 There we go. So welcome to our first speaker of the 9th Virtual International Day of the Midwife. Our keynote speaker this morning is Mary Renfrew. Mary is the Professor of Mothers and Infant Health at the University of Dundee. She has been a health researcher and midwife for over 30 years after qualifying from Edinburgh University. Currently, Mary is a member of two WHO advisory boards, a board member of UNICEF UK, and is leading the work to review the midwifery standards for nursing and midwifery council. In 2014, Mary was elected as a Fellows of the Royal Society of Edinburgh. Welcome Mary. Thank you Sarah and hello everyone. Good morning, good afternoon, good evening and good night. Wherever you are in the world, we I think are all around the 24 hour clock. So it's brilliant to have you here listening and participating. It's a real honor to be talking to this conference. It's fantastic. It's the International Day of the Midwife 2017. Happy IDM 17 and thank you very much for the invitation to talk to you. We're going to be talking about a really important topic today, rebalancing care and transforming lives and that is what midwives do every day of the year around the world in every country. Before I start talking, I'll just draw your attention to the Twitter names down at the bottom of my slide there. If you do want to tweet, that's great. That's my own Twitter at Mary Renfrew, but you'll also find I'm good to talk about the Lancet Midwifery series and that Twitter is at Midwifery Action and the hashtag is Lancet Midwifery and I think if I'm right, Sarah, the hashtag for the whole conference is hashtag VIBM 17 if you want to tweet. So this slide here shows you the summary, if you like, of the Lancet series on Midwifery which was published in 2014 and it says Midwifery is a vital solution to the challenges of providing high quality maternal and newborn care for all women and all infants in all countries and that proudly went on the cover of the Lancet which is the highest profile medical and health journal in the world with their full support and it has had such an impact across the world and I'm going to be talking a bit about that tonight but I think we should all feel proud on this international day of the midwife that we can say with evidence and with total confidence that Midwifery is a vital solution for all women and infants in all countries. I'm going to talk, set the scene a little bit, look at national and global challenges and talk about how Midwifery is I think a bit of the crossroads right now and I'll explain that. Then I'm going to talk about the Lancet series on Midwifery and some of the key messages and then talk a little bit about Midwifery and how it rebalances care and transforms lives. My session tonight fits right in with the key theme of the international day of the midwife this year which is partnership. It's midwives, mothers and families, partners for life and partnership is such a huge part of what we all do whether that's partnering with women themselves, partnering with other midwives with other professionals or with organizations in all sorts of ways. So let's start by looking at the global challenges. Many of you work in many, many different countries and you work in very different settings from each other but actually across the world we're still seeing over 300,000 women dying as a result of pregnancy and childbirth across the world. That's more than 800 women every single day. It's unacceptably high and still a major challenge for all of us. As well as that, about 2.6 million women will encounter stillbirths. There'll be 2.9 million neonatal deaths and of course many, many more women with serious morbidity and ongoing harm after that. And the sustainable development goals, particularly sustainable development goal 3 is really challenging us to tackle that and midwives really are at the front line of bringing in several of the sustainable development goals and particularly the one on happy and healthy lives. But those are not the only global challenges. It's not just about lives that need to be saved. It's also, as you know, about lives that need to be lived. About 138 million women and 136 million babies survive birth every year. It's not just about survival and death. It's about what happens after those babies are born. And what we find looking at the evidence, looking at the literature, looking at what people write about organizing maternal and newborn care is that often those longer term and psychosocial outcomes are overlooked, the attachment, the formation of families, how you become a mother. There's also unsustainably high rates of unnecessary interventions, caesarean sections of physiotomies and so on, inductions that are unnecessary. They're life-saving interventions when they're needed, but very, very high levels in many, many countries of interventions that are not needed. We see growing inequalities in outcomes and care more affluent women often get better care paradoxically than women living in more deprived circumstances. And care and compassion are often seen as less important and yet they're integral to system failures when things go wrong. It's often the failure of care and compassion either for women themselves or often between staff. And it's breakdown of communication and compassion between staff that actually cause problems. We also see sadly high levels of disrespect and abuse of women and children in the health system and there are now many, many accounts of that as we become more and more aware of that across the world. And often we have a disconnect between the evidence that's telling us what to do and the policy and the practice that actually makes that happen. Midwifery itself, it's essential, we know it's absolutely fundamentally important for women and children, but it's often contested and I'm going to talk about that a little bit later. What do I mean by midwifery at the crossroads? Here we are in 2017 and there's