Modezaak BronwasserWoman actief voor White Ribbon
Rond Moederdag is de actie van BronwasserWoman begonnen. Enkele honderden White Ribbon pinns werden gekocht en de klanten kregen een White Ribbon uitgereikt na hun aankoop.
Midden voorin de zaak staat de mooie banner. Het geheel ziet er heel verzorgd uit. Vele dames pinnen wat extra voor White Ribbon, nadat ze de informatie tot zich hebben genomen. De dag voor Moederdag zijn enkele White Ribbon dames zelf in de zaak om tekst en uitleg te geven over White Ribbon.
Ook wordt er het fietsproject Africa Classic van Loes Happe voor Amref getoond. De opbrengst voor dit project is nu bijna 10.000 euro. Door Loes en haar medewerkers bijelkaar gewerkt door allerlei acties. De bijdrage van White Ribbon voor Loes wordt nog bekend gemaakt.
De actie bij BronwasserWoman op het Gelderlandplein in Amsterdam Buitenveldert duurt nog tot eind van de maand Mei.
Waar mag de elegante White Ribbon banner in de maand juni staan? In welke modezaak of welke praktijk?
White Ribbon diner 2018
Zaterdag 10 maart 2018 was het jaarlijkse White Ribbon Diner rondom de Internationale Vrouwendag. Veel gepassioneerde gasten en inspirerende sprekers: Professor Kitty Bloemenkamp en Professor Tarek Meguid. Ze wisten bij iedereen de juiste snaar te raken en op een indrukwekkende manier de tragische boodschap vorm te geven en daarbij de up to date stand van zaken te presenteren.
Burgemeester Ahmed Aboutaleb verzorgde ook een belangrijke aandeel en ging in op de goede acties in Rotterdam, in beeld gebracht door White Ribbon, die Veilig Moederschap centraal stellen. Zie beeld hierboven, vervaardigd door Merel van Meurs, vormgeefster White Ribbon.
Spreker Tarek Meguid kreeg, blij verrast, uit handen van Aboutaleb de White Ribbon award 2018. Met volledige bijval van de aanwezige gasten! Hij heeft de award: een bronzen flamingo, zeer verdiend. Jarenlang heeft hij zich ingezet voor Veilig Moederschap in Europa en Afrika. In Namibië, Tanzania en Zanzibar.
Veel aandacht en feedback was er voor de toekomst en de rol van White Ribbon. De reacties en adviezen van de gasten en vrienden worden uitgewerkt.
Natascha Deguelle verwende het gezelschap met haar zang en passie voor het onderwerp.
Het diner vond plaats in restaurant Lommerrijk te Rotterdam! Fantastische ambiance, geweldig buffet en betrokken en vakkundig personeel.
Diner 2018: een historisch moment en dat was het!
Safe Motherhood 30 jaar in actie. Belangrijke speeches!
Een geweldige bijeenkomst betreffende Safe Motherhood, 30 jaar actief, te volgen via bovenstaande link.
Speeches, die de essentie en de historie van het werk betreffende Moedersterfte en Vrouwengezondheid duidelijk voor het voetlicht brengt.
Plaats: Woodrow Wilson International Center for Scholars, Washington D.C.
Onderzoeks instituut in Washington D.C. Verenigde Staten.
Panelleden onder meer:
Petra ten Hoope, voorzitter en Barbara Kwast, inspirerend spreker
Zeer de moeite waard!
Nieuwe banner van White Ribbon
Vanaf vandaag, 6 september 2017, kan de mooie nieuwe White Ribbon banner ook staan in uw werkomgeving of andere openbare ruimte om iedereen te attenderen op de nog veel te hoge Moedersterfte in de wereld.
White Ribbon wil graag pinns verkopen en vrienden maken.
De banner kan staan in Verloskundige Praktijken, Gezondheids centra, Ziekenhuizen, buurthuizen, op uw congres en waar u maar wilt.
Aandacht en actie voor het probleem van Moedersterfte in de wereld. Mail: email@example.com
Franka Cadee, sinds 17 juni 2017 president van de ICM: International Confederation of Midwives.
Op donderdagochtend 24 augustus in het kantoor van de Koninklijke Nederlandse Organisatie van Verloskundigen spraken de verloskundigen Franka Cadee, Marianne Sanders en Leonie Welling (maakte ook de video) elkaar.
Allereerst natuurlijk om onze felicitaties aan Franka namens White Ribbon over te brengen voor haar uitstekende werk om deze internationale toppositie te verwerven. Dat heeft ongetwijfeld heel wat voeten in de aarde gehad. White Ribbon besloot haar een mooie Nederlandse broche te schenken, die door haar in dank werd aanvaard!
Nieuwe plannen werden gesmeed tussen onze organisaties, want we kunnen veel voor elkaar betekenen. Als eerste staat op het programma het intensiveren van onze contacten met de White Ribbon collega's in de USA, aangezien Franka daar binnenkort een gesprek mee heeft. Korte internationale lijntjes worden het op deze manier, we zijn heel benieuwd en enthousiast. Franka is sinds het begin van WR-NL vriend en actief voor White Ribbon geweest, dus ze weet als geen ander hoe wij te werk gaan.
Symposium Working Party 1 december 2017
Sprekende afbeeldingen reproductive health ter illustratie van de voorlichtingseducatie.
Goed nieuws voor de pasgeboren en jonge vaders!
!! ING GEEFT JONGE VADERS in 2018 EEN MAAND
BETAALD VADERSCHAPSVERLOF !!
