Canada The International Confederation of Midwives, Americas Regiona l Conference, "Midwifery in the Americas Woman to Woman ' , was held in Van- couver, British Columbia, May 23-25 1986, followed by a 2-day I C M executive committee meeting. Both events were hosted by the Midwives Association of British Columbia.
The conference was attended by 200 delegates and had a wide international representation from Aus- tralia, Africa, Canada, Chile, Holland, Jamaica, Japan, Norway, Sweden, West Germany, United Kingdom and the United States. Delegates included midwives, consumers, childbirth educators, nurses, physicians, women's organisations and other interested parties. We had excellent media coverage with many of the keynote speakers being interviewed on television and radio. We were very lucky to obtain funding from the Canadian International Development Agency to sponsor three midwives; two from Chile and one from Jamaica.
The purpose of our theme was to look at the current state of midwifery in the Americas region; the on-going work and the outlook for the future. Presentations from Chile, Nicaragua, areas of the United States and Canada, and an international panel achieved this aim, giving delegates a comprehensive view of midwifery from many angles. The international panel was par- ticularly well received and it became apparent that more time for both the presentations and delegate par- ticipation would have been enjoyed by all. We thank the panel: Margaret Peters, Pamela Hayes, Vicki Van Wagner, Else Marie Vengene, Gwendolyn Omphroy- Spencer, Helga Schweitzer, Sumiko Maehara, Cheiko Nohno, Teddy Charvet, Frances Cowper-Smith and the moderator, Lesley Weatherston, for an excellent job.
A wide range of topics was presented in the program and one of the highlights was a very 'wel l attended workshop on a code of ethic5 for midwifery, presented by Dr Henry Thompson from the University of Penn- sylvania. The second part of this workshop, looking at ethics for midwives, was presented by Linda Irene- greene, consulting attorney for the Midwives Alliance of North America. Both sessions sparked lively discus- sions and provided a great opportunity for midwives to debate this most important issue. Our thanks to Hank Thompson and Linda Irenegreene.
Dr Murray Enkin gave an excellent opening key- note address on midwifery integration into the health care system. This topic was timely as the Ontario Government has committed itself to legislation for midwifery and is at present employing a task force to study how implementation will take place. Murray's presentation was thoughtful and gave us an overview of the politics and practicalities of the situation, outlin- ing the difficulties and realities of implementing mid- wifery in the present health care system. He cautioned us that we may introduce midwifery, but at the cost of our autonomy, and encouraged us to keep working at it, since it was worth fighting for.
Professor Robert Evans gave an entertaining presen- tation on the economics o f c h a n g ~ o f p a r t i c u l a r inter- est to Canadian midwives, as we have always seen economics as b e i n g an enticement to implementing midwifery into our health care system. It is well known that our statistics show very high rates of intervention, the costs of which are enormous. We are indeed grate- ful to Bob Evans for his contribution.
The second part of the theme, 'Woman to Woman' , addressed not only the midwife's relationship and work with her clients but also midwives' relationships with each other. We were privileged to have Filippa Lugtenburg, I C M President, deliver a luncheon address. Her remarks on the importance of unity and loyalty among midwives were inspiring and reinforced the notion that our biggest asset in our work for the advancement of midwifery is in our solidarity. Our heartfelt thanks to Filippa.
We were privileged to have a representation from the World Health Organization, Marsden Wagner, who in reporting of the W H O study, 'Having a Baby in Europe' , talked about how the position of the mid- wife as the independent manager of normal pregnancy and childbirth ~s being eroded, resulting in child- bearing women being deprived of those special skills midwives provide. These include emphasis on the nor- mality of childbearing, continuity of care and a sensi- tivity to psychosocial, as, well as clinical, needs. Also discussed was the high r a t e , f intervention in obstetrics today, especially in North america , and how this seems to be related to the absence.of the midwife in the health care system.
