The world's midwives represented at the ICM's Executive Committee.

It was a great pleasure that every single member of the Executive Committee was able to be present at this important meeting, including all Regional Representatives, Board of Management members and the Vice-President and Immediate Past President. Secretary General Petra ten Hoope-Bender also attended, as did Nester Moyo and Elizabeth Duff from ICM headquarters staff. In addition was welcomed Cecilia, daughter of Alicia Cillo, who ably assisted in Spanish-English translation. The midwives present came from their own countries of Argentina, Australia, Austria, Canada, Denmark, Ghana, Italy, Japan, the Netherlands, New Zealand, Switzerland, Tanzania, the United Kingdom, the United States of America and Zimbabwe--but they represented the midwives of the world.

Regional and country reports

All representatives had endeavoured to contact other member associations within their region for an update on developments in their country, but responses were variable. In some countries conditions were difficult, midwives under pressure and communication was disrupted.

Europe: Rising rates of Caesarean section (CS) deliveries were reported from all areas. Midwives are deeply concerned, but in many areas not empowered to take action. Karlene Davis noted that a national audit of CS practice took place across England, Wales and N. Ireland about two years ago. Guidelines based on this information are awaited.

The post of 'family health nurse' is popular in some countries, reported Lillian Bondo who represents the Nordic nations, and these nurses are taking over some midwifery functions.

Ruth Brauen described a number of issues in the Francophone countries. She has met with a collective association of French midwives, which includes the current ICM member (ONSSF), and altogether represents 16,000 midwives. Here too, midwifery services are under pressure and several maternity units are now only used for postnatal care.

Africa: Kathlyn Ababio from Ghana spoke of her work in west Africa. The Ghana Registered Midwives Association celebrates its 50th anniversary this year. A new government in Ghana has made safe motherhood and reduction of maternal mortality a priority; violence against women is also recognised as an area where midwives' contribution is valuable. However because of shortages of midwives, community health nurses are being involved in much of this work. Kathlyn has arranged to meet with the maternal and child health leaders at the West Africa College of Nursing, and hopes to discuss ICM matters here.

Joyce Safe from Tanzania had also been in touch with the East Central and Southern Africa College of Nursing who had held a conference on 'Nurses and midwives responding to health challenges'. The issues identified included adolescent reproductive health, and feeding of infants born to HIV-positive mothers. Midwives from 15 countries attended this meeting and some showed interest in joining ICM.

Ruth Brauen had been in touch with midwives in Benin and Mali, where prevalence of HIV/AIDS remains a major issue.

Americas: Both midwives and mothers are suffering from the poor economic situations current in Argentina and other Latin American nations, reported Alicia Cillo. Malnutrition is widespread among women, and there are many low-birth-weight babies. Alicia has recently visited Peru, to talk to midwives about the issues of violence against women; and she is to go to Ecuador for a meeting of the region's midwifery associations.

In Canada and the USA, Bridget Lynch described concerns that reflect those in Europe: CS rates at 25-30%, many carried out for 'social' reasons. Women are sent home from hospital 36 hours postoperatively, as keeping them longer imposes greater costs. Bridget attended a conference in San Miguel, Mexico, in June 2002, of midwives from Central America. A great deal of midwifery practice is carried out by 'traditional midwives' in these seven countries, and pressure to stop these women practising could cause the loss of a huge body of knowledge. A single school, known as 'Casa', provides education for the traditional midwives: however, there is a chance that the University of Mexico will offer a combined course with Casa. Meanwhile, the Caribbean midwives are looking forward to hosting the ICM Mid-Triennium meetings in 2004.

Asia-Pacific: New Zealand midwife Sandy Grey highlighted the Asia-Pacific region as the most diverse of all in its variety of language and culture, and the vast inequalities between groups of people. As elsewhere, communication in some areas is difficult and disrupted, whether electronic or postal. Sandy has been making contacts with member associations and suggests that more guidance on the role of the Council delegate is needed.

Shortages of midwives are prevalent everywhere, nevertheless governments tend to resist investing in recruitment, but instead question the need for midwives, so that the profession is forced to spend time and resources defending its own existence. In Australia there are problems with provision of insurance for midwives. The Hong Kong midwives are organising an Asia-Pacific conference in November this year.

Junko Kondo from Japan agreed with the points made by Sandy, and added a report about Japanese midwives initiating preventive work against the spread of HIV, sexually transmitted infections and polio.

