International Confederation of Midwives, an organization with a vision

Posted in: Advocacy, Birth, Health, Midwifery Education|July 10, 20118 Comments

Pt 2 : Perspectives on Global Midwifery; A US midwife’s diary of the 29th ICM Triennial Congress [Click here for Pt 1]

As an advocate for US midwifery and women’s health, I recently had the opportunity to be temporarily lifted out of the trenches of our national battle for access to midwifery care.  As an Observer member of the Midwives Alliance of North America (MANA) delegation to the International Confederation of Midwives (ICM) Council I was given the opportunity to attend the 4-day meeting of the ICM Council at which historic decisions were made for the future of midwifery across the globe.  As a Congress [conference] Delegate, sent by my partners in Private Practice to network and learn about charting requirements and global issues as we continue to design and develop software for midwives, I was able to gain a perspective on the work that we do in the trenches.  Trenches that become so deep at times that we can no longer see the field or a “vision” of what it would look or feel like to no longer be digging.

The importance of a cohesive vision for any movement can sometimes be overlooked when we are shoveling “dirt” that seems to be piling back into our trench faster than we can move it out.  For a country like the US with a mainstream maternity model that is antagonistic to midwifery, the vision becomes very narrow and more of a battle strategy as we fight for the survival of our profession and the integrity of normal birth.

As a midwife who has been entrenched for more than 15 years in the consuming work of battling over birth in the US, the vision articulated by ICM sounded at first to me like so many organizational visions…too broad and ambitious to be realistic.

“ICM envisions a world where every childbearing woman has access to a midwife’s care for herself and her newborn.”  ICM Vision Statement

As those of us involved in organizational work know, what follows a vision is generally a mission, or purpose for organizing:

ICM’s Mission-To strengthen member associations and to advance the profession of midwifery globally by promoting autonomous midwives as the most appropriate caregivers for childbearing women and in keeping birth normal, in order to enhance the reproductive health of women, and the health of their newborn and their families.

Sounds great, but how does a vision and mission like that translate into anything but a cheering squad while we keep up our digging? Especially when you consider that the steps each member association or country would need to take to reach this common goal would be unique and wrought with different challenges. When the digging of the trench nearby inadvertanly throws more dirt into our own, it can lead to internal turf battles and stuggles over principles and purpose. In the United States where this has happened among midwives too many times to count, how can we come together on the steps to take and why should we spend the time trying?

We should come together because mothers and babies are dying at an alarming rate in most of the world. As an American midwife who cares for a predominately healthy, white, middle-class population in a community with access to multi-levels of maternity care, attending a global midwifery conference in a country with maternal mortality rates that are 14 times that of the US was sobering. [1] The paradox of the overuse of medical interventions being a driving force for midwifery in the US with the lack of access to vital, life saving interventions for most of the world’s mothers driving the promotion of midwifery globally is as significant as it is startling.

The Big Picture

In 2008, ICM reflected on its mission and then took steps to address maternal mortality as a primary issue.  By strengthening midwifery in developing countries that face severe issues of mortality and morbidity for mothers and babies, the ICM hopes to move closer to its vision of a midwife for every mother. One symbolic and tangible step was to plan for it’s first ever conference in Africa, specifically sub-Saharan Africa which bears a huge percent of the global burden of maternal and newborn death.

Rebecca Ullman is a certified nurse midwife from Oregon state. She retired from 23 years in a hospital based private practice and traveled to Niger to work with midwives.  Sitting with her at dinner in a café in Durban, South Africa, I was educated on the reality of the high stillbirth rate as an everyday occurrence for midwives, women and families in the developing world.

“While there is always joy in delivering babies, in Niger, that joy is mixed with the sadness and grief that is all too prevalent when childbirth becomes dangerous for mothers and babies because of poor health conditions and poverty.  During my three weeks in Niger, I delivered more stillborn babies than live ones.  We can only imagine the toll that puts on health workers, women, their families, the community and the nation.”

During a presentation about charting and clinical assessment using the WHO partograph, I learned that a typical provider/patient ratio on a labor unit is 3 to 25 in Ghana. Constancia Atachie, Prinicipal Nursing Officer with the Ghana Ministry of Health described conditions in a typical hospital where she worked and conducted research.

“You are literally running from bed to bed, sometimes carrying a new baby under your arm as you race to the operating theatre with another woman. Babies keep coming and you never stop until your shift ends and you do it all again the next day.”

Access to midwifery care is a big issue for us in the US, but access to any care at all is the bigger issue for most of Africa and the developing world.  As we dig in our trenches dedicated to development of the midwifery profession in the US, we need to understand that not only could our efforts be contributing to a more cohesive vision for global midwifery, but also our resources could be shared in ways that we can’t even imagine unless we are listening to the voices of midwives from across borders and oceans.

First Steps on a Path to a Vision

At ICM, Debbie Pulley, CPM, shares information at the MANA Booth with midwives from Sierra Leone.

It was with these images in my mind that I looked to the steps toward the vision being presented by the leadership of ICM at this Congress.  ICM is stepping up to lend its voice in a powerful way to the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) in their efforts to promote midwifery care as a means to reduce maternal mortality.  The voice is coming in the form of a set of Global Standards, Competencies, and Tools that were developed and designed to guide the leaders of the world in the development, implementation, and promotion of midwifery in their countries.

