FIGO calls for global policies to reduce inequality in patients’ access to safe, indicated and high-quality gynaecological surgery: the right patient, the right surgery, by the right surgeon and at the right time.

Quality of and access to health services depends largely on patients’ biological sex, race, geographical location and socioeconomic level.^1,2,3 Women around the world face several barriers to accessing essential health services. There is a substantial gap between the need for health care and the level of access, in high-income as well as low- and middle-income countries (LMICs).^4,5 Global evidence shows that the simple fact of being a woman affects the quality of health care received.^6,7 This negative effect is more pronounced for women who are violently displaced, belong to vulnerable populations (such as ethnic or religious minorities) and those facing discrimination or labelled as inferior owing to social, cultural or economic factors.^1,8

Women around the world have higher barriers to surgical care

Even in high-income countries, women tend to receive lower-quality health care than men. This disparity is more marked for LMICs. When it comes to accessing surgical procedures, the gap is even greater.^9,10,11

In general, compared to men, women are less likely to participate in shared decision-making or to choose the type of surgical procedure.¹² The quantity and quality of information available pertaining to surgical procedures and preoperative counselling is less optimal when proposing to perform surgery on women. Gynaecological surgery is significantly worse than other surgical specialties in terms of quality, access, information flow and safety.^2,5,8

Patient access to benign gynaecological surgery: the vicious cycle of scarcity

The concept of offering patients only procedures that the doctor “feels comfortable with” has become untenable and unjustifiable. Patients should be offered the appropriate procedure for their condition: the right surgery, by the right professional and at the right time.^13,14 Both patients and doctors must have in their treatment arsenal all the options, both medical and surgical, and must select the best option for each particular case.

However, due to economic, sociocultural and gender disparities in particular, globally women do not always have timely access, do not receive complete and adequate information and do not always have the capacity to express an opinion about the procedures to which they will submit. This results in women ultimately experiencing medical interventions that negatively affect their quality of life.^7,8

When patients have an indication for benign gynaecological surgery, especially in LMICs, they face the so-called “vicious cycle of shortages”. This confronts both doctors and patients with the incongruity between patients’ needs, financial access and availability of essential supplies and equipment.^15,16,17

FIGO recommendations

• FIGO recognises the negative impact of discrimination against women when accessing benign gynaecological surgery.
• FIGO calls for global gender-mainstreamed and socially inclusive policies to reduce inequality and allow women to have safe, timely and adequate access to surgical care.
• Decisions about benign gynaecological surgical care should be based on individual patient needs and not economic, political, social or religious constraints.
• Patients have the right to receive adequate and complete information about their health conditions and the surgical and non-surgical options available for their management. Education is the basis of decision-making and women must be able to participate actively in the surgical decision-making process.
• It is crucial that patients receive complete and detailed counselling about the risks and benefits of each treatment option, allowing them to make an adequate informed decision regarding management.
• FIGO promotes quality continued medical education that allows professionals to offer patients the best surgical techniques according to individual health conditions. FIGO also discourages the provision of surgical procedures by unqualified personnel in suboptimal settings. Proper training makes it possible to reduce complication rates and decreases the burden that benign gynaecological surgeries exert on society.
• Unrestricted access to benign gynaecological surgical care is vitally important and can translate into a significant decrease in preventable disabilities and deaths among women.
• FIGO recommends that affiliated societies implement local and regional mechanisms that provide visibility to the problem of patients’ access to gynaecological surgery and support development of health policies that reduce the access gap for women.
• FIGO is committed to universal health coverage and works as hard on preventive care strategies as it does on access to medical, surgical and emergency care.

References

1. Stone J. Disparities in access to health care for women. www.forbes.com/sites/judystone/2017/11/22/disparities-in-access-to-health-women/?sh=c414bb84783d Accessed 23 June 2022.

2. Waqar U, Ahmed S, Rauf H, Hameed AN, Inam H. Disparities in access to quality surgical care for women in resource-constrained settings: Bottlenecks and the way forward. J Pak Med Assoc 2022;72(S1)(2):S86–90.

3. Elliott MN, Kanouse DE, Burkhart Q, et al. Sexual minorities in England have poorer health and worse health care experiences: A national survey. J Gen Intern Med 2015;30(1):9–16.

4. Aninye IO, Digre K, Hartnett ME, et al. The roles of sex and gender in women’s eye health disparities in the United States. Biol Sex Differ 2021;12(1):57.

5. Pollack LM, Olsen MA, Gehlert SJ, Chang S-H, Lowder JL. Racial/Ethnic disparities/differences in hysterectomy route in women likely eligible for minimally invasive surgery. J Minim Invasive Gynecol 2020;27(5):1167–1177.e2.

6. McClurg A, Wong J, Louie M. The impact of race on hysterectomy for benign indications. Curr Opin Obstet Gynecol 2020;32(4):263–8.

7. Lovejoy LA, Eaglehouse YL, Hueman MT, Mostoller BJ, Shriver CD, Ellsworth RE. Evaluation of surgical disparities between African American and European American women treated for breast cancer within an equal-access military hospital. Ann Surg Oncol.2019;26(12):3838–45.

8. Hisam B, Zogg CK, Chaudhary MA, et al. From understanding to action: Interventions for surgical disparities. J Surg Res 2016;200(2):560–78.

9. Knisely A, Huang Y, Melamed A, et al. Disparities in access to high-volume surgeons within high-volume hospitals for hysterectomy. Obstet Gynecol 2021;138(2):208–17.

10. Barnes WA, Carter-Brooks CM, Wu CZ, Acosta DA, Vargas MV. Racial and ethnic disparities in access to minimally invasive gynecologic surgery for benign pathology. Curr Opin Obstet Gynecol 2021;33(4):279–87.

11. Ptacek I, Aref-Adib M, Mallick R, Odejinmi F. Each uterus counts: A narrative review of health disparities in benign gynaecology and minimal access surgery. Eur J Obstet Gynecol Reprod Biol 2021;265:130–6.

12. Blears EE, Pham NK, Bauer VP. A systematic review and meta-analysis of valued obstetric and gynecologic (OB/GYN) procedures in resource-poor areas. Surg Open Sci 2020;2(3):127–35.

13. Shah R, Launer J. Escaping the scarcity loop. Lancet 2019;394(10193):112–3.

14. Solnik MJ, Munro MG. Indications and alternatives to hysterectomy. Clin Obstet Gynecol 2014;57(1):14–42.

15. Bright T, Felix L, Kuper H, Polack S. A systematic review of strategies to increase access to health services among children in low and middle income countries. BMC Health Serv Res 2017;17(1):252.

16. Mariani G, Kasznia-Brown J, Paez D, et al. Improving women’s health in low-income and middle-income countries. Part I: challenges and priorities. Nucl Med Commun 2017;38(12):1019–23.

17. Mariani G, Kasznia-Brown J, Paez D, et al. Improving women’s health in low-income and middle-income countries. Part II: The needs of diagnostic imaging. Nucl Med Commun 2017;38(12):1024–1028.