International Journal of Gynecology and Obstetrics 130 (2015) 89–92

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SPECIAL ARTICLE

The role of obstetrics and gynecology national societies during natural disasters André Lalonde a,b,⁎, Lauré Adrien c a b c

Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada McGill University, Montreal, QC, Canada Department of Obstetrics and Gynecology, State University of Haiti, Port-au-Prince, Haiti

a r t i c l e

i n f o

Keywords: Disaster relief team OB/GYN professional association National societies Natural disasters Support societies

a b s t r a c t 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. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

1. Introduction The role of the obstetrician/gynecologist (ob/gyn) and their professional association during a natural disaster is not well defined in most countries. As a result, the international response does not prioritize pregnant women and their newborns during natural disasters. The present article discusses the role of national societies in providing support to regions affected by natural disasters. In the last decade there have been several catastrophic natural disasters, such as the floods in Pakistan in 2005, the tsunami in Sri Lanka in 2004, the earthquake in Haiti in 2010, and the earthquake and tsunami in Japan in 2011. A review of the literature revealed very few specific details on the organizational role of the ob/gyn and their professional organization. Disaster relief teams may or may not include ob/gyn specialists, with the exception of the Israeli Defense Force Field Hospitals. A description of their effort in Haiti will be described later in the article. The following obstetric organizations were contacted by the senior author in 2013 to verify whether policies concerning the role of the organization and its members during a natural disaster are in place: the International Federation of Gynecology and Obstetrics (FIGO), the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and the Society of Obstetricians and Gynaecologists of Canada (SOGC). ⁎ Corresponding author at: 5 Willard Street, Ottawa, ON K1S 1T4, Canada. Tel.: +1 613 804 1801. E-mail address: [email protected] (A. Lalonde).

Given the paucity of literature, the aim of the present article is to review the responses obtained from these high-resource international organizations and refer to a specific example of a major natural disaster—the Haiti earthquake in 2010—to discuss the challenges for local professional organizations when disaster strikes.

2. Policies of the obstetrics/gynecology organizations contacted ACOG reported that it has no particular plan, but that it provides contact information for over 50 organizations who seek volunteers overseas. In the last few years ACOG has joined the Merck for Mothers Initiative (http://www.merckformothers.com/) (personal communication, M. Mitchell, August 2013). FIGO stated that it supports societies affected by instances of armed conflict or natural disasters. However, FIGO does not have the financial or human resources to effectively conduct relief in these areas. FIGO receives requests for assistance and transmits these to a high-resource country for their consideration. The goal is to mobilize resources from societies in countries and territories not affected by conflict or disaster (personal communication, H. Rushwan, August 2013). RANZCOG does not have a specific policy for disaster relief; however, it responds from time to time to natural disasters occurring in Southeast Asia. For example, the College offered financial contributions after the 2004 tsunami in southeast Asia, the 2009 tsunami in Samoa, the 2011 earthquake and tsunami in Japan, the 2011 earthquake in Christchurch, New Zealand, and following typhoon Pablo in the Philippines in 2012. The College contributes financially and offers human resources usually through the Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG) in support of local ob/gyn societies in various countries, but

http://dx.doi.org/10.1016/j.ijgo.2015.04.022 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

