The International Federation of Gynecology and Obstetrics (FIGO) Committee on Health Systems Strengthening and Respectful Care recognizes the detrimental effects of disrespectful and abusive practices within maternity care on maternal and neonatal health outcomes. In response, the committee advocates for the implementation of strategic, evidence-based interventions aimed at safeguarding women from substandard and disrespectful treatment during pregnancy, childbirth, and the postpartum period. This statement presents FIGO's recommendations for adopting respectful maternity care into health systems. The proposed policy interventions and clinical strategies are designed to foster compassionate, person-centered, and culturally competent care, thereby contributing to improved maternal and perinatal outcomes globally.

OBJECTIVE:To demonstrate that successful health systems strengthening (HSS) projects have addressed disparities and inequities in maternal and perinatal care in low-income countries.METHODS:A comprehensive literature review covered the period between 1980 and 2022, focusing on successful HSS interventions within health systems' seven core components that improved maternal and perinatal care.RESULTS:The findings highlight the importance of integrating quality interventions into robust health systems, as this has been shown to reduce maternal and newborn mortality. However, several challenges, including service delivery gaps, poor data use, and funding deficits, continue to hinder the delivery of quality care. To improve maternal and newborn health outcomes, a comprehensive HSS strategy is essential, which should include infrastructure enhancement, workforce skill development, access to essential medicines, and active community engagement.CONCLUSION:Effective health systems, leadership, and community engagement are crucial for a comprehensive HSS approach to catalyze progress toward universal health coverage and global improvements in maternal and newborn health.

We read with great interest Guideline No. 431: Postpartum Hemorrhage (PPH) and Hemorrhagic Shock1 and congratulate the authors on a well-researched compilation of PPH prevention and management strategies, medications, and devices.

SynopsisFIGO and the International Confederation of Midwives produced two joint statements endorsing WHO guidelines on prevention and treatment of postpartum hemorrhage.

Andre B. Lalonde MD Chair, FIGO International Childbirth Initiative and Working Group Email: [email protected] Dr Lalonde is Professor of Obstetrics and Gynecology at McGill University, Ottawa, Canada. He is Past President of FIGO’s Safe Motherhood and Newborn Health Committee, present Chair of the FIGO International Childbirth Initiative (ICI) Working Group, and Chair of the FIGO Congress Organizing Committee (COC) 2021. Currently he is responsible for the development and implementation of the ICI initiative on quality of obstetrical care. He is a recognized expert in postpartum hemorrhage simulation workshops and training of obstetricians, family physicians, and midwives to help reduce maternal mortality and morbidity.The ICI website can be found at www.internationalchildbirth.com. The International Federation of Gynecology and Obstetrics (FIGO) is dedicated to the improvement of women's health and rights, the reduction of disparities in healthcare for women and newborns, and advancing the science and practice of obstetrics and gynecology. Marking 65 years of work to improve the wellbeing of all women, FIGO has renewed its commitment to a future where every woman is empowered to achieve active participation in her own health and rights. The FIGO ICI Working Group supports the International Childbirth Initiative (ICI) 12 Steps for Safe and Respectful MotherBaby–Family Maternity Care.1 This initiative promotes quality healthcare practice with a multidimensional approach that ensures evidence-based approaches and interventions focused on better (bio)-medical and psychosocial health and wellbeing outcomes for the MotherBaby–Family triad. MotherBaby–Family refers to an integral unit during pre-conception, pregnancy, birth, and infancy influencing the health of one another. Within this triad, the MotherBaby dyad remains central in importance, as the care of one significantly impacts on the other. The ICI initiative also encourages and supports the active participation by providers and users of services in a sustainable quality of care monitoring and evaluation process. FIGO is one of the ICI founding partner organizations, along with the International MotherBaby Childbirth Organization (IMBCO). ICI was built upon their respective previous initiatives,2, 3 incorporating the most recent scientific evidence and insights relating to quality maternity care provision. This initiative is aligned with the ongoing work on quality improvement and respectful care of many organizations involved in maternity health care worldwide. The ICI has been endorsed by 20 partner organizations including maternity care professionals and other care providers, facilities providing maternity care, advocacy organizations, educators, and research institutions.1 ICI documentation has been translated into more than 20 languages, and five facilities (in four countries) are current ICI implementers. Pregnancy and birth are not isolated events in the lives of women, their partners, and their families. Physical and mental health; social, lifestyle, and financial environment; stress and fear in work and relationships; nutritional intake; and parenting skills are only some of the many factors influencing pregnancy and birth outcomes and the growth and development of the baby, newborn, and infant. The period from conception until two years of age is a window of opportunity for parents and caregivers to lay the foundation for health and wellbeing to last a lifetime and to positively affect future generations. Quality, evidence-based care with respect and compassion are essential for every MotherBaby–Family to have the ability to survive, thrive, and transform their lives. Hill and Brower’s4 groundbreaking publication brought international attention to the issue of women undergoing disrespect and abuse during the continuum of MNCH care.5 Since then, there has been a growing body of evidence from countries throughout the world documenting these violations of human rights and the mistreatment of women and newborns. There is increasing global recognition of the need for respectful maternity care (RMC).6-8 This paradigm shift in thinking around the broader concept of quality MNCH is demonstrated in the WHO framework for quality care, which identifies two key dimensions of quality hospital services for the mother and newborn: provision of care—including evidence-based practices, efficient information, and referral systems, and experience of care—including effective communication, respect, dignity, and emotional support.9 Research and case studies that involve listening to women’s voices have resulted in a much better understanding of the intersection between respectful maternity care and quality care, showing that RMC is more than merely the absence of mistreatment. In fact, Miller et al.10 noted that even evidence-based interventions are not as effective if they are not delivered with respect and dignity. The results of the What Women Want Campaign are a resounding call for better quality health services, with respectful and dignified care being foremost among issues that women identified.11 The ICI is a template for MotherBaby–Family-focused timely, effective, and respectful care that can be implemented by facilities, centers, hospitals, and units providing care before, during, and after birth to women and their babies throughout the world. The ICI embodies an evidence and value-based approach that acknowledges the MotherBaby dyad, the importance of family inclusion, and the influence of interactions with healthcare providers and health systems on the health and wellbeing of the MotherBaby–Family and societies. The ICI 12 Steps for Safe and Respectful Maternity Care (Table 1) are building blocks to guide quality improvement at the intersection between RMC and the provision of evidence-based essential interventions, while also addressing a number of health system issues that contribute to the achievement of quality of care in practice, including working conditions and relationships between healthcare providers. ICI has developed a minimum dataset for monitoring and evaluation. Real-time data and lessons learned will be shared by implementing facilities in the web-based ICI Learning Community of Practice. Funds were awarded by the government of New South Wales, Australia for a legacy grant for a 3-year project to implement the ICI 12 Steps in Papua New Guinea, Solomon Islands, and Fiji. This project will be a pragmatic exercise in initiating change in the clinical maternity setting. The FIGO ICI Working Group will oversee this project, working closely with a multi-disciplinary regional advisory and support group based in Australia and country point-persons. FIGO believes that the international community has a responsibility to ensure that women, wherever they are, are given choices in their lives and are given the means to implement these choices. The ICI envisions that FIGO member societies can endorse the ICI and partner at the country level with other health care professional associations and key stakeholders in maternal, newborn, and child health, both governmental and non-governmental, to promote ICI and implement the 12 Steps. We call upon FIGO member societies to work with us to achieve our goal of 1000 ICI-recognized facilities by 2025. We look forward to improved and enhanced experiences and outcomes for mothers, babies, and families everywhere, as well as rewarding work for maternal healthcare professionals.

