 All right, so we're going to get our World Health Organization pre-conference session started, so I'd love to invite our esteemed guest speakers, Mrs Elizabeth Eero and Ms Fran Maconville, to join me on screen as I introduce them for their presentation. There we are, welcome both, so I'm going to go ahead and introduce you both, and we're still looking forward to your talk and thank you again for joining. Elizabeth Eero is the World Health Organization Chief Nursing Officer who commenced this role in January 2018. She is based in Geneva, Switzerland. Mrs Eero is from the Cook Islands and prior to taking up her role in the World Health Organization she served as our country's Secretary of Health since 2012 to 2017. She was the first nurse midwife and women to be appointed to this role in the Cook Islands. Her priorities while in this role focused on legislative reforms to strengthen the country's health system and developing national health strategic plans and a national health roadmap. Mrs Eero was trained in New Zealand as a nurse and midwife and holds a Masters in Health Science in Nursing and also an MBA. She has held various nursing roles such as Chief Nursing Officer, Registrar of the Nursing Council and was President of the Cook Islands nurses. Welcome Elizabeth, we're so glad you're here. Fran Maconville has been the midwifery advisor at the World Health Organization for the past eight years and is based at the World Health Organization headquarters in Geneva. Fran's focus is on addressing how women, newborns and their families can access quality equitable and dignified midwifery care that strengthens women's own capabilities, prevents unnecessary interventions and ensures timely referral to obstetrical emergency obstetric and newborn care if needed. Fran initially gained development experience as a BSO midwife in Bangladesh and then through field work in Africa, Asia and the Middle East while being a lecturer in maternal and newborn health, gender and reproductive health at the University of Wales in Swansea. Fran is a midwife, a nurse, has an MA in health economics, a BSE in life sciences and in 2020 Fran was awarded the title of honorary professor of practice at Queen's University Belfast. Welcome Fran and Elizabeth, thank you so much. Thank you Jane. Good morning, good afternoon and good evening to all our friends, our colleagues and midwives all over the world. It gives me great pleasure to welcome once again to this virtual session as we celebrate this international day of the midwife, a message for all midwives from the World Health Organization's Director General Dr. Tedros. The international day of the midwife is an opportunity to celebrate the incredible contribution that midwives make to women, infants and their families all over the world. Pregnancy and childbirths have not stopped during the pandemic, midwives have continued to do their jobs and some have lost their lives. We honor their service and their sacrifice. Today is a time to not only celebrate midwives but also to ensure a safe and dignified workplace for midwives and to invest in their education and training. And all of that needs the leadership of midwives for midwives. To mark the international day of the midwife, WHO, the UN Population Fund and the International Confederation of Midwives have come together to launch the state of the world's midwifery report. The report highlights the critical need to invest in midwives across the full range of issues. Leadership, models of care and research, safe working environments and policy design and implementation. Thank you to every midwife for everything you do. The world needs you more than ever. I thank you. This year's celebration of the international day of the midwife is one I concur with Dr Tedros. This is a time to say thank you to all the midwives all over the world for all that you do for your commitment, courage, compassion, quality care that you are giving every day, everywhere to help save the lives of women, newborns, children, adolescents and families. Despite the risk of working during the pandemic, midwives have continued to provide respectful care, even when essential health care services have been disrupted. This pandemic has added significant burden of risk and harm. Women and newborns are exposed to during childbirth due to the breaks in supply chains, women's inability to access care and the shortage of skilled health professionals. We know that midwives are also affected by the pandemic. Many have been infected and many have died. Many are struggling with mental health issues and burnout. We must look out of the midwives that we have as well as focus on recruiting more to the profession. Many of you have been steadfast and resilient. Although significant progress has been made in reducing maternal and neonatal mortality, the Sustainable Development Goal 3 targets are still far from being achieved. Even before the pandemic, approximately 810 women and 7,000 newborns died daily, with the causes occurring mainly around the time of childbirth. So what is not surprising to share with you all that WHO has confirmed a theme for this year's World Patient Safety Day on September 17 is safe maternal and newborn care, with action points around at now for safe and respectful childbirth. I look forward to seeing many of you engage in this campaign. Midwives are critical to drive progress towards the SDGs by effectively providing a wide range of essential and sexual reproductive maternal newborn adolescent healthcare services. Whether you represent associations, academia or government bodies, or are a midwife working in hospitals, or in communities, or in a midwife-led clinics, we all have a role to play in providing evidence and direction to our ministers of health and social care in our countries and support national policy dialogues around investment in the midwifery workforce in order to achieve the triple dividend for health, economic growth and gender equity. Bold investments are urgently needed in midwifery education, working environments, workforce planning and midwifery leadership in health policy and service delivery. I want to thank you for your contribution to the state of the world's midwifery report 2021 to be launched on this International Day of the Midwife. I also want to thank you for your contribution to the Global Strategic Direction for Nursing and Midwifery 2021 to 2025, which your ministers of health are coordinating to adopt with a resolution at the World Health Assembly this month. This will be the first resolution focus on nursing and midwifery in 10 years. All this data, evidence and contributions provided by you in the midst of a global pandemics is commendable. So I want to say on this day have a wonderful International Day of the Midwife and look after yourselves and each other. Thank you to all the midwives of the world for all that you do. We want to share with you a video made by WaterAid called Parallel Lives. This is an amazing video of midwives working in different settings and really appreciated differences and all importance to accessing clean and safe water. On that note, I would like to acknowledge that May the 5th is also the World Hand Hygiene Day and midwives are role models for other staff through influencing behaviour change towards adherence to effective hand hygiene practices because achieving effective hand hygiene is integral to improving quality of health care. Please enjoy the video. So hi everyone, it's Fran again now and thanks so much to Elizabeth and for the DG for that introduction and that film always gets to me. It doesn't matter how often I see it and as you could tell it was Liverpool in the UK on one side of the screen and it was Uganda actually on the other side and in terms of birth equity there is so much that that involves absolutely hand hygiene water and sanitation but look at the difference between where they were and the environment, pain relief, separation of the baby, there was just so much in that film. So I'm just amazed all of you coming from all around the world so I'm going to just say how happy I am that it's International Day of the Midwife 2021 and it's a really really exciting time. So I'm going to take you through some of the state of the world's midwifery report headlines. I think