a whole lot of different trends and developments across the world, whether that's in world politics or whether that's in economics and particularly in the world of maternal and newborn health where both economics and politics has a huge effect. There are some really important things happening and I've put some of them on this slide. You may know about the global strategy for women's, children's and adolescents' health and I'm coming back to it towards the end of the talk and its strap line is survive, thrive and transform. It's a real challenge to the world to tackle the big problems for women and children but not just see them as problems, see them as opportunities for transforming society. There's a strategy for every newborn to end newborn deaths. The strategy is towards ending preventable maternal mortality that are global and involve all sorts of different organizations working together and we know a lot more about midwifery now than we used to. The 2014 report on the state of the world's midwifery for example gives lots of details about midwifery across the world and that graph in the middle is part of our opportunity, our risk and our choice. That is the trends in Caesarean section rates just in developed countries, the high income countries across the world back over the last 25 years and what you see there is a steady, steady growth, a relentless growth in Caesarean sections. Some of those will be life-saving, many of those will be unnecessary and we're actually seeing that trend in middle and low income countries as well in some parts of the world as systems develop. So we have lots of challenges, we also have lots of opportunities and it's those opportunities that I really want to talk about tonight. But also one of the things that happens when people start to talk about quality of care and I'm sure this will have happened to you in your own countries. Once you start talking about the quality of care that women and children need sometimes people just disagree. Some people stress how we have to save lives whereas others talk about health and well-being. Some people are focused on women's health whereas others are focused on children. Some people talk about the need for essential interventions and others are talking about a discourse of normality and care. Some people think that it's all about the birth and they focus on the birth, others look more at the continuum and then we've got the language of high risk versus low risk, safety versus choice. There's all sorts of decisions and choices and different ways of looking at high quality maternal and newborn care. In the middle of all of this, there's midwifery, midwifery which cares both for women and children, midwifery that cares both for women who are having very straightforward pregnancies and births and also those who are having lots of complications. Right in the middle of the page, it's essential but actually it's contested and sometimes it's even rendered invisible. When we read some of the evidence and the research around midwifery and its impact, we find it's not even mentioned and we found indeed in one of the previous Lancet series on maternal health that midwifery was called obstetrics and was rendered therefore completely invisible. It's also often contentious and contested. This recent report from the World Health Organization surveyed midwife's own stories, their own voices, their own realities of the lives they lived at the moment and they found high levels of problems, harassment at work, not being treated with respect, not having the financial support they need to exist and many, many of them being exhausted and these were midwives across the world living in different circumstances. Now this report is a very important one and it's called to people's attention what's going on for midwives worldwide and there is a film that's been done by Fran McConville, the lead midwife at the World Health Organization that will be on the Facebook page for this conference and is currently on the WHO website and it talks a bit more about this report as well as talking about this event and the International Day of the Midwife itself. Right at the heart of these problems for midwives this survey found were issues of gender inequality and disempowerment and it's not just the women that midwives care for who tackle those who have to live with those problems, it's midwives themselves as well. So what can we do to help decision makers? What can we do to change this situation? And what light can we bring in using evidence around what should happen around the world? Back a few years ago a number of organizations got together, the World Health Organization, UNFPA, the Gates Foundation, the International Confederation of Midwives and the Lancet and they decided to inform international decision making by having a Lancet series on midwifery. It was truly, truly exciting and exciting development. And as that group talked and talked with some of us about doing this, we became really clear that the most important way to look at the evidence and to look for the evidence was to start by putting women and children right in the middle of the page. And I'm coming back to that because it's a really key issue all the way through the rest of my talk. So what is the Lancet series on midwifery? Many of you will have seen it. For those of you who haven't, it's a series of five papers, four of them published in 2014, that looked at quality care in various different ways. I'm going to talk a lot tonight about paper one around midwifery and quality care where we define midwifery and looked at the impact that midwifery could have, a huge impact. The second paper looked at the scale of that impact on survival and mortality, particularly in low income countries. The third paper looked at different countries' experiences of strengthening midwifery and tackling mortality. The fourth paper looked at how we actually improve, what can we do to change