The closing speaker was Dorothea Lang, I C M re- gional representative for the Americas region. She pre- sented a fascinating picture of the history of midwifery in North America, demonstrating how midwives gradually lost their status, linking with the processes midwifery is now going through as it regains its strength. Dorothea's constant work and long-term
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commitment to midwifery are gratefully acknow- ledged. Other speakers also deserve special mention here: Deborah Black for her excellent presentation of midwifery in an alternative setting, the free-standing birth centre; Joy Garder for her two sensitive, suppor- tive workshops on death and loss in childbirth; Veronica Baez Pollier and Sabine Rojas for their dis- cussion of midwifery in Chile; Cathy Ellis and Dr Cheryl Anderson for their wonderfully moving presen- tation on midwifery in rural Nicaragua; Jane t Isaacs Ashford for her slide presentation of mothers and midwives--a history of childbirth in pictures, which was enjoyed by all; Drs Bernd Wit tman and Duncan Farquarson, for their excellent workshops on current trends in obstetrical ultrasound; Sister Angela Maur- daugh for her engaging report of the special caring work she does with Hispanic women in the Rio Grande Valley of Texas; and last but certainly not least, the inimitable Sheila Kitzinger, on her amazing presen- tation, which took us from laughter to tears and back again, touching that place in us where lies the commit- ment to helping women give birth safely, with dignity and pride.
In among this sharing of information, it became apparent that we all have much to le/arn from each other and about each other. In her opening remarks, Deborah Farnsworth, MABC President, put out a challenge to the international sisterhood who have the privilege of working in countries with recognised mid- wifery services, to maintain these services at an optimal level, to strive to keep midwifery in high profile and to support those who are struggling to bring midwifery to its rightful place in health care. As the conference pro- gressed, it became evident that we are all struggling to preserve the services we have, to restore the ones that have been eroded, to legalise and implement where there is no service and to improve and expand the role of midwifery in health care throughout the world. Unity was the theme that arose and ran all through the conference, with an appreciation and respect for the diversity in our profession, a diversity which serves our childbearing families well, and the importance of working together and supporting each other in order to bring midwifery to its rightful place in health care.
We were very encouraged to hear the Assistant Deputy Minister of Health for British Columbia, announce for the first time publicly, at our opening ceremony, that the Ministry does see a place for mid- wifery in the health care system of BC.
We would like to thank the ICM.board of manage- ment, Karin Christiani, Margaret Peters and Margaret Brain, the I C M President, Filippa Lugten- burg, and special thanks to I C M executive secretary, Frances Cowper-Smith, for her valuable assistance. As conference coordinator, I wish to acknowledge the assistance and commitment of my committee, Linda Jordan-Knox, Carol-Anne Letty, Joanne Daviau, Alison Rice, Carol Bullock, Heather Martin and the
special, invaluable aid and encouragement from MABC Past-President, Karen May.
Deborah Farnsworth MABC President and Conference Coordinator
Denmark: First report The regional committee of W H O Europe is the decision-making body of the regional office, passing resolutions on a variety of issues including health policy, the budget and the general programme of work for the next few years. They do this in the light of accepted W H O global policies, goals and strategies, and in response to the information put before them by the regional office staff and by the chairmen of special sub-committees and working groups. They last met in official session at the European headquarters of W H O , Copenhagen, September 1986.
Voting delegates of the committee are representa- tives of the government of each member state. All 32 member states of the region were present. In addition, the meeting was open to Non-Governmental Organi- sations in official relations with WHO. There were 40 NGOs represented, including the International Con- federation of Midwives, the International Council of Nurses and the International Committee of Catholic Nurses. We were all given an invitation to make a brief statement to the regional committee. The following extract is from a statement presented by Frances Cowper-Smith, on behalf of the International Con- federation of Midwives, to the regional committee of W H O , in Copenhagen, September 1986.
'The most fundamental issues pertaining to healthy populations begin with the childbearing woman, before and during pregnancy, with her experience of childbirth and with her ability to nourish and nurture her child. Without women in optimum physical, men- tal and emotional health, during the time surrounding childbirth, all other issues concerned with health can have little value.
In addressing the question of how health workers and policy makers can use their time and skills most effectively in the health of childbearing women, the focus has now, quite rightly, been placed firmly upon the midwife. This key worker, wherever she (or h e ) provides a service, is recognised all over the world as having an intrinsic and vital part to play in Health For All.
The International Confederation of Midwives has been working to establish a foundation on which its members can work, within their own communities, to- wards the goals outlined by the World Health Organi- zation. In particular, our collaborative work with W H O has led to firm support for the W H O goal of Health for All, addressing the most relevant targets, such as equity in health (Target Ii, the reduction of in- fant and maternal mortality (Targets 7 & 8) and the increase of life expectancy at birth (Target 6).
