Childbirth-related maternal mortality represents a major loss within families and communities around the world. Yet the 400,000 maternal deaths that occur annually are largely preventable. The most common cause of death is postpartum hemorrhage, followed by hypertensive disorders (eclampsia), sepsis, obstructed labor, complications of unsafe abortion and concurrent diseases such as HIV or malaria. Modern medical management can help eliminate the mortality associated with these conditions, as evidenced by the comparative maternal mortality in developed and developing countries—17 vs. 290 maternal deaths per 100,000 live births respectively. Deaths are particularly high in sub-Saharan Africa and South Asia. Although the maternal death rate in poor countries is declining at a substantial rate, it will not come close to meeting the UN’s 2015 Millennium Development Goal of a 75% reduction from 1990.
A similar situation exists for perinatal mortality (newborn deaths plus stillbirths). There, the death rate in developing countries is five-fold higher than in advanced ones. Most of these deaths reflect poor maternal care. The parallel with maternal deaths should come as no surprise even if not as dramatic. Perinatal health is directly related to maternal health and perinatal deaths stem from similar conditions, including women’s early and frequent pregnancy, poor maternal nutritional status, inadequate prenatal care, mismanagement of the complications pregnancy and labor, and unsanitary conditions during and after delivery. Improving maternal health therefore greatly reduces perinatal deaths.
An ideal group to attempt to bridge this health divide would be the gynecology/obstetrics physicians in resource-limited countries. They are, however, thinly stretched and poorly organized. The London-based International Federation of Gynecology and Obstetrics (FIGO) has come up with a project to improve this situation. Known as LOGIC (Leadership in Obstetrics and Gynecology for Impact and Change), this initiative focuses on high birth mortality countries whose ob/gyn associations could gain greater public health leverage with sufficient training and support.
Rushwan Hamid, FIGO’s executive director says, “In 2007, we appealed to the Gates Foundation on how best we could engage our member associations on the ground. We decided to concentrate on influencing government health policies. We hadn’t mobilized our member associations before. They may be small, but they have a strategic position since they are the ones to implement health programs.”
LOGIC emerged from FIGO’s previous “Saving Mothers and Newborns Initiative,” which was funded by the Swedish International Development Co-operation Agency. This program was a less focused effort than LOGIC. It worked with FIGO’s member associations in ten low-income countries, letting each choose its own four-year project to improve pregnant women’s and/or newborn’s health. The local midwifery associations were also involved in eight of the countries.
Each of the initiative’s associations received mentoring from a FIGO member association in a developed country, most frequently the Society of Obstetricians and Gynaecologists of Canada or the Royal College of Obstetricians and Gynaecologists in the UK. These projects generally included implementing new guidelines, training and provision of essential and emergency care. The Haitian ob/gyn association developed a maternity hospital outside of Port-au-Prince and maintained its operations after the catastrophic 2010 earthquake. Uruguay’s project involved advocacy and training to minimize the health problems stemming from illegal abortions.
Mortality reviews, in which physicians and midwives report the details of maternal and newborn deaths, were one of the central strategies employed by several projects. Using these reports as a basis, health care personnel meet on ways to avoid future deaths.
Setting up the LOGIC Initiative
FIGO learned through the Saving Mothers and Newborns Initiative that its support can help member associations significantly reduce maternal and newborn mortality. The association members’ experience with the Initiative enhanced their skills and morale, moving them away from a “social club” atmosphere. FIGO also learned that there is a danger in spreading its funding too thinly. LOGIC is therefore a streamlined initiative centered on furthering the associations’ leadership role.
LOGIC’s main goal is to strengthen the organizational capacity of eight member associations in low-income countries. The associations develop the strength to move directly and through government channels to influence the quality of maternal and newborn health delivery. The associations’ dialogue with health policy makers and other stakeholders will require the ability to generate sound, evidence-informed proposals that justify making maternal and newborn health a priority for new investment. To be influential, the associations will have to produce proposals fleshed out with detailed operational plans and specific milestones. They then seek to become active players in implementing, monitoring and evaluating those plans.
Bart Vander Plaetse, LOGIC’s Senior Management Specialist, says, “The intention is to create powerful organizations that play strong roles in their countries. Often the member organization is isolated in the capital’s central hospital while mothers die mostly elsewhere in the country. We need to make sure that the member association is engaged at the highest political level but also in touch with countries’ issues.”
