Reducing Maternal Mortality Rate

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Roberta Speyer: "This is Roberta Speyer for OBGYN.net, reporting from the 47th ACOG annual clinical meeting here in Philadelphia. I have the pleasure of interviewing Dr. Fathalla from Egypt. Dr. Fathalla, you have so many credentials with your hospital and the associations that you have been President of and worked on. I would like you to introduce yourself rather than me try to and botch up that list. You certainly are the recent past President of FIGO."

Dr. Mahmoud Fathalla: "I am the past President of FIGO, but I like to be better known as an obstetrician-gynecologist who practices in a relatively underdeveloped part of Egypt, and tries to serve women in the best way I can."

Roberta Speyer: "I particularly enjoyed listening to your talk yesterday where you were discussing the maternal mortality rate in the world and what efforts you've been working on with your colleagues in trying to reduce that. But I sensed in looking at it that it isn't moving as fast as you'd like to see it moving. Could you share with our viewers some of the figures that you discussed which were very poignant about just how real a problem this is in the world in underdeveloped countries compared to what is really, virtually, an extinct problem in countries like my country - the United States?"

Dr. Mahmoud Fathalla: "Roberta, it's a real problem, it's a problem of big dimensions, and it's a problem that shouldn't be a problem because we know the solution to it. Just to give you an idea about the dimension, a woman dies every minute somewhere in the world because of something related to pregnancy and childbirth. Every year the latest information compiled by Labrature and UNICEF was 585,000 women dying every year because of this, and think of these mortality figures as just the tip of an iceberg of mobility and human suffering. For every woman who dies, there are at least 20-30 women who suffer from their complications and whose health will continue to be affected for some time. Sometimes we have very serious conditions like vesicovaginal fistula with incontinence of urine, or with impairment of their fertility, or with pelvic inflammatory disease. So it's a real serious problem in terms of magnitude, but that's not only why it is a big problem, inequity is another serious issue. From that large number of deaths of more than a half million, which I mentioned - all except about 4,000 are taking place in the developing world. Of course, there are differentials in mortality between the rich and the poor which goes across everything - health - women's health, men's health, children's health, but there is no indicator in which the disparity is as marked, as striking, as ugly, as the maternal mortality. Think of the lifetime chance of a woman to die because of pregnancy and childbirth, in Canada - it is 1 in 7,700 - that's the lifetime chance. In parts of Africa, like in Ethiopia for example, it's one in every nine women. You can go to a small school in Ethiopia and see those young girls in the school, and you can say one of nine of these young girls is going to die because of pregnancy and childbirth. The worst part of it is that it's not because of a disease which we cannot diagnose or which we cannot treat. It's because of a condition that for a long time we know how it can be detected, how it can be managed, and it can be done effectively. There are even some poor countries who manage to make motherhood safer for their women."

Roberta Speyer: "You spoke to the concept of what is the cost - what is the dollar value we place on a woman's life - and that then equated to why this is happening. Would you care to comment on that particular point of view?"

Dr. Mahmoud Fathalla: "It's one of the issues which troubles me, and I think it troubles many people in this field is - why is it so? If we know what can be done to make motherhood safe, and if we know that this is something that can be affordable - why is it not made safe? I discussed this with some serious health economists who study these issues. And they gave me the simple but painful, to me, painful answer - it is a matter of how much that life is considered worth and that society, whether consciously or unconsciously, always puts an estimated price tag on each human life. It may be done consciously or it may be done unconsciously, and that price tag will decide how much society would be willing to spend in order to save your life. That invisible tag on your life, which you carry while you are moving around is, according to my health economists colleagues, determined by two factors - how much society has invested in you and how much society expects from you - how much does society value your product. Now apply this creed of logic to the reality of women's lives in many parts of the world today where investment in girls lags far behind the investment in boys, and where women's work - however important it is, how every valuable it is - is not generally counted. It's not counted in the gross domestic product of a country, and that was the cruel explanation but logic why countries are not investing in saving women's lives."

