Jerker LiljestrandFIGO Treasurer

Obstetrics and gynecology ina globalperspective

Outline of talk

• Background: Global health, reproductive healthand maternal/newborn health

• The abortion issue

• Instrumental delivery

• HPV vaccine

• HIV/AIDS

• Overarching issues

Is the world getting better?

Life expectancy at birth, global

0

10

20

30

40

50

60

70

1960 1970 1980 1990 2000 2005

Life expectancy, yrs

Jerker Liljestrand, SMI, Soc med, LU / MAS

Under 5 mortality, global

0

50

100

150

200

250

1960 1970 1980 1990 2000 2005

U5MR

Jerker Liljestrand, SMI, Soc med, LU / MAS

Total fertility rate, TFR, global (”average number of

children”)

0

1

2

3

4

5

6

1960 1970 1980 1990 2000 2005

TFR

Millennium Development Goals (MDGs)

• Eight major goals:– Eradicate poverty and hunger– Achieve universal primary education– Promote gender equality and empower

women– Reduce child mortality– Improve maternal health– Combat HIV/AIDS, malaria and other

diseases– Ensure environmental sustainability– Develop a global partnership for development

http://www.developmentgoals.org/

No certain global decline in MMR

• Uncertain indicator! Needy countries lack registration of births and deaths

• Latest 3 UN estimates use different methodologies, not comparable

• Some countries are successful (Vietnam, Honduras, Bolivia?)

Källa:WHO: Make every Mother and Child Count , WHO 2005

9

Africa south of Sahara has the highest MMR

”The rule of two thirds”

• Of infant mortality (<1 year) 2/3 occursduring the first month

• Of these deaths, 2/3 happen in the first week

• And of these, 2/3 take place

during the first 24 hrs after birth

Leading causes of death in children, developing countries, -02

• Birth related 23.0%• Pneumonia 18.0• Diarrhoea 15.0• Malaria 10.7• Measles 5.4• Malform. 3.8• HIV/AIDS 3.6

• Whoop. cough 2.9• Tetanus 1.8• Malnutrition 1.4• Others 14.0

529 000 pregnancy-related deaths yearly

Sepsis14.9%

Haemorrhage24.8%

Indirect causes19.8%

Other direct causes7.9%

Unsafe abortion12.9%

Obstructed labour6.9%

Hypertensivedisorders 12.9%

Specific action against the 5 mainmaternal killers

• Eclampsia: MgSO4• Obstructed labour: surgery by non-dr• PPH:- active mgmt. of 3rd stage =>- => Misoprostol by traditional birth att. ?- intrauterine baloon tamponade

The abortion issue

Unsafe abortion

• Ongoing global struggle• Mixed progress• Gradual opening in Ethiopia, Nepal,

Mozambique, Portugal…• …but restriction in Nicaragua, Poland

Every country can do something to reduce deaths from unsafe abortion• Provide abortion as the law permits• Improve postabortion care• Emergency contraception• Information & education on sex/FP• Improve access to contraception• Especially for young/poor women• Combat gender based violence/rape• Enforce min. age at marriage• Formative research

Postabortion care

• Uncontroversial!• Consists of- Correct medical treatment- Evacuation with manual vacuum aspiration- Contraceptive counseling/provision- Non-discrimination

New: misoprostol for incomplete abortion

Postabortion care requires

• Active delegation to non-doctors• Training• Policy change?• Our collaboration!

Instrumental delivery

• High and increasing CS rates in manycountries

• Low or falling rates of instrumental vaginal delivery

• Also in low and middle income countries

• E.g. county hospitals in China have CS rates 60-85% !

CRANIOTOMY

Extraction by scalp traction

Instrumental vaginal delivery

• Can be life-saving for the baby• And save much morbidity in the mother• For many women an access issue

• Are they disappearing?

• Will they be available to midwives?• Will they be available everywhere?

Assuring Access to Vaccines that Prevent Cervical Cancer

Amy E. Pollack MD, MPH: Joanna Cain, MD

Cervical Cancer Screeningand the PAP Smear

= Secondary prevention

Cervical Cancer Screeningand the PAP Smear

= Secondary prevention

• Most common screening test• Expensive infrastructure

including trained technicians • Sensitivity varies • Delayed results– high loss to

follow-up• Quality Assurance is difficult.

Age specific incidence of cervical cancer in two countries with and without centralized and

widespread screening programs

X. Bosch, D Harper. Gynecologic Oncology 103 (2006) 21-24

Alternative Screening ApproachesAlternative Screening Approaches

Alternative screening strategies should preserve sensitivity and specificity but decrease structural barriers, focused on different AGE group:

VIA; simpler HPV tests;

cryotherapy treatment

Screen and treat protocols

Broader range of health care providers

Self sampling for HPV

Alternative screening strategies should preserve sensitivity and specificity but decrease structural barriers, focused on different AGE group:

VIA; simpler HPV tests;

cryotherapy treatment

Screen and treat protocols

Broader range of health care providers

Self sampling for HPV

HPV as a Necessary Cause HPV Types in Cervical Cancer

53,5

2,3

2,2

1,4

1,3

1,21,0

0,7

0,6

0,50,3

1,24,4

2,6

17,2

6,7

2,9

0 10 20 30 40 50 60 70 80 90 100

XOther

827368395156593558523331451816 53.5%

70.7%77.4%80.3%82.9%85.2%87.4%88.8%

HPV

gen

otyp

e

Cervical cancer cases attributed to the most frequent HPV genotypes (%)

Munoz N et al. Int J Cancer 2004; 111: 278–85.

How much do we think risk can be decreased?

Knowledge Gaps in Vaccine Performance that will Influence Service Implementation

• Duration of action: (5 + years to date) Booster?

• HIV infected populations and gender: no study data

• Cross-Protection: ongoing need for screening

• Distribution requirements: 3 injections over 6 months;

• Vaccine co-administration: Hepatitis B only; otherwise unknown

Summary: HPV is major problem

• Vaccine offers hope for cancer free futures• Barriers: lack of health services, economic

status of women, maldistribution of providers, limited transport, adolescent issues, separation of vaccine/ reproductive health

• KEY: education of public, providers, politicians, community leaders

• GAP: older women and screening program

Source: UNAIDS 2007

Source: UNAIDS 2007

Source: UNAIDS 2007

A Framework for Priority Linkages

Key Linkages

Learn HIV status

Promote safer sex

Optimize connectionbetween Maternaland Child Health

Integrate HIV/AIDS withMaternal an infant

health

SRH

• Family planning

• Maternal and infant care

•Mgment of STIs

•Mgment of otherSRH problems

HIV/AIDS

• Prevention

• Treatment

• Care

• Support

Contraceptive Costs, Developing CountriesDonor Support for Contraceptives and Estimated CostsMillions of US$

1321126812161164

111410641014966920875830

807791773754

919904888873857841

824

203209

176218

1330

200

400

600

800

1000

1200

1400

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: UNFPA, Donor Support for Contraceptives and Condoms for STI/HIV Prevention 2004.

Total Estimated Contraceptive Costs(including condoms)

Total Estimated Contraceptive Costs

Actual Donor Support

Overarching issues in sexual & reproductive health

• A rights-based approach• Female empowerment, gender equity• Policy change and practice development• Strengthen midwifery – midlevel-providers

• Large role to play for ob-gyn societies!

Thank you!