It has been 15 years since the historic signing of the Programme of Action at the International Conference on Population and Development (ICPD), held in Cairo in 1994. As the most comprehensive international agreement on sexual and reproductive rights and health, the Programme of Action is in grave need of revival since many countries struggle to tackle high rates of maternal and newborn mortality and morbidity. Further objectives were set out in 2000 with the Millennium Development Goals (MDGs), and with goal 5 focused on the improvement of maternal health. Unfortunately, this same goal is faring badly among the 8 targets, seeing regression in some countries of intervention [1]. What the ICPD effectively highlights is the need for a comprehensive and holistic approach to issues related to maternal health. Regardless of whether the MDGs or the Programme of Action more appropriately reflect women's health needs, both complementary global initiatives have the closing date of 2015, and yet neither is on target.
FIGO's Safe Motherhood and Newborn Health (SMNH) project aims to achieve the goals set out by the ICPD and the MDGs through direct interventions aimed at reducing maternal mortality and morbidity, and improving access to maternal and newborn care. FIGO is uniquely placed to call upon its membership of obstetricians and gynecologists based in over 100 countries who can effect change through programming interventions, influencing national policy, providing education, and building partnerships.
FIGO called on its member societies to submit proposals to promote safe motherhood and newborn health. Ten countries were selected to receive grants over a 4-year period to implement their projects. From the project's inception, programming has been customized to each country's needs. The SMNH project includes countries as diverse as Haiti, Moldova, Nigeria, Uruguay, Kenya, Kosovo, Pakistan, Peru, Uganda, and Ukraine. Each represents differing demographics and stages of development; however, all have obligations to fulfill toward maternal and newborn health. The country projects are working toward achieving programs and activities determined by those most familiar with a country's maternal and newborn health status: its healthcare providers and professionals. The logframes, workplans, and indicators for each of the 10 projects within the profile of the FIGO umbrella have all been developed and determined by each country's obstetrics and gynecology member society.
The projects are under the direction of the SMNH Chair, a fulltime Project Coordinator based in London, and the FIGO Chief Executive. The SMNH Committee offers expert advice to all projects (Table 1) and Options UK provides continuous evaluation and monitoring.
Despite the expertise of its implementers, this project model is not without its flaws and challenges. With the work largely undertaken by fulltime health practitioners, the country projects rely heavily on volunteerism. The program's use of a twinning mechanism, whereby an active member society in a high-income country is paired with a committed and active member society in a country with high rates of maternal and newborn mortality, is meant to assist in easing the burden on already overstretched health professionals in low- and middle-income countries through encouraging capacity building and the sharing of lessons learned. Twinned societies have discovered an experience of shared learning, with each society gaining knowledge and experience from the partnership.
All projects aim to improve women's access to quality, cost-effective, evidence-based, and lifesaving innovations in maternal and newborn health that are easily implemented and sustained with appropriate support and training. The achievement of each country's project goals involves collaborations beyond the twinning mechanism and with related professional associations, especially midwifery associations, as well as government and civil society.
The projects have proven successful in involving health professionals providing obstetric and gynecological care in each country. Although at times a challenge for these busy practitioners, they are to be commended for their commitment to maternal, newborn, and child health. Many more projects of this nature could make a critical difference to women's lives.
The project objectives can be considered under a number of crosscutting themes which capitalize on the unique role of FIGO's worldwide network of health professionals to support the projects. These include the following areas.
1. Provision of maternal and newborn healthcare services to underserved and hard-to-reach areas (Haïti, Pakistan, Peru, Uganda)
The majority of the SMNH country projects focus on regions where accessing basic maternal health care services is difficult or simply not provided. A number of factors may contribute to this unmet need such as geography, poverty, discrimination, or the need to strengthen services and coverage in highly populated areas. The projects tackle this issue by focusing resources on the areas in need through the rehabilitation of maternity wards and health centers, the training of midwives and other maternal health personnel in emergency obstetric care, and community sensitization to the needs of mothers and newborns to ensure utilization of the new services provided.
