'Moved by the energy, strength and commitment of midwives': speakers at the ICM Congress: the programme of plenary sessions at the 28th Triennial Congress moved from a rousing opening to a moving close, with a succession of powerful keynotes between.

Two linked and significant themes connected the content of all the keynote speeches given at the Glasgow Congress: the desperate need for action to combat continuing high levels of maternal mortality--and the fact that midwives, working together with global support, should be the people at the heart of that action.

'Top often sorrow and fear replace the joy and celebration that should mark childbirth and babyhood'

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Princess Muna al-Hussein of Jordan, patron of nursing and midwifery for the World Health Organization Eastern Mediterranean region, spoke of the disturbing lack of progress towards the 5th Millennium Development Goal (MDG) of reduced maternal mortality. She said that safe motherhood is a human right--not just a 'component of economic development'. Midwives can not only provide healthcare but encourage better education for girls, which has been shown to help delay early motherhood and reduce numbers of pregnancies. Motherhood, she stressed, should be an expansion of life--not the suspension of life.

'More skilled attendants, greater political will'

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These words were the simple message from Dr Aparjita Gogoi, who began her address with 'Greetings from the White Ribbon Alliance (WRA) and from the midwives of India!'. She listed some of the main obstacles to safe motherhood in her own country--poverty, lack of transport, weak health systems--but also highlighted successful action taken by the WRA to raise awareness of maternal deaths at every level and tackle political inertia. As well as a strong movement in India, the WRA has achieved marked successes elsewhere including Tanzania, Burkina Faso and Indonesia. Her words sparked debate among the audience around issues such as midwives' relationship with traditional caregivers, the need to involve men in this cause at all levels, the dangers of diverting resources from personnel to machinery and the consistent effort needed to combat the spread of HIV. ICM Board member Karen Guilliland explained the recent work carried out at Council towards a positive link with traditional caregivers, and Senior Midwifery Adviser Nester Moyo reminded the audience of ICM's work in strengthening midwives' associations and in training for care of women who are HIV positive.

'Promoting competent midwifery care, dependent on the needs of nations and communities'

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The Princess Royal, patron of the RCM and president of the Save the Children Fund, brought a knowledgeable view to the Congress. Her extensive experience has put her in touch with communities where there is little maternal health care and she has seen the adverse impact. In declaring open the scientific programme of the Congress, 'because I know the knowledge gained will enhance care for mothers and babies', she also demonstrated familiarity with the ICM's core documents, such as the Essential Competencies for Basic Midwifery Care, describing them as vital knowledge for governments. She had researched details of the previous UK-hosted ICM Congresses: her grandmother had attended in 1934 when 300 midwives came from 10 countries; her mother (the present queen) was patron of the 1954 Congress, with 800 midwives from 46 countries; she was delighted herself to welcome 3,500 midwives from 75 countries.

'Midwives must stand up and be counted'

Paul Martin, Chief Nursing Officer for Scotland, spoke first on the theme of the day 'Appropriate use of technology in maternal and newborn health', urging that technology should not obscure the central principles of midwifery, but should be 'embedded in an ethos of care'. He referred also to the Scottish government's actions in support of midwives in developing countries, where they are active in Ruanda, Tanzania, Uganda, Sudan, Malawi and a number of schemes in India.

'The movement to humanisation of birth gathers pace'

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Describing herself as the only midwife offering a home-birth service in Rio de Janeiro, a city of 16 million people, the midwife speaker from the Americas region was Heloisa Lessa--a midwife, nurse and anthropologist. She told of the diversity and contrasts within Brazil, where in urban private hospitals the caesarean section rate is around 98%, while in the Amazon basin there are communities where women must travel by boat for two days and by aeroplane for six hours to reach a health centre. The movement towards 'humanisation' of birth is gathering pace. Heloisa works to bring women who have experienced home births together with pregnant women, so the word is spread. More women in Brazil can now have a companion with them; in some places rates of interventions such as episiotomy are falling. Referring to the theme of the Congress day--appropriate use of technology--she said she encourages technology in labour care: particularly the use of water technology and birth-ball technology!

