Three workshops on safe motherhood issues: obstetric fistula, PPH and skilled birth attendants: ICM was involved with workshops held in Brisbane, Australia; Lusaka, Zambia; and Behror, India.

This event was one of the ICM workshops presented at the Triennial Congress in Brisbane in July 2005, in collaboration with partner organisations. Around 50 midwives attended, from countries including Afghanistan, Australia, Barbados, Denmark, Hong Kong, Jamaica, Kenya, New Zealand, Uganda, the UK and USA.

The facilitators presented a varied programme to raise awareness, share information among participants and stimulate brainstorming to achieve the development of recommendations by the end of the session.

Nester Moyo, ICM, discussed the significance of obstetric fistula from the perspective of ICM, Wame Baravilala, UNFPA, presented on the Campaign to End Fistula; Joseph Ruminjo, from Engender Health, introduced the video 'Love, Labor, Loss'; P Annie Clark, of ACCESS and ACNM, explained the ACCESS project's offer of small grants for those working to prevent obstetric fistula. Participants were asked to discuss the midwife's role in prevention, counselling, management, treatment and follow-up of women with fistula, and to answer the following questions: What is the midwives role now? What do we think it should be? What can we do to make it happen? What recommendations do we have for ICM?

A questionnaire to assess participants' baseline knowledge about fistula was administered at the beginning of the workshop. Among questions asked of participants were those shown in the box below:

The brainstorming session on 'what can we do?' elicited a large number of ideas from participants, including:

* Raise awareness of the risk of fistula by means of radio, drama, newspapers and other media

* Provide education on the benefits of delayed marriage and first childbirth

* Establish peer counselling in hospitals and support groups for women with fistula

* Educate family/birth attendants regarding the dangers of obstructed labour

* Educate midwives to identify obstructed labour and fistula early and intervene with catheterisation to promote healing

* Educate women after they have received surgical repair in fistula prevention, self-care and contraception

* Establish partnerships with local leaders to raise community awareness focusing on women's and young girls' needs for nutrition, antenatal care and family planning 

There was also focus on the problems of countries where health professionals, including midwives, leave to work overseas.

It was suggested that unethical recruitment strategies be highlighted, that countries recruiting midwives take more responsibility for training and that governments be lobbied to improve midwives' salaries to promote retention of staff.

Answers to 'True or false': 1 = T; 2 = F; 3 = T; 4 = T; 5 = T; 6 = F; 7 = F; 8 = F; 9 = T; 10 = F

P. Annie Clark, ACCESS/American College of Nurse-Midwives and Nester T Moyo, ICM

East Africa Regional Workshop on Prevention of Post-Partum Haemorrhage

A total of 30 participants--midwives, gynaecologists and obstetricians--from Ghana, Malawi, Tanzania, Uganda, and Zambia attended this event in October 2005, Lusaka, Zambia.

Postpartum haemorrhage (PPH) is a life-threatening event for women and yet its incidence can be reduced through endeavours such as the Prevention of Post Partum Haemorrhage Initiative (POPPHI), which ensures appropriate use of active management of the third stage of labour (AMTSL).

The joint statement by ICM and FIGO, first issued in 2003, which emphasises the need for birth attendants to be able to offer AMTSL to save mothers' lives, was the guideline for teaching at this workshop. AMTSL has three major components: administration of a uterotonic agent (the drug of choice is oxytocin, 10 units 1 m); controlled cord traction; uterine massage after delivery of the placenta.

Zambia Health Officials, the director of JHPIEGO and representatives from POPPHI and USAID spoke at the official opening of the workshop. The health statistics of the East Africa region were showing an evident increase in maternal mortality. In Zambia, for example, 25% of maternal deaths are from preventable conditions; 30% of these women die within 24 hours of delivery. Maternal mortality is a critical area in Zambia with 11 women dying per day and 1 in every 23 women dying from pregnancy-related causes.

Although the use of AMTSL is seen as a powerful tool in combating deaths from PPH, other strategies of prevention ofhaemorrhage include expansion of antenatal care and strengthening of skilled attendance at birth. The USAID representative revealed that Phase One of prevention of PPH focussed on four countries: Benin, Ethiopia, Mali and Zambia. Phase Two of the POPPHI project will be global. Professional associations will be vital partners in this work.

A representative from each country described the way AMTSL is practised there. There were variations in the practice: in all countries a uterotonic is given during the third stage of labour, but there are differences in the type of drugs given. The midwives shared their experiences, as well as the challenges encountered and lessons learnt.

As ICM representative for Africa East, I led the session on the 'Role of professional associations in the expansion of AMTSL'. What came out from the presentations is that we are the conscience of the profession and should commit ourselves wholly to the POPPHI project and because of the evidence available the associations are convinced that it is possible to stop women bleeding to death at childbirth.

Much as there is scientific evidence that AMTSL effectively reduces maternal mortality, is not expensive and can be practised by midwives trained to do so in the remotest of areas, there are still issues that create challenges. Those raised by midwives through discussion groups include: drug unavailability, problems of drug storage, lack of knowledge among skilled attendants, loss of skilled attendants to other countries, resistance to change, high cost of training and lack of policy guidelines. The list is not exhaustive.