MIDWIFERY 53
I C M will be conducting a joint workshop, with W H O and U N I C E F , on The Midwife and Women's Health, at the time of our next international congress, in The Hague, August 1987.
Dr Halfdan Mahler, W H O Director General, addressed the meeting, calling on member states to 'ward off pernicious attacks on W H O ' , which was the 'only socially relevant organisation for health in the world'. He referred also to the often repeated warnings of financial collapse of W H O , saying that a 'liquidity crisis looms', but that it was more of a confidence crisis or lack of faith. He also criticised W H O representa- tives for laxity in planned use of resources: too many ad hoc supplies and ad hoc meetings, with fellowships not being used effectively.
In his regional director's report, Dr Joe Asvall addressed, more or less exclusively, doctors as health administrators, managers, and planners; the inference being that the W H O still views physicians as the guar- dians and promoters of health an odd assumption in view of the fact that physicians work by treating illness, compared with midwives, health visitors and, to a lesser extent, nurses, who work to promote health and prevent illness. It is an interesting phenomenon that W H O both pushes Primary Heal th Care* (PHC) and conducts its dialogue and activities predominantly between doctors. This indicates an acceptance by W H O (also run by physicians) that they are the people who hold the political and financial power in every health service, in every country.
The mairi resolutions passed by the regional com- mittee were:
1. To establish a concerted Heal th For All cam- paign against tobacco use, including a European Non-Smoking Day.
2. To continue promoting peace in Europe, not only as an absence of war and violence but as a positive relationship between states and peoples which fosters understanding and friendship.
3. To recognise that AIDS is an epidemic disease in Europe; regional activities should be directed at its containment, surveillance and control, through W H O collaborating centres and national institutions.
4. To limit health implications of transboundary radioactive contamination caused by nuclear accidents through joint evaluation and guidelines for safety, and the establishment, at regional headquarters, of information and guidelines for emergency response.
The total budget allocation for the biennium 1988- 1989 for the W H O European Region has been in- creased by about 13% to US$43477800. A con- tingency budget has also been prepared in the event of a reduction in. their income of a possible $3 million. The budget for the Nursing/Midwifery Unit has been increased by about 9.6% to $875 200 for 1988-1989.
The budget for the Maternal and Child Health Uni t has been cut by 1% to $357 800.
* The Alma Ata Declaration of 1978 called for Health For All by the year 2000, through Primary Health Care. The eight elements of PHC were identified thus:
i. Education concerning prevailing health problems and the methods of preventing and controlling them.
ii. Promotion of food supply and proper nutrition. iii. Adequate supply of safe water and sanitation. iv. Maternal and child health care, including family plan-
ning. v. Immunisation against the major infectious diseases.
vi. Prevention and control of locally endemic diseases. vii. Appropriate treatment of common diseases and injuries. viii. Provision of essential drugs.
Frances Cowper-Smith Then Executive Secretary I C M
Denmark: Second report Strategies for health workers in the promotion of breast-feeding and the International Code of Market- ing of Breast-milk Substitutes,* were examined at a conference, organised by the Nutrition Uni t of W H O Europe, in Copenhagen, October 1986. The purpose of this meeting was to look at the role of health workers in fulfilling the aims of the code and to try to define the main obstacles to successful breast-feeding, and how these could best be overcome. The following statement was presented on behalf of the International Con- federation of Midwives, by Karin Christiani.
'Many of the problems today stem from what can now be seen as the extensive medicalisation of preg- nancy and birth. The majority of babies are born in a hospital or hospital-like setting. Experts surround and supervise the mother and later, the baby. Pregnancy and birth are no longer seen as something natural and normal, other than retrospectively.
New research and evaluation of maternal care show that this development has been detrimental for the women and also, to some extent, the role of the mid- wife. Efforts are now being made to reverse this devel- opment and to try to find a better balance between natural birth and medical intervention, and the use of technology. The recommendations from the 1985 joint E U R O / P A H O ( W H O ) working group on Appropri- ate Technology for Birth, show how far down the road ofmedicalisation many countries have gone.
