 What I'd like to do now is to introduce Dr. Jemima Denise Antwe and Free, and she gave me lessons on trying to pronounce her name and I'm still not very good at it, so my apologies. But I hope that I did an okay job of it. She is an international consultant with over 29 years experience in nursing and midwifery health, system strengthening programs and project planning and implementation and qualitative research. She runs the new Centre for Health Development and Research. She is on the International Confederation of Midwives, member of the Board of Directors representing Anglophone Africa. Her current interests include research, capacity building of health workforce, strategic planning, nursing and midwifery and sickle cell disease genomics. Dr. Denise Antwe has been involved with several international efforts in midwifery, nursing and health workforce strengthening including being a member of the technical working groups for the WHO, ICM, UNFA, FPA and UPICO. In Anglophone Africa she has worked for over 10 countries strengthening their midwifery systems based on the ICM, WHO and UNFPA policies. In Ghana she is the current and inaugural president of the Ghana College of Nurse and Midwives. She initiated and led efforts to establish and grow the Fellowship College as a centre of academic excellence. She has also served in many other leadership positions for projects and programs, development in health promotion, learning materials, development and work in the health sector. Dr. Denise Antwe I welcome you to the International Day of the Midwife Conference and I'm really excited to hear your presentation. Let me hand over to you. Dr. Denise Antwe Thank you very much. I hope everybody can hear me. Dr. Denise Antwe I can hear you well. Dr. Denise Antwe Great. I wish to congratulate every midwife and to say greetings from Ghana, my motherland where I live and to say that the midwives of the world today is a great day for you. We appreciate you. We recognize you and mothers and their newborns are alive today because you did your work well. Surely quality care counts. I am excited to work you through my presentation and as part of my presentation I would like to talk to you about the fact that today we are celebrating midwives and we are seeing that midwives we are leading the way with quality care. As midwives we are with the woman, we are with the newborn, we are with the family and we have done this since the beginning of creation. My presentation is looking at expanding midwifery in Anglophone Africa and I'm pitching it within the context of the ICM-UNFPA collaboration that took place between 2009 to 2013 and for which continuing efforts continue to take place through UNFPA support and also country-based initiatives and I would also want to touch looking into the future with respect to current discussions around the table for maternal and newborn health. And therefore as part of my presentation I will look at overview of the 2008-2013 ICM-UNFPA collaboration, the pillars of development, key initiatives that were taken within the Africa setting, some of the best practices and then the current discourse around midwifery improvements and implications for Africa. Of course being a representative for Africa, for the International Confederation of Midwives let me indulge you a bit by sharing with you that ICM is a non-governmental organization representing over 500,000 midwives globally and our vision is that we, a vision, a world where every child-bearing woman has access to a midwife's care for herself and her newborn and of course to extrapolate we are looking at the families as well. Our mission is to strengthen our midwives' associations and to advance the profession of midwifery globally by promoting autonomous midwives as the most appropriate caregivers to child-bearing women and keeping birth normal in order to enhance their productive health of women and the health of their newborns and their families as well. As ICM our goal for midwifery strengthening is to ensure quality improvement in maternal and newborn health services and we are doing this through the availability and the practice by competent professional midwives, developed and upgraded through a standardized system of midwifery education, regulation and association development and informed by the ICM global standards for midwifery practice which have been globally disseminated and which are being used in many countries. As ICM we work locally with our midwives' associations, we work regionally through our regions and collaboration with member associations. We also work globally with over 500,000 midwives by representing, sorry, I need to go back to my screen, yes. We also collaborate with our partners at local, regional and global levels. We also ensure equitable harnessing of the diverse representations on our board. So if you come on our board we have various people coming from all the six regions of ICM and then also we expect that every member acts responsibly, accountably and with integrity. The ICM UNFP Inverting Midwives Program was a collaboration between UNFP and ICM between 2009 to 2013 by preparatory activities began in 2008 and the sponsorship was from the Swedish and Dutch governments for supporting 12 Anglophone and Francophone countries and the target was about 20 countries in all. It started in March 2009 and it covered Africa, Asia and Latin America and within my remit I was responsible for 10 African countries and it looked at positioning international midwife advisers and regional advisers within the regions where the projects covered. The impetus was on looking at midwives and this was in response to the advent of the MDGs we started in the 2000s and the call for a decade of action to ensure