Roberta Speyer: "It's a pretty chilling thought, isn't it?"

Dr. Mahmoud Fathalla: "It is. It is sad, sad but true."

Roberta Speyer: "You started your work - was it with the Save the Mother's Fund or did that come later? When did you start your work on trying to assess and develop programs that could change this? Then take us through your expectations and where you're at now, and if those expectations have been met or how you feel they have been, and where their improvement could lie."

Dr. Mahmoud Fathalla: "Roberta, it's two decades now - two decades - and I have been involved in it all from the beginning, and I recognize three phases in the safe motherhood initiative. The first phase is a phase, which ended in 1987, in an international conference in Nairobi, which was attended by all the major United Nations and other agencies. It was all about safe motherhood. I called that first phase - the phase of awareness. That was a time when people began to realize that we are having a big problem. We have gotten used to women dying because of pregnancy and childbirth but there was not enough realization how big a problem that is, how serious it is, that it should be challenged, and it should not stay. That was the first phase. The second phase took probably another decade, and if the first decade was the decade of the "should we do something," it was the decade of "what can we do." We have learned through that decade many lessons, many positive lessons and many mistakes, which we learned during that past decade. Now we are in the third phase which I think after we decided that something should be done, after we know that something can be done, it's the phase of commitment now. We need the commitment to get it done, and a part of that commitment was the commitment which obstetricians over the world are taking upon themselves through the Save the Mother's Fund Project to contribute to the solution of what we call - one of the greatest health scandals of our time."

Roberta Speyer: "How does an Obstetrician-Gynecologist that is on OBGYN.net and is watching this interview, how do they support your work? How do they get involved? How do they help with the Save the Mother's Fund?"

Dr. Mahmoud Fathalla: "One of the things which really fascinated me in working in this area when I was President of the International Federation of Obstetrics and Gynecology was how much a sense of social responsibility there is in our profession. I think it's something probably rather unusual among the other health professions where you just deal with sporadic doctor-patient relationships. You just have a disease at one point in relation with a doctor, and that ends it. In our profession we have because of it's nature, a long continued relationship with our patients. That gradually builds among obstetricians, particularly, as they grow older and more experienced - a sense of social responsibility that goes beyond the sense of dealing with the individual patient which is still important. But we feel as obstetricians as responsible not just for the patients who are fortunate enough to come under our care, but we also feel socially responsible for those patients who could not come under our care, and we tested this. We tested this in 1997, when we sent a questionnaire around to all obstetric and gynecology societies around the world to ask about how they feel about this issue and whether they would be willing to be involved and to contribute. We sent this to obstetricians in the countries where women are still dying in large numbers because of maternity, as well as to countries where this is no longer a public health problem. In a country like the U.S. - here most of obstetricians would probably end their career without witnessing this tragedy of a maternal death. That's completely different from other countries where women are dying in thousands. It was impressive that we got the positive response from obstetricians on both sides - those who have the problem and that's understandable, but even those who don't have the problems and said they were willing to work and contribute. So we managed to get from the International Federation of Obstetrics and Gynecology some funding to start activities in that area.

We were fortunate to find a pharmaceutical company which has no specific interest in maternal mortality; they don't have any products even to promote for the area of safe motherhood - that was Pharmacia Upjohn when they joined together. But they are concerned about other aspects of women's health, and they felt an obligation that they would like to do something for women's health, particularly, as we tried to persuade them, that there is no more serious issue to women than their right to life. If they go through a pregnancy and childbirth, it's a woman's right to life to go safely through a pregnancy and childbirth. So they contributed to FIGO 750,000 U.S. dollars to work in this area, and then we approached the United Nations, and the United Nations Population Fund was very happy to match that amount. Then we approached the World Bank, and the World Bank said - yes, investing in saving women's life is a good investment. They are bankers, they know where a good investment is, and said - we are going to contribute to your activity - and so we started partnerships between countries to work in this area. It was a tough selection because there were many societies willing to work but we had to make only five partnerships. And I'm happy to say, they are working with enthusiasm on both sides between the U.S. and countries in Central America, between Canada and Uganda, between the United Kingdom and Pakistan, between Sweden and Ethiopia, and between Italy and Mozambique. In this project, obstetricians are not working as individual healers, they are team leaders - so they are trying to see what human resources are available in those countries and to mobilize them. If you go to a country in Mozambique where you can count the number of qualified obstetricians on the fingers of your hand, then you have to see what other degrees of health personnel are there, and you can train and you can mobilize, and they can do something useful and that's being done by obstetricians, team leaders."