The International Childbirth Initiative (ICI) Twelve  Steps to Safe and Respectful Maternity Care was developed to promote quality in practice within a broader scope and multidimensional approach to quality that ensures evidence based practice focusing on better (bio)-medical and psychosocial health outcomes for the Mother-Baby-Family unit. It also addresses a number of health system issues that contribute to the achievement of quality of care in practice including working conditions and relationships between health care providers. The ICI Foundational Principles and 12 Steps are building blocks for equitable, Mother-Baby-Family focused, timely, effective and respectful care that can be implemented by facilities, centres, hospitals and units providing care before, during and after birth to women and their babies throughout the world. The ICI supports organizational implementation and facilitates a learning community of practice for ICI implementers. As one of the founding organizations with IMBCO, FIGO has embraced this initiative and Dr. Carlos Fuchtner has declared it as a FIGO Presidential Initiative for the period 2019-2022 and has established a FIGO Working Group for the ICI that will continue to collaborate with partners to support ICI implementation and recognition status.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) offers many training and educational programs but ALARM (Advances in Labour and Risk Management) is the flagship. Since its inception, tens of thousands of Canadian obstetricians, family physicians, nurses, midwives, trainees and other health professionals, and their counterparts in developing nations, have benefited from this practical evidence-based training. moreOB, the SOGC-developed obstetrical team training program, is being implemented in the U.S. and Canada, where more than 80% of births in Canada occur in moreOB hospitals. This article recounts how three major SOGC programs—ALARM, ALARM International and moreOB—came to be and will revisit their milestones and the key people who made them possible. ALARM began in 1994, in an era when the SOGC had established itself as the premier organization developing practice guidelines for optimal obstetrical care. Yet, it was clear that these guidelines were not always being adopted and that variations in care were leading to adverse outcomes. The forerunner to the ALARM course began in the early 1990s. Drs. George Carson and Roger Turnell with the Saskatchewan Perinatal Education Advisory Committee developed an educational program on the management of labour that was successfully presented throughout the province. At the 1994 International Federation of Gynecology and Obstetrics (FIGO) meeting in Montréal, Dr. André Lalonde, then–executive vice-president proposed a course be developed to present, in a practical and effective way, the SOGC guidelines on intrapartum care. In June 1995, the Council of the SOGC recommended “the development of a comprehensive hands-on Canadian labour and risk management course… using the expertise of a national working group of family physicians and obstetricians,” recognizing that the publication of up-to-date guidelines was necessary but not sufficient to change practice. Obstetrical practice in Canada is interprofessional, and from the beginning, ALARM embraced the same approach with family physicians, nurses and midwives joining obstetrician-gynecologists. This new working group developed a complete syllabus, based on the best available evidence, with case-based workshops, and text and audio-visual materials that covered all important aspects of intrapartum and immediate postpartum care. Consistent with the founding principles of ALARM, it was agreed that its faculty should be interprofessional. Dr. Carlos Brailovsky, an educational consultant for the College of Family Physicians of Canada (CFPC), assisted the working group in the development of the evaluation process, consisting of both a written examination and objective standardized clinical evaluations (OSCEs). The 2-day ALARM course, with OSCE, was officially launched at the 1995 SOGC Annual Clinical Meeting in Calgary. One of the early distinguishing features of the ALARM program was its commitment to annual content updates based on the best available evidence. The field of evidence-based medicine was young, but two of its early leaders came from the ranks of obstetrics and gynaecology: Dr. John Collins, a former president of the SOGC, and Dr. Murray Enkin, both of whom were pioneers of the Cochrane Collaboration. The ALARM program was well received, and in its first 10 years over 4000 health care providers successfully completed the course; approximately one-third of them obstetricians, one-half family physicians, and the balance nurses and midwives. The ALARM Instructors’ Course was developed in 1996 to ensure consistency in the delivery of the ALARM program. In 1998, the ALARM course was adapted to meet the needs of health care providers in the developing world. The 5-day ALARM International Program was developed by Lalonde and Liette Perron, the director of the SOGC's International Health Division. ALARM International's objective was to train an interprofessional group of health care providers in the tools needed to address the most common causes of maternal mortality in their hospitals and communities. In addition to clinical training, participants were taught how to use the maternal death audit to reduce maternal mortality rates, and promoted a sexual health and reproductive rights framework for addressing systemic contributors to maternal mortality. The program used a train-the-trainer approach whereby the SOGC partnered with 3 countries—Haiti, Uganda, and Guatemala—to refine the program so that it reflected the needs of low resource countries. Wherever the international program was deployed, the SOGC worked with the local obstetric and gynaecologic professional society to strengthen their organizational capacity to improve care on behalf of their patients. Each country was then able to deliver the program on its own. A complementary course, ALARM for Hospital Administrators, was developed in 2007 to provide leadership with an understanding of the challenges facing their frontline staff and an awareness of the importance of hospital-wide recognition of the needs of labouring women within