health systems to bring in midwifery to increase the numbers of midwives and the quality of care provided. And the fifth paper just published a few months ago is a research agenda that is really, really important for funders to look at about how we ask different questions to improve our evidence. And thanks, Sarah. She's just put up the link to the whole series. You can read the papers, they're completely free. You have to register on the site, but reading the papers can be downloaded free. The series was put together by all of these authors. I'm not going to stop very long on this slide, but just to say these fantastic authors, about 50 of them from five continents, midwives, researchers, obstetricians, pediatricians, economists, epidemiologists, all got together and shared views, shared experiences and shared talents to really do this job. Very multidisciplinary, lots of partnership. The biggest question we had to start with, surprisingly, was what is midwifery? And the reason we had to do this was we found that different people from different settings, from different backgrounds, all had different views on what midwifery was, what midwives do. From country to country, midwives actually are allowed to do different things. In some countries, their scope of practice is very limited. In others, there actually are no midwives. And in countries where there are midwives and those midwives are strong and able to do their work, even there, their practice can vary. So it was quite important when we were looking at the evidence to work out what we meant by midwifery, just look at the work of midwives, because the scope of practice was so varied. So we set out to do that and we agreed, first of all, we had to start with women and babies when we were thinking about what they needed, what did they need from midwifery? Then we thought, so what we have to do is we have to build around them a health service that really works for them. And then we thought, so inside this health service, we put lots of different things because women and babies need all of these different things sometimes. They may not need very many of them. They may have lots of complications and need lots of those. Then we looked again at that diagram and we thought, you know, that's not right. There's something about midwifery that's different. And we moved midwifery there, wrapped around every woman and every baby and that felt a lot better because actually all women and all babies need midwifery and some of them need those other things as well. But if they have that midwifery wrapped right around them, then they can access those other services as and when they need and they'll have someone to help them do that. And we thought, so that looks a bit lonely now. And actually that is midwifery. That's a visual image of the words that we then put on the page. And these are the words that we put on the page about midwifery. Skilled, knowledgeable and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life. Core characteristics of midwifery 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. We've had really positive feedback about this definition, but of course I'm really keen always to know what people think. And if this reflects the work that you do, so please, comments in the chat box would be really, really welcome. What we then had to do was basing ourselves on this work. We then had to go and examine all the evidence, which we did. And we built out of that evidence a framework for the quality care that women and babies in every country need. And what we realized was that all women and all infants kind of need the same thing. They may be living in different settings. They may be living somewhere in real poverty or they may be living somewhere really affluent. They may have had other babies before it, maybe their first baby, they may be having twins, they may be having one baby. Actually, they still all need high quality care and they need this. We need this that we then summarized from all the evidence from this framework. And I'm going to talk you through it quite quickly tonight because we don't have a whole lot of time, but you can go back and read it and take your own time to think about it. This framework has now been used by people to plan education curricula, to plan services, to think about monitoring services and planning their own work. So let's have a look at it in more detail. The first component is that we're thinking about all childbearing women and infants and care that needs to be given to everybody. We then think about extra add-on care for childbearing women and infants with complications. So we haven't divided this into high risk and low risk. Sometimes if somebody becomes labeled as high risk, they actually stop getting the normal care that other women get sometimes. So in the care for all childbearing women and infants, they need education, information, health promotion, assessment screening and care planning, promotion of normal processes and prevention of complications. And then for the women and infants with complications, they also need some of them for slime management of complications. And then the special medical obstetric and neonatal services. You'll notice those boxes get smaller as you go along and that's because fewer women need that. If women get those good preventive and supportive care, then they need less. They'll get less complications and they'll need less specialist care there. Now moving on down the framework, having those practices is not enough. People need care organized in the right way. They need it available, accessible, acceptable and good quality. They need adequate resources and a competent workforce. Really importantly, they need continuity and those services integrated across community and facilities. But that's not enough either. They need it provided with respect, good communication, community knowledge and understanding and care that's tailored to women's circumstances