that we position the required human resources to achieve MDG5 and this was to drive ICM vision for increasing midwife access to women of childbearing age and their children. And therefore my work in Africa covered Ethiopia, Ghana, Liberia, Malawi, Nigeria, Sierra Leone, Sudan, South Sudan, Uganda and Zambia. The pillars of development were critical at education, regulation and association strengthening and of which the ICM essential competencies was the overarching factor which cuts across the three pillars and for which we ensure that every midwife would be trained according to the seven ICM essential competencies. We were looking at the mother and baby as a fau crôme for everything that was done as a midwife and we believe that the mother and the baby needed to be impacted upon by a fully qualified midwife who is able to demonstrate the essential competencies that is the seven ICM essential competencies and the person has gone through a midwifery education that means the ICM global standards and the person is a member of the midwifery association within the country and is regulated by the regulatory body based on legal provisions and also the global standards for regulation and of course that the status of midwives is recognized by the country within which the midwife practices and therefore we're looking at the mother and baby be impacted by competent midwife who is educated and regulated and belongs to a body of midwives or within a global standard of recognition and therefore if you look at this slide you see the autonomous midwife in the middle and that autonomous midwife can only be an autonomous midwife if the person is regulated the person is effectively educated the person also belongs to the midwife association and continually remains competent in whatever he or she does okay at the start of our program we realized that our various countries were at different levels of development so quickly we needed to know what the status was by inception and for some of the countries that were able to collect data from inception we had Ethiopia having a three-year direct entry diploma program they also had a four-year bachelor direct entry program and they had just started with a master's in midwifery program Ghana then had a three-year direct entry diploma program for for somebody to become a licensed midwife and then in North Sudan they had a four that is Sudan now they had four-year midwifery bachelor curricula which started in 2010 and they continue to have what they call the village midwifery program which was upgraded to a technician program and then we have in Sudan in South Sudan 18 months program that stream what they call community midwives and which then was being revised to a three-year diploma program and then we had Zambia which had a one-year post nursing program and then a road midwifery program but generally I would say that in most of these countries there were various levels of training to become a midwife who sometimes was very confusing and which sort of got us all thinking whether are we dealing with a professional midwife or we are dealing with auxiliary midwifery programs and generally I would say that this has been a very big tug of war across many countries how to standardize and make sure that there is one program for midwives or for people to become midwives and for which people are clearly able to go along the lines and develop themselves as competent midwives. Generally we have less than 50 percent of African governments having given next a midwifery profession the privilege to self-regulate there were absence of councils and they were and and this has had negative impact on the quality of education and practice also where we had challenges around how to harmonize curricula and also accelerate the achievement of the health-related MDGs. By regulation there were 20 countries that had national legislation for autonomous midwifery the definition of autonomy of midwifery was either inconsistent or unclear and three out of 50 countries that are generally in Africa had distinct midwifery regulatory bodies. A number of countries cited the ICM definition of midwives or provided comparable language others use educational criteria and legal recognition of practice to define the midwife. Mechanisms exist for country to country practice in about 96 percent of the 50 countries that were studied according to the SOMI 2011 report and majority have accreditation system for training institutions and these are country-based accreditation systems and about 80 percent have authorized license and registration system in place and most of these were found in Anglophone countries. Again according to a situational analysis by a study that was done by WHO using a professional regulatory framework document that developed we realized that we had about 41 countries that had rules and regulation for nursing and midwifery and that 41 percent of African region countries had these and these included countries like Angola, Botswana, Gambia, Ghana and all and then we also have 52 percent of African countries that had no regulatory system and mostly coming from as I said the French countries and a few of the central African countries and luckily for us we had Benin, Bukina Faso and Mali we had just started the process of developing regulatory systems. As I said most of the Anglophone countries had some forms of regulatory systems in place though they were not able to meet the entirety of the ICM global standards. So I would say that guided by the ICM global standards that looked at computer basic education standards, regulation standards and then the MACAT that is a nuclear association capacity assessment too. We also had the competency equipment list for skills lab and then