their facility, from the medications required on hand to the need for effective communication and emergency transport to the next level of care. In 2000, Dr. Ken Milne joined the SOGC as associate executive vice-president responsible for patient safety. Between 2001 and 2003, Milne and Lalonde created the moreOB program; Lalonde secured the financing and Milne developed the extended team-focused patient safety and culture change program. Based on emerging research on how human factors impact the function of high reliability organizations, the moreOB program was launched in 2003. On the recommendation of the executive vice-president the SOGC, Council invested close to $1 million to develop the program. In 2004, the program gained province-wide adoption in Alberta, growing quickly to become an indispensable hospital-based source of content on both obstetrical care and teamwork. In 2007, after a year of negotiations, the SOGC partnered with the Health Care Insurance Reciprocal of Canada (HIROC) to form an independent company: Salus Global. The SOGC sold 51% of the new company to HIROC and the new partner committed 30 hospitals to moreOB training. This new company took on the responsibility of enhancing and implementing moreOB, while the SOGC continued to provide up-to-date content. With the support of the Obstetrical Review Committee, the content of moreOB, like that of ALARM, continues to be based on the best available evidence, carefully scrutinized by an expert interdisciplinary team of clinicians. Today moreOB, and its French counterpart amproOB, have been offered across North America and are highly regarded in the field of obstetrical patient safety. To date, over 16 000 participants in over 300 units have taken part. Adverse outcomes are significantly less frequent for women and babies who receive their care in participating institutions, which also results in lower institutional liability costs. Although it was initially thought that moreOB would replace ALARM, it turned out that the programs were complementary. ALARM is an intensive and efficient learning package that is delivered to diverse groups of learners from a variety of practice environments and covers the major problems that can arise in the late prenatal and intrapartum periods. Now with the “flipped classroom” approach, ALARM offers learners more opportunities to learn from different perspectives. In contrast, moreOB training is delivered in one institution—all of the members of the team who provide care together learn together. There is less diversity but greater emphasis on teamwork. In 2014, ALARM was introduced to a new generation of physicians when the SOGC entered into a memorandum of understanding with the CFPC to designate the program as their residents' obstetrical training program of record, replacing the previously used ALSO program. The CFPC chose ALARM on the basis of its interprofessional nature and annually updated content—both of which the CFPC felt provided a superior training experience for Canadian family physicians. The next target for ALARM was small communities limited by travel distance to major centres and facing unique demographic challenges. Today ALARM is taught to over 1500 health care providers annually and demand for courses continues to grow. In many institutions having up-to-date ALARM or moreOB credentials is required for hospital privileges in obstetrics. The moreOB program continues its evolution. While the original moreOB program was a fairly structured 3-year curriculum, the newer version addresses relevant gap–focused milestones using a continuous quality improvement process. It is now more responsive to the specific needs of the unit or province in which it is deployed and incorporates state-of-the-art approaches that respect the way humans learn and unlearn. During the 3-year engagement, moreOB invariably leads to enhanced communication, teamwork, and culture change and allows for knowledge application at the unit level to be far more reliable and sustainable. In 2018, the partnership between HIROC and the SOGC was expanded to include a third partner, the Canadian Medical Protective Association (CMPA). Salus Global is currently in strategic planning mode (its own continuous improvement process) focused on ways to improve the functioning of the health care team and the outcomes for patients and their families through the program. As we celebrate the SOGC's 75th anniversary, we can honestly say that at no time before:•has effective functioning of the interprofessional health care team been more important to the safety and well-being of patients;•have clinicians needed access to up-to-date evidence; and•have accreditors and regulators demanded that programs demonstrate that they are continually upgrading the skills of their participants. In this environment, the ALARM and moreOB programs, which were ahead of their time, even visionary, have never been more important. But neither of these programs would have succeeded without the tens, perhaps hundreds, of thousands of hours put in by SOGC national office staff, faculty, and committee members (who were never paid for their work developing and maintaining these programs). These programs are a true reflection of the dedication and expertise of these people. Finally, it is a tribute to SOGC council members that Canada is one of the safest countries in the world to give birth. Since 1994, their vision, support, and wisdom have made ALARM and moreOB possible, improving patient safety in Canada and contributing to significant reductions in maternal mortality and morbidity in many low resource countries. Les programmes GESTA et amproOB façonnent le présent et l'avenir de la formation sur le travail et l'accouchement au Canada comme à l’étrangerJournal of Obstetrics and Gynaecology Canada Vol. 41PreviewLa Société des obstétriciens et gynécologues du Canada (SOGC) offre de nombreux programmes de formation, dont GESTA (Gestion du travail et de l'accouchement) est le programme phare. Depuis son lancement, cette formation pratique fondée sur des données probantes a profité à des dizaines de milliers d'obstétriciens, médecins de famille, infirmières, sages-femmes, apprentis en médecine et autres professionnels de la santé au Canada, ainsi qu’à leurs homologues dans certains pays en voie de développement. Full-Text PDF

