 Now it gives me enormous pleasure to introduce the first speaker, Professor Leslie Page. As many of you will know, Leslie is President and a Board Member of the Royal College of Midwives and she began her office just recently in April this year. She was the first Professor of Midwifery in the UK at Thames University, Valley University and Clean Charlotte Hospital. She's a renowned international academic advocate and activist for midwives, women and babies with more than 32 years experience. Her accomplished career has encompassed practice, management, leadership, academic and policy work and she's practised as a midwife in the community, hospital and home birth settings and continues to practice in Oxford's year. And many of us certainly know Leslie from her writing and her presentations. She's also a visiting scholar of midwifery at Florence Nightingale School of Nursing and Midwifery King's Colleagues London, an adjunct professor with UTS in Sydney and a visiting professor at the University of Sydney. So she has lectured and worked in 13 different countries. Outside academia she's also an expert advisor to the King's Fund, independent inquiry into the safety of maternity services in England and Leslie's had many years working as a senior manager in the NHS. Professor Page is currently on clinical attachment at the Oxford University Hospital's NHS Trust, Coltswood, Coltswold, thank you for maternity service and has more than 37 years experience in the NHS. So we're thrilled to have Leslie and all that wonderful experience and skills that she brings. So welcome Leslie and over to you. Thank you very much Deborah and I just want to check that everybody can hear me. That's great. Thank you. Just let me know if you lose me. Well Deborah, thank you for your kind words of invitation but I wanted particularly to thank Sarah for inviting me to open this wonderful conference, a virtual conference that's bringing so many of us together. Thank you for all the amazing work you and many others have put into this. It's uniting us into one world and hello to everyone gathered here in our virtual room. I've just started as president of the Royal College of Midwives and this is really my first public speaking engagement. I spoke to the Student Fixings College, University London Justice Hall group but this I think is really my entry into my world as president and many of you will know the Royal College of Midwives has about 40,000 members and that every woman in Britain has a midwife and we're slightly different to other parts of the world. I just wanted to tell you a little secret. Sarah Stewart was my advisor in my election campaign. I used social media and I was a very kind of lukewarm user of Facebook and LinkedIn and Sarah gave me huge encouragement and support and technical advice and I want to thank her. Thank you also for that wonderful Mari welcome, Jay and Candice. It was very moving. The International Day of the Midwife is a really important one. It was developed in the 1990s by the International Confederation of Midwives. To help us inform the world about what midwifery is and how important it is and this meeting today is symbolic of a world that's getting smaller. It's getting smaller because of our communications, the internet, film, social media, mobile phones and television. I learned the other day that in Africa about 50% of people have a mobile phone. This new technology is the basis of revolution in the way we think and work and communicate. Just watching the notes about Twitter made me realize how ignorant I am and I've just started to use it but you saw a new language developing, a new way of talking. But it's also the basis of other revolutions, of social revolutions. We all saw in the Arab uprisings that the ability of people to mobilize and have the courage to stand up to the regimes was actually through the use of mobile phones and the internet. But we're also in a world that's very deeply divided. It's divided by different levels of affluence, by war, by poverty, by ethnicity, culture and religion. And these divisions actually have huge effects on us as midwives. We also I think have a tendency to become warriors. I watched with distress some of the newscasts in Syria and it was strange really to watch how the camera people could film the catastrophes and the tragedies close by but we could do nothing to help. And I think that that is one of the things that we need to think about when we're thinking about midwifery around the world. How do we become more than warriors, more than people watching what's happening in other parts of the world? And actually get together in solidarity to help each other. There is a huge division in the maternity world. There's one part of the world where there aren't enough skilled carers, there's not enough resources, there's not enough information, not enough medical care and intervention and where too many women and their babies die are injured. On the other hand there's the other world where there's too much. Too much resource used on interventions, too many interventions. Often in this other world there's not enough access to home birth, to community care, to midwife-led, non-medical care. And one of my questions is how might we achieve a balance? The main question for me in thinking about today and looking at this world where we're all interdependent for resources, for our economy, for ecology and peace is this. Is the kind of midwifery required the same whether it is in Oxford where I practice or for example Afghanistan? Do we share common ideals, common values, common approaches, common knowledge base? Do we all need to rethink, reaffirm for the world we live in, a world where pace of change is unprecedented, where even in affluent parts of the world the economic meltdown threatens resources in the health services? Above all I want to ask a question, how do we use globalization to advantage so that we can work through a global community to help each other? The International Day of the Midwife was developed so that we could inform, celebrate and motivate. Inform about the work of midwifery, about the importance of midwifery, about achievements and challenges and this is important wherever we are. Even in parts of the world where midwifery is well embedded in the culture, in the health services and communities we live in, there can be difficulties in our technocratic ways in understanding and practicing to the full extent of our