Among the proper activities of the IAPM, “the preparation of STATEMENTS about specific issues related to Perinatal Medicine”. is outstanding, according to article 4 of the Constitution.
These Statements are intended to, not only to the perinatologist, but also to the authorities and the people in general. Its aim is to orientate these collectives concerning themes of the scientific and social interest, promoting the dialogue and reflection about the same.
Up to now, four Statements have been published coinciding with each of the four Plenary Meeting of the IAPM.
FOUNDATIONAL STATEMENT of the International Academy of Perinatal Medicine:
Perinatal Medicine is among the most challenging and beautiful areas of study and practice. It deals with events before birth, when the fetus is a patient and during the immediate neonatal period. The newly formed IAPM is dedicated to the study of all aspects of perinatal biology, physiology, screening, diagnosis, management and ethics, with
the goal of continuous quality improvement in the care of maternal, fetal and neonatal patients.
The role of the «International Academy of Perinatal Medicine» is guided by the international ethical concept of fiduciary responsibility to protect and promote the health of pregnant women, fetal patients and newborns globally. In furtherance of this role, to promote knowledge of Perinatal Medicine and its clinical and technological applications, placing special emphasis on its social, ethical and anthropological dimensions.
The main objectives of the «International Academy of Perinatal Medicine» must be: to promote research and education in the field of reproductive health (Forums, Symposiums, Courses, etc.), to develop and improve the exchange of information and dialogue, to foster international aid to developing countries, and specially the application of values, style and outstanding academic principles in the field of Perinatal Medicine.
The present generation of perinatologists is enjoying two of the most beneficial transformations in human history: a revolution in life expectancy and the liberation of women from the burden of their biology. But, there is something else.
Birthrates in developed countries from Italy to South Korea have sunk below the levels needed for their populations to replace themselves.
Where did those billions go? Millions of babies have died, a sizable fraction of them from AIDS, far more from malaria, diarrhea, pneumonia, and even measles. Millions more have been aborted, either to avoid birth or, as in China and India, to avoid giving birth to a girl.
However, the real missing billions are the babies who were simply never conceived.
Our Academia is founded at the beginning of the third millennium with all of the challenges which living generations are expected.
Undoubtedly, Perinatal Medicine is now a global area of study. The bonds that link perinatologists together transcend geographic, political, religious and lingual differences, resulting in a globalisation that optimizes clinical care.
Some health impacts of globalisation can already be denned as positive such as telemedicine, that could help in the provision of antenatal services in remote areas.
At the time of fast globalisation it is clear that no human endeavor is more adapted to the globalized world than science, for its very nature is global. The brotherhood of scientists is truly international. This is an immense privilege, but equally so an immense responsibility for the development of humanity. Like art, it is a universal possession of humanity, one of its vital potentials and the scientist generating or transmitting new ideas has been and will remain the essence not only of scientific existence but also of the civilization of an environment.
We firmly believe that the globalized world will be run by those who know how to synthesize; that is people able to put together the right information at the right time, think critically about it, and make important choices wisely.
Many of the most important questions in medicine are hard to quantify and therefore tend to get ignored; and many of the answers we seek come in the form of anecdotal evidence. We do not need to remind you that medicine is an art as well as a science and that every patient is a unique individual who does not necessarily conform to the conclusions of a meta-analysis. Our serious warning is that if our profession is not careful, the freedom to use clinical judgment will be steadily eroded by administrators and others concerned mainly with economic factors advised by statisticians and others who worship at the altar of evidence-based medicine.
All members of Academia should recognize that time is running out. Indeed, we should all be proud of the extraordinary progress made in perinatal medicine over the last 45 years. But there is still much to do, particularly in the developing world. We have to stress that the work of the international community has begun to show that even an extremely difficult and logistically complex problem, such as that of ensuring safe motherhood for all women of the planet, can be tackled and eventually resolved: if there is a will, there is a way.
Prepared by A. Kurjak with the acquiescence of the Foundotionol Comitte of IAPM
(Proj. E. Soling, A. Kurjok, Proj. F Chervenok Proj. Aris Antsoklis and Proj. J. M. Correro)
BARCELONA STATEMENT of the International Academy of Perinatal Medicine:
In last decade globalisation create new ground for scientific and technological achievements based on rapid economic and social transformation, deregulation of national markets, new trade regiment and revolutionary communication possibilities.