you're going to be the first to hear them because of course it's late at night here in Geneva so I'll start taking you through and look forward to any questions to all of us towards the end. So this for me is one of the headlines from the State of the World's Midwifery Report. I love it, it means that we can do 90% midwives when educated, regulated to international standards, supported and integrated into that health system. Midwives can really provide about 90% of all sexual reproductive maternal adolescent health needs but with less than 10% of the workforce we're about 8% globally. There was a huge huge gap and even if you look at the percentage of time spent on sexual reproductive maternal adolescent health care only 19% of staff are midwives and the others are nurse midwives or nurses or people who do not have all of those essential skills. So for me that's a huge and powerful message coming out of this latest State of the World Midwifery Report which I think as you all know is the third one and they're just getting better and better and what the report says which is really interesting is that there are now four things it's increasingly clear. None of them are new but these are absolutely obvious that we have to invest not just in quantity of midwives which I think has been quite a focus we must train so many we must employ so many but actually the quality of those midwives and the quality of the care that they can give. So the first invest is in the health workforce planning management regulation and in that all important safe and caring environment that we need to work in. Secondly is midwife led, thank you DG for talking about midwife led leadership, midwife led improvements to sexual reproductive health services and service delivery. Thirdly and we know this high quality education and training it's got to really move now and the fourth one I just think is terrific because it's about investing in leadership and governance by midwives for midwives including having a chief nursing midwifery officer in countries. So this is what UNFPA, WHO and ICM and all the evidence in this report is pointing to so we have a good case to be made here. So I'm going to go into those in a bit more detail but first of all this is these PowerPoints are actually from the State of Wales midwifery report you will find them all on the UNFPA website any moment now we did say that VIDM was happening and could they get their details up it's been embargoed if you don't see it now it will be there in the morning so these slides will also be available for you. So why invest and these are the kind of arguments that we absolutely have to make to ministries of health and donors and foundations which is for start it promotes the health and well-being of women adolescents and newborns we know that but the evidence is just getting clearer and clearer it puts more safer and more effective SRMNAH care within the reach of more people at the moment very few women can really access a good quality of care in fact one in five women have no care at all in 2020 it's quite terrible it's exceptional and then we could save an estimated 4.3 million lives a year by 2035 and I'm going to come on to that if there was universal coverage of international standard midwives of course midwives and women contribute hugely to national and local economies and of course strong midwifery contributes to women's empowerment and to gender equality so I'll talk through those issues but those are the big five now many of you will have seen this paper that was published in the Lancet Global Health at the end of 2020 and I want to acknowledge that this is actually a presentation developed by Andrea Nové and shared at the launch of this paper if you have not seen it I really urge you to look at it it is just tremendous and what did we do is we found 31 midwife delivered essential interventions we used the live save tool so this is estimates this is not evidence these are modeled estimates to estimate maternal deaths newborn deaths and stillbirths if coverage of these interventions these 31 midwife delivered interventions stayed the same to 2035 in 88 high mortality countries mostly low income or low and middle income but not only and this was repeated across four scenarios just a model scale up of midwifery of 10% every five years a substantial scale up of 25% increase in access to midwife delivered interventions every five years universal coverage 95% by 2035 and they also looked at attrition which is inevitable in some countries of around a 2% decrease over five years and this is what they found and if you look at the left hand side in the blue column the deaths averted with universal coverage of midwife led interventions include 67% of maternal deaths 64% of newborn deaths 65% of stillbirths totaling 4.3 million lives saved per year by 2035 and that's really something again it's modeled estimates but we know that this is where we could go to if you swing to the right hand side even if you could just do a modest 10% increase which is a lot for many countries at the moment increase in coverage every five years you could still avert 22% of maternal deaths 23% of newborn deaths and 14% of stillbirths and save 1.3 million lives per year by 2035 so even if we we in some countries can only do the minimum it's still absolutely worth doing so what we found also in this paper was the high impact interventions really make a big difference so and enabling midwives to provide the all-important modern methods of contraception that was around half of deaths averted and in many countries midwives are not providing contraception still so that's a real big one and and it's not the most expensive one and it's really doable hypotensive disorders case management to prevent stillbirths antinatal corticosteroids assisted vaginal birth management of preterm babies management of neonatal sepsis which is huge and pneumonia to reduce newborn deaths and hypertension screening and management parenteral uterotronics and assisted vaginal birth to reduce maternal death so those are the big high impact interventions and what does this study add well I'm really pleased to say that after the amazing Lancet series of midwifery in 2014 this just adds more confidence to that initial data that came out in 2014 and it focused specifically on midwife delivered interventions and we didn't know it would it could have gone the other way it could have sort of said well 2014 data was a bit spurious but it doesn't it says it was really good the 2014 data and here's even more confidence in what midwives can do and the impact that they have and on which interventions have the greatest impact and there's a great section which describes the barriers that we have to overcome to ensure that we can achieve this potential and it calls for action on these so that is fed in to the stake the words midwifery report it's been hugely important that paper for the evidence in this report now so these are the first slides coming out of the SOMI report and I'm going to take you through the four invests and the first one is this health workforce planning management and regulation and in the work environment and that came out so strongly that the environment in which midwives work in so often is really just not good enough it's really poor and not safe or so and what we found about data systems is we've got a long way to go not one single country out of the 194 countries that submitted the data which is all of the WHO member states could submit all of the data required so we still don't have systems even in the high infant countries where we can get the data that we need those countries that did submit data could often not distinguish clearly between professional midwives what they call associates in the paper which is nurses nurse midwives auxiliary midwives as well as nurses just between nurses midwives and nurse midwives so isn't a system at the moment to even know so we actually can't say how many countries have midwives and how many don't because we don't have the systems yet to collect the data but that's a real positive out of this report because we now know much more than we did in the previous two reports about the data systems so at least we now know that and we know WHO will be doing a lot of work along with many