be easily taught. The standard table can provide much insight into the
philosophy of care in the population of women studied and also provide information on data quality. With
standardization of audit of events and outcomes, any differences in either sizes of groups, events or outcomes
can be explained only by poor data collection, signicant epidemiological variables, or differences in practice.
In April 2015, WHO proposed that the TGCS (also known as the Robson classication) is used as a global standard
for assessing, monitoring, and comparing cesarean delivery rates within and between healthcare facilities.
1. Introduction
2. The 10-Group Classication System
One of the most important decisions in obstetrics is the decision to end

a pregnancy before spontaneous labor has started. This may be for a maternal, or more commonly, a fetal reason and it may be by induction of
labor or a pre-labor cesarean delivery. Likewise, if labor has started spontaneously or has been induced, it may sometimes be necessary to perform
a cesarean delivery for either a fetal reason or lack of progress in labor.
There is no standardized classication or methodology used for analyzing
the outcome and the results of these decisions [1]. It is therefore difcult
to compare results over time in one organization or between different organizations. There is often little consensus on the way we diagnose labor,
the methods we use to accelerate labor, the way we monitor the fetus
during labor, the indications and methods for inducing labor, or the indications for cesarean delivery.
Standardizing the way we analyze events and outcomes should
be easier than standardizing the processes we use in labor and
delivery. The aim of the present paper is to describe the 10-Group
Classication System methodology (also known as the Robson classication) using 2013 data from the National Maternity Hospital, Dublin,
Ireland [2].
The National Maternity Hospital in Dublin is a tertiary referral hospital

and one of the largest maternity hospitals in Europe. It produces an annual clinical report each year that is available for external scrutiny. Over the
years, development of the methodology of audit of labor and delivery has
been rened and now many other hospitals use the same principles. The
National Maternity Hospital uses the 10-Group Classication System
(TGCS) [3]. This system has been used extensively internationally to analyze cesarean deliveries [4,5], but it was originally designed so that all
labor and delivery events and outcomes could be analyzed in the context
of the different types of management that each unit may have. In addition, signicant epidemiological variables could be incorporated either
within the 10 groups or used to analyze the distribution of the 10 groups
within different epidemiological subgroups.
The way the TGCS table is constructed and presented is important
(Table 1). It is essential that there is a disciplined and standard way of
interpreting the results [6]. Any particular group can only be interpreted
individually in detail after rst interpreting the different relative sizes of
the other nine groups.
The groups are described in the rst two columns. Ten groups were
chosen to give some discrimination to the population; more than 10
would become difcult to remember. The different groups were chosen
because of their clinical relevance and some were chosen to assist the
determination of data quality. The order and relationships of the groups
in the table are also important to enable rapid and easy interpretation of
Corresponding author at: National Maternity Hospital, Holles Street, Dublin 2, Ireland.
Tel.: +353 1 637 3100.
E-mail address: Mrobson@nmh.ie (M. Robson).
S24
M. Robson et al. / International Journal of Gynecology and Obstetrics 131 (2015) S23S27
Table 1
The Ten Group Classication system for cesarean deliveries, National Maternity Hospital, Ireland, 2013.
Group
Description
2013
2024/8755
(23.1%)
Size of group, %
Cesarean delivery
rate in group, %
Contribution
of each group
(23.1%)
1
2
3
4
Nulliparous, single cephalic, 37 weeks, spontaneous labor

Nulliparous, single cephalic, 37 weeks, induced or cesarean before labor
Multiparous (excluding previous cesareans), single cephalic, 37 weeks, spontaneous labor
Multiparous (excluding previous cesareans), single cephalic, 37 weeks, induced or cesarean
before labor
Previous cesarean, single cephalic 37 weeks
All nulliparous breeches
All multiparous breeches (including previous cesareans)
All multiple pregnancies (including previous cesareans)
All abnormal lies (including previous cesareans)
All single cephalic, 36 weeks (including previous cesareans)
146/2040
468/1305
31/2564
130/944
23.3
14.9
29.3
10.8
7.1
35.9
1.2
13.8
1.7
5.3
0.4
1.5
683/1003
167/178
124/138
130/198
40/40
105/345
11.5
2.0
1.6
2.3
0.5
3.9
68.1
93.8
89.9
65.7
100
30.4
7.8
1.9
1.4
1.5
0.5
1.2
5
6
7
8
9
10
the data. All groups could be further subdivided and some groups need
to be amalgamated to provide more appropriate denominators depending on what events and outcomes are being analyzed. However, the
more frequently the 10 groups are used internationally, the more useful
they become as a common starting point for further analysis. The third
column heading provides the numerator for the total number of cesarean deliveries and the denominator for the total number of
women who delivered in the institution; the column contains the
numerator and denominator for the number of cesarean deliveries
and women who delivered, respectively, for each group. The numbers in each group should add up to the totals at the top. The percentage of women that cannot be classied gives a reection of data quality.
The fourth column in the table gives the size of each group as a
percentage and is calculated by the number of women in each group divided by the total number of women in the population. It is remarkable
how consistent the sizes are in different populations and it therefore becomes relatively easy to either question the quality of the data or indeed
identify unique populations.
The fth column provides the cesarean delivery rate in each group
by dividing the number of cesareans carried out in each group by the
number of women in each group.
The sixth column provides the absolute contribution of each group
to the overall cesarean delivery rate. This is calculated by dividing the
number of cesarean deliveries in each group by the total number of
women in the population. The contribution to the overall cesarean delivery rate is inuenced by the cesarean delivery rate in each group
and also the size of the group. The absolute (rather than relative) rate
of contribution is recommended for use in Table 1. It is then easy to
quickly interpret both the absolute and relative rates of contribution
to the cesarean delivery rate.
Induction rates are most often described in terms of overall rates.
This is misleading as not all women can or will potentially be induced.
In addition, the incidence of induction of labor varies according to different groups of women as do the indications, methods of induction, implications of inductions, and outcomes. The most signicant group in this
context is group 2: nulliparous women at greater or equal to 37 weeks
of gestation with a single cephalic pregnancy who are induced or have
a pre-labor cesarean delivery [7]. The group of women who are induced
is often referred to as group 2a. The appropriate denominator for the incidence of inductions in this group is all nulliparous women at greater or
equal to 37 weeks of gestation with a single cephalic pregnancythe
total of groups 1 and 2 (Table 2). Group 2 is not split initially in the
Table 2
Total single cephalic nulliparous pregnancies at greater than or equal to 37 weeks of
gestation (groups 1 and 2: n = 3345), 10 Group Classication System, National Maternity
Hospital, Dublin, 2013.
Spontaneous labor
Induced labor
Pre-labor cesarean
61.0% (2040/3345)
35.7% (1195/3345)
3.3% (110/3345)
TGCS as, paradoxically, more information can be gleaned more quickly

by keeping group 2 undivided.
The same principles are applied to groups 3 and 4 to analyze induction of labor in all multiparous women at greater or equal to 37 weeks of
gestation with a single cephalic pregnancy but no previous scar.
The only other groups of women that in practical terms are induced
are relatively small, and because of this and their unique characteristics
they should be audited completely separately. These include women in
groups 5, 8, and 10.
2.1. Indications for inductions and cesarean deliveries
Indications for induction of labor, just like indications for cesarean
deliveries, are becoming problematic in terms of audit as there seems
to be an endless list developing, including no medical indication.
These indications are often difcult to dene, which leads to inconsistency in their use. The principles adopted are that some grouping of indication is required. Undoubtedly there is some overlap, but the
indications are grouped according to the most signicant one. Each
group of indications for inductions can be analyzed in more detail, if
required, to determine the particular specic indication.
The same principles are adopted for indications for pre-labor cesarean deliveries. Ideally, pre-labor cesarean deliveries should be divided
into fetal, maternal, and no medical indication. However, these
are difcult to dene because of overlap and are therefore difcult
to implement.
Finally, the indications for cesarean deliveries performed in spontaneous labor or after labor has been induced are described in Fig. 1 [1].
The principles of this classication are to distinguish between cesarean
deliveries carried out for fetal reasons (no oxytocin) and cesarean deliveries carried out for dystocia (failure to progress). It uses the need for
oxytocin as a distinguishing feature between fetal reasons and dystocia.
It also describes the two common types of dystocic labors leading to
cesarean delivery: labors progressing at less than 1 cm per hour
(inefcient uterine action, IUA) and those that progress at more than
1 cm per hour initially and then subsequently fail to progress (efcient
uterine action, EUA). IUA and EUA are subsequently subdivided.
For dystocia, the subdivision IUA, poor response (Dys/IUA/PR) is when
oxytocin is prescribed and in theory reaches the maximum dose according to that delivery units guideline, but the labor fails to progress at
more than 1 cm per hour. The subdivision IUA, inability to treat overcontracting uterus (Dys/IUA/ITT/OC) is when oxytocin is prescribed and
is unable to achieve the maximum dose because the uterus over contracts.
IUA, inability to treat, fetal intolerance (Dys/IUA/ITT/FI) is when oxytocin
is prescribed and is unable to achieve the maximum dose because the
fetus does not tolerate the oxytocin. Lastly IUA, no oxytocin (IUA/no
oxytocin) is when there is poor progress (less than 1 cm per hour) but
no oxytocin is prescribed for varying clinical reasons. Efcient uterine action (EUA) is divided into cephalopelvic disproportion/obstructed labor
(EUA/CPD/obstruction) or malposition (EUA/malposition).
S25
Classification of Cesarean
Delivery in labor
Fetal
Dystocia
(no oxytocin)
Inefficient
uterine action
(IUA)
IUA
Poor response
IUA
Inability to treat
overcontracting
Efficient uterine
action (EUA)
IUA
Inability to treat
fetal intolerance
IUA
No oxytocin
given
EUA
Persistent
malposition
EUA CPD
(Obstructed labor
multiparous)
Variables
Error in
diagnosis,
induction
Intact
membranes
Delay in
oxytocin
Inadequate
dose oxytocin
Appropriate
dose but
hesitant use
Diagnosis of labor
Fetal monitoring
Assessment of progress
ARM and oxytocin regimen
Epidural
Fig. 1. Classication of the indications for cesarean deliveries performed among women in spontaneous labor or after induction of labor. A version of this gure appears in Murphy et al. [14].
The classication is constructed so that it can be used by any delivery

unit irrespective of what denition they have for the diagnosis of labor,
and also irrespective of how and when they accelerate (augment) labor
using articial rupture of membranes and oxytocin or the method of
monitoring the fetus in labor. The concept behind this method of quality
assurance is that, like the TGCS, the results will stimulate discussion regarding a units processes (management of labor) when comparing it
with other units.
3. Example using National Maternity Hospital data for 2013

In 2013, 8755 women delivered 8954 neonates each weighing more
than or equal to 500 g [1]. All of the women were classied according to
the TGCS, shown in Table 1. This is the standard table used as the
starting point for the classication system.
The distribution and size of the groups are reasonably standard. The
raw numbers add up to the total, there are no missing data, and the size
and cesarean delivery rate in group 9 signify good quality data.
The nulliparous and multiparous distribution is also reasonably standard, but there is a less than 2:1 ratio between the sizes of groups 1 and
2. This suggests a high incidence of induction and pre-labor cesarean
deliveries in this cohort of women. In any given population, the ratio
between the sizes of groups 3 and 4 is relatively higher than the ratio
between groups 1 and 2.
The size of group 5 is appropriate relative to the overall cesarean delivery rate, as is the ratio between groups 6 and 7 and their combined sizes.
The size of group 8 at 2.3% is slightly higher than average, suggesting
in vitro fertilization and replacement of more than one embryo or possibly a tertiary referral center.
The size of group 10 at 3.9% does not signify a particularly high rate
of preterm delivery. With a cesarean delivery rate of 30.4%, there is
neither a preponderance of spontaneous pre-term labor nor iatrogenic
cesarean delivery.
The cesarean delivery rates in groups 1 and 3 are as low as any other
international comparison [8].
The cesarean delivery rate in group 2 is high, suggesting a slightly

high pre-labor cesarean delivery rate in addition to the actual increased
size of group 2 noted previously. The group 4 cesarean delivery rate is
pretty standard, reecting a more balanced ratio between the induction
of labor and pre-labor cesarean delivery rates.
The cesarean delivery rate in group 5 is higher than average at 68.1%.
The high rates in groups 6 and 7 are pretty standard internationally. The
cesarean delivery rate in group 8 is increasing steadily everywhere and
again would not be very different to most if not all other delivery units.
The rate of 100% in group 9 is what you would expect.
Overall, groups 1, 2, and 5 contribute to 14.8% in absolute terms to
the total cesarean delivery rate of 23.1%. This makes up approximately
two-thirds of the overall cesarean delivery rate, which is very standard.
Table 2 shows groups 1 and 2 subdivided into spontaneous, induced
labor, and pre-labor cesarean deliveries. It is crucial to conrm these relative proportions by size before interpreting the cesarean delivery rates
in groups 1 or 2a. The induction of labor rate is 35.7%, which is high.
Table 3 shows the indications for cesarean delivery in Group 1 classied by the descriptions given in Fig. 1. It shows a low cesarean delivery
rate. The highest subgroup is IUA/inability to treat for fetal reasons,
which suggests a more active approach to labor, probably an earlier and
Table 3
Indications for cesarean delivery in group 1 (single cephalic nulliparous pregnancies at
greater than or equal to 37 weeks of gestation in spontaneous labour), 10 Group
Classication System, National Maternity Hospital, Dublin, 2013.
Indication for cesarean delivery
No.(146/2040)
% (7.1)
1. Fetal reasons (no oxytocin)

2. Dyst/IUA/ITT/FI
3. Dyst/IUA/ITT/OC
4. Dyst/IUA/PR
5. Dyst (no oxytocin)
6. Dyst/EUA/CPD/POP
25/2040
72/2040
30/2040
9/2040
1/2040
9/2040
1.2
3.5
1.5
0.4
0.05
0.4
Abbreviations: Dyst, dystocia; IUA, inefcient uterine action; ITT, inability to treat; FI, fetal
intolerance; OC, over contracting; PR, poor response; EUA, efcient uterine action; CPD,
cephalopelvic disproportion; POP, persistent occipito posterior position.
S26
Table 4
Events and outcomes in group 1 (single cephalic nulliparous pregnancies at greater than or equal to 37 weeks of gestation in spontaneous labour), 10 Group Classication System, National
Maternity Hospital, Dublin, 20072013.
Group 1
2013 (%)
ARM to accelerate
Oxytocin
Epidural
Electronic monitoring
Fetal blood sample
Vaginal operative delivery
Apgar b7 at 5 min
Cord pH b7.0
Overall cesarean delivery
Cesarean delivery at VE = 10
Admitted to neonatal unit
Episiotomy
OASIS
Duration of labor N12 h
Neonatal weight 4.0 kg
Maternal age 35 y
Body mass index 30
PPH N1000 ml
HIE
Blood transfusion
1102/2040
1100/2040
1428/2040
1790/2040
424/2040
479/2040
14/2040
4/2040
146/2040
19/2040
349/2040
936/2040
55/2040
59/2040
296/2040
374/2040
146/2040
34/2040
1/2040
35/2040
54.0
53.9
70.0
87.7
20.8
23.5
0.7
0.2
7.2
0.9
17.1
45.9
2.7
2.9
14.5
18.3
7.2
1.7
0.05
1.7
2012 (%)
2011 (%)
2010 (%)
2009 (%)
2008 (%)
2007 (%)
52.8
53.9
73.0
86.0
22.4
24.0
0.8
0.3
9.3
1.2
10.1
48.6
3.1
3.4
15.4
16.7
8.2
1.3
0.1
1.5
53.6
53.2
73.7
79.0
24.6
24.6
1.1
0.5
7.4
1.4
11.7
56.8
2.5
2.8
15.9
16.7
8.1
1.0
0.2
-
52.9
51.2
68.6
77.2
21.5
25.7
0.2
0.2
7.5
1.3
10.6
56.1
2.9
2.2
13.6
14.5
8.4
0.4
0.0
-
52.4
49.6
66.4
75.7
20.3
27.8
0.6
0.3
7.8
1.4
9.8
52.6
2.6
1.5
13.2
14.0
7.2
0.5
0.1
-
53.5
50.3
63.9
74.1
18.4
24.1
0.7
0.3
7.2
1.2
9.4
51.0
3.0
3.5
13.6
13.8
7.3
0.2
0.1
-
54.5
50.5
64.7
73.8
21.7
28.0
0.8
0.6
6.1
1.1
7.2
56.0
3.4
3.7
14.1
14.2
9.3
0.4
0.1
-
Abbreviations: ARM, articial rupture of membranes; VE, vaginal examination; OASIS, obstetric anal sphincter injuries; PPH, postpartum hemorrhage; HIE, hypoxic ischemic
encephalopathy.
higher-dose oxytocin regimen; however, not necessarily a higher incidence of oxytocin.

Table 4 shows other events and outcomes in group 1 between 2007
and 2013. It is important to include these within all the different groups
because no perinatal event should be interpreted on its own.
Table 5 shows the indications and grouping for induction of labor in
nulliparous women at greater or equal to 37 weeks of gestation with a
single cephalic pregnancy. Post-date pregnancy is dened as 42 weeks
of gestation and greater. Finally, the indications for pre-labor cesarean
deliveries are shown in Table 6.
Although not shown here, a similar analysis in groups 3 and 4 should
be carried out and would show completely different results.
4. Discussion
The principles of perinatal audit are rstly that overall rates of events
and outcomes are meaningless. Secondly, no perinatal event or outcome
should be considered in isolation from other events, outcomes, and organizational issues. Thirdly, any classication of perinatal audit must
be able to incorporate other variables that are important for interpreting
the quality of perinatal care.
The purpose of the present paper is to demonstrate how the TGCS
can be used as a common starting point to routinely audit induction of
labor and cesarean deliveries [9]. However, other information including
perinatal and maternal morbidity and mortality is required to ensure
overall quality of care. The advantage of the TGCS is that it can be used
to analyze all labor events and outcomes, while taking into account
Table 5
Indications for induction of labor in group 2a (single cephalic nulliparous pregnancies at
greater than or equal to 37 weeks of gestation), 10 Group Classication System, National
Maternity Hospital, Dublin, 2013.
Indication for induction of labor
No. (1195/3345)
% (35.7%)
Fetal reasons
PET/hypertension
Post-date pregnancy (42 wk)
SROM
Maternal reasons/pains
Nonmedical reasons or dates b42 wk
310/3345
115/3345
253/3345
318/3345
136/3345
63/3345
9.3
3.4
7.6
9.5
4.1
1.9
Abbreviations: PET, pre-eclamptic toxemia; SROM, spontaneous rupture of membranes.
any signicant epidemiological variables. The full benet of the system

will not be realized until it is used routinely by all labor and delivery
units with a spectrum of different philosophies and management of
care [10,11].
With standardization of perinatal audit of events and outcomes, any
differences in either events or outcomes can be explained only by poor
data collection, signicant epidemiological variables, or differences
in practice.
The challenges of implementing the system include explaining the
philosophy of this new way of thinking and encouraging the importance
of routine, standardized audit of each delivery units results. The emphasis in current obstetrics of practicing evidence-based medicine is
appropriate, but continually collecting the evidence that we are providing quality care is as important and must be acknowledged and encouraged. Ideally this should result in an annual clinical report. Training will
be required to best explain the methodology of collection, how to use
the system to its full potential as well as how to interpret the results [6].
The benets of the system are that it could be used to audit all
perinatal outcome globally. This will allow all clinicians to learn from
each other and on the basis of their results examine their practice. The
sheer numbers of women in these databases will inevitably help to
improve the quality of perinatal care.
Even though midwives and obstetricians in many countries have
already made their choice, endorsement of the system both at national
and international level is crucial. At the present time only the Society of
Obstetricians and Gynaecologists of Canada [12] and WHO have formally endorsed the system [13]. In April 2015, WHO proposed that the
system is used as a global standard for assessing, monitoring, and
Table 6
Indications for pre-labor cesarean delivery in group 2b (single cephalic nulliparous pregnancies at greater than or equal to 37 weeks of gestation), 10 Group Classication System,
National Maternity Hospital, Dublin, 2013.
Indications for pre-labor cesarean delivery
No. (110/3345)
% (3.3)
Fetal reasons
PET/hypertension
APH/placenta previa/abruption
Maternal medical reason
No medical indication
43/3345
9/3345
15/3345
29/3345
14/3345
1.3%
0.3%
0.5%
0.9%
0.4%
Abbreviations: PET, pre-eclamptic toxemia; APH, antepartum hemorrhage.
comparing cesarean delivery rates within and between healthcare facilities. WHO will also develop guidelines to assist healthcare facilities
adopt the system [13]. Professional organizations could, by formally endorsing the system, facilitate a truly global initiative.
Conict of interest
Michael Robson developed the TGSC. The authors have no conicts
of interest.
References
[1] Robson MS. Labour ward audit. In: Creasy RK, editor. Management of Labour and
Delivery. Oxford: Blackwell Science; 1997. p. 55970.
[2] National Maternity Hospital. Annual Report 2013. http://www.nmh.ie/_leupload/
Annual%20Reports/FB%20NMH%20AR%2013%20English%20Final.pdf.
[3] Robson MS. Classication of caesarean sections. Fetal Matern Med Rev 2001;12(1):
2339.
[4] Torloni MR, Betran AP, Souza JP, Widmer M, Allen T, Gulmezoglu M, et al.
Classications for cesarean section: a systematic review. PLoS One 2011;6(1):
e14566.
[5] Betran AP, Vindevoghel N, Souza JP, Glmezoglu AM, Torloni MR. A systematic
review of the Robson classication for caesarean section: what works, doesnt
work and how to improve it. PLoS One 2014;9(6):e97769.
S27
[6] Robson M, Hartigan L, Murphy M. Methods of achieving and maintaining an appropriate caesarean section rate. Best Pract Res Clin Obstet Gynaecol 2013;27(2):
297308.
[7] Brennan D, Murphy M, Robson M, OHerlihy C. The singleton, cephalic, nulliparous
woman after 36 weeks of gestation: contribution to overall cesarean delivery
rates. Obstet Gynecol 2011;117(2 Pt 1):2739.
[8] Brennan D, Robson M, Murphy M, O'Herlihy C. Comparative analysis of international
cesarean delivery rates using 10-group classication identies signicant variation
in spontaneous labor. Am J Obstet Gynecol 2009;201(3):308.e18.
[9] Robson M. The Ten Group Classication System (TGCS) a common starting point
for more detailed analysis. BJOG 2015;122(5):701.
[10] Vogel JP, Betran A, Glmezoglu AM. Use of the Robson classication has improved
understanding of caesarean section rates in France. BJOG 2015;122(5):700.
[11] Le Ray C, Blondel B, Prunet C, Khireddine I. Deneux-Tharaux, Gofnet F. Stabilising
the caesarean rate: which target population? BJOG 2015;122(5):6909.
[12] Farine D, Shepherd D. Classication of caesarean sections in Canada: the modied
Robson criteria. J Obstet Gynaecol Can 2012;34(10):97683.
[13] World Health Organization. WHO Statement on Caesarean Section Rates. WHO/
RHR/15.02. Geneva: WHO; 2015. http://apps.who.int/iris/bitstream/10665/
161442/1/WHO_RHR_15.02_eng.pdf?ua=1.
[14] Murphy M, Butler M, Coughlan B, Brennan D, O'Herlihy C, Robson M. Elevated amniotic uid lactate predicts labor disorders and cesarean delivery in nulliparous
women at term. Am J Obstet Gynecol 2015. http://dx.doi.org/10.1016/j.ajog.2015.
06.035.

