Portal de Periódicos da CAPES

Millennium development goal 5 – an obstetric challenge

2012; Informa; Volume: 91; Issue: 9 Linguagem: Inglês

10.1111/j.1600-0412.2012.01505.x

1600-0412

Henriette Svarre Nielsen, Torbjørn Moe Eggebø,

Global Health and Surgery

In the year 2000 all the world's countries and all the world's leading development institutions agreed to eight Millennium Development Goals (MDG) to end extreme poverty, hunger and disease by the year 2015. Enormous efforts have been put forward by the international community to achieve these goals and it has paid off. On July 31st this year, UN Secretary-General Ban Ki-moon announced the good news that three important targets on poverty, slums and water have been met three years ahead of 2015. Unfortunately, the MDG number 5 that is directly related to our specialty is the goal with the least progress and additionally it is the area with the biggest inequality between the richest and poorest countries in the world (1). The MDG number 5 target is to reduce the maternal mortality ratio by three quarters and achieve access to reproductive health facilities for all women. The complex issues related to reproductive health such as the acute nature of obstetrics demanding skilled care and operating facilities around the clock, traditional patterns of sex roles, lack of women's empowerment, inadequate political and religious agendas, and infrastructural and economic barriers, are all contributing to the slow progress for reaching the target goal number 5. In this issue of the journal we present four manuscripts all related to the millennium development goal 5. Thidar Pyone and co-workers in Copenhagen, Denmark conclude in their systematic review (pp. 1029–1037) on childbirth attendance strategies and their impact on maternal mortality and morbidity, that there is a need for clearer conceptual frameworks for both research and action. They also suggest getting inspiration from the UN General Assembly on HIV/AIDS where such detailed framework is established. Indeed our medical colleagues have had better success in reaching the millennium development goal 6 to combat HIV/AIDS. Christentze Schmiegelow and co-workers in Denmark, Holland, Sweden and Tanzania have investigated perinatal mortality in Tanzania (pp. 1061–1068). Nanna Maaløe and co-workers in Denmark and Tanzania have evaluated the indications for cesarean sections (CS) in two rural hospitals in Tanzania (pp. 1069–1076). The perinatal mortality is high in sub-Saharan Africa, but increasing the CS rates is probably not the best solution. The CS rate might increase from less than two percent to more than 20 percent in a few years with better access to operation facilities. Schmiegelow et al. identified preeclampsia, small-for-gestational age and preterm delivery as key risk factors associated with perinatal mortality. They recommend that interventions should target the prevention and handling of these conditions. Maaløe et al. found the overall CS rate in their material to be above 20%. They analyzed the indications for CS in more than 300 emergency cases and found that 25% appeared to be decided on the basis of inappropriate indications, and in an additional 38%, the indications were unclear. A previous cesarean section increases the risk of labor complications in the next pregnancy, and especially uterine rupture; which is a common life threatening condition in Africa, making the right indications crucial. Use of simple interventions such as vacuum deliveries, routine use of the WHO partograph and exact diagnosing of presentation, multiple pregnancies and placental location are important means of keeping the CS rate low. It is also important to avoid CS for dead fetuses. These two manuscripts are from a low resource setting in sub-Saharan Africa, but still the resources described are better compared to other African areas. CS on a fetal indication is not an option in some places. In some countries the women have no rights themselves and an informed consent from the husband is mandatory before a CS can be performed. The lack of obstetricians in Africa is a huge problem contributing to maternal mortality. Training midwives in performing vacuum deliveries, delivering breeches and twins, and handling post partum bleeding is needed if maternal mortality has to be reduced by large numbers. Live-saving and CS-sparing manual vaginal procedures must not be forgotten. Sarah Neal and co-workers in UK, Norway, USA and Switzerland report surprising new data as their analysis puts into light that one million births occur annually to girls under the age of 15 (pp. 1114–1118). In several Sub-Saharan African countries more than 10% of girls under the age of 16 become mothers. It is evident that many of the countries with high adolescent pregnancies also have some of the highest maternal mortality ratios. The risk of dying from pregnancy and childbirth is considered extremely high among the adolescent population. Strategies are urgently needed to reduce these numbers if poor reproductive health is to be alleviated and MDG5 achieved. Chronologically, this months issue commences with a guest editorial from Magnus Westgren in Stockholm, Sweden (pp. 1009–1010) calling for Nordic collaboration to perform a multicenter randomised controlled trial to test bilateral salpingectomy for ovarian cancer prevention. Electronic intrapartum fetal monitoring has been a subject of controvercy and debate for decades (2, 3) and Branka Yli and colleagues from Oslo Norway contribute to the ongoing debate with their commentary on pp. 1011–1014. AOGS are open to all scientifically well argued views, so follow the debate also in the coming issues. Christian Rifberg Larsen and his Copenhagen based colleagues review the efficacy of virtual reality simulation training in laparoscopy (pp. 1015–1028). The evidence is convincing that virtual reality simulation training can increase basic laparoscopic skills for laparoscopic novices. Using virtual reality simulation training of young doctors seems to be obviously of benefit for the patient, the trainees and their supervisors, as well as for operation efficiency. Why not look at the promising long-term surgical results of severe vulvar vestibulitis that ruin sexual life of young women reported by Paivi Tommola and co-workers from Helsinki, Finland (pp. 1086–1093)? Sexual well-being and decrease of dyspareunia were similar in women not responding to conservative management with subsequent posterior vestibulectomy and among women managed conservatively. Quality of life five years after adoption is high, and as good as after having a spontaneously or IVF-conceived child. (pp. 1077–1085). Regular use of aspirin reduces the risk of ovarian cancer (pp. 1094–1102). Management of women with low-grade squamous intraepithelial lesion cytology should not be based on their menopausal status (pp. 1109–1113). Flow pattern in the splenic vein could represent a tool for prenatal detection of chorioamnionitis and funisitis in PPROM pregnancies (pp. 1119–1123). A novel meeting coming up is the 1st Nordic Congress on Obesity in Gynaecology and Obstetrics, NOCOGO, in Billund, Denmark on 22–24 October 2012. Look at http://www.NOCOGO.dk for information. For 2013 start to prepare for the 4th Nordic Endometriosis congress in Turku, Finland on 23–25 May (http://www.NCE2013.fi) and the ISSHP (International Society for the Study of Hypertension in Pregnancy) European Congress in Tromsö, Norway, 12–14 June (http://www.isshp.org). Note the short-cut to AOGS on the NFOG website or at Wiley-Online Library to establish YOUR personal on-line access to AOGS at home and at work.