To start, FIGO in 2009 selected eight member associations in Africa and Southern Asia with a wide range of resources: Burkina Faso, Cameroon, Ethiopia, Mozambique, Nigeria, Uganda, India and Nepal. They were chosen based on their high level of maternal mortality and their ability to use LOGIC support in synergy with other programs, including other Gates-funded programs. Hamid says, “Some associations existed in name only. They now have offices and staff but need more nurturing. India and Nepal are strong, and we are doing a good job over there. Some of the African countries are excellent, too.”
The realization that the policy component requires a base in clinical data led LOGIC to encourage initiation or expansion of the maternal-newborn death reviews. Vander Plaetse deems them “a catalytic activity.” Recording how deaths actually occur in the field leads to new care recommendations and guideline updates.
To institute death reviews in areas where none occurred before, the LOGIC-participating association forms a review committee in one or more hospitals. The staff who managed the case later go over the situation and discuss how the death could have been prevented. The results are then presented to other staff anonymously. Two common recommendations are better supply of necessary medications and shortening the time between decision for surgery and the procedure itself.
One possibility is to authorize lower level staff to perform certain interventions. After this pilot death review program, the goal would be to work with the government to scale up the maternal and perinatal death reviews to become a national mortality audit. LOGIC participants are already working with their governments to do this in three countries. They are training large numbers of health care providers on how to properly record the review information. Ideally the nationwide scale-up would also entail an independent national review committee.
The LOGIC associations also advocate around more general issues that would lower maternal and perinatal mortality – more funding, better training, and greater access to new drugs. The associations would like to work with the Ministries of Health in training staff and executing these general measures.
One specific drug whose access the LOGIC participants would like increased is misoprostol for postpartum hemorrhage. In contrast to the standard drug, oxytocin, misoprostol is oral and inexpensive. Even traditional birth attendants outside hospitals can administer it, if necessary. The potential for such task-shifting has created some resistance in global professional circles, which are calling for more studies of misoprostol’s safety and effectiveness in the field.
To assist the local ob/gyn associations, the LOGIC team at FIGO headquarters provides technical guidance and oversight through periodic meetings and monthly calls. Weaker associations are linked with other groups working on the same issues. LOGIC also conducts training sessions in financial management, advocacy and project management. The advocacy trainings help shape the associations’ priorities and enhance their ability to write policy papers and interact with the news media.
Developing Organizational Synergies in Uganda
One of the strongest LOGIC programs is in Uganda, where that country’s Association of Obstetricians and Gynaecologists (AOGU) began in 1985 as a social group. It has grown over the years into an officially recognized professional association with elected executive officers. The Association’s LOGIC team includes a supervisor, a program coordinator/manager and an administrative assistant. It works with AOGU membership and the Ministry of Health plus parliamentary representatives, the news media and the branches of such international nonprofits as the White Ribbon Alliance for Safe Motherhood and Save the Children. There is also an ongoing partnership with the Society of Obstetricians and Gynaecologists of Canada as a result of the previous Saving Mothers and Children Initiative.
AOGU as a result has developed greater capacity to cooperate with other groups in advocacy, training and winning grants. AOGU specifically has allied with other Ugandan medical associations—the Uganda Paediatric Association, Uganda Medical Association, and Uganda Society of Anaesthesiologists—to further LOGIC’s goals. Most importantly, AOGU has partnered with two midwifery associations, the Uganda Private Midwives Association and the African Midwives/Nurses Association.
AOGU’s relationship with the Ministry of Health has evolved in the course of the initiative. Daniel Murokora, program manager for LOGIC in Uganda and past AOGU president reports, “The Ministry of Health relationship with AOGU is great—we have been engaged in various ways in almost all reproductive health programs. We are invited to key events, and our opinion sought on key issues, such as maternal death audits.” The AOGU is a sitting member of the Maternal and Child Health, the Maternal and Perinatal Death Review, and the HIV committees. AOGU and the Ministry have also developed a memorandum of understanding (MoU) allowing the Association to implement reproductive health activities on the Ministry’s behalf.
The administrative system still needs to become more response to clinical needs in the maternity units. There are delays in policy implementation because of poor funding and shortages of human resources on both the Association’s and the Ministry’s part. The AOGU remains a small membership organization with a constricted financial base. It does not have physicians available to work on everything it would like to do. Murokora reports, though, that along with strengthening AOGU’s leadership team, LOGIC has contributed to an increased sense of belonging among the slowly increasing membership.
“It would be nice to be able to add clinical mentorships in obstetrics and gynecology to all health facilities,” Murokora muses. With an overall shortage of specialists, ob/gyn training is needed to make the corrections implied by the death audit results. But such mentorships would require the resources to enable gynecologists to stay in a single health facility rather than move around.