also GAP analysis too. We had a lot of our countries begin to do a reassessment of their systems looking using the global standards at the benchmark to be able to assess and to do a mapping as to how far they have been able to deliver their midwifery systems. We also had the need for definition of a lot of times and we must say that the ICM glossary of times was very helpful in helping countries to really define and redefine most of their technologies and the meaning of the expressions that they used and therefore we looked at midwifery practice that is looking at preventive measures, the promotion of normal bed, looking at assessing of medical care, carrying out of emergency measures, looking at the midwife having the important tasks in health counseling, education and looking at the woman, the family and then the community. So there was the need to sort of get the midwife to have this broad scope of work within which the midwife can practice and base on regulation by the countries. There was a lot of advocacy effort that we put in place because there was a lot of challenges around recognizing the midwife to be at the decision-making table. Most often the midwife is only there to receive instructions and to act as such. Decisions were being made and continue to be made for midwives without the midwife being necessarily at the decision-making table. So the state of the world midwifery reports that were issued that in 2011 and 2013 served as very good advocacy tools. We also, most African countries began to celebrate the international day of the midwife that began to draw attention to what the midwife does and the ability of the midwife to save and to reduce maternal and newborn mortality. Again it also brought a lot of the politicians and also policy because and the governmental leadership at the table to interact with midwives and that began to draw their empathy and also for them to appreciate the work of the midwives. We also had regional meetings, regional conferences and that ensured that midwives could present, make presentations and to share the work that they were being done. Of course, for the first time the 29th China Congress of ICM was held also in Deban, South Africa, which also brought a lot of African stakeholders to the table and brought Africa to the limelight. And WHO continued to work with Africa and also with the international partners in releasing frameworks that will help countries to begin to strengthen their midwifery systems. And I must say that in most of African countries, nursing and midwifery tend to go together where you have regulatory councils, where it is both for nursing and midwifery. And you go to certain countries also where it is mainly a nursing council, a regulatory body for which midwifery is considered as a subsidiary of nursing. And these are some of the issues where our advocacy efforts sought to address. Some of the key initiatives in education regulation and association strengthening. Sorry about this. There were a variety of needs assessments that were conducted in countries in order to determine the basis along which strategic programming could be taken from. In the area of midwifery education, a lot of work was done around particular reviews to integrate the ICM competencies and to begin to reflect the ICM education standards. Some programs needed support to reframe their curricula. Some needed support to set up new programs and to upgrade a certificate program to diploma. Some to degree and some also to masters. The ICM skills list reference documents helped countries to begin to look at their skills labs and how they can resource them with models and also computer lives to help students to better learn. And there was a lot of investment from UNFBA and GPI group working with countries to establish their skills labs. And then we also had continued professional education being set up for tutors and clinicians in order to ensure continual competencies. And then clinical size began to be upgraded and also to be identified in order to help the increasing numbers of midwives to have adequate practical skills. In the area of regulation, most of the observation that we came up with was that a lot of the legislative instruments that set up the regulatory bodies were way over outdated and had not been renewed for several years. And therefore, countries began to go back to legislature to request for their regulations to be revised and to be renewed. There was also the need to re compile professional ethics and begin to encourage or to promote ethical behaviors. In some countries there was the need to establish councils which did not exist or to begin to recognize midwifery decks at the councils. There was advocacy for deployment of midwives so that there would be equitable distribution of midwives. And for some, as I said, acts were reviewed, changes in name came up to include midwifery or discussions around the table began to look at including midwifery in the titling for the regulatory bodies. We also had counter, as we began to do a lot of advocacy efforts in countries, midwifery bodies which were initially subsumed and the nursing began to make efforts to stand on their own. So we had countries like Zambia, countries like South Sudan, which did not have anybody begin to form associations. We had countries, the midwives being able to stand up and say that they want to glean themselves from the nursing bodies and begin to be on their own. So this happened in Liberia, we had Nigeria, all of them coming up to say that as midwives we want to stand on their own. We had recently Kenya also coming up to stand on their own and Namibia coming up so all these are efforts or report effects of trying to recognize the midwife and to get the