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also via other channels such as emergency relief organizations (personal communication, M. Quinlan, October 2013). RCOG has points of contact in 29 countries via country chairs on their international representative committee. RCOG was involved after the 2005 Pakistan floods. It was approached by the UK government to provide 6–8 female ob/gyns to travel in rotation to earthquake zones in Pakistan. Each volunteer was expected to stay for three to four months. There was no financial remuneration provided and all travel, boarding, and lodging was provided locally. The College also negotiated with British Airways for discounted air flights. In 2005–2006, RCOG was involved after the tsunami in Sri Lanka. It provided funding for 10 oneday training workshops on improving quality of labor and management (from July 2005 to December 2006). Seventy-five participants attended these training programs. RCOG also responded to the Libyan crisis, but it was assured that the health service was reasonably intact and did not need further assistance. In 2013, the UK government realized that when they deployed surgeons in natural disasters, their work included the provision of emergency obstetric care, but most of these surgeons did not have adequate training for this. Therefore, RCOG was asked to assist in providing training for surgeons who were deployed in natural disaster zones. The RCOG Foundation also provided financial support for the Haiti earthquake relief organized by the SOGC (personal communications, T. Falconer, August 2013). Natural disaster planning occurs in many high-resource countries, but typically low-resource countries do not have the resources for such planning. Apart from the WHO disaster relief plan, there is no practical relief plan that can be organized within 24–48 hours of a disaster. Many countries can send intervention teams, comprised of surgeons and orthopedic surgeons, but rarely are ob/gyn health professionals part of the team. 3. SOGC and La Société Haitienne en Obstétrique et Gynécologie (SHOG) earthquake relief in Haiti, 2010 As a case study, the earthquake in Haiti in 2010 demonstrated the issues surrounding societal involvement in natural disasters. On January 14, 2010, at 16:53 hours, Port-au-Prince, the capital of Haiti, endured a massive earthquake measuring 7.0 on the Richter scale. Massive destruction occurred in a city of over one million people. More than 250 000 people died, 300 000 were severely injured, and half a million people were left without proper shelter or food [1]. All government services were completely disrupted as most government institutions were either destroyed or seriously damaged. Along with the widespread death and morbidity, there was very little preparation for such a major disaster. The international response was swift but disorganized, and obstetric and gynecological care received little or no priority. In the main hospital in Port-au-Prince, the obstetric unit was closed to make way for major trauma teams and pregnant women were left to fend for themselves (personal communication, L. Adrien, October 2012). SOGC and FIGO had partnered with SHOG to establish a level 1 maternity unit in the southwest district of Port-au-Prince, Croix-desBouquets, in 2009/2010. The center had opened a few months prior to the earthquake. The population of that area was approximately 100 000 people with no access to a local birthing facility. The development of this unit was very difficult and after surmounting numerous political and administrative difficulties, the center was localized in an outpatient clinic that had previously only offered prenatal and postnatal services. Prior to the earthquake, three midwives under the supervision of an ob/gyn were assisting approximately 150 women per month with level 1 obstetric deliveries. Within 24–48 hours of the massive earthquake, SOGC had managed to reach the clinical director of the new maternity unit and, after discussions and securing funding commitment from SOGC, the director agreed to reopen the maternity unit as soon as possible. In the first 48 hours, two midwives provided support to laboring women and those who

had delivered. Most of the staff had left the hospital and did not return to work because their own houses had been totally or partially destroyed and many of their family members had been killed or severely injured. There was also great anxiety about aftershocks. Two ob/gyns had been killed at the University Hospital Midwifery School (the building had collapsed during a lecture) and many others had injuries; most of them had lost their houses or clinics, but all were asked to contribute to the relief efforts. It was immediately established that the midwives, doctors, and the support personnel needed to be reassured that they would receive their salaries and that it was important to reopen the maternity unit. A large tent was set up on the grounds of the maternity hospital as people were too scared to sleep inside because of the aftershocks. Within five days, SOGC had transferred funds via the Dominican Republic to support staff to maintain the level 1 and level 2 maternity services. Through daily cell phone communications, SOGC collaborated with colleagues in Haiti and devised a plan that included securing the workers, renting a house nearby for staff, ensuring petrol for the generator, and organizing transfer of medical supplies and equipment from Canada. SOGC reassured Canadian physicians that there was no need for them to go to Haiti as the society had prioritized the use of local ob/gyns in Haiti to fulfill the role of providing obstetric and gynecological care. SOGC decided at that time to send regular funds for staff salaries and to help secure and ship necessary equipment. Intermediate plans were made to complete the new operating room so that level 2 and level 3 support could be effectively provided for pregnant women. In addition, funding secured a well for clean water and provided 20 extra obstetric beds for antepartum and postpartum patients, including two delivery rooms and offices for nursing and medical staff. The project prior to the earthquake had been negotiating with two UN agencies for over 1.5 years to secure funding to dig a well, but had not been successful. However, it took one week to secure funding in Canada from SOGC and Canadian ob/gyn donations and then dig the well, install the pipes, and have clean running water into the clinic. 3.1. SOGC campaign for Haiti relief The SOGC Executive Committee and Council immediately committed US $50 000 toward the relief for Haiti and called on other Canadian organizations and members of FIGO to raise US $500 000 toward the support, rehabilitation, and expansion of the maternity unit in Croixdes-Bouquets. FIGO, the Canadian Medical Association Foundation, the Wellness Foundation of RCOG, St Michael Hospital in Toronto, the Japan Society of Obstetrics and Gynecology, university departments, and many individuals contributed and the funds provided staff salaries for a minimum of 12 months, medical/surgical supplies and equipment, and drugs to operate the Croix-des-Bouquets maternity unit. 3.2. Medical equipment and supplies There was an urgent need to get medical equipment and supplies into Haiti and especially to the Croix-des-Bouquets Hospital. SOGC immediately secured medicines that were airlifted through the Belinda Stronach Foundation and the Society provided supplies for 6–12 weeks. Within a few weeks, the executive vice president of the SOGC, with the approval of the board, scheduled a four-day visit to Port-au-Prince to assess the ongoing situation. Owing to the large population displacement, the maternity unit was the only medical facility open, catering for approximately 250 000 people. The hospital was treating level 1 and level 2 cases with only eight postpartum beds available. There were more than eight deliveries per day, therefore more staff were hired. It became very clear that an additional 15 beds and two delivery rooms were needed, as well as offices for staff. The construction of the operating theater was accelerated and in the meantime, cesarean deliveries were referred to a level 3 hospital in the area. The operating room was completed and functional in six weeks. The well provided clean running