Starting from Scratch in Mozambique
The Mozambique Association of Obstetricians and Gynecologists (AMOG) was in a much weaker condition than the Ugandan one. Still experiencing the legacy of a bloody 15-year civil war, the country is very poor and has considerably higher maternal and perinatal mortality rates. AMOG itself began only two years before LOGIC started. “When LOGIC arrived, we had no ability,” says Cassimo Bique, AMOG’s treasurer. “LOGIC gives us a chance by having experts come to Mozambique. It gave me an office, too. Before, the office was a bag.
Two experts came to review the tools for reviewing maternal and perinatal deaths. One expert from Canada helped us with organizational and strategic plans. Also, LOGIC systemized our finances and administrative activities – we now have two assistants.”
AMOG has developed a five-year plan with LOGIC’s support that goes beyond the mortality reviews to actually making improvements. It has signed a Memorandum of Understanding (MoU) with the Ministry of Health to help supervise local hospitals and train staff in rural areas as well as to implement the death reviews.
The Association finds that in general it has greater access to the Ministry, which looks to it for help, specifically in writing guidelines and running workshops on cervical cancer. Fetal deaths are another area. Uterine removal of expired fetuses is supposed to employ vacuum aspiration, but rural facilities are not capable of performing this procedure. One alternative is, again, misoprostol, which causes uterine contractions. AMOG is studying its use in this area with Ministry approval.
To improve access to care, AMOG is establishing an initiative to train nurses and midwives in surgical skills so that they can treat infections and the women do not need to be referred elsewhere. Task-shifting is an essential tactic in Mozambique to compensate for the lack of ob/gyns. “LOGIC will help in the future with implementation,” says Bique. “We need the capacity to go to the provinces to see if they institute guidelines and use the tools we provide.”
Aside from the dearth of skilled medical providers, a further hindrance AMOG’s plans is that there is a separate national obstetricians’ society. Bique relates, “We are discussing with that society about working on neonatal health. We are telling them to work with Ministry to get an MoU. Then they can get working, and we can work with them.”
In 2010, the USAID sponsored a survey of hospital obstetrical practices in Ethiopia. Ethiopia is a LOGIC country, and FIGO’s local member association, the Ethiopian Society of Obstetricians and Gynecologists (ESOG), helped organize the survey. The final survey report showed how much work ESOG and LOGIC have ahead of them. The study found the quality of care was substandard for women in labor and newborns. Only 29% of the facilities managed postpartum hemorrhage risk according to international guidelines. Adequate management of other pregnancy-related conditions such as eclampsia was rarer still. The mere knowledge of proper maternal and newborn care was lacking in many respects. Sometimes, though, all the resources were in place, and implementation still was lacking. This indicates a lack of organization or supervision.
With a 20-year history, more than 250 well-connected members and a long list of international sponsors, ESOG is one of the stronger FIGO member associations in Africa. It has already worked with the Ministry of Health and other Ethiopian medical organizations on an extensive number of improvement projects. Among them are three specifically aimed at improving management of postpartum hemorrhage. Yet change has come slowly.
In an online comment concerning the survey’s results, Andre Lalonde, the chair of FIGO’s now completed Saving Mothers and Newborns Initiative wrote, “The study on quality of care demonstrates that short one- to three-year projects have limited value… We are asking the impossible with these short projects. We need to train, then support supervision with frequent recall and update of training. Leadership at each institution is critical. Multi-disciplinary actions, result oriented, would allow for better progress.”
Lalonde recommended that improvement projects last at least ten years if they are to have an enduring effect. LOGIC is supposed to build local ob/gyn associations’ capacity for successful long-lasting campaigns.
Yet LOGIC itself is scheduled to wind down in 2013, after its five-year grant terminates. What happens then? Cassimo Bique forecasts, “We will have a big problem if LOGIC ends because fundraising is not easy.” Daniel Murokora in Uganda is uncertain, too. He says, “We’re hoping that the grant-writing skills obtained through LOGIC will help us continue to win more grants. But more needs to be done at an organizational level to build an institutional CV that attracts big grants. The MoU with the Ministry of Health will go a long way to support our long term work.”
LOGIC’s aftermath will therefore depend on how much momentum it can impart in its participating associations. If they can develop a record of breaking through the difficult organizational barriers to improving maternal and newborn health, the associations will have an enduring influence on international health care efforts.