Nester Moyo, ICM Programme Manager, commented that it was very useful to hear the different reports, as it helped to inform her work in project initiation, and identified which midwifery issues were global, regional or national. She is currently working on the ICM projects or partnership programmes: Young Midwifery Leaders; Strengthening Midwifery Associations; and HIV/AIDS and midwifery.

WHO--who it is and who it isn't

Della Sherratt, the midwife on the Making Pregnancy Safer programme at WHO's Geneva headquarters, gave the Executive Committee a 'lightning tour' of the World Health Organisation. She explained WHO's principal activities, including promotion of maternal and child health and welfare; co-ordination of international work in health; collaboration with governments, professional and scientific associations and other UN agencies; and technical assistance in emergencies. WHO cannot initiate work in a country unless invited by the government.

Governance of WHO is effected by the World Health Assembly (with all 192 member states represented); and the Executive Board with delegates from 32 states. There are regional offices in Africa, the Americas, Eastern Mediterranean, Europe, SE Asia, and Western Pacific: worldwide, 3,500 professional staff.

WHO's current major contribution to the long-established Safe Motherhood Initiative is the Making Pregnancy Safer programme, and the watchword of this campaign is 'skilled care'. The components of skilled care are:

* A skilled attendant (i.e. one with midwifery, skills) present at birth and the immediate postnatal period

* An enabling environment (an appropriate birth venue and availability of basic equipment)

* A referral system for emergency obstetric care.

Midwives present were urged to find out who represents their own countries at the World Health Assembly, and ensure that these delegates are briefed on midwifery issues. What is placed on each agenda, and how much time is spent on it, are highly political issues and difficult for midwives to influence. However, reproductive health may often be touched upon under other topics headings, and no opportunity should be lost Petra ten Hoope agreed she would try to provide member associations with information and guidance on this.

New constitution for ICM

During the meeting of the Executive Committee, members met with the ICM's lawyer, Marie-Jeanne Zillikens, who assisted in explaining the benefit of an amended constitution, partly to enable the Confederation better to conform with Dutch law but also to make the democratic processes of its governance more inclusive and more effective.

The proposal is to have an 'Executive Board' replacing both the current Board of Management and Executive Committee, while the full International Council has greater involvement and an expanded role. The President will also be elected following a different process from the present one, which will enable midwives from all member associations to hold the office, not just those from countries where resources are substantial enough to host the Congress.

There was lengthy and vigorous discussion of all of these points and more, with much questioning to ensure that any new system of representation will remain as equitable as possible, and the central aims of the ICM not be lost. Following this meeting, some members of the Executive will be working further on certain aspects of the Constitution to present proposals for terms of reference in the new structure, voting processes, details to be covered in the by-laws, conflicts of interest and the overall guiding principles--to include transparency, commitment and flexibility. The detailed plans that are concluded to be the best and most balanced solution will in due course be circulated to member associations for comment and feedback.

Position statements

The Committee considered revised versions of the statements that had been initially proposed for adoption at Council last year but where some amendment had been requested. Agreement was reached on the statements:

* Violence against young girls and women

* Collaboration and partnership for healthy women and newborns

* Ethical recruitment of midwives

* Framework for midwifery legislation and regulation

* Midwives, women and human rights

* Qualifications & competencies of midwifery teachers

The statement on 'Ethical recuitment' was highlighted as an important one for midwife representatives to use in discussions and lobbying with employers and policy-makers.

The 'Philosophy and model of midwifery care' was also discussed and this will be finalised shortly.

Joint statements

On 'Skilled attendants': a draft document was discussed which encapsulates the concept of 'skilled attendant' as a component of the WHO proposal for skilled care as the key to 'Making Pregnancy Safer'. This campaign has strong international support at the moment but needs to prove its own success quickly. The Executive Committee was asked to consider agreeing the statement in a short time-frame rather than waiting for a full Council endorsement. Questions were asked, and some concern expressed, around the possibility of nurses being regarded as appropriate skilled attendants, and also about the role of TBAs. A second draft will be circulated.

On 'Active management of 3rd stage of labour': a proposal had been initiated by USAID for a joint statement on this topic. Joyce Thompson had drafted a document and asked for comment on it from the Executive. Minor amendments were suggested and adopted. The statement will be finalised shortly. Joyce's actions on behalf of ICM were strongly applauded by the Executive Committee.

The ICM Executive Committee, which brings together Board of Management and Regional Representatives met in The Hague, the Netherlands, March 2003