Vaders die werkzaam zijn bij ING kunnen volgend jaar de eerste maand na de geboorte van hun kindje met betaald verlof. Daarna mogen ze nog eens drie maanden onbetaald verlof opnemen.!!
Een eerste begin van ouderschapsverlof, in navolging van het Zweedse systeem. White Ribbon juicht het van harte toe!
Zo geeft ook eindelijk onze maatschappij een belangrijk en goed signaal af aan de jonge gezinnen!
Op naar ruim vaderschapsverlof Nederland breed!!
Nieuwsoverzicht Veilig Moederschap en moedersterfte
Oratie Prof. Dr. Jelle Stekelenburg
Op 17 januari 2017 hield Jelle Stekelenburg zijn oratie
'Maternal health, a left right'
in Groningen. Jelle Stekelenburg is namens de NVTG hoogleraar Internationale aspecten van reproductieve gezondheidszorg, in het bijzonder veilig moederschap. Zie de tekst van zijn oratie in het Engels.
Maternal health, a left right
Inaugural lecture by Jelle Stekelenburg, MD-IHTM, PhD, Gynaecologist/obstetrician, Professor ‘International aspects of Reproductive Health, in particular Safe Motherhood’, at the University of Groningen, The Netherlands
Mr Rector-Magnificus, Members of the Board of Management, Board Members of the NVTG, Directors of MCL and MCL Academy, Honourable Professors, Dear Colleagues, Friends and Family, Dear Students, International PhD-candidates, Friends and Colleagues, and those watching this lecture through a live stream in Ethiopia, Tanzania, India, Korea, Zimbabwe, Indonesia, Afghanistan and the US,
Ladies and Gentlemen,
It is a great honour and pleasure to address you with the opening lecture of my tenure as Professor ‘International aspects of Reproductive Health, in particular Safe Motherhood’ at the University of Groningen.
It is thirty years ago that I first met Professor Ivan Wolffers, eventually my promotor, who taught me about the 1978 Declaration of Alma Ata, expressing the need for urgent action by all governments, all health and development workers, and the world community, to protect and promote the health of all people; the first international declaration underlining the ambition to achieve the goal of "Health For All by the year 2000”.
In 2004, my co-promotor, colleague and friend, Jos van Roosmalen, mentioned in his inaugural lecture
‘De moeder het kind van de rekening’
that the rights of women giving birth are repeatedly and continuously violated and that it is our duty to raise questions about this issue and to contribute to improving it . Unfortunately, but of course as expected, the work is not yet finished. The title of my lecture, “Maternal health; a left right”, refers to maternal health on one hand being a right, a human right, and, on the other hand, the observation that motherhood is not yet safe for many women and their babies, who are left behind.
In this lecture, I will focus on maternal health issues. After the story about Lula, I will give you an overview of the current maternal health situation in the world, introduce the Sustainable Development Goals, explain the model of the three phases of delay and discuss the importance of gender in relation to maternal health. After that I will explain how the activities undertaken under my professoriate can contribute to improving maternal health care. At the end of the lecture I will discuss the juridical aspects of the topic. Other reproductive and sexual health themes, which are definitely also subject of my lectures and my research will not be discussed today. “In der Beschränkung zeigt sich der Meister”. Less is more!
Lula, the girl who will never be a woman
Lula is a 14 years old school girl who attends the clinic with an unwanted pregnancy. She is raped. Lula doesn’t dare to tell anybody what has happened to her. When she realises that she is pregnant, she tries to hide the signs of the pregnancy. She is afraid to be sent away from school. Lula stays in the house of her relatives not far from her school. The village where she comes from, and where her parents still live, is too far away. One day her aunt discovers that she is pregnant. A criminal abortion is arranged, but Lula refuses and runs away. She has heard stories about women dying from the complications of unsafe abortions. She goes back to her village. Her father is furious. Her mother comes to the clinic with her.
Lula is advised not to go back to the village (too far away) and to come back to give birth at the hospital. Unfortunately, she still goes back to the village because she does not have a place to stay near the hospital with her mother.
When labour starts she wants to go to the hospital, but Lula’s father refuses and sends for the traditional birth attendant to help her. Labour does not progress well and at the second day Lula is carried to the hospital, where she arrives, exhausted, dehydrated, anaemic, in shock and close to death. The baby is dead. She is resuscitated, and operated on. She has a necrotic uterus. The dead baby is taken out and the uterus has to be removed. The situation remains critical for several days, but at the end she recovers and survives; without a living child and without a uterus. Her pelvic floor is severely damaged and she is incontinent for stools and urine.
This is where the story ends: Lula, a 15-year old girl, she conceived during rape, her baby died during birth and she now has to try to live with incontinence and without a womb. The story of a girl who will never be a woman.
The story about Lula, that was just presented by my daughter Jante, happened in March 1999, in Kalabo, in rural Zambia. Jante was born there, that same month. Today, almost 18 years later, such stories still happen every day!
In the past 3 decades investments in accelerating programmes to meet the needs of the world’s poorest have been extremely successful. Almost all targets of the Millennium Project, ranging from halving extreme poverty rates to halting the spread of HIV/AIDS and providing universal primary education, have been reached . Whilst significant reductions of maternal and neonatal mortality were also measured, the fourth and the fifth millennium development goal have not been reached and safe motherhood is still unattainable for many women.
The definition of Safe Motherhood is: a woman’s ability to have a safe and healthy pregnancy at a time she wants.
A decline in maternal mortality of 44% has been reached since 2000. However, globally still around 300.000 women die during pregnancy and childbirth every year, more than 800 a day!
