Peter S. Bernstein, MD, MPH


January 10, 2007

The dramatic disparities in women's and perinatal health outcomes for those in resource-limited and resource-rich countries was the topic of this year's annual Autumn in New York conference, sponsored by the Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, and the Albert Einstein College of Medicine, Bronx, New York. This year's meeting, the 25th annual gathering, was held in honor of Dr. Allan Rosenfield, Dean of Mailman School of Public Health, Columbia University, New York, NY. Dr. Rosenfield was honored by the speakers and the attendees for his extraordinary contributions in improving the health of women and their families worldwide. His remarkable mentoring of many of the leaders in the battle to improve the health of the underserved has also been a significant contribution.

The meeting featured an assortment of speakers who covered a wide variety of topics, including family planning, complications of labor and delivery, and epidemic conditions that affect women's health. One of the sessions was devoted to the efforts of academia, including medical schools like the University of Michigan, the Albert Einstein College of Medicine, Vanderbilt University, and the University of Maryland, as well as organizations such as the World Health Organization and the Geneva Foundation for Medical Education and Research, to encourage the development of leaders who would devote themselves to global health issues.

How family planning and contraception relate to women's health was the focus of the opening session. Dr. Daniel Mishell, University of Southern California, Los Angeles, provided an overview of the history of contraception in its varied forms, with special attention to the intrauterine device (IUD). He contended that in the United States, in particular, the IUD developed an undeserved, poor reputation in the armamentarium of contraceptives for 2 reasons. The first was due to the problems associated with the Dalkon Shield, which tarred the reputation of all IUDs. The second was the misperception that IUDs prevent pregnancies because they act as an abortifacient.

Dr. Mishell noted that the increased risk for upper genital tract infection (most frequently pelvic inflammatory disease [PID]) associated with the Dalkon Shield was related to a design issue limited to that particular IUD -- its tail string was not monofilament. In contrast, the monofilament IUDs commonly used today are associated with only a slightly increased risk for PID in the first 3 weeks after insertion. He also reviewed data that rather conclusively demonstrated that IUDs are not abortifacients. Instead, they create an intrauterine environment that prevents sperm from getting to the fallopian tubes and thus prevents fertilization from occurring. Given the high effectiveness, ease of reversibility, and lack of systemic risks, an IUD may be one of the best types of contraceptives available. Dr. Mishell maintained that wider use of the device could have a significant impact on the scandalously high rate of unintended pregnancy in the United States (nearly 50%) and throughout the world.

Given the high rates of maternal mortality in resource-poor nations, preventing unplanned pregnancies can both save the lives of women and prevent abortion. Dr. Ruth Merkatz, of the Population Council and Albert Einstein College of Medicine, New York, characterized access to effective contraception as a human right, as this can help women both control and even save their lives. In many less-developed countries, contraceptive use has made inroads. As a result, women are beginning to be able to choose how many children they desire. In particular, compared with the more developed world, IUD use and sterilization are more commonly employed by couples.

A presentation by Dr. Timothy Johnson, of the University of Michigan, Ann Arbor, picked up where Dr. Merkatz left off. He focused on 3 topics related to women's health: terrorism, fundamentalism, and compartmentalism. The code strictly limiting women's access to the world outside their homes imposed by the Taliban following rise to power in Afghanistan in 1996 was cited as a glaring example of terrorism. Additionally, women who worked for women's rights were murdered.

Closer to home, he described the chilling effect created by the Bush Administration in its efforts to restrict access to abortion following Attorney General John Ashcroft's request for medical records of women who had undergone second-trimester abortions. Although the Attorney General's office had promised to keep records confidential, the names of women in Nebraska who had undergone second-trimester abortion were mistakenly leaked to the press.

Dr. Johnson divided fundamentalism's impact on women's health into religious and antiscience components. The Vatican's opposition to encouraging condom use as a way to control the spread of HIV infection was used as an example of religious fundamentalism, and the denial of HIV as the cause of AIDS by South African authorities, until recently, was described as an example of antiscience fundamentalism.

How compartmentalism compromises women's health is a bit more subtle. Dr. Johnson cited how aid programs in many resource-poor countries provide only limited services, making access to care more difficult. Thus, women might be required to go to one place to get vaccinations and to another for family planning support because of the mandates of the respective funding organizations.