REPRODUCTIVE HEALTH
Cancer of the cervix: Early detection and cost-effective solutions

Lynette Denny a,, Walter Prendiville b
a
b
University of Cape Town/Groote Schuur Hospital, Cape Town, South Africa

International Agency for Research on Cancer, 150 Cours Albert Thomas, Lyon, France
a r t i c l e
i n f o
Keywords:
Cervical cancer
Cost-effectiveness
HPV
HPV DNA testing
Secondary prevention
Visual inspection with acetic acid
a b s t r a c t
Cervical cancer is known to be a preventable disease through the detection of cervical cancer precursors,
historically using cytology of the cervix as the primary screening test. Over 85% of cervical cancer cases and
deaths occur in low-resource countries. Alternatives to cytology have been investigated with the strongest
possibilities being visual inspection with acetic acid (VIA) and HPV DNA testing. HPV DNA testing has been
shown in randomized trials to be signicantly more sensitive for the detection of cervical cancer precursors
than either cytology or VIA. In this paper we argue that prevention really does cost less than cure, or that
prevention and treatment of cancer costs less than no prevention, in effect just treatment, of cancer. The true
cost savings of prevention will include a more difcult assessment of the socioeconomic savings associated
with longer, healthier lives for women in their prime who have a major role in supporting their families.
2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
This is an open access article under the CC BY-NC-ND license
1. Introduction
2. Secondary prevention
Globally there were 14 million new cases of cancer and 8 million

cancer-related deaths in 2012 [1]. This database reveals that breast and
cervical cancer are among the most common incident sites of cancer in
women, representing over one-third of the total. Among women, breast
cancer has a substantially higher incidence (43.3 per 100 000) than any
other cancer, representing 25.2% of all cancers diagnosed in females [2].
In Sub-Saharan Africa, the incidence of cervical cancer is equivalent
to breast cancer, each constituting approximately one-quarter of the
total burden (Figs. 1 and 2). The incidence and mortality rates for
cervical cancer in Sub-Saharan Africa are 34.8 and 22.5 per 100 000
respectivelythe highest of any world region. In Sub-Saharan Africa,
cervical cancer is the most common cause of cancer death in women
(23.2% of the total) [3]. Cancer of the breast and cervix kill more
women than any other forms of cancer in all low-resource regions of
the world [4]. Sixty-two percent (n = 57 318) of women in SubSaharan Africa diagnosed with cervical cancer died compared with
50% (n = 47 583) of women with breast cancer [5]. Over 85% of incident
cases and deaths from cervical cancer occur in low-resource countries
where the initiation and/or maintenance of cervical cancer screening
programs have proved impossible [5]. Weak healthcare systems, lack
of nancial and human resources, competing health needs, war and
civil strife, and widespread poverty have prevented many governments
from supporting cervical cancer prevention programs.
While historically cervical cytology has been the mainstay of

secondary prevention and, where successfully implemented, has had a
major impact on reducing the incidence of and mortality from cervical
cancer, the demands of the test are too complex for many lowresource countries. The past 15 years has seen a surge in studies
designed to nd alternative tests to cytology, specically to allow
point-of-care testing to enable women to be screened and treated in a
single visit, without the necessity for complex and expensive laboratory
investigations as well as colposcopy and histological examination.
In low-resource countries, these studies have focused mainly on using
visual inspection with acetic acid (VIA) and testing for DNA of high-risk
types of HPV, so-called HPV DNA testing. Cross-sectional studies of VIA
initially were quite reassuring and most studies demonstrated relatively
high sensitivity, but low specicity and positive predictive value. Sauvaget
et al. [6] performed a meta- analysis of 26 studies of VIA performed in
low- and middle-income countries. Overall, VIA had a pooled sensitivity
of 80%, specicity of 92%, a positive predictive value of 10%, and a negative
predictive value of 99% for the detection of cervical intraepithelial neoplasia (CIN) 2+. In all of the studies, VIA was performed in asymptomatic
women who all underwent conrmatory testing; however, there were inconsistencies among the studies.
In longitudinal studies however, Denny et al. [7] in a randomized
controlled trial of 6555 unscreened women aged 3565 years of age
showed that the sensitivity of VIA for high-grade precursors was around
48% when women were followed for 36 months. By contrast the
sensitivity of HPV DNA testing for high-risk types (using Hybrid Capture
2; Qiagen, Gaithersbury, MD, USA) was consistently higher than either
Corresponding author at: H45, Old Main Building, Groote Schuur Hospital,
Observatory, 7925, Cape Town, South Africa. Tel.: +27 21 404 4485; fax: +27 21 4486921.
E-mail address: lynette.denny@uct.ac.za (L. Denny).
L. Denny, W. Prendiville / International Journal of Gynecology and Obstetrics 131 (2015) S28S32
S29
Table 1
Cost of treating cervical cancer among Medicaid beneciaries in North Carolina, USA.a
12-month cost, US $
a
Fig. 1. Sub-Saharan Africa. Estimated age-standardized (World) cancer incidence and

mortality rates (ASR) per 100 000, by major sites in men and women, 2012. Reproduced
with permission from: Forman D, Bray F, Brewster DH, Gombe Mbalawa C, Kohler B,
Pineros M, et al., eds. Cancer incidence in ve continents, Vol. X (electronic version).
Lyon: IARC; 2013. Accessed 24 September 24, 2014.
cytology or VIA and had a sensitivity of 86% for high-grade cervical

cancer precursors over a 36-month follow-up period. Further, for
every 100 women screened, the HPV screen-and-treat strategy eliminated 4.1 cases of CIN 2 or greater compared with VIA-and-treat,
which eliminated 1.8 cases.
In another landmark study, Sankaranarayanan et al. [8] performed a
cluster randomized trial of 131 746 women aged 3059 years who were
randomly assigned to one of four groups: HPV testing; cytological testing;
VIA; or standard of care that involved no screening as the control group.
The incidence rate of cervical cancer stage 2 or higher and death rates
from cervical cancer were signicantly higher in the cytological, VIA,
and control groups compared with the HPV testing group. Furthermore,
the age-standardized incidence rate of invasive cancer among women
who had negative test results on cytological or VIA testing was more
than four times greater than the rate among HPV-negative women.
These data suggest that primary screening with HPV DNA,
followed by treatment will be associated with a signicant reduction
in cervical cancer and cervical cancer precursors. HPV DNA testing is a
Stage 0
Stage I
Stage IIIV A
Stage IV B
6347
32 255
46 681
83 494
Source: Subramanian et al. [15].
laboratory-based test and current commercially available tests are not

affordable in low-resource countries. The ideal test for HPV DNA
detection would provide a result at the time of examination and
screeninga point-of-care test. Such a test has recently become
available, the GeneXpert test (Cepheid; Sunnyvale, CA, USA), which
can provide a result within one hour. Clinical trials in a screen-andtreat setting are soon to be established.
?twb=0.27w?>There is currently a great deal of research on using
HPV DNA testing as either a primary screen or as an adjunct to cytology
in women over 30 years of age. Ronco et al. [9] reported on 176 464
women aged 2064 years who participated in four randomized trials in
Sweden, the Netherlands, England, and Italy. Women were randomly
assigned to HPV-based (experimental arm) or cytology-based (control
arm) screening and were followed for a median of 6.5 years during
which 107 invasive cervical cancers were identied. Detection of invasive
cancer was similar in the two arms in the rst 2.5 years of follow-up but
was signicantly lower in the HPV screening arm. Further, the cumulative
incidence of invasive cervical cancer in women with a negative screening
test at entry was double in the control versus the experimental arm. These
four trials showed that HPV testing provides 60%70% greater protection
against invasive cervical cancer compared with cytology and the authors
recommend initiation of HPV-based screening from age 30 years and to
extend the screening intervals to 5 years.
While many studies have focused on the characteristics of screening tests, the programmatic issues often pose the strongest barriers
to successful screening. WHO began a demonstration project called
Prevention of cervical cancer through screening using VIA and
treatment with cryotherapy [10], which recruited 19 579 women
from September 2005 to May 2009 from six countries in Africa
(Madagascar, Malawi, Nigeria, Uganda, Tanzania, and Zambia). Overall, 11.5% (n = 1980) of women screened were VIA positive and 1.7%
(n = 326) were found to be suspicious for cancer. Of the 1980
women with positive VIA, 87.7% (n = 1737) were eligible for cryotherapy and 60.9% (n = 1058) underwent cryotherapy, 34.6% (n = 601)
were lost to follow-up, and 4.5% (n = 78) did not undergo cryotherapy.
Fig. 2. Sub-Saharan Africa. Estimated cancer ve-year prevalence proportions by major sites, in both sexes combined, 2012. Reproduced with permission from: Bray F, Ren JS, Masuyer E,
Ferlay J. Global estimates of cancer prevalence for 27 sites in the adult population in 2008. Int J Cancer 2013;132(5):113345.
S30
Table 2
Cost of treating all cervical cancer cases in Taiwan, 20022010.a
Expected life-years lost

Lifetime costs, US $
a
Stage 0 (n = 17 701)
Stage I (n = 6236)
Stage II (n = 2987)
Stage III (n = 1157)
Stage IV (n = 716)
1316
6.3
7020
11.6
10 133
12.7
11 120
18.6
10 015
Source: Hung et al. [16].
Of those undergoing cryotherapy, just under 40% (n = 243) had the

procedure performed on the same day as screening. Furthermore,
around 50% of women treated returned for their follow-up visit one
year later.
Of the 326 women with possible cancer, only 29.4% (n = 96) were
investigated, of whom the majority79 womenwere conrmed to
have cancer, and 77 received treatment. There was no information on
70.6% (n = 230) of women with a cervix suspicious for cancer. These
data underscore that there are no quick xes to screening programs,
even using a low technology accessible test such as VIA. Despite huge effort, the coverage rate of the target populations was way below what
was anticipated, there was signicant loss to follow-up, and poor uptake
of same day treatment. Furthermore, the majority of women with a
cervix suspicious for cancer were not investigated. Some of the reasons
for the lack of investigation of these women were lack of access to
pathology services or inability to pay for pathology services.
3. Cost-effectiveness
It is perhaps intuitive to think that cancer prevention programs
(vaccination and screening) are cost-effective, yet relatively few
countries have implemented them. Data audits and predictions are
reported variously as cost-effectiveness, cost-benet, and cost-utility.
These terms differ according to the index of measurement chosen
(cost per life year saved, cost per dollar of intervention, cost per years
saved, and quality of life adjusted years saved) and the interested reader
is referred to the recent overview by Subramanian [11].
In 2010, cervical cancer accounted for over 7 million disabilityadjusted life years lost [2]. If cervical cancer prevention programs had
been implemented globally it has been estimated that between 10 and
230 million dollars and almost 1 trillion dollars in value of a statistical
life (VSL) would have been saved [12,13]. In the present paper we
argue that prevention really does cost less than cure, or that prevention
and treatment of cancer costs less than no prevention, in effect just
treatment, of cancer. The true cost savings of prevention will include a
more difcult assessment of the socioeconomic savings associated

with longer, healthier lives for women in their prime who have a
major role in supporting their families. This wider cost will not be
addressed here, largely because of the lack of valid information [11]
and because it may have less impact on healthcare budget holders
than tangible resources savings.
Sankaranarayanan (personal communication, December, 2014) described a model that compares three approaches to the management
of cervical cancer:
(A) Prevention by vaccination and screening with treatment of
pre-cancer cases plus treatment of cancer surgically and
with radiotherapy.
(B) Screening and treatment of pre-cancer plus early cancer.
(C) Diagnosis and treatment of symptomatic cancer patients
without any preventive program.
A recent study at Harvard estimated a cost saving between groups
A and C ranging from 54% to 65% in different WHO regions and a cost
saving between 32% and 38% for groups A versus B [14].
Clearly the cost of treating cervical pre-cancer and cancer will be
greater in an adequately resourced country. But does the relative difference in treating cancer at different stages prevail between adequately
resourced and poorly resourced countries? Directly comparable gures
are not easily available. Tables 1 and 2 show the costs in regions at
different ends of the income spectrum and demonstrate a stark relative
difference in the cost of treatment at different stages. These comparisons are likely to underestimate the true cost as they do not include
the socioeconomic costs; however, they do show a consistent cost
saving of well over 50% when comparing the treatment of pre-cancer
to late stage disease, whether in Taiwan or the USA.
Taiwan introduced cytology screening in 1995 and despite an
increase in population there has been a 43% decline in cervical cancer
incidence between 2002 and 2009 [16,17]. Again the cost savings of
this reduction (approximately US $42.2 million) is likely to be a conservative cost savings estimate (Fig. 3).
2002-2009
2002-2009
Cervical cancer actual cases
diagnosed
Expected number of cervical cancer

cases in the absence of screening
19 384
11 096
Total costs for screening and
treatment of cancer cases
Expected costs of treatment of

cervical cancer cases
US $157.5 million
US $199.7 million
Cost savings during 2002-2009
US $42.2 million (21.2%)

Fig. 3. Projected cost savings following introduction of cervical cancer screening in 1995 in Taiwan.
S31
Table 3
Estimated costs of cervical cancer treatment and follow-up care in public hospitals in India.a
Stage
Number of cases
Estimated one-year costs (direct medical

costs, treatment plus follow-up care) and
indirect costs (transportation, food and
stay during treatment, lost wages), US $
Total costs, US $
I (radical hysterectomy with bilateral pelvic lymphadenectomy)
12 284 (assumed to be
10% of annual burden)
110 560
2127
26 128 068 (26.1 million)
3439
380 215 840 (380.2 million)
3111
36 987 124 (37.0 million)
50 per visit
75 000 000 (75 million)

518 331 032 (518.3 million)
II, III, IVA (external beam therapy 4550.4 Gy 2528 fractions, with
midline shielding after 36 Gy, 56 sittings of high-dose rate
brachytherapy to a total of 2530 Gy to point A, and 56 weekly
concurrent chemotherapy with cisplatin 40 mg/m2 beginning on
day 1 of radiotherapy)
IV B
Follow-up visits of prevalent cancer cases
Total estimated costs of cervical cancer care per year
a
12 284 (assumed to be
10% of annual burden)
1.5 million visits
R. Sankaranarayanan, personal communication, December, 2014).
Perhaps the most useful country data to study come from India,
which has the worlds largest burden of cervical cancer (122 844 cases
per annum, 67 477 deaths per annum, and 1 125 960 prevalent cases
at ve years [18]. Table 3 details the estimated one-year costs of cervical
cancer treatment in public hospitals in India (Sankarayarayanan;
personal communication, December, 2014). If India were to introduce
HPV vaccination and two-visit HPV screening (assuming 70% coverage),
Diaz et al. [19] estimated a reduction in lifetime cancer risk of 63% in
the context of the Indian healthcare environment. In Fig. 4, an estimation of the cost savings has been made were India to introduce a
three-dose vaccination of 12-year-old girls and a single round of
HPV screening at age 35 over the next 30 years. As is shown in the
Fig. 4, there would be a marginal reduction in cost if prevention were
introduced (vaccination and one-off HPV screening at 35 years of age)
but a massive reduction in costs (over US $6 billion) after 30 years of
the prevention program. This may seem a long time to wait; however,
even in the rst 30 years of the prevention program the costs do not
increase, but rather decrease, albeit marginally. Again these estimates
are conservative. The cost of vaccination, especially if bought in bulk at
a national level and of screening is likely to reduce, whereas the cost
of treatment of later-stage disease may well increase.
The assessment of cost will be different from the perspective
of a gynecologist to that of a national healthcare budget holder.
Although eliminating surgical and radiotherapy costs from a hospital makes immediate sense to the caring doctor, it might have little
inuence on a healthcare budget if the surgical and radiotherapy
resources are so limited that they will be used up by other diseases
once freed from cervical cancer needs. However as more and more
diseases are prevented, ultimately healthcare resources should
reduce overall.
Health economics are perceived very differently between low- and
high-income countries, and priorities will depend not just on the
relative cost of prevention versus cure but also on the absolute cost
of any intervention and the impact of that intervention on other
health resources in that region. If the absolute cost of preventing
cervical cancer is not affordable then it will not happen. It is hoped
that the cost of vaccination and HPV testing will plummet over the
coming years.
Conict of interest
Lynette Denny has received honoraria for appearing on various
speaker forums on HPV vaccination for GlaxoSmithKline and Merck
and has received research funding from both organizations. Walter
Prendiville has no conicts to declare.
Fig. 4. Cost of treatment ( prevention) in India in US dollars.
S32
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[9] Ronco G, Dillner J, Elfstrom KM, Tunesi S, Snijders, Arbyn M, et al. Efcacy of HPVbased screening for prevention of invasive cervical cancer: follow-up of four
European randomized controlled trials. Lancet 2014;383(9916):52432.
[10] African Population and Health Research Center, International Agency for Research on
Cancer, World Health Organization. Prevention of cervical cancer through screening
using visual inspection with acetic acid (VIA) and treatment with cryotherapy: A
demonstration project in six African countries: Malawi, Madagascar, Nigeria, Uganda,
the United Republic of Tanzania, and Zambia. Geneva, Switzerland: WHO; 2012.
http://www.who.int/reproductivehealth/publications/cancers/9789241503860/en/.
[11] Subramanian S. Cost-effectiveness of screening for and early diagnosis of breast and
gynecological cancers in low-income countries. In: Shetty MK, editor. Breast and
Gynecological Cancers: An Integrated Approach for Screening and Early Diagnosis
in Developing Countries. New York, USA: Springer; 2013.
[12] Ginsberg OM. Breast and cervical cancer control in low and middle-income
countries: human rights meet sound health policy. J Cancer Policy 2013;1(34):
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[13] Knaul FM, Gralow JR, Atun R, Bhadelia A, editors. Closing the cancer divide: An
equity imperative. Boston, MA: Harvard Global Equity Initiative; 2012.
[14] Seinfeld J. Cost-benet analysis of cancer care and control: The case of cervical, colorectal
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icb.topic1011506.les/CCC%20-%20Breast_Cervical%20and%20Colorectal%20cancer%
20cases_AB.pdf. Accessed January 20, 2015.
[15] Subramanian S, Trogdon J, Ekwueme DU, Gardner JG, Whitmore JT, Rao C. Cost of
cervical cancer treatment: implications for providing coverage to low-income
women under Medicaid expansion for cancer care. Womens Health Issues 2010;
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[16] Hung MC, Lit MT, Cheng YM, Wang JD. Estimation of savings of life-years and cost
from early detection of cervical cancer: a follow-up study using nationwide
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[17] Chu PC, Hwang JS, Wang JD, Chang YY. Estimation of the nancial burden to the
National Health Insurance for patients with major cancers in Taiwan. J Formos
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Lyon, France: IARC; 2013. http://globocan.iarc.fr.
[19] Diaz M, Kim JJ, Albero G, de Sanjose S, Clifford G, Bosch FH, et al. Health and economic
impact of HPV 16 and 18 vaccination and cervical cancer screening in India. Br J
Cancer 2008;99(2):2308.

REPRODUCTIVE HEALTH
HPV vaccination: The most pragmatic cervical cancer primary

prevention strategy
Rengaswamy Sankaranarayanan
International Agency for Research on Cancer, Lyon, France
a r t i c l e
i n f o
Keywords:
Cervical cancer
HPV vaccination
National programs
Prevention
Screening
a b s t r a c t
The evidence that high-risk HPV infections cause cervical cancers has led to two new approaches for cervical cancer control: vaccination to prevent HPV infections, and HPV screening to detect and treat cervical precancerous
lesions. Two vaccines are currently available: quadrivalent vaccine targeting oncogenic HPV types 16, 18, 6,
and 11, and bivalent vaccine targeting HPV 16 and 18. Both vaccines have demonstrated remarkable immunogenicity and substantial protection against persistent infection and high-grade cervical cancer precursors caused by
HPV 16 and 18 in HPV-nave women, and have the potential to prevent 70% of cervical cancers in adequately vaccinated populations. HPV vaccination is now implemented in national programs in 62 countries, including some
low- and middle-income countries. The early ndings from routine national programs in high-income countries
are instructive to encourage low- and middle-income countries with a high risk of cervical cancer to roll out HPV
vaccination programs and to introduce resource-appropriate cervical screening programs.
1. Introduction
Cervical cancer is the fourth most common cancer in the world with
an estimated 528 000 new cases and 267 000 cervical cancer deaths
annually, of which 445 000 new cases and 230 000 deaths occur lowand middle-income countries (LMICs) in Sub-Saharan Africa, Central
and South America, Asia, and Oceania [1]. Lack of screening programs
and high prevalence of HPV infection in the population are the major
factors responsible for the high risk observed in LMICs. The knowledge
that persistent infection with one of the oncogenic HPV types is the necessary cause for cervical cancer has led to HPV vaccination and HPV testing as emerging strategies for prevention and early detection of cervical
cancer. However, these are yet to be implemented in national programs
in many LMICs, where they are most needed. The overarching role of
HPV vaccination as the most pragmatic and feasible primary prevention
strategy for cervical cancer is briey discussed here.
2. HPV infection and cervical cancer
Cervical cancer is a rare long-term outcome of infection with a highrisk HPV type (HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68),
particularly HPV 16. Peak frequency of HPV infection occurs in adolescence and early adulthood, with a life-time probability of infection of
International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372, Lyon
Cedex 08, France. Tel.: +33 472 73 85 99; fax: +33 472 73 85 18.
E-mail address: sankarr@iarc.fr.
approximately 80% 90%. The frequency of incident HPV infections declines steadily with age. HPV infection persists in 5% 15% of the
infected women, while 85% 90% of the infections become undetectable
within two years. Those with persistent HPV infection are at high risk for
cervical cancer and HPV 16 and 18 cause 70% 75% of the cervical cancer cases across the world [2,3]. HIV-infected women are at higher risk of
HPV infection despite the advent of antiretroviral therapy (ART) and are,
therefore, at high risk for cervical neoplasia.
The natural history of cervical cancer involves four stages, namely HPV
infection of the transformation zone (TZ), HPV infection persistence, clonal expansion of HPV infected cells to high-grade cervical intraepithelial
neoplasia (CIN 3) or adenocarcinoma in situ (AIS), and their progression
to invasive cancer [2]. Minor cellular abnormalities, such as atypical squamous cells of undetermined signicance (ASCUS), low-grade squamous
intraepithelial lesions (LSIL), or atypical glandular cells of undetermined
signicance (AGUS), on cytology or low-grade CIN (CIN1) on histology
may be observed within months following incident and transient HPV infections. With the clearance of infection in the vast majority (N 80%), the
low-grade lesions resolve [2]. CIN 3 and AIS are considered to be the
real precursors of cervical cancer and 40% 50% of untreated lesions
may progress to cancer over a 5 30-year period [46]. The duration between HPV infection and developing CIN 3 is shorter than the time between CIN 3 developing into invasive cancer. Although healthy
lifestyles, improved socioeconomic status, awareness, empowerment of
women with education and better social status, male circumcision, and
improved hygiene contribute to reducing risk of cervical cancer,
prophylactic HPV vaccination of pre-adolescent/adolescent girls before
S34
R. Sankaranarayanan / International Journal of Gynecology and Obstetrics 131 (2015) S33S35
sexual debut is singularly the most cost-effective and efcient primary

prevention strategy [7,8].
3. Prevention
The fact that high-risk HPV infections cause almost all cervical cancers
has led to two new approaches for cervical cancer control: primary prevention by vaccination to prevent HPV infections in pre-adolescents and
adolescents (9 18-year-old girls) and early detection of cervical precancerous lesions such as CIN 3 and AIS by HPV screening in women aged
30 years and older. Two recombinant HPV vaccines containing viral-like
particles (VLP) are currently available: quadrivalent vaccine targeting oncogenic HPV types 16, 18, 6, and 11, and bivalent vaccine targeting HPV 16
and 18. Both vaccines have demonstrated remarkable immunogenicity
and substantial protection against persistent infection, CIN 3, and anal
intraepithelial neoplasia caused by the vaccine-targeted HPV types in
women aged 1526 years nave to the corresponding type at the time
of vaccination. Both vaccines have the potential to prevent 70% of cervical
cancers in adequately vaccinated populations [9]. Efcacy against persistent infection with vaccine-targeted HPV types and related CIN 3 frequency in HPV-nave populations in Phase III clinical trials exceeded 99% [9].
Immunogenicity bridging studies demonstrated strong immunogenicity
and excellent safety in pre-adolescence, although clinical trials did not include pre-adolescent girls who are the primary target populations for current national immunization programs. The evidence on safety and
efcacy of the vaccines in clinical trials, demonstration projects, and routine public health settings all strongly support the introduction of HPV
vaccination in national immunization programs. Mild to moderate
injection-site pain, headache, and fatigue were the most common adverse
events following HPV vaccination.
HPV vaccination is currently part of the national immunization program in 62 countries targeting pre-adolescent and adolescent girls and
catch-up immunization of older cohorts with upper age limits up to
26 years. Cost-effectiveness studies support the implementation of
HPV vaccination of pre-adolescent/adolescent girls before sexual onset
including LMICs provided the vaccines are affordable; the costeffectiveness in LMICs is heavily inuenced by the unit cost of the vaccine [7,8,1012]. Difculty in procuring vaccines due to high costs is a
major challenge, although in recent years vaccine costs have been coming down. From a realistic implementation perspective, government
commitment, procuring HPV vaccines at affordable prices (through
tiered pricing or negotiated pricing, or through the Gavi vaccine alliance
or the PAHO revolving fund), using the recently recommended two
dose schedules as well as education of the community at large to create
awareness about the safety and efcacy are critical to introduce HPV
vaccination in national immunization programs in LMICs.
It is estimated that full vaccination of a cohort of 58 million 12-yearold girls in 179 countries for which UN population estimates are available will prevent 690 000 cervical cancer cases and 420 000 deaths at
a net cost of US $4 billion; HPV vaccination was cost-effective (with
every disability-adjusted life-year averted costing less than the per
capita gross domestic product of the country) in 156 (87%) of the 179
countries [8]. Although studies differ in their conclusions about the optimal age for catch-up vaccination, a catch-up round for young adolescent girls (1215 years), whose future access to screening is uncertain
in LMICs, is worth considering and 16% 20% of HPV 16/18 protection
from vaccination is attributed to catch-up vaccination strategy [13].
Only a few cost-effectiveness studies indicate that including boys in
HPV vaccination programs would be a cost-effective strategy [7,14].
Vaccinating with fewer than three doses will lower costs, ease logistics
of vaccine delivery, increase accessibility, and improve adherence to vaccination. Immunogenicity following two doses in adolescent girls has been
shown to be non-inferior to that of a three-dose course in the age group
where efcacy against persistent infection and pre-cancerous lesions has
been demonstrated [1519]. Protection in terms of persistent infection of
vaccine-targeted HPV types among a small sample of women who received
two doses, or a single dose only by default, has been reported [20]. Based on
ndings that immunogenicity of two doses is comparable to three doses in
9 14-year-old girls, the European Medical Agency and 10 countries in
Central and North America, Africa, and Asia have licensed the use of twodose regimens. Whereas most countries continue to use the three-dose
schedule in their national immunization programs, based on the recent research evidence, a two-dose regimen is being used in some countries such
as Canada, Chile, Colombia, Mexico, South Africa, and Switzerland, and
England will switch over to a two-dose schedule from September 2014 onward. The guidelines in England for switching over to two-dose regimen
suggest that the rst dose can be given at any time during school year 8
(12 13-year-old girls) followed by a minimum of six months and a maximum of 24 months between doses; for operational purposes a 12-month
gap between the rst and second doses has been recommended.
Among LMICs, Bhutan, Malaysia, Uzbekistan, Fiji, Rwanda [21], South
Africa, Zambia, Uganda, Panama, Mexico, Brazil, Chile, Argentina,
Colombia, Peru, Uruguay, and Paraguay have implemented HPV vaccination as part of a national immunization program. High coverage of the
target populations (N90% third dose or second dose) and excellent safety
prole have been observed in Bhutan, Malaysia, Rwanda, Brazil, and
South Africa among others. Ten LMICs (nine in Sub-Saharan Africa, i.e.
Ghana, Kenya, Madagascar, Malawi, Mozambique, Niger, Sierra Leone,
Tanzania, and Zimbabwe, as well as Laos in Asia) have introduced HPV
vaccination demonstration projects supported by GAVI. Uganda,
Rwanda, and Uzbekistan are currently receiving support from GAVI
alliance for HPV vaccination in their wider national immunization programs. The introduction of HPV vaccination as part of national immunization programs in some LMICs has happened in spite of anti-vaccination
campaigns in different countries. Indeed, one of the real challenges at
present seems to be the signicant anti-vaccine propaganda, political
and media frenzies spreading misinformation, and exaggerated and erroneous adverse event coverage in many countries.
Preliminary evaluation of HPV vaccination programs, in some highincome countries where vaccination was introduced 4 or 5 years ago,
has shown that the frequency of vaccine-targeted HPV infections, precancerous lesions, and genital warts associated with vaccine- included
HPV types among vaccinated cohorts is declining [2224]. In April
2007, Australia introduced quadrivalent HPV vaccination for 12 13year-old girls through a school-based program followed by a catch-up
vaccination for 13 26-year-olds via schools, community-based programs, and general practices during July to December 2009. Thirddose coverage among the primary target group exceeded a modest
70%. A signicant decline in the prevalence of HPV types 16/18/6/11
after introduction of a national HPV vaccination program such as a
77% fall in prevalence of HPV vaccine-related infections, 90% reduction
in genital warts, and 48% reduction in CIN3/AIS lesions in the vaccinetargeted age group has been reported in Australia [22], corresponding
to model-based projections made in 2007 [25]. In Scotland, a signicant
decline in HPV 16 and 18 prevalence was demonstrated among HPVvaccinated women (prevalence = 150/1100 [13.6%]) compared with
unvaccinated women (prevalence = 1018/3418 [29.5%]) in a crosssectional study involving 1000 women aged 2021 years recruited annually during 2009 2012 [24]. Six years from the introduction of
HPV vaccination in Denmark in 2006, the risk of atypia or worse lesions
and CIN2 and 3 lesions have signicantly declined among vaccinated
women; there is a 44% reduction in CIN2 3 lesions among vaccinated
cohorts of women born during 1991 and 1992 and a 73% reduction in
CIN2 3 lesions in the 19931994 birth cohorts [23].
4. Conclusion
After reviewing the evidence, WHO currently recommends a twodose HPV vaccination schedule for girls with a minimal interval of six
months between the doses, if vaccination is initiated prior to 15 years
of age; this interval may be extended to 12 months if this facilitates
vaccination [26]. This new recommendation on two doses makes
R. Sankaranarayanan / International Journal of Gynecology and Obstetrics 131 (2015) S33S35
implementation of HPV vaccination programs more feasible and affordable than a three-dose schedule. A three-dose schedule at 0, 12, and
6 months remains necessary if immunization is initiated after the girls
15th birthday and for immunocompromised individuals, including
those known to be HIV infected.
The early ndings on safety and intermediate endpoints from routine national programs in high-income countries are instructive to encourage LMICs with a high risk of cervical cancer to roll out HPV
vaccination programs to prevent cervical cancer and to introduce resource appropriate cervical screening programs taking into account
the post vaccination scenario of successive cohorts of women at low
risk for HPV infection and CIN as vaccination proceeds. High-income
countries eventually need to reorganize their existing screening programs to balance the overall costs of both vaccination and screening taking into account the challenges for cytology screening and colposcopy
triage in view of the anticipated low frequency of HPV infection and dysplastic changes due to both post vaccination immunogenicity and herd
immunity. Based on the anticipated impact of vaccination on the performance of cytology, a changeover to HPV testing as the primary screening test followed by cytology triage (in view of the already built-up
cytology infrastructure in high- and in some middle-income countries),
later initiation of screening (at 30 or 35 years), and less frequent screening (e.g. one in 10 years or even a single round of screening in low- and
low-middle-income countries) is inevitable in due course. While HPV
vaccination will result in successive cohorts of women at low risk of
HPV infection and cervical neoplasia as vaccination progresses, screening will reduce the risk of cervical cancer deaths among targeted
women not yet protected by HPV vaccination or in women in whom
vaccination has failed. The timing of the effect of vaccination on cervical
screening will be country-specic and will depend on any catch-up
vaccination, variation in coverage, the impact of herd immunity, and
the age at which screening started.
Conict of interest
The author has no conicts of interest to declare.
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REPRODUCTIVE HEALTH
A historic and scientic review of breast cancer: The next global

healthcare challenge
Sven Becker
Department of Gynecology and Obstetrics, University Hospital Frankfurt, Frankfurt, Germany
a r t i c l e
i n f o
Keywords:
Breast cancer diagnosis
Breast cancer treatment
Breast cancer systemic therapy
a b s t r a c t
Breast cancer is fast becoming the leading cause of oncologic morbidity and mortality among women worldwide.
Demographic changes in Asia, Southeast Asia, and South America will further accelerate this trend. Different specialties are involved in the treatment of breast cancer patients: gynecology, surgery, pathology, hematology/
oncology, radiology, radiation oncology, and nuclear medicine. Optimal results are seen in countries providing
standardized breast cancer care in certied breast centers. The present article provides an overview of current
state-of-the-art treatment strategies and explains the contributions of different specialties to optimal and individualized care for breast cancer patients. Breast cancer will be one of the most important health issues facing
physicians involved with womens health and a basic understanding of current treatment objectives will be
essential medical knowledge for everyone taking care of female patients.
1. Introduction
Breast cancer is the most common cancer among women, the number one cause of cancer mortality, and one of the leading causes of
morbidity and mortality for women worldwide [1,2]. This represents
a major change in morbidity and mortality specic to women; only
50 years ago, cervical cancer and morbidity associated with childbearing
were the leading healthcare problems of women [3].
The main risk factor for breast cancer is age. Other signicant risk factors are low parity and low rates of breastfeeding, which explains more
than any other factor why breast cancer is the classical cancer of highresource nations and continues to increase in almost all countries [4].
Breast cancer has always been a common disease of women. It is no
coincidence that the surgical treatment of breast cancer was one of the
rst systemized surgical treatments during the rst surgical revolution
at the end of the 19th century. The scientic description and assessment
of the radical mastectomy by Halstead remainsboth in its groundbreaking association of science and surgery as well as with regard to
its limitations as an overly radical local solution to a systemic diseasea
fascinating example of how oncologic treatment started off barely
120 years ago [5].
Life expectancies in high-resource nations in Europe, North America,
and Australia for women now reach 80-plus years. Life expectancies in
China and India, representing almost 40% of the worlds population,
Womens University Hospital, Frankfurt University, Theodor-Stern-Kai 7, 60590
Frankfurt, Germany. Tel.: +49 69 6310 5115.
E-mail address: sven.becker@kgu.de.
have continued to increase at dramatic rates. The same can be said of