Neonatal health outcome indicators give a comparable picture. Progress was made between 2000 and 2015, but still almost 3 million babies die every year in their first month, up to half of them within their first 24 hours. A similar number of almost 3 million babies die already before birth, the so-called stillbirths .
Almost all maternal and neonatal deaths occur in low and middle income countries, where the cumulative risk of death due to pregnancy related complications is many times higher compared to high income countries; 1 in 8700 in the Netherlands, compared to 1 in 64 in Ethiopia .
Figure 1. Life time risk of maternal death, by region/group and by income group. http://data.unicef.org/wp-content/uploads/2015/12/MM-11-Nov-2015_300ppi_175.png
Whilst there is an enormous disparity between countries, disparity within countries is also increasing. The proportion of all maternal deaths occurring in the bottom two quintiles of the socio-demographic index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility, increased from 68% in 1990 to more than 80% in 2015 .
In high income countries like the Netherlands, disparity also exists. Ethnic, socioeconomic, educational and geographical determinants influence maternal and neonatal outcome . Examples of vulnerable groups of pregnant women in our country are asylum seekers and women living in poor social conditions, with psychiatric disorders and sometimes addiction to alcohol and/or drugs. Worries about geographical disparity dominated discussions in Friesland two years ago when the clinical obstetrical unit of the smallest hospital in the country, in Dokkum, closed.
Back to Lula!
She nearly died but survived a complication. Her case is classified as severe acute maternal morbidity or ‘near miss’. It is estimated that for every case of maternal death there is a 10-20 fold number of cases of severe maternal morbidity. In others words, 3 to 6 million women per year survive severe complications.
Some of them will suffer from the resulting damage. Lula is one of them, suffering from incontinence, not having a living child and not being able to get pregnant anymore.
The Sustainable Development Goals
In 2015 a new set of goals and targets has been defined. They are called the Sustainable Development Goals (SDGs) . The comprehensive character of the SDGs serves us a reminder that health is prerequisite to development and that health depends on many non-medical determinants. Some of these determinants are poverty, hunger, education, gender equality, water and sanitation, work and economic growth, climate and peace.
Sexual and reproductive health issues, including maternal health, are not the only challenges: others are global mental health, the unfinished agenda of fighting infectious diseases, like HIV/Aids, tuberculosis and malaria, and the rising frequency of non-communicable diseases, like hypertension and diabetes.
Figure 2. The Sustainable Development Goals. http://www.un.org/sustainabledevelopment/blog/2015/12/sustainable-development-goals-kick-off-with-start-of-new-year/
The three phases of delay
What went wrong in the case of Lula can be analysed easily by making use of the model of the three phases of delay . Delay is perceived to be the key contributing factor to obstetric disasters and can happen during three phases: (a) delay at home in recognition of danger signs and making the decision to try to access care; (b) delay in travelling to a medical facility; and (c) delay in the facility in receiving adequate and appropriate treatment as a result of poor responsiveness.
The first phase of delay is caused by sociocultural factors, such as level of education, knowledge about danger signs of pregnancy or low status of women in societies. Delay can also be caused by low expectations of the quality of care in the clinic. The second phase of delay can be caused by long distances, absent or inadequate transport systems and irrational geographical distribution of health institutions in some areas. The third phase of delay is about substandard care. Most maternal deaths result from a sequence of all three phases of delay.
Figure 3. The adapted model of the three phases of delay (Gabrysch 2009) .
Gender and maternal health
Lula’s case started with sexual violence, rape. Her attacker failed to use a condom and consequently she became pregnant. She did not know how to access services to safely terminate her unwanted pregnancy, she was afraid to be sent away from school and her father did not want her to go to the clinic when labour started. She suffered from her low status in her family and in the society.
This cascade of unfortunate events is an example of the discriminatory practices against girls and women. Women’s lack of power in family dynamics and society constrains decision-making about their own health needs. It also limits the level of investment in maternal health services and the quality of care women receive. Many studies indicate that women’s low status is a barrier to obtaining reproductive health services. Fundamental inequalities between men and women and the neglect of women’s rights contribute to the morbidity and mortality of women.
These gender-based inequalities are at the basis of many issues in sexual and reproductive health care which will not be discussed in depth in this lecture. Just to mention some: (domestic) sexual violence, inadequate access to family planning services, restrictive abortion laws, and discrimination of lesbians, gays, bi-, trans- and intersexuals.
One issue needs more attention though: female genital mutilation (FGM), or female genital cutting. More than 25 million girls and women from 29 countries in Africa and the Middle
East are living with mutilated genitals. Most of the victims were circumcised between infancy and the age of 15 years. FGM has acute and chronic complications. Acute complications include pain, bleeding and infection. Chronic complications can sometimes have serious consequences on maternal health and are fistula, infertility and sometimes inability to deliver vaginally, causing obstetric complications and newborn deaths. Women who have undergone the cut cannot have normal sexual relations and pain during sex is common.
In 1993 FGM was classified as a form of violence against women under the International Human Rights Law. In 2012 the UN General Assembly passed a resolution on elimination of FGM. Progress has been made and today 24 of the 29 countries where FGM is concentrated have enacted legislation against the practice.
I am very happy to be involved with the work of Amref Health Africa (AHA), the largest health development organisation on the continent, as a member of the Supervisory Board of Amref Netherlands and as a member of the Health Program Committee of AHA. Amref stands for the rights of women and has been successful in working together with communities to slowly change ‘the rites of passage’, so that girls can now become women without cutting .