midwife empowered so that they can represent themselves. A lot of training was also done for midwifery and the market tool was introduced into the associations to help them to identify where their strengths and their gaps are in order that they can revamp the associations and to get it working. We also recognized that there were regional bodies that existed on the continent and there was a need for us to associate with them and to link up with them. And therefore we looked at the Eastern Central Southern Africa conference of nurses that we called the EXACON. We began to interact with them and to work with them in partnerships so that we will be able to share the midwife story. And again I want to emphasize that in the Africa region, nursing was very much the profound profession where midwifery was obscured under nursing. So to begin to advocate for midwifery was not an easy task. Sometimes you were branded as trying to bring confusion between the two professions and you were also seen as trying to cause dissension within countries. But we persisted and gradually we were able to tell the midwife story and to continue to get midwives to be at the table. And people began, a midwife began to decide that I want to be a midwife rather than be a nurse midwife or be subsumed under midwifery. So it gave quite some impetus for midwives to sit at the table. We also participated in meetings around the African Regulatory Collaborative which was again an initiative that was set up with PEPFA fans and supported by Emory University of the United States of America. And that was also an initiative where we tried to get midwifery to stand out. So some countries chose to look at projects within midwifery and to strengthen midwifery. I want to briefly touch on some of the best practices that emerge. I would say that in all we had over 20 African countries being impacted by the ICM-UNFPA initiative because as we started with 12 we had more countries deciding to come on board. And I must say that UNFPA countries, offices in countries, were the driving links within which most of the initiatives took place. And this had a very good knock on effect within countries which were originally not even part of the initiative that came on board and said we wanted to join. So globally we had over 40 countries in Africa, Asia and Latin America coming on board to use the same template or to apply the strategic direction that was used by the project in order to expand their midwifery systems. So today you have UNFPA having country midwifery advisers within their countries trying to drive the midwifery effort. So if you look at Ethiopia for example now they can even boost our PAG programs in midwifery. And there's been a lot of strengthening of the midwifery association to become a very strong organization. We have large numbers of midwives who are receiving continuous professional development in order to keep them updated. And clinical size and schools received a lot of support through the Swedish and the Dutch support. Now we have a lot of the countries doing direct entry training south Sudan which used to be a country with no with no structure. Now it has engaged in diploma level education and we have every year the school churning out midwives with diploma level qualification. The village where certificate midwifery program has been scrapped and they are looking at moving to the next level of bachelor training in midwifery in the very near future. In Ghana through the midwifery initiative we had a bachelor level program being introduced so that midwives can acquire first degrees. Through a special dispensation of government fellowship programs have been introduced where midwives can develop themselves to become fellows of the Ghana College of Nurses and Midwives where I sit as the inaugural president. And now we can have direct entry midwifery training. We're looking at introducing masters in midwifery in the very near future and expecting that we would also follow up with training in at PhD levels and we are hoping for international collaborations in this area. We also have done a lot of work looking at that is Ghana looking at career advancement in midwifery where now midwives can progress along their own direct lines and as I say to the level of specialist and midwives also we are looking at how we can get government to recognize a midwifery desk at the level of policy decision making and midwives can also rise up to the same ranks as nurses have risen in the past. We also have what we call the community based health planning and services program which have been designed to create more access to midwifery where midwives can be placed at communities within five kilometer radius where women and their families can access a midwife's care. This is an initiative that government has adopted that is looking at creating over 4,000 such centers around them within deprived communities to enable a midwife access. Through the initiative also we had quite a number of north south training programs that will enable the north to impact on the south and to bring a partnership and exchange of ideas exchange of expertise around the world. So we have Sierra Leone and the midwives association of the Dutch midwives forming a twin. We now have Sierra Leone the Dutch midwives and Ghana forming a new collaboration. We have Zambia partnering with ACNM of the United States and then we also have South Sudan and Canada coming up with twin activities some of which were shared at Triana congresses to bring attention to development. Now the current talk is looking at south south collaboration and looking at other very good strong midwifery associations within Africa that can also impact on other African countries that are just about