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water and the clinic received over 150 women and children on a daily basis. A budget was established and estimated at US $15 000 per month for operating costs, not including supplies. Meanwhile, in Canada equipment such as delivery beds, operating room beds, and various supplies including resuscitation bassinets, were organized and shipped via a container to Port-au-Prince. The container had enough equipment and supplies for at least 6–12 months. SOGC continued to lobby UNICEF for the organization and support of a pediatric unit for newborns; however, this was not successful. The Society had set up the Haiti Relief Ad Hoc Committee, which met on a weekly basis for the first two months and then on a biweekly basis to supervise the campaign and transfer of funds, and discuss the requests from Haitian colleagues.

facility set up in Port-au-Prince had to perform cesarean deliveries in a tent as the main operating rooms were occupied. Half of all deliveries were complicated by pre-eclampsia and 31% were preterm (less than 33 weeks and 2 days). The recommendation of the Israeli team is that it is imperative that ob/gyns are included among the humanitarian aid delegation sent to sites of natural disasters. The complicated cases require highly skilled obstetricians and there is a serious shortage of specific medications for these women. Such cases also raised important ethical and practical issues in the face of very limited resources, specifically concerning how to deal with very premature babies.

3.3. Problems

One year after the earthquake, many accomplishments implemented by SOGC had supported the maternity unit of Croix-des-Bouquets. The cost of salaries for all staff and maternity services were covered. The project allowed Haitian health professionals to quickly return to the workforce and to provide essential services for their country. The project hired more staff to meet the demands for services as the maternity service became extremely busy. Repair and renovation of the center following the earthquake were accomplished within four months—much quicker than international organizations would have been able to deliver. Provision of equipment and an operating room for emergency procedures, as well as renovations to the second floor for increased antepartum and postpartum beds, were completed in record time. A container supplied by SOGC arrived full of medications and supplies, ensuring that sophisticated medical equipment was in place within two months. Important renovations to meet the demands were the digging of a well for access to safe water, reconstruction of the latrines, installation of a reservoir for fuel for the generator, and a new connection to the city’s electrical grid. On the medical side, there was integration and prevention of mother-to-child transmission of HIV, infection control measures, and screening for cholera cases. A total of 2000 women utilized the prenatal services and skilled attendants were present during childbirth for approximately 1900 women. Emergency obstetric care was provided to 500 women, including 216 cesarean deliveries.

