Protecting the autonomy of midwifery in Paraguay: ICM and members' support is crucial: Wilfrida Sosa and Miriam Isabel Yegros de Ortiz, Asociacion de Obstetras del Paraguay, welcome international support in their struggle for professional recognition.

En primer lugar, estamos agradecidas por todo el apoyo recibido de las Obstetras colegas de otros paises, fue muy oportuna las acotaciones, las recomendaciones, los materiales de apoyo para mejorar el documento de Fundamentacion, del porque la carrera de Licenciatura en Obstetricia se debe desarrollar en forma separada de la carrera de Licenciatura en Enfermeria.

La ICM significa para la Asociacion de Obstetras del Paraguay un apoyo fundamental. Para las autoridades paraguayas consideran mucha importancia el estar asociada a una organizacion internacional que representa a los gremios de Obstetras del mundo.

De hecho sirvio para frenar una resolucion favorable al pedido de las Lic. en Enfermeria y no emitir una resolucion apresurada, sin investigar seriamente la situacion.

La discusion entre las Licenciadas en Enfermeria y las Licenciadas en Obstetricia no va a parar, de no ser que las enfermeras renuncien a su objetivo--La de desarrollar la carrera de Obstetricia como especialidad de enfermeria. Las mismas creen que la mejor opcion para el pais y para las usuarias es que una sola persona desarrolle funciones de enfermeria y obstetricia a la vez. Fundamentan ante autoridades que de esa forma se puede abaratar el costo de servicios con un solo rubro cubriendo dos areas.

No piensan en el fin ultimo, que para disminuir la Morbi Mortalidad Materna en nuestro pals se deben preparar profesionales con formacion adecuada para cada area, con mejor capacidad de resolucion.

En nuestro pais se ha desarrollado formacion de Enfermera Obstetras por mas de 12 anos y se ha lanzado al mercado producto con resultado no satisfactorio. No se ha mejorado el indice de Mortalidad Materna por el contrario ha aumentado, razon por lo cual se ha fundamentado suficientemente para que cambie la modalidad de formacion por la de entrada directa a la Carrera de Licenciatura en Obstetricia, preparando profesionales Lic. en Obstetricia que pueda desarrollar el CONE basico Competencias Obstetricias y Neonatales Esenciales, ser parte de la intervencion del equipo para el desarrollo de CONE integral Competencias Obstetricias y Neonatales Esenciales Integrales. Para el logro de que la Atencion de la Salud Materna sea accesibles y asequibles, realizada por profesionales calificadas y bien especializadas para la atencion de la Salud Sexual y Reproductiva de la familia, focalizando a la atencion de la mujer en todo su ciclo de vida--al recien nacido--nino/a.

Las Obstetras ahora estamos abocadas a trabajar en las reglamentaciones de nuestra carrera, tenemos realizado:

* La Ampliacion y adaptacion de la malla curricular de la formacion de Licenciatura en Obstetricia en nuestro pais.

* Documento quefundamenta nuestra permanencia como profesional autonoma, con entrada directa a la formacion academica en el nivel Universitario y Tecnico.

* El codigo de Etica con resolucion ministerial No 50-02/2006 recientemente elaborado.

* Estamos completando el borrador de actualizacion del manual de funciones de las Obstetras, para la validacion y la resolucion.

* La AOP participa activamente en todos los emprendimientos nacionales en lo que se refiere a Atencion Salud Materna y Atencion Primaria de Salud.

* Es miembra activa de CEPUP Confederacion de Entidades, Profesionales Universitarios del Paraguay, para conseguir la ley Marco del Ejercicio Profesional (ley de Colegiatura)

* Recientemente presentamos la solicitud para participar como miembro de Comite Nacional de Salud, en el Parlamento Nacional del Paraguay, y como Miembro del Consejo Nacional de Salud Sexual y reproductiva--a traves del Comite de legislacion de la AOP.

* El comite de cultura de la AOP coordinada por la Secretaria de Relaciones de la comision directiva es la encargada de socializar el documento fundamenta la permanencia de la Licenciatura en Obstetricia como profesional autonoma y la formacion de la carrera de Lic. en Obstetricia separada de la carrera de Lic. en Enfermeria.

Necesitamos de apoyo tecnico y financiero para mejorar la situacion de las obstetras en el nivel pais, en todos los aspectos, social cultural preparar lideres que pueda orientar dentro del esquema politico del pais.

Para fortalecer la RENOP Red Nacional de Obstetras del Paraguay, de la AOP en las distintas regiones sanitarias, articulados y organizados motivados y comprometidos objetivos comunes.

Contamos con proyecto de formacion de comites interinstitucional en las regiones sanitarias (Hospitales Regionales, Hospitales Distritales, Centro de Salud, Puesto de Salud) para unificar criterios de Atencion de la Salud Materno, con atencion humanizada y enfoque de la calidad total.

Saludos cordiales, desde Paraguay a todas las obstetras de otros paises, estaremos siempre en contacto de acuerdo a las evoluciones del caso.