wanting to start their associations. Of course having been able to come this far we continue to have ex challenges to expanding midwifery in Africa. A lot has been done through the ICM UNFP initiative. Unfortunately the program ended in 2013 but we know that most of the countries are continuing to work around midwifery but of course the challenges come up as we have come up with the sustainable development goals looking at the 17 goals and investor access to help. There are big issues around and creating the enabling environment for midwives to work and provide quality care and as we celebrate the internationality of the midwife to look at midwives providing quality care without enabling and the environment without the midwife being effectively resourced without the midwife having a standardized system of education to cut out all these various levels of entrance into midwifery. It is a big challenge still in Africa. We also continue to experience economic downturns in countries that undermine the employment of adequate numbers of midwives. So though the human resource directors may have the staffing norms you go into certain facilities and they do not have the full complement of midwives in order that quality care can be provided and this does undermine the sort of care that midwives provide. Then also we continue to have various levels of entry into midwifery in the region which countries defend by saying that they need lower cadres of midwives that they can afford to pay and also the high trained midwives are not willing to go into the communities and therefore the only way is to train lower levels so that they can place them in communities. These are sensitive issues that we continue to talk around with governments. It does undermine the image of the midwife, the ability of the midwife to develop career because the lower you train the more difficulties for you to lift yourself up to come to the limelight. So it does surely affect the profession of midwifery. There's also the issues around overproduction and inequitable distribution still. We have a lot of countries for example our country Ghana where so many midwives have been produced and the government is not able to recruit all of them annually and therefore we tend to have two years of backlog of midwives who have not been recruited and this is a worrying situation in our countries and which is also ill influencing midwives to divert into other professions or to find other themselves in other careers which they didn't train. And then of course the issue of our limited career pathway where in most countries you train as a nurse or a midwife you are either a faculty or you are a clinician. Most countries have not been able to develop a variable career path with where midwives can branch into and therefore it seems as though you are you either teach or you either provide best side service and sometimes it does not give the young midwives the needed challenge to want to stay in the profession. We also have issues around competent faculty and continuing and keeping themselves continually competent and I think the issues around that is that most often there are challenges around faculty preparation. Currently because of again the work that has been done in Africa trying to get African countries to recognize midwifery now with the introduction of higher level education now you have faculty who are who are increasingly getting their masters and their PADs. It used to be the most faculty where either at the level at which they trained and therefore it meant that if you are you have fair degree you cannot be allowed to train people at masters level so this tends to delay a lot of progress in academic development of midwives but we are glad that gradually countries are now opening up and they are having higher degree programs but the challenge is making faculty continually clinically competent. Most faculties stop practicing midwifery when they go into academics and therefore there is the issue around maintaining the theory and clinical skills that does not augur well for continuing education of students and also of residents who want to develop themselves in their profession. Again there's also a lot of governmental infiltration into regulation of nursing and of midwifery whereby government tends to dictate the level at which midwives should be trained and this is all sometimes politically engineered where they promise communities that they are going to make available to them a certain caliber of I mean healthcare services and they realize that people who are trained at the level of expertise may not be willing to go to the community level because the services and the and the system that they provide at the community level is so basic that it does not allow for quality care and therefore they insist on training subsidiary auxiliary staffing to put them at the community and of course the community people often do not know that these are not people who are fully trained and they do that as I said for political reasons and that is a big challenge for the midwifery profession. We also have challenges around midwives being able to stand as independent organizations as I said there are some countries that still have to battle with being under the nursing unionized bodies and are going through a lot of challenges trying to assess themselves and to stand as independent midwives so this continue to happen in certain countries especially the southern part of Africa and also the central part for most of eastern and west Africa you have made wise being able to stand on their on their own. Very sorry to interrupt just a reminder there just a couple of minutes left until the end of the presentation. Thank you I'm ending soon so now as we