partners UNFPA ICM and others and interestingly these systems would say midwife not midwife nurse midwife whatever but we didn't know if those midwives were clinical practitioners were researchers or were educators so we still don't know how many practicing midwives we have or research or education so that's a big gap that we will now address and we don't know how much time nurses and doctors also spend providing sexual reproductive maternal and adolescent health care so we learned a lot but we now know better what we don't know and what we need to work on when we collect data in the future so I think what was really good to know and has come out strongly is the need for gender transformative work environments we can't continue as we are in these very negative environments that we have to work in given that 93% of midwives of women and four critical issues came out leadership as we've said decent work free from discrimination and harassment the gender pay gap has got to be closed and occupational segregation as well so we really need now to think of work through test out try do the research on gender transformative policies these are complex difficult societal level changes but we really know we need to start on that seriously and measure what changes we can make and what works and what does not effective regulation is quite shocking we found that just 24 out of 73 countries that reported on regulation so not even all countries reported on regulation but showed that one in three of those countries doesn't even require regular relicencing relicensing based on continuing professional development which means you could have qualified 20 or 30 or more years ago and you can continue to practice so we know that much practice is really outdated and if you look at the number of unnecessary interventions such as episiotomy things really we need to update people with the evidence and we need to help them and help the educators to do that they've been left in in systems that don't function to support them properly so that was number one about workforce and now a favourite of mine and many of us is about high quality education and training and I think for many years we just talked about training two to three days two to three weeks two to three months and it wasn't particularly high quality so we were going for numbers perhaps not so much for the quality so now we recognise how important quality really is and this was interesting and this was a combination of the WHO educator survey and the ICM they did a more recent and really interesting survey through their midwifery associations there's a lot of very good detail of that in the report they've done great work and almost 50 percent of countries say they're midwifery educators are midwives which means over 50 percent aren't and six percent of countries have no educators who are midwives at all so what are they learning about and on average 65 percent of educators are midwives so we have a serious global gap in educators who are midwives who are highly experienced who are able to teach who have materials who have access to clinical sites and even have 40 to 50 percent don't even have water or sanitation so no one wants to go to even learn to be a midwife let alone provide care in that so we need a serious investment in midwifery education so this again backs up previous data and it's just getting stronger and stronger so many of you will know that WHO with I'm delighted to say UNFPA and UNICEF and the International Confederation of Midwives launched this report at the World Health Assembly in 2019 which seems a long time ago but it wasn't really and the nice thing was it wasn't us who launched it actually it was member states who launched it and they took it forward and they launched it and they really want WHO and all of us to work together to support this so I'm just going to highlight some of the the factors in this this of course is on the WHO website and there's lots here and still why do we need to focus on midwifery education and latest data shows that approximately 810 women die every day and without good education we can't stop that happening really it's 2.4 million sorry the million is not there newborn deaths every year and one stillbirth every 16 seconds and I'm very pleased to say that stillbirths are becoming increasingly recognised we didn't talk stillbirths so much before and this is where we see that almost one in five women absolutely have no care at all educators lack basic competencies knowledge skills behaviors they don't have the education and training materials and water and sanitation situation is dire so what's great about this report is the first time that all these agencies came together and came to a global consensus that the title midwife should only be used for providers who are educated to those international standards and globally in many countries in various languages anybody with any anyone who has anything to do with women and and babies can be called a midwife and then people get completely the wrong impression of who and what a midwife is it's a bit like calling anybody an obstetrician so we really agree that this title really has to be reserved for those who are educated trained regulated supported we agree to improve leadership and I think you can see this in this report and our coordination and the report itself could cast break from our coordination that I just want to highlight that more women die in fragile states and anywhere else 60% of global maternal mortality and 5% that's all we know but I'm sure it's more than that takes place in fragile and conflict settings and you have regions like the eastern Mediterranean where nearly all of those countries at the moment are in a serious conflict and it really is midwives who are uniquely able to provide these essential services in the most difficult circumstances it's not doctors or obstetricians or pediatricians it's the midwives who live and work in those communities and the photograph you can see here is from Somalia where they have just made the most extraordinary progress on midwifery and it's really heartening to see it can be done in a conflict in a famine and in really difficult circumstances so this report has we we all concluded that we needed an action plan and the action plan that we developed from all the evidence over three years of policy dialogue to develop this report has seven steps now this is just an example to show you what India has been doing it's actually made more progress than you can see on this slide but straight away you can see that step one that we agreed on in 2019 was leadership because we cannot move anywhere until we get that leadership and too often we found that leadership on midwifery education was by somebody else obstetricians ministers it wasn't actually by midwives at all so that the leadership by midwives was missing and getting the policy right get you gather and get your data and evidence build your public engagement get on board your parliamentarians your women your obstetricians whoever you need get them on board before you start get your educational institute set up well and your clinical mentors ready to really give that support get your faculty ready invest in the faculty it's really important get your standards agreed based on your policy and develop your curriculum based on your country needs in some countries the biggest problem is going to be malaria and midwives have a huge role in that in others it's going to be midwife led continuity of care so everyone is at a different place but develop your curriculum to meet the needs of that country and in massive countries like india it's going to be different slightly in different states then educate and then lastly monitor and we haven't really been great at that we've been good at educate so this this this is a cycle so you act on this you monitor it you review it you continually improve it and i'm very pleased to say this is not published yet but it will be we will update this framework for action we now have for the first time a joint who unifpa unicef and icm framework a results framework for midwifery education and we've taken the seven steps that you can see in blue down the left hand side it's a bit small this slide you'll see it better when it's published and we've