and needs. But that's not enough either. They need care delivered with a particular philosophy that optimizes normal processes, strengthens women's own capabilities and uses interventions only when indicated. And then finally we get to who are those care providers and they are practitioners who combine clinical knowledge and skills with interpersonal and cultural competence in a division of roles and responsibilities based on need, competencies and resources. What we're arguing based on the evidence and over 500 pieces of evidence went into building this framework is that every woman everywhere needs care that consists of all of those components. It's not just what people do, it's how it's done, it's how it's organized and who's giving it. We then define the scope of midwifery so if you look at this framework, that blue line that goes around it, midwifery is everything in the framework except those special medical obstetric and neonatal services at the right hand end. You could if you like to find the scope of obstetrics and people are now doing that, or you could define the scope of community health work, but whatever you do you can use the framework to think about all of the components that are in there. So what are the key messages from the Lancet series on midwifery? There's a lot of very dense academic talk in those papers and I know that it sometimes takes a while to read them and digest them and some people have to read them several times to really get the messages and we're aware of that, they are academic papers. Let's distill down the essence of the key messages. Now I'm going to say to you here, the symbol of the Lancet series on midwifery is this key, it's a double sided key. Now I'm going to come back to it in a minute, but while I talk for another few minutes I want you to think why the symbol of the Lancet series is a double sided key. So the first key message I've said it several times I'm going to keep saying it and I will keep saying it whenever we talk. You start with women and babies why is that important? Why is that different? I think midwives get that midwives do that anyway but when people plan systems and the way care is provided they often start with the system. Here's a hospital, how do we make the hospital work? We have to plan community services, how do we make them work? Every time you start planning something you start with the needs of the woman and the baby and not the needs of the system and not the needs of the care providers. The second key message from the Lancet series is we managed to measure by this reanalysis of all the evidence, the size and the breadth of the impact that midwifery creates. Now just look at what midwives across the world are doing every day. Over 50 outcomes improved by midwifery. Midwifery reduces mortality it reduces preterm birth and low birth weight it reduces morbidity really importantly it reduces interventions in labour that are unnecessary. It improves those important psychosocial outcomes attachment, parenting increases breath spacing and family planning use increases breastfeeding and for the system it brings shorter hospital stays improved referrals increased attendance with a known midwife and universal implementation of midwifery could reduce maternal and newborn mortality and stillbirth by over 80% that I think midwives should feel very very proud of themselves. It is astonishing it's a huge intervention and where it to be introduced universally and to its full scope it would be completely transformative. This information is having a huge impact on a lot of people's knowledge and understanding at global level and at government levels across the world. But another key message is it's not just what we do it's how we do it. We're talking about skilled and compassionate care for all with preventive and supportive care throughout not just birth but across the continuum done with continuity respect and understanding focusing on normality and keeping processes as normal as possible and interdisciplinary working and partnership working the how is just as important as the what that we do and the who provides it absolutely essential midwives are essential midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed and regulated and midwives were most effective when integrated into the health system in the context of effective teamwork and referral mechanisms and with sufficient resources there are few benefits from relying on less skilled healthcare workers that doesn't mean they have nothing to offer of course they do but it means that if you want the most efficient and effective health system you need the primary caregivers for women to be midwives another key message is midwifery is an integral part of all care for all women and babies and all families. There's been several Lancet series published since the midwifery series one on maternal health, one on stillbirths one on newborn deaths and one on breastfeeding for example and the fascinating thing is that in every single one of these midwives and midwifery are right in the middle of the page in terms of actually implementing the action and creating the change that will make a difference it's integral for all women and babies and families. Another key message is that midwifery is a vital solution I started with that message it's really important the other people's words here have said the Lancet series in midwifery is pivotal in not just valuing midwifery but strategically positioning midwives as integral for achieving healthcare reform and global stability. Wow not just catching babies but actually making sure that health systems work well and in balance midwives are the single most important cadre for preventing maternal neonatal deaths and stillbirths say the healthy newborn network and Margaret Chan the director general of the World Health Organization is not given to hyperbole and overstating the case and as she said we need midwives we need midwives we need