La Société des obstétriciens et gynécologues du Canada (SOGC) offre de nombreux programmes de formation, dont GESTA (Gestion du travail et de l'accouchement) est le programme phare. Depuis son lancement, cette formation pratique fondée sur des données probantes a profité à des dizaines de milliers d'obstétriciens, médecins de famille, infirmières, sages-femmes, apprentis en médecine et autres professionnels de la santé au Canada, ainsi qu’à leurs homologues dans certains pays en voie de développement. amproOB, le programme de formation de la SOGC créé à l'intention des équipes d'obstétrique, est actuellement mis en place aux États-Unis et au Canada; plus de 80 % des naissances au Canada ont lieu dans des hôpitaux qui adhèrent au programme amproOB. Le présent article relate la naissance de trois importants programmes de la SOGC, soit GESTA, GESTA International et amproOB. Il aborde également les jalons importants de ces programmes ainsi que les personnes qui ont rendu leur création possible. Le programme GESTA a été lancé en 1994, à une époque où la SOGC s’était positionnée comme chef de file dans l’élaboration de directives cliniques axées sur des soins obstétricaux optimaux. Malgré tout, il était évident que ces directives n’étaient pas toujours adoptées et que les variations dans les soins offerts entraînaient des issues défavorables. Le précurseur du programme GESTA a été mis sur pied au début des années 1990. De concert avec le Saskatchewan Perinatal Education Advisory Committee, les Drs George Carson et Roger Turnell ont mis au point un programme de formation sur la prise en charge du travail et de l'accouchement, lequel a été présenté dans toute la province. À l'occasion du congrès de la Fédération internationale de gynécologie et d'obstétrique (FIGO) qui s'est tenu à Montréal en 1994, le vice-président exécutif de la SOGC de l'époque, le Dr André Lalonde, a proposé l’élaboration d'une formation visant à présenter de manière efficace et pratique les directives cliniques de la SOGC sur les soins intrapartum. Comme il reconnaissait que la publication de directives cliniques à jour était nécessaire, mais ne suffisait pas à changer la pratique, le Conseil de la SOGC a recommandé, en juin 1995, la création d'une formation canadienne exhaustive et pratique sur la prise en charge du travail et de l'accouchement et des risques en faisant appel à l'expertise d'un groupe de travail national composé de médecins de famille et d'obstétriciens. Étant donné la nature interprofessionnelle de la pratique obstétricale au Canada, le programme GESTA a adopté dès le début une approche semblable pour les médecins de famille, les infirmières et les sages-femmes qui travaillent aux côtés des obstétriciens-gynécologues. Le nouveau groupe de travail a élaboré un programme de cours complet fondé sur les meilleures données probantes disponibles et comportant des ateliers d'apprentissage par cas, des documents écrits et du matériel audiovisuel pour couvrir tous les aspects fondamentaux des soins intrapartum et post-partum immédiats. En conformité avec les principes fondamentaux du programme GESTA, il a été convenu que son corps professoral se devait d’être interprofessionnel. Le Dr Carlos Brailovsky, conseiller en éducation auprès du Collège des médecins de famille du Canada (CMFC), a aidé le groupe de travail à mettre au point le processus d’évaluation, lequel se compose d'un examen écrit et d'examens cliniques objectifs structurés (ECOS). De pair avec l'ECOS, le cours GESTA de 2 jours a officiellement été lancé à l'occasion de l'assemblée clinique annuelle de la SOGC à Calgary en 1995. L'une des caractéristiques ayant rapidement distingué le programme GESTA était son engagement à actualiser chaque année le contenu en fonction des meilleures données probantes disponibles. La médecine factuelle était encore embryonnaire, mais comptait parmi ses précurseurs deux spécialistes en obstétrique et gynécologie : le Dr John Collins, ancien président de la SOGC, et le Dr Murray Enkin, pionnier de la Collaboration Cochrane. Le programme GESTA a reçu un accueil positif. Dans ses 10 premières années, plus de 4 000 fournisseurs de soins de santé ont suivi la formation avec succès : près du tiers d'entre eux étaient des obstétriciens; la moitié, des médecins de famille; et le reste se composait d'infirmières et de sages-femmes. Le cours d'instructeur GESTA a été créé en 1996 pour assurer l'uniformité dans la prestation du programme. En 1998, le programme GESTA a été adapté pour répondre aux besoins des fournisseurs de soins de santé dans les pays en voie de développement. Le Dr André Lalonde et Mme Liette Perron, directrice de la division internationale de la SOGC pour la santé des femmes, ont conçu conjointement le programme GESTA International de 5 jours. Le programme GESTA International visait à former un groupe interprofessionnel de fournisseurs de soins de santé et à leur fournir les outils nécessaires pour remédier aux causes les plus fréquentes de mortalité maternelle au sein de leurs hôpitaux et collectivités. En plus de la formation clinique, les participants apprenaient à utiliser les audits de décès maternels en vue de réduire le taux de mortalité maternel. La formation faisait également la promotion d'un cadre de travail en matière de santé sexuelle et de droit génésique pour contrer les facteurs contributifs systémiques de mortalité maternelle. Dans le cadre de son approche de formation des instructeurs, la SOGC s'est associée à 3 pays, à savoir Haïti, l'Ouganda et le Guatemala, pour parfaire le programme de façon à ce qu'il reflète les besoins des pays aux ressources limitées. Partout où le programme international a été mis sur pied, la SOGC a collaboré avec la société professionnelle locale d'obstétrique et gynécologie pour renforcer sa capacité organisationnelle et améliorer les soins offerts aux patientes. Chaque pays a ensuite été en mesure d'offrir le programme par lui-même. Un cours GESTA complémentaire à l'intention des administrateurs d'hôpitaux a été conçu en 2007 pour permettre aux équipes de direction de mieux comprendre les difficultés auxquelles leurs employés de première ligne doivent faire face et les sensibiliser à l'importance de reconnaître les besoins des femmes en travail au sein de leur établissement, des médicaments requis sur place à la nécessité d’établir des communications ouvertes et des transports d'urgence efficaces vers le niveau de soins supérieur. En 2000, le Dr Ken Milne s'est joint à la SOGC en tant que vice-président directeur adjoint responsable de la sécurité des patientes. Entre 2001 et 2003, les Drs Milne et Lalonde ont fondé le programme amproOB; le Dr Lalonde a recueilli les fonds nécessaires et le Dr Milne a mis au point le programme de changement de culture et de sécurité des patientes axé sur l’équipe élargie. Fondé sur des recherches émergentes portant sur les conséquences des facteurs humains sur les activités d'organismes hautement fiables, le programme AMPROOB a été lancé en 