looked at what the activities the outputs and the short term and long term outputs outcomes could be for each of these seven steps so if you look at gather data and evidence where the arrow is you can see that what we want to see as a long term outcome is increased use of research and evidence to inform midwifery education now we put that there and agree to that because often education is just what you knew when you learned 20 or 30 years ago and it's not based on evidence or research so we want to see the evidence and research in that country as well as regionally globally into that edge into the education process and now we actually have measures for the first time and so again if you look at gather the data and evidence the measure that we have agreed is evidence informed annual review of midwifery education policy and practice now imagine if every country especially that was new to midwifery to strengthening midwifery had an annual review of how they were doing just on that one measure we could see how much progress has been made and the important thing then is you can cost it and then you can go to a donor to the government for their own domestic resources you can go to a bilateral donor a UN donor or big foundation and say look if you want to save women and newborns lives and prevent stillbirths it's going to cost you this much and these are the things we're going to do and we can tell you what worked and what didn't and every year through an annual review we will improve this and I can promise you that's what people need to hear because we've had a lot of impassioned advocacy for midwifery but economists who make big decisions and ministries need to know what they're going to get for the money that's spent so I think this is good we're going in a good direction and we need to work on this over the next few years really help countries support them to make this work and see what difference it makes so number three this is brilliant invest in midwife led improvements to sexual reproductive maternal newborn and adolescent service delivery now this has been coming down the track but it's here and it's loud and it's proud and it's right up front now that it is about midwife led care and we know we need this because for the first time I think in history certainly since we've been measuring it the lancic global health came out a year ago two years ago now and said that shockingly in facilities in facilities neonatal deaths or about half of them are taking place in a facility and similarly at the bottom half of maternal deaths are taking place in facilities now if you think back 10 20 30 years ago the big push was to make sure women delivered in facility to save their lives and now we're finding them half of them are dying and that's because the quality of care is numbers in facilities have increased education support regulation financing of everything that's needed has not and so we've got this terrible situation where you can see that on the left here's a caesarean section I really hope that was needed and it was not unnecessary I like to think that that is you know one in 10 women will need some intervention so I like to think that that is really life-saving and then on the right you have this desperate situation which is all too common where there's absolutely nothing at all so never in history before have we had these huge gaps it's completely inequitable so if we want both equity for all we have to change this picture and the lancet maternal health series you may remember in 2016 came out with this phrase too much too soon and too little too late and the lancet global health commission it was 2018 poor quality of care is now a bigger barrier to reducing mortality than insufficient access to care we've got a lot to do here so the fact that the state of the world's midwifery report now says move on this midwife led continuity of care it's important the evidence I'm delighted to say is in the WHO antinatal intrapartum and postnatal care guidelines that this is really important for me at WHO because now we have a recommendation on midwife led continuity of care it is about high income countries and where midwifery systems are working well but we know it works and we can use that and there's going to be more research following up on this recommendation coming soon so it's enabled us now because it's in these documents to move forward and to inform our member states our ministries that this really is evidence-based and it's something to invest in and many of you will know but I'll still go through it again that this work led by Professor Jane Sandler at King's College continues this is one of Jane's slides and it just talks about the profound impact on the provision of care experience and outcomes that midwife led continuity of care has and if you look at the arrow on the left I find this just so amazing that women are still it evidence is still saying the same the more they do it 24% less likely to experience a pre-term birth with midwife led continuity of care and I just want to go if this was a vaccine everyone would be funding it so let's work on that and let's really get this investors model of care invested in a lot of research where does it work how does it work in different settings and different contexts and then of course it just overall improves women's experience of care and if you think of those families who have experienced so many deaths of women in facilities once that improves and the experience of care improves we will get more women going to facilities to actually get much better quality of care through this model so it's really exciting that this is in the state of the world's midwifery report and then and I love this quote too which is of course we know this most of us are midwives here midwives do not just attend births and the number of times I've been in countries where I've been to where midwives are seen as the person in the labour ward that's it and they're trained to do that and they say that it's really difficult to spend your entire life in the labour ward you could imagine the burnout that would take place but that is the impression that we just care for women during birth and so I won't go through this complex slide it is in the education report it arises from the Lancet series Mary Renfrew and I developed this from the 2014 series to go into the 2019 framework for action but you can see mortality reduced harm to women reduced improved outcomes interventions reduced improved public health breastfeeding always comes to mind is the most important the first public health intervention and just overall societal level improved health outcomes including improved referrals for complications I think many medics think that midwives don't want to refer in fact what we find is that you know more experienced midwives will identify quicker and refer more and so you can see it reduces mortality reduces serious morbidity it increases satisfaction reduces postpartum depression reduces all that augmentation caesarean sections of pesiotomies increases spontaneous vaginal birth interestingly reduced smoking late pregnancy very important I mentioned breastfeeding less day on a labour ward and all the rest of it so really important that the message is getting out now that midwives don't just care for women during birth so I just wanted to mention something that's coming it's mentioned briefly in SOMI that we are talking about human rights here but from WHO side we're working a lot more now on human rights standards for respectful midwifery care across all those issues in the previous slide I'm not going to go into this in detail because coming soon is the essential respectful care course of the midwifery education toolkit and the first module is on human rights and midwifery so I just want to highlight that there are these four international human rights treaties perceptual reproductive maternal and child health as well the first one is the convention on the rights of the child the second is the convention on elimination of all forms of discrimination against women the c door the third is the international covenants on civil and political rights and the fourth is economic social and cultural rights so these treaties aim to respect and protect the human rights of pregnant women rather than