midwives the message is absolutely coming home another key message is midwifery brings balance to the system do you remember that slide I showed you a bit before about mortality versus health and well-being or women versus children well all midwives know that it's not either or if you're caring for women you're also caring for her baby if you're trying to prevent her dying you're also looking after her health if you're trying to use the right interventions and not the wrong ones you're having to support and optimize her own normality if you're wanting her to have the best birth you have to look after her in pregnancy and so on these are not dichotomies and choices between each other actually we need all of them and it is the balance between these things and of course choice matters those are not in opposition to each other we need all of them and we need balance so I'm going to take you back and remind you of that double sided key and the reason we have the double sided key as the logo for the series is first of all the key is the solution the key is the vital solution it is the key that opens the door to the balance between these things it's making sure we keep a focus on mortality and on health on women and children on birth and the continuum so it's that balance that double sided key that helps us and as we look at this side again of that relentless trend upwards in cesarean section rates that's now mirrored right across the world midwifery is the answer to this it tackles over medicalization and brings back balance to the system so that the women who need interventions get them and the women who don't need them don't get them and a huge message from our series is it's not just midwifery what we could say from the evidence is these findings support a system level shift from fragmented maternal and newborn care focused on identification and treatment of pathology to skilled care for all midwifery is pivotal to this approach midwives should indeed feel very proud of themselves because this is the care that they give and are capable of giving and are capable of giving more midwifery can indeed rebalance care and transform lives and just in the last couple of minutes of this talk I want to bring you back to the global strategy for women's children's and adolescents health that I mentioned earlier on with its strapline of survive and thrive and transform there's work going on now in a number of global organizations to make clear that midwifery sits in the middle of this global strategy and that it has such a huge contribution to make to survive and thrive and transform across the world all these organizations on this side are now working together to bring this evidence and other relevant evidence into action they're working together to promote advocacy the white ribbon alliance for example a fantastic organization they have a great website if you want to go looking for them are coordinating an advocacy effort that's bringing all these organizations together to promote midwives and midwifery for every woman and every child across the world there's lots of collaboration going on there's work together to tackle the barriers hi Mary hello is that Sarah yeah hi, yes it is I'm just giving you a 5 minute warning thank you I'll only be a couple of more minutes for that so all this partnership working is tackling barriers it's working with governments across the country to improve political will is midwifery being brought into Bangladesh for example the Indian government is now in talks about bringing midwifery in there and other governments across the world education it's really important evidence to bring into education of future midwives and we're really seeing that here in the UK as we're reviewing our own midwifery standards and we'll be using this framework to inform that work to base the new standards on the work on quality of care the World Health Organization is developing standards for quality of care where midwifery is absolutely fundamental and all of that evidence is being used new research priorities that were mentioned earlier but here we are with all these organizations working together WTO, UNFPA, ICM, UNICEF White Ribbon USAID CHIPIGO that's the UK's department for international development for example and the Swedish international development agency lots of governments, professional associations many many midwifery associations around the world and lots of universities, academics, researchers and educators all working together on this tremendous alliance partnership all focused on rebalancing care and transforming lives so let me go back to that slide just for a minute and remind you of Fran McConville's film that I mentioned earlier that Sarah put the link up to I think that will talk about this in detail and tell you more about the world collaboration that's going on now and you can also find a series of YouTube films and I think we can post that link for you as well called Midwifery Action where you'll find people from different organizations talking about the importance of this evidence and how it's being used in practice and in policy so thank you very much for patiently listening tonight it's great just for this hour to have this partnership with you and I think that theme of partnership and of evidence is so important to all of us working with women, working with others each other and working with other organizations to bring the best possible quality care for all women and all babies in all countries thank you very much now look forward to your comments thank you very much Mary that was a fascinating presentation and you do wonderful work for all mothers and babies so thank you for that and there's lots of comments going on down the chat box now there was some interesting comments earlier on I noticed that Elizabeth Bannon commented that language is so important in Midwifery and it's discussed a lot at the moment and how the definition of the midwife reflects the