Southeast Asia, postcommunist eastern Europe, and South America.
The worlds population continues to increase in size, albeit at a
decreasing rate. The single most important demographic factor determining future healthcare burdens will be age. For the gynecologist,
this means an increase in diseases associated with age: problems of hormone deciency, pelvic oor problems, and genital cancers such as endometrial and vulvar cancer. The incidence of ovarian cancer appears to
be decreased by the use of oral contraceptives [6]. The one oncologic
disease certain to increase is breast cancer: a disease affecting all ethnic
groups in all prospering nations.
Breast cancer is an individual tragedy for those affected. It is a highly
curable disease when detected early, and an inevitably mortal disease
when discovered too late. Access to high-quality care leading to early
diagnosis can mean the difference between life and death. Access to
proper surgical and medical treatment can mean the difference between life and death [7].
Breast cancer is at the same time a major healthcare burden:
screening programs are costly and difcult to organize, involving
major logistic and quality control issues. Proper surgical treatment
requires appropriate operating room facilities and highly qualied
healthcare providers. More advanced treatment approaches involve
local radiation, requiring facilities beyond the scope of most healthcare
systems in low-income countries.
Adequate systemic treatment with chemotherapy or hormonal therapy is costly both in itself as well as with regard to the management
of potentially severe adverse effects. All sophisticated breast cancer
treatment requires the resources of advanced pathology, including
S. Becker / International Journal of Gynecology and Obstetrics 131 (2015) S36S39
immunohistochemistry and molecular pathologic analysis. New

targeted therapies remain an evolving eld where only one thing is certain: individual treatment costs are already threatening the best funded
healthcare systems [8].
Breast cancer is a challenge for all countries: The present article will
review how organizing and centralizing breast care around integrated
breast centers can potentially provide optimal care to individual patients within different healthcare systems. On the other hand, lack
of systematization and failure to focus resources will strain healthcare
systems, particularly among emerging economies, to breaking point.
The article looks at screening, imaging, diagnosis, treatment stratication, surgical treatment options, systemic treatment and follow-up,
and specically addresses logistic and nancial issues.
2. Screening and imaging

Early diagnosis is key to the successful treatment of breast cancer. T1
tumors measuring less than 2 cm in size have a 10-year survival of approximately 85%, while T3 tumorsessentially the result of delayed
diagnosishave a 10-year survival of less than 60% [9].
Four diagnostic procedures lead to the ultimate detection of breast
cancer: (1) clinical examination; (2) mammography; (3) breast ultrasound; and (4) breast magnetic resonance imaging (MRI).
Clinical examination is the most readily available mode of diagnosis.
It is a simple form of early detection, capable of diagnosing tumors between 1 and 2 cm and bigger, depending on location and breast size.
To this day, it remains the most common way breast tumors are rst detected, normally by the affected women herself. Breast examination,
however, assumes a fairly advanced understanding of what breast
cancer is. The technical term is awarenessone of the key concepts in
the ght against breast cancer [10].
Healthcare providers who are in regular contact with women need
to be aware of breast disease as well as willing to examine women
on a regular basis. The people who represent health care need to be
recruited for breast cancer detection. Realistically, not all healthcare
providers will qualify. Physicians and healthcare specialists, such as
nurses or midwives, who are in regular contact with women qualify.
On the other hand, women themselves need to be aware of this
disease threat. They need to be informed and willing to expose themselves to routine breast examinations.
Particularly in societies lacking advanced information technology
and societies structured along patriarchal beliefs, as well as in societies
with a high desire for female privacy, promoting the need for examining
otherwise healthy breasts will require a considerable effort on the part
of regional healthcare systems and providers [11].
With regard to early diagnosis and systematic screening, only
mammography provides the key qualities: easy to perform, minimal
technical set-up, easy to standardize, possible review, and possible
direct comparison with previous mammographies. Because of this,
almost all the available literature evaluating breast cancer screening
modalities looks at mammography. Many countries with highly developed health systems have introduced systematic mammography
screening for women, usually between 50 and 70 years of age in an
effort to reduce breast cancer mortality, usually every two years. Because the available literature is heterogeneous, with a majority of
publications supporting the ability of mammography to reduce mortality long term, acceptance among women has been variable and the
systematic screening approach remains controversial. Many women
are afraid of the procedure, which is often painful and cannot avoid
some radiation exposure [12].
Breast ultrasound is an excellent tool in the management of breast
disease. Most, but not all, breast cancers seen on mammography or
MRI can also be visualized on ultrasound and subsequently biopsied
using ultrasound-guided core biopsy techniques. Because the quality
of breast ultrasound depends on a variety of variables, including breast
S37
size, glandular tissue density, previous surgeries, or radiation and examiner experience, it has not been used as a large-scale screening tool [13].
The most expensive and logistically most demanding breast examination modality is MRI. With the best sensitivity but overall low specicity it is the favorite of many radiologists, who appreciate its accuracy,
but do not have to deal with the clinical management of nonspecic
and often benign ndings that require extensive patient counseling.
To rule out malignancy particularly in questionable cases and within
breasts heavy on scar tissue, MRI remains second to none [14].
3. Diagnosis
Breast examination, mammography, breast ultrasound, and MRI
only raise the suspicion of breast cancer. Ultimately, they nd a lump,
an area of microcalcication, a suspicious area on ultrasound, or a
gadolinium-enhanced area on MRI. The next step is key to the diagnosis:
histologic conrmation or exclusion of malignancy.
Some 80% 90% of breast cancers can ultimately be identied on
ultrasound, even if the primary diagnosis is made by one of the other
imaging modalities.
Breast sonography allows direct, ultrasound-guided biopsy. Core
biopsies allow an exact histologic diagnosis: invasive ductal or invasive lobar breast cancer, a rst grading, as well as a determination of
estrogen- and progesterone-receptor status and HER2 receptor status.
4. Treatment stratication
At this point, all relevant information to determine appropriate
treatment is available: tumor location, tumor size, histology, and
tumor-specic properties. Lymph node status can be assessed clinically,
sonographically, andif necessaryusing cytology. Together with patient age and overall health status, a treatment course can be discussed.
Two major questions need to be answered:
(1) If chemotherapy is needed, should it be delivered before surgery as
a neoadjuvant therapy or after surgery as an adjuvant treatment?
(2) Depending on the timing of chemotherapy and surgery, is breast
conserving surgery possible or does the breast need to be removed
totally (mastectomy)?
Adjuvant versus neoadjuvant therapy and breast conservation versus mastectomy remain the key decisions at the beginning of breast
cancer treatment. For discussion at this pointwithin the available
resourcesare options for breast reconstruction should mastectomy
be necessary.
As with prognosis, the earlier the diagnosis, the smaller the tumor,
the lower the percentage of mastectomies, and the lower the number
of costly breast reconstructive procedures. Again, early detection remains key both at an individual level as well as at a nancial level.
5. Surgical treatment options
Surgery for breast cancer has undergone tremendous change over
the past 20 years. Radical mastectomy as introduced by Halstead was
modied but remained the standard of care until well into the 1980s.
It still remains standard therapy in many countries where healthcare
systems lack a specialized focus for breast disease.
In the early 1970s, two outstanding physicians, Umberto Veronesi,
Italy, and Bernhard Fisher, USA, developed the concept of breast
conserving surgery, advocating that the removal of the malignant
tumor, combined with local radiation provide the same cure rates as
mastectomy. This revolutionary concept was introduced against
tremendous opposition. Its ultimate success has greatly improved the
lives and the fate of hundreds of thousands of women worldwide, if
not millions [15,16].
S38
Breast conserving surgery has become a challenging area of surgery

with the introduction of oncoplastic surgery. It requires an intimate
knowledge of what is and what is not possible. It requires and understanding of the breast as a physiologic and aesthetic entity that is composed of two different parts: the skin and the glandular tissue, which
need to be treated almost separately, only to be reconnected within a
new breast shape at the end of the procedure.
Only specialist breast surgeons will develop the necessary competence to provide acceptable breast conserving solutions for up to 70%
of patients with small tumors and only few countries will offer this
kind of specialization within their health systems. Surgeons performing
abdominal surgery, cholecystectomies, andpossiblymastectomies
will have neither the time nor the interest to focus on this small but
aesthetically challenging area of surgery [17].
In countries without a strong specialization for breast and breast
conserving surgery, mastectomyoften performed by a nonspecialized
general surgeonand, if possible, reconstructionoften performed by
a nonspecialized plastic surgeonare the best alternatives, leading to
a fragmentation of care and making treatment decisions unnecessarily
complicated for patients. The higher the skill of the surgeon and the
smaller the tumor, the lower the mastectomy rate.
What kind of mastectomy is performed determines what kind of reconstruction is necessary or possible. The most advanced versions of
mastectomy are skin-sparing mastectomy or nipple-sparing mastectomy, allowing direct reconstruction with articial implants. These surgical techniques were developed in the 1990s. Again, a specic kind
of training is required: An insufcient resection, leaving behind too
much subcutaneous tissue, will also leave behind too much breast
tissue, while a too radical resection will lead to excessive thinning of
the skin and subsequent necrosis.
Autologous reconstruction techniques are either vascularized skin/
muscle aps (latissimus dorsi ap, TRAM ap), or free aps (DIEP, superior gluteal ap) and allow either the reconstruction after skin-sparing
mastectomy or the plastic reconstruction after loss of the breast skin
as part of a traditional mastectomy.
An integral albeit changing aspect of breast cancer surgery is the
management of the axilla. Traditionally, axillary dissection along anatomic levels dened by the pectoralis minor muscle was an important
part of adequate staging and thought to be an important part of curative
surgery. In recent years, large prospective studies have raised doubts
about the therapeutic benets of axillary resection now only considered
diagnostic. The introduction of the sentinel lymph node was one of the
major advances to reduce nontherapeutic morbidity. As our diagnostic
insights into the prognostic aspects of molecular proling improve,
therapeutic decisions rely less and less on knowledge of the status of
the axillary lymph nodes. Future treatment concepts might be able to
do without any kind of axillary exploration [18].
6. Systemic treatment
Chemotherapy for oncologic disease was rst introduced as a therapeutic measure during the 1950s to treat nonsolid tumor entities such
as leukemia. The treatment of solid tumors was much less successful,
particularly in advanced disease. During the 1970s, using breast cancer
as a model, the concept of adjuvant therapy was developed and remains
one of the cornerstones of breast cancer treatmentalthough the exact
mechanism of action remains unexplained. One of the oncologic mysteries of breast cancer is why a locally cured disease has the potential
to recur systemically after one, two, orsometimes and even more
intriguinglyafter 10 or more years as metastatic and incurable breast
cancer. A question that remains to be answered is where exactly in
the human body do these breast cells with oncologic potential hide,
how do they survive, and why do they ultimately metastasize? [19].
The big molecular biologic mystery can be clearly dened: cells
metastasizing from the primary tumor should have a high oncologic
potential; therefore, it makes no sense that these cells somehow
transform to dormant cells hiding somewhere within the body only

to reappear much later as incurable disease [20].
The theory of micrometastatic tumor cells that have left the primary
breast tumor and spread into the body led to the therapeutic concept of
adjuvant chemotherapy. After appropriate local treatment, almost all
breast cancer patients are clinically free of disease. Depending on prognostic factors such as tumor size, lymph node status, hormone receptor
status, HER2 receptor status, and grading, a certain percentage of these
initially cured patients will have a systemic treatment failure over the
course of 510 years. These treatment failure rates vary between 5%
up to 50% depending on the factors mentioned previously.
Large prospective studies were able to show a measurable decrease
in long-term systemic failure and mortality between 10% and 20% in patients treated with adjuvant chemotherapy; although up until now, it
has been impossible to determine exactly which patient will benet,
leading to overtreatment of thousands of patients worldwide and an interesting hunt for genetic tumor proles beneting from chemotherapy
and proles already cured by local therapy.
Over the years, different chemotherapeutic regimens have developed,
beginning with the CMF regimen (cyclophosphamide, methotrexate, and
5-uorouracil) and leading to todays standard of epirubicin and cyclophosphamide, followed by paclitaxel (EC-paclitaxel) [21].
A multitude of other therapeutic agents have been tested, mostly
in the metastatic but also in the adjuvant phase, including docetaxel,
capecitabine, vincristine, gemcitabine, eribulin, pegylated liposomal
doxorubicin, and so on.
The other major oncologic breakthrough specic for the treatment of
breast cancer was the introduction of targeted therapy using antiestrogens such as tamoxifen and fulvestrant and, later, aromatase inhibitors.
The effect of oophorectomy on the disease progression of metastatic
breast cancer was already established in the 1890s.
With over 60% of patients positive for estrogen and progesterone receptors, adjuvant treatment with antihormonal medication has proven
as successful as adjuvant chemotherapy [22].
During the rst decade of the 21st century, an additional targeted
therapy introduced another revolution for those 15% of breast cancer
patients positive for the HER2 receptor. With the treatment option
trastuzumab, recently increased with further substances such as
lapatinib, pertuzumab, and TDM1, treatment of HER2-positive breast
cancer has become an entire chapter in the textbook [23].
In most countries, the systemic treatment of breast cancer remains
in the hands of medical oncologists. Again, while basic breast chemotherapy is not difcult, the multiple treatment options available in neoadjuvant, adjuvant, and metastatic situations require a specialization
similar to the treatment of the different leukemias. It is unlikely that
the same doctor will be an expert in the treatment of leukemias and
an expert in the treatment of breast cancer.
These systemic breast cancer treatment plans need to be closely coordinated with the surgical and radiation oncology measures. Outside
specialized breast cancer centers, patients will be mostly on their own
to nd the best appropriate individual care, as treatment propositions
will depend too much on the specialist they rst encounter.
7. Radiation oncology
Breast radiation is an integral part of breast conserving surgery. The
extent and necessity of radiation in an elderly population are undergoing considerable changes. Evaluation of the indications for breast radiation is particularly interesting in low-income countries. On the one
hand, breast conservation is key to educating women how to detect
breast cancer early, so that the breasta major esthetic symboldoes
not need to be removed. Breast conservation gives breast cancer treatment a human face. On the other hand, more than any other part of
breast cancer treatment, breast radiation requires modern, state-ofthe-art, high-cost facilities to avoid considerable adverse effects. While
centralization is the logical answer, in many countries, travel options are

limited if not impossible.
8. Follow-up
In advanced health systems, 80% 85% of breast cancer patients will
be cured. Owing to long-term relapse, follow-up becomes a major issue
as patients with previous breast cancer are at high risk of developing
subsequent breast cancers, i.e. in the contralateral breast. At the same
time, breast cancer survivors are breast cancer advocates. They show
how this increasingly common disease can be cured. Raising awareness
of breast cancer within different cultures is the main challenge, particularly in emerging economies with developing healthcare systems.
Management of breast cancer survivors will play an integral part.
9. Summary
The way breast cancer is diagnosed and treated has undergone tremendous changes over the past two decades. In health systems with a
long tradition of breast cancer care, this process has inevitably led to
the creation of breast cancer centers, where the different specialties
involvedgynecology, pathology, radiology, surgery, plastic surgery,
radiation oncology, nuclear medicine, and medical oncologycome
together for the benet of the patient. In an increasing number of
countries, the lead physician has been the gynecologist as the doctor
with the most contact with otherwise healthy women. Breast cancer
represents a major nancial burden that will only increase in years to
come as the proportion of elderly women increases. New treatment
concepts need to consider all of these aspects.
Conict of interest
The author has no conicts of interest.
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REPRODUCTIVE HEALTH
Adolescent sexual and reproductive health: The global challenges

Jessica L. Morris , Hamid Rushwan
International Federation of Gynecology and Obstetrics, London, UK
a r t i c l e
i n f o
Keywords:
Abortion
Adolescents
Contraception
HIV/AIDS
Pregnancy
Sexual and reproductive health
a b s t r a c t
Adolescent sexual and reproductive health (ASRH) has been overlooked historically despite the high risks that
countries face for its neglect. Some of the challenges faced by adolescents across the world include early pregnancy and parenthood, difculties accessing contraception and safe abortion, and high rates of HIV and sexually
transmitted infections. Various political, economic, and sociocultural factors restrict the delivery of information
and services; healthcare workers often act as a barrier to care by failing to provide young people with supportive,
nonjudgmental, youth-appropriate services. FIGO has been working with partners and its member associations
to break some of these barriersenabling obstetricians and gynecologists to effect change in their countries
and promote the ASRH agenda on a global scale.
1. Introduction
Adolescent sexual and reproductive health (ASRH) comprises a
major component of the global burden of sexual ill health. Although
overlooked historically, international agencies are now focusing on improving ASRH and providing programmatic funding. ASRH rights are
based in various legal instruments: in 2002, the UN General Assembly
Special Session on Children recognized the need to develop and implement health policies and programs for adolescents that promote their
physical and mental health [1]; in 2003, the Committee of the Convention on the Rights of the Child issued a General Comment recognizing
the special health and development needs and rights of adolescents
and young people [2]. Other supporting instruments are the Convention
on the Elimination of All Forms of Discrimination Against Women
(CEDAW) and the right to healtha concept included in various international agreements such as the Universal Declaration of Human Rights
and the international Millennium Development Goals, which include indicators to reduce pregnancy rates among 1519 year olds, increase HIV
knowledge, and reduce the spread of HIV among young people [35].
Various terms are used to categorize young people: adolescents refers to 1019 year olds (divided into early [1014 years] and late
[1519 years] adolescence); youth refers to 1524 year olds; and
young people refers to 1024 year olds. In the world today, approximately half of the population is under 25, with 1.8 billion people aged between 10 and 24 years90% of whom live in low- and middle-income
countries (LMICs) and many experiencing poverty and unemployment
Corresponding author at: International Federation of Gynecology and Obstetrics

(FIGO), FIGO House, Suite 3, Waterloo Court, 10 Theed Street, London SE1 8ST, UK. Tel.:
+44 20 7928 1166; fax: +44 20 7928 7099.
E-mail address: Jessica@go.org (J.L. Morris).
[6,7]. While sexual initiation and sexual activity vary widely by region,
country, and sex [8], in all regions young people are reaching puberty earlier, often engaging in sexual activity at a younger age, and marrying later
[911]; consequently they are sexually mature for longer before marriage
than has historically been the case.
The risks of neglecting ASRH are great; a painful or damaging transition
to adulthood can result in a lifetime of ill effects. For girls, early pregnancy/
motherhood can be physically risky and can compromise educational
achievement and economic potential. Adolescentsgirls in particularface
increased risk of exposure to HIV and sexually transmitted infections
(STIs), sexual coercion, exploitation, and violence. All of these have huge
impacts on an individuals physical and mental health, as well as longterm implications for them, their families, and their communities.
An adolescents sexual and reproductive health is strongly linked to
their particular social, cultural, and economic environment. In addition to
regional variation, experiences are diversied by age, sex, marital status,
schooling, residence, migration, sexual orientation, and socioeconomic status, among other characteristics. Access to health care and sources of education, information, and support also varies widely. The variations demand
country-level analyses of patterns but despite these variations, key issues,
barriers, and challenges, as well as potential solutions, can be identied
across the board.
2. The global challenges
2.1. Pregnancy, contraception, and abortion
Sixteen million girls aged 1519 give birth each year, which is approximately 11% of all births worldwide [12]; 95% of these births
occur in LMICs. Important regional differences exist; for example, births
to adolescents as a percentage of all births range from approximately 2%
J.L. Morris, H. Rushwan / International Journal of Gynecology and Obstetrics 131 (2015) S40S42
in China, to 18% in Latin America and the Caribbean, to more than 50% in
Sub-Saharan Africa [13]. Pregnancy among very young mothers is a signicant problem; in LMICs, almost 10% of girls become mothers by age
16, with the highest rates in Sub-Saharan Africa and South Central and
Southeast Asia [13]. Pregnancies among unmarried adolescent mothers
are more likely to be unintended and end in induced abortion; coerced
sex (reported by 10% of girls who rst had sex before age 15) contributes to unwanted adolescent pregnancies, among a plethora of other
negative consequences [13].
Adolescents face a higher risk of complications and death as a result of
pregnancy than older women. For example, in Latin America, the risk of
maternal death is four times higher in adolescents under 16 years old
than women in their twenties [12]. In terms of complications, anemia,
malaria, HIV and other STIs, postpartum hemorrhage, and mental
disorders, such as depression, are associated with adolescent pregnancy
[13,14]. Pregnancy and delivery for girls who have not completed their
body growth expose them to problems that are less common in adult
women; 9% 86% of women with obstetric stula develop the condition
as adolescents, with traumatic, often lifelong consequences [15]. Low
socioeconomic status, substance abuse, and likelihood of receiving
low and/or inadequate prenatal care are associated with pregnant
adolescents, and poor outcomes for the offspring of adolescent
mothers are well documented and include higher rates of preterm
birth, low birth weight and asphyxia, and perinatal and neonatal
mortality [10,12,16].
Globally, it is estimated that more than 220 million women in LMICs
have an unmet need for family planning [18]. Overall, little progress has
been made in increasing uptake of contraception. While increases in use
have been slightly higher with adolescents than older women, this
group are more affected by contraceptive failure and discontinuation
rates, and use of traditional methods of contraception are still notable
[11,17]. Adolescent girls who have ever had sex or are currently sexually active are more likely to be or have been married than boys in the
same categories [19]. Married adolescents often do not want a pregnancy, but have low contraceptive rates; in fact, recent data have shown
that current use of contraceptives is often lower among sexually active,
married adolescents [11]. For example, in Bangladesh contraceptive use
among women aged 1049 years rose from 49% 61% from
19962011, while for married adolescents aged 1519 years it rose
from 33% 47% in the same time period [20]. Similarly, in Malawi, contraceptive use among married women aged 1549 years increased from
13% 46% from 19922010, whereas among married adolescents aged
1519 years it rose from 7% 29% [20]. Unmet need for both married
and unmarried adolescents is therefore still extremely high [8]. Research suggests that current contraceptive use prevents approximately
272 000 maternal mortalities per year, and if current family planning
needs were met, another 104 000 lives would not be lost [21], many
of which would be adolescents lives saved.
One major outcome of unmet need for family planning is unwanted
pregnancy and, consequently, high levels of unsafe abortion. Complications from pregnancy and childbirth are the leading cause of death in
girls aged 1519 years in LMICs where almost all of the estimated three
million unsafe abortions occur [16]. Worldwide, mostly as a result of unintended pregnancy, nearly 4.5 million adolescents undergo an abortion
each year, with approximately 40% performed under unsafe conditions.
Regional differences exist; for example, 1519 year olds account for
25% of all unsafe abortions in Africa, but the proportion in Asia and in
Latin America and the Caribbean is much lower [22]. In Nigeria, adolescents account for up to 74% of all induced abortionsapproximately
60% of all gynecological hospital admissions. In Tanzania, approximately
half the number of adolescent patients seeking abortions were aged
17 years or younger [19]. Adolescents are more seriously affected by
complications than older women [12]. The physically devastating potential consequences of unsafe abortion include cervical tearing, perforated
uterus and bowel, hemorrhage, chronic pelvic infection and abscesses, infertility, endotoxic shock, renal failure, and death. The long-term
S41
sequelae include ectopic pregnancy, chronic pelvic pain, and infertility

[23]. Potential discrimination and rejection by family or community
members, psychosocial stress, forced marriage, and violence often impact
these young women [19].
2.2. HIV/AIDS and STIs
Young people are currently the group most severely impacted by
HIV/AIDS. In 2009, young people aged between 15 and 24 years
accounted for 41% of all new HIV infections among adults over the age
of 15 and it is estimated that worldwide there are ve million young
people (1525 years) living with HIV. Most of these young people live
in Sub-Saharan Africa, most are women, and most do not know their
status. Globally, young women make up more than 60% of all young
people living with HIV, and in Sub-Saharan Africa that rate jumps to
72% [24] with prevalence among teenage girls in some countries ve
times higher than among teenage boys [25]. Rates of STIs also show
the highest prevalence among 2024 year olds, followed by 1519
year olds, again often with adolescent girls bearing the higher burden
[26]. Biologically, the immature reproductive and immune systems of
adolescent girls translate to increased susceptibility to STIs and HIV
transmission [9,25]. In addition to biological vulnerability, cultural and
socioeconomic factorsparticularly social inequality and exclusion, as
well as having older partnersincrease their susceptibility.
Treating STIs is essential because they can facilitate the transmission of HIV
as well as causing lasting damage. Only a minority of adolescents have access
to any acceptable and affordable STI/HIV services. In most countries, comprehensive and accurate knowledge about HIV is low and HIV testing in this age
group is rare [27]. Outcomes for young people with HIV are poor; while a recent analysis estimated a 32% decrease in AIDS-related deaths among nonadolescents (aged 09 years and aged 20 and older) between 2005 and
2012, among adolescents (aged 1019 years) there was a 50% increase in
AIDS-related deaths, especially among boys [28].
3. Barriers and challenges
A series of multifaceted barriers currently prohibits good sexual and
reproductive health for adolescents. At the political level, ASRH is low
priority and there are often restrictive laws and policies in place. Various
societal, cultural, and religious factors create an inhibitive environment
for discussion of ASRH as many societies hold a deeply embedded sense
of disapproval of adolescent sexual activity; this is often demonstrated
through the stigmatization of sexual health concerns, in particular
STIs/HIV. Judgmental attitudes about sexual activity abound, especially
for those out of marriage and sexually active girls and women. In
some regions, accepted practices of early marriage and childbearing,
age differences between partners, and societal pressure prohibiting
use of contraceptive methods may also exist. Poor ASRH can be further
confounded by conict, migration, urbanization, and lack of schooling.
With regard to service-related barriers, poor health systems for sexual health, family planning, and maternal health are common, with unmarried adolescents ignored in some cases, married adolescents in
others, and an overall deciency of youth-friendly services. Lack of integration is seen where services that might address counselling and family planning fail to include HIV/STI care, etc. Services may also be
hampered by corruption and lack/erratic availability of supplies and
equipment. Economic and physical accessibility restrict adolescents access to services where they do exist. On a personal level, young peoples
care-seeking behavior may be restricted because of fear (of people nding out and other condentiality issues that may result in violence), embarrassment, lack of knowledge, misinformation and myths, stigma, and
shame [11]. A range of people have an inuence on adolescents access
to information and services, including peers, parents, family members,
teachers, and healthcare workers. Some argue that the single most important barrier to care is provider attitude [29]. Many healthcare
workers deter adolescents from using services because of their lack of
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J.L. Morris, H. Rushwan / International Journal of Gynecology and Obstetrics 131 (2015) S40S42
condentiality, judgmental attitudes, disrespect, or not taking their

patients' needs seriously.
is critical to the future of a countrys health and must be led by those at

the vanguardthe healthcare workers.
4. Opportunities and potential solutions
Conict of interest
Opportunities for improving ASRH come from myriad directions.