newborns whilst in the care of providers and they have the right women to respect indignity bodily integrity privacy and confidentiality confidentiality etc and to reach this highest attainable standard of health as well as a legal identity nationality but I won't go into detail but we as midwives have an incredible responsibility to meet the needs of women legally these are legally binding documents and we feel it's time now and it says so in the summary report that this needs to be integrated into midwifery education right from pre-service and that continuing professional development needs to remind midwifery care providers so including obstetricians pediatricians and nurses as well as midwives that there are these human rights standards and it is our duty we are duty bearers to uphold these standards so I keep your eyes open and your all the rest of it peeled for these new discussions around human rights and the new modules that will support you in being able to deliver that that I just want to mention COVID and say what Somi said which is this COVID crisis has exacerbated the global shortage of 900,000 midwives with the health needs of women and newborns being overshadowed midwifery services being disrupted and midwives being deployed to other services now many of you in the countries that are sending messages in the chat will have experiences first hand in a way that I haven't and it's all countries high income middle low income but now we're going to go and hear from a wonderful midwife who is just working beyond belief in the lawy and that is Harriet Chanza and before I introduce Harriet I hope you've all seen this app it's the WHO Academy COVID-19 app where all the updates will be so I'm not going to talk about that but I want to move to Harriet and we have a short film of her and you can see she's done it under quite a lot of duress she's extremely busy Malawi has been hit extremely hard by COVID they haven't had vaccines there's been a lot of anxiety very senior people ministry health have died and Harriet is dealing with the most enormous workload as national professor national professional officer in WHO for family health and population in the WHO office in Malawi so this film is now going to be played Harriet hello everyone my name is Harriet Chanza I'm a nurse midwife working in the WHO country office Malawi I just want to share with the world on this very memorable day international day of the midwives about midwifery and COVID-19 in Malawi Malawi has a population of 17 million and more than four million are women of childbearing age and we have 4,000 midwives, nurse midwives in the country against that population and the ratio of nurse midwife to the population is one to more than 1,000 and we can see that that's a huge a huge gap the midwives in Malawi have not been spared from the pandemic some of them have contracted the pandemic some of them have died from the pandemic leaving their families orphans but they continue to provide the necessary services including antinatal family planning labor and delivery postnatal care even follow-up care that requires their work their presence midwives in Malawi face huge challenges we've heard of cases where they have been evicted from their homes because of the COVID-19 pandemic people actually attacking them thinking that they are killing people in the in the in these hospitals but they continue to provide their services and I really appreciate all the bedside midwives that are still working despite the challenges of having inadequate resources like PPEs even essential medicines essential equipment and supplies sometimes they're not there isn't sterilization sometimes people they have to boil the the things that are supposed to be sterilized but despite all those challenges they continue to provide the needed services to the women and children I really appreciate this day and I really appreciate all the midwives in Malawi and midwives all over the world thank you very much so you know huge thanks to to Harriet for for sending that to us and and she's really doing an amazing job so we're going to move on to midwifery leadership and hear from another midwife in India soon but this is the fourth one and I just love it we've needed this for a long time so I just want to step back a little bit we did a systematic mapping a few years ago because when I first came to WHO and there are many of us thinking the same midwives were being blamed for poor quality of care it was really clear that it seemed to be you know our problem and not a systemic problem and so we wanted to look at what is it that is preventing midwives from providing the quality of care that we know we all want to provide you don't become a midwife if you don't want to give the best quality of care you can so we asked this question on what are the social economic and professional barriers I'll slip through this because time is short 82 items came up we published it in plus one and then we did a follow-up paper later on midwifery is a vital solution what is holding us back and we also we got that data and then we thought we also need to ask midwives so we put out a survey thinking we might get a couple a hundred people and within two weeks we had to stop it because we had two and a half thousand midwives and we thought we can't cope with any more and it came in from 93 countries in four languages it hasn't been updated so it's still relevant but we do think we're going to be able to take this report further and dig deeper with an anthropologist and sociologist to really find out what's going on in terms of power here and it's the midwives voices midwives reality report obviously find it on the WHO website and this quote is from Chile which is obstetricians have taken over childbirth midwifery personnel that work mostly as their obstetric nurses following orders and discouraged to voice their opinion but that really could be a global quote I think in many places and gender inequality is the root of it all lack of voice lack of space in the political agenda issues of safety and security were huge and we have I think this is quite complicated yes so this is just a summary of everything that we found so socio-cultural issues care birth considered women's work midwifery really isn't accepted culturally in many countries it transgresses accepted gender roles and extraordinary how vulnerable midwives are to physical and sexual assault and you heard that even in a crisis like COVID in Malawi they're very vulnerable to being attacked we find that professionally there's this huge lack of investment in in education regulation medical hierarchies can stain constrain the scope of practice we can't practice to the level that we should and economically shocking wages often don't appear for months can't feed their kids have to take a second job have to run the farm it's not possible to live like that and provide quality midwifery care so we have a gender penalty from our low social status midwifery is feminized it's women's work not profession it's just what women do and moral distress burnout and poor quality of care so that was a real great process and I think so much has come out of that 37% of midwives globally had suffered harassment fear violence or live an unsafe accommodation it should not be like this for the women who are caring for other women much more recently just at the end of last year Asha George and others put this paper out that violence against female health workers remember 93% of midwives of women is just the tip of an iceberg it's huge violence against women health workers but lots is going underneath and we have to understand the extent of nature of the problem we have to talk about it acknowledge it and not pretend it is not there and we have to reframe and challenge our ways of seeing this professional associations must step up and regulatory bodies have really got to be more representative it's been something we didn't want to talk about too late it's up and out there now it's in the state of the world's midwifery report us as women health workers have got to say we're not tolerating this anymore and we have to mobilize our own collective action and without this change we cannot improve quality of care and even in this pandemic the change that we can make will be limited