2003. Sur recommandation du vice-président directeur, le Conseil de la SOGC a investi près de 1 M$ pour enrichir le programme. En 2004, le programme a été adopté dans toute l'Alberta; il a rapidement pris de l'ampleur et est devenu une source de contenu en milieu hospitalier indispensable en matière de travail d’équipe et de soins obstétricaux. En 2007, après un an de négociations, la SOGC s'est associée à la Health Care Insurance Reciprocal of Canada (HIROC) pour constituer une entreprise indépendante : Salus Global. La SOGC a vendu 51 % des parts de la nouvelle entreprise à la HIROC. Le nouveau partenaire a obtenu l'adhésion de 30 hôpitaux au programme amproOB. La nouvelle entreprise a assumé la responsabilité d'améliorer et de mettre en place le programme amproOB, tandis que la SOGC a continué à fournir du contenu à jour. Avec l'appui du Comité d'examen du contenu obstétrical, le contenu du programme amproOB, tout comme celui du programme GESTA, continue de s'appuyer sur les meilleures données probantes disponibles, lesquelles sont minutieusement analysées par une équipe interdisciplinaire de cliniciens experts. De nos jours, le programme amproOB et son pendant anglophone moreOB sont offerts dans toute l'Amérique du Nord et jouissent d'une excellente réputation dans le domaine de la sécurité des patientes en obstétrique. À ce jour, plus de 16 000 professionnels ont pris part au programme dans plus de 300 unités. Les issues défavorables sont considérablement moins fréquentes chez les femmes et les bébés qui reçoivent des soins dans les établissements participants. Cette réalité réduit également les coûts liés à la responsabilité civile des établissements. Même si, au départ, on a cru que le programme amproOB allait remplacer le programme GESTA, ils se sont révélés complémentaires. Le programme GESTA est un programme de formation intensive et efficace offert à des groupes diversifiés de participants issus d'un vaste éventail de milieux de pratique. Ce programme aborde les problèmes graves susceptibles de survenir en fin de période prénatale et pendant la période intrapartum. Grâce à la méthode de la « classe inversée », le programme GESTA offre aux participants davantage d'occasions d'apprendre en fonction de différentes perspectives. La formation amproOB, quant à elle, est donnée dans un seul établissement à la fois. Par conséquent, tous les membres de l'équipe qui fournissent des soins ensemble apprennent ensemble. La diversité est moindre, mais le travail d'équipe y gagne. En 2014, le programme GESTA a été présenté à une nouvelle génération de médecins après que la SOGC a signé un protocole d'entente avec le CMFC. En vertu de ce protocole, le programme GESTA était désigné comme programme de formation de référence pour les résidents en obstétrique et remplaçait ainsi le précédent programme ALSO. Le CMFC a choisi le programme GESTA en raison de sa nature interprofessionnelle et de son contenu mis à jour chaque année, deux caractéristiques qui, selon le CMFC, fournissaient une expérience de formation de qualité supérieure aux médecins de famille canadiens. Le programme GESTA a ensuite ciblé les petites collectivités éloignées des grands centres urbains et qui sont confrontées à des enjeux démographiques qui leur sont propres. Aujourd'hui, le programme GESTA est formé chaque année plus de 1 500 fournisseurs de soins de santé, et la demande pour ces cours ne cesse de croître. Dans plusieurs établissements, les professionnels sont tenus d'avoir des crédits de formation GESTA ou amproOB à jour pour pouvoir profiter de droits hospitaliers en obstétrique. Le programme amproOB poursuit son évolution. Même si le programme amproOB original comportait un curriculum de 3 ans assez bien structuré, la nouvelle version corrige les jalons pertinents axés sur les lacunes au moyen d'un processus d'amélioration continue de la qualité. Il répond dorénavant mieux aux besoins particuliers de l'unité ou de la province dans laquelle il est mis en place et intègre des approches de pointe qui respectent la manière dont les personnes apprennent et désapprennent. Pendant l'engagement de 3 ans, le programme amproOB optimise invariablement les communications, le travail d’équipe et le changement de culture, en plus d'améliorer l'efficacité et la durabilité de l'application des connaissances au sein des unités. En 2018, le partenariat entre la HIROC et la SOGC a été élargi pour inclure un troisième partenaire, l'Association canadienne de protection médicale. Salus Global est actuellement en période de planification stratégique (son propre processus d'amélioration continue), qui vise l'amélioration du fonctionnement de l’équipe des soins de santé et des issues pour les patientes et patients et leurs familles grâce au programme. En ce 75e anniversaire de la SOGC, nous pouvons honnêtement dire que jamais auparavant :•l'efficacité du fonctionnement des équipes interprofessionnelles de soins de santé n'a joué un rôle aussi important pour la sécurité et le bien-être des patientes;•les cliniciens n'ont eu besoin d'avoir accès à des données probantes à jour;•les organismes d'accréditation et de réglementation n'ont demandé à ce qu'il soit démontré que les programmes continuent d'actualiser les compétences des participants. Dans un tel contexte, les programmes GESTA et amproOB, qui étaient en avance sur leur époque et qu'on pourrait même qualifier de visionnaires, sont plus importants que jamais. Cela dit, aucun de ces programmes ne connaîtrait le succès d'aujourd'hui sans les dizaines, voire les centaines, de milliers d'heures investies par le personnel du bureau national de la SOGC, le corps professoral et les membres des comités (lesquels n'ont jamais été rémunérés pour leur travail à élaborer et perfectionner ces programmes). Ces programmes sont un véritable reflet du dévouement et de l'expertise de ces personnes. Enfin, le fait que le Canada soit l'un des pays les plus sécuritaires pour accoucher témoigne du travail des membres du Conseil de la SOGC. Depuis 1994, leur vision, leur soutien et leur sagesse ont rendu possible la mise en œuvre des programmes GESTA et amproOB, lesquels améliorent la sécurité des patientes au Canada et contribuent à réduire considérablement la mortalité et la morbidité maternelles dans plusieurs pays aux ressources limitées. ALARM and moreOB: Shaping the Present and Future of Labour and Delivery Training in Canada and AbroadJournal of Obstetrics and Gynaecology Canada Vol. 41PreviewThe Society of Obstetricians and Gynaecologists of Canada (SOGC) offers many training and educational programs but ALARM (Advances in Labour and Risk Management) is the flagship. Since its inception, tens of thousands of Canadian obstetricians, family physicians, nurses, midwives, trainees and other health professionals, and their counterparts in developing nations, have benefited from this practical evidence-based training. moreOB, the SOGC-developed obstetrical team training program, is being implemented in the U.S. Full-Text PDF