With regard to services, we must ensure access to quality youthfriendly, integrated services, provided by healthcare workers who
have been trained to work with adolescents. Sex education programs
should be scaled up and offer accurate, comprehensive information
while building skills for negotiating sexual behaviors [9]. Healthcare
workers should be equipped to provide accurate, balanced sex education, including information about contraception and condoms so that
young people have the means to protect themselves, provided within
a context of healthy sexuality, without stigma or judgment.
Healthcare workers are also well placed to inuence policy and ensure service provision for those who need it. For example, healthcare
workers can work to ensure young pregnant women receive early and
tailored prenatal services to address their high risk and specic problems
of anemia, malaria, HIV, and other STIs, as well as giving them special attention during obstetric care, given that they are most at risk of complications and death. Many improvements require political and legal
maneuvering and healthcare workers can be advocates for legal abortion, adequate postabortion care services for young people where abortion is restricted or adolescents have difculty in accessing legal
abortions, contraception provision for all who have unmet need, as
well as other ASRH initiatives that can have a direct and strong impact
on adolescent health.
5. What is FIGO doing?
To determine how best to lever its strengths to effectively contribute
to improving adolescent health, FIGO commissioned a review of its
ASRH activities and research including a literature review on adolescents
attitudes toward sexual and reproductive health and their perceptions of
health professionals, ASRH programs and their level of effectiveness, and
tools and guidelines available on ASRH. Utilizing its member associations,
FIGO conducted a KAP survey (knowledge, attitudes, and perceptions)
with obstetricians and gynecologists. The ndings highlighted the important role FIGO could play by engaging more deeply and strategically in
ASRH initiatives through strengthening the credible voice of obstetricians
and gynecologists in support of increasing young peoples access to highquality contraceptive and safe abortion services. To do this, FIGO has been
conducting regional workshops bringing together obstetricians and youth
in Africa, Asia, Latin America, and Europe. These workshops provide space
for obstetricians and gynecologists to meet with young people to discuss
important issues, generate practical and innovative strategies for improving ASRH, and strengthen the capacity of obstetricians and gynecologists
to advocate and provide better sexual and reproductive care for young
people. FIGO hopes to continue these activities as well as build on its
ASRH portfolio in the coming years.
6. Conclusion
Innumerable health and social challenges face young people in all
countries; it is time to improve our understanding of this age group
and to focus our energies on alleviating these problems. Political efforts
need to be directed to providing youth-appropriate services, and the
health establishment must follow a comprehensive, evidence-based approach that raises the capacity of health workers and implements bold
initiatives for, and with, adolescents. Importantly, obstetricians and
gynecologiststhrough their national associations and through FIGO
at the international levelhave an important role to play in the advancement of ASRH services so that healthcare workers move from
being part of the problem to part of the solution. FIGO is committed to
promoting ASRH. Addressing the global challenges of adolescent health
The authors have no conicts of interest to declare.

References
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REPRODUCTIVE HEALTH
Ending preventable newborn deaths in a generation

Nadia Akseer a, Joy E. Lawn b,j, William Keenan c,j, Andreas Konstantopoulos d,j, Peter Cooper e,j, Zulkii Ismail f,j,
Naveen Thacker g,j, Sergio Cabral h,j, Zulqar A. Bhutta a,i,j,
a
Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
Department of Pediatrics, St Louis University, St Louis, MO, USA
d
Department of Pediatrics, University of Athens, Athens, Greece
e
Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
f
School of Medicine, KPJ Healthcare University College, Kuala Lumpur, Malaysia
g
Deep Children Hospital and Research Centre, Gandhidham-Kutch, Gujarat, India
h
Estacio de Sa University, Rio de Janeiro, Brazil
i
Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
j
International Pediatric Association, Elk Grove Village, IL, USA
b
c
a r t i c l e
Keywords:
Newborn death
Stillbirth
MDGs
Mortality prevention
i n f o
a b s t r a c t
The end of the Millennium Development Goal (MDG) era was marked in 2015, and while maternal and child
mortality have been halved, MGD 4 and MDG 5 are off-track at the global level. Reductions in neonatal death
rates (age b1 month) lag behind those for post-neonates (age 159 months), and stillbirth rates (omitted
from the MDGs) have been virtually unchanged. Hence, almost half of under-ve deaths are newborns, yet
about 80% of these are preventable using cost-effective interventions. The Every Newborn Action Plan has
been endorsed by the World Health Assembly and ratied by many stakeholders and donors to reduce neonatal
deaths and stillbirths to 10 per 1000 births by 2035. The plan provides an evidence-based framework for scaling
up of essential interventions across the continuum of care with the potential to prevent the deaths of approximately three million newborns, mothers, and stillbirths every year. Two million stillbirths and newborns could
be saved by care at birth and care of small and sick newborns, giving a triple return on investment at this key
time. Commitment, investment, and intentional leadership from global and national stakeholders, including all
healthcare professionals, can make these ambitious goals attainable.
1. Introduction
As the Millennium Development Goal (MDG) era ends, the international community applauds the MDG 4 and MDG 5 achievements of reducing maternal and child mortality by 50% since 1990. However,
differentials in reduction rates demonstrate that declines in neonatal
mortality rates (b28 days) (NMR) have been lagging notably behind
those of post-neonates (159 months) (Figs. 1 and 2). The rate of
death among newborn infants has dropped only 40% from 1990 to
2013, compared with 56% for post-neonatal children (Fig. 2) and 45%
for mothers [1]. In the same period, the share of neonatal deaths
among under-ve deaths increased from 37% to 44%a trend that is
expected to continue as under-ve mortality rates (U5MR) continue
to decline. Today, approximately 2.8 million children die annually
Corresponding author at: Centre for Global Child Health, The Hospital for Sick
Children, SickKids Peter Gilgan Centre for Research and Learning, 686 Bay Street,
Toronto ON, M5G A04, Canada. Tel.: +1 416 813 7654x328915.
E-mail address: zulqar.bhutta@sickkids.ca (Z.A. Bhutta).
within the rst 28 days of life [2]. Of these, 36% die on rst day, 37%
within the next six days of life, and 28% between day 7 and day 27 [3].
Even more alarming is that another 2.6 million babies are stillborn
every year [4]a population that has been virtually invisible in the
MDG agenda. Stillborn deaths (dened as fetal death at greater than
or equal to1000 g or greater than or equal to 28 weeks of gestation)
may be due to similar causes as early neonatal deaths, and each year
over one million occur during labor [5]. Maternal and fetal deaths are intrinsically linked; the critical 48-hour window around labor and delivery is when almost half of all stillbirths, maternal, and neonatal deaths
occur [5,6], which emphasizes the need for lifesaving integrated
intrapartum care for both the mother and child.
The majority of neonatal deaths are from preventable causes such as
preterm birth complications (accounting for 36% of neonatal deaths),
complications during labor and delivery (23%), and infectious diseases
(15% sepsis, 5% pneumonia, 2% tetanus, 1% diarrhea)trends that are
consistent across MDG regions and countries (Fig. 3) [3,7]. Small size
at birthdue to preterm birth or small-for-gestational-age (SGA) or
bothis the biggest risk factor for more than 80% of neonatal deaths
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N. Akseer et al. / International Journal of Gynecology and Obstetrics 131 (2015) S43S48
60
51
50
46
40
36
31
30
33
30
26
28
27
26
30
25
20
22
22
21
15
14
14
20
13
9
10
World
Developing Regions
Developed Regions
Eastern Asia
Latin America and the Caribbean
Northern Africa
Western Asia
South-eastern Asia
Caucasus and Central Asia
Oceania
Southern Asia
Sub-Saharan Africa
3
0
Fig. 1. Neonatal mortality rate by Millennium Development Goal region, 1990 and 2013 (deaths per 1000 live births). Adapted from: United Nations Inter-agency Group for Child Mortality
Estimation [1].
and increases risk of post-neonatal mortality, growth failure, and adultonset noncommunicable diseases [3]. Additionally, an estimated four
million neonates annually have other life-threatening or disabling conditions including intrapartum-related brain injury, severe bacterial infections, or pathological jaundice [3].
Impressive global reductions in preventable mortality among
women and children mask wide variations between countries and regions. Sub-Saharan Africa and South Asia account for more than 75%
of the annual global newborn death burden, and countries in these regions also tend to have the most births and slowest progress in reducing
neonatal mortality (Fig. 2). Nine countries had an NMR greater than
90
2. An action plan for ending preventable newborn deaths

and stillbirths
In light of the reality of over 15 000 deaths each day, global partners
and governments have recently committed toward the unnished agenda of improving newborn survival, health, and preventing stillbirths. In
83
80
70
or equal to 40 per 1000 live births in 2013, eight of these were in

Sub-Saharan Africa [1]. At the current rate, it will be more than a century before babies born in Africa have the same chance of survival as those
born in high-resource nations [3].
69
73
58
60
76
69
67
66
57
56
50
50
47
42
62
55
55
42
40
56
40
32
56
40
33
30
19
20
10
World
Developing Regions
Developed Regions
Oceania
Sub-Saharan Africa
Southern Asia
Caucasus and Central Asia
South-eastern Asia
Western Asia
Northern Africa
Latin America and the Caribbean
Eastern Asia
Fig. 2. Decline in neonatal (age b1 month) and post-neonatal (age 159 months) mortality rates, by Millennium Development Goal region, 19902013 (percent). Adapted from: United
Nations Inter-agency Group for Child Mortality Estimation [1].
S45
World 5.0%
Oceania 5.1%
Sub-Saharan Africa
24.0%
35.0%
28.6%
29.9%
Southern Asia 4.0%
35.2%
Western Asia 3.9%
35.1%
21.2%
Northern Africa 3.4%
35.8%
20.7%
Latin America and the Caribbean 3.8%
35.1%
10.0%
11.4% 0.5%
30.0%
40.0%
10.1%
14.1%
6.9%
14.4%
11.2%
14.2%
4.1%
50.0%
60.0%
Preterm birth complications
Intrapartum related events
Congenital abnormalities
Diarrhoea
18.7%
16.6%
18.1%
0.1%
0.2%
0.3%
20.9%
0.2%
9.7%
20.5%
0.1%
24.3%
Other conditions
8.3% 0.8%
7.8%
70.0%
Pneumonia
7.1%0.7%
5.6%
8.1%
8.8%
14.2%
16.5%
24.4%
20.0%
6.5%
17.8%
20.0%
24.0%
6.4%
0.0%
18.1%
19.9%
22.0%
32.5%
South-eastern Asia 3.8%
Eastern Asia
10.0% 0.7%
20.4%
40.5%
Caucasus and Central Asia 3.6%
8.3%
29.8%
30.5%
6.4%
17.1%
80.0%
14.9%
1.9%
90.0%
100.0%
Sepsis/meningitis/tetanus
Fig. 3. Neonatal (027 days) cause of death by Millennium Development Goal region, 2013 (percent). Source: Liu et al. [7].
accordance with the UN Secretary-Generals Global Strategy for Women

Childrens Health [8], the accompanying Every Woman Every Child
Initiative, recommendations from the Commission on Information and
Accountability for Womens and Childrens Health [9] and the United
Nations Commission on Life-Saving Commodities for Women and Children [10], an accelerated newborn action plan was conceptualized that
would advance existing commitments such as A Promise Renewed
(the appeal to end all preventable child deaths) [11] and would work toward universal coverage of maternal, newborn, and child health interventions across the continuum of care.
Based on epidemiology and evidence of effective interventions, the
Every Newborn Action Plan (ENAP) was developed with direct inputs
from over 43 governments, 23 global organizations, and more than
2000 individuals, and set a framework to end newborn deaths and stillbirths by 2035 [12]. In May 2014, the World Health Assembly formally
endorsed ENAP at its 67th sessions in Geneva. The plan ambitiously envisions a world in which there are no preventable deaths of newborns
or stillbirths, where every pregnancy is wanted, every birth is celebrated, and women, babies and children survive, thrive and reach their full
potential [12]. The two main goals call upon all countries to reach an
NMR of 10 or less, and a stillbirth rate of 10 or less per 1000 total births,
by 2035, with interim goals for 2020, 2025, and 2030. The plan also proposes targets for coverage of essential reproductive, maternal, newborn,
and child health (RMNCH) interventions, and includes an impact framework, milestones, and indicators to measure progress. If the plan is effectively implemented and succeeds in scaling up health coverage during
the time of birth, it has the potential to prevent the deaths of approximately three million newborns, mothers, and stillbirths annually [12].
To achieve the overarching vison and goals, ENAP has proposed ve
strategic objectives:
(1) Strengthen and invest in care during labor, birth, and the rst
day and week of life
The critical window after 28 weeks of gestation to the rst month of
birth is particularly amenable to effective interventions that can not
only improve maternal and fetal survival, but can also promote early
childhood interaction and development, including newborn cognitive
and psychosocial skills. It is during this period that the largest proportion of stillbirths and maternal and newborn deaths occur [5,6], and
these along with complications can be avoided with ensuring highquality essential care to mother and baby.
(2) Improve the quality of maternal and newborn care
Evidence suggests that the quality of maternal and child care is suboptimal in many high-burden countries, even among those with access
to health facilities and trained health workers. Facilities are often poorly
equipped, and/or lack lifesaving commodities for women and newborns
(such as those identied by the United Nations lifesaving commodities [10]), comprehensive emergency obstetric care, and appropriate
referral services. The standard of education for physicians, nurses,
midwives, and other health workers is often low, and staff shortages
and low remuneration lead to poor morale and quality of care.
Safeguarding high-quality care and making accessible low-cost highimpact essential interventions and services is key to improvement and
reducing inequities.
(3) Reach every woman and newborn to reduce inequities
Inequalities in access to health services and skilled health workers
remain one of the tenacious factors behind high maternal and newborn
fatality rates in many countries. Fewer than one in six high burden
countries currently meet the minimum threshold of 23 doctors, midwives, and nurses per 10 000 population for healthcare provision [13].
Various factors contribute to the disparities including the high direct
and indirect costs incurred by patients and families in seeking care,
and poor working conditions/incentives for health workers in remote
areas. Reducing inequities necessitates investment in all aspects of the
health system including the workforce, infrastructure, commodities
and supplies, service delivery, health information systems, nancing
and importantly, good leadership and governance.
S46
(4) Harness the power of parents, families, and communities

Parents and families are at the forefront of providing care for the
newborn and child, and men (as decision-makers in maternal and newborn care-seeking behavior) can have a particularly important role in
improving maternal and child health. In low-income countries, nearly
50% of mothers have no access to skilled attendants at birth, and more
than 70% of deliveries that take place outside a health facility receive
no newborn or maternal postnatal care [14]. Families and communities
must be empowered to be aware of maternal and newborn health
issues, adopt a healthy lifestyle, and secure health services when
required. Essential actions for this objective include inuencing
attitudes and behavior using media, mass communication strategies,
education of communities regarding home healthcare provision,
capacity building of community and health centers to access marginalized areas, developing targeted strategies and plans based on systematic
analysis of barriers to maternal and newborn care, and ensuring sustainable demand for healthcare services.
(5) Count every newborn: Measurement, program tracking, and
accountability
The availability of vital statistics is essential to accountability,
planning and evaluation, and to the designing of effective policies
and strategies for women and newborns. However, such registries are
nonexistent in many countries and existing systems are seriously
decient in many high burden countries [15]. Often systems are only
partly active, and/or not all deaths are counted, or global recommendations on who to count are not adhered to. Of the 137 million births in
2012 globally, nearly all neonatal deaths and stillbirths went unregistered [3]. Some essential actions for scale-up include implementing
comprehensive birth and death registration systems, certication, appropriate recording of birth outcomes in vital registration databases,
monitoring neonatal morbidity outcomes to plan intensive care programs, mobilizing the government and community members to promote public participation in data collection, and collaborating with the
private sector to improve the quality of existing vital registration
systems.
The aspiring targets as set by the ENAP will necessitate countries to
accelerate progress to double or more of current trends, particularly
among the high burden nations. Those that have reached their targets
should continue to reduce death and disability and close subnational
equity gaps to ensure that no-one is left behind [12]. Through the lens
of effective country leadership, human rights, equity, integration,
accountability, and innovation, these ambitious targets and objectives
can be achieved with high-quality and seamless cover of essential interventions across the continuum of care.
3. Interventions that work
Averting preventable deaths entails a lifecycle approach to care,
which includes scale-up of interventions and spans the preconception,
prenatal, intrapartum, and immediate postnatal periods, and links to
child health care (Fig. 4). At the periphery of the continuum, the use
of preconception interventions such as delaying age at rst pregnancy,
meeting unmet need for family planning, birth spacing, and enhancement of prepregnancy nutrition status have all been related to improved maternal, fetal, and neonatal health outcomes [16]. Bhutta
et al. [17] systematically reviewed interventions across the continuum
of care and various delivery platforms, and then modelled the
effect and cost of scale-up in the 75 high-burden MDG Countdown
countries. It was estimated that use of family planning services could reduce child deaths by 47% and stillbirths by 64%. Routine prenatal and
postnatal care for women and their newborns including home visits
and support for breastfeeding is also important for longer term health
and nutrition.
Interventions around the time of birth can prevent more than

1.5 million maternal and newborn deaths and stillbirths by 2025. The
most important interventions include skilled care and emergency obstetric care (including the specics for stillbirths and neonatal mortality
reduction such as management of preterm labor care, including prenatal corticosteroids, intrapartum fetal monitoring, etc), immediate care
for every newborn including cord care (delayed cord clamping, hygienic
care), breastfeeding support, thermal protection for every newborn, and
newborn resuscitation if required [17].
Focusing on small or sick newborns could achieve the next highest impact; interventions that reduce infection risk, thermal stress, and delayed/
poor nutrition have the potential to prevent almost 600 000 newborn
deaths by 2025. Much of this impact is possible in facilities without intensive care, with the most important being care of preterm neonates including Kangaroo mother care as an entry point and adjunct to more
comprehensive neonatal care, such as respiratory support, prevention/
management of neonatal sepsis, and prevention/management of
neonatal jaundice and of neonatal encephalopathy after intrapartum
hypoxia [17].
While facility-based care has the highest impact, achieving high and
equitable coverage and healthy home behaviors requires community
approaches such as womens groups and home visits. In hard to reach
contexts, specic curative care such as neonatal sepsis case management remains an important option [17].
4. How many lives can be saved and at what cost?
Meeting Every Newborn targets will necessitate accelerated scaleup of the most effective care targeting major causes of newborn deaths.
Closure of the quality gap through the provision of effective care for all
women and newborn babies that are already being delivered in facilities
could prevent an estimated 113 000 maternal deaths, 531 000 stillbirths, and 1.3 million neonatal deaths annually by 2020 at an estimated
running cost of US $4.5 billion per year (US $0.9 per person) [17].
Increased coverage of preconception, prenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths
(1.9 million [range 1.62.1 million]), 33% of stillbirths (0.82 million
[0.600.93 million]), and 51% of maternal deaths (0.16 million
[0.140.17 million]) per year (Fig. 5). These reductions can be achieved
at an annual incremental running cost of US $5.65 billion (US $1.15 per
person), which amounts to US $1928 for each life saved, when combining stillbirths, neonatal, and maternal deaths. This analysis underlines
the importance of counting newborn deaths and stillbirths rather than
maternal deaths alone, making the investment in care at birth highly
cost-effective. Most (82%) of this effect is attributable to facility-based
care which, although more expensive than community-based strategies, improves the likelihood of survival. The analysis also indicates
that available interventions can reduce the three most common causes
of neonatal mortalitypreterm, intrapartum, and infection-related
deathsby 58%, 79%, and 84%, respectively.
The time around labor and birth, plus the rst week, is the most critical for maternal and newborn death and stillbirths, and for child disability. Intervening at this time is not only crucial for reducing deaths
but also for decreasing the risk of life-long morbidities. Investments to
scale-up coverage of care would have a triple return on investment as
three million additional lives would be saved each year at an additional
nominal cost of US $1.15 per person [17].
5. The way forward and what healthcare professionals can
do together
The ENAP provides an evidence-based roadmap toward care for
every woman, and a healthy start for every newborn baby, with a
right to be counted, survive, and thrive to their fullest potential. Its implementation will need concerted effort and support by pediatricians
S47
N.Akseer et al. / International Journal of Gynecology and Obstetrics 131 (2015) S43S48
Fig. 4. Intervention packages by level of care. Adapted with permission from Bhutta et al. [17].
worldwide, for which the International Pediatric Association will provide full support.
The implementation of the ENAP will require several important
paradigm shifts: (1) intensication of political attention and
leadership; (2) promotion of parent voice, supporting women, families,

and communities to speak up for their newborn babies and to challenge
social norms that accept these deaths as inevitable; (3) investment for
an effect on mortality outcome as well as harmonization of funding;
Overall
Count
% reduction
1 900000
(1 5583002103000) 71%
(56%76%)
NEONATAL DEATHS
AVERTED
820000
(601100932400)
33%
(23%38%)
STILLBIRTHS AVERTED
160000
(143900168100)
51%
(44%53%)
MATERNAL DEATHS
AVERTED
90%
80%
70%
60%
50%
Neonatal
Deaths
40%
Stillbirths
30%
Maternal
Deaths
20%
10%
0%
OVERALL
NMR 5 to <15 NMR 15 to <30
NMR >=30
Fig. 5. Effect of scale-up of interventions on averting stillbirths and neonatal and maternal deaths by the year 2025 from base year 2012. Adapted with permission from Bhutta et al. [17].
S48
(4) implementation at scale, with particular attention to increasing

health worker numbers and skills with attention to high-quality childbirth care for newborn babies as well as mothers and children; and
(5) evaluation, tracking coverage of priority interventions and packages
of care with clear accountability to accelerate progress and reach the
poorest groups [18,19]. In addition, there is a clear need to improve
the quality of care for mothers and newborns in health systems
everywhere.
All of these actions need multiple partners. We the leaders of the
International Pediatric Association, representing 139 countries and
over 100 000 pediatricians worldwide, feel truly invigorated by the
opportunity to contribute to this process. At the closing of the MDG
period, we believe that newborn survival and health are critical to
achieving the aspirations of sustainable development in the post-2015
era. We have a special opportunity of joining hands with our partners,
members of the obstetric community represented by FIGO, as well as
midwives and nurses represented by the International Confederation
of Midwives and the Council of International Neonatal Nurses,
respectively. The task will not be easy and we will face constraints,
both in terms of human capacity and material resources. However,
together with healthcare workers in every country, we have the opportunity to complete the unnished agenda of the MDGs and give every
newborn a healthy start.
Acknowledgments
We would like to acknowledge the Every Newborn Lancet series
executive summary authors from which this review has been
largely adapted.
Conict of interest
The authors conrm that they have no conicts of interest.
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45567.