It was enlightening and encouraging to see midwives and doctors in the Africa East region working together. It was also good to see that the problems in the region were typical of others, so that it is helpful to network and collaborate in order to solve the problems.

Associations have the mandate to expand the POPPHI, sensitise personnel and involve stakeholders through service and in-service workshops.

Judith Chamisa, ICM Board Member, Africa East region

Strengthening Accreditation of Community-based Skilled Birth Attendants

The 2005 World Health Report Make every mother and child count urged Member States to take action to ensure skilled care at every birth--one of the key messages for achieving the Millennium Development Goals (MDGs) 4 & 5 on reduction of infant and maternal mortality.

For most of the countries in WHO South East Asia Region (SEARO) and in Afghanistan and Pakistan, this means that a skilled birth attendant (SBA) must be available at the community level, where most births take place. The constraints to achieving this are numerous: not the least is the lack of accreditation and regulation for such practitioners.

It is clear that an urgent issue to address for increasing coverage and quality of services for mothers and newborns is the quality of production of human resources. Effective accreditation of both programmes and institutions is crucial.

The workshop, held in Behror, Rajasthan, India, December 5-9, 2005, and jointly funded by WHO SEARO and UNFPA SAWA, attracted 62 participants from Afghanistan, Bangladesh, Bhutan, India, Indonesia, Myanmar, Nepal and Pakistan as well as representatives from Sri Lanka and Thailand as resource persons. Participants, facilitated by experts in the field of midwifery, from ICM, the Commonwealth Secretariat, WHO and UNFPA, deliberated on ways to strengthen accreditation, regulation and education of community-based SBAs--community midwives or their local equivalents--in their respective countries.

Regional Director UNFPA SAWA, Dr Wasim Zaman, urged agreement on measurement of the indicator of progress towards MDG 5--proportion of births attended by a skilled birth attendant. He congratulated countries in the region on initiating activities to help health professionals meet the ICM/FIGO/WHO criteria as, he said, regulating and licensing of skilled birth attendants is of paramount importance.

Dr Saramma Mathai outlined the consensus arrived at in an earlier Islamabad meeting on Skilled Birth Attendants. All participating countries had agreed in principle on the ICM/ WHO/FIGO definition of the SBA and on the scope of practice for SBAs at community level and in institutions.

Reports on progress since the Islamabad meeting showed:

* Afghanistan--already in the process of developing community midwives with support from USAID/REACH

* Bhutan--activities for strengthening midwifery initiated

* Maldives--activities to upgrade the skills of peripheral workers such as assistant nurse midwives (ANMs)

* Pakistan--the nine-month community midwifery programme has been extended to 18 months, but training is yet to start

* India--ANMs now allowed to use oxytocins, magnesium sulphate and misoprostol. Standards for various levels of care have also been developed

* Nepal--agreed to upgrade eligible MCH workers to ANMs; upgrade the skills of nurses and doctors at various levels of care in BemoC and a national SBA policy has recently been developed, which includes revising ANM curriculum and developing a specialist professional midwife

* Bangladesh--The national six-month training programme for primary health workers, started in 2004 to enhance midwifery services at community level, has resulted in a total of 1500 community-based SBAs in 28 districts. It has been decided to further refine and lengthen the current training.

Della Sherratt emphasised the need to have a strong accreditation process in place. Accreditation is essentially a quality assurance/quality improvement mechanism and is critical to ensure and improve the quality of healthcare.

Despite initial confusion about the technical meaning of accreditation, country teams agreed the need for a 'verifiable process by which institutions and programmes for community-based SBAs are deemed to be operating at or above the minimum standard' as established by the relevant regulatory authority. Action required to establish or strengthen country systems was agreed, as was the need for both regional standards for benchmarking, and the technical assistance required from WHO SEARO, UNFPA SAWA and ICM.

This summary is based on a report by Della Sherratt, then

Acting Regional Adviser on Gender and Women's Health, WHO SEARO, now working as a midwifery consultant.

Extract from the 'baseline knowledge' questionnaire
Please answer the following questions by circling 'T' = true or
'F' = false.

 1. Obstetric fistula is a childbirth injury.             T/F
 2. Obstetric fistula is not preventable.                 T/F
 3. Obstetric fistula is treatable.                       T/F
 4. Discussing fistula can reduce the stigma
    associated with it.                                   T/F
 5. It costs $400-800 for surgery to repair a fistula.    T/F
 6. If a fistula repair is not done, it will eventually
    heal on its own.                                      T/F
 7. Fistula is almost exclusively found in
    sub-Saharan Africa.                                   T/F
 8. There are approximately 25,000 new cases
    of fistula each year.                                 T/F
 9. The official estimate of the number of women
    living with fistula is 2 million.                     T/F
10. Fistula mostly affects older women
    between 35 and 40.                                    T/F

(Check answers at the end of this report)