Being pregnant continues to be a life-threatening condition in resource-poor nations. The rate of mortality in the developed world ranges from about 8 to 12 deaths per 100,000 live births, but in the developing world ranges from 100 to 1000 per 100,000 live births. Dr. Allen Rosenfield addressed the maternal mortality crisis facing the developing world. He noted that although abortion is illegal in many developing countries, it is also very common. As a result, the procedure is often unsafe, resulting in 60,000-110,000 deaths per year. The exact numbers are difficult to ascertain because women dying of unsafe abortion complications do not often divulge that they underwent the procedure.

Finally, Dr. Rosenfield noted that maternal mortality could be significantly decreased with only modest investments. He described what has taken place in Sri Lanka and Malaysia, where the maternal mortality rates have been reduced by half. Some of the keys to success include educating locals in the villages on when to transport a pregnant woman to a hospital; appropriate training of birth attendants; access to transportation to allow a woman in jeopardy to make it to an appropriate facility; and availability of drugs such as magnesium sulfate, misoprostol, and various antibiotics.

Obstetric fistulas, a maternal morbidity common in societies without access to appropriate obstetrical care, were the primary focus of a presentation from Dr. Charles-Henry Rochat, of the Geneva Foundation for Medical Education and Research and the Center for Robot-Assisted Laparoscopic Surgery, Suisse Romande, Switzerland. He noted that an estimated 2 million women suffer from this problem -- and it is possible that the number may be as many as 4 million. In sub-Saharan Africa, the rate may be 2 of every 1000 deliveries. Most of these fistulas occur because of obstructed labor and are also associated with a high rate of perinatal mortality. Dr. Rochat described the pioneering efforts of the Geneva foundation to address this epidemic

The relationships between breastfeeding and neonatal mortality and other childhood health outcomes were described by Dr. Avroy Fanaroff, of Rainbow Babies and Children's Hospital, Cleveland, Ohio. It has become increasingly apparent that breastfeeding is one of the most effective interventions for decreasing childhood mortality. Breastfed babies in developing countries have significantly less diarrheal disease, a leading cause of mortality. In fact, formula-fed babies have a 4-fold increased risk for mortality compared with those who are breastfed. For mothers and children in both developed and developing countries, breastfeeding reduces the risk for sudden infant death syndrome, childhood obesity, inflammatory bowel disease, type 1 diabetes mellitus, and childhood lymphoma. For women, breastfeeding reduces the risk for osteoporosis and breast and ovarian cancer, and accelerates postpartum weight loss.

No conference on global women's health issues would be complete without attention to the problem of HIV infection. Dr. Patricia Toro, of Mailman School of Public Health, Columbia University, New York, NY, described a new take on the phrase made famous in women's health by Dr. Rosenfield and Deborah Maine 2 decades ago. In 1985, they posed the question, "Where is the 'M' in maternal child health (MCH)?", referring to the neglected tragedy of maternal mortality at a time when MCH was really only a euphemism for efforts to reduce childhood morbidity and mortality in the developing world. The new version of the phrase is "Where is the 'M' in MTCT?" MTCT stands for "mother-to-child transmission (of HIV infection)."

Unfortunately, although impressive efforts have been made to reduce the incidence of vertical transmission of HIV infection, caring for the mother with HIV has received much less attention. While saving a baby from acquiring HIV infection during childbirth is an important achievement, children who lose their mothers to HIV infection have other increased risks for morbidity and mortality, even if they have not acquired HIV infection. Dr. Toro described the MTCTPlus program, an initiative at Mailman to develop and implement a model of HIV care supporting multiple family members with HIV disease in various areas of the developing world.

This sampling of some of the key points presented in a few of the talks does not do justice to the diversity of presentations at this year's Autumn in New York meeting. The meeting itself cannot do justice to the range of issues that need to be addressed to improve the status of women and children in the world.

A fitting summation of this year's Autumn in New York meeting was "Making Every Mother and Child Count," the presentation of Dr. Herbert Peterson, University of North Carolina, Chapel Hill. He drew the audience's attention to the Millennium Development Goals set out by the United Nations. The fifth goal is to reduce the maternal mortality ratio by 75% worldwide. Currently, women in the developing world have a 1 in 16 lifetime risk of dying from pregnancy. As noted previously, a significant cause of many deaths is unsafe abortions. Worldwide each year, 45 million unintended pregnancies end in abortion and more than 19 million of these are unsafe procedures. Thus, adequate access to family planning could dramatically reduce both the incidence of abortion and maternal mortality associated with unsafe abortion. If women can avoid unintended pregnancies, they can decrease their overall lifetime risk of mortality associated with childbirth.


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