role. There are parts of the world where there are very few midwives or where the role has been suppressed and confined but I think that we all have to make sure that we recognize that there's a great deal to celebrate too. First I want to just take a moment to think about the fundamental part of our role in helping women and their families around the birth of their babies, the start of new life and new family. This makes a tremendous difference to individuals and families and I like to think that every birth will make a difference to the world. The phrase that keeps coming into my mind is that we build a better world one birth at a time. We should also celebrate developments in midwifery. ICM itself is a huge achievement and is a powerful force in the world. There is some movement towards the Millennium Development Goal 5 and I understand a reduction in maternal mortality. In many countries midwifery developments, midwifery-led care, birth centres, research, publications about and formid-wise flourish. To me, motivation is mainly found in understanding the profound impact of our work. Midwifery makes a huge difference. Not only do midwives save lives but they also set the woman and her baby and family on the right path to parenting. It's not just physical care but sensitive emotional and psychological support and enabling that crucial bond or attachment that binds mother, baby and family together over years. These two, ensuring a physically healthy mother and baby and supporting a strong, confident, competent mother able to fully love and commit to her baby are at the base of our work. Above all, emotionally sensitive midwifery is as important as physical care. Women, wherever they are, want to be treated with respect, kindness, listening to and involved in making decisions about their care. Recently, it's been reported that some child milk child-going women have been so harshly treated with amounts of salt and that women will avoid going to healthcare institutions because they are treated so unkindly. Sensitive care is not a luxury add-on. It's crucial. Today, in my local National Health Service, midwives are going to meet parents, explain midwifery and each baby will have a card in its crib saying that the baby was born on the international day of the midwife. This is one way of spreading the word about midwifery but we need to be realistic about the huge inequalities and the huge problems in the world, both between and within countries. The State of the World's Midwifery Report that was published at the Congress of the International Confederation of Midwives last year in South Africa is accessible on the ICM website and this shows the stark contrast. Focused on 58 countries in which there are 81 million births, 58% of the world's births in 2009, but only 17% of the world's midwives, nurses and physicians. This has 91% of the global burden of maternal mortality, 80% of silver and 82% of neonatal mortality. In this one world of ours, there are many different worlds. The division isn't simply between developed and developing worlds because within countries outcomes between different populations, wealthy and poor, different ethnic groups are different. Actually, poverty is one of the biggest risk factors. And particularly in the emerging economies, there may be a majority of women who do not have enough care, but a group of women who have an extremely high bearing section rate. Those of you listening may be able to talk about this in more detail and from experience. One of the concerns that we might want to share is the lack of global justice in these huge inequalities. There may be development, but often they bypass the disadvantaged, those who need them the most. This sense of justice I think needs to underlie all of the midwifery development that we think about on this very important day. I was driving to work the other day through beautiful lanes and it's springtime here. It's cold and grey, but the flowers are out and the birds are singing. And I was listening to the news. There had been bombings in Afghanistan. And I had just read a Royal College of Midwives report that maternal mortality had been reduced through the training and placement of midwives. If you look at the figures here, you'll see that in Afghanistan they had one of the highest maternal mortalities, much of this related to disruption and war, 1,600 per 100,000 births. Yet this rate had been brought down by the introduction of well-trained midwives. And I couldn't help but think, as I heard about these awful bombings, what effect these setbacks would have? We hear a lot about the casualties of war and disaster. Indeed, every day, every newscast we hear about soldiers and civilians killed. What doesn't get broadcast is the toll on maternity services, on maternity care, of the loss of infrastructure, hating the lives of mother and their babies as mothers and babies. The earthquake in Haiti increased problems in the country that already had one of the highest maternal mortality rates in the region. 630 per 100,000 births, despite an outpouring of aid. Famine 2 will take its toll on the invisible ones, the pregnant and breastfeeding women and mothers. We should remember too that it's estimated that 48 million women around the world give birth without someone attending who has recognized midwifery skills. There is often no or little access to healthcare facilities or medical aid. But in much of the developed world, there is a different problem. The excess of medical and surgical invention that uses resources disproportionately, but more importantly, poses a health risk to mothers and babies. The Sicilian section rate in the United Kingdom is 25%, and it's estimated the normal birth rate is just over 40%. And this is far from the highest Sicilian section rate in the world. In China, 46% of women give birth by Sicilian section. In the United States of America, and all of you here in the room with me will put me right if I'm wrong, the rate has risen to 34%, one in three babies. There's a growing awareness of the risks of staring section to mother and baby. Some of the research is difficult to interpret and shows in conflicting results, but evidence indicates that there is an increased maternal and neonatal mortality and morbidity, a risk for future pregnancies and an increase in stillbirth in subsequent pregnancies after Sicilian section. And that is even in groups of women who don't have medical