Nigeria: Abakaliki town in Ebonyi State, Mile Four Hospital. Mile Four Hospital is a Catholic hospital run by the Medical Missionaries of Mary order of nuns. (MMM) Mother Cynthia Ugorji Nogzi, 34, is having a planned C-section performed by Dr. Eze Chiemeke, 30 (far left). Aux. nurse Ezelgbo Kelechi, 23 (second from the left), assists Eze in the C-section. Uzonwanne Udochukwu "Udo" (second form the right, in the back), the head midwife and floor supervisor for the maternity/delivery floor, also assists Eze.

Safe Surgical Care for Women

Improving surgical care prevents millions of women from experiencing disability or death due to complications from childbirth.

Karen Kasmauski/MCSP

Millions of women in low- and middle-income countries (LMICs) disproportionately suffer or die each year from preventable complications of childbirth.1,2 The vast majority (94 percent) of maternal deaths occur in low-resource settings, 86 percent in South Asia and Sub-Saharan Africa.2  More than two billion people around the world lack adequate access to essential, safe surgical care. Enormous disparities between and within countries remain in quality, access, and availability of surgical care for obstetric complications, including Caesarean section and hysterectomy. Unsafe surgery can also contribute to complications and chronic injury, such as iatrogenic fistula.3-5 Without adequate care, prolonged and obstructed labor can lead to obstetric fistula. It is estimated that up to one million women live with fistula in sub-Saharan Africa and South Asia.6 Obstetric fistula often results in incontinence and infertility, contributing to depression, social isolation, and stigma. Although fistula is surgically repairable, many countries lack surgical teams with the necessary skills to perform the surgery.

A lack of surgical capacity also impacts family planning. Many LMICs have a shortage of skilled providers able or willing to offer contraceptive implant removal, postpartum intrauterine device (IUD) insertion, and permanent family planning methods. This shortage inhibits women’s access to a range of voluntary family planning options and puts them at risk for unintended pregnancies.

MOMENTUM’s Approach

We aim to dramatically increase access to safe surgical care for women in USAID partner countries. This approach prevents current and future pregnancy-related mortality and morbidity by improving medically necessary Caesarean delivery and childbirth-related hysterectomy. MOMENTUM also improves voluntary family planning surgical services, including postpartum IUD insertion, removal of contraceptive implants, and voluntary permanent methods such as tubal ligation and vasectomy. Safe surgical care also restores dignity to women suffering from obstetric fistula.


Increase community-level awareness and care seeking

Many women and couples face significant socioeconomic and structural barriers to safer obstetric and voluntary family planning surgeries. When complications begin during labor at home, for example, diagnosis and the decision to go to a health facility are often delayed. Families are often not prepared to provide or pay for transportation to a health facility or for health care once there. MOMENTUM addresses community obstacles that prevent prompt care seeking for prolonged labor and symptoms of obstetric fistula, as well as access to voluntary IUD or implant removal.

CHRD2 in Brickaville, a referral hospital. working with midwife, Ravakaniaina Ravoloconandra , who is working with a first time mom, 15 year old, Clara who had her first baby in the village and she need to be sewed up, she had ripped. Her husband is 19 years old. Her mother-in-law, Fidele Raharlosa , 38, brought her in along with her grandmother, Madailaine, 57.
Karen Kasmauski/MCSP

Strengthen health system capacity to provide safer surgeries

MOMENTUM improves public and private health providers’ abilities to deliver high-quality surgical care from patient entry to discharge and follow-up care. Project technical assistance includes strengthening integrated preoperative and postoperative health care; safe and effective anesthesia and pain management; availability of trained midwives and medical staff; management of complications; and availability of surgical commodities and equipment.

Following infection prevention protocols is at the center of establishing quality FP services. Here a staff nurse prepares for a tubal ligation procedure.
Mubeen Siddiqui/MCSP

Generate and share evidence and lessons learned

MOMENTUM collaborates with a range of public and private sector partners to ensure that country experiences and evidence on safer surgeries inform national policy and guideline development. This collaboration includes testing innovative approaches to country-specific barriers to safer surgical care for women, such as organizing services for around-the-clock provider coverage and improving caseload management.

Tamatoave IFIRP a teaching hospital where student nurses and doctors have classroom as well as practicals in the ward. Nursing Students using skill labs. Then they are doing practicals at CHU Analakininina where also saw safe surgery in action with a c-section.
Karen Kasmauski/MCSP


  1. Firoz T, Chou D, von Dadelszen P, Agrawal P, Vanderkruik R, Tunçalp O, Magee LA, van Den Broek N, Say L; Maternal Morbidity Working Group. Measuring maternal health: focus on maternal morbidity. Bull World Health Organ. 2013 Oct 1;91(10):794-6.
  2. Trends in maternal mortality: 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2019.
  3. Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, Nutt CT, Greenberg SL, Kotagal M, Riesel JN, Esquivel M, Uribe-Leitz T, Molina G, Roy N, Meara JG, Farmer PE. Global access to surgical care: a modelling study. Lancet Glob Health. 2015 June;3(6):e316-23.
  4. Benova, L., Cavallaro, F. L., and Campbell, O. M. R. 2017. The landscape of cesarean sections in Sub-Saharan Africa and South and Southeast Asia. New York: EngenderHealth/Fistula Care Plus.
  5. Raassen TJ, Ngongo CJ, Mahendeka MM. Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries. Int Urogynecol J. 2014 Dec;25(12):1699-706.
  6. Adler AJ, Ronsmans C, Calvert C, Filippi V. Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013 Dec 30;13:246.

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