(Int J Gynecol Obstet. 2019;146:65–73) An initiative to guide and support quality maternity care has been launched by the International MotherBaby Childbirth Organization (IMBCO) and the International Federation of Gynecology and Obstetrics (FIGO). “The International Childbirth Initiative (ICI): 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care” is a guide to implementing evidence-based maternity care with consideration of the MotherBaby dyad and family environment. The traditional medicine model has been shifted by the development of value-based care models focusing on the partnership between the provider and the care recipient. The ICI places the “MotherBaby-Family” unit as the central recipient of care, as the health of 1 member of the MotherBaby dyad has important impacts on the other. This model incorporates the practice of midwifery as a foundation of safe and respectful care.

The ICI has developed a quality assurance program of 12 steps for safe and respectful MotherBaby–Family maternity care that all birthing units can implement.

In May of 2017, the long-awaited results of the World Maternal Antifibrinolytic Trial (WOMAN study) of the benefits of tranexamic acid (TXA) for the treatment of postpartum hemorrhage (PPH) were published. 1 WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017; 389: 2105-2116 Abstract Full Text Full Text PDF PubMed Scopus (745) Google Scholar The study is one of the largest ever randomized trials in maternal health and certainly the largest related to PPH care. Just over 20 000 women with PPH in 193 hospitals in 21 countries around the world were randomized to receive 1 g of intravenous TXA or matching placebo. The primary outcome was death from PPH, and this was reduced from 1.9% to 1.5% in women who received the TXA, a risk reduction of 0.81 (95% CI 0.65–1.00). The effect was more pronounced in women who received the drug within 3 hours of giving birth, in whom there was a 31% reduction in the rate of death (from 1.7% to 1.2%). The risk of laparotomy for bleeding was reduced even further by nearly 40%. Importantly, TXA appeared to benefit those women with both atonic and traumatic bleeding and was unrelated to the mode of birth. There were no significant differences in any other outcomes. This finding is not surprising, given that multiple therapies (including uterotonics, tamponade, manual removal of placenta, hysterectomy, and blood transfusion) are often used concurrently at the time of a PPH, and they would have been given before the TXA (or placebo) had a chance to work. These other therapies therefore, although classified as “outcome measures,” could just as well be seen to be “baseline data” and are consequently evenly distributed between the study arms. The one exception is “laparotomy for bleeding,” where the procedure tends to be carried out later for ongoing trickling, and for this there was a clear benefit for TXA (unless its administration was delayed for >3 hours). This finding largely fits with TXA's having an important (but not immediate) effect, largely on the “tricklers” who continue to have ongoing blood loss for some hours after birth.