so I really say suggest read that paper it's got a lot of good in it it is all about power what do we know who has what power who does what with power who is valued and who decides so there's a lot that we need to now start talking about and thinking about it's exciting talking about power now as well as all the really important midwife stuff now just a little something for me on midwifery before I hand over to Emily and I on leadership during the year of the nurse midwife so many great things happened and there was lots of media and lots of tweets and a lot of online stuff and I kept looking for the pictures of midwives that were about leadership and what I saw was lots of pictures dating back I don't know what this is 15 16th century to clinical practice lots about birth and if you just go online and google pictures of midwives every single one you will see is with a mother or baby in clinical practice they're beautiful great pictures I like to want the bottom because that's a woman's view of the midwife I really like that but I don't see pictures online of midwives doing research I don't see it anywhere we're not visible in the media or you know out there in social media as researchers and we're not visible in these leadership management roles and ministries of health we're just not there so I'm going to hand you over to Emily who is working with Elizabeth Iroh I'm really pleased to say she has been brought in to support Elizabeth solely to look at leadership so Emily over to you thank you very much Fran that's been really really interesting and so relevant and important so fascinating and thank you get a glass of water before you come back for your next bit and so I'm going to just talk a little bit about the work that we're doing in the WHO just now around supporting our governments to develop the roles of the government chief nurse and tonight particularly I'm going to talk about the role of the government chief midwifery officer and we've been working on a project to really try and understand the mechanisms that support people in these posts to have the conversations and start reviewing the strategies that are so important and the documents that are coming out that Fran's been talking about today are critical in moving this agenda forward for some time we've recognised the role that the midwives play in strengthening the midwifery workforce and back in 2001 strengthening nursing and midwifery presented at the World Health Assembly called on governments to create government chief nurses and government chief midwifery officer positions and it also called on them to empower those already in the post but it has taken some time in 2015 the WHO published a manual to outline the roles and responsibilities and competencies for this role and it advocated that the role must be positioned in government visible at the heart of decision making policy dialogue strategic planning it must have a voice and influence at all levels of management and it talked about the importance of influencing policy development and strategic directions but having listened to many people talking about the importance of senior midwifery leaders it's really clear I think now more than ever that we all agree that this role is vital in the development of policy and healthcare strategy but it's also important that we learn the lessons more than ever now we embrace the change and move forward when we finally emerge from the COVID-19 pandemic but despite the resolution in 2001 the guidance in 2015 and many many more things in between many countries do not yet have a government chief nurse or a government chief midwifery officer in role and what our recent study has showed that in each country where they do exist their position status and influence is very different approximately 50% of the 194 WHO member states have a government chief nurse or midwifery officer in post who is fully empowered their level of authority and influence is variable some government chief nursing and midwifery officers are not nurses or midwives midwifery leaders have rarely been seen as part of government decision makers and advisers during the pandemic and that's despite the huge issues with maintaining maternity services during a crisis there are very few countries who have achieved midwifery midwifery officer yet and you can see there on the screen two absolute trailblazers from midwifery Jackie professor Jacqueline Dunkley bent from the UK and JJ Cartes Bravo recently appointed to the role in Chile so how do we move forward so we invest in leadership for the future of the profession it takes time effort and investment to lead recognizing that to build a strong experience leaders capable of taking on these really senior roles will take some time leadership development should be a core competency of being a midwife leaders are not just the people in senior positions you're all leaders leading every day wherever you work in the community in hospitals in universities and therefore we must make leadership an essential component of all education and training and we must create opportunities to bring our leaders together one of the key requests from the government chief nursing officers and then midwifery officers I spoke to recently was that they wanted the chance to work and learn from each other many described feeling quite isolated from the opportunities to share their knowledge and expertise and learn from experiences in different countries so we need to ensure that networks of leaders exist that enable support and mentorship they share innovations and learning of which there is so much and we need to gain experience outside of midwifery and I think this is a really important point and they all raised this midwifes midwives are experts in midwifery that is really clear but in order to be part of wider discussions around health education the economy climate change law politics all of which affect maternal child and adolescent health we need to be able to be well informed and able to speak about these issues recognizing how they relate to the issues that are relevant to the people under our care so we have a really really important voice and we must make sure we are heard thank you Emily let's get my oopsie trying to get my picture up again thank you Emily for that and it's really wonderful to have somebody just pulling all this together so as you can see we take leadership very seriously around midwifery in WHO and now as we come towards the end of this we're going to hear from Pregati Sharma a young nurse midwife in India but who is helping the government of India through WHO works through the ministries of health in pushing forward this whole program in India to develop a whole cadre of midwives India had never had midwives before and one of the things step one of that seven step action plan that you saw is that they have developed a midwifery specific leadership program for really important people in each of the states India has many states and the focus is on six states to start with and in each state it will be the midwifery association most senior government person leading on midwifery and the most senior educator so I'm going to hand you over to the film about Pregati and you'll see what she's doing hello I'm Pragati from India and I'm honored to join you on the international day of the midwife I bring greetings from India where midwifery is very high on government of India's agenda following the kids of advocacy for midwifery in 2018 the government of India launched the midwifery services guideline with a vision to provide quality maternal health services through professional midwives trained to international standards as the implementation started grave need for midwifery leadership was felt this initiative at its core needed to be led and sustained by midwives representing the government associations NGOs education institutions etc. WHO India at the request of ministry of health and family welfare designed and launched the midwifery leadership program in April under the guidance of government chief nursing and midwifery officer at the at its heart the India leadership program aims to help reduce maternal and newborn mortality and morbidity and improve the quality of care by supporting state level midwifery and nursing leaders to implement the