REPRODUCTIVE HEALTH
The global epidemic of abuse and disrespect during childbirth: History,

evidence, interventions, and FIGOs motherbaby friendly birthing
facilities initiative
Suellen Miller a,, Andre Lalonde b,c
a
b
c
Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, University of California, San Francisco, CA, USA
University of Ottawa, Ottawa, Ontario, Canada
McGill University, Montreal, Quebec, Canada
a r t i c l e
Keywords:
Abuse
Accountability
Baby friendly
Birthing facilities
Disrespect
Mother friendly
Quality of care
Rights
i n f o
a b s t r a c t
Recent evidence indicates that disrespectful/abusive/coercive service delivery by skilled providers in facilities,
which results in actual or perceived poor quality of care, is directly and indirectly associated with adverse maternal and newborn outcomes. The present article reviews the evidence for disrespectful/abusive care during childbirth in facilities (DACF), describes examples of DACF, discusses organizations active in a rights-based respectful
maternity care movement, and enumerates some strategies and interventions that have been identied to decrease DACF. It concludes with a discussion of one strategy, which has been recently implemented by FIGO
with global partnersthe International Pediatrics Association, International Confederation of Midwives, the
White Ribbon Alliance, and WHO. This strategy, the Mother and Baby Friendly Birth Facility (MBFBF) Initiative,
is a criterion-based audit process based on human rights doctrines, and modeled on WHO/UNICEFs Baby
Friendly Facility Initiative.
1. Introduction
2. Background
In the past few years the relationship between lack of quality of care
and adverse maternal outcomes is being highlighted globally. The WHO
recently issued a statement for the prevention and elimination of disrespect and abuse during facility-based childbirth [1]. The United Nations
issued a resolution on preventable maternal mortality as a human rights
violation, and issued a technical guidance on the application of a human
rights-based approach to reduce maternal deaths in 2012 [2,3].
The present article documents examples of disrespect and abuse and
the lack of quality care in maternity facilities, and demonstrates connections
between these and continuing high maternal mortality, despite increasing
facility-based deliveries with skilled attendants [4,5]. The global efforts to
reduce disrespect and abuse in facilities are described and we discuss
FIGOs Mother and Baby Friendly Birth Facility (MBFBF) Initiativea
human-rights and criterion-based audit process, which FIGOs Safe Motherhood and Newborn Health Committee developed in collaboration with the
International Pediatrics Association (IPA), International Confederation of
Midwives (ICM), the White Ribbon Alliance (WRA), and WHO [6].
Despite an emphasis on facility-based birth with skilled providers,

many women still choose to deliver at home, due in part to poor conditions in facilities or because of perceived or veried abuse/coercion/
neglect at facilities [1,7]. International and national organizations have
documented the lack of quality care and professional accountability at
birthing facilities [4,7,8] and various types of abuse, such as physical
abuse, non-consented care, and discriminatory care [9], which have
been termed disrespectful/abusive care during childbirth in facilities
(DACF). Evidence collected in diverse settings documents associations between poor quality care and negative maternal and newborn health outcomes [1014]. A 2014 review of maternal and newborn quality of care
found that improving access to facilities did not guarantee improved maternal outcomes [5]. In the same year, WHO published their statement on
disrespect and abuse in facilities and called for greater action, dialogue, research, and advocacy on disrespectful and abusive treatment [1].
Corresponding author at: Department of Obstetrics, Gynecology and Reproductive

Sciences, Bixby Center for Global Reproductive Health and Policy, University of
California, San Francisco (UCSF), 550 16th Street, 3rd oor, San Francisco, CA 94158,
USA. Tel.: +1 415 476 5916.
E-mail address: suellenmiller@gmail.com (S. Miller).
3. History of quality of care, patientprovider interaction,

patient-centered care
As early as the 1970s, midwives, nurses, and doctors in low-resource
countries began relating improved outcomes, including fewer cesareans,
enhanced bonding, improved breastfeeding, decreased reports of
S50
S. Miller, A. Lalonde / International Journal of Gynecology and Obstetrics 131 (2015) S49S52
stress after birth, and reduced need for operative deliveries, when
women had companions during labor and birth, were treated as
equals in the birth process, and were allowed to hold and breastfeed
their babies immediately after birth. Midwifery education and practice emphasized the concept of respect and compassionate care in
childbirth [15]. Even emergency procedures, such as those described
in the American College of Nurse-Midwives Life Saving Skills
Manual for Midwives [16] included not only the steps to performing
lifesaving functions, but caveats about the importance of gentleness
and always explaining procedures and rationales for procedures to
the woman and her family.
In the context of woman-centered reproductive health, quality of
care, became shorthand for not only improving physical standards of
care and skills, but also of interpersonal relationships between
healthcare workers and women with reproductive health needs. Quality
of care was sometimes framed in a human rights perspective,
particularly after the 1994 International Conference on Population and
Development in Cairo, Egypt [17], where the human rights of girls and
women, and the concepts of rights and dignity were strengthened in
the context of reproductive health and health care [18,19].
4. Human rights and maternity care
This human rights lens failed to focus as rapidly on abuses during
childbirth or links between adverse maternal outcomes and abusive
practices and lack of quality of care. In 2000, womens rights to dignity
and respect in childbirth became acknowledged in Latin America
where, following a Birth Humanization Conference in Brazil, the Latin
American and Caribbean Network for the Humanization of Child Birth
(RELACAHUPAN) was founded [20].
In 2003, Miller et al. [21] noted paradoxically high rates of maternal
mortality in the Dominican Republic, despite 98% facility delivery by
skilled attendants, high literacy rates, and well-developed transport
systems. In this multidisciplinary, multisite qualitative assessment,
observers found these conditions in the labor ward of the largest referral
hospital: Women were not informed of the results of their examinations. Women with complications labored together with those labeled
normal in the one large, brightly lit and noisy ward. Some women
were naked, most were lying on bare plastic mattresses, the one sheet
having been soiled with urine, feces, or drenched in amniotic uid.
There was no privacy, no dignity, and no attempt to honor the human
and reproductive rights of the laboring women [21].
Study results demonstrated that DACF, poor quality of care, and lack
of accountability were contributors to preventable maternal mortality.
5. Categories of DACF
Since that time, much has been done to document DACF, leading to a
categorization of the types of DACF conceptualized by Bowser and Hill
[9] in their USAID Translating Research into Action Project (TRAction)
Report. The seven categories formulated are shown in Table 1, along
with DACF examples. Categories of abuse may overlap; for example,
the provider electing to perform an unnecessary episiotomy and not
asking for the womans consent would be considered non-consented
care and physical abuse. If this is performed in an open delivery ward
without privacy curtains, than it is also non-condential care. The
White Ribbon Alliance has noted that the categories of abuse occur
along a continuum from subtle discrimination to overt violence [22].
Table 1
Seven categories of disrespect and abuse.a
Abuse category
Example
Physical abuse
Hitting, roughly forcing legs apart, fundal pressure

for normal delivery
No informed consent for procedures, such as when
provider elects to perform unnecessary episiotomy
No privacy (spatial, visual, or auditory)
Humiliation by shouting, blaming, or degrading
HIV status, ethnicity, age, marital status, language,
economic status, educational level, etc.
Facility closed despite being 24/7, or if open, no
staff can or do attend delivery
Not releasing mother until bill is paid
Non-consented care
Non-condential care
Non-dignied care
Discrimination based on
specic patient attributes
Abandonment of care
Detention in facilities
a
Adapted from Bowser and Hill [9].
Alliance, Columbia Universitys Averting Maternal Death and Disabilitys

and Ifakara Health Institutes STAHA Project, Harvards Hansen Project,
USAID/Jhpiegos Maternal and Child Health Integrated Program
(MCHIP), Respectful Maternity Care (RMC), and others working across
many countries.
Most of these groups have statements rooted in human rights doctrines; including the White Ribbon Alliance [22] and the International
MotherBaby Childbirth Initiative (IMBCI) [25], which each have
human rights-based guidelines and steps for providing humane practices promoting optimal birth. The IMBCI has rights-based demonstration projects in Quebec, Canada and Uruguay.
Further, these groups recognize that underlying etiologies of DACF
can lie in abuse of healthcare providers in facilities. Provider demoralization related to weak health systems and shortage of human resources
and professional development opportunities led Kenyan midwives to
observe that many nurses and midwives had difcult personal situations, they were underpaid, had to commute long distances to work,
and often received no breaks during their work [9].
DACF studies are summarized in the evidence synthesis of Bohren
et al. [4], which served as a basis for the WHO 2014 DACF statement
[1]. A series of papers was published in 2014 in BMCs Reproductive
Health Series, summarizing the evidence for lack of quality of care in
maternal and newborn health [12], including a review of facility-level
inputs for improvement [26].
The work on DACF is continuing to grow. In 2014, Freedman and
Kruck [27] contextualized the global denition of disrespectful care to
include care that local consensus nds undignied or humiliating. Furthermore, in 2015, Bohren et al. [28] used a mixed-methods systematic
review of evidence on DACF and expanded Browser and Hills typology
[9] to include not only interpersonal interactions, but systemic failures
at health systems and health facility levels.
7. Links between DACF, low quality of care, and negative maternal
and newborn outcomes
The links between negative maternal and newborn outcomes and
DACF are both direct and indirect. DACF indirectly affects outcomes because women who have previously experienced DACF or who have
heard of others who have may avoid delivering in facilities, even
if they have complications. DACF directly affects outcomes when
women are ignored or abandoned during labor or birth and deliver unattended. One case from the Dominican Republic noted a woman in a facility for over 24 hours, but no-one noted that fetal heartbeats were
absent or that she had a ruptured uterus [21].
6. Groups and agencies working in DACF and recent publications

8. Strategies for eliminating DACF
The concept of DACF is so recent, that denitions of disrespect/abuse
and even quality of care are still being formulated [23,24]. Work is underway to create denitions of DACF by varied organizations, which
are also working toward consensus on evidence-based interventions
to decrease DACF. Some of these agencies include the White Ribbon
Numerous attempts are currently underway at a number of levels:

community, civil society, individual providers, professional associations,
district level facilities, and at highest levels of national, regional, and international policy making. Many of the interventions are multifactorial
and reach across stakeholder groups; others aim at single groups or certain aspects of the continuum of DACF. Jhpiegos RMC country experiences categorize these strategies and interventions into various
approaches and/or health system levels: advocacy, legal approaches,
health facility, educational and training programs, community, research,
monitoring, and evaluation [20].
9. Strategies for professional associations to effect facility-level
changes to eliminate DACF
A thorough review of these strategies is beyond the scope of this
paper; we focus on strategies for professional associations at the facility
level. Such strategies include training, awareness raising, values clarication, supportive supervision, and criterion-based audits, which are
objective, systematic analyses of the quality of care measured against
a set of criteria of best practice [23].
9.1. Rights-based, criterion-based audits
Table 2
Summary of criteria and indicators for qualifying a facility as mother and newborn
friendly.a
Criteria
Indicators
Adopt preferred positions in labor for

women and provide food and
beverages
Non-discriminatory policy for
HIV-positive women, family
planning, and youth services
Privacy in labor/delivery
Choice of birthing partner
Culturally competent care
No physical, verbal, emotional, or
nancial abuse
Affordable cost, free maternity care
No routine practice
Nonpharmacological and
pharmacological pain relief
Skin-to-skin mother baby care,
breastfeeding
Written policy and implementation
The certication process of the MBFBF includes criterion-based

checklists and, even more importantly, observations of care delivery.
Thus, the MBFBF process can serve as both a tool for certication as
well as an approach for quality improvement. The criteria used for certication as an MBFBF are rights-based. FIGO, ICM, WRA, IPA, and WHO
developed the MBFBF initiative in response to ndings that low quality
of care and DACF are violations of womens human rights and are intrinsically linked to poor maternal and neonatal outcomes [6]. One of the
major human rights documents that supports the MBFBF initiative is
the WRAs Charter on the Universal Rights of Childbearing Women
[22], which raises awareness of childbearing womens rights and claries links between human rights and quality of care.
10. FIGO, ICM, WRA, IPA, and WHO MBFBF initiative
FIGO believes that every woman has the right to a positive birth
experience and to compassionate care from knowledgeable, skilled
providers. Professional associations and facilities should provide
the best evidence-based quality of care, and provide women with
dignity, privacy, information, supportive care, pharmacological or
nonpharmacological pain relief, and choice of birthing companion(s),
without abuse, nancial extortion, or differential care based on age, ethnicity, or marital, HIV, nancial status, etc.
The FIGO, ICM, WRA, IPA, WHO Mother and Baby Friendly Birthing
Facilities Initiative states, whereas:
Every woman has the right to be treated with dignity and respect by
facility staff regardless of background, health, or social status, this includes, but is not limited to, women who are young, older, single,
poor, uneducated, HIV positive, or a minority in her community.
The gap between rates of maternal and newborn mortality of women
with access to quality care and those without access to quality care
is unacceptable.
Every woman has the right to a positive birth experience and to
dignied, compassionate care during childbirth, even in the event
of complications.
Every woman and every newly born baby should be protected from
unnecessary interventions, practices, and procedures that are not
evidence-based, and any practices that are not respectful of their
culture, bodily integrity, and dignity.
A womans ability to have a health delivery outcome and to
care for her newborn is signicantly inuenced by a positive
birthing environment.
Table 2 summarizes the criteria and indicators for qualifying a
facility as mother and newborn friendly.
S51
Implementation of guidelines for

HIV-positive women, family planning,
and youth services
Curtains, walls, etc.
Accommodation of partners
Training, posters, policies
Written policy, display Chart of Human
Rights
Costs in line with national guidelines
Evidence-based interventions
Training on pain relief
Provide combined care for mother/baby,
breastfeeding
Reproduced with permission from FIGO et al. [6].
10.1. Criteria
A FIGO, ICM, WRA, IPA, WHO motherbaby friendly birthing facility:
1. Offers all birthing women the opportunity to eat, drink, walk, stand,
and move about during the rst stage of labor and to assume the position of her choice/comfort during the second and third stages,
unless medically contraindicated.
2. Has clear, nondiscriminatory policies and guidelines for the treatment and care of HIV-positive mothers and their newborns, as
well as policies for counseling and provision of postpartum family
planning, and youth-friendly services.
3. Provides all mothers with privacy during labor and birth.
4. Allows all birthing women the comfort of at least one person of her
choice (e.g. father, partner, family member, friend, and traditional
birth attendant as culturally appropriate) to be with her throughout
labor and birth.
5. Provides culturally competent care that respects the individuals
customs, nonharmful practices, and values around birth, including
those women who experience perinatal loss.
6. Does not allow physical, verbal, emotional, or nancial abuse of
laboring, birthing, and postpartum women and their families.
7. Provides care at affordable costs in line with national guidelines
and assures nancial accountability and transparency. Families
will be informed about what charges can be anticipated and
how they might plan to pay for services. Families must be
informed if any additional charges apply for complications.
Health facilities should have a process for payment that does
not include detention of the woman or baby. Refusal of care for
the mother or the baby because of inability to pay should not
be permitted.
8. Does not routinely employ practices or procedures that are not
evidence-based, such as routine episiotomy, induction of labor,
or separating mother and baby care etc., consistent with international guidelines and action plans. Each birthing facility should
have the capacity, staff, policy, and equipment to provide neonatal and maternal resuscitation, minimize the risk of infection,
provide prompt recognition and prevention/treatment of emergent maternal and neonatal needs, have established links for
consultation and prospectively planned arrangements for stabilization and/or transport sick mothers or sick/premature infants.
9. Educates, counsels, and encourages staff to provide both nonpharmacological and pharmacological pain relief as necessary.
10. Promotes immediate skin-to-skin mother/baby contact and actively support all mothers to hold and exclusively breastfeed
S52
their babies as often as possible and provides combined care for

mother and baby as appropriate.
Facilities that adhere to these criteria will be awarded a FIGO, ICM,
WRA, IPA, WHO Mother and Newborn Friendly Birthing Facility certicate. The certicate will be posted on the organizations web sites and
the web sites of other organizations that support this project.
10.2. Process
International and national agencies will develop cadres of assessors
to conduct site visits to certify and monitor this process. Assessors will
be equipped with checklists to observe policies, informational posters
and, most importantly, direct observation of providerpatient interactions. Facilities will be held to these criterion-based audits during the
certication process, and instructed on how to improve through constructive critique and two-way feedback. FIGO, WHO, and ICM will
work with national governments to start this process. Annual certication could be considered if the hospital adheres to the criteria.
Certicates could be prominently posted for inclusive viewing.
11. Conclusion
Improving attitudes and behaviors of facility-based providers alone
will not be adequate to improve facility-based quality of care and eliminate DACF. The problem of DACF is multifactorial; therefore, the response to DACF must be between, among, and across all stakeholder
groups involved in maternity health and between, among, and across
ministries of health, education, nance, and gender. It is likewise imperative that all professional associations, governmental, nongovernmental, and grassroots organizations, as well as community and family
members, work together to provide for and demand that MBFBFs provide high quality, evidence-based care. FIGO joins with IPA, WRA, ICM,
and WHO to utilize a criterion-based audit approach to certifying facilities as motherbaby friendly to improve maternal and newborn health
directly through improved care and a rights-based approach, and
indirectly, by overcoming barriers to womens acceptance of facilitybased, skilled providers.
Acknowledgments
The authors wish to thank the many collaborators on the MBFBF
Initiative: M. Limbu, White Ribbon Alliance; F. McConville, WHO;
M. Mathai, WHO; J. Brown, International Confederation of Midwives;
Z. Bhutta, W. Keenan, P. Cooper International Pediatrics Association;
and the members of the FIGO SMNH Committee: W. Stones
Chair, Malawi; C. Hanson, Sweden; P. Shah, India; M. Vidarte,
Colombia; and O. Ladipo, Nigeria. Thanks also to Ms Emma Rouda for
manuscript preparation.
Conict of interest
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REPRODUCTIVE HEALTH
What can obstetrician/gynecologists do to support abortion access?

Alice G. Mark a,, Merrill Wolf a, Alison Edelman a,b, Laura Castleman a
a
b
Ipas, Chapel Hill, NC, USA

Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
a r t i c l e
Keywords:
Abortion
Maternal mortality
Mifepristone
Misoprostol
i n f o
a b s t r a c t
Unsafe abortion causes approximately13% of all maternal deaths worldwide, with higher rates in areas where
abortion access is restricted. Because safe abortion is so low risk, if all women who needed an abortion could
access safe care, this rate would drop dramatically. As womens health providers and advocates, obstetrician/
gynecologists can support abortion access. By delivering high-quality, evidence-based care ourselves, supporting
other providers who perform abortion, helping women who access abortion in the community, providing
second-trimester care, and improving contraceptive uptake, we can decrease morbidity and mortality from
unsafe abortion.
1. Introduction
We are making progress in the global ght against maternal death. Recent estimates from WHO document a 45% decline in maternal deaths
worldwide in the last two decades, from about 523 000 in 1990 to
289 000 in 2013 [1]. This trend reects concerted attention by the international health community to achieve the Millennium Development Goals.
Successful efforts have increased skilled birth attendance; improved prenatal, delivery, and postpartum care; increased contraceptive prevalence;
and improved sexual and reproductive health services.
Unsafe abortion causes approximately13% of all maternal deaths
worldwide, with higher rates in areas where abortion access is restricted
[2]. Because safe abortion is so low risk, if all women who needed an abortion could access safe care, this rate would drop dramatically [2]. In highresource regions, the death rate from safe, legal abortion is 0.7 per 100 000
cases. In contrast, the unsafe abortion death rate was estimated to be 520
per 100 000 procedures in Sub-Saharan Africa, 200 per 100 000 in southcentral Asia, and 30 per 100 000 in Latin America as recently as 2008 [2].
In low-resource regions, 41% of unsafe abortions (nearly 9 million
procedures) are among young women aged 1524 years [3]. Young
women are particularly likely to experience unwanted pregnancy and
to seek abortion from unskilled providers. They are also more likely to
delay seeking both abortion and treatment for resulting complications,
signicantly increasing their clinical risks [4].
As both healthcare providers and advocates for women, obstetrician/gynecologists have an important role in ensuring that all women
and girls have access to comprehensive reproductive health care,
Corresponding author at: PO Box 9990, Chapel Hill, NC, 27515, USA. Tel.: +1 919 960
5581; fax: +1 919 929 0258.
E-mail address: marka@ipas.org (A.G. Mark).
including safe abortion. Effective strategies to increase access to safe

abortion are available, affordable, and well known, but too few stakeholders prioritizeor even addressthis critical issue. By supporting
safe abortion in our clinical practice and beyond, we can signicantly
reduce a preventable cause of maternal mortality.
2. What can obstetrician/gynecologists do?
Obstetrician/gynecologists care for women throughout their life
cycle, from adolescence through pregnancy and childbirth, to menopause. Unplanned pregnancy is common during the reproductive
years; worldwide, an estimated 40% of all pregnancies are unintended
[5]. Offering a full range of contraceptive options is part of our work
and is as lifesaving a technology for obstetrician/gynecologists as cancer
care or emergency obstetrics. Providing women with a method as soon
as they request it, without unnecessary testing or requirements, can
reduce the risk of unplanned pregnancy.
When a woman ends a pregnancy, obstetrician/gynecologists have a
professional and moral obligation to assist in her care. FIGOs Resolution
on Conscientious Objection [6] afrms our obligation to women who
need abortion care. Even doctors who may have a personal objection
to abortion must refer patients for services, provide timely care when
referral is not possible and, in emergency situations, treat women
regardless of their personal beliefs.
Beyond basic care, obstetrician/gynecologists may take a number of
steps to improve abortion access and quality. Most simply, we can incorporate evidence-based abortion care into ofce practice and offer
women a full range of contraceptive options as part of the abortion service. In addition, we can support nurses, midwives, and other health
professionals to perform abortions, ensure that women who obtain
medical abortion outside the health system can do so more safely, and
S54
A.G. Mark et al. / International Journal of Gynecology and Obstetrics 131 (2015) S53S55
expand our clinical practice to include second-trimester abortion care.

Finally, obstetrician/gynecologists can bear witness to the impact of
unsafe abortion and advocate for womens rights to safe care.
2.1. Offer women evidence-based, quality abortion care
Medical abortion (Box 1) and manual vacuum aspiration can be
done safely, easily, inexpensively, and comfortably in the outpatient
setting. Both WHO and FIGO recommend using medical abortion
and vacuum aspiration rather than sharp curettage, which requires
anesthesia, operating room time and resources, and carries increased
risks to women [7,8].
When incorporating abortion into clinical practice, protocols need to
remain updated. This is especially pertinent with medical abortion.
Resources for updated clinical information include WHOs Reproductive
Health Library (http://apps.who.int/rhl/en) and Ipass Clinical Updates
in Reproductive Health (www.ipas.org/clinicalupdates).
Staying current with protocols and regimens can be challenging, especially for practitioners working in low-resource or rural settings with
limited internet access. Reaching remote providers is a priority for organizations concerned with maternal health outcomes. New avenues for
disseminating evidence, including peer-to-peer support, clinical mentorship, and mobile networks need to be explored. For example, Ipas
Nigeria piloted a text messaging service for trained uterine evacuation
providers to keep them updated on current evidence and give them remote support. Over the course of a year, Ipas sent 50 to 77 text messages
with clinical updates, support, and announcements to 163 providers.
The messages were well received, with 90% of providers reporting that
the messages inuenced their patient care and 99% reporting that they
wanted to continue receiving the messages.
Creating a safety culture in health care promotes teamwork, communication, evaluation, and learning from error. When a safety culture
is in place, error reporting improves, adverse events are reduced, burnout decreases, and patients have better outcomes [10]. Quality improvement processes promote data tracking and use of quality indicators to
improve patient safety and experience. While much work has occurred
to dene quality in other areas of health care, the denition of quality in
abortion is still evolving. Abortion quality may include technical skills
(for example, whether vacuum aspiration or medical abortions are
used instead of sharp curettage) along with patient experience (for
example, waiting times at the health center) [11]. Dening quality in
abortion and then putting the processes in place to monitor and
improve it can engage staff, increase safety, and improve womens
satisfaction with care.
Box 1
Medical abortion in the first trimester (up to 12 weeks).
Mifepristone and misoprostol
Up to 9 weeks:
Mifepristone 200 mg orally followed in 24 48 hours by misoprostol 800 g buccally, vaginally, or sublingually. Buccal misoprostol can be used from 9 to 10 weeks.
9 to 12 weeks:
Mifepristone 200 mg orally followed 36 to 48 hours later by misoprostol 800 g vaginally then 400 g vaginally or sublingually up
to four further doses until expulsion of the products of conception.
Misoprostol only (when mifepristone is not available)
Up to 12 weeks:
Misoprostol 800 g vaginally or sublingually every three but no
more than 12 hours for up to three doses.
Source: WHO [7] and Winikoff et al. [9].
2.2. Support other abortion providers

Task-sharing, where mid-level clinicians deliver reproductive health
interventions, improves womens access to care. WHO recommends
that nurses, midwives, associate clinicians, and nonspecialist doctors
give all types of reversible contraception, including intrauterine devices
and implants [12]. In addition, rst-trimester medical abortion and
manual vacuum aspiration are provided as safely and effectively by
nurses, nurse practitioners, midwives, and other health professionals
as by doctors [13]. Expanding the provider pool gives women increased
access and choice about whom they see when they need abortion.
When other health professionals perform abortion, obstetrician/
gynecologists can be a supportive referral partner for complex cases
and women who present at more advanced gestations.
2.3. Support women who access abortion outside the health system
Women have long known about misoprostols abortifacient effect
and used it on their own to end unwanted pregnancies, especially in
Latin America, where it has been linked to a decline in abortionrelated morbidity and mortality from more harmful methods [14].
Pharmacists [15], womens groups, clinicians who deliver information in a harm-reduction model [16], and telemedicine or internet providers [17] assist women in accessing misoprostol outside the health
system. More comprehensive research needs to be done to explore
where women obtain drugs, how they determine eligibility and gestational age, what regimens and medications they use, and the success
and complication rates of medical abortion outside the health system.
Supporting women who obtain medical abortion outside the health
system is important for clinicians who work in areas where this practice
is prevalent. Partnerships between clinicians and community providers
can ease referrals to the health system for women who are not good
candidates for community-based care or for women who experience
complications.
Women who present to the health system with bleeding or incomplete abortion after self-induced or community-based abortion need
safe, respectful, quality services. Treating women for complications of
abortion or incomplete abortion, often known as postabortion care, is
always permissible even if induced abortion is restricted [7].
Finally, understanding why at times women prefer communitybased abortion even when legal services are available can help the
health system improve to meet womens needs. Women may evaluate
safety differently than obstetrician/gynecologists, preferring services
where they are able to maintain privacy, avoid time off work or away
from family, and prevent legal involvement in their decision to end a
pregnancy even if the clinical risks of community-based treatment are
unknown. Women may not know that they have a legal right to abortion. When clinics and hospitals create barriers for women through
cost, abusive or judgmental handling, unnecessary or expensive testing,
reporting, lack of condentiality, or inconvenience, women will seek
care elsewhere [18,19].
2.4. Provide second-trimester abortion
Abortions performed at over 12 weeks of gestation make up a relatively small proportion of cases in areas where safe abortion is easily accessible. However, where abortion is restricted, women have a higher
likelihood of presenting in the second trimester, with presentation
rates as high as 17% in Cambodia [20], 35% in Malawi [21], and 41% in
Kenya [22]. Risk factors for second-trimester abortion include young
age, nancial hardship, domestic violence, and late recognition of
pregnancy. Adolescents in particular are likely to present for care later
in pregnancy [23,24]. Unsafe abortion in the second trimester disproportionately contributes to maternal morbidity and mortality from
abortion, as these women are more likely to suffer severe complications
and death [25].
A.G. Mark et al. / International Journal of Gynecology and Obstetrics 131 (2015) S53S55
Box 2
Medical abortion in the second trimester (12 to 24 weeks).
S55
Conict of interest
The authors have no conicts of interest to declare.
Mifepristone and misoprostol

Mifepristone 200 mg orally followed 36 48 hours later by misoprostol 800 g vaginally then 400 g vaginally or sublingually
every three hours for up to four further doses.
Misoprostol only (when mifepristone is not available)
Misoprostol 400 g vaginally or sublingually every three hours for
up to five doses.
Source: WHO [7].
WHO recommends both dilation and evacuation and medical

methods for second-trimester abortion. Dilation and evacuation requires specic training, specialized instruments, and an ongoing case
volume to maintain skills. Alternatively, medical abortion using the
WHO-recommended dose of mifepristone and misoprostol in the second trimester is highly effective, with complete expulsion rates of
over 98% at 24 hours and 99% at 36 hours, and a median time to fetal expulsion of 6.25 hours [26]. Misoprostol alone is recommended when mifepristone is not available (Box 2).
Rarely, complications or failure may occur. Because secondtrimester medical abortion complications are similar to obstetric emergencies (for example, hemorrhage or retained placenta), obstetrician/
gynecologists and other obstetric providers already have the skills and
knowledge to treat women. By expanding practice to include secondtrimester medical abortion, obstetrician/gynecologists can provide a
life-saving intervention using familiar skills.
2.5. Advocate for womens access to safe abortion
In addition to making changes to clinical practice, obstetrician/
gynecologists can make invaluable contributions as advocates. Their
rst-hand experience caring for women makes them powerful witnesses to the harmful impact of restrictive abortion laws and the need
for reform of both policies and practices. Because of their respected position in society, when doctors speak out, they inuence their peers, the
public, the media, and policymakers. When Dr Nozer Sheriar speaks to a
global audience about why he performs abortion in India (https://www.
youtube.com/watch?v=O6b6huiAOv4), or Dr Willie Parker testies in
front of the Senate Judiciary Committee to support legislation that protects abortion access in the USA (http://www.judiciary.senate.gov/imo/
media/doc/07-15-14ParkerTestimony.pdf) their stories put a human
face on the value of safe abortion.
In Ethiopia and Nepal, the support of national obstetrician/
gynecologist associations contributed to successful abortion law reform
and to development of clinical standards and guidelines to help clinicians apply the law. Professional associations in many countries contribute to FIGOs Initiative for the Prevention of Unsafe Abortion and its
Consequences and implement the country-based action plans developed through the initiative. Other advocacy opportunities include serving on ministry of health advisory boards, mentoring medical students
and trainees, conducting research, writing letters to the editor, visiting
legislative ofces, and serving as expert witnesses.
3. Conclusion
Whether telling our patients stories, performing abortions ourselves, or supporting those who do, the obstetrician/gynecologists
role as advocates for women can profoundly affect the attitudes and
practices that give women access to safe, respectful, high-quality care.
References
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by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population
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9789241507226_eng.pdf. Accessed October 31, 2014.
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518.