Three types of changes characterize the process: spatial changes which affects how people perceive and experience physical or territorial space; temporal changes affects how they perceive time and cognitive one bring new impact on our cultures, values, beliefs and knowledge, All of them have the impact on health and human wellbeing.
By changing the burden and disease pattern and rapid spread out around the world it was recognised that globalisation has a complex influence on health: developed countries become again more vulnerable for communicable diseases (SARS, viral and bacterial infections caused by antibiotic resistant strains, MDRTB, AIDS/HIV) and developing countries faced by numerous communicable diseases start to suffer more and more from non communicable diseases (diabetes, cardiovascular disorders) which become unsustainable for their health system and economy.
Therefore todays problems of economic development are inevitably discussed together and in association with health indicators like life expectancy at birth, child and maternal mortality. The free movement of capital and advantages that will bring better standards of living and health, undoubtedly interfere with an increase in the inequality gap between the world’s of rich and poor. Moreover, it is now widely accepted that disease control is not just a health sector issue, but one that involves inputs of multisector approach: from education to trade, knowledge management to policy and economy.
Health as a global public good become necessary investment for development process especially in developing countries. It was shown that human development index depends to a great extent on life expectancy at birth, but indirectly on perinatal and childhood losses as well as maternal mortality rate. There is no doubt that continuous rise in life expectancy is not spread out equally and differences among regions in the world even rise.
Despite the magnificient progress made in past decades, todays perinatologists have great, concern on two problems: 1) declining fertility rates in developed world below the levels needed for their population replacement and 2) high maternal and perinatal mortality in developing countries.
Declining birthrates have been registered in all parts of our world, in developed countries to roughly 1.6 children per woman and developing 10 3 in 2001. The future threat for those countries where fertility rate is below replacement level is not only population and demographiC issue, but to a large extent threat for economy and development. The challenge for professionals is in creating health policy to answer and acting in favor of such level of fertility which is balanced with replacement at least.
But in spite of decrease in perinatal mortality in general there are still between 7 and 8 million perinatal deaths mostly in developing countries, and it is not known exactly how many are stillbirths and how many are early neonatal deaths, Most of neonatal and perinatal deaths in developing countries are preventable and the result of poor maternal health and inadequate care during pregnancy and delivery.
The current rate of HIV/AIDS infection in young women is accelerating (one half of infections in developing countries occur between ages 15-19 and 47 % of them are women). Rising awareness of critical role of this disease on reproductive choices is not only challenge but even more duty for health profession. The real challenge for members of our profession is to widen and follow best practices and global strategy for declining perinatal mortality.
Maternal mortality rate differs to a greatest extent among developed and developing world. The average risk for women in developing countries of dying in childbirth is 1 in 60, but it can go as high as 1 in 10 in the least developed countries. In comparison, in Western Europe, the risk is 1 in 10,000. Maternal, infant and child mortality illustrate the largest gaps between the rich and the poor in today’s world. The data on maternal mortality in poor countries are shocking. Every year more than half million women die in pregnancy, during childbirth or from unsafe abortions, 97 % of those deaths are in developing countries. The major direct causes of maternal deaths are related to severe bleeding, infection, eclampsia, obstructed labor, unsafe abortion and other curable and preventable conditions. The reason is mainly due to lack of access to basic medical and obstetrics care.
This situation is unacceptable for us as professionals and scientists, members of IAPM.
At the Millennium Summit in New York heads of states of the world rogether with UN and WHO, in 2000, declare Millennium Development Goals (MDG). By 2015 the target is to reduce by two thirds perinatal mortality rate and by three quarters the maternal mortality rate. By 2003 all major organisation active in the field of maternal health joined forces and launched in Kuala Lumpur Partnership for Maternal and Neonatal Health (PMNH).
International Organisation of Gynecology and Obstetrics (FIGO) and World Association in Perinatal medicine ONAPM) become and serve as leading organisation for further implementation of strategies identined to achieve safer pregnancies and deliveries. Matres Mundi International (MM!) as international non governmental organisation founded in Barcelona with special aim to improve the reproductive conditions needed in any part of the world act now as associate agency of WAPM and IAPM. All named stakeholders together with governments, other supportive agencies and private institutions form a network to reach the MDGS goals of safe pregnancies and deliveries.
