6 World Health • 51 st Year, No. l, January-February 1998
The challenge to obstetricians
Mahmoud F. Fathalla
Women have a right to safe motherhood. Obstetricians have an indispensable role to play in making it happen.
They should take up the challenge.
I
n the professional career of an obstetrician, there is no more tragic event than a maternal death. Most obstetricians in devel- oped countries are fortunate enough to end their professional career without witnessing such a tragedy.For those practising in developing countries, however, maternal mor- tality is not an academic subject of numbers and words. It is about women who have names. It is about human beings in deep distress, whose faces may live forever in our memory and haunt our dreams.
These women, in the prime of life, die at a time that should be one of expectation and joy. They experi- ence one of the most terrible ways to die: bleeding to death, the convul- sions of eclampsia, the agonies of obstructed labour, severe infection after delivery, or unsafe abortion.
Even more distressing for an obste- trician is the fact that a maternal death is a tragedy which should not have been allowed to happen. In most cases, it can be avoided.
A risky business
In Tanzanian folklore, an expectant mother tells her older children, "I am going to the sea to fetch a new baby.
The journey is dangerous and I may not return." She is right: many
A health centre in Egypt, where women are given advice on the use of contraceptives. Family planning contributes to safer motherhood. Photo WHO/P. Rouleau
women do not return. Every preg- nant woman is at risk. There is no way to prevent or predict all possible life-threatening complications of pregnancy and childbirth. However, with the knowledge we now have, complications are detectable and they can be effectively managed.
The exposure to risk is not lim- ited to poor women. From the expe- rience of developed countries, we know that socioeconomic develop- ment in itself has only a limited impact on safe motherhood.
Maternal mortality in most European countries did not decline until after 1930, when advances in medicine at last started to become available on a large scale. Obstetric care is needed to make motherhood safe.
The road to safe motherhood
An estimated 585 OOO women die every year because of complications of pregnancy and childbirth. A further million survive complica- tions but suffer from the conse-
quences. This is a health scandal of our time, since almost all of the deaths and suffering are avoidable.
In many countries, maternal mortal- ity is now seen as a thing of the past.
A road to safe motherhood exists, but ensuring that it is open to all women depends upon the commit- ment of both their own societies and the international community. First, safe motherhood should be recog- nized as a human right. Societies have an obligation to protect women's right to life while they are in the risky process of giving life.
Second, safe motherhood should be recognized as a sensitive indicator of whether women enjoy their rightful status in society. When societies underestimate women's worth, they are less likely to invest in their health and welfare, particularly in poor areas.
On the road to safe motherhood, three specific service stops need to be available. At the first stop, women exposed to pregnancy must be provided with family planning services. They need access to infor-
World Health • SlstYeor, No. l, Jonuory-Februmy 1998
mation as well as the means to regu- late and control their fertility. They also need to be empowered to use them. Risks of pregnancy and chjld- birth recur with every pregnancy.
The lifetime risk of pregnancy and childbirth depends on how many times the woman gets pregnant. In addition, an unwanted or unplanned pregnancy may often take place at the wrong time. It may occur at a period which is not optimal, from a health and social point of view, for the mother and child. Where safe pregnancy termination services are not readily available, women have to resort to unsafe abortion for an un- wanted pregnancy, introducing an additional serious risk.
At their next stop on the safe motherhood road, women should be provided with access to community- based maternity services (during pregnancy, during delivery and after delivery). Although the complica- tions of pregnancy and childbirth are not always preventable or
predictable, community health work- ers at the primary health care level can detect the early danger signals.
Early detection will allow safe and effective management at the referral level.
For those at risk of life-threaten- ing complic·ations the third stop is needed. The essential obstetric func- tions have to be accessible at the first referral level. Efficient arangements for emergency transport should be in place, to take women to where they can get help.
An expanded role for obstetricians
Obstetricians need to expand their role to meet the challenge of safe motherhood. The role of the special- ist will continue to be essential for the management of complications of pregnancy and childbirth detected at the primary health care level. Yet it is not enough.
All mothers need basic maternity care. They can only achieve univer- sal access to services if obstetricians play the responsible role of team
Doctors are team leaders, and can play a ma;or role as social advocates of safe motherhood Photo Keystone/Camera Press/ A Edwards ©
leaders. Health workers should provide services, wherever appropri- ate, close to the community.
Obstetricians should train, support, delegate and supervise.
Obstetricians also need to play the role of social advocates. They should advocate the allocation of appropriate resources for women's health, and for the best use of these resources. They can help to make essential obstetric functions accessi-
7
ble and available at the first referral level in a cost-effective way. In most situations, the cost of doing this is marginal in that it only involves adding specific services to the exist- ing infrastructure. Reallocation of existing resources can meet some of these costs. For allocating additional resources, societies must honestly answer the question, "How much are mothers worth?".
The International Federation of Gynecology and Obstetrics has recently established a "Save the Mothers Fund" to help obstetricians play an additional active role. Its objective is: "to demonstrate through action and document through re- search, at the district level, in as many communities as resources will permit, that the lives of mothers can be saved, and that many lives can be saved at a cost that is affordable to any society that upholds women's right to life". •
Dr Mahmoud F. Fathalla, Professor of Obstetrics and Gynaecology, is a former president of the International Federation of Gynecology and Obstetrics (FIGO}, and a former director of the Special Programme of Research, Development and Research Training in Human Reproduction cosponsored by UNDP, UNFPA, WHO and the World Bank.
His address is P 0. Box 30, Assiut, Egypt.
A baby born by caesarean section in Sri Lanka. Obstetricians play a key role in the management of pregnancy and childbirth complications. Photo WHO/L. Cashew