REPRODUCTIVE HEALTH
Evidence supporting broader access to safe legal abortion

Anibal Fandes a,b,, Iqbal H. Shah c
a
b
c
Department of Obstetrics and Gynecology, State University of Campinas, Campinas, Sao Paulo, Brazil
Center for Research in Reproductive Health, Campinas, Sao Paulo, Brazil
Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
a r t i c l e
i n f o
Keywords:
Abortion law
Abortion-related maternal mortality
Access to safe abortion
Prevention of induced abortion
Unsafe abortion
a b s t r a c t
Unsafe abortion continues to be a major cause of maternal death; it accounts for 14.5% of all maternal deaths
globally and almost all of these deaths occur in countries with restrictive abortion laws. A strong body of
accumulated evidence shows that the simple means to drastically reduce unsafe abortion-related maternal
deaths and morbidity is to make abortion legal and institutional termination of pregnancy broadly accessible.
Despite this evidence, abortion is denied even when the legal condition for abortion is met. The present article
aims to contribute to a better understanding that one can be in favor of greater access to safe abortion services,
while at the same time not be in favor of abortion, by reviewing the evidence that indicates that criminalization
of abortion only increases mortality and morbidity without decreasing the incidence of induced abortion, and
that decriminalization rapidly reduces abortion-related mortality and does not increase abortion rates.
1. Introduction
A recent assessment of global maternal, newborn, and child health indicated that unsafe abortion continues to exert a heavy toll on womens
lives and well-being as it accounts for 14.5% of all maternal deaths globally [1]. These deaths are entirely preventable if women have access to safe
legal abortion, as has been shown by the accumulated evidence and
abortion reforms in a number of countries, including Guyana, Nepal,
and South Africa. Of course, the primary prevention for unintended pregnancy is through consistent use of effective contraception. However, no
contraceptive method is 100% effective, resulting in accidental pregnancies that the WHO has estimated to total 33.5 million each year [2]. In addition, many womenmostly youngsuffer sexual violence and rape
and some become pregnant with an unwanted pregnancy. Thus, the simple means to practically eliminate all unsafe abortion-related complications and maternal deaths is to make abortion legal and institutional
termination of pregnancy broadly available and accessible [2,3].
Despite the evidence, abortion continues to be stigmatized, there are
still several countries where abortion is strictly prohibited or permitted
only to save a womans life, and access to safe abortion is denied in
many countries even when the legal condition for abortion is met.
Moreover, one of the main barriers to accessing safe abortion is the
resistance of health professionals to provide these services by alleging
conscientious objection, although many times the real reason is fear of
Corresponding author at: Cemicamp, PO Box 6181, CEP 13085075, Campinas,
Sao Paulo, Brazil. Tel.: +55 19 32892856; fax: +55 19 3289.
E-mail address: afaundes@uol.com.br (A. Fandes).
being stigmatized for providing legal abortion services [4]. Approximately

one in ve women in South Africa who were aware of the legal status that
entitled them to a safe legal abortion did not seek it from the legal services
because of the anticipated fear of rude treatment by the medical staff or
because of the expected poor quality of service [5]. Little attention is
given to the vital recommendation of the FIGO Committee for the Ethical
Aspects of Human Reproduction and Womens Health, notably: The
primary conscientious duty of obstetriciangynecologists at all times is
to treat, or provide benet and prevent harm to the patients for whose
care they are responsible. Any conscientious objection to treating a
patient is secondary to this primary duty [6].
The FIGO Committee for the Ethical Aspects of Human Reproduction
and Womens Health also states that: Abortion is very widely considered to be ethically justied when undertaken for medical reasons to
protect the life and health of the mother and, when referring to abortion for non-medical reasons, the Committee concludes that a womans
right to autonomy, combined with the need to prevent unsafe abortion,
justies the provision of safe abortion [6].
In contrast, only 40% of Brazilian obstetricians/gynecologists were
willing to help a patient requesting a safe abortion and only 2% were
willing to provide the abortion themselves [7]. In Gabon, health providers, mostly residents in obstetrics and gynecology, grossly delayed
the care of severely ill abortion patients in contrast to much faster care
provided to women with nonabortion-related conditions [8].
The contradiction between what many of our colleagues believe and
practice [79] and what the FIGO Committee for the Ethical Aspects of
Human Reproduction and Womens Health supports [6], is the result
of our failure to communicate the evidence supporting the greatest
A. Fandes, I.H. Shah / International Journal of Gynecology and Obstetrics 131 (2015) S56S59
possible access to safe abortion, while maintaining the position of promoting the reduction in the number of induced abortions worldwide.
The purpose of the present article is to contribute to a better understanding that one can be in favor of a greater access to safe abortion
services, particularly for poor women who depend on public health
services, while at the same time not be in favor of abortion.
2. Why FIGO favors greater access to safe abortion services
Declaring that one is in favor of greater access to safe abortion is not an
easy decision for any individual or institution in the current environment
of abortion stigma, harassment, and political backlash. It is only after careful evaluation of the evidence and the professional and ethical obligation
to protect womens health and lives that an organization such as FIGO can
publicly declare to be in favor of womens access to safe abortion. Hence, it
is important to make clear the basis for such a courageous position.
The rst basic reason to favor broad access to safe abortion is that
most women faced with an unintended/unwanted pregnancy resort to
abortion, irrespective of the law. Where access to abortion is restricted,
women will have no option but to risk their lives and health by resorting
to an unskilled clandestine provider performing abortion under
unhygienic conditions [3,10]. Unsafe abortions cause suffering and
death, as shown by numerous studies worldwide [3,10,11].
Unsafe abortion is one of the main causes of maternal mortality in
countries in which abortion is restricted or is legally permitted but
services are not accessible. The unsafe abortion mortality ratio was 1
per 100 000 live births in Europe in 2008, falling from 5 per 100 000 in
1990. In the opposite extreme, the unsafe abortion mortality ratio in
Africa was 80 per 100 000 live births in 2008, which showed only a
small decline from 100 per 100 000 in 1990 [10,12]. Asia and Latin
America and the Caribbean had ratios of 20 and 10 unsafe abortion
deaths per 100 000 live births, respectively, in 2008, down from 50 and
30 deaths per 100 000 in 1990 [10,12]. Each year, over ve million
women are admitted in hospitals because of complications due to unsafe
abortion [13] and the loss of productive years of life due to unsafe
abortion is estimated at 2.1 million [14]. A systematic review of studies
during 19902010 showed the median severe complications ratio of
596 per 100 000 live births [15].
These data also show the great inequality in the risk of dying as a
result of an unsafe abortion. While the unsafe abortion rate is higher in
Latin America than in Africa, the risk of death as a result of unsafe abortion
is about 15 times higher for a woman living in Africa than for a woman living in Latin America [12]. It is a rare exception for an abortion-related
death to occur in a private hospital providing services to economically
privileged women. Almost all deaths occur in public hospitals where
poor women receive care or in their own homes, or wherever an abortion
practitioner provides a clandestine and unsafe abortion service [16]. Thus,
the poorest women in the poorest countries are the main victims of criminalization of abortion and lack of access to safe abortion care.
Deaths are only the tip of a broad-based iceberg, which includes a
large number of acute and chronic complications, some of which have important social implicationsas in the case of infertility and chronic pelvic
pain [17,18]. All of these consequences, which affect the health and wellbeing of millions of women globally every year, can be prevented if every
woman had access to safe abortion when she needed it.
A second reason to favor broad access to safe abortion is that the
main factor preventing access is criminalization of abortion, which
only increases mortality and morbidity without decreasing the incidence of induced abortions [19].
The effect of criminalization of abortion on abortion-related mortality was dramatically demonstrated in Romania after the abrupt decision
to prohibit abortion in November 1965. Criminalization of abortion was
followed by a rapid increase in the abortion-related mortality ratio from
approximately 15 per 100 000 live births to over 140 per 100 000 in a
few years [19]. Although maternal mortality for other causes decreased
during that period, the overall maternal mortality ratio increased from
S57
approximately 80 at the time of the change in the abortion law, to

170 at the peak of abortion mortality. Mortality declined dramatically
when abortion restrictions were removed [19].
While criminalization of abortion has been shown to be efcient in
increasing maternal mortality, it has not been efcient in producing
the effect expected by the legislators who voted to make abortion a
crime: to prevent women voluntarily terminating their pregnancies.
The lowest abortion rates are observed in countries where abortion
laws are broadly permissive and access to safe abortion is easy, such
as in western European countries; for example, Netherlands, Belgium,
Germany, and Switzerland where abortion rates in 2008 ranged from
79 per 1000 women aged 1544 years [20]. Countries where abortion
is highly restricted have three- to ve-fold higher abortion rates. For
example, the abortion rate was 29 in Pakistan, 27 in the Philippines,
and 46 per 1000 women of reproductive age in Kenya [2123]. It is
true that the highest abortion rates were found in Eastern Europe [11],
where abortion laws are liberal and access is easy, but in this region access to modern contraception was limited until recently, and when
methods became accessible, the abortion rate dropped by 50%from
90 in 1995 to 43 per 1000 women in 2008 [11].
More recently Sedgh et al. [11] showed a clear association between
the proportion of women living in countries with liberal abortion laws
and the abortion rate in the same regions, which were used as the unit
of analysis. They found a signicant inverse correlation, with lower abortion rates in the regions where a higher proportion of women lived in
countries with liberal abortion laws. These results conrm the inefciency of criminalizing abortion as a mechanism to reduce their numbers.
The third reason that prompted FIGO to promote access to safe abortion in the framework of more permissive laws is that decriminalization
rapidly reduces abortion-related mortality and, consequently, maternal
mortality [19,24].
This was dramatically demonstrated in Romania when, after the fall
of President Nicolae Ceausescu, abortion law was again liberalized and
access to safe abortion became easy. There was an immediate and dramatic fall in abortion-related mortality, resulting in a decline in total
maternal mortality from 170 in 1989 to 75 in 1991 [19].
More recently, studies of abortion-related deaths in public hospitals
in South Africa showed that the number of deaths fell from 425 in 1994,
before the promulgation of the Choice on Termination of Pregnancy Act,
to an average of 40 per yeara 91% reduction after the law reform [24].
Portugal had low abortion-related mortality as shown by 14 deaths
resulting from abortion over a seven-year period (20012007) prior to
liberalization of the abortion law. This was reduced to only one death
in the six years (20082013) following liberalization [25].
The fourth reason for FIGO to defend access to safe abortion in a
more favorable legal environment is that decriminalization does not
increase the abortion rate, as it is usually assumed [26].
In some countries there is an initial increase after decriminalization,
but it is impossible to determine whether it is a real increase or the result of under-reporting when abortion is criminal, and greater registration after abortion becomes legal and there is no legal reason to hide its
occurrence. A few countries, such as Spain, have shown increases in
abortion rates following liberalization of the abortion law. These are exceptions however, and consideration should be given to the trend in increased sexual activity, especially among unmarried adolescents, and
the increase in unintended pregnancies in cultures where birth outside
marriage persists as a social taboo.
In Turkey, data on the frequency of abortion are derived from a series
of Demographic and Health Surveys, with women directly responding
to a question about their experience of abortion. As it is known that
there is underreporting when women are asked directly in population
surveys [27], it is expected that such underreporting diminishes and
the number of declared abortions increases after legal reform, as was observed in Turkey, for about a decade. After underreporting is corrected,
the proportion of all pregnancies terminated by abortion decreased, as
found in surveys from 1983 to 2008 [2833] (Fig. 1).
S58
recognizes that the aim of reducing the number of induced abortions

will be achieved by not criminalizing its practice or denying care
when requested within the limits of the law, as is currently the case in
many countries. The number of induced abortions will be reduced
through education and access to effective contraception. To criminalize
abortion only causes suffering and deaths, particularly in less privileged
countries and among the most marginalized sectors of societyexactly
the group of women whose health and well-being FIGO has the duty to
protect with all its capacity. Making safe termination of pregnancy
broadly available is, paradoxically, one of the means that will help
reduce the number of abortions.
Fig. 1. Number of induced abortions per 100 pregnancies, by year, in Turkey (19832008).
In France and Italy the abortion rate per 1000 women of reproductive age showed a minor upward uctuation during the rst two or
three years after decriminalization, but fell continuously at least from
19801996 [26]. In Portugal, where abortion law became broadly liberal
in 2007, the number of abortions remained stable or went down from
more than 18 000 in 2008 to 17 414 in 2013. This equates to an abortion
rate of 7.3 per 1000 women of reproductive age, which is among the
lowest in the world [25].
There is no direct cause effect relationship between legalization
and improved access to safe abortion and a decline in the abortion
rate. A reduction in the frequency of unintended pregnancies that lead
to abortion is usually the result of improved information and access to
effective contraception. A possible explanation is that where abortion
is a crime and carried out clandestinely, the abortion providers are
primarily commercially motivated and, consequently, not interested in
reducing repeat abortion. When abortion is legal and accessible within
the health system, there is a motivation to prevent the repetition of
abortion and postabortion counseling and provision of contraceptive
methods improves, leading to a reduced incidence of repeat abortion.
As repeat abortion constitutes at least 40% or more of all induced
abortions, its reduction can at least partially explain a drop in the total
abortion rate, recalling that women who have an induced abortion are
demonstrating that they do not want a baby (or another baby) and
will take any risk to avoid an unwanted birth. As such, they are at high
risk of aborting again if they get pregnant.
It is not that decriminalization alone will reduce the frequency of
abortion, but rather facilitate the opportunities for its prevention.
More importantly, it does not automatically increase abortion rates,
which is the reason often argued for opposing decriminalization and
better access to safe termination of pregnancy.
The sudden and dramatic reduction in abortion rates in Eastern
Europe between 1995 and 2008, coinciding with improved access to
safe and effective modern contraceptives, is a good demonstration
that women prefer to prevent a pregnancy than to abort it, even if
termination of pregnancy services are legal and accessible. By making
legal and safe abortion care accessible and providing contraceptive
information and services, abortion rates can be drastically reduced.
In Zimbabwe, women receiving counseling and services had signicantly fewer unintended pregnancies and repeat abortion during the
12-month follow-up period than the control group that received no
counseling or services [34]. A recent review of evidence indicates that
most women initiate contraception following abortion or treatment
of abortion complications if contraceptive information and services
are provided [35].
3. Conclusions
Analysis of the reasons that FIGO is in favor of greater access to safe
abortion should make it clear that it is not in favor of abortion or an
increased incidence of induced abortion, but on the contrary, it strives
to reduce the number of abortions to the minimum possible. FIGO
Conict of interest
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REPRODUCTIVE HEALTH
Global trends in use of long-acting reversible and permanent methods of

contraception: Seeking a balance
Ritu Joshi a,, Suvarna Khadilkar b, Madhuri Patel c
a
b
c
Department of Obstetrics and Gynecology, Rukmani Birla Hospital and Research Institute, Jaipur, India
Bombay Hospital and Medical Research Center, Mumbai, India
Nowrosjee Wadia Maternity Hospital, Parel, Mumbai, India
a r t i c l e
i n f o
Keywords:
Global trends
Long-acting reversible contraception
Permanent contraception
Sterilization
a b s t r a c t
The global trend shows that the use of permanent contraception to prevent unintended pregnancy is high. Although
the trend also shows a rise in the use of long-acting reversible methods, these are still underutilized despite having
contraceptive as well as non-contraceptive benets. Lack of knowledge among women, dependence on the
provider for information, and provider bias for permanent contraception are cited as reasons for this reduced
uptake. Training of healthcare providers and increased patient awareness about the effectiveness of long-acting
reversible contraceptive methods will increase their uptake and help prevent unintended pregnancies.
1. Introduction
Unintended pregnancies remain a substantial global public health
issue despite considerable advances in contraceptive technologies. In
the 21st century, women have gained access to many contraceptive
options. However, the unmet need for contraception in low-resource
countries has been estimated at 222 million women who are not using
any contraceptive methods to delay or stop childbearing [1]. Numerous
reasons explain this, such as limited choice of methods available, limited
access to family planning services, fear or experience of adverse effects,
cultural or religious opposition, poor quality of available services, and
gender-based barriers. A basic right of all couples and individuals is to decide freely and responsibly the number and spacing of their children and
to have the information, education, and means to do so.
2. Contraceptive prevalence
Contraceptive use and unmet need for family planning are key to
understanding how reproductive health can be improved. Globally, contraceptive prevalence among married or in-union women of reproductive
age has increased from 55% in 1990 to 63% in 2011 [2]. In the lowestincome countries, 36% of married or in-union women are using contraceptive methods, while it is twice as high in high-income countries at 66% [3].
Female sterilization and intrauterine devices (IUDs) were the two most
common methods used in both 1990 and 2011 [3]. Method-specic prevalence has varied widely across regions since 1990, with female
Corresponding author at: Rukmani Birla Hospital and Research Centre, Shanti Nagar,
Gopalpura, Jaipur-302016, India. Tel.: +91 141 2761172; fax: +91 141 2762091.
E-mail address: ritujoshi01@rediffmail.com (R. Joshi).
sterilization common in Asia, Latin America, and the Caribbean and

North America, and IUDs continuing to be important in Asia and Europe.
In countries where childbearing begins at a young age, the dominance of female sterilization (estimated to be 65% in India [3]) indicates
a need for effective reversible methods that could help meet womens
preference to delay the start of childbearing and to space birth. In
high-resource countries, one out of every four contraceptive users relied
on female sterilization or IUDs [3]. By contrast, in low-resource countries the methods with highest prevalence were female sterilization
(21%) and IUDs (15%), accounting for 57% of overall contraceptive use
[3]. Nine out of every 10 contraceptive users in the world rely on modern methods of contraception [3].
Table 1 shows that although the proportion of women using modern
contraceptive methods did not increase substantially between 2003 and
2012, the number of users increased by 139 million over the same time
period, with average annual increases of 15 million. Of this increase, 106
million is attributable to increased numbers of women, and 33 million
to growth in the proportion using modern methods.
Between 2003 and 2012, the total numbers of women using each type
of method increased, while the distribution by type of method showed increasing use of long-acting reversible contraception (LARC), oral contraceptives, and barrier methods, and falling trends in use of sterilization and IUDs.
3. Permanent methods
Sterilization has become the most popular method of contraception
[4], and more than two-thirds of all sterilization procedures worldwide
are performed for contraceptive purposes [5]. Around 190 million couples rely on tubal occlusion [6].
R. Joshi et al. / International Journal of Gynecology and Obstetrics 131 (2015) S60S63
Table 1
Percentage distribution of women using modern contraceptives by type of method in
2003, 2008, and 2012.a
Region
All low-income countries

PM
IUD
LARC
OCs
BM
Number (millions) of women
(aged 1549 years)
Number (millions) wanting
to avoid pregnancy (%)
69 poorest countries
PM
IUD
LARC
OCs
BM
Higher-income countries
PM
IUD
LARC
OCs
BM
Year
2003
2008
2012
47
27
6
12
7
1321
42
30
8
11
10
1448
38
28
9
13
13
1520
716 (54%)
827 (57%)
867 (57%)
49
14
12
16
9
48
11
14
16
11
45
12
16
16
11
46
34
4
10
6
38
41
4
8
9
33
38
4
1
14
Abbreviations: PM, permanent method; IUD, intrauterine device; LARC, long-acting reversible contraception (injectables or implants); OC, oral contraceptives; BM, barrier
methods.
a
Source: Darroch and Singh [42].
3.1. Contraceptive prevalence

Globally, female sterilization is used by 19% of women aged 1549
years who are married or in union [3]. It is the most prevalent method
in Latin America and the Caribbean (26%), with the highest prevalence
found in the Dominican Republic (47%). In Columbia, Costa Rica, El
Salvador, and Puerto Rico, prevalence ranges between 30% and 40%,
whereas it is over 25% in Brazil, 27% in China, and 36% in India [3]. Despite being safer, simpler, and more effective than female sterilization,
male sterilization lags behind. The number of female sterilization procedures exceeds the number of male procedures by 5:1 [7]. Worldwide,
2.4% of men of reproductive age have had a vasectomy.
Female sterilization is a safe and effective method that involves occlusion of the fallopian tubes by either an abdominal or transcervical route.
Using the abdominal route, the fallopian tubes can be accessed either by
mini-laparotomy or laparoscopically. This procedure can be performed
at the time of delivery or shortly after (puerperal sterilization) or at any
time (interval sterilization). Puerperal sterilization performed during the
postpartum hospital stay is a convenient, efcient, and cost-effective
means of preventing future pregnancy. Most sterilization procedures performed in low-resource countries are by mini-laparotomy owing to lack
of equipment, facilities, and expertise in laparoscopic surgery. Laparoscopic sterilization can be carried out under local anesthesia, which is
well tolerated. The transcervical route of sterilization is performed either
by hysteroscopic blockage of tubal ostia or by placement of quinacrine hydrochloride pellets in the uterine cavity.
3.2. Long-term concerns with permanent sterilization

Post-tubal sterilization syndrome and risk of menstrual disturbance
following sterilization have been identied. The CREST study showed an
association between tubal occlusion and subsequent hysterectomy [8],
but there is no evidence suggesting a higher risk of subsequent menstrual disorders following tubal sterilization [8]. One study showed a direct association between tubal sterilization and a greater risk of
S61
hospitalization for menstrual disorders, but a biological association

was not supported by the results [9].
Failed sterilization may result in ectopic pregnancy and the risk is 7.3
per 1000 procedures for all methods of tubal occlusion [5].
The probability of a woman regretting having undergone sterilization
is estimated to be 14% [5], which may be due to a number of psychosomatic factors. The CREST study reported regret following sterilization
among 11 232 women [10,11]. According to this study, regret was more
commonly expressed by women who were sterilized under the age of
30, women of low or nulliparity, and those sterilized immediately after
delivery. Factors that have been identied that can reliably predict regret
among women include young age at the time of sterilization followed by
subsequent life changes such as divorce and remarriage [12]. Regret was
three times more likely among women who had substantial conict with
their husband prior to tubal sterilization [12].
Request for reversal of sterilization is ve times more likely among
women who have had a conict with their partner or husband prior to
the procedure [12]. Following reversal, successful pregnancy rates will
depend on the age of the woman, the type of tubal occlusion method,
and use of microsurgery. The successful pregnancy rate following reversal
is approximately 50%, although the rate of successful reanastomosis
varies between 30% and 70% [5].
3.3. Non-contraceptive benets of permanent methods
Epidemiologic studies have shown that tubal ligation may reduce the
risk of developing ovarian cancer in women with the BRCA1 gene mutation [13]. The underlying mechanism of this is yet to be determined.
Although tubal sterilization does not provide protection from sexually transmitted infections, tubal occlusion prevents ascending pelvic
infections and therefore reduces hospitalization resulting from pelvic
inammatory disease.
3.4. Failure of permanent methods
A multicenter, prospective cohort study of 10 685 women (CREST)
suggested that the failure rate was related to the method of sterilization
and age of the woman [14]. The failure rate was 1.3% for tubal occlusion
and the highest probability of failure was with the use of spring clips
(36.5 pregnancies in 1000 procedures) [14]. The younger a woman is,
the greater the failure rate; women over the age of 40 have the lowest
failure rate (18.5 in 1000 procedures [14]). The lifetime failure rate for female sterilization is 1 in 200, with a 10-year failure rate of 23 in 1000
procedures [15]. The reasons for failure of sterilization are: incorrect
placement of the mechanical device; development of tuboperitoneal
stula; spontaneous recanalization of the ends of the fallopian tube;
and unidentied luteal phase pregnancy.
4. Long-acting reversible contraception (LARC)
LARC methods comprise intrauterine contraception (including copper intrauterine devices and the levonorgestrel intrauterine system),
injectables, and implantable progestogens. LARC methods are the
most effective modern contraceptive methods for preventing unintended
pregnancy. They are long-acting, reliable, safe, cost-effective, and have additional non-contraceptive benets for a broad range of women seeking
spacing or limiting methods of contraception. LARC methods do not
rely on user adherence and are also suitable for women with medical
disorders.
4.1. Contraceptive prevalence
Globally, 61% of women aged between 15 and 49 years who were
married or in a consensual union used some form of contraception in
2003, with only 9% and 18% using LARC methods in high- and lowresource countries, respectively [16]. In the UK, 53% of women of
S62
reproductive age use some form of reversible contraception, but only

17% use LARC [17]. Globally, IUDs are used by 14% of women of reproductive age who are married or in union [3]. IUDs are the second most
common method used worldwide, used by 18% of women of reproductive age in Asia and over 40% in China [3].
hyperplasia/cancer owing to the progesterone component [32]. Finally,

the release of progestogen from the implant causes ovulation suppression
and thus helps relieve the symptoms of dysmenorrhea [33]. A pilot study
reported that LARC methods decreased pain scores by 68% when the impact of etonogestrel on endometriosis was studied [34].
4.2. LARC methods
4.5. Long-term concerns with LARC
These methods do not depend on compliance or user adherence and

do not require daily attention or use at the time of intercourse; hence,
failure rates are low (b1%) [18].
Progesterone-only methods can cause menstrual irregularities such as

unscheduled bleeding, prolonged and heavy bleeding, infrequent bleeding, and amenorrhea [35]. In addition, IUDs can cause heavy menstrual
bleeding, dysmenorrhea, pelvic inammatory disease, perforation, expulsion, and pain [35]. With injectables there may be irregular bleeding patterns, weight gain, depression, and risk of bone density loss [35].
4.2.1. Copper IUD