complications. The World Health Organization says that the best outcomes are with a Sicilian section rate of between 5% to 10%. Rates above 15% do more harm than good. Where the Sicilian section rate is this high, unless there are real efforts to reduce it, the rate is bound to rise. This leaves those women choosing normal birth in the minority. We're not able to measure the evolutionary effects of a high Sicilian section rate. Many people now are talking about the effect on epigenetics and the possibility that we might be switching off genes for future generations that will make normal birth more difficult. And we are, of course, needing to consider the loss of the neurohormonal cascade that is so important to mother-baby relationships, particularly oxytocin. Our main emphasis, I think, should be to help first-time mothers avoid Sicilian section because they're starting out on their mothering lives. And once you've had one Sicilian section, you're more likely to need another. Home birth, out-of-hospital birth and midwifery-led care are safe options for the baby and they've got considerable advantages to the mother. They're associated with a lower intervention rate and a higher quality of experience. At present in the United Kingdom, we have considerable development in midwifery-led care, but the home birth rate is only 3%. But it's higher where there is strong midwifery leadership and the rate varies a great deal from place to place. I believe, as does the Royal College of Midwives, that midwifery-led care should be the default option for women, rather than going, by default, into medical or consultant-led care. We've got very supportive government policy to midwifery-led care and a choice of place of birth. Sometimes it can be difficult to change in practice. We really need strong midwifery leadership in this area. A particular interest and passion of mine is continuity of care, having the woman and her midwife getting to know each other over time, forming a relationship of trust. This improves the quality and safety of care. I know that there's considerable work going on in this area in Australia and I look forward to learning more about it when I visit at the end of the year. I can't finish without saying what an example of development of midwifery New Zealand is. I reviewed the book by Sally Pearman and Carrie Gilliland, Women's Business, about the New Zealand College of Midwives. It was such a good read and helped understand how transformation of an entire country had been created. Similarly, in many parts of Canada, which is my other home, there are examples of the best models of practice. What we see is the lynchpin, the heart, the essence of midwifery, is the relationship between midwife and mother, the midwife working with a woman in a positive relationship, doing the best for her by up-to-date skills, use of evidence in practice, and understanding her life and life situation. There are some parts of the world where healthy choices are made unavailable, sometimes through extreme measures. One of the examples that comes to mind is the criminalisation of home birth in Hungary and many of you will know about Agnes Greb, who is imprisoned for attending home birth, although she was a qualified obstetrician and midwife, and she's still under house arrest and is seeking pardon from the President. We need a balance. We need a balance between safety and humanisation. We need to have, thank you, somebody's putting my slide right, I think. Women need access to midwifery-led care. They need access to medical care also, because we need a particular level of adhering section. There should be access to adhering section. Women around the world need access to facilities, and they also need access to out-of-hospital birth. But through all of this, there should be respectful, sensitive care. I think I have an empty slide here. The phrase that the ICM is putting out for this international day of the midwife is the world needs midwives now more than ever. I think it needs midwives who can practice to the full extent of their power. Midwives who are skilled, midwives who are knowledgeable, who can work in relationship with, in and of the community women live in, able to lead and inspire change, who can do the politics of improving care, who can do research and write and teach and influence governments, who can use social media, who can be out in the world talking about midwifery. We should always remember that the birth of the baby is the birth of the mother. The kind of birth that the baby has will actually influence the way the mother cares for the baby. Thank you for listening, my dear colleagues. I think we're all going to build a safer world. We're going to build safer care and a better world for mothers and babies. I salute you all, and I'm very happy to take any questions, and above all, very happy International Day of the Midwife. Thank you. Thank you, Leslie. I couldn't think of anyone better to open this conference because you were able to give us such a wonderful global view but at the same time pull together the strands of the things that hold us all together. Thank you so much. I think that there are lots of people that do have questions, and perhaps if we invite you one by one starting with Susan one. Just reminding you that if your microphone is muted, you'll need to unmute your microphone to be able to speak. Susan, did you have a question? Okay, we might move on to Linda. Are you able to talk, Linda Wiley? Okay, if anybody else has a question, just speak or raise your hand. Denise Hynd? This is working. I was wondering if Leslie has any suggestions about anything else we can do for Agnes and midwives in similar situations and being an Australian in New Zealand, I'm very concerned for my colleagues in Australia as well. I'm not sure if you all thought I had done that. Can you hear me now? Yes. Okay, there's a lot that you can do. There are a number of websites about Agnes and they're wanting midwifery associations in particular to write to the President of Hungary to ask for clemency for Agnes. She's under house arrest at the moment and is due to go back into prison and many people believe that physically she wouldn't survive. Prison in Hungary is very, very harsh indeed. There are a number of questions about her trial because the experts that were called weren't midwives, they were doctors who'd never practiced outside in the community. And one of the things that the Royal