The chair and the Working Party
The injustice that happened to Lula and other violations of reproductive health rights form the base of my work inside and outside the University. My chair is established by the Netherlands Society for Tropical Medicine and International Health (NVTG) and paid for by the Medical Centre Leeuwarden. The Working Party International Safe Motherhood and Reproductive Health , a committee under the board of both, the NVTG, and the Dutch Society for Obstetrics and Gynaecology, the NVOG, became an important professional network for me after returning from Zambia where I worked for four years as a ‘tropical doctor’. I feel honoured to be given opportunity to be the chairman of the Working Party ever since 2008.
The activities that are undertaken under the umbrella of the Working Party can be grouped into four pillars: education, patient care, research and advocacy. The name of the Working Party and the name of my chair are almost similar and, of course, that is not coincidental. I strongly believe that in my work at the University these same four pillars, education, patient care, research and advocacy, should also go together. We teach students how to do basic research, how to use research findings in patient care and how to educate patients. We care for patients, we educate and treat them. We use research findings to define the best possible treatment and we do research to find out what is the best way to educate patients and students. Science, education and patient care are inextricably integrated. And in my lectures, in my research and in my care, I will always advocate for the right to maternal health!
In the continuation of this lecture I will explain how I aim to contribute to improving accessibility and quality of maternal health care.
Education The new curriculum in the medical faculty of the University of Groningen is called G2020. It intends to address the role of future doctors expected to start working in the system in 2020, who will have to deal with an increasingly complex and changing healthcare system, rapidly expanding knowledge, technology and globalization. Newly graduated doctors must be able to find relevant, up-to-date and correct information quickly, put this into context and apply it .
In G2020, students spend up to a quarter of their study hours in a learning community. One of the four learning communities is the Learning Community Global Health. In this learning community students acquire the necessary knowledge and skills to develop a global perspective on medicine and healthcare. Academic training in the Learning Community Global Health focuses on healthcare systems, health indicators and disease in relation to political, social and cultural determinants . It is important that our students learn as much about reproductive health issues as possible, because these represent the largest part of the unfinished agenda of the Millennium Project. At the end of the bachelor phase our students undertake a project, the bachelor project. It is rewarding to help and support students doing their Bachelor projects in different settings. Just to give you some examples: 4 students will soon depart for Ethiopia. They will help one of our PhD candidates working on the implications of severe acute maternal morbidity in the post-MDG era  and the validation of a set of criteria to define near miss cases to be used in sub-Sahara Africa.
Unfortunately, the criteria developed by WHO are not adequately applicable [15,16]. Other students will work on access to care for pregnant asylum seekers in the Netherlands, improving knowledge about the dangers of alcohol use during pregnancy in a community project in Beira, Mozambique, and on influencing the determinants of health care-seeking behaviour in pregnant women with heart problems in Namibia.
Working together with these young and motivated people is extremely satisfying. I hope to inspire them to become maternal health advocates, who, in future, will be able to make adequate decisions about how to further collaborate with counterparts in LMIC to continue improving accessibility and quality of maternal health care!
Patient care Most people, when they hear that I will go to Ethiopia for a week or two, still expect me to go to a hospital to do operations. And, to be honest, I still like to perform operations and I still do sometimes when I visit young tropical doctors who ask me to assist them in more complex surgery or Ethiopian gynaecologists who want to be trained. However, I do not perceive this any longer to be my core purpose.
In the field of medical development cooperation we have been arguing about the sense of selective and elective surgical care programmes. I used to quarrel with my promotor about his publication “Een blanke dokter is maar een onhandig ding” . However, I am confident that the way the Ethiopian government is now expanding its system’s capacity to make essential surgery available to all by training midcadre levels of anesthetists and surgical emergency officers  is significantly more sustainable. I am worried about the emphasis that has recently been put on access to surgical care, for example Caesarean sections (CS) [19,20]. Of course, all women should have access to essential surgery. However, in obstetrics, we must also prevent the alarming number of unnecessary CSs by performing appropriate and timely interventions to prevent CSs, such as using a partograph, artificial rupture of membranes, oxytocin augmentation and instrumental vaginal delivery in the second stage of labour. Health workers should first be trained how to prevent CSs, while learning how to perform them .
Figure 4. Werner van der Wolf performing a Caesarean section in Medisch Centrum Leeuwarden as part of his ‘tropical doctor’ training; he first learned how to prevent Caesarean sections, then how to do them safely. He now works in Gambo General Rural Hospital, Ethiopia.
Figure 5. Health workers in in Kilwa District, Tanzania, trained to use partogram.
Figure 6. Teaching vaginal breech delivery in Ethiopia
Research Whilst my own thesis, titled ‘Health care seeking behaviour and utilisation of health services in Kalabo District, Zambia’  mainly concentrated on the first and second phase of delay, the research projects that I am now involved in are mainly about quality of care. Recently a Memorandum of Understanding was signed between the Working Party, Share Research Institute Groningen, Athena Institute Amsterdam and the John Hopkins Institute for Education in Gynecology and Obstetrics (Jhpiego). Jhpiego is an international non-profit
health organization affiliated with The Johns Hopkins University and has been working to bring life-saving measures to mothers and newborns around the world for more than four decades . Together with Young-Mi Kim, I now supervise 10 of the most capable employees of Jhpiego to do their PhD-research.