This method can provide contraception for up to 10 years. Its effectiveness is dependent on the correct insertion technique. The expulsion
rate is less than 1 in 20 women and is highest within the rst three
months of insertion and during menstruation [18]. Return of fertility is
immediate after removal of the device. The risk of ectopic pregnancy associated with IUD use is very low. It can be used as emergency contraception when inserted up to ve days after unprotected intercourse.
4.2.2. Levonorgestrel intrauterine system (LNG-IUS)
This method can provide contraception for up to ve years but it
may continue to be effective for at least seven years in parous women
and for treatment for menorrhagia [19]. Return of fertility is immediate
following removal and 80% of women conceive within 12 months of removal. Suppression of proliferation of the endometrium by the LNG-IUS
alters the menstrual bleeding pattern causing marked reduction or
complete cessation of uterine bleeding, which in turn prevents iron deciency anemia [20]. Oligomenorrhea and amenorrhea are frequently
reported with the rst year of use [20]. Despite the advantages of reduced menstrual ow and relief of dysmenorrhea, only 1% of women
who require contraception choose the LNG-IUS [21].
4.2.3. Injectable contraceptives
Two most commonly used injectable contraceptives are depot
medroxyprogesterone acetate (DMPA) and norethindrone enanthate
(NET-EN). The median conception time is 810 months after the last injection of DMPA [22].
4.2.4. Etonogestrel single-rod contraceptive implant
This implant can provide three years of contraceptive cover. It has high
efcacy [23], low failure rate [24], a high continuation rate, and is costeffective [25]. Besides the contraceptive benets, implants may result in
lighter, less frequent, or absent bleeding. Ovulation resumes rapidly
after removal [26]. The failure rate is lower than most IUDs, LNG-IUS,
and female sterilization [24]. The rate of ectopic pregnancy is low.
4.3. Contraceptive benets of LARC
The benets of LARC methods are the limited effort required by the
user to maintain long- term and effective protection; rapid return to fertility once discontinued; they are safe to use after abortion as well as
after delivery; they are safe during the lactation period; and they are
suitable for women who want an estrogen-free contraceptive method.
4.4. Non-contraceptive benets of LARC
Copper IUDs have a protective effect against endometrial cancer
[27,28]. The LNG-IUS can be used in women with menorrhagia, with evidence suggesting a reduction in monthly menstrual blood loss of 90% at
1 year and 2% 4% of women becoming amenorrheic at 1 year [29]. In
addition, evidence suggests a reduction in the size of uterine myomas
by local delivery of levonorgestrel [30]. For women with endometriosis,
use of the LNG-IUS helps reduce pelvic pain and dysmenorrhea [31]. Furthermore, use of the LNG-IUS protects the endometrium against uterine
4.6. Failure rate of LARC methods

With a failure rate of less than 1%, LARC is the most effective method
of reversible contraception. With typical use, the rst year failure rate of
the copper T 380A is 1%, the LNG-IUS is 0.1%, and with implants it is 0.1%.
This is similar to permanent methods [36].
5. Counselling on appropriate method of contraception
Counselling by healthcare providers about family planning is essential
to help women make informed choices about the various methods
available and matching their lifestyles and requirements. A multicenter
observational study conducted by the Federation of Obstetric and
Gynaecological Societies of India (FOGSI) evaluated the inuence of structured contraception counselling on Indian womens selection of contraceptive methods [37]. The study found that counselling resulted in a
signicant increase in women opting for modern contraceptive methods.
Poor adherence to contraception is one of the factors contributing to
unintended pregnancies, with an estimated 48% occurring in women
who are using contraception [38]. LARC methods do not rely on user adherence for effectiveness. In the USA, unintended pregnancy is very
high among sexually active adolescents and women aged 2024 years
[38]. These women are the right candidates for LARC methods. The
American College of Obstetricians and Gynecologists (ACOG) describes
LARC methods as the rst-line options for all women and adolescents
on the basis of their top-tier effectiveness, high rates of satisfaction
and continuation, and no need for daily adherence [39]. Adolescents
using LARC methods should also be advised to use condoms to prevent
sexually transmitted infections. The contraceptive CHOICE study in the
USA found that when women are counselled with balanced information
about contraceptive options they choose LARC methods in preference to
user-dependent methods such as short-acting reversible contraceptives
[40]. Among women aged 1449 years, 67% opted for LARC methods
and the 12-month continuation rate was 86% [40].
Counselling about female sterilization should include information on
other contraceptive options, the probability of later regret having had
the procedure, and also that surgical procedures for reversal are expensive and have a limited success rate.
6. Balance between LARC and permanent methods
Although the global trend shows that more than half of contraceptive users relied on female sterilization, use of LARC methods is increasing. In countries where childbearing begins at a young age, the
dominance of female sterilization indicates a need for transfer to effective reversible methods. The rate of IUD use increased from 0.8% in
1995 to 5.6% in 2010 [41], but still there is lack of utilization. A review
of global contraceptive trends from 2003 to 2012 based on data from demographic and national surveys shows that intrauterine contraception
use has increased in low-income countries from 27% to 28% and implants and injectables have increased from 6% to 9% [42]. The proportion
of women using oral contraceptives remains stable, while the percentage using male or female sterilization fell from 47% to 38% [42].
LARC remains underutilized despite the contraceptive and noncontraceptive benets, eligibility for women of any age or parity
including those who are postpartum or post rst- or second-trimester
abortionand women with medical disorders. The reasons for underutilization are lack of knowledge among women about LARC, dependence on the provider for information, womens misconceptions and
misinformation, higher initial cost of the method itself and the placement procedure, and provider bias against the method [40]. Female
sterilization is considered a simple gynecological procedure, but is associated with medico-legal issues related to pre-procedure counselling,
surgical complications, and failures.
As LARC methods have similar failure rates and more benets than
permanent methods, strategies and policies should be adopted to reinforce their use. Public awareness about LARC methods has increased
their use from 2.4% in 2002 to 5.6% in 20062008 [43]. Effective health
professional training programs, addressing the high cost of LARC, and
fully funded family planning programs for users in low-income countries are a few recommended activities to increase uptake of LARC.
Conict of interest
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REPRODUCTIVE HEALTH
Global efforts for effective training in stula surgery

Sohier Elneil
University College London Hospitals NHS Foundation Trust, London, UK
a r t i c l e
Keywords:
Implementation
Obstetric stula
Outcomes
Standardized training
Surgery
i n f o
a b s t r a c t
Obstetric stulas continue to be a problem in low- and middle-income nations, affecting women of childbearing
age during pregnancy and labor and resulting in debilitating urinary and/or fecal incontinence. Historically, this
predicament also affected women in high-income nations until the middle of the last century. This is not a
new world crisis therefore, but simply one of economic and health development. In the last two decades,
new global initiatives have been instituted to improve training and education in preventative and curative stula
treatment by developing a unied and competency-based learning tool by surgeons in the eld in partnership
with FIGO and its global partners. This modern approach to the management of a devastating condition can
only serve to achieve the WHO objective of health security for women throughout their life span.
1. Introduction
Obstetric stulas remain a major health problem in Africa and Asia
[1,2]. Access to effective and safe obstetric care, including cesarean
delivery, is often limited in these countries [3]. Furthermore, long
distances combined with the high cost of care and poor nutrition
make women more vulnerable to obstetric stulas, particularly in
Africa [4] and the Indian subcontinent [57]. The tremendous disparity
between risks associated with pregnancy and labor faced by women in
low- and middle-income countries compared with women from
wealthier nations has not changed in decades.
The global effort to eradicate obstetric stula has moved in leaps and
bounds in the last decade. Clinical efforts have become more coordinated
to prevent duplication of care, as the charity sector is working hand-inhand with indigenous stula surgeons, who are also often qualied
obstetrician/gynecologists or urologists working within dedicated government or university hospitals. Communication channels were opened
to enable better coordination of efforts to ensure well-managed and
targeted service provision [8]. Primarily, this came about with the input
of stula surgeons through the auspices of the International Society of
Obstetric Fistula Surgeons (ISOFS), formed in 2008, funding bodies
such as the Fistula Foundation and Engender Health, and professional
bodies like the International Federation of Gynecology and Obstetrics
(FIGO). The second approach was to look at the classication of stula.
Although there have many attempts to formulate a universally accepted
stula classication to enable accurate communication between different units and surgeons, the consensus seemed to be to agree not to
Department of Uro-neurology, National Hospital for Neurology and Neurosurgery,
Queen Square, London, WC1N 3BG, UK. Tel.: +44 203 448713; fax: +44 203 4484748.
E-mail address: sohier.elneil@ucl.ac.uk.
disagree. Several systems remain in use in the published literature,

but only two appear to have been validated [9,10]. Unanimous agreement on a classication system would be helpful, so the consortium originally established by WHO, UNFPA, FIGO, and several nongovernmental
organizations and professional bodies, along with ISOFS will continue
to try and reach an agreement [1114]. It is an extremely difcult area
to reach consensus because it raises the hackles in many a surgeon
[15]. Nonetheless, most surgeons use one of the validated classication
systems and this has helped diffuse the situation to some degree. Perhaps the most signicant change in the last few years has been the implementation of the FIGO and partners training program in stula
surgery, which has strengthened and supported surgical services.
In the last six years, the work of FIGO and its partnersISOFS, UNFPA,
Engender Health, Pan African Urological Surgeons Association, the Royal
College of Obstetricians and Gynaecologists (RCOG), and the Fistula
Foundationhas helped implement a competency-based training manual within a training program [16]. The aim remains the provision of
standardized training using a modular competency-based approach.
Each module has specic objectives and can be achieved within a stipulated period of time, as determined by the trainer and the trainee. This
initiative has been the rst of its kind developed for a specic internationally recognized health condition.
2. Implementation of the training manual and developing
the program
Since the training manual was published in June 2011, there has
been signicant uptake by many trainers in the eld. All trainers
underwent training courses run by the FIGO team and local faculty
members. The rst training the trainers course took place in Dar es
Salaam, Tanzania, in August 2011. This was to introduce the manual
S. Elneil / International Journal of Gynecology and Obstetrics 131 (2015) S64S66
and to train the current senior stula surgeons in Africa and Asia on how
to use the manual. The training took place over two days and discussions were held on how to implement the competency-based training
system within different teaching environments, how to appraise and
achieve accreditation in stula surgery, and how to manage the difcult
trainee. All participants, being well-established stula surgeons within
their own right, found the training sessions helpful in their understanding of how the manual should be used. Competency-based learning in
Africa and Asia is a new concept in medical education and is only now
starting to take off in mainstream postgraduate medical training.
Since then, training courses have been run in Dakar, Senegal
(July 2012); in Nairobi, Kenya (April 2013); Addis Ababa, Ethiopia
(August 2013); Lagos, Nigeria (December 2013); and Dar es Salaam,
Tanzania (June 2014). Over fty trainers have been trained so far.
Following the publication of the manual, several challenging issues
have arisen regarding the implementation of the training program,
including how the trainees were selected, how long it would take to
train each trainee, nancial support for the trainee and the training
facility, and who would provide accreditation.
2.1. Selecting the trainees
Originally the guidelines for the selection of trainees for the stula
training program were determined by members of the FIGO and
Partners committee. They believed that all applicants should have completed at least three years of surgical or obstetrics and gynecology training following graduation from medical school. One of the major
problems, in the past, has been that many trained stula surgeons
often did not stay in their homeland but left to pursue careers elsewhere. This presented a form of brain drain of stula surgeons
throughout low-resource nations. The committee felt that all prospective trainees should be encouraged to offer a minimum term of service
determined by their country in providing a stula surgery service, be
it within a dedicated stula hospital or a general hospital setting. This
was felt to be crucial, so that each countrys ministry of health could
maintain autonomy of its own workforce development strategy.
As the program has become implemented within each country, in
the last two years trainees have been selected increasingly by their national professional urology or obstetrics and gynecology organizations
or by their ministry of health to undertake the program.
2.2. The training period and training facility
All trainees need to be accepted by a trainer who must ensure that
the appropriate facilities for training are available, such as adequate patient numbers [17], good surgical facilities/equipment, computer access,
and accommodation. Feedback and evaluation are critical to ensure that
the program is t for purpose.
The training period is individually tailored following a discussion
between the trainee and trainer. The trainees ability and original
competence helps determine how soon a trainee can be signed off at standard, advanced, or expert level of competency. Different trainees complete each phase of training at differing times, as the focus remains on
competency rather than on a dened period of training time. It is
anticipated that most trainees will need at least 68 weeks of training in
an accredited center to achieve a standard level of competency. Achievement of a higher level of competency is determined on an individual basis.
As of May 2014, eight stula surgeons have been accredited
with standard or advanced competency in stula surgery using the
grandfather clause, whereby well-established stula surgeons were
accredited as trainers without needing to do the actual training program. A further 16 new stula surgeons have achieved standard level
of competency in stula surgery using the training manual. The trainees
came from different countries including Togo, Niger, Uganda, Kenya,
Senegal, Nigeria, Madagascar, and Nepal. A new call for applicants was
launched in September 2014 by FIGO.
S65
2.3. Mentoring of the trainee

The FIGO and partners program has been the start of increasing
capacity in stula surgery in under-resourced settings. Together with
their partners, FIGO has understood that increased capacity also
means increased need for the trainees to improve their local surgical
facilities to accommodate their newly acquired skills. In addition,
mentoring of the trainees at their local site is also important to ensure
they maintain and develop their skills, and thus FIGO and partners
have undertaken a mentoring and evaluation program to run concurrently with the FIGO training program. Data on the number of patients
looked after by the newly trained surgeons are being collected on a
quarterly basis, and visits to the training centers have been conducted
by the FIGO and partners team to ensure that governance and standards,
according to the principles of the program, are maintained. At the recent
FIGO and partners meeting in Dar es Salaam in June 2014, the trainers
heard from a young female trainee who had completed her standard
level of competency training in Northern Nigeria in 2013, using the
FIGO and partners training manual. At the time of the meeting she
had already operated on over 80 patients on her own over a ninemonth period, with a 91% success rate of stula closure. It is this type
of capacity building that we need in stula surgery provision.
2.4. Accreditation and certication
The accreditation and certication process for completion of each
level of competency is shared between FIGO and the professional
societies and/or trainer. FIGO is working in tandem with the national
professional societies, or universities, to accredit centers and trainers.
The accreditation and certication of the trainees is currently in the
hands of FIGO. As the numbers of trainees increase, it is planned that
each countrys designated professional body along with its academic institutions will provide the competency-based stula surgery training
program as a specialized form of postgraduate education.
2.5. Funding the training program
The funding of trainees accepted to the FIGO and partners training
program, which covers travel expenses and accommodation, has been
provided by a mixture of donor agencies working closely with and guided
by FIGO. This includes the Fistula Foundation, WAHA International,
Engender Health, UNFPA, Johnson and Johnson, and several others.
In the future, it is anticipated that governments and institutions will
take over funding of the training program, when they become part of
the established postgraduate education system.
3. Monitoring and evaluation of the training program
Data on the number of patients seen and operated on are very helpful to establish whether the global efforts are helping eradicate stula
globally. Certainly the help provided by donor agencies, professional
bodies, and the surgeons themselves in evaluating hospital units and
ensuring that they are ready to be training facilities, and provide adequate support for trainees trained in their home base hospitals, has
been critical to the success of the program.
In the last year, corporations such as the pharmaceutical giant
Astellas Pharma have become involved in provision of funding in association with stula organizations, such as the Fistula Foundation, to provide training and capacity building. Their in-house monitoring and
evaluation of the project, based in Kenya, has been very helpful for the
rest of the stula community to learn from as it not only focuses on
the number of surgeries performed but also on the outcomes, costeffectiveness, and the long-term rehabilitation overheads required to
ensure a holistic care package for every woman treated.
The cost of monitoring and evaluation is high and the pooling of
effortssuch as that seen between FIGO, Fistula Foundation, and
S66
S. Elneil / International Journal of Gynecology and Obstetrics 131 (2015) S64S66
Engender Healthand formation of teams to do the work means we are

likely to get more robust and useful data in the future that can be used to
improve long-term national planning of stula services.
4. Conclusion
Over the last four years more units have become better equipped to
provide training to a much improved level, and the numbers of such
units continue to grow. They have experienced trainers, adequate number of cases and satisfactory training facilities. They are already equipping young surgeons with the necessary skills to return to the eld to
further extend this work. The independent bodies who in the past
have taken on the task of producing their own training manual in an
attempt to formalize the training process and to be involved in the stula world, are working more closely with the surgeons, donor agencies,
and governments to ensure training and education is standardized,
rather than disparate and imprecise, as it had been in the past [9].
Thus, the only manual used in training now is the FIGO and Partners
manual. Clearly many needs have been met, but there are still many
that have not, such as the availability and training of specialist nurses,
physiotherapists, counsellors, social workers, occupational therapists,
and rehabilitation specialists.
The many positive changes that have taken place in the last decades
in helping women with stula to access care cannot be underestimated.
Raising awareness of obstetric stulas was the starting point in helping
deliver this care. As a community we have nally been able to move forward. The tremendous efforts of the surgeons in the past have brought
obstetric stulas to the forefront of the worlds medical media. This exacting work has meant that more women are being treated, more specialized units are being developed, more doctors are being trained, and
most importantly, more lives are being rebuilt. Without the dedicated
teams of doctors, nurses, physiotherapists, occupational health therapists, social workers, cured and non-cured patients working as health
auxiliaries, nongovernment organizations, and philanthropists, none of
this would have been fully realized. But it must not be forgotten that
this condition is completely preventable. Therefore, the issues that are
the basis for itsocial and economic development of at risk girls and
womenmust be on the agenda for them to be tackled. Furthermore, it
should be on the human rights agenda for women and girls.
Until there is universal access to emergency obstetric services, prenatal healthcare services, and improved transport and socioeconomic
status, improving medical care for these women will be a challenge. A
holistic approach to medical and surgical treatment, rehabilitation,
and follow-up in the community is a step in the right direction.
Implementation of the FIGO and partners competency-based training program is helping provide a standardized approach to the medical
and surgical management of stula surgery. We anticipate that in time it
will improve outcomes for women. However, the training program has
to be part of a wider picture, as more surgeons do not wish to simply be
stula surgeons but part of the wider specialty of urogynecology,
reconstructive pelvic oor surgery, and female urology. They are increasingly seeking this recognition and looking at developing national
programs where stula surgery is integrated into these subspecialties.
In addition, incorporating integrated social, economic, and cultural
development programs with the surgical/medical interface is essential.
Programs like Terrewode in Uganda have put patient advocacy at the
heart of its campaign, thus helping patients access care and in time educate the community in preventing the problem. There is no doubt that
in the long term, socioeconomic development will be more costeffective and sustainable than medical treatment in the future. But
until then, we must rely on the dedication and delivery of good care
by all the professionals working in this eld. The FIGO and partners
competency-based training program has contributed to this commendable objective.
Conict of interest
The author has no conicts of interest to declare.
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Task shifting: A key strategy in the multipronged approach to reduce

maternal mortality in India
Himanshu Bhushan a, Ajey Bhardwaj b,
a
b
Maternal Health Division, Ministry of Health and Family Welfare, Government of India, New Delhi, India
Avni Health Foundation, Mumbai, India
a r t i c l e
i n f o
Keywords:
Comprehensive emergency obstetric care
Maternal deaths
Maternal mortality ratio
Task shifting
a b s t r a c t
Task shifting from specialist to nonspecialist doctors (NSDs) is an important strategy that has been implemented
in India to overcome the critical shortage of healthcare workers by using the human resources available to serve
the vast population, particularly in rural areas. A competency-based training program in comprehensive emergency obstetric care was implemented to train and certify NSDs. Trained NSDs were able to provide key services
in maternal health, which contribute toward reductions in maternal morbidity and mortality. The present article
provides an overview of the maternal health challenges, shares important steps in program implementation, and
shows how challenges can be overcome. The lessons learned from this experience contribute to understanding
how task shifting can be used to address large-scale public health issues in low-resource countries and in
particular solutions to address maternal health issues.
1. Overview of maternal healthcare challenges in India

India, with a population of 1.2 billion, is the second most populous
nation in the world [1]. Signicant differences between richer and
poorer nations exist in the availability of healthcare workers as a
percentage of the population [2]. If healthcare worker density levels
are insufcient or there is a critical shortage, it is unlikely that the population will receive high coverage of essential medical interventions.
Given that healthcare worker numbers and quality of services are
positively associated with maternal survival, critical shortages affect
coverage and quality of service delivery [3].
In India, access to health care remains a challenge given that 69% of
the population resides in rural areas and there is a critical shortage of
healthcare workers. The 2006 family welfare statistics showed that
49% of community health centers (CHCs) and 29% of rst referral units
(FRUs) did not have an obstetrician; and 63% of CHCs and 31% of FRUs
did not have an anesthetist [4]. These shortages affected delivery of
health care as only approximately 47% of deliveries were conducted
by health personnel, only 39% of women delivered in a health facility,
and 58% of mothers did not receive postnatal care within two months
of delivery [5]. In addition, 12% of CHCs did not have an operating
theatre, 69% did not have a separate aseptic labor room, and 90% did
not have regular blood supplies [4].
Corresponding author at: Avni Health Foundation, 101, Prangan Coop. Hsg Sty, 15
Malviya Road, Vile Parle East, Mumbai, India. Tel.: +91 22 26631665; fax: + 91 22
26631044.
E-mail address: avnihealth@yahoo.com (A. Bhardwaj).
Although services were affected by a critical shortage of specialists,

87% of primary health centers had a nonspecialist doctor (NSD)
[6,7]a legally qualied and licensed practitioner of medicine.
However, the policy of the Government of India (GOI) encouraged
only qualied postgraduate obstetricians to perform cesarean
deliveries. NSDs, who obtain a basic medical degree after 5.5 years of
medical education, were unable to perform cesarean deliveries or any
other emergency surgery [8]. Furthermore, condence in the public
sector to deliver health services was abysmally low owing to the quality
of services and lack of availability of a nearby facility [5]. Therefore,
approximately 65% of all households sought health care from the private
medical sector. Critical shortages in personnel, lack of quality, and lack
of infrastructure contributed to high dependency on the private sector;
a high maternal mortality ratio (MMR) of 301 per 100 000 live births;
and hemorrhage, anemia, sepsis, abortion-related complications, and
hypertensive disorders, which are the leading causes of maternal
death and all preventable through simple measures [9].
2. Impact of the National Rural Health Mission

The GOI launched the National Rural Health Mission (NRHM) in
2005. Its objectives included enhanced focus on reproductive and
child health, augmented human and nancial resources and local
exibility, focus on health systems strengthening, and emphasis on
decentralization [10]. The key strategies that were implemented under
the NRHM had a signicant impact on improving service delivery.
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H. Bhushan, A. Bhardwaj / International Journal of Gynecology and Obstetrics 131 (2015) S67S70
The years following implementation of the NRHM showed improvements as reported in the Rural Health Statistics 2014 [11] and Health
and Family Welfare Statistics 2013 [6]. The health infrastructure comprising sub-health centers, primary health centers (PHCs), and CHCs increased by 4.3%, 7.6%, and 6.0%, respectively. Human resources in terms
of doctors at PHCs, and nursing staff and obstetrician gynecologists
(ob/gyns) at CHCs increased by 35%, 120%, and 6%, respectively, thereby
improving the presence of staff to 109%, 102%, and 37% of the sanctioned
staff numbers at these locations. In addition, 83% of deliveries were
attended by health personnel; postnatal care of women within 48 hours
of delivery increased to 67% of the total women who delivered; output
from medical colleges increased from 30 290 to 51 979 graduates; and
availability of blood storage facilities at CHCs increased to 15%. An operating theatre and aseptic labor room were available in 82% and 92% of CHCs,
respectively. Some 93% of CHCs were functioning 24 hours a day, seven
days a week and 42% of FRUs had a blood storage facilitythese facilities
were also operational 247 and were able to provide healthcare services
including cesarean delivery. Janani Shishu Suraksha Karyakrama
scheme to offer cashless maternity services to mothersand training programs in comprehensive emergency obstetric care (CEmOC) to increase
trained nonspecialist medical doctors at 2000 rst referral units, plus
247 PHCs and CHCs, dramatically increased institutional deliveries
from a mere 0.7 million in 200506 to 16.7 million in 201213.
The national MMR reduced to 178 per 100 000 live births in 2013
[12]. However, India has to accelerate the pace of decline before it will
meet Millennium Development Goal 5, which sets out to reduce MMR
to 150 by 2015 [13], or the national 12th Five Year Plan of India,
which sets out to reduce MMR to 100 by 2017 [14].
3. Task shifting initiative to train nonspecialist doctors
Although the GOI initiated several steps to bring about a positive
change in the health indicators of India, the present article focuses on
task shifting. Task shifting describes a process of delegation whereby
tasks are moved, where appropriate, to less specialized health workers.
By reorganizing the workforce in this way, task shifting can make more
efcient use of the human resources currently available [15].
Task shifting or sharing has been highlighted as an important strategy
to optimize health worker performance in resource-poor settings [16] and
provide the right mix of skills required to undertake the activities necessary for the service [17]. Task shifting through training, certication, and
support frees up specialists to provide more complex care and reduces
the patient load on higher centers involved in critical care of patients.
In 2006, the GOI initiated task shifting through training of NSDs in
CEmOC as a way forward to operationalize its FRUs, CHCs, and 247
PHCs to allow them to provide key services in maternal health that
were otherwise dependent on specialists.
4. Broad CEmOC program implementation goal
The overall goal of the program was to operationalize health
facilities in underserved areas by ensuring increased availability of
NSDs who would be able to provide high-quality CEmOC and contribute
toward the reduction of maternal mortality and morbidity.
5. Program implementation (20062013)
5.1. Task shifting policy
The CEmOC task shifting policy, training curriculum for trainers and
trainees, and the operational plan were approved for implementation
at the national level. NSDs who successfully completed the CEmOC
competency-based certicate training program were allowed to
manage emergencies including cesarean deliveries at FRUs. To create
an enabling environment, FRUs were equipped with an operating
theatre, blood storage bank, nursing staff, and an anesthesiologist.
5.2. Building partnerships

Task shifting from specialists to NSDs required that specialists were
in complete agreement with the GOIs vision of improving maternal
health outcomes in India. To take the program to scale, the GOI developed partnerships with the Federation of Obstetric and Gynaecological
Societies of India (FOGSI)one of the worlds largest bodies of ob/gyn
specialistsand the Indian College of Obstetricians and Gynaecologists
(ICOG)the academic wing of FOGSI. Together this strong partnership
designed the curriculum for master trainers and trainees and developed
the certication, implementation, mentoring, and monitoring processes
for program scale-up across India.
5.3. Setting up a program management unit
GOI and FOGSI agreed that for task shifting to be successful it was
important that the program planning, management, implementation,
and nancial processes were followed according to the operational
plan by all those involved in training, certication, implementing,
mentoring, and monitoring. Instead of doing these activities themselves,
FOGSI and GOI partnered with the Avni Health Foundation (AVNI)an
organization of professionals specializing in program management
and scale-up. AVNI designed the operational plan; dened the roles
and responsibilities; xed the certication, nancial, and program
reporting norms; and implemented a real-time web-based program
management tool to track the progress of the program. AVNI provided
operational and troubleshooting support on a day-to-day basis, ensured
appropriate communications with all the stakeholders, and maintained
databases of trainers, trainees, logbooks, certication, documentation,
and nancials across the 34 training centers located in 21 States of India.
5.4. Nodal training sites
Nodal training sites for developing ob/gyn master trainers were set up
in leading medical colleges. All trainers from the nodal centers were
trained in standardized modules of clinical skills and the program also
addressed the softer issues such as communication skills, managing difcult participants, time management, supportive supervision, monitoring,
and mentoring.
5.5. Set up tertiary training sites
Housed within the medical college, one to two sites per State were
strengthened by training ob/gyn master trainers, providing them with
training infrastructure, anatomical models, drills for implementing
best practices of training, and administrative support manpower for
record keeping and smooth program implementation. Trainers from
the nodal centers visited the tertiary sites to mentor them and provide
technical updates.
5.6. Set up district hospital training sites
In phase one, eight district sites with 15002000 deliveries per year,
and those that had motivated ob/gyns interested in the program were
selected. In phase two, more ob/gyns from the same facility and subsequently from newer facilities were selected. A tertiary center master
trainer visited each of these sites before and during the training program to prepare the sites to receive the trainees, to conduct certication
exams, and for mentoring and monitoring.
5.7. Curriculum and course framework for task shifting from specialists
to NSDs
The curriculum was 16 weeks long, with six weeks conducted at the
tertiary training centers where illustrated lectures, role plays, demonstrations and practice on anatomical models, and emergency drills were
S69
Fig. 1. Number of cases identied, managed, and treated at the facilities by nonspecialist doctors trained during 20062013.
conducted. Broadly the curriculum covered early recognition of obstetric

emergencies and their management, administration of oxytoxic drugs
and parenteral anticonvulsants, normal childbirth and newborn care,
prevention of infection, intravenous therapy including uid replacement
and blood transfusion, emergency medical treatment (sepsis, eclampsia,
severe anemia), emergency surgical procedures, contraception, postpartum care, safe abortion, resuscitation of newborns, prenatal diagnostic
techniques, and acts governing medical termination of pregnancy. Nine
weeks of self-directed clinical practice at a district training site was conducted. Each NSD had to maintain a logbook, and independently and
under supportive supervision manage 120 normal deliveries, 15 cesarean
deliveries, 7 vacuum extractions, 5 forceps delivery, 50 episiotomy/
perineal tear repairs, and 10/15 induction/augmentation of labor. In the
nal week the NSD returned back to the tertiary training center for
further mentoring, coaching, and examination.
of all the stake holders; selection criteria for NSDs; identication of

nodal centers, tertiary centers, and district centers and their trainers;
certication norms and process; batch sizes and placement of NSDs
at training sites; monitoring, evaluation, and reporting norms; and
program budget norms.
6. Program achievements (20062013)
Four nodal master training centers, 34 tertiary training centers with
221 master trainers, and 253 district hospital training sites with 385
master trainers spread across 21 States of the country were set up. A
total of 1500 NSDs successfully completed the 16-week CEmOC
competency-based training program.
Analysis of 178 trainee records from 12 States comparing the
one-year pre-training and post-training achievements have shown that:
A detailed operational plan (OP) was framed to ensure successful

implementation of the task shifting program. The OP gave guidelines
on the ow of the program implementation; roles and responsibilities
(1) Availability of trained NSDs improved antenatal care coverage by

