Kaham Rogo, MD

“Mine is a fairly simple task of trying to summarize in context       what my very illustrious colleagues have already given you.        The topic really was safe abortion services what has made the       difference and what can make the difference?        I think it’s important that a call for action is made to       obstetricians and gynecologists who are at this Conference.        I chose this statement before I knew that Nafiz Sadik would be on this last Sunday here in our August gathering.        It’s a statement that Nafiz made during the Women’s       Conference in Beijing, you will agree with me that it was extremely       relevant then, five years ago, but it shocked me at how relevant it still       is, particularly, to this meeting five years later.        She was talking to women but this is a statement that is extremely       critical if she were here today and made the statement to obstetricians       and gynecologists.  It strikes       me that a statement that’s so relevant to women is even more relevant to       obstetricians and gynecologists, and to me, this is where the       conference’s one interest comes into focus.         

The big question, though, is to what extent have obstetrics and       gynecologic societies responded in the way that Nafiz Sadik wanted women to respond?  You       probably know, particularly the obstetricians and gynecologists who are       here, that the FIGO Committee for the Ethical Aspects of Human       Reproduction in Women’s Health came out with ethical guidelines       regarding induced abortion for non-medical reasons.        It was formulated in 1998 in Cairo, published in 1999 in the       International Journal of Gynecology and Obstetrics, and it’s also       contained in one of the ethical guideline books, a blue one that I believe       has been distributed to everybody starting this conference.        At Ipas

 we decided early this year to send out a       questionnaire and the objective was to try and assess the extent to which       the obstetric and gynecologic society is more knowledgeable of these       guidelines that come from FIGO, and whether they accept the guidelines or       not, and much more important, to determine the extent to which they’re       being utilized, to shift national policies and service deliverers in       countries in which we can.  It       was a very, very simple survey.  We       sent a one-page questionnaire to 101 obstetric and gynecologic societies       who are officially registered and paid up members of FIGO.  We got a surprise – fifty-seven responses, that’s 56%,       which the older members of FIGO tell me is extremely good.  We analyzed fifty-five, two we did not analyze because the       response from those societies were that our laws are clear on this so that       is not a response that we can give you.        But the fifty-six that were analyzed had very interesting       responses, one is that the obstetric and gynecologic society is generally       well aware, as you’ll see there; awareness was the first question and is       implicit.  How many have acted       - that is a lot lower, less than 40%.        How many accept - extremely high, going nearly to 100%.        Interestingly too, is how we made the Ministers of Health aware of       these things and, again, we come way down to just about 30%.         

What we see here clearly is that when it comes to knowledge,       awareness, and acceptance our societies are knowledgeable, they are aware,       and they accept but when it comes to acting and doing something about it       either themselves or through their Ministers of Health, then we start       finding a major problem.  We’ve       analyzed this further as shown in this slide to differentiate between the       societies from counties where maternal mortality is high and where       maternal mortality is low.  We       did this because we thought that probably some of the responses of not       acting was because those societies were in countries where the laws and       everything was already so good that they would not do anything despite the       fact that last year this thing was sent to them.        But what you see here is a similar pattern, even in countries where       maternal mortality is still high; we know too that those are countries       where abortion is still a major killer.        Look at the second question and the fifth response there, you see       the same thing happen in question one, three, and definitely question six,       knowledge and acceptance great but action either by societies themselves       or with the Minister of Health is extremely low.        We believe that this is an important finding for FIGO because often       times at international meetings it will be quoted that the obstetric and       gynecologic societies and FIGO has already made this statement but       everywhere that we go in the country that we come from women still       continue to die of the very things upon which we make that great       statement.   

Our plenary       conclusion is clear that there seems to be very, very strong support for       the recommendations on this issue that come from FIGO but a very, very       significant gap between acceptance and action.        Action, I believe, is an issue that Mahmoud Fathalla has raised,       and let’s talk about it but in acts.        This to me is the issue that we have to put in context that, yes,       over the last one hundred years differences       have been made because of the laws and laws have helped us because of       technologies.  Yes, they’ve       helped us and to some extent because they have been providers, members of       obstetric and gynecologic societies and members of the medical profession       that have committed themselves to doing something.        Therefore, I propose, and this is something we’re bringing from       Ipas, there may be room for us to start thinking of some six cardinal       rules and responsibilities that all obstetric and gynecologic societies       and the gynecologists should be able to undertake if we are to make bigger       strides in the next millennium.  The       first is that we must commit ourselves to expanding services, geographic,       economic, and cost has been an issue that Rebecca touched on, and even       more important is the level of providers.  

We are not enough as obstetricians, gynecologists, medical       practitioners, and physicians, so going down to a midlevel provider       becomes an imperative.  Second is the commitment and the role of creating awareness       amongst women in communities and amongst men.        Rebecca mentioned very clearly that where women are empowered with       knowledge they tend to access the services better, safer, and earlier.        This is a responsibility of providers as much as everybody else.        Third is improving the quality of care, in terms of the skills for       the providers, a key area for us because members of obstetric and       gynecologic societies are the biggest trainers, teachers, and professors       in reproductive areas in their countries, in terms of the other areas such       as attitude, which again, we’ll say that attitudes still remains a major       problem for us.  In terms of technology, yes, we have not tried enough of that       but we’ll mention that technology did come and has made a difference but       cannot do it on its own.  In       terms of treatment protocols, they are not there in places where they’re       supposed to be.  Fourth, is       simplifying guidelines and regulations for access to service and, again,       Rebecca touched on this quite amply in terms of who is to give consent.        Three physicians to give consent in a country where there is       probably less than one-hundred physicians in total - is that really       realistic?  All the relatives       to give consent when the person, the victim, does not want any relative to       know - is that realistic?  Look       at it in terms of planned flow, how many stops do you have before you       eventually get your service, and how many people laugh at you and do not       keep the secret?  In terms of       waiting time, that makes you move from the first trimester when it is safe       to the second trimester or even beyond the second trimester and,       therefore, you have to deliver the baby.        Fifth, a responsibility is our support for legislative change.        Teamwork is a key here, we cannot do it on our own but, again,       Rebecca stated clearly that the law is not just what is written there,       there’s much more to it that needs to be put in place, and in our       country where laws are not changed, our voices have not been heard enough.        The sixth one of these responsibilities is the protection of       preservation of existing legal and solvate opportunities because we know       that even in countries where there have been changes, the goal is a threat       for reversal.  The threats are here in the United States, the threats have       been in Poland, I believe they’re reversed and moving one way or the       other.  They are having       resistance in South Africa, and it has been there in India.        So those opportunities are important that when they’re there you       take care of them.  

The big       question still is - will we be able to do this thing so that we make a       difference?  I seriously       believe that deserving as every other honoree was that was given the honor       on Sunday evening by FIGO, one thing was glaringly missing.        We did not even mention a name of a colleague or a provider who       lost his or her life in the line of duty.        If this had been a military gathering, and it could have been       extremely relevant in this country where our colleagues have died simply       because they are providing a service, those names would have been there on       a role of honor, even posthumously.  To       me, that would probably be the biggest statement that FIGO could make in       their commitment to the lives and dignity of women if before we leave this       conference, we did mention the names of those people who have died in this       country for no reason other than doing what the military people call       ‘died in the line of duty.’   

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OBGYN.net Conference CoverageINTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS: Washington DC, USA

Kaham Rogo, MD

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Safer Abortions – What’s Made the Difference?