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WHO, ICM and FIGO launch: 'making pregnancy safer: the critical role of the skilled attendant'; ICM Secretary General Kathy Herschderfer introduces a ground-breaking joint statement that underscores the importance of midwifery skills in safe motherhood.

Making pregnancy, safer:, the critical role of the skilled attendant is a statement produced jointly by the World Health Organization (WHO), the International Confederation of Midwives (ICM) and the International Federation of Gynaecologists and Obstetricians (FIGO). Its focus is the importance of a person with midwifery skills being present during a woman's labour and delivery. The statement represents official recognition at global level that this presence is the highest priority in the endeavour to achieve safe motherhood and the 5th Millennium Development Goal--a 75% reduction in maternal mortality ratios before the year 2015. I attended the launch of this powerful new document, which took place in Geneva, Switzerland, in November 2004.

Midwives and 'skilled attendants'

The crucial need for skilled attendance during a woman's labour and delivery is widely acknowledged. However, fill now, there has been a lack of precise definition of who a skilled attendant is and what exactly she or he can and will do. This new joint publication successfully clarifies the issues and provides evidence-based guidance so that work to build the level of human resources needed can continue on an assured basis.

The introduction to the statement makes clear that:

'Skilled care refers to the care provided to a woman and her newborn during pregnancy, childbirth and immediately after birth by an accredited and competent health care provider who has at her/his disposal the necessary equipment and the support of a functioning health system, including transport and referral facilities for emergency obstetric care. Since skilled care as defined above can be provided by a range of health professionals, whose titles may vary according to specific country, contexts, it has been agreed to refer to this health care provider as the "skilled attendant" or, "skilled birth attendant", so as to avoid confusion over titles. Thus:

A skilled attendant is an accredited health professional--such as a midwife, doctor or nurse--who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.

... In issuing this statement, WHO, ICM and FIGO are advocating for skilled care during pregnancy, childbirth and the immediate postnatal period. This statement is especially, aimed at countries in which the coverage of skilled attendance at birth is below 85%.

Section 2 of the statement describes the required skills and abilities of the skilled attendant. It begins with the assertion that 'all skilled attendants must have the core midwifery' skills' and refers to the ICM's Essential Competencies for Basic Midwifery Practice.

Also set out is a list of 'types of skilled attendant', which includes, in this order, midwives, nurses with midwifery skills, doctors with midwifery skills, and obstetricians.

Continuum of care

The joint statement sets the work of the skilled attendant in a clear context, which ensures that a midwife or other attendant is not expected to achieve the required goals while working in isolation:

'... In childbearing, women need a continuum of care to ensure the best possible health outcome for them and their newborns. The continuum starts with the woman and her family in the woman's own home--i.e. self-care and prevention. It is followed by the first level of health care (at a health post, clinic or in the client's home) and involves the provision of high-quality midwifery care.... However, when complications occur, women and/or their newborns will need care at secondary or tertiary levels of the health system ...

'The successful provision of the continuum of care requires a functioning health care system with the necessary, infrastructure in place, including transport between the primary level of health care and referral clinics and hospital *.

'The skilled attendant is at the centre of the continuum of care. At the primary health care level, she/he will need to work with other care providers in the community, such as traditional birth attendants and soda/workers. She/he will also need strong working links with health care providers at the secondary and tertiary levels of the health system.'

Action at global level: the WHO, ICM and FIGO pledge

The three author organisations have not just agreed on the wording of the statement, but have confirmed they are prepared for vigorous collaborative action in building the necessary capacity to achieve skilled attendance for 90% of all births:

Recognizing the pivotal role of the skilled attendant in reducing maternal and newborn mortality and morbidity, WHO, ICM and FIGO undertake to work together to increase access to skilled attendants for all women and newborns in pregnancy, childbirth and the immediate postnatal period. Working in collaboration with the member associations of ICM and FIGO and with WHO Member States, the three organizations will urge governments, policy-makers, health care providers, donors and communities to increase access of childbearing women and their families to a continuum of skilled care.

'....Unfortunately, in spite of overwhelming evidence on the value of skilled attendants from the developing countries that in recent years have succeeded in lowering their maternal mortality ratio, sufficient numbers of skilled attendants remain unavailable in many developing countries.'

This last sentence is significant. It is clear from recent experiences, not only in developing countries, that a shortage of skilled attendants in any area has a devastating effect on maternity services and places an unacceptable burden on those who are left coping.

Broad-based calculations carried out by WHO conclude that 'the number of skilled attendants in developing countries needs to be increased by at least 333,000 ... The lowest levels [of skilled attendance] are in Eastern Africa (33.6%), South-Central Asia (37.5%) and Western Africa (39.6%), with much higher levels in South America (84.8%). Globally, only 61% of all childbirths are attended by a skilled birth attendant.'

ICM, through its mission and global strategy, is committed to striving for safe motherhood through the advancement of midwifery and the strengthening of midwives' associations. We welcome the wide dissemination of this joint statement, as it confirms the value of earlier ICM work, such as the compiling of the Essential Competencies. It also strongly resonates with other ongoing ICM work, such as promotion of midwifery regulation and expansion of the role of professional associations.

The full document can be accessed at."

ICM Secretary General Kathy Herschderfer introduces a ground-breaking joint statement that underscores the importance of midwifery skills in safe motherhood
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Author:Herschderfer, Kathy
Publication:International Midwifery
Geographic Code:4EUUK
Date:Nov 1, 2004
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