ICM sees these core documents as “pillars” of its global effort to provide high quality, evidence-based health services for women, newborns, and childbearing families. These “pillars” were developed over the last 3 years by expert Task Forces and were adopted by the Council of Delegates in Durban last month. They include:

• Updated Essential Competencies for Basic Midwifery Practice
• Global Standards for Midwifery Education and Companion Guidelines
• Global Standards for Midwifery Regulation
• and a new tool for strengthening Midwifery Associations, the Member Association Capacity Assessment Tool (MACAT).

US Delegates to ICM Council in Durban. Holly Powell-Kennedy, ACNM President, Melissa Avery, ACNM Past President, Diane Holzer, MANA Past President and Geradine Simkins, MANA President.

In the months to come, US midwives will be having important conversations about the impact of these standards on our models of midwifery and our current and future efforts to move forward as part of this new vision.  There is much to digest and reflect upon, but some immediate highlights of challenges and triumphs from the documents include the separation of nursing from midwifery, autonomous regulation, and access to training and education that allows for a scope of practice that honors the central role between mother and midwife and the primary care relationship.

Though some of the standards might cause a struggle for many US midwives to support, if we can understand the context for the inclusion it may become easier to keep a shared vision for the future.  Since we are not in a position to imagine a system that could allow for autonomous regulation or access to adequate midwifery education for direct entry midwives in all 50 states, it makes it hard for us to embrace documents that set these kinds of standards for our profession. When we read that the basic skills of a midwife should include things like HIV treatment, pharmacologic augmentation of labor, and pharmacologic pain relief in labor, we can’t help but wonder how this would relate to midwives who provide care in out-of-hospital settings in the US. As we review these documents together we must keep in mind two important things:

1. In most of the developing world, midwives do not have a higher-level provider to refer to in their community.  Referrals and transfers of care take place over hours of travel, and often there is not time or resources to make the trip.  These standards will be invaluable tools for those countries that are in the process of establishing midwifery as a profession through internationally funded projects. Whatever the midwives are trained to do will be the extent of the care most women and babies in the world will receive.
2. These standards are a vision, not a mandate.  We have an opportunity to lend our voices to the ongoing development of guidance and companion documents for each of the standards.  The council was told by outgoing ICM President, Bridget Lynch, “These are living documents.  Take them into your communities.  Understand them, live with them, and bring back your thoughts to the next Congress (2014 in Prague!).”

Digging our trenches
Playing on the beach as a kid, my brother and I used to dig holes in the sand around our castles.  As we dug our trenches, we aimed our digging for each other.  We had to dig to the same depth and start our turn towards the same spot at the same time.  I still remember the funny thrill of getting closer and closer with our arms until we finally broke through and I felt his digging fingers wiggling at the tips of mine.  We would join hands inside our own trenches and thrill at the ocean waters now flowing back and forth between our projects.

Watching other countries touching fingertips as they merge their visions within their own systems created a bit of a longing for me and a new perspective about the unique challenges we face here in the US.  In the context of Canada, New Zealand, and even most developing countries, we really have an incomparable health system. In fact, in the context of these documents it might be fair to say that we have no health system.  We are unique in our array of 50 different regulatory bodies that create different definitions, designations, and limitation for all types of midwives.  Canada has a health system that provides for health care for all of is citizens. New Zealand has no malpractice insurance issues because health providers can’t be sued in that country.  We are a “high-resource” country with models of care that are more in line with “low-resource” countries in terms of a lack access to quality care for all of our citizens.

Looking to ourselves and visioning our future for US midwifery
Midwifery has been fighting for survival for more than 100 years in the US.  This has resulted in a significant lack of access to training in a model of care that we all agree needs to be preserved and resurged as standard for all maternity providers to integrate and utilize.  We don’t have enough midwives to train the workforce needed. The result is that we have aspiring midwives spending years and countless dollars learning to be nurses before they can become midwives or leaving the country to gain training in out of hospital birth in foreign context and cultures.  How will we integrate those experiences for young midwives as they return from Haiti, Africa, and Indonesia?  How will we move forward with our vision to unify US midwives and grow our profession while still maintaining the integrity of our foremothers efforts to keep birth normal by keeping it simple?  How can we reconcile our converging priorities and unique challenges with the rest of the world?

If we want to be part of the global vision, the first step is in understanding it.  When we can appropriately place ourselves in the global context, we not only gain tools to understanding our unique obstacles and challenges, but we also discover opportunities for strengthening our purpose and our profession. Taking time to read through the ICM core documents should be a priority for all practicing midwives and midwifery advocates in the US.  Alongside these documents, the newly released UNFPA report, The State of the World’s Midwifery, Delivering Health, Saving Lives gives the much-needed global context to understanding the ICM vision.

Complete Lunar Eclipse

Witnessing the full lunar eclipse over the Indian Ocean was a symbolic moment for many of us. A reminder to be humble, to remember that there are greater forces at work, and that we all share one magestic world. The Road to Durban was a worthwhile trip but it will be the journey home that will prove to be most important step towards uniting midwives around the world.

1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet. 2010 Apr 12; 375:1609–23.