Lic. Wilfrida Sosa, Vice Presidenta AOP

Over the last year the Association of Midwives of Paraguay and all the midwives in the region have been in a struggle with the country's authorities to protect and support the autonomy of the midwifery profession. Various nurses' associations from countries in the Latin America region met in Paraguay in October 2005 at an international seminar on education and training for nursing and midwifery. One of the proposals at this seminar was to make midwifery a specialty within nursing and to take away its professional autonomy.

Since this time the AOP has been mobilising efforts to convince the national authorities of the critical importance of maintaining the autonomy of the midwife and to ensure that separate professional training is retained. While midwifery is officially recognised as an autonomous profession by the National Constitution and the Code of Public Health and Social Welfare, the law of professional practice has not yet been approved in the country and the profession still runs the risk of being absorbed into nursing. In recent years the AOP has carried out research studies to demonstrate to the government and health authorities that a distinct profession of midwifery is crucial for reducing neonatal and maternal morbidity and mortality. These studies have indicated that in areas where health professionals are employed who are trained in both nursing and midwifery (with a minimum of specialised midwifery training) there is no effective improvement in maternal and neonatal health.

Members of the AOP, along with other institutions such as the Management of Midwifery (a body within the Ministry of Health), the College of Midwives, and the Society of Licentiates in Midwifery, have also met with officials and lobbied to promote the professionalism of midwifery and to demonstrate the positive impact that midwives have on maternal and neonatal health.

I would like to say how grateful we are for the support we have received from other countries. Their letters, advice and materials of support have been very useful in helping to improve our core document outlining reasons why the professional midwifery programme should be developed separately from the nursing programme.

The International Confederation of Midwives has been a fundamental source of support for the AOP. The Paraguayan authorities consider it of great importance to be in association with such an international organisation which represents midwives worldwide and we have used the ICM's core documents and position statements to back many of our arguments. This has had a lot of impact, as have the international networking opportunities at the ICM's various workshops and congresses.

This fact of ICM support and membership actually helped us put a stop to the resolution that had been proposed by the nurses without first seriously investigating the question. At the moment the situation is still precarious, but awareness of the importance of midwives and midwifery is growing. Through dedicated efforts of the AOP and other institutions, together with their national and international networks we are beginning to convey the message of the critical role that midwives play in the country's health and the situation seems to be improving, with midwives slowly beginning to get the recognition that they deserve.

It seems likely that the discord between nurses and midwives in this country will not cease unless this group of nurses withdraw their objective to make midwifery a specialty within nursing. They argue to the country's legislative authorities that the inclusion of both specialties under a single professional title is the best option for keeping service costs low. The midwives, instead, are keeping in mind the ultimate objective, people's health, and the fact that in order to reduce maternal mortality here it is necessary to train professionals with adequate education and skills in each distinct area, to enable better chances of on-the-spot recovery and treatment.

In our country the nurse-midwife training programme (in addition to the midwife programme which also exists) has been in development for over 12 years and it seems that a final product has been agreed without a satisfying result for the public. The rate of maternal mortality in areas which employ nurse-midwives (nurses with only minimal training in midwifery) has not been reduced; in fact it has risen. The alternative is a professional education programme that entails direct entry into midwifery training, which would train midwives in essential midwifery and neonatal competencies. This would be a big step towards making Maternal Health Care truly accessible, and ensure it is carried out by qualified and specialised professionals in sexual and reproductive health, focusing on women's health and care of the newborn.

The midwives are now bent on working on the regulations of our profession. We have achieved:

* The broadening and adaptation of the curricular network of the educational degree in midwifery in our country.

* A document which establishes our permanence as an autonomous professional, with direct entry in the educational training at University and Technical level.

* The code of ethics with ministerial resolution No 50--02/2006 (recently elaborated).

* A draft manual of the duties of the midwife, for validation and resolution.

* The AOP actively participates in national undertakings with respect to Maternal Health Care and Primary Health Care.

* The AOP is an active member of the Confederation of Professional Entities and Universities of Paraguay, in order to obtain the law Framework for Professional Practice (collegiate law)

* We recently applied to participate as a member in the National Health Committee, in the National Parliament of Paraguay, and as a member of the National Council on Sexual and Reproductive Health

* The committee of culture of the AOP is in charge of the socialisation of the document which establishes the permanence of the degree in midwifery as an autonomous profession and the educational training of the midwifery profession as separate from the degree in nursing.

We are in need of technical and financial support in order to improve the situation of midwives at country level, in all of its aspects, and in order to prepare leaders who will orient themselves within the political structures of the country, and also in order to strengthen the National Network of Midwives of Paraguay in the various health regions. We are counting on education and training projects of inter-institutional committees in the health regions in order to unify criteria for Maternal Health Care, with humanised care and a focus on total quality.

My very best wishes from Paraguay to all the midwives in other countries around the world.

Note: the ICM works closely with the International Council of Nurses towards the goal of members of both professions being educated, regulated and supported in a positive fashion by national governments, to provide safe, appropriate care for the public.

ICM, WHO and FIGO agree that a skilled attendant at birth is a midwife or other healthcare provider with midwifery skills.

Lic. Wilfrida Sosa, Vice President AOP Translated from Spanish by Jessica Gonzalez, with special thanks to Miriam Isabel Yegros de Ortiz for her supplementary documentation and assistance.