We members of IAPM commit ourselves through our action to fasten all actions and specmc strategies to meet the health needs of most vulnerable population on our world, women in reproductive age and children. We will work in partnership with relevant national and international bodies and organisations to ensure equity, maternal and child health gain and better quality of care during. pregnancy and labour (including reduced inequalities in its infrastructure, gap in professional knowledge). We will collaborate on specific issues in some regions at risk, including harmonisation of policies, legislation and information systems, institutional capacity building and networking to pursue regional goals and building safe world for those in needs. We will meet the health
needs of target population mobilizing human and financial resources to the extent possible to:
We see globalisation as an accelerating process in now of information, technology, goods and services. Using global goods it is possible to create challenges for the governance of global maternal and child health, including the need to form a network of international organisations capable to respond to global threats to public health. The rapid development in prenatal diagnosis (molecular, ultrasound etc,) urged to develop and create programs for distribution of essential knowledge and services to medical professionals in cooperation with network of international stakeholders. Facilitating flow of information through IT, rapid transportation, knowledge, telemedicine, globalisation might be beneficial to all countries in need to improve maternal and child health. We members of IAPM request partnership and support of all previously recognised international organisations in next meeting to monitor and evaluate progress achieved by such partnership for maternal and child health.
Prepared by A. Kurjak with the acquiescence of Board of Directors of IAPM
BUDAPEST STATEMENT of the International Academy of Perinatal Medicine:
The new genomics will greatly expand the type and amount of diagnostic information about the fetus. This expanded diagnostic capacity will create ethical challenges for perinatologists. To inform clinical judgment and decision making, the Academy offers the following ethical framework.
Obtaining genomic information about the fetus is medically reasonable and therefore should be offered nondirectively to all pregnant women, depending on availability, as a matter of fiduciary responsibility. The opportunity to obtain this information will enhance the pregnant woman’s autonomy. The pregnant woman should be encouraged to share this information with her genetic partner. Disclosure of information about genomic assessment should be guided by the reasonable person standard. This standard is met when the physician provides the pregnant woman with information that a competent perinatologist would judge to be clinically important.
The ethics of first -and second- trimester risk assessment currently provides a model for decision making with and by pregnant women about genomic assessment of the fetus. It has been demonstrated that pregnant women can make sophisticated decisions, which are consistent with scientifically derived information, about the use of riskassessment information in subsequent decisions about invasive diagnose. Pregnant women, with the support of an appropriate informed consent process, should be expected to make similarly sophisticated decisions about genomic assessment of the fetus,
The policy for disclosure of the results of genomic assessment should be that information about genetic conditions and carrier status will routinely be disclosed. Information about later-onset conditions is controversial. Therefore, it is permissible but not obligatory to provide such results. Results of uncertain or unknown clinical significance today should not be disclosed.
There is strong ethical consensus that genomic information, like all medical information, should be protected by the professional obligation of confidentiality. Perinatologists should advocate for public policy that protects the confidentiality of genomic information about the fetus.
Depending on associated costs, patents on genomic tests may create significant economic barriers to fetal genomic assessment and may impede research. Perinatologists should advocate for public policy, appropriate to their national setting, that reduces or eliminates these barriers and fosters research in perinatal medicine.
In conclusion, ethics is an essential component of genomic assessment of the fetus. Perinatologists have resources in medical ethics adequate to guide them in leading responsible change. These resources include the ethics of informed consent, the enhancement of the pregnant woman’s autonomy, protection of professional integrity, fiduciary responsibility to pregnant and to fetal patients and the persons they will become, and advocacy for access to fetal genomic assessment.