College of Midwives and others are saying is that there should be proper regulation of midwifery and when things go wrong there should be a board of midwives who assesses fitness practice. It shouldn't go through the criminal justice system. But Agnes is just the tip of the iceberg. There are a number of midwives in East Europe who are going through similar situations. I don't mean to say Agnes is the tip of the iceberg. That sounds really inhuman but she isn't the only example. She's not the only midwife who's going through this. There are midwives in Eastern Europe who are having similar difficulties. I wonder, international consideration of midwives. Do they have a page or something of that midwife who are being prosecuted so that we can all watch? Well, I understand. I work closely with Frances Des Sturks. She's actually one of the directors in the Royal College of Midwives and she's president of ICM. And ICM apparently will help a country set up a structure that they won't interfere or they won't become involved in individual cases. And I think it's probably up to midwifery associations to do what they can. I see that somebody's put up the link. Thank you very much indeed. But I should emphasize that Agnes isn't the only person and there is a huge issue I think about extreme measures that will be gone to to stop access to home birth. Leslie, I wonder what your reflections of that are because as people have pointed out, it's getting worse in many parts of the world and 20 years ago when I had my daughter at home, I never would have imagined that it would be harder to access a home birth 20 years later. And the Netherlands are now struggling and they've been the leading light in this area. But the UK seems to, from the literature not being in the country, seems to have held on to that home birth option. I wonder what your reflections are about this whole movement, this anti-home birth movement in the UK. Well, the UK official position, the government policy is that women should have a choice of where they give birth to their babies. But there is, I think, a need to change the culture and I know that we've got real problems and I'm aware of what's going on in Holland and I'm aware that people will interpret the evidence on home birth differently. But I actually think that we're on the edge of the shift and this shift is going to take midwives, both individual midwives, doing what they can to alter the perception of birth and what healthy birth is, but also groups of midwives. And one of the interesting things that's happening is an awareness, a growing awareness and understanding of the importance of physiological birth. And so I think that there might be a shift in the paradigm. So I think, and I don't want people to feel despondent because each individual can make a difference and even if you're working in a maternity service where you're very restricted, actually in your individual interaction with women you can make a difference. But I think what we're looking for is really strong leadership in midwifery and a lot of this will be an ability to interpret evidence, to put the evidence out there so that women and governments understand it, to show that out-of-hospital birth for women who don't have complications can be the best choice if that's what the woman wants. I like the comment about giving women their power and women owning the birth. It's just that we do have to change governments and we do have to change through organizations without, I think, without that solidarity, the ability to unite. It's very difficult to change. Someone raised the issue of the Birth Ice UK study. What sort of impact is that having Leslie in the UK? Well, first of all, the main message about the birthplace study is that midwifery-led care is safe. And that is hugely important. And many of you will know that the birthplace study says that for women who've had one baby already or have had babies before, to give birth at home is as safe for the baby as getting birth in hospital. And for the mother it has considerable advantages because the intervention rate is lower. The problematic part of the birthplace study is that it indicated that there was a greater incidence of adverse outcomes where first-time mothers had their babies at home for the baby. And I don't have time to go into the intricacies, but basically what they did was bring together a number of adverse outcomes to make the study powerful enough. And that, I think, has created quite a few difficulties for us. But I see women who are thinking about where to have their babies. And the main thing we have to remember is that the birthplace study starts with the assertion that generally birth is very safe. And actually there might be a very slightly increased risk for the baby where mothers are having their first babies at home. I'm not absolutely convinced about this. We need to look at why that is and we need to hold it in context because the differences aren't huge and it's a kind of risk that we think about every day in our daily lives and when we're looking after our children. And also I always emphasize the risks of giving birth in hospital. A colleague of mine says to women when they're choosing where to give birth, if you walk into hospital you have a 25% chance of having a searing section. So I think we need to be turning the world on its head and talking to women about how we can help them avoid searing sections if they don't need one, how we can help them have a physiological birth and to consider really seriously having their baby out of hospital. The birthplace study did of course look at midwifery-led units both out of hospital and in hospital. And my fear is that it will actually give impetus to developing birth centres within hospital and I think the most powerful care can be found in birth centres out of hospital. Thank you Leslie. I think we'll wrap it up there so that we can get ready for the next presentation. But I want to thank you so much as I said before. I couldn't think of a better person to have this first presentation in this conference and it was wonderful and I love the text with people being able to comment and the immediacy of that so people put up links to the article that we were referring to and the support groups and whatnot in that text section. So it's just been wonderful and thank you, thank you very much. Just to remind you that the recordings of these people are very, very important. Thank you.