The 30th International Confederation of Midwives Triennial Congress: Improving Women's Health Globally

The 30th International Confederation of Midwives Triennial Congress, held June 1–5, brought together over 3,700 midwives and others from around the world during 4 days in Prague in the Czech Republic. A gathering of this size is inspirational and creates the opportunity for participants to share experiences and to find out what life is like being a midwife in many different countries and cultures. The Congress was launched by “Voices of Midwives,” which gathered 1,563 midwives from over 100 countries, setting a world record, and sang with a 30-piece orchestra to raise awareness for midwifery. The theme for the 2014 Congress was “Midwives: Improving Women's Health Globally,” which reflects the Millennium Development Goal 5: To improve maternal health. The International Confederation of Midwives works with midwives' associations to secure women's rights and access to midwifery care before, during, and after childbirth. It aims to encourage and support the effectiveness of midwives' associations by strengthening what are called the “three Pillars” of a strong midwifery profession. The Pillars include education to provide a competent, qualified midwifery workforce, regulation of the activities of midwives, and organization of midwives in a strong association. All of the International Confederation of Midwives Core Documents and standards on practice, education, and regulation have been helpful globally, and can be found on the website in a range of languages at http://www.internationalmidwives.org/. The Congress presented a strong focus on the role of the International Confederation of Midwives in the global arena, and it is clear that the organization has played a major role in global initiatives to improve maternity and perinatal care, specifically representing the contribution of midwives. Two important documents were presented in the plenary sessions. The first report, on the State of the World's Midwifery 2014, is the second global report to be published on the midwifery workforce, and copies were made available at the conference. However, the plenary session was poorly presented and did not do justice to the report, which covers 73 of the 75 low- and middle-income countries that carry the burden of more than 96 percent of maternal deaths and 93 percent of newborn deaths globally. Regrettably, since the report fails to cover some middle- and high-income countries, the state of midwifery in Europe, North America, Australia, and New Zealand is unknown. Many of these countries would benefit from the very detailed analysis in the report (http://unfpa.org/public/home/pid/16021). The second report, The Lancet series on midwifery, was also presented in a plenary session, but was not published at the time of the conference. The plenary provided a general overview of the key messages in The Lancet series, which are highly relevant to the conference participants and to informing global maternal and perinatal care policies. It was a great shame that the details and key findings of The Lancet series were not available for midwives to discuss and take home, since they were very excited about and interested in the implications of the series for their countries. The series is now published and available online at http://www.thelancet.com/series/midwifery. Integral to both of these key reports is a crucial debate on how midwifery is defined. Is it defined as the work that midwives do using the International Confederation of Midwives definition of a midwife, or is it defined as the work that may be done by a range of health care providers? The State of the World's Midwifery 2014 report defines midwifery as “the health services and health workforce needed to support and care for women and newborns, including sexual and reproductive health and especially pregnancy, labor and postnatal care.” In The Lancet series, midwifery is defined as: “Skilled, knowledgeable and compassionate care for childbearing women, newborn infants, and families across the continuum throughout prepregnancy, pregnancy, birth, postpartum, and the early weeks of life. Core characteristics include optimizing normal biological, psychological, social, and cultural processes of reproduction and early life, timely prevention and management of complications, consultation with and referral to other services, respecting women's individual circumstances and views, and working in partnership with women to strengthen women's own capabilities to care for themselves and their families.” Thus both reports use a definition for midwifery that includes a range of health care professionals and others apart from midwives. Some of the most heated discussion in and around the conference and from the floor was on this issue. How midwifery is defined has important policy implications. From a health system perspective, health policymakers would wish to know whether the widest coverage and the same outcomes can be achieved using a range of health care providers or whether a qualified midwife is necessary to achieve these outcomes. Should money be spent on educating midwives or on other categories of health workers? From the perspective of the midwifery profession, how can the unique contribution of midwives be captured and valued? The Lancet series investigates this issue and concludes that educated, trained, licensed, and regulated midwives can provide the full scope of midwifery as defined in this series, but benefits are limited where reliance is solely on less skilled health care workers. A major theme coming from the individual presentations was related to the definition and management of risk, particularly from countries with large private health systems. The topics of defensive practice, risk aversive policies, and financial incentives to intervene were discussed as influencing the experiences of women and babies and affecting midwifery practice. The plenary session by Professor Cecily Begley challenged professional complacency about current midwifery practice or acceptance of the latest fad that time would prove to be unsupported by evidence. The challenge for researchers is in presenting these uncomfortable truths to an audience who do not wish to change. This was not a research conference, but some presentations made grand claims about the effect of an intervention without any evidence of causality. This is a concern, as many of these innovations were greeted with enthusiasm by audience members wishing to replicate the ideas in their practices. This makes an interesting case study on how innovations with little evidence get taken up with fervor, whereas others with strong evidence are ignored. Conference speakers need guidelines about responsible presentation of findings, and participants need guidelines about avoidance of bad science so that they can identify questionable claims. Some opportunities were missed. The voice of women and service users was weak, and no plenary session was given by a service user or a representative from a user organization. The workshops were oversubscribed, and the conference did not take advantage of a great opportunity for participants to hear about related areas of work, such as health systems research, implementation and improvements in science, and future plans for the Cochrane Library. This Congress really provided the first opportunity for the International Confederation of Midwives to use social media. The potential for social media is huge, and much more can be done in the future. Live streaming was employed, but unfortunately, this technology was not free and open access was not available for the millions of midwives around the world who could not afford to attend. Personally, I would rather see a conference budget being spent on this technology than on expensive opening ceremonies and gala nights. On the other hand, it was so impressive to see the amount and quality of research coming from Australia and the huge increase in research capacity and enthusiasm by Australian midwives, who were one of the largest country contingents. Many countries could learn from their story because building research capacity is a constant struggle in many countries. The International Confederation of Midwives Congress has always provided an opportunity for midwives to share, and one of the themes in Prague was using the new evidence around midwife-led settings and midwife-led care. Since the last Congress, midwife-led settings such as home and birth centers, either in the hospital or out of hospital, now have a stronger evidence base. Models of midwife-led continuity of care also have a stronger scientific evidence base. One key challenge is how to implement, scale up, and spread these models of care. Another challenge relates to their relevance and applicability to countries whose health system is different from those where the research was conducted. Previously, the International Confederation of Midwives Congress has provided a catalyst for political change in the country where it is held. However, a mismatch was apparent between the conference location in beautiful Prague and the relative silence on the troubled politics of midwifery and childbirth in Eastern Europe. Some sessions on political issues were offered, but these could have been highlighted more in the program—a missed opportunity. One of the most popular sessions was that on human rights in childbirth, and I look forward to more sessions such as this in future conferences. In 2017, the International Confederation of Midwives will hold its 31st Triennial Congress in Toronto, Canada, hosted by the Canadian Association of Midwives. For more information, please see http://www.canadianmidwives.org/main.cfm?l=en&p=06_600.

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