Why do we need obstetricians and gynecologists?

<p class="article-intro">Humanitarian crisis are characterized by many challenges. Among them are the safe access to basic needs, communication, safety, lifesaving health care including reproductive health care, prevention and response to sexual violence, reduction of HIV transmission, identification of vulnerable individuals with specific needs (children, minors and disability), education for young people, and provision of economic opportunities. But among these challenges, maternal health – deliveries – is a daily emergency.</p> <p class="article-content"><div id="keypoints"> <h2>Personal background</h2> Nelly Staderini has been a medical referent in MSF Switzerland for 7 years, based in Geneva. After many years on the field in various context and positions (Cambodia, Afghanistan, Pakistan, Chad and Burundi) she is currently advising on sexual and reproductive health issues in more than 15 countries, in humanitarian crisis, a third being conflict situations. She has been recently visiting MSF intervention in conflict settings such as Chad, Syria and Irak. She was invited in June 2017 to the SGGG congress by the working group of Humanitarian action to give a talk in Lausanne, highlighting the need of obstetricians on the field. This article is based on her presentation.</div> <p>About 56 % of maternal and child deaths take place in fragile settings. Women and children are up to 14 times more likely than men to die in a disaster. For every person killed directly by armed violence, between 3 and 15 die indirectly from diseases, medical complications and malnutrition.<br /> Saving mothers&rsquo; life is a priority as 800 women die every day due to complications in pregnancy and childbirth. The reduction from 523 000 deaths in 1990 to 289 000 in 2013 is already a great achievement, but the most dangerous place for a women to have a baby is still in sub- Saharian Africa where the lifetime risk of dying during pregnancy and childbirth is 1/40 compared to 1/3300 in Europe.<br /> Increased incidence of neonatal death, preterm delivery and increased number of infants with intrauterine growth restriction, low birth weight and a small head circumference are seen in disasters.<br /> More than 15 % of pregnant women experience complications that are often not predictable. Access to emergency obstetric care services for all pregnant women is important and key interventions need to be provided to answer to the five main causes of maternal death.</p> <h2>The main causes of maternal death</h2> <p>What the women are dying from has been known for years: starting with 27 % of severe bleeding, 14 % of pregnancy-induced high blood pressure, 11 % of infection &ndash; mostly after childbirth &ndash;, 9 % of obstructed labor and other direct causes, 8 % of abortion complications, 3 % of blood clots and 28 % of pre-existing medical conditions exacerbated by pregnancy (HIV, malaria, diabetes and obesity). What is needed to save those lives is also known: emergency obstetrical care including safe blood supply, essential medicines such as antibiotics and oxytocin, safe abortion services and availability of counselling and a range of contraception methods (WHO).¹<br /> Maternal death worldwide is linked to a series of delays starting at the community side: recognition of the problem and decision to seek care, transport to care, receiving quality care at first and secondary levels of care including caesarian section option. To prevent those delays, some work needs to be done starting with birth preparedness, sensitization and mobilization. Referral systems and financial incentives, antenatal risk screening and even sometimes maternity waiting homes are key components of projects that target reduction of maternal mortality and morbidity. Then investment in skilled birth attendance for emergency obstetrical and neonatal care including neonatal resuscitation is a key strategy to be able to respond quickly in any emergency crisis.<br /> But most of the time countries in conflict have less than half the minimum number of recommended health workers to be able to answer those needs.</p> <h2>MSF, a medical emergency organization</h2> <p>Created in 1971 &ndash; the Biafra crisis in Nigeria &ndash; by medical doctors and journalists, the first objectives of the organization are to provide health care and carry out awareness and advocacy. In the 2015 annual report of MSF more than 8 million consultations were done worldwide (2.3 million related to Malaria and 600 000 antenatal consultations), 600 000 hospitalizations including 220 000 deliveries and 83 000 surgical interventions were provided. 37 000 employees (84 % national staff) are working in more than 64 countries (450 projects). To be able to keep the main principles of the institution alive (neutrality, independence and impartiality) 92 % of the 1.4 billions budget are private funds (5.7 millions private donors).<br /> MSF is working mainly in Africa (60 % ), and 30 % of the work is done in conflict settings.<br /> Severe constrains are faced in armed conflicts or natural disasters contexts such as poorly or nonfunctioning health facilities, lack of drugs and equipment, disrupted referral systems, shortage of skilled medical professionals, insecure environment as well as emergency and complexity are the top challenges to take up.</p> <h2>Sexual and reproductive health strategies in emergency situation</h2> <p>More than 200 000 deliveries yearly are assisted directly by MSF worldwide. Obstetric needs are considered a priority in terms of lifesaving interventions and to be able to answer, the appropriate human resources for the specific medical needs are important. But the lack of appropriate staff is a key challenge to address the quality of the interventions.<br /> As a minimum package of sexual and reproductive health in emergency, the provision of live saving services such as emergency obstetrical and neonatal care including post-abortion care are essential. Services to answer the medical needs of sexual violence are generally added in this package &ndash; as women who experience disasters for example are at an increased risk of sexual assault &ndash; but need to be addressed to men and children as well. The basic services that need to be available are antenatal consultation, normal deliveries, treatment for postpartum complications, treatment of reproductive tract infection, safe abortion care and contraception.<br /> At project level, midwives are mainly managing normal deliveries, neonatal care and resuscitation and recognize early the complications, provide emergency management and refer complicated cases. Obstetricians are also needed to identify and manage those complicated pregnancies and deliveries. In some contexts, task shifting to less specialized staff than midlevel providers is done: national doctors with surgical competencies or general surgeons performing caesarian delivery, midwives performing instrumental deliveries and manual vacuum aspiration, nurses administering magnesium sulfate for eclampsia and misoprostol to prevent postpartum hemorrhage, nurse-aides providing intrapartum supervision to enable midwives or doctors to handle obstetric emergencies.