43%, 44%, and 58% during the rst, second, and third trimesters,
respectively. Identication, management, treatment, and referral
of hypertension, hemorrhage, abortions, sepsis, and miscellaneous cases increased (Fig. 1), contributing to the overall decline
in maternal deaths by approximately 50% at these facilities.
(2) Trained NSDs were able to identify complications and ensure
timely referral (Fig. 2).
(3) The number of women referred for treatment as a percentage
of total antenatal care in the respective trimesters showed a
decline in the rst trimester and an increase in the second
and third trimesters. This is because the trained NSDs are
able to manage the cases at the facility and ensure proper
referral (Fig. 3).
(4) Absolute numbers of complications managed by the NSDs increased. All percentages increased when specic complications
were looked at individually (Fig. 4).
Fig. 2. Number of cases referred out from the facilities during the three trimesters by
nonspecialist doctors trained during 20062013.
Fig. 3. Percentage of all complicated cases referred out from the facilities during the three
trimesters by nonspecialist doctors trained during 20062013.
5.8. Three-tier certication process

Tier I was conducted during the rst six weeks, tier II was conducted
during the following nine weeks, and tier III was completed during the
nal week. Objective Structured Clinical Examination (OSCE) was used
in tier III to evaluate trainees in clinical skill performance and competence. NSDs had to obtain a score of 85% or higher in all three tiers to
qualify for certication. Course duration for NSDs who scored less than
the qualifying scores was extended by 12 weeks for extra guidance
and to ensure acquisition of skills following which tier III was repeated.
5.9. Operational plan
S70
Fig. 4. Percentage breakdown of all cases treated/managed and referred out from the facilities during the three trimesters by nonspecialist doctors trained during 20062013.
7. Challenges and solutions during program implementation

Trainer burnout, retirement, and transfers posed challenges. A pool
of additional trainers was created. While transfers and retirement of
trainers is State government policy, this was limited by dialogue with
ofcials so that trainers were not transferred during the training
program. Over the years a critical mass of additional trainers was
reached and thus the program continued smoothly.
Other challenges were training quality, lack of motivation to attend
training away from home, underutilization of the centers training
capacity, and delay in placement of trained NSDs leading to skills
decay. Monitoring visits during each and every batch were undertaken
for each NSD placed at the district training site and a three-tier certication process was implemented for each segment of the training. More
district training sites were created closer to the homes of the NSDs,
and NSDs awaiting postings were placed at the district hospitals so
that they could continue practicing their skills and those who could
not be posted were recalled for a few weeks at the tertiary center for
practice before posting.
8. Lessons learned
Task shifting was a success in India owing to the program ownership
by GOI, its leadership, and the presence of a dedicated team of ofcials
who began the program and continued to support the program for its
entire duration of implementation. Partnering with organizations like
FOGSI and ICOG comprising ob/gyn specialists ensures its quality
and success. Involving an independent program management unit
like AVNI comprising program management specialists ensures
regular and timely administrative support, adherence to the program
guidelines, timely communication, understanding and providing quick
resolution to the issues, database management, monitoring, and overall
programmatic control to ensure the program is on track.
9. Way forward
Owing to the successful implementation and positive outcomes of
the task shifting training program, the CEmOC program has been
extended until 2017. As a policy, the GOI is pursuing implementation
of similar task shifting initiatives in other disciplines; for example, in
the eld of nursing and midwifery, pre-service and in-service task
shifting program policy is being implemented.
Acknowledgments
We would like to thank the maternal health division team at GOI,
FOGSI, ICOG, chief coordinators, technical coordinators, master trainers,
nodal ofcers, State Government ofcials, and Avni Health Foundation

team members who have contributed and continue to contribute
toward the successful implementation of this task shifting initiative.
Conict of interest
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The role of health professional organizations in improving maternal and

newborn health: The FIGO LOGIC experience
David J. Taylor ,1
Emeritus Professor of Obstetrics and Gynecology, University of Leicester, Leicester, UK
a r t i c l e
i n f o
Keywords:
Clinical guidelines
FIGO LOGIC Initiative
Health professional organizations
Maternal and newborn health
Maternal death review
Near-miss review
Organizational capacity
a b s t r a c t
The FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and
Newborn Health improved the internal and external capacity of eight national professional organizations of obstetrics and gynecology in six African and two Asian countries. The initiative was funded by a grant from the Bill
and Melinda Gates Foundation and had three key objectives: to support the eight FIGO member associations to
strengthen their capacity to work effectively; to inuence national policies on maternal and newborn health;
and to work toward improving clinical practice in this area. Through improved capacity, and underpinned by
Memoranda of Understanding with their governments, the associations inuenced national policy in maternal
and newborn health, impacted clinical care through the development of over forty national clinical guidelines,
delivered national curricula, trained clinical and management staff, and led the development of national maternal
death and near-miss review programs.
1. Introduction
Every year, hundreds of thousands of women and millions of babies die
during pregnancy, birth, and just after birth. In 2012, the Maternal Mortality Estimation Inter-Agency Groupa collective that comprises WHO,
UNICEF, UNFPA, United Nations Population Division, and The World
Bankworked in collaboration with academics from the University of California to assess trends in maternal mortality. This analysis revealed a fall in
the number of women worldwide who had died from complications during pregnancy and childbirth, from a total of 546 000 deaths in 1990 to 287
000 deaths in 2010 [1]. Although this decline in mortality was hailed as
progress, the rates recorded by low-income countries remained dire,
with Sub-Saharan Africa and South Asia accounting for 85% of all maternal
deaths globally. The maternal mortality ratio recorded in 2010 was 500
deaths per 100 000 live births in Sub-Saharan Africa and 220 deaths per
100 000 live births in South Asia. It is estimated that 56 million babies
die during late pregnancy or during the rst week of life [1].
The vast majority of these deaths are preventable through improving the health and well-being of women and facilitating their access to quality maternity services. However, investment in these is a
low priority in low-resource countries. The reasons for low prioritization of womens health care arise from lack of awareness of the scale
of the problem. First, the challenges to improve such care are perceived
University of Leicester, University Road, Leicester, LE1 7RH, UK.
E-mail address: davidjtaylor1@me.com.
1
Professor Taylor was employed by the International Federation of Gynecology and
Obstetrics (FIGO) as the Director of FIGO LOGIC between July 2009 and October 2013.
as too difcult or too expensive to solve, which they are not. Second, the
case for investment has not been well made, particularly the benets to
the long-term strength of a nations social and economic development
from the health and well-being of women and children. Finally, and perhaps most importantly, women have historically lacked advocates to
promote their agendas, needs, and demands among policy makers.
However, it has been argued that one national organization above all
others could advocate and overcome the reasons for low prioritization
of womens health care, namely the national professional associations
of obstetrics and gynecology [2].
The Partnership for Maternal, Newborn and Child Health recognized
the potential contribution that health professional associations can
make in a statement in 2007: Strong professional organizations provide
leadership. They set standards of education, practice and professional
competency assessment, and can work together with governments
and other stakeholders in setting and implementing health policies to
improve the health of women, newborns, children and adolescents.
However, the ability of professional associations to make such contributions depends on individual organizational and institutional capacities
at country level. This is especially true in resource-poor settings,
where the vast majority of maternal, newborn and child deaths and
morbidity occur [3].
Arising out of that stimulus, FIGO developed the organizational capacity of the national obstetric and gynecologic associations operating
in eight African and Asian countries through its Leadership in Obstetrics
and Gynecology for Impact and Change (LOGIC) Initiative in Maternal
and Newborn Health [4]. Participating in this initiative enabled the
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D.J. Taylor / International Journal of Gynecology and Obstetrics 131 (2015) S71S74
national associations to contribute to improvements in maternal health

policy and practice.
2. The FIGO LOGIC Initiative
The eight participating professional associations recruited to
FIGO LOGIC were: the Society of Gynaecologists and Obstetricians
of Burkina Faso (SOGOB) [5]; the Society of Gynecologists and
Obstetricians of Cameroon (SOGOC) [6]; the Ethiopian Society of
Obstetricians and Gynecologists (ESOG) [7]; the Federation of
Obstetric and Gynaecological Societies of India (FOGSI) [8]; the Mozambican Association of Obstetricians and Gynaecologists (AMOG)
[9]; the Nepal Society of Obstetricians and Gynaecologists (NESOG)
[10]; the Society of Gynaecology and Obstetrics of Nigeria (SOGON)
[11]; and the Association of Obstetricians and Gynaecologists of
Uganda (AOGU) [12]. The FIGO LOGIC Initiative had three clear objectives to support the mission of these associations: (1) to strengthen
their capacity to be effective organizations; (2) to inuence national
policies on maternal and newborn health; and (3) to work to improve
clinical practice in the area of maternal and newborn health.
2.1. Capacity building
The main approach to strengthening organization capacity was
through the Organizational Capacity Assessment (OCA) and Organizational Capacity Improvement Framework (OCIF) of the Society of Obstetricians and Gynaecologists of Canada (SOGC) [13]. The approach
is strongly participatory, working with key stakeholders within the
associations, not only elected ofcers, but also senior management
and nance staff. It is based on a process of self-examination against
standards in repeated cycles of self-assessment, action, and learning.
The OCIF tool has many similarities to organizational audit/ assessment
tools used in health facilities in many countries, but it is used as a selfassessment tool to ensure ownership, both of the issues identied but
also for achieving change to rectify them. The tool enables the team undertaking the initial assessment to score against each standard and for
scores to be consolidated by clusters in the following ve areas: culture,
operational capacity, performance, external relations, and function.
A review of the pre- and post-initiative OCA results indicated that all
the associations made improvements with major gains in all areas. In
the core dimension of culture, the associations proved successful in enhancing considerably their associations vision, mission, and values. In the
core dimension of operational capacity and function, enhanced capacity was noticeable in the areas of strategy and nancial management,
where four of the seven associations started from a very low baseline
(Burkina Faso, Cameroon, Mozambique, and Nigeria) [9]. In the core dimension of function, strengthened capacity was particularly in the
areas of advancing professional practice, which feeds off the innate expertise of the ofcers and members of the associations. More modest gains
were made in the core dimensions of performance and external relations/how the association is perceived. Specic successes were
witnessed in the formulation or updating of a strategic plan; review of
the constitution; the development of nancial strategies; improved nancial management systems; increased membership; updated members directory; increased income to the associations, for example through
follow-up of payment by members; improved skills in grant writing;
postgraduate training; holding training courses, workshops, and conferences; better communication with members [10]; publication of newsletters; and review and/or dissemination of code of ethics.
2.2. Policy inuence
The improved operational capacity of the associations led directly
and indirectly to an increased network and increased recognition as
stakeholders. This success created a larger environment, within which
they can inuence and determine maternal and newborn health at
national level and guide, accompany, mentor, and supervise at operational levels. Some general examples are given here.
All the eight participating associations signed a memorandum of
understanding (MOU) with their ministries of health [6] and, in addition,
signed MOUs with key partners. All became active members of governmental technical working groups and have regular scheduled opportunities to
inuence maternal and newborn health (MNH) policysignicantly more
than they did before the start of the FIGO LOGIC Initiative. Seven completed
advocacy training and have developed advocacy strategies.
The associations inuenced policy to achieve specic outcomes, such
as policies having been adopted or piloted, notably in relation to over
40 national guidelines and maternal death and near-miss reviews
(MD/NMRs). The associations also helped to raise public awareness
about MNH issues, such as the importance of skilled birth attendants
and attendance for prenatal care. Quantication of the attribution of association input is difcult as the associations form part of a wider group
of stakeholders. In any case, the fact that they belonged to that group of
inuencing stakeholders, and are explicitly recognized as such by a
wide range of stakeholders at national level, is a success in itself.
All the associations now have a functioning relationship with the
relevant departments and groups within the ministry of health in
their country. For example, the associations regularly attend technical
working groups and are recognized as important partners in the development of over 40 guidelines and policy documents. In many cases the
associations were the leading partner. In addition, FIGO LOGIC project
steering committees were enhanced to support these relationships in,
for example, Burkina Faso, Cameroon, and Ethiopia.
Although it was only formed in 2006, AMOG now sits on a number of
governmental committees and working groups, of which the Sector-Wide
Approaches (SWAp) group is the most important, since funding decisions
for MNH are taken here. This forum, in addition to AMOG having access to
the Cabinet and the Minister of Health, facilitated the presentation of
work undertaken by AMOG on the successful use of misoprostol in the
prevention of postpartum hemorrhage (PPH) in women delivering at
home. With Pathnder International, Venture Strategy International,
and the USAID Maternal and Child Health Integrated Program and
LOGIC, AMOG will be a leading partner in the roll-out of community
based self-administration of misoprostol for the prevention of PPH. In addition, AMOG plays a leading role in the development of clinical guidelines and maternal death review (MDR) policy in Mozambique.
AOGU, in collaboration with partners such as Save the Children
Fund, UNFPA, and the White Ribbon Alliance inuenced the First
Lady, the Ugandan Womens Parliamentary Forum, and a range of
Parliamentarians to lobby for increased funding to reproductive health
in Uganda. This advocacy resulted in the annual MNH health budget
being increased by $30 million to enhance the number and salaries of
health workers [12]. During FIGO LOGIC, AOGU became the leading
inuencer of a national policy in MNH through the Sexual and Reproductive Health guidelines in 2012 and AOGUs strength and effectiveness was recognized by being awarded the contract to lead a national
program of maternal and perinatal death reviews (MPDR) in 2013.
Arising out of the FIGO LOGIC project steering groups, three member associations (ESOG, SOGOB, and SOGOC) have developed effective
and respected multiagency platforms for sharing information, collaborating, and coordinating efforts in MNH. In Ethiopia, the Working
Group of Health Professional Associations and other partners meet
every six months. The organizations include ESOG, the Ethiopian
Pediatrics Society, the Ethiopian Nursing Association, the Ethiopian
Midwives Association, the Ethiopian Public Health Association, Addis
Ababa University, Health Science College, the Ethiopian Society of
Anaesthesiologists, the Ethiopian Medical Association, WHO, UNFPA,
UNICEF, the Packard Foundation, and the Federal Ministry of Health.
In 2012, the rst outcome of the group was recommendations about
key activities in behavior, change, and communication relating to maternal and newborn care, particularly at home deliveries. In Burkina
Faso, a similar body comprising SOGOB, the Mother and Child Health
Department at the ministry of health, WHO, UNFPA, UNICEF, Family

Care International, Jhpiego, and the professional associations of midwives, nursing, pediatricians, and anesthesiologists.
In Nigeria, SOGONs inuence and advocacy were effective on a
number of fronts. SOGON was a signicant inuencer in the development of the successful Midwifery Service Scheme, contributing to the
curriculum, training manual, and national training of midwifery returnees. SOGON has collaborated with other stakeholders in high-level
advocacy to the Executive and Legislative Arms of Government to support task shifting in maternity services. During 2012 and 2013, SOGON
has been working with the Federal Government on a strategy for a national program of MDRs [11]. This was nally ratied at a meeting of
the Federal National Council of Health in August 2013.
Several member associations identied developing relationships
with the media as a way of increasing public knowledge of MNH issues
and inuencing policy and increased investment. Four have achieved
regular exposure for public education (AOGU, ESOG, FOGSI, NESOG).
ESOGs work with the media was particularly extensive. Over 160 articles on sexual, reproductive, and maternal health have been published
in the weekly newspaper Addis Admas Saturday. A similar number
of items were broadcast on FM Addis 97.1 every Thursday morning to
an area within a 100-km radius of Addis Ababa. Recently ESOG has
started a radio broadcast on Radio Fana three days a week. AOGU published a series of articles in New Vision, a national newspaper. Of
particular note, was an article sensitizing the public about MDR and
specically calling for an end to the culture of blame associated with
maternal deaths. This article was in response to a minister calling for
all events of maternal death to be reported to the police. Hitherto,
NESOG in Nepal had given frequent, but irregular exposure to maternal
health topics in the press and media. NESOG now has an agreement
with Radio Segarmata for a radio broadcast on maternal health issues
three days a month. Recently NESOG developed a TV advert, which promotes the importance of girl child nutrition and a talk show on safe
motherhood. Of note, NESOG has completed a lm advocating action
against female feticide, which was launched by the Minister of Family
Health in August 2013.
2.3. Clinical practice improvement
Two instruments were selected by the associations to inuence
clinical practice: evidence-based guidelines and maternal death and
near-miss reviews. Over 40 national clinical guidelines/policy documents and training of health professionals were developed.
AMOG partnered with the ministry of health to develop a manual of
MNH guidelines related to family planning, emergency obstetric care,
prenatal and postpartum care, screening for cervical cancer, and comprehensive postabortion care. The third edition of the Sexual and Reproductive Health and Rights policy guidelines of Uganda published in
2012 was the result of the joint efforts of the ministry of health and
AOGU. This signicant document covers every aspect of reproductive
health, including family planning, maternity care, and cancer care.
SOGOB contributed over 30 chapters to the revision of the norms and
protocols in MNH and also contributed (as a full member of the steering
committee) to the evaluation of emergency obstetric and newborn care
(EmONC) conducted in 2011. SOGOB played a leading role in the issue
of a joint Declaration of Commitment by all major partners in MNH,
which declares to enhance maternal and newborn care through
improvements in compassionate care. Working with Family Care International, SOGOB is undertaking a national training program in this
endeavor. The participatory process encourages clinical staff to selfdiagnose the quality of their caring and respect for patients and their
relatives and then commits to a set of 10 behaviors compatible with respectful care. SOGOC provided training support for several government
priority areas in MNH, providing training for heads of district hospitals
(district level medical doctors) and anesthetic nurses to allow them
to cover emergency cesarean deliveries, training health providers to
S73
insert intrauterine contraceptive devices, and providing pedagogic

skills training for tutors of midwifery. SOGOC was the major contributor
to the development of the national midwifery curriculum for the eight
newly established midwifery schools and colleges. The renaissance
of midwifery in Cameroon comes after a 20-year period without
any educational/training centers for midwifery. FOGSI, with the
Government of India, revised the national curriculum for emergency obstetric care (EmOC) training. This was adopted and is being implemented across all 35 EmOC training centers.
Several of the member associations described improvements in
maternity services through implementation of maternal death and
near-miss review.
Mozambique has a multidisciplinary National Audit Committee for
Maternal, Perinatal and Neonatal Deaths devoted to the development
of MDRs, at which AMOG has two representatives. This Committee
oversees the activities of the provincial, district, and hospital-based
MDRs, processes, and documentation. With the support of LOGIC,
AMOG has played the leading role in harmonization of the data collection forms and training of clinical and allied staff in the processes.
The AMOG tool has been chosen for nationwide roll-out. With representatives from the ministry of health, AMOG visited South Africa in 2013
to explore the development of National Condential Enquires into
Maternal Deaths.
MPDRs were initiated in Uganda in 2006, since when AOGU has been
an active member of the National MPDR Committee. Through LOGIC,
AOGU extended MPDR to four regional hospitals, workwhich assisted
not only local improvements in carebut also led to AOGU being asked
to revise the national documents and tools, and then in 2013 being
contracted by the Government of Uganda to lead the national program
of MPDR. This program is being implemented initially in the 14 tertiary
regional centers. Plans are in place to extend reviews into the
surrounding communities, for which AOGU has been prepared and received training through LOGIC.
ESOG, with the Federal Ministry of Health of Ethiopia and the support of LOGIC introduced facility-based MD/NMRs in nine regional hospitals and their 45 satellite health centers. Impressive improvements in
care have been brought about, such as better case record information;
better note retrieval; extension of services to 24 hours, seven days a
week; the development of shift rotas; assignment and capacity building
of midwives; written referrals; improved linkages with health centers;
decreased unnecessary referrals; improved team spirit; increased use
of partographs; improved blood availability; initiation of intensive
care services in three centers; and the purchase of ambulances [7]. The
next challenge for ESOG is the integration of this successful program
into the MDRS system, which is being implemented in Ethiopia.
FOGSI, with other partners, had assisted the Government of India to
develop a system and guidelines for MDRs. With LOGIC support, FOGSI
piloted the tools and systems in two districts of Rajasthan, Jhunjhunu
and Sikar. Training of 3392 staff was undertaken in 155 sectors, two
district hospitals, two subcenters, and 34 primary health centers. The
ndings were analyzed and presented to the district and state authorities and the systems modied in response. Arising out of this work,
FOGSI developed software for data capture and reporting of MDR,
which has been inserted and incorporated into the national maternal
and child health tracking systema major achievement [8]. In addition,
the visionary step of developing a national NMR program was undertaken by FOGSI, with the support of LOGIC and the Government of
India. The denitions, criteria, tools, and guidelines have been developed and are now being piloted in six medical colleges.
MPDRs are well established in Nepal. With LOGIC support, and
with the Family Health Department, NESOG has developed a novel
program of NMR in 14 facilities in the Kathmandu valley, with a view
to national roll-out.
SOGON with governmental, UN agencies, donors, and professional
partners received training in MDRs through two training workshops
under the auspices of LOGIC. SOGON then devised a curriculum and
S74
strategy for the national roll-out of MDRs, which was taken to the
Federal Ministry of Health. The Federal strategy was approved in August
2013. The program is to be piloted in six states with the support of a
new donor to the tune of US $300 000.
Through LOGIC, SOGOC developed MDRs in Cameroon, initially in
Yaounde, Douala, and Bertoua. With the Ministry of Public Health,
WHO, and UNFPA, SOGOC has developed a national curriculum and
training manual based on those devised by the Institute of Tropical
medicine, Antwerp, Belgium, on behalf of LOGIC [14]. This work of
SOGOC has been catalytic in incorporating MDRs as a component of
Cameroons Campaign on Accelerated Reduction of Maternal Mortality
in Africa (CARMMA) in 2013.
SOGOB piloted MDR in three facilities at three different levels of
the health system. They actively engaged with other partners involved
in similar approaches, and contributed to the now nationally agreed
MDR guidelines and training curriculum. Together with its partners,
the ministry of health is now rolling this curriculum out to every health
facility in the country. SOGOB has the specic responsibility to train the
trainers and mentor teams that have recently introduced MDR in their
facilities. SOGOB was instrumental in organizing the rst review of the
roll-out process in 2013.
3. Conclusion
The FIGO LOGIC Initiative has demonstrated that external support of
national professional associations of obstetrics and gynecology, over a
relatively short period of time, can signicantly enhance their internal
organizational capacity. From this base, the organizations developed
effective working relationships with the appropriate departments and
groups within the ministry of health within their countries, developed
functioning networks, and enhanced their reputations at national and
international levels. The associations are now better equipped to enhance maternity care within their countries and have begun to do this
through the development of national guidelines and policies, clinical
training, and national programs of maternal and near-miss reviews.
Acknowledgments
The FIGO LOGIC Initiative was supported by a technical advisory
group that comprised the following membership: Prof. Hamid Rushwan
(Chair), Prof. Sir Sabaratnam Arulkumaran, Prof. Gamal Serour,
Prof. Dorothy Shaw, Dr Andre Lalonde, Dr Will Stones, Prof. Zul Bhutta,
Dr Ann Blanc, Prof. Peter von Dadelszen, Dr Garry Dearden, Ms Abigail
Kyei, Prof. Gwyneth Lewis, Mrs Liette Perron, and Dr Beverly Winikoff.
FIGO are grateful to the Society of Obstetricians and Gynaecologists of
Canada, the International NGO Training and Research Centre, Mango,
and Bond for International Development for their support in capacity

building; to Prof. Gwyneth Lewis, Prof. Vincent De Brouwere,
Prof. Carine Ronsman, Dr Veronique Filippe, Dr Alberta Bacci, Dr Therese
Delvaux, and Peter Byass for the development of maternal and near miss
reviews; to Prof. Jim Neilson for his support of systematic reviews and
guideline development; and to the Bill and Melinda Gates Foundation
for funding the FIGO LOGIC initiative.
Conict of interest
The author has no conicts of interest.
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This edition of the World Report on Women's Health

World Report on Womens Health 2015

Official publication of FIGO

Guest Editors: Chittaranjan Narahari Purandare,

International Journal of Gynecology & Obstetrics

Volume 131, Supplement 1

World Report on Womens Health 2015

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The Secretariat of FIGO is at FIGO House, Suite 3,

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FIGO Staging of Gynecologic

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The unfinished agenda of womens reproductive health

Strengthening accountability to end preventable maternal deaths

Emergency obstetric care: Making the impossible possible through

Implementation of maternal death surveillance and response (MDSR) is key to strengthening

P. von Dadelszen, L.A. Magee,

Moving beyond silos: How do we provide distributed personalized

M. Hod, E. Hadar, L. Cabero-Roura

Prevention of type 2 diabetes among women with prior gestational

N.C. Ngene, J. Moodley

New drug regimens for HIV in pregnancy and a national strategic

Quality assurance: The 10-Group Classification System (Robson

Cancer of the cervix: Early detection and cost-effective solutions

HPV vaccination: The most pragmatic cervical cancer primary

A historic and scientific review of breast cancer: The next global

J.L. Morris, H. Rushwan

Adolescent sexual and reproductive health: The global challenges

N. Akseer, J.E. Lawn, W. Keenan,

Ending preventable newborn deaths in a generation

The global epidemic of abuse and disrespect during childbirth: History,

Disrespectful/abusive/coercive care in maternity facilities has been indirectly and directly

A.G. Mark, M. Wolf, A. Edelman,

What can obstetrician/gynecologists do to support abortion access?

A. Fandes, I.H. Shah

Evidence supporting broader access to safe legal abortion

R. Joshi, S. Khadilkar, M. Patel

Global trends in use of long-acting reversible and permanent methods

Global efforts for effective training in fistula surgery

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problem, they do not provide sufcient information for targeted action