In what way has this been detrimental? The women have been reduced to patients, with all that that word signifies. The combination of her passive role and the hospital care, allows routines and attitudes to develop which are not always furthering the goal of having a confident, self-reliant mother, breast-feeding her baby when she leaves our care. Most of the routines and attitudes existing have come from wanting to do the best for mother and baby. The problem is that they have developed from what the experts or the hospital
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think is good for the mother and baby. The mothers have not been involved. It is always harder to change routines and attitudes when they are based on well- meaning ideas. It is even harder when most of the personnel have an education and training based on nursing sick people. The midwife is in a unique posi- tion. Her education gives her competence to care for women when pregnancy and delivery are normal, and to give care in co-operation with the doctor when there are deviations from the normal. The medicalisation of pregnancy and delivery, though, have limited her pos- sibilities to use her competence maximally. Now that the process of demedicalisation has started, she will be the person who can speed the process and show the way. But midwives need the support from both official bodies, such as governments, W H O and UNICEF , and other organisations such as breast-feeding mothers' support groups, in the efforts to change the approach towards pregnancy and birth. It is not easy for experts not to be experts in all situations. Part of their new role will be to try to build up the women's own resources so that they can play the central role in the different aspects of care. This normalisation pro- cess requires changes in the different educational pro- grammes for personnel, including the in-service training programmes. Only when the majority of per- sonnel involved encompass the normal approach will it be possible to change routines, in the sense of a real change, not just the exchange of one routine for another. It is absolutely necessary that the normal approach is also used in the care of premature or sick babies: they are normal in all other aspects than their sickness or prematurity.
A lot of research and evaluation is being done. The dissemination of the results, though, is a problem. New possibilities have opened through the recently launched international journal, Midwifery, and also through the newly established database, Midwives In- formation and Resource Service (MIDIRS) , both based in the UK.
It will be necessary to try to establish links between all people involved in the care 'of mothers and babies. Linking up and pooling resources can only speed up the process, so that soon we will have confident, self- reliant mothers, who breast-feed their babies. These mothers will be the model for growing generations.'
Karin Christiani Director, Board of Management ICM
* The International Code of Marketing of Breast-milk Substi- tutes, published by World Health Organization, Geneva, 1981.
China A conference on midwifery, the first of its kind in China, was held inJ inan , East China's Shandong pro- vince. The meeting was jointly sponsored by the
Chinese Ministry of Public Health and the United Nations Childrens Fund (UNICEF) . Lin Jiamei, wife of President Li Xiannian, and an adviser for the Chil- dren's Development Centre in Beijing, congratulated China's six million midwives and health workers on a
j o b well done. She hoped that health workers would continue to devote themselves to fostering the builders of the 21st century. Robert Parker, a U N I C E F official, expressed great appreciation for the efforts of the Chinese government to improve midwifery training, preventive health measures and public participation in managing health centres.
China has more than 270 maternity hospitals and 2700 health centres for women and children at country level, according to statistics provided at the meeting. Modern delivery methods have been applied in more than 90% of China's cities and rural areas. The infant mortality rate has dropped from 200/1000 in 1949, the founding year of the People's Republic of China, to 35/1000 in 1985. Pre-marital examinations and hereditary-disease analysis were also begun in China in 1985. f U N I C E F / X i n h u a News Agency
OTHER NEWS
AI DS up-date A total of 31 646 AIDS cases had been reported to the World Health Organization by September 1986. One hundred countries representing all continents are reporting on AIDS to W H O . Seventy-four of these countries have now reported AIDS cases. The largest number of these reported cases (27 166 from 33 c o u n t r i e s 8 6 % of the total) is from the Americas. Europe has reported 3127 cases from 22 countries; Africa 1008 cases from 10 countries; Oceania 239 (all from Australia and New Zealand) and Asia 52 cases from 7 countries.
AIDS cases reported to W H O give a limited reflec- tion of the scope of the AIDS problem of the world, says WHO. However, as Dr Jonathan Mann, Respon- sible Officer for the W H O Control Programme on AIDS, explains: 'Given the emotional and political cli- mate which tends to eharacterise AIDS issues, we con- sider the reporting of even a fraction of known cases by national health authorities to be an expression of national willingness to deal constructively with the AIDS problem.' W H O is encouraging its member states to set up surveillance systems in order to improve the reporting and thus get a more accurate picture of the Scope of the problem.
The first case of AIDS was described only 5 years ago. AIDS is present in many countries and in many population groups, and it will continue to spread un- less efficient control programmes are established, says