Prepared by Prof. Z. Papp with the acquiescence of the board of Directors and Support of:
AMIEL-TISON, Claudine (Paris, France)
ANTSAKLIS, Aris J. (Athens, Greece) (Vice-President)
ARABIN, Birgit (Zwolle, The Netherlands) (Treasurer)
BANCALARI, Eduardo (Miami, USA)
BENEDETTO, Chiara (Torino, Italy)
BRENT, Robert (Philadelphia, USA)
CABERO, Louis (Barcelona, Spain)
CARRAPATO, Manuel R. G. (Porto, Portugal)
CARRERA, Jose (Barcelona, Spain) (Secretary General)
CHERVENAK, Frank A. (New York, USA) (Vice-President)
Di RENZO, Gian Carlo (Perugia, Italy)
DUDENHAUSEN, Joachim (Berlin, Germany)
HOLZGRAVE, Wolfgang (Basel, Switzerland)
KURJAK, Asim (Zagreb, Croatia) (President)
LEVENE, Malcolm (Leeds, UK)
MAEDA, Kazoo (Yonago, Japan)
MANDRUZZATO, Giampaolo (Trieste, Italy)
NICOLAIDES, Kypros H. (London, UK)
NISHIDA, Hiroshi (Tokyo, Japan) (Vice-President)
PAPAGEORGIOU, Apostolos (Montreal, Canada)
ROMERO, Roberto (Detroit, USA)
SALING, Erich (Berlin, Germany) (Former President)
SCHENKER, Joseph G. (Jerusalem, Israel)
UZAN, Serge (Paris, France)
VAN ASSCHE, Andre (Leuven, Belgium)
VILLE, Yves (Paris, France)
The Prediction and Prevention of Preterm Birth and its Consequences: An Unmet Challenge to Perinatal Medicine, Science and Society:
The Declaration of Dubrovnik
Preterm birth is the defining challenge to obstetrics and neonatology at the beginning of the XXI century. The advances in care of preterm neonates in the last decades has improved survival dramatically in developed and in developing countries, so that the definition of viability has been reframed. Yet, survival of the extreme premature neonate has come with high risk of long term disability. Therefore besides improved survival, the quality of life of these vulnerable infants should be emphasized by careful and lifelong evaluation of their progress. A legitimate question is whether neonatal has approached the limit of intact extra-uterine life.
The success of neonatal medicine in treating the consequences of preterm birth has not been matched by the prevention of spontaneous or indicated preterm birth. The essential problem has been an incomplete understanding of the mechanisms of disease responsible for spontaneous preterm labor with intact or ruptured membranes or maternal and fetal disorders which result in indicated preterm delivery (e.g. preeclampsia and intrauterine growth restriction).
The taxonomy of obstetrical disorder responsible for preterm birth is in an early phase in which pathology is recognized by symptoms and signs rather the underlying mechanism of disease leading to these clinical manifestations. The time has come to use the tools of “discovery science” to identify such mechanisms, as well as to find early biomarkers of risk and interventions aimed the prevention of preterm birth. It is now clear that preterm birth is not caused by only one pathologic process – but many. The naïve view that a single test and single intervention will prevent all cases of preterm birth should be recognized as an obstacle to identified, others remain to be discovered. A unique feature of pregnancy is the co-existence of two hosts in intimate contact with different genomes and environments. Moreover, while cooperation of the hosts should be expected, the biological interests of fetus and mother may not always coincide. Environmental exposures may have different effects on a mature host than in a developing organism. Viviparity has created conditions which allow for the potential development of unique pathologic process absent when there is not symbiotic relationship and there yet unrecognized in medicine.
The identification of known (in order disciplines) and unknown mechanisms of diseases responsible for preterm birth the major challenge of perinatal medicine. Our discipline must commit itself to the use of the tools of “discovery science” and computational biology to meet this urgent need. This needs to be followed by rigorous translational science and ethically designed clinical trials.
At the same time, advances in understanding gained to date and the knowledge of promising clinically simple strategies to identify the patient at risk (e.g. vaginal pH testing to identify dysbiosis) and specific interventions to prevent birth, deserve systematic and urgent rigorous testing because of their promise to achieve a dramatic and rapid reduction in the rate of this adverse pregnancy outcome.
The importance of behavioral, social and economic issues predisposing to prematurity, need to be recognized and addressed. We advocate adequate support and protection for pregnant women as an integral health promoting activity to prevent preterm birth in all cultures. Pregnant women in developing countries should be protected from heard work, mistreatment and any kind of exploitation as the causes of prematurity. Governments least obstetrical and neonatal care. This approach should be aimed to reduce prerinatal and maternal mortality by up to 50 percent in the next ten years. It is also desirable to reduce prematurity rate between 32 and 36 weeks of gestation in developing countries by 50 percent within the next ten years.
Governments, scientific societies, funding bodies and charitable organizations which fund clinical and basic research need to realize the importance for society of the consequences of preterm birth. We believe that the prevention of preterm birth is possible if perinatal medicine, science and society give the necessary priority to this most problem of maternal, fetal and neonatal patients.
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