The first one was Nasrat Ansari, a gynecologist from Afghanistan. He works on his PhD-thesis about the “Availability of Maternal and Neonatal Quality Health Service Delivery at Primary Health Care level in Afghanistan”. The health sector of Afghanistan was devastated by three decades of war and political instability. Maternal and newborn health indicators were among the poorest in the world. Nasrat studied several interventions to improve outcome: prevention of postpartum hemorrhage at home birth , the prevention and management of severe pre-eclampsia/eclampsia , upgrading of post abortion care in health facilities  and newborn resuscitation .
Other PhD-candidates from Jhpiego, from countries like Ethiopia, India, Indonesia and Tanzania, all work on finding locally acceptable and achievable ways to improve the quality of maternal health services. Ethiopians work on solving the human resources for health crisis [18,28,29,30]. Ephrem Daniel works on the concept of Respectful Maternity Care. Many women experience disrespect and abuse during pregnancy and childbirth. For that reason, the concept of respectful maternity care has been launched by WHO and other organisations [31,32]. Ephrem works on developing a tool to measure women’s perception of respectful maternity care in Ethiopia. Tienke Vermeiden studies how to promote utilisation of maternity waiting homes. Several studies underlined the need to take local customs and practice into account . Rob Mooij showed that in low resource settings, antenatal corticosteroid therapy for fetal lung maturation is not always beneficial in preterm birth [34,35,36]. Ever heard about a Bakri balloon? It is used in the treatment of postpartum haemorrhage, the most important cause of maternal mortality worldwide. It can save lives but it is too expensive for low resource settings. Dunstan Bishanga, in Tanzania, studies the feasibility and effectiveness of a much cheaper application, making use of a urinary catheter, a condom and a suture.
Figure 7. Balloon tamponade (slide presentation of Dunstan Bishanga)
Impact and societal relevance
The research questions we try to answer are relevant! We contribute to preventing maternal and neonatal morbidity and mortality by improving accessibility and quality of maternal health care in low resource settings.
Unfortunately, obtaining financial support for this kind of work is difficult. Two developments play a role.
First, societal relevance is not the most important indicator for successful research. University Medical Centres (UMCs) concentrate on fundamental, translational and curative specialists’ research. The rating of research programmes is based on impact factors of journals, citation indexes and so on, not on the societal relevance of the research questions to be answered. UMCs claim that additional funds for answering such research questions should come from the government.
Secondly, there is a tendency in our society and in our government only to be willing to help others if you can benefit from it yourself. The budget for Development Cooperation decreased to even below 0.7% of the Gross National Product under the two cabinets of Rutte. And part of that expenditure now even goes through the Ministry of Defence for so-called peace keeping missions and through the Ministry of Security and Justice for reception of asylum seekers. The Dutch development cooperation policy is now based on the idea that investments in the South should benefit the Dutch economy. And, in order to get financial support for doctors to be trained in International Health (‘tropenopleiding’), the NVTG had to show that this will eventually benefit the Dutch health care system. Can it be true that solidarity and ordinarily helping other people who live in worse circumstances have become a taboo in the Dutch society, whilst we are richer than ever?
I feel privileged to be working together with partners like Jhpiego, Liverpool School of Tropical Medicine, World Vision and, of course, Medisch Centrum Leeuwarden, who are willing to financially invest in the programmes that I have discussed in this lecture. I hope the University will follow.
Women and their right to maternal health
The title of this lecture suggests that it has a juridical perspective as well. Maternal health, a left right. Can we claim having a right to health? Yes and no! Of course, nobody can claim the right to be healthy. It is not an absolute right. Professor Toebes, who wrote her thesis about this subject , taught me that there is a very good reason to talk about the right to (maternal) health and to defend it. Health does not only depend on care, it also depends on healthy living circumstances, like clean water, proper sanitation, adequate food and shelter. These absolute rights are all included in international human rights treaties. We are used to be talking about rights; the right to privacy, the right to life (or live), which are also not absolute rights.
The concept of the right to health evolved from “the right to the highest attainable standard of health” to "the right to the progressive realization of the highest attainable standard of health”. So, if we say that women have maternal health rights, we mean to say that women have the right to access the best possible standard of maternal health. In other words, state parties, governments, multilateral health organisations and individual health professionals have the immediate obligation to work on the progressive realisation of the highest possible standard of reproductive, sexual and maternal health.
With this explanation in mind, the question is how we should respond to situations that Lula and other women have to face daily: inhuman and collapsed health care systems, shortages of staff, medical supplies, equipment and medicines.
And how should we interpret the research finding of Steffie Heemelaar and Ellen Nelissen, who studied 216 cases of women with severe maternal morbidity and mortality in a rural hospital in Tanzania; one-third had undergone a CS, less than half of the CSs were performed on proper indication and within time. All other women had a CS either too late or too early, without proper medical reason, leading to unnecessary maternal and neonatal morbidity and mortality . Is that a violation of the right to health? And, if yes, what should we do? Should doctors performing these unnecessary or delayed CSs be sued? And what about the owners of private clinics in Iraq, where just for economic benefits, CS percentages are at 79% (with upper range up to 100%) ?
I could start lecturing about health and legal communities joining forces, about how to achieve global justice, good governance, independent accountability and respect for human rights. However, I in this instance I believe it is more beneficial to keep it simple. Tarek Meguid helps us to understand that health care systems should be (re)humanised and dignity and agency of the patients should be placed at the centre . He wrote:
“The task … is … to (re)humanise health care. This entails actively recognising a fellow human being in the patient, born or unborn, alive or dead. This recognition then needs to be expressed in the way that we interact and communicate with the patients …. with respect for the person, her fears, wishes, demands, needs, etc.