<br /> The two human resources scenarios for an optimal emergency obstetrical and neonatal care are: midwife and general surgeon and in this case the team is more polyvalent but can have a lack of obstetrical skills that could have an impact on proper and timely indication of caesarian section related to task shifting to midwives beyond their expertise. The second scenario is midwives and an obstetrician that is less polyvalent but that can address all range of obstetrical skills with a functioning task shifting to the midwives under proper supervision.<br /> The place of the obstetrician is highly valuable for obstetric procedures such as caesarian section (technique and indication), assisted vaginal delivery, embryotomy, breech, twins, vaginal birth after caesarian section, full management of postpartum hemorrhage or sexual transmitted diseases.<br /> But obstetricians can face many challenges in the field such as: availability for short periods of time (often no more than a couple of months), a significant clinical obstetric experience is requested to be the referent person for complex cases, ability to work in a multi-disciplinary team within a comprehensive approach of the emergency, ability to work under stressful conditions, solution-oriented thinking, flexibility, diplomacy and cross-cultural awareness.</p> <h2>Experiences of sexual and reproductive health in emergency crisis²</h2> <p><strong>Chad</strong><br /> Two years ago, MSF started to support the Governmental Hospital in Bol because of the insecure environment (Boko Haram area): supporting a maternity with less than 50 deliveries per month, but still after one full year of support one or two maternal deaths are seen every month. Main challenges are the lack of national doctors and the problem of motivating the staff, but also the delays that women are facing to access quality care services. MSF started few months ago a new community strategy that will allow us to work more closely with traditional birth attendants at village level since the maternal mortality in such context needs a holistic approach. How many years of investment are needed to get results is a question that should drive decision makers as most of the time short term interventions will not answer to the complexity of the situation and some cultural changes need to happen, but can take a lot of time. This is an illustration of the dilemma faced sometimes by MSF as an emergency organization.<br /><br /> <strong>Syria</strong><br /> MSF has supported the maternity &ndash; 2500 deliveries assisted in 2.5 years &ndash; in a governmental hospital in North East Syria and no maternal deaths have occurred. The caesarian section rate was reduced from 40 % to less than 20 % in this period of time with appropriate diagnosis for surgical intervention. See graph 1 for the indication of caesarian section.<br /> Other projects are ongoing with two other maternities and access to free caesarian section in this context is a priority as this intervention can be very costly for the patients and not always related to medical needs.<br /><br /> <strong>Irak</strong><br /> Two MSF maternities (one in a Syrian refugee camp in Dohuk and one in Ninewa Governorate, both north of Mosul) have been there for months. In 2017, two more emergency interventions with sexual and reproductive health intervention, both in the city of Mosul &ndash; in two very different parts of the city &ndash;, have been initiated.<br /> On the east side of the city, it was a short emergency intervention (526 deliveries including 130 caesarian section) as the private system restarted fast after the end of the battle (Table 1): 24 hours activities has started in week 9 with the surgical capacity (including caesarian section option), in week 15 the activity at governmental hospitals has started again, and the end of the international staff was in week 19.<br /> This summer the other project in Mosul West began in a very challenging environment with weekly increasing activities up to now.<br /> The medical challenges faced so far in this Middle East context are the high caesarian section rate (33 % ) &ndash; mostly indicated by previous caesarian section &ndash;, the lack of infection prevention and control (even wearing gloves for vaginal exam), the routine episiotomy and general anesthesia and lack of good data documentation.</p> <p><img src="/custom/img/files/files_datafiles_data_Zeitungen_2017_Leading Opinions_Gyn_1703_Weblinks_s22_gra1.jpg" alt="" width="1417" height="817" /></p> <p><img src="/custom/img/files/files_datafiles_data_Zeitungen_2017_Leading Opinions_Gyn_1703_Weblinks_s22_tab1.jpg" alt="" width="1417" height="750" /></p> <h2>Beyond MSF</h2> <p>Research on reproductive health in emergency conducted a few years ago, had highlighted challenges perceived by aid workers implementing reproductive health programmes during humanitarian crises. The results of the study were that challenges to implement reproductive health are diverse and multi-layered. As for example, a lead person does not necessarily facilitate collaboration and collaboration does not necessarily lead to implementation. Disagreement, fragmentation and political as well as economic changes have hampered further development of reproductive health. Joint agreement, dedication and strong commitment from all participating parties are fundamental for increasing awareness and attracting funding. Awareness and funding will, in turn, facilitate recruitment of staff and acquisition of medical supplies.<br /> The results on common barriers to implement reproductive health (found in 13 studies) were analyzed and the main challenges were lack of coordination, collaboration, medical goods and specialized staff. Other problems included lack of funding, priority given to those services or lack of awareness has also been mentioned.</p> <h2>Conclusion</h2> <p>In crisis situation the focus for sexual and reproductive health needs to be on emergency obstetrical (including caesarian section option) and neonatal care as lifesaving interventions. As many pregnancies seen are unplanned or unwanted for many reasons, increased access to contraception and safe abortion care are two other key interventions to reduce maternal mortality. Those activities need to be highlighted as priority interventions, need specific attention in terms of coordination, funding and medical expertise such as midwives and obstetricians.</p></p> <p class="article-footer"> <a class="literatur" data-toggle="collapse" href="#collapseLiteratur" aria-expanded="false" aria-controls="collapseLiteratur" >Literatur</a> <div class="collapse" id="collapseLiteratur"> <p><strong>1</strong> Say L et al.: Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2: e323-33 <strong>2</strong> Information shared from internal MSF reports</p> </div> </p>