Recent evidence indicates that disrespectful/abusive/coercive service delivery by skilled providers in facilities, which results in actual or perceived poor quality of care, is directly and indirectly associated with adverse maternal and newborn outcomes. The present article reviews the evidence for disrespectful/abusive care during childbirth in facilities (DACF), describes examples of DACF, discusses organizations active in a rights-based respectful maternity care movement, and enumerates some strategies and interventions that have been identified to decrease DACF. It concludes with a discussion of one strategy, which has been recently implemented by FIGO with global partners-the International Pediatrics Association, International Confederation of Midwives, the White Ribbon Alliance, and WHO. This strategy, the Mother and Baby Friendly Birth Facility (MBFBF) Initiative, is a criterion-based audit process based on human rights' doctrines, and modeled on WHO/UNICEF's Baby Friendly Facility Initiative.

When a natural disaster occurs, such as an earthquake, floods, or a tsunami, the international response is quick. However, there is no organized strategy in place to address obstetric and gynecological (ob/gyn) emergencies. International organizations and national ob/gyn societies do not have an organized plan and rely on the good will of volunteers. Too often, local specialists are ignored and are not involved in the response. The massive earthquake in Haiti in 2010 exemplifies the lack of coordinated response involving national organizations following the disaster. The Society of Obstetricians and Gynaecologists of Canada (SOGC) engaged rapidly with Haitian colleagues in response to the obstetric and gynecological emergencies. An active strategy is proposed.

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Background: Maternal and perinatal mortality are major problems for which progress in subSaharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel.Methods/Design: This is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews.The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along with the inventory of resources and the satisfaction surveys administered to the health personnel, will allow us to measure results before, during, and after the intervention. The overall rate of maternal mortality measured in hospitals during the post-intervention period (Year 4) is the primary outcome. The evaluation will also include cost-effectiveness.Trial Registration: The QUARITE trial is registered on the Current Controlled Trials website under the number ISRCTN46950658 http://www.controlled-trials.com/.

This article reviews the major activities of health care professional organizations (HCPAs), and emphasizes the role they can play in advocating for women and children and influencing maternal, newborn,and child health (MNCH) programs and policies. The ICM/FIGO joint effort to prevent postpartum hemorrhage and the 40-year partnership between the American Academy of Pediatrics (AAP) and the Indian Health Service (IHS) are highlighted as examples of how and why HCPAs should assume a leadership role in advocacy work. The action-oriented multicountry HCPA workshops organized by the Partnership for Maternal, Newborn, and Child Health (PMNCH) and the international HCPAs are also described. These capacity building workshops are aimed at strengthening the ability of HCPAs to organize, coordinate activities, and become more involved in program and policy development. (C) 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