To achieve this, to (re)humanise health care, we need to first remove all the factors that dehumanise our patients. These are numerous and exist on many different levels. ….. the physical layout and state of decay of many health facilities in the world …. where far too few health workers are responsible for far too many patients …. health workers are almost forced to block out the blatant suffering of their patients...”
Meguid’s language could lead to the interpretation that it is task of the supply side of the system to (re)humanise health care. That is not feasible nor realistic. Patients cannot act as spectators and stand by idly while their health is jeopardised; they should take the lead!
Figure 8. Delivery room in a health centre (from Marieke Meulenbeld)
Lula, who most likely still lives in the rural areas of Kalabo District, was the guest of honour in my lecture. I used her moving story to help you visualise what my work is about, what I do and why I do what I do. The problems she encountered when she was still so young, so vulnerable, act as an example for the still existing reality of unnecessary unsafe motherhood for many women all over the world.
I will not stop playing my part in trying to solve some of these problems. For that reason, I am happy to now have an academic base in Groningen. From here I can more easily support my PhD-candidates and act out my role in the education of young doctors. My role will be to help them to broaden their perspectives, to be aware and compassionate, critical and reflective, to become good doctors.
I hope to have made clear what my program looks like. Important research questions are still to be answered. These questions are about how to bring evidence-based and effective interventions to where they are most needed, so that also the patients who are now still left behind can benefit. It is their right!
With these words I am honoured and pleased to accept my position as professor in ‘International aspects of Reproductive Health, in particular Safe Motherhood’, at the University of Groningen.
Ik heb gezegd!
Board NVTG (Nederlandse Vereniging voor Tropische Geneeskunde en Internationale Gezondheidszorg)
Directors MCL (Medisch Centrum Leeuwarden) and MCL Academie
Professors Jos van Roosmalen, Hans Hogerzeil, Menno Reijneveld and Jan Borleffs
Young-Mi Kim and Linda Fogarty (Jhpiego)
Nasrat Ansari, Partamin Zafrullah, Tegbar Yigzaw, Sharon Kibwana, Firew Ayalew, Somesh Kumar, Dunsan Bishanga, Maya Tholandi, Ephrem Daniel, Jin Won, Tienke Vermeiden and Rob Mooij
Maatschap Gynaecologie MCL
Board members of the Working Party International Safe Motherhood and Reproductive Health
Barend Gerretsen, Maria van Selm and Tarek Meguid
Petri Blinkhoff & Rik Peeperkorn
Tobias Rodriguez and Floris de Klerk Wolters
Iza Stekelenburg, Jante Stekelenburg & Christine van der Pal
Koos & Ria Stekelenburg
Many other people
The blessings of Safe Fatherhood are interwoven with happiness and balance in my life and, therefore, conditional for whatever I did and do. Thank you Christine, Iza, Jante, Jorrit and Marijn.
“I am, because we are”
1. Prof. Dr. Jos van Roosmalen. De moeder het kind van de rekening. Rede uitgesproken bij de aanvaarding van het ambt van bijzonder hoogleraar Nationale en Internationale aspecten van Safe Motherhood. Faculteit der Geneeskunde , Vrije Universiteit Amsterdam/VU Medisch Centrum, 25 april 2008.
2. United Nations, New York 2015. The Millennium Development Goals Report 2015. http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf
3. Miller S, Abalos E, Chamillard M, Ciaponni A, Colaci D, Comandé D, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016;388:2176-92.
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5. GBD 2015 Maternal Mortality Collaborators Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1775–812.
6. de Graaf JP, Steegers EAP, Bonsel GJ. Inequalities in perinatal and maternal health. Curr Opin Obstet Gynecol. 2013;25(2):98-108.
7. http://www.un.org/sustainabledevelopment/sustainable-development-goals/ (Accessed November 16, 2016)
8. Thaddeus S & Maine D . Too far to walk: maternal mortality in context. Soc Sci Med 1994;38:1091–110.
9. Gabrysch S, Campbell OMR. Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy and Childbirth 2009; 9: 34.
10. http://amref.org/news/news/female-genital-mutilation-has-no-place-in-africa (Accessed January 7, 2017)
11. http://www.safemotherhood.nl (Accessed December 27, 2016)
12. http://www.rug.nl/umcg/education/medicine/g2020-concept/ (Accessed November 16, 2016).
13. http://www.rug.nl/umcg/education/medicine/g2020-concept/global-health (Accessed November 16, 2016).
14. Tura AK, GebrehiwoY, Zwart JJ, van Roosmalen J, Stekelenburg J, Scherjon S. Systematic review of severe acute maternal morbidity (near miss) in sub-Saharan Africa: implications for the post-Millennium Development Goals era. 2015; Available at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015023883.
15. Van den Akker T, Beltman J, Leyten J, Meguid T, Stekelenburg J, van Roosmalen J. The WHO maternal near miss approach: consequences at Malawian district level. PLoS One. 2013;8(1):e54805. doi: 10.1371/journal.pone.0054805. Epub 2013 Jan 25.
16. Nelissen EJT, Mduma E, Ersdal HL, Evjen-Olsen B, van Roosmalen J, Stekelenburg J. Applicability of the WHO maternal near miss criteria in a low-resource setting. PLoS One. 2013 Apr 16;8(4):e61248. doi: 10.1371/journal.pone.0061248. Print 2013. 17. Wolffers I. Een blanke dokter is maar een onhandig ding Medisch Contact 1992;47:775-6.
