Four months, nine countries, three regions: keeping in touch with midwives worldwide: Petra ten Hoope-Bender, ICM Secretary General, describes the multiple activities on behalf of midwives which she carried out in her last few months at ICM.

Handover to new Secretary General

As announced with great pleasure by Joyce Thompson in the last issue of IM, Kathy Herschderfer was selected for this position and an orientation programme was initiated. She was welcomed to headquarters in The Hague in September, and fortunately has been able to spend increasing amounts of time with us over the months of October and November, with the aim of making the handover smooth and effective.

Kathy and I attended the Averting Maternal Death and Disability Network Conference in Kuala Lumpur, Malaysia, in the first week of October (see below), which provided a wonderful opportunity to introduce her to the main actors in the field of Safe Motherhood and to some of our official counterparts in WHO, UNICEF, UNFPA and FIGO.

Maternal mortality: pregnant adolescents

A meeting to discuss the Millennium Development Goal (MDG) on maternal mortality reduction, with reference to pregnant adolescents was held at WHO, Geneva, Switzerland, on 4-6 August 2003. The aim was to achieve consensus on the key interventions required, to prioritise these interventions, to identify key research gaps and to develop an action plan.

Participants came from the UN agencies, WHO, FIGO, ICM, Population Council, Family Health International (research agency), Family Care International, IPPF and bilateral donors including DfID (UK) and GTZ (Germany).

Background materials available included the review of the evidence developed by Dr Pieter Treffers and 'Adolescent Pregnancy--unmet needs, undone deeds' by Dr. Dina Neelofur-Khan. The meeting was opened by Dr Joy Phumaphi, the new Assistant Director General for Family and Community Health (FCH), successor to Dr Turmen, who spoke strongly on behalf of adolescents (10-19 years old) and their right to 'have their lives back'. Deaths of adolescent girls in pregnancy make up 18% of maternal mortality worldwide and the MDG will not be met without a special focus on their problems.

The main issues addressed were: sustainability of effects of interventions; clarity on definitions of child pregnancy and adolescent pregnancy; clarity between married and unmarried adolescents (their problems are similar, but legal ramifications are different); links into health systems and other programmes under development; contraceptive needs, including postpartum contraception; and the widespread lack of evidence for successful interventions, especially from developing countries.

Management of the third stage of labour & PPH

This FIGO/ICM Consensus Development meeting, held in in Ottawa, Canada, 7-8 August, was organised and funded by USAID with the aim of producing a joint statement on active management of the third stage of labour, to be the basis for a campaign for the prevention of post-partum haemorrhage (PPH) (see pp 66-67). ICM delegates were Joyce Thompson, Bridget Lynch, Deanne Williams and myself. Donna Vivio attended on behalf of JHPIEGO. Other participants represented FIGO, WHO, JHPIEGO-MNH, USAID, ACOG (American College of Obs/Gyn) and SOGC (Canadian Society of Obs/Gyn) plus the Population Council and PATH.

An extensive technical discussion resulted in a joint statement and a technical guidance document. USAID agreed to fund the campaign and to help develop materials for the launches which later took place at the FIGO Congress in Chile (October 2003) and at the ICM Asia Pacific Regional conference in Hong Kong (November 2003). JHPIEGO-MNH drafted an outline for PPH workshops for midwives, to be run by Anne Hyre from MNH-Indonesia and Joyce Thompson, prior to the Asia Pacific Regional Conference in Hong Kong. A second workshop is planned to be held at the ICM Americas Regional Conference in Trinidad in April 2004.

28th Triennial Congress in Glasgow, Scotland

The year 2008 seems far away but detailed forward planning is essential for events such as the triennial congresses. ICM representatives Franka Cadee, Anne van Geen, Ellen de Ranitz (Congrex conference organisers) and I met with the Royal College of Midwives planning committee Karlene Davis (General Secretary), Louise Silverton (Deputy General Secretary), Francis Day-Stirk (International Affairs) and Simon Morrison (Finance and Communications) on 11 September in London, UK. The meeting provided a good opportunity to address the collaboration between ICM, RCM and Congrex on a basis of world-wide commitment to women and women's health.

Global reproductive health

A consultation on the Global Reproductive Health Strategy was held at WHO, Geneva, Switzerland on 18-19 September 2003. The aim of this meeting was to review the draft strategy and identify the essential parts to be presented to the WHO Executive Board in January 2004. This is a 'country-owned' strategy, so the focus will be on action options for countries. The main points in the overview presentation were:

* stagnation or regression in spending and development of the core areas of sexual and reproductive health (SRH)

* achievement of reproductive health requires a functioning health system in countries

* opportunities such as the MDGs, poverty reduction strategies and other projects need to be harnessed

* SRH set of issues is subject to political influence, so political will is needed to make SRH central to many strategies.

Unsafe abortion

'Saving Women's Lives: the health impact of unsafe abortion' was the last meeting organised by the Inter-Agency Group for Safe Motherhood and took place on 29 September-2 October, in Kuala Lumpur, Malaysia. The objectives were to highlight unsafe abortion as a major public health problem within the context of safe motherhood and women's health, to illustrate the context within which unsafe abortions occur and to foster the development of strategies to address the problems.

Participants came from Bangladesh, Cambodia, India, Indonesia, Malaysia, Pakistan, Papua New Guinea, Nepal, Sri Lanka, Thailand and Vietnam, as well as key international agencies. The programme addressed the legal and policy framework, prevention of unwanted pregnancies, post-abortion care, expanding access to safe services where not against the law and quality of care. Some interesting questions raised were: is more law better than less law? why is abortion still regulated in criminal law instead of within medical regulations? what is the role of the man? how can barriers to family planning be reduced? Emergency contraception is not the same as abortion and has been shown not to lead to increased promiscuity, nor to be bad for women's health. How to deal with those myths?