Many problems were encountered from the beginning. The first problem was that staff had nowhere to live, no food, no access to their banks, and no income. They had lost everything. SOGC was able to make arrangements to transfer funds immediately to cover their living expenses and rented a house nearby for the staff. The cost of food had increased by 50%, and there was no fridge, stove, or microwave in the center for staff, which meant that renting a house became a priority. A serious problem was biological waste. Organizing the pick-up of biological waste was initially not possible, and every day it had to be driven out to the countryside to bury. SOGC lobbied with UN agencies to include Croix-des-Bouquets in an active waste management plan and after many months this was finally successful. Overcrowding of the facility and lack of staff and supplies were considerable problems. Medical supplies were double the previous costs and in extremely short supply. The staff shortage was exacerbated by bidding wars between agencies and relief organizations to hire local doctors and midwives to work for them, which took them away from the local government facilities. Bureaucracy and inaction by large international agencies and donors posed severe problems. There was little action on the ground and very serious difficulty in accessing funds. Teams arrived on the third or fourth day after the earthquake and were completely disorganized, with many teams having little or no experience—most teams had no obstetrics/ gynecology representation. These teams occupied every free space with their temporary tents and many had insufficient logistics, food, and medical supplies. Unfortunately, many international organizations on the ground seemed to be more interested in making sure that they were filmed and reported back in their home country rather than working with local people in providing services. This was a great discouragement for local leadership. In a time of urgent need, no-one was making decisions. Finally, international organizations created massive staffing problems. On initial arrival, most international organizations did not make any effort to contact or involve local physicians, nurses, and midwives to see how they could best help, be it pediatrics, obstetrics, gynecology, or otherwise. After a few days, the maternity unit of the General Hospital (the only level 3 hospital in Port-au-Prince) was closed, leaving hundreds of women to die from postpartum hemorrhage, pre-eclampsia, and other obstetric complications. It was deplorable that the national professionals were marginalized and that there was very little collaboration and/or acceptance of their expertise by other international organizations. 3.4. Lessons learned from an obstetrics and gynecology field hospital response to a natural disaster A field hospital was deployed by the Israeli Defense Forces as part of the international relief effort after the Haiti earthquake in 2010 [2]. The team treated 44 pregnant and 24 non-pregnant women, and preformed 16 deliveries and 3 cesarean deliveries under extreme conditions. The

4. Haiti one year later: January 2011

5. Recommendations SHOG and SOGC were successful in obtaining funding from UNFPA and the Packard Foundation to maintain the maternity unit. This unique collaboration between two obstetrics/gynecology societies in the relief effort following the Haitian earthquake led to the following recommendations: 1. There is an urgent need for international relief organizations to include obstetrics/gynecology as an essential service in any international aid relief for flooding, earthquakes, and other disasters. 2. International UN organization personnel on the ground need to have the decision-making power to facilitate the distribution of funds. 3. There is an urgent need through WHO and FIGO to have immediate contact with the national organizations in obstetrics, pediatrics, and midwifery to establish the need for personnel and/or equipment. 4. Use of local resources should be prioritized whenever possible and then supported or supplemented with funding for staffing, materials, and equipment. 5. Care must be taken about meeting local needs with local personnel, ensuring the cultural safety of that population. 6. An urgent meeting should be arranged—under the guidance of possibly the PMNCH—to bring together FIGO, the International Confederation of Midwives, the International Council of Nurses, and the International Pediatric Association to plan and prepare for international collaboration in the face of future natural disasters.

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7. International emergency response teams in natural disasters need to coordinate their actions through international ob/gyn organizations for the safety of pregnant women and their newborns. International professional societies can rapidly identify local professionals to provide essential services in the appropriate language and culture. Sending health professionals from other countries is more often counterproductive. Local professionals need funding, supplies, and equipment. Conflict of interest The authors have no conflicts of interest.

References [1] Disasters Emergency Committee. Haiti earthquake facts and figures. http://www.dec. org.uk/haiti-earthquake-facts-and-figures. Accessed February 10, 2015. [2] Pinkert M, Dar S, Goldberg D, Abargel A, Cohen-Marom O, Kreiss Y, et al. Lessons learned from an obstetrics and gynecology field hospital response to natural disasters. Obstet Gynecol 2013;122(3):532–6.

The role of obstetrics and gynecology national societies during natural disasters.

When a natural disaster occurs, such as an earthquake, floods, or a tsunami, the international response is quick. However, there is no organized strat...
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