2. Improvement and provision of quality basic emergency obstetric care (Haïti, Nigeria, Pakistan, Uganda, Ukraine)
In many regions of maternal health intervention, comprehensive services are not available. In such cases, the demand outweighs the supply often resulting in overworked staff, a lack of or distressed physical resources, and distrust in the medical system by the public. FIGO utilizes the expertise of its membership and each project's twinning mechanism to share knowledge and skills, whereby training is an integral part of the overall SMNH project. Courses for nurses, midwives, physicians, and medical personnel in emergency obstetric care and sexual and reproductive rights aim to improve the provision of care needed by women and their families.
3. Establish functional clinical and perinatal audits (Kenya, Moldova)
Utilizing data that already exist but which are not collected is the crux of implementing an audit system. Questioning mothers who have experienced a perinatal death not only provides medical and/or clinical evidence of the outcome, but also allows health personnel to understand potential sociocultural factors affecting a pregnant woman or her baby's health. This essential information is a simple intervention in improving the lives of women and newborns. Conducting clinical and perinatal audits enables health centers to systematically measure the quality of care and identify areas of substandard service provision, which may subsequently lead to improvements in maternal and newborn care. Utilizing a human rights approach, the country projects involved in audits employ a participatory, no blame, confidential, and evidence-based approach to the collection of information.
4. Development of new maternal and newborn healthcare protocols (Kosovo, Nigeria, Uganda)
The development of guidelines and protocols that include a sexual and reproductive rights approach has been an element of a number of SMNH country projects. The protocols involve the building of professional capacity and the establishment of appropriate methods of care and response to issues in maternal and newborn health. Examples of protocols developed include 11 new protocols in Kosovo, adapted in conjunction with the Ministry of Health, and training protocols for clinical audit in Kenya where information collection has been paired with data collection with the National Coordination Agency for Population and Development.
5. Community education and sensitization to women's rights in sexual and reproductive health (Peru, Uruguay)
While community education and sensitization is an important aspect of each country project, those countries indicating the capacity to respond appropriately to issues of emergency maternal and newborn care continue to struggle with community and health professionals' perceptions around issues of reproductive health and rights. Two of the SMNH countries have dedicated project objectives to the sensitization and education of the community and medical personnel in sexual and reproductive rights and health. They are particularly seeking to improve patient and health professional relations, increase uptake of existing health services, and working toward the destigmatization of women seeking abortions or who have undergone unsafe abortions.
6. Reducing the risk of unsafe abortion (Uruguay)
Unsafe abortion remains a leading killer of women in many parts of the world and accounts for a large percentage of maternal deaths in South America. In line with the objectives set out at the ICPD, the project in Uruguay has employed a counseling and consultation service for women presenting unwanted and/or unacceptable pregnancies, allowing for the transmission of accurate health information. The project has trained health providers, teachers, and journalists in sexual and reproductive rights to help avoid the stigmatization of women who have undergone unsafe abortion as well as to emphasize the importance of and the right to confidentiality. An important overall project goal is the implementation of a national and sustainable model transferable to similar legal contexts for reducing the number of abortions performed under unsafe conditions.
Rooted in the Programme of Action and drawn along the objectives in MDGs 4 and 5, the FIGO SMNH project serves as an example of a series of rights-based, cost-effective interventions that utilize the unique role of health professional associations to learn from and support each other in creating a world where women and newborns can live healthier and longer lives. While we are more than halfway to 2015 (according to the MDG timeline) with significant gains still to be made to achieve the goals put forth in 1994 and 2000, small projects uniquely attuned to the needs of intervention countries are undoubtedly a step in prioritizing the lives of pregnant women, mothers, and newborns. Although there are no easy wins in maternal and reproductive health, investing in the lives of mothers and newborns benefits entire nations [2]. If the political will can be met to put this realization into action alongside implementation of the full complement of the ICPD's objectives, then 2015 will prove to be a significant marker for the improvement of not just women's and newborns' health, but in fact health on a global scale.
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