18. Kibwana S, Woldemariam D, Misganaw A, Teshome M, Akalu L, Kols A, et al. Preparing the health workforce in Ethiopia: A Cross-sectional study of competence of anesthesia graduating students. Educ Health (Abingdon). 2016 Jan-Apr;29(1):3-9. doi: 10.4103/1357-6283.178931. 19. Botman M, Meester RJ, Voorhoeve R, Mothes H, Henry JA, Cotton MH, et al. The Amsterdam Declaration on Essential Surgical Care. World J Surg 2015; 39(6):1335-40. 20. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015.
21. Rijken MJ, Meguid T, van den Akker T, van Roosmalen J, Stekelenburg J; Dutch Working Party for International Safe Motherhood & Reproductive Health. Global surgery and the dilemma for obstetricians. Lancet 2015;14:386. doi: 10.1016/S0140-6736(15)00828-4.
22. Stekelenburg J. Health care seeking behaviour and utilisation of health services in Kalabo District, Zambia. Thesis Vrije Universiteit, Amsterdam 2004 – ISBN 90-9018603-4.
23. www.jhpiego.org (Accessed December 27, 2016)
24. Haver J, Ansari N, Zainullah P, Kim YM, Tappis H. Misoprostol for Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan: Program Expansion
Experience. J Midwifery Womens Health. 2016; 61(2): 196-202. doi: 10.1111/jmwh.12413.
25. Kim YM, Ansari N, Kols A, Tappis H, Currie S, Partamin, et al. Prevention and management of severe Pre-Eclampsia/Eclampsia in Afghanistan. BMC Pregnancy Childbirth. 2013 Oct 12;13:186. doi: 10.1186/1471-2393-13-186.
26. Ansari N, Zainullah P, Kim YM, Tappis H, Kols A, Currie S, et al. Assessing post-abortion care in health facilities in Afghanistan: a cross-sectional study. BMC Pregnancy Childbirth 2015 3; 15:6. doi: 10.1186/s12884-015-0439-x.
27. Kim YM, Ansari N, Kols A, Tappis H, Currie S, Partamin, et al. Assessing the capacity for newborn resuscitation and factors associated with providers’ knowledge and skills in Afghanistan. BMC Pediatr. 2013;13(1):140.
28. Yigzaw T, Ayalew F, Kim YM, Gelagay M, Dejene D, Gibson H, et al. How well does pre-service education prepare midwives for practice: competence assessment of midwifery students at the point of graduation in Ethiopia. BMC Med Educ. 2015 Aug 14;15:130. doi: 10.1186/s12909-015-0410-6.
29. Yigzaw T, Carr C, Stekelenburg J, van Roosmalen J, Gibson H, Gelagay M, et al. Using task analysis to generate evidence for strengthening midwifery education, practice, and regulation in Ethiopia. Int J Womens Health. 2016 May 27;8:181-90. doi: 10.2147/IJWH.S105046.
30. Ayalew F, Kols A, Kim YM, Schuster A, Emerson MR, Stekelenburg J, et al. Factors Affecting Turnover Intention among Nurses in Ethiopia. World Health Popul. 2015;16(2):62-74.
31. WHO 2014. The prevention and elimination of disrespect and abuse during facility-based childbirth: WHO Statement. Geneva , Switzerland: WHO.
32. Hastings MB 2015. Pulling back the curtain on disrespect and abuse: the movement to ensure respectful maternity care. Washington DC: White Ribbon Alliance.
33. Lonkhuijzen van, L., Stekelenburg, J., Roosmalen van, J. Maternity Waiting Facilities for improving maternal and neonatal outcome in low-resource countries (Review), The Cochrane Library, 2012, Wiley Publishers.
34. Althabe F, Belizan JM, McClure EM, Hemingway-Foday J, Berrueta M, Mazzoni A, et al. A population-based, multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of neonatal mortality due to
preterm birth in low-income and middle-income countries: the ACT cluster-randomised trial. Lancet 2015, 385(9968):629-639.
35. Mooij R, Lugumila J, Mwashambwa MY, Mwampagatwa IH, van Dillen J, Stekelenburg J. Characteristics and outcomes of patients with eclampsia and severe pre-eclampsia in a rural hospital in Western Tanzania: a retrospective medical record study. BMC Pregnancy Childbirth 2015, 15(1):213.
36. Mooij R, Mwampagatwa I, van Dillen J, Stekelenburg J. Antenatal corticosteroid therapy for foetal maturation in women with eclampsia and severe pre-eclampsia in a rural hospital in Western Tanzania. BMC Pregnancy Childbirth 2016;16:235. doi: 10.1186/s12884-016-1023-8.
37. Toebes BCA. The right to Health as a Human Right in International Law. Thesis Faculteit Rechtsgeleerdheid Universiteit van Utrecht, 1999.
38. Heemelaar S, Nelissen E, Mdoe P, Kidanto H, van Roosmalen J, Stekelenburg J. Criteria-based audit of caesarean section in a referral hospital in rural Tanzania. Trop Med Int Health. 2016; 21(4): 525-34. doi: 10.1111/tmi.12683.
39. http://www.nbcnews.com/id/44162856/ns/health-womens_health/t/births-private-hospitals-iraq-are-c-sections/#.WCy_TPnhA2w (Accessed November 16, 2016).
40. Meguid T. (Re)Humanising Health Care – Placing Dignity and Agency of the Patient at the Centre. Nordic Journal of Human Rights 2016; 34: 60-4.