'Focus your efforts on the countries in transition!'

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Eugene Declerq is Professor of Public Health at Boston University, but played down his credentials, describing himself as a 'data analyst', and expressing his nervousness at taking the podium after 'two princesses ... and distinguished midwives!'. He managed to give a light-hearted feel to a talk about the dangers of high levels of caesarean section (CS), warning that, in spite of the myths, high CS rates are a serious health problem; they are an issue in low-income countries; there is little evidence that rising rates are due to women's demands; and this issue is the concern of midwives. In particular, he stressed, the dangers lie in the countries in transition from low- to middle-income and it is here that efforts to reduce interventions should be focused.

'Midwives, you have the skill, you have the experience and you have a powerful voice'

Sarah Brown, patron of the White Ribbon Alliance UK, and wife of the Prime Minister, was quite clear about the appropriateness of technology at birth. 'Midwives', she said, 'the most important presence at a birth is you!'. She underlined the failure to move towards MDG5, confirming 'We don't need to invent a cure for this. We have the knowledge--we need the political will.' Mrs Brown paid tribute to the work of UK midwives, which she had seen at first hand, and said, 'I have also seen the marvellous dedication of midwives in other countries throughout the world ... I commend every one of you for the care you provide for mothers and their newborns, sometimes in the most difficult of conditions'.

'Value what you have--let the tall poppies grow'

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Scottish midwife Cathy Warwick described her work in the UK, as leader of a service for women in London, but made clear the principles were important for a service anywhere. She keeps the system flexible, dynamic and effective for both the women and the midwives. Midwives work the hours that suit them, they are encouraged to experience secondment to different service areas caring for women both high- and low-risk, and Cathy ensures there is a critical mass of practitioners skilled in home birth and settings of women's choice. Midwives feeling confident helped women to achieve confidence in their transition to parenthood. Her emphasis was on the need to take care of the midwives who take care of the women: she asked midwives to respect each other, not to undermine each other's efforts and to 'let the tall poppies grow'.

'Midwives are the servants of new life'

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Ana Polona Skocir, midwifery lecturer in the University College of Health Studies in Ljubljana, Slovenia, gave her keynote on the theme 'strengthening midwifery'. Her proposed route was through professionalisation: she made clear that 'midwives are the servants of new life'--not as in domestic service, but chosen servants, as professionals. She reminded midwives that a profession has a distinct name, education system, its own autonomous association/s, philosophy and code of ethics. It strives to provide a service in the public interest. Once professions claimed and used power and authority, but midwives work through partnership and consultation--a way of working, she said, that suits women's skills of empathy and collaboration.

'There is a right to health for every human being'

Professor Angela Sawyer, director of the Regional Prevention of Maternal Mortality Network in sub-Saharan Africa, gave a hard-hitting speech: again she reminded the audience of the mainly avoidable half-million maternal deaths each year, adding that the babies and young children who die following loss of their mother brings the total to around 10 million. In addition, even when women survive problems in childbirth, there can be devastating morbidity from obstetric fistula and other conditions. HIV takes a toll of both mothers and babies. She noted the 'three delays'--deciding to seek care, getting to a place of care, receiving appropriate care once arrived--that contribute to mortality and warned that midwifery services are also endangered by three obstacles: an ageing workforce, staff moving to developed countries and the generally low status of women.

A welcome to South Africa 

The somewhat sombre mood provoked by Angela Sawyer's thought-provoking talk was soon lightened by a look forward over three years to another part of Africa. In 2011, the 29th Congress will be held in South Africa. Deliwe Nancy Nyathikazi, President of the Society of Midwives of South Africa, gave delegates a lightning virtual tour of the Durban congress centre, a choir of South African midwives stirred the whole hall with their anthem 'Until I reach my goal' and the Mayor of Durban invited the world's midwives to his city with the words 'Welcome to the Zulu Kingdom--welcome to Durban--welcome to Africa!'.