Emergency Obstetric Programs Play Key Role in Maternal Health Goals

Published on July 5, 2014
Fourteen years have passed since the World Health Organization and United Nations identified and vowed to reduce the problem of maternal health. Programs like Advanced Life Support for Obstetrics are leading the way in meeting the need for emergency care at the community level.

Emergency cardiac care, focused on elderly and often requiring expensive technology, simply does not have the same moral imperative of saving a healthy mother's life during labor.

In September of 2000, world leaders signed a United Nations Millennium Declaration committing themselves to fight some of the world’s most imposing issues, including poverty, hunger, and disease. From this Declaration came the Millennium Development Goals, a set of eight objectives that the combined 193 members of the UN aimed to achieve by the year 2015. The fifth goal on this list is to improve maternal health. More specifically, the hope is to reduce the maternal mortality ratio by three quarters and to achieve universal access to reproductive health.

In the past, this goal might have seemed outside the purview of emergency medicine, but that is changing as emergency physicians the world over take an interest in global health. One out of three emergency medicine residency programs in the United States have international health fellowship programs. If can harness this interest and combine it with critical knowledge of obstetric emergencies, we’ll go a long way towards proving the role of emergency medicine internationally.

When I first got interested in maternal health and obstetric emergencies I thought that I already knew all about Life Support courses. I was quite surprised to hear that there was an Advanced Life Support for Obstetrics (ALSO) course that has trained over 160,000 people to date. In reviewing the materials in order to prepare a student to teach the course in Guatemala, I was led down an exciting rabbit hole of maternal health. This journey brought me far beyond my experience as an emergency physician in the United States. Eventually I began to teach ALSO courses in Mexico, and the results have been life changing.

The ALSO Course is a typical Life Support Course which uses mnemonics and simulations with manikins before ending with a “Mega Delivery.”  It is competency-based certification for the management of postpartum hemorrhage, pregnancy induced hypertension, and obstructed labor. Our workshops in Mexico include vacuum-assisted delivery, FAST OB ultrasound, and neonatal resuscitation. The Basic Life Support in Obstetrics (BLSO) course is directed at nurses and EMTs and the new EM Community. CLSO, or The Obstetrics First Responder, is directed at low literacy community levels, bringing traditional midwives and community health workers into the “Chain of Survival” for the new mother and child.

Originally designed so that family physicians could become credentialed in US hospitals, the ALSO program underwent a rebirth in the international arena. One important shift taking place globally is that in various countries emergency physicians have taken the lead in the implementation of ALSO training.

The fact is that in most locales, especially in less urbanized settings, emergency specialists do not exist. Because EM is an urban specialty, there are typically OB Specialists that manage all of these cases wherever there are EM training programs. Yet there are many urban areas that have no emergency specialists at all. As emergency medicine ventures into the prehospital arena and into almost all emergency departments, we see that third trimester pregnancies are being evaluated in emergency departments. The emergency physicians throughout the world need this type of training as much as they need to train in trauma and pediatrics, and probably more than they need to train in cardiac.

New UN data shows a 45% reduction in maternal deaths since 1990. An estimated 289,000 women died in 2013 due to complications in pregnancy and childbirth, down from 523,000 in 1990. Eleven countries that had high levels of maternal mortality in 1990 have already reached the MDG5 target of a 75% reduction in maternal mortality. SOURCE: WHO

This need can be seen in Ethiopia, for instance, where there is an EM residency training program which trains in the ALSO courses because of the burden of obstetrical problems facing EDs. In India there are over 8,000 EMTs that have been trained in the BLSO course. In Hong Kong the emergency specialists are leading ALSO training courses.

In Mexico, our PACE Program runs a successful ALSO Program that has trained over 8,000 providers. PACE adapts ALSO to the various settings in Mexico and PACE has helped set up programs in Argentina, Chile, Panama, and Costa Rica with future plans to introduce the program to Cuba.

While PACE teaches Basic and Advanced Cardiac Life Support and Pediatric and Trauma Life Support courses – standard for any EM training – we have found that it is the emergency obstetrics programs that can lead the way for better emergency care in general at the community level.  Postpartum hemorrhage requires that hemorrhagic shock be managed. Pre-eclampsia/eclampsia requires that IV medications be used and airways managed. Neonatal resuscitation requires that there be some critical care management at a pediatric scale. It requires that EMS and communities in austere settings develop “chain of survival” capabilities.  And of course, it requires that prevention and early warning signs be learned.

Emergency cardiac care, focused on elderly and often requiring expensive technology, simply does not have the same moral imperative of saving a healthy mother’s life during labor. A dead mother and child is a devastating event for the family and for the community. The home is destroyed, the children are orphaned, often scattered. The community disintegrates, losing faith in their healthcare providers and their government. The social fabric is frayed. These are loaded issues, and they are indicative of our society’s values. Civilizations advance when women are literate and safe. As emergency physicians, lets engage the global maternal mortality rate as a marker of progress. We have much to offer in this battle, and a moral obligation to do so.

This article originally appeared in Issue 13 of Emergency Physicians International.

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