André Lalonde, MD Society of Obstetricians and Gynaecologists of Canada, Ottawa, Canada and Amanda C. Lee, MSc International Federation of Gynecology and Obstetrics, London, UK Dr André Lalonde is the current Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada (SOGC). A lifelong proponent of collaborative maternity care, Dr Lalonde led the Multidisciplinary Collaborative Primary Maternity Care Project (MCP2). Dr Lalonde also pioneered a maternal risk management program to address maternal and newborn mortality and morbidity, both in Canada and around the world (the ALARM International Program). Since 1999 Dr Lalonde has been Co-Chair of FIGO's Safe Motherhood and Newborn Health Committee, supervising projects in 10 low-resource countries to reduce maternal and newborn mortality and morbidity. Dr Lalonde is also FIGO's representative on the Partnership for Motherhood and Newborn Child Health. The mandate of the Partnership is to support the achievement of Millennium Development Goals 4 and 5. Amanda C. Lee has a multidisciplinary background. With a BA in Film Studies (Columbia, USA), she also holds an MA in Near and Middle Eastern Studies from the School of Oriental and African Studies (London, UK), and an MSc in Reproductive and Sexual Health Research from the London School of Hygiene and Tropical Medicine. Her public health research experience includes analyzing reproductive and sexual health programs for young people in countries as diverse as Lebanon and Liberia. She currently serves as FIGO's Safe Motherhood and Newborn Health Project Coordinator. As Co-Chair of FIGO's Safe Motherhood and Newborn Health (SMNH) Committee and Project Coordinator we are fortunate to work with an outstanding number of individuals from across the world who help in the management of the SMNH project (Table 1). In 2005 and early 2006, FIGO secured funding for 6 country projects to be implemented over a 5-year period. Further discussions resulted in FIGO investing 1 million US dollars to accept 3 additional countries to develop and implement projects to reduce maternal and newborn mortality and morbidity. One further country received partial funding from the USAID/Intrahealth Capacity Project. The 10 countries are Haiti, Kenya, Kosovo, Moldova, Nigeria, Pakistan, Peru, Uganda, Ukraine, and Uruguay; and the aims of the projects are to fill identified gaps in the provision of maternal and newborn health in each country. A few projects began in 2006 whereas the majority began in 2007. The Haitian project seeks to ensure the provision of quality basic and comprehensive emergency obstetric care (BEmOC and CEmOC) at the district health center of Croix-des-Bouquets. Despite the country's political instability and administrative delays brought about by the Ministry of Health's procedures, the Haitian team's perseverance has ensured that provision of 24-hour basic obstetric care has begun and renovation of the health center's building has been completed. In Kenya the project goal is to improve the quality of maternal and perinatal care through maternal mortality audits in 5 project facilities. In May 2008 the Kenyan team held a clinical audit training workshop facilitated and attended by multidisciplinary health professionals including midwives, obstetricians, gynecologists, nurses, and clinical officers, which signaled the commencement of the project's clinical audit intervention. The Kosovo project is providing capacity building to strengthen maternal and neonatal care services, including enhancement of the organizational capacities of the Kosovo Obstetrics and Gynecology Association (KOGA) and the Kosovo Midwifery Association (KMA). Interventions to improve the quality of neonatal and maternal care in Pristina University and 2 regional maternity units, Gjakova and Gjilan, are underway. The team has also developed 11 protocols (7 on obstetric care and 4 on neonatal care), which will be presented to the professional associations to enable their implementation. Implementing new approaches to reviews of perinatal deaths is the target of the project in the Republic of Moldova. Under the direction of an active committee, seminars in perinatal auditing were held in 16 maternities across the country, resulting in the training of 100 specialists in the use of tools and methodology. As a result of perinatal auditing, the leading cause of stillbirth in the intervention sites was found to be intrauterine growth restriction (IUGR). In November 2007, members of the Moldovan Society together with the Perinatal Medicine Society met with representatives from Romania to focus on and discuss this finding. The Nigeria project seeks to improve maternal and neonatal outcomes in the 3 states of Edo, Anambra, and Kaduna. Three selected hospital sites have conducted baseline data research to ascertain each facility's maternal mortality and case fatality rates. Newly established safe motherhood committees will guide project activities with the main aim of providing training. A national training curriculum for emergency obstetric care has been developed and it is hoped that this will be presented in all 3 sites and to health care providers in their catchment areas. The project in Pakistan is conducting community-based interventions to reduce maternal and perinatal mortality and morbidity in 2 subdistricts of rural Sindh. Key initial steps for ensuring the success of these interventions has included upgrading health facilities and providing accommodation to key staff to ensure a 24-hour service. Comprehensive emergency obstetric and neonatal care is being provided for women who have never previously had access to such services. The Peruvian project seeks to reduce the geographical, economic, and cultural access barriers to care and improve the relations between health personnel, customers, and the community within the Morropon-Chulucanas Health Network of DISA Piura. Its activities have been challenged by the rural isolation of DISA Piura and difficulties in motivating health authorities to support the project. Through relationship building and dissemination of the project's objectives to health network staff, the team has strengthened the participation of the authorities and will continue to do so with the provision of training in obstetrics and neonatal emergency care for health professionals. Uganda has selected 6 pilot health units in Kiboga and Kibaale districts in which to deploy appropriate EmOC and essential newborn care. Additional aims include capacity strengthening of the African Midwives Research Network (AMRN) and the Association of Obstetricians and Gynecologists of Uganda (AOGU), and mobilizing the communities to access emergency obstetric and newborn care in the intervention districts. Facility and qualitative needs assessments have provided information on the scale and nature of shortfalls and have helped to establish community perceptions and beliefs on pregnancy companion, birth and emergency preparedness, and other factors affecting pregnancy. The ALARM International Program (AIP) Ukraine project aims to strengthen the organizational capacity of the Ukrainian Association of Obstetricians and Gynaecologists (UAOG) to improve the quality of emergency obstetric care and family planning services. Making use of a train-the-trainers approach, the project focuses on building the capacity of 2 national teams of AIP instructors to roll out the program to health providers in the 2 pilot regions of Donetsk and Vinnitsa. The goal of the Uruguay project is to improve relations between users and health professionals when addressing unwanted and unacceptable pregnancy. It aims to implement the “Sanitary Initiatives” health model in health centers across 4 districts in Uruguay with other centers serving as a control group. Activities for 2007 include the introduction of counseling and consultation services for women presenting with unwanted and/or unacceptable pregnancies, dissemination of information to communities on the rights of women, and the duties of health professionals in providing confidentiality. The project teams are led by a part-time project director often supported by a project co-director and researcher. Mentoring and twinning duties are taken up in-kind by FIGO member associations in high-resource countries to further support the capacity building aspects of the projects. External evaluation is ongoing, with over half of the project countries visited by an independent health consultancy selected for the monitoring and evaluation of the overall SMNH project.

Élaborer des points de repère en ce qui a trait aux temps d'attente en obstétrique-gynécologie. Les points de repère énoncés dans le présent document ont été recommandés par le comité spécial de la SOGC sur les temps d'attente, dont les membres comprenaient des spécialistes en obstétrique, en gynécologie, en urogynécologie et en gynécologie oncologique. Une analyse documentaire a été menée sur les temps d'attente et l'accès aux soins; de plus, les directives cliniques et les documents sur les normes de diligence existants ont fait l'objet d'un examen. La présente déclaration de principe, élaborée par le comité spécial de la SOGC sur les temps d'attente, a été adoptée par le Conseil de la SOGC dans le cadre de sa réunion du 10 novembre 2007. Le Conseil de la SOGC compte des représentants de toutes les régions du Canada, des spécialistes de tous les domaines de pratique en obstétrique-gynécologie, des médecins de famille, des infirmières, des sages-femmes, des directeurs de programme et des résidents, ainsi qu'une représentante du public. Formulation par consensus de recommandations quant aux temps d'attente en obstétrique-gynécologie.