breadth of the role that we do and Sheila Clough also commented that it's talk about care for people with complications rather than high risk and Linda commented that it's more like individualized care rather than discussing people with high risk do you work a lot do you have trouble with definitions when you're sort of creating these things thanks Sarah and thanks to everybody who made those comments because you're absolutely right language was one of the most important things for us because we found that everybody was using language and concepts differently and that's why that slide I have of the dichotomies of the people focusing on different things actually was so important because we discussed the language we found that some of our colleagues were really focused on some parts of the story but not on other parts and the language reflected it so people would talk about risk people would talk about women and not talk about babies and so on and so forth a huge amount of her time was spent discussing language and that was even before we discussed different languages and translation because actually translating the word midwifery into different languages is surprisingly difficult and so that has been a real discussion that's also run and run as people have tried to translate it into French into Portuguese and other languages and discovered that actually there isn't a word for midwifery those languages have words for midwife but not what that midwife is doing and what the health system needs to provide and that's the really important thing about the concept of midwifery not just the work of midwives but what does the health system need to make sure that is in place for women and babies to have the best quality care and to enable midwives to do their jobs to the best quality that they can do so yes language is really important it's also quite fun to have those discussions okay we've got time for one more question Deborah Davis asks what do you think is the best strategy to deal with the way midwifery is contested the best strategy to deal with it being contested well there's a huge amount of work going on at that at the moment we had a meeting about that last year in Washington and the top strategy that came out of that we need to work at many many different levels but the top strategy that came out of that meeting I found interesting and it was to make sure that there's more midwives at senior senior levels of the system so I don't know what it's like in your countries but often midwives don't get right to the top of the health service planning often it's nurses who are taking responsibility for midwifery or it's not even nurses it's maybe medical doctors who are making the very very senior decisions and so the very top strategy that came out of that meeting which had people from different countries different organizations was we have to work really hard to find out where midwives are in senior positions and get them into decision making positions right through governments through the health service and so on so I don't know what you think about that there's many many other strategies which is making sure that midwives have good terms and conditions they have adequate pay for example they can work in safe circumstances and that's about working with governments to make sure that there's adequate funding and adequate support for midwives because if you think about the slide I showed you where it said you know who's the best person to provide midwifery let me go back there what we didn't just say was the midwife what we said was midwives who are educated trained licensed and regulated and integrated into the health system with teamwork referral and sufficient resources that's really important so it's another reason why we have to talk about the kind of quality of midwifery care that women and babies need because midwives need these things so they can provide that quality brilliant thank you for that Mary Deb says that's a great one thanks and we've got a hand up by Sue Sue would you like to speak I'm going to give you a microphone and let's see where have you gone Sue there you go you've got a microphone so if you want to go through your audio set up let's see if we can hear Sue I've lost her no Sue's gone okay one last one very quickly Jane asks can you say why it is a double sided key okay did you get that Jane did you miss it let me try again so it's about it being a vital solution this vital solution and the key is if you like the vital solution I'm trying to look for finding the key at the moment but it's also I need to go back I'm sorry I'm fiddling with my slides trying to find the right one it's also about the ands and not the verses it's so here we are the vital solution key but it's about mortality and health it's about straight forward and women with complications it's about women and children it's back to my slide with all the dichotomies on it it's about how it's not dichotomies it's about how these are ands and so it's the balance between safety choice it's the balance between women and children so it's about the vital solution and the ands that's it balance it's also balance between interventions when you need them and avoiding them when you don't once you get your head into it you find it's all sorts of different things and everybody then uses balance finds their own double-sidedness to the key so that's what it's about okay thank you Mary so much we really are going to have to stop here because we've come right to the end of the session and we have to set up for the next one so we have got two sessions running consecutively now we've got Maggie Banks in the workshop room so I'm just going to put the link up for that now and then the next speaker is in this room I should have saved this earlier there you go so I've put the link up for the workshop for those that want to come for the Maggie Banks um breach birth one please follow the link and I will stop the recording