Roberta Speyer: "How do you get these team leaders? How are they selected?"

Dr. Mahmoud Fathalla: "The society selects them, so we agree first that we are giving the priority to these five partnerships, then the American college would decide who their people are who would be most qualified, most committed, and most willing to devote their time and effort - it's a voluntary effort, to work with countries in Central America, usually people who have some contacts with these countries, the same with the Swedes or with the U.K. who is going to work with the other country. Then the other societies, say in Pakistan or in Uganda, they are going to see who in their profession is really committed, and that will decide on the team. I think it's a great thing for the obstetric profession to be involved in."

Roberta Speyer: "So are there plans to expand the partnerships between the developed and the underdeveloped countries? Do you have any new funding sources on the horizon that are going to help you accomplish that?"

Dr. Mahmoud Fathalla: "Two things - one in the nature of our projects, these are what we call "demonstration" projects. While they are not going to solve the problem of maternal mortality in the country, they will demonstrate in a localized area of the country - normally the size of a district - what can be done, at what cost, what will be the outcome, how many lives will be saved, and how many women will go out of pregnancy and childbirth safely and happy because of this intervention. Now this demonstration project aims at mobilizing support for a wider scale project in the country but we hope that when you have the scientific facts, when you can show what can be done and what cost - you can shape the countries into action. No country can say that they are poor to the degree that they can let their women die, every country can find the resources to do that.

The international community is spending more, about 50-60 billion U.S. dollars in official development assistance in the world, a fraction of that can save the lives of women. Our concern now is to demonstrate what can be done, how best it can be done, and what it would cost. We plan to present that next year when we have the World Congress of Obstetrics and Gynecology in Washington, and Washington is a very good place where you can publicize the message. So that's one answer to your question. The second answer is that because of the increased awareness about this problem, we are happy to see some infusion of funding getting into this area. The most recent and most impressive was the decision made by Bill Gates and his wife - who's currently pregnant incidentally, but it may have helped in the decision. They decided to contribute 15 million U.S. dollars for safe motherhood over a period of five years, and with a commitment that they would probably contribute at least another 25 million over the next five years. That money is going to Columbia University, which has done pioneering work on maternal mortality in Africa before, so they have a lot of experience. But it's meant to be funding that will be farmed out to groups that are willing to do something about maternal mortality."

Roberta Speyer: "That's certainly quite a legacy for the unborn child, I would say. I look forward to the opportunity to talk to you again at FIGO 2000 after you've had the presentation of the findings. To recap just how everything is turning out with these projects - can you give us a little bit of an indication, is some of these things going well, and does the work look promising at this time?"

Dr. Mahmoud Fathalla: "I think overall - it's going well. In the first week of December, we are going to meet in London to review the progress that has been made to discuss with our colleagues from both developed and developing countries the progress that has been achieved. I'm very optimistic that by the time of the World Congress in Washington, D.C. - where we are going first to have a pre-Congress workshop, then we are going to have a exhibit in the Congress - that we would be able to show not only that the lives of women can be saved by measures that are affordable in most countries but that obstetricians have really stood to their social responsibility. And I look forward to seeing you there."

Roberta Speyer: "Thank you so very much, Dr. Fathalla, for sharing this. I look forward to it also."

Dr. Mahmoud Fathalla: "Thank you."

More Information on theSave The Mother's Fund can be found here