government of India's midwifery initiative in the context of related local national and global goals the main objective of the program is to build the individual and collective leadership capacity of senior nurse midwives who have responsibility for midwifery maternal and child health services education practice and regulation the program as of now is implemented as a pilot which after evaluation will hopefully be implemented pan india afterwards we hope to create a wider leadership network of program graduates across all participating states and wider that will participate in state level and wider fora including the national midwifery task force the leadership network will provide support mutual learning and will serve as a powerhouse for midwifery development with this pilot program for this pilot program we have 21 participants from six states and central government we have three participants from each state and three participants from central government institutions who are called state trios each state trio comprises usually one person from the state government one from the university or state nursing council and one from society of midwives india to ensure adequate representation from different areas which have the presence of midwives in our first cohort we have participants who are hospital superintendents and still actively working for covid principles in college nursing colleges midwifery association presidents directors of state nursing councils and practicing midwives we have had a great start with the leadership program and with our experience till date we see the participants are motivated despite the covid situation in the country we had few participants who had to drop out temporarily but now we have a full cohort who are actively participate participating and catching up we hope that this leadership program which is one of a kind we can support the implementation of government of india midwifery initiative through capable and empowered midwifery leaders thank you and happy international day of the midwife i hope i'm unmuted now so that was prigati and she's an absolute joy to work with and there must be other midwifery leadership programs somewhere but this is quite extraordinary and you can imagine the population of a state in india is bigger than that of the uk so when when we're covering six states it's like covering six countries so and you can see there's a really good leader in development here along with many others that that are coming so i just want to to finish on that note on the state of world's midwifery report that was the fourth big invest and all the data you'll see on the unfpa.org forward slash somie website which if it's not up and running by now will be extremely soon and i just wanted to come to the end by saying the contribution of midwives to global commitments i don't think has ever been as recognized as it is now and i think we're just beginning to be recognized the dg said last year nurses and midwives are critical to achieving this important goal of universal health coverage you heard what he said today including about leadership we have the 2019 astana declaration of primary health care and focusing much more about the link that midwives have between high-level facilities and communities there's a global action plan on healthy lives and well-being the political declaration on universal health coverage and this year is the year of the health and care worker 2021 for who and the member states although many countries including malawi have kept on year of the nurse midwife as we know international confederation of midwives have done too so it's really good news what has happened and what to look forward to already so much this year we have the launch today state of world's midwifery report we have the icm triennial congress there is a huge amount going on there um they've just turned my light sockets i've not been waving my hands around which means i have to stop lots of things going on from who new maternal health strategy i feel like it's halloween now i'm going to have to stop lots on leadership a lot of research coming down the track on networks of care models of care a lot of collaboration partnership and i'm sure we're going to have deeper analysis on power and that's my thank you and time to go and stand up and get the lights back on thank you so much and i just hope you all enjoy international day of the midwife 2021 thank you for listening and for all the work you do i don't think you ever know how much you are valued by women their families and certainly by all of us at who so thank you to all midwives everywhere on this international day of midwife 2021 thanks and at this point we'd love to invite our esteemed panel back up with our gratitude for questions and answers and just thank you so much also in the chat box that's one of the main things that we really enjoy here midwives helping midwives with links and comments and help so if the panelists would like to come back up with our cameras and we'd love to take some questions from the audience and thank you it was so comprehensive talking about leadership and education respectful care i think we really touched on so many things so does anyone would anyone like to have a microphone or would anyone like to ask some questions in the chat so ceil jevitt is asking do the data on midwifery education provided by midwives as educator educators account for courses such as pharmacology that many programs have taught by pharmacologists or statisticians courses that are taught by biostatisticians i can take a stab at answering that can you hear me now that i've got my lights back on the answers we don't know you know the data that we put up said we don't even know the difference between the different people caring at the moment we're learning what we do know but we didn't have the chance in so many to go into that kind of detail and i guess it would it will vary hugely from country to country as well and there's a comment about is there any way this could this should be provided to the united nations to bring more pressure and support to these most important of issues i think that's a really good question elizabeth shall i go ahead because there will be some message given to the secretary general the un secretary general and and of course we are the united nations who the united nations population fund so we are very aware of it and certainly for who this message goes across our international day of hand hygiene our water and sanitation teams our malaria teams and all the rest of it so elizabeth you may want to add on to that um just probably just to say that um the strategic direction for nursing and midwifery is going to be it has been coordinated by member states enough and by countries um and the ministers of health with the anticipation to having that endorse at the world health assembly on the 20 which starts on the 24th of may um they also uh have the will be seeking to adopt a resolution on nursing and midwifery uh which is uh you know something that that can be very useful as we push also from our midwifery perspectives uh in countries to actually um have our ministers uh ensure that uh these uh documents that they have adopted at the you know the global level is also filtering down to the country levels so i think you know this is a very powerful uh an important time for for midwifery and for nursing um as we align we don't line our energy our commitments uh to making sure that uh you know the investment that we seek is actually made possible because i think that's something that we really need and i think the message that's coming through tonight around that you know the investment need is that's really critical so this time it's time for us to take action and we have a voice at the um that's wonderful and there's a question that's yet will there be more investment in the development of midwives into wider leadership roles as discussed earlier such as the law business management etc thank you shall i talk about that i think it's really important and i think when we're looking at at um how leadership training needs to be beginning when midwives start to learn um i think there are some midwifery curriculums that include policy politics and debate um but i think it's about putting pressure on organizations