The meeting concluded that legislation alone does not increase numbers of abortions, and that post-abortion care alone does not decrease the number of abortions. It is important to network outside those only involved in sexual and reproductive health and to use several approaches at once.

Averting maternal death and disability

The Averting Maternal Death and Disability Network Conference was also set in Kuala Lumpur, Malaysia, on 19-23 October 2003. This was a 5-year completion-of-project meeting that addressed many facets of emergency obstetric care.

During the 3 day conference results were presented from more than 80 projects aimed towards reducing maternal death and disability carried out in more than 50 countries. A number of these projects were presented by midwives involved in the various projects, mostly dealing with training for emergency obstetric care and human resource issues. The ICM organised a lunch get-together for all the midwives present which resulted in an inspiring exchange of information and inspiration from colleagues from all over the world.

ICM was invited to be involved in the evaluation of the AMDD project, and a further report will be made available.

Midwives in primary health care

I made a presentation to the Hellenic (Greek) Midwives' Association (HMA) on the 'Role of midwives in Primary Health Care (PHC)', Ioaninna, Greece, 25 October 2003. Because midwives in Greece currently work under the auspices of obstetrician/gynaecologists, they had asked for an informative presentation on the possibilities of a role for midwives in PHC, which would help them start the process of redressing the balance and putting the midwife strongly back into reproductive health as an autonomous health care provider. My presentation was translated by Katerina Daliani, the General Secretary of the HMA, and the session was chaired by Eleni Samaritaki, the ex-President. A detailed discussion between Katerina and myself had taken place earlier and much of its contents was relayed to the audience. It was a very good meeting which gave the Greek midwives a better idea of how their international colleagues work and how some of the approaches may succeed in Greece.

'Are we ready for the future?'

This was the title of a presentation I gave for the 90th anniversary celebration of the midwifery school in Kerkrade, the Netherlands, where I myself was trained. It was the closing address to a one-day conference on 30 October 2003, which aimed to look critically at the past, present and future of midwifery in the Netherlands. I summarised some of the challenges which lay ahead for the midwifery profession in the Netherlands. The increase in workload, cutbacks on governmental financial support and a shift in attitude of childbearing women towards a more risk- and medically-oriented model are some of the issues facing Dutch midwives today. I encouraged the midwives to look into developing their own midwifery model of care which includes women at all levels of care (primary, secondary and tertiary) and suggested that that they could look beyond their own borders to learn from colleagues in other situations and countries.

FIGO Congress 2003

Attendance at the XVIIth FIGO Congress, 2-7 November 2003, in Santiago de Chile, Chile, was the last official piece of representation I carried out for ICM.

ICM's first panel session centred on the need to take further the important messages of collaboration between midwives and obstetricians. The speakers were Dr Indra Pathmanthan from the World Bank; Ivelise Segovia, a midwife from Chile; Jerker Liljestrand and myself. We first presented historical data about how the professionalisation of midwifery reduced maternal mortality in Europe during the 19th and early 20th centuries; then outlined and analysed the successes in Malaysia and Sri Lanka, and the situation for midwifery in Chile. Finally we presented the policy implications of supporting midwifery and the role of the obstetrician in that.

The second panel session, with Dr Luc de Bernis from WHO, focussed on the role of professional organisations in reducing maternal mortality. I spoke on ICM's advocacy and leadership work and the Young Midwifery Leaders programme.

The keynote speech at the President's Session was on the theme of 'Partners on the Road to Safe Motherhood' and followed on from the challenge Joyce Thompson had put to FIGO in 2000 (to increase collaborative efforts of ICM and FIGO in the international arena). I summarised what FIGO and ICM have achieved together over three years (including work with the IAG, the Partnership for Sale Motherhood and Newborn Health, and the Prevention of PPH Campaign). The challenge was now for the national ob/gyn societies and midwives' associations to bring the collaboration to the next level and so closer to women and their families.

The Campaign for the Prevention of PPH was launched by FIGO at this Congress, during the President's Address in the Closing Ceremony. The presidents of the national societies all signed a declaration of support. USAID staff were present, available and very supportive. Access materials that had been drafted for this occasion were forwarded to Hong Kong to be used during the ICM launch of the PPH Campaign.

Colegio de Matronas de Chile

While in Santiago, Bridget Lynch (ICM Regional Representative), Peg Marshall (former ICM Regional Representative, now working at USAID in the Latin America department) and I visited the Colegio de Matronas de Chile and were very warmly welcomed to their offices in Santiago. We heard how the association is organised, how midwives and obstetricians always work together in Chile and that there are teams of them at all levels of the health departments and districts as well as in health service delivery. Midwives carry out family planning and certain gynaecological interventions, and are the advocates for women in all their reproductive health needs. We also greatly enjoyed a visit to the Department of Women's Health, School of Nursing, Catholic University, where the director for international affairs is Ilta Lange, who is also a member of the Global Advisory Group for Nursing and Midwifery (GAGNM). It was an excellent opportunity to meet with her staff and learn about nursing and midwifery education, and the role of the midwife in women's health (from the cradle to the grave) in Chile.

Thank you

I have enormously enjoyed these very busy last weeks at ICM, most of all working with wonderful partners and colleagues in strengthening midwifery and the broad agenda of women's and children's health.

It has been a joy to know you and to work together; I trust that the many friendships that have developed will continue.