Oratie van professor Kitty Bloemenkamp 1 december 2016
MEER AANDACHT VOOR GEZONDHEID VAN MOEDERS RONDOM BEVALLING
Van Website: UMC UTRECHT
Vrijdag 2 december 2016
Het aantal zwangere vrouwen met een ernstige zwangerschapsvergiftiging (eclampsie) is de afgelopen 10 jaar sterk afgenomen. Daarentegen is er een toename van vrouwen die rondom hun bevalling met een hartstilstand of met teveel bloedverlies te maken krijgen. Dit maakte de eerste Utrechtse vrouwelijke hoogleraar verloskunde, Kitty Bloemenkamp, op 1 december tijdens haar oratie bekend.
Haar leerstoel richt zich met name op de gezondheid van de zwangere vrouw. Kitty Bloemenkamp, verbonden aan UMC Utrecht, zegt hierover: “Opvallend is dat er in Nederland in de discussie over de geboortezorg weinig aandacht is voor complicaties en de gezondheid van de moeder. Is onze verloskundige zorg op dit gebied zó goed dat complicaties bij de moeder nauwelijks voorkomen? Zijn baby’s belangrijker dan de moeders? De babysterfte is in Nederland de afgelopen jaren gelukkig gedaald, maar hoe zit het met de gezondheid van de moeders?”
Bloemenkamp: “Sinds 1990 is de moedersterfte wereldwijd bijna gehalveerd. Maar er zijn grote verschillen. In Nederland sterven er jaarlijks 5 vrouwen per 100.000 geboortes, vergelijkbaar met de ons omringende landen. Maar in Suriname ligt dit aantal op 130 en op Zanzibar zelfs boven de 500.” De moedersterfte mag dan in welvarende landen laag zijn, de bijna-sterfte neemt toe. “Vroeger werd vrouwen met een ziekte – zoals een hart- en vaatziekte of een nieraandoening – vaak afgeraden zwanger te raken. Nu niet meer. Dit is mogelijk één van de oorzaken dat het aantal vrouwen dat rondom de bevalling met een hartstilstand te maken heeft nu drie keer vaker voorkomt als 10 jaar geleden. Door het in 2013 ingestelde registratiesysteem Nethoss (Netherlands Obstetric Surveillance System) kunnen we trends in sterfte en bijna-sterfte van de moeder waarnemen, internationaal betrouwbare vergelijkingen maken en op basis daarvan indien nodig interventies plegen.”
ZWANGERSCHAP IS TOPSPORT
Het doel is, zoals eerder genoemd, een gezonde moeder én een gezond kind. Om dit zoveel mogelijk te bereiken moet de kwaliteit van zorg optimaal zijn. Bloemenkamp: “zwangerschap is topsport. Alle organen werken harder. Hierdoor kunnen onder meer bestaande ziektes verergeren. Goede zorg op maat is daarbij cruciaal. Daarom zijn er in het WKZ Geboortecentrum multidisciplinaire spreekuren opgezet voor zwangeren met een aandoening, zoals diabetes, nierziekten, reumatische ziekten en hartafwijkingen. Hierbij krijgen de mensen met een kinderwens preconceptioneel advies en worden de vrouwen zo goed mogelijk op een eventuele zwangerschap voorbereid. De zwangerschap wordt begeleid door gynaecologen en verloskundigen, maar waar nodig ook door specialisten zoals bijvoorbeeld internisten, cardiologen en nefrologen.”
VAKER VEEL BLOEDVERLIES
Gegevens van Perined – een instelling die de kwaliteit van de zorgverlening rondom de geboorte wil vergroten – laten zien dat tegenwoordig vaker vrouwen veel bloed verliezen tijdens de bevalling. In Nederland heeft meer dan 6 procent van alle bevallende vrouwen minimaal 1 liter bloedverlies (in 2000 was dat nog 4 procent). Bloemenkamp: “De geboortezorgverleners in onze regio hebben met elkaar afgesproken om dit getal binnen drie jaar te halveren. Hiervoor is het protocol aangepast, wetenschappelijk onderzoek ingezet en bij elk ochtendrapport bespreken we de bevallingen waarbij meer dan een liter bloedverlies was. Ik weet niet of die 50 procent daling gehaald gaat worden, maar 30 procent minder is al fantastisch.”
Goed nieuws voor Veilig Moederschap!
16 mei - De Verenigde Naties hebben de nieuwste cijfers rondom Veilig Moederschap gepubliceerd. In 1990 overleed er nog élke minuut een vrouw aan complicaties bij haar zwangerschap of bevalling, in 2010 was dat 1 vrouw óm de minuut. Dit betekent dat moedersterfte in twintig jaar gehalveerd is.
Toch overlijden er nog dagelijks 800 vrouwen terwijl ze leven geven. Om Millenniumdoel 5, het terugdringen van moedersterfte met 75%, te bereiken, moet er nog heel veel gebeuren!
Lees hier het volledige rapport van de VN: "Trends in Maternal Mortality, 1990 to 2010"
Koninklijke onderscheiding voor adviseur White Ribbon NL!
Jos van Roosmalen, gynaecoloog, hoogleraar Safe Motherhood aan de VU en adviseur van White Ribbon NL, nam op 4 november 2011 afscheid als gynaecoloog van het LUMC. Ter gelegenheid hiervan was er een symposium, "De moeder, het kind van de rekening".
Aan het einde van de dag werd Jos verrast met een koninklijke onderscheiding! Eigenlijk moest hij voor het opspelden het White Ribbon-lintje afdoen, maar dat weigerde hij pertinent. Zodoende waren er twee lintjes op zijn revers te bewonderen!
White Ribbon NL feliciteert hem van harte met deze welverdiende onderscheiding voor zijn inzet voor Veilig Moederschap.
Copyright foto's: Jeroen Hiemstra