who are teaching to be able to teach the subjects that midwives need to know about um i think i think it would be fantastic to see programs where you can do midwifery with law and midwifery with politics because i think that will create the the confidence in the laws to be able to step into those jobs and and it's it's that when you're faced with conversations around around your own professional knowledge it you feel very confident but when you're suddenly faced with conversations that are outside of the zones which you've been taught to talk about i think you can feel very frightened and and that perhaps that stops people stepping into those roles so that the more people get used to having conversations about what's going on in the world read really widely and encourage those really deep conversations about climate change and how that would affect midwifery from a very early part of the training then i think we start putting pressure on curriculums to change and that will mean we've got a workforce that has a much broader ability to speak up about those issues and thank you um for the respectful care module and I know we're all very excited about including that going forward in our programs as an educator so thank you for that as well. Bupe in the chat says they had an opportunity of auditing midwifery qualification in Zambia and their manuscript is under publication and so we're hoping Bupe that you can maybe talk next year about the information you found out about um midwifery in Zambia we'll look forward to hearing about that um Keveri's got an interesting question I don't know if you can speak to this about the cuts in your FPA funding by the UK government if that's something you're able to speak about uh what challenges would you see that may have an impact on midwifery investment? So Elizabeth I'll have a I'll have a go at that if you like and I think having worked for DFID for many years at the time when USAID was not able to give money for sexual reproductive health and it swings around abouts um it's very politically based but certainly what tends to happen is when USAID couldn't fund UNFPA DFID came in when DFID can't fund you'll find other donors try and come in so we do try and and keep covering I think for WHO particularly it is a member state organization so what you may not all realize is that each country provides money core funding to WHO and then WHO is able to allocate that to priorities that ministers at the World Health Assembly every year uh make and so um having this state of the world's midwifery report and having a policy dialogue with ministers on the 18th of May which will take place ministers and others will increase the knowledge and understanding of ministers and ministries and their economists who make those decisions to invest in midwifery but the first step is having the evidence and those model estimates that we have now so so Calvary you know very good question um I think the whole fluidity about funding for donor issues um you know goes up and down at the moment of course huge amounts of money are being diverted into COVID um so you know that you know that will change as well indeed a lot of the UK funding is going to COVID so um it will we hope that it will be balanced out over time but it's an incredibly important one to watch and keep advocating for thanks and we are coming to the end of our presentation however there's three questions that we'll take that are in the chat um Jemima is asking about the global and national efforts to bring attention to midwifery and midwives it's been very impressive and diverse but how do we have leadership roles um sorry I've lost that in the chat leadership roles um nationally um because currently uh we really need to look at increasing um the strength of leadership uh nationally and how do we bring this to the World Health Organization um maybe I'll have a go um team Jemima I think you know it says to the World Health Assembly meetings oh sorry I apologize thank you so I'm kind of like you know this is these uh the World Health Assembly meetings are meetings of ministers of health health annually um because we're in the you know I think what has happened in the past is that I think in 2019 we we were able through the DG uh encouraged ministers of health to bring their nursing and their midwifery leaders as part of their delegation to the World Health Assembly so I think you know for us the same message because it's virtual meetings uh this year um I think what we perhaps need to reach out is that member states uh have uh include the the chief midwives or midwifery leaders to participate in some of the the dialogue that happens at these meetings at certain intervention points um there hasn't been trial this year because we're just adopting to this virtual platform but I think we do have room to maneuver in terms of making sure that midwives are part of that delegation to the World Health Assembly and there's a couple of comments in the chat speaking to that as well Elizabeth that um leadership is being included in the curricula in Canada and in the UK and I don't know this probably speaks a bit to this as well is there any update on schools curricula across the world being accredited by ICM so training of midwives can be done according to a single standard thus promoting direct entry autonomous midwifery so I I think that's a question for ICM um but um I mean they are doing a tremendous um amount of work on on this and curricula development ICM it was ICM who came to India and supported India to revise its entire curriculum um and they have got their MEAP they midwifery education um assessment program and Anne is on the call I don't know if she's still here but Anne would be the person to to answer but but it is a huge issue and I think there is a question as to whether or not um I think we need to set the standards for the curriculum and ICM as you know has set the core competencies but countries need to adapt them to their needs as well we shouldn't be dictating we should be supporting um and so those ICM core competencies are really important too but ICM will be able to give you much more detail because they work in so many countries with their uh wonderful midwifery associations can I can I just add Jane I'm just so pleased to be reminded by UK and Canada that those leadership leadership is already in standards and and in some of the curricula and I think from our side at WHO I need to look in those in more detail and share them with other countries so that they can use them um and and really make more of that so that's really great to see great great comments in the chat thank you everybody and just we'll take this one final question because I know you've you've been up there for a long time are there any current twinning type projects for educators of midwifery to support each other globally I'll go for this one if that's right there are between some countries um and I think you want to Frank Acade and her PhD was in twinning um but again they start they finish it varies and that's not something that I can answer about in detail what I do know is that twinning has to be done extremely carefully um it will often benefit the high income country better than the low income country because when you do something like that you learn so much about what is going on in another country that it's quite difficult actually to make a significant change particularly in the short time but when they're well designed they can be extremely helpful and provide a lot of confidence um and support and the countries love it they really like it's very encouraging very positive well thank you so much uh to our wonderful guest speakers from the World Health Organization Organization let's thank you again Elizabeth Eero much respect Elizabeth Fran McConville and Emily Wartler thank you so much everyone and beautiful presentations so comprehensive covered so much ground we do record all these and they will be available on our YouTube channel so you'll be able to um access this incredible presentation and really a great way to start our celebrations uh for International Day of the Midwife so thank you again everyone thank you Jane for all of us thank you us happy International Day of the Midwife happy International Day of the Midwife everyone