On International Maternal Health and Rights Day: The role of emergency and essential surgical care.

“If you want to know how strong a country’s health system is, look at the well-being of its mothers.” – Hillary Clinton

<Dr Aliyu Ndajiwo>

What is a mom, but the sunshine of our days and the north star of our nights. Of all rights of women, the greatest is to be a mother. Women are the backbone of every family and the society. On this special day – The International Maternal Health and Rights Day – we, InciSioN are standing strong along with other organizations and individuals to voice out the need for improved maternal health care and rights for all women around the globe. We believe every mother counts!

In 2014, the International Maternal Health and Rights Day was launched by the Center for Health and Gender Equity (CHANGE), along with other prominent Maternal Health organizations. It is indeed a great initiative that deserves more special attention. It is every woman’s right to have access to safe care before pregnancy, during pregnancy, in childbirth, and even after giving birth.
A woman dies in pregnancy or childbirth every two minutes, and everyday over 800 women die from complications during pregnancy and childbirth. 99% of all maternal deaths occur in developing countries, and 90% of the complications that lead to maternal death can be avoided when women have access to quality prevention, diagnostic, and treatment services.

An often-overlooked issue in improving Maternal Health Systems and rights is improving access to safe surgical care. Over 5 billion people globally lack access to safe, timely, and affordable surgical care, and anesthesia, with the majority living in lower-and middle-income countries. This staggering fact has become a common phrase on the lips of several global health leaders, advocates, surgeons, health workers and even medical students. It made the World Health Organization (WHO) pass a resolution on “Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage” at the 68th World Health Assembly in 2015. The WHO along with many other institutions, and organizations are also pushing countries, especially the developing ones, to improve their respective surgical systems by developing and implementing a National Surgical, Obstetrics and Anesthesia Plan (NSOAP).

Improving access to safe surgical care has enormous potential in promoting and contributing to maternal health and rights, maternal wellbeing, improved economic productivity, supporting Universal Health Coverage, and achieving the Sustainable Development Goals (SDG). By 2030, Low- and middle- income countries are estimated to lose as much as $12.3 trillion dollars in Gross Domestic Product (GDP) if they fail to invest in safe surgical, obstetrics and anesthesia care. Improving access to safe surgical care also has a positive feedback to the health system as services such as infrastructure, workforce, equipment’s and supplies, health information systems and policies all need to be improved to provide safe surgical care.

Each year over 136 million women give birth. 1 out of 3 of them will require medical or surgical intervention during the course of the pregnancy, and about 5-15% will require a caesarian section during birth. Over 25 million females of reproductive age require surgical and obstetric services. In 2015, an estimated 303,000 maternal deaths was reported with almost all occurring in developing countries. The Sustainable Development Goal (SDG) 3 aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births between 2016-2030.
Developing countries have a maternal mortality ratio of 230 per 100,000 live births compared to developed countries with a ratio of 16 per 100,000 live births. About one third of all global maternal deaths occur in India and Nigeria. With India producing about 17% and Nigeria producing 14%.

As of 2013, there was an estimated shortage of 17.4 million health care providers in the global health workforce as reported by the “Global strategy on human resources for health: Workforce 2030”, of which 9 million were nurses and midwives. Just increasing the coverage of midwifery-led care by 10% will result in a 27% reduction in maternal mortality in low-income countries. A recent study revealed that countries with higher densities of surgeons, anesthesiologists and obstetricians (SAO) had a significantly lower maternal mortality ratios compared to countries with a lower density. These shortages have adverse effects on maternal health outcomes. Task shifting and task sharing are strategies that could be used to manage these shortages. In Malawi, Mozambique, and Tanzania, a study revealed that Medical officers were able to perform safe caesarian section surgery when properly trained.

Improving access to basic surgical and obstetric interventions can reduce the burden of disease in maternal and newborn populations by around 40% by preventing obstructed labor. It will also help to ensure high standard of care for women and their families. It is every woman’s right to have access to interventions such as Caesarian sections, exploratory laparotomies, fistula repairs, etc. However, many women in low- and middle- income countries still lack access to such interventions, which result in high maternal mortality rates in those countries. Due to the poor state of health in developing countries, many women especially in rural areas tend to give birth at home in the presence of unskilled health workers who cannot provide life saving surgical services in cases of obstetric complications. Even pregnant women that want to deliver in the hospital find it very difficult because the hospitals are often located very far away, and are usually short staffed. In many developing countries such as Gambia and Rwanda, longer travel time between health center and district hospital was associated with poor maternal and neonatal outcomes.

One of the most disabling conditions women acquire due to poor access to emergency obstetric care is obstetric fistula. It occurs when there’s prolonged or obstructed labor for periods lasting from several days to a week, where the yet to be born baby’s head exerts significant pressure on the soft tissues around the womb, eventually creating a hole through which urine, menstrual blood, and/or faeces can leak through. Death from blood loss during childbirth, and infections are serious complications of this disabling condition. Patients with fistula usually undergo surgery. About 80-95% of fistulas can be closed surgically. Untreated obstetric fistulas are a common cause of morbidity in low-resource settings affecting 2-3 million women and resulting in social stigma and ostracisation. Women suffering from fistulas are unable to assume their normal social and marital roles, and they become more dependent on others. In Tanzania, women’s lack of decision-making power, lack of money, unavailability of transportation to and long distances to health care facilities were huge contributing factors to women acquiring this disabling condition. Perhaps if the rural areas had good emergency transportation system, skilled workers, and social and financial support there would be many more women and children alive today without any form of disability

Dr. Amina Sani Bello Founder of Raise Foundation performing Fistula repair surgery on a VVF patient in Minna, Nigeria.

Child marriage and early pregnancy are also risk factors to developing obstetric complications. A study showed that a 10% reduction in child marriage among girls could decrease a country’s maternal mortality rate by 70%. Pregnancy and childbirth complications are the leading cause of death among 15 to 19 year-old girls globally, with low and middle-income countries accounting for 99% of global maternal deaths of women ages 15 to 49 years. A study in North-Eastern Nigeria revealed that 71% of pregnant teens had experienced at least one serious pregnancy or birth-related health problem, with almost 50% being as a result of obstructed and/or prolonged labor.

There’s an increasing rate of caesarian section deliveries in the developed countries, which could be linked to improved maternal health outcomes. However, in the developing countries, majority of the women prefer natural birth to caesarian deliveries due to several personal and socio-cultural beliefs. A caesarian section is a proven life saving surgical intervention. It is listed as one of the five bellwether procedures used as an indicator in measuring surgical systems globally. Women suffering from conditions such pre-eclampsia, breech presentations, hemorrhage, prolonged or obstructed labor can be saved by this surgical intervention, yet many women don’t have access to such intervention. The rate of caesarian sections in some countries in Sub-Saharan Africa and South Asia is less than 2%, while the WHO recommends rates of at least 5-10%. An unequal coverage of caesarian section rates was discovered in Pakistan. It was noted that lower rates was seen in women that were less educated, poor, and living in rural areas, while higher rates was seen in women that were better educated, rich and living in urban areas. Several educational, financial, infrastructural and cultural barriers need to be broken in order to improve maternal health and rights.

Universal access to emergency obstetric care should be prioritized on the global health agenda. The role of emergency and essential surgical care in maternal health and rights cannot be overemphasized. There’s an urgent need to improve emergency and essential surgical care, as it is critical in reducing maternal mortality and improving maternal health outcome in cases of emergency obstetric complications. It is time to make maternal health and rights a priority, and it cannot be achieved without improving access to emergency and essential surgical care services.

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