look at the current discourse around midwifery for quality improvement we have the SDGs to contend with and we know that for the midwife to be able to provide quality care the midwife is critical to the SDG achievements and we are actually assuming look at SDG 3A the workforce is critical if we would attain the indices for maternal improvement the midwife must have access to the woman and by access governments need to set up systems that would ensure that the qualified competent midwives are placed within the community not auxiliaries fully trained and educated midwives must be positioned and supported and enabled to provide competent services. We're looking at the global strategy for women children and adolescent health when we're saying that the mother and the newborn must try they must survive they must try so that they can transform and continue their societal responsibilities this will call again for the educated and competent midwife they must be where they must be to be able to ensure that everybody is able to practice their rights and this I believe is a big challenge which governments should be brought to to book in order to get them to give the needed attention to the midwife we also have the human resources for global strategy that also has been disseminated worldwide as I said countries a lot of countries have a challenge with ensuring accessible acceptable midwifery workforce for quality health system because they are not able to recruit even the midwives that are trained within the countries to be able to position them to increase this access to quality health and this is a challenge that African governments need to deal with we also have the African regulatory framework that has been developed and definitely as you WHO drives this effort countries need to begin to look at regulatory bodies some countries decide to have ground regulatory body for all health professionals because they do not like professionals being able to get the needed empowerment to stand on their own and this is also a challenge that we need to deal with in Africa as we look into the future for SDGs and investor health we need to continue to disseminate the ICM global standards we need to continue to do the international regional advocacy for adoption and I believe that ICM needs to do a lot of regional advocacy efforts we need to translate the regulatory policies to feed into education and continually engage policymakers around regulatory issues in in midwifery there is the need to standardize midwifery education across Africa so that even if we decide that diploma qualification is the minimum all countries can have diploma education and therefore they can be cross country uh uh recognition of qualification so that people if countries are over producing they professionals can find themselves in other countries to be able to provide service and then this is very critical we also need to recognize that a midwife is a midwife a midwife wherever they are and therefore again it is going to enhance the cross country and globalization of the recognition of midwives there we have issues around respectful care and therefore we need to continue to uh look at professional ethics and attitudes to care if we are looking at our team quality care but there's a lot of work that needs to be done around uh around that in order to ensure that there's universal access to midwife care we also need to look at synergy in leadership and to do a lot of work around the associations to develop leadership that will stand for the profession and advocate for the profession and actually virtually get governments to pay attention to to leadership most often the leadership sometimes are not able to stand up to government and that sometimes leads to undermining of the power of midwives we also now we tend to have a lot of young midwives who are coming up into the profession and who are very much unclear as to what the opportunities are we need to have a mentoring system that will ensure that the young midwives are confident and have the skills and the leadership ability to speak for the profession research is very very minimal around the countries we need to look at our academic institutions and to encourage midwifery research and to get a lot of midwives going to academics and being able to stay focused in midwifery research and then we have the configuration of African midwives associations that is Konama which is a very young body of African representation that has been set up to speak for midwifery across the continent and this I believe that is it's synonymous to the European midwives association body and also what has been set up in the Caribbean and I believe that this is a body that needs to be denounced and nurtured to be able to stand for African midwives and therefore as we look towards 2030 we need to look at standardization of a lot of our midwifery education resources we need to have a very strong supervisory system we need to look at mentorship and perception is very weak in a lot of countries we have to continue to look at midwifery revelation association and to bring them to the global standards of ICM our policy direction should need should begin to look at self regulation for for midwifery even if it is together with nursing midwifery should be seen out there and to stand out there should be accessibility of services at the community level and we need to encourage what we call independent midwifery services or what countries called private midwifery most of these are dying out because of aging midwives who are going on retirement with nobody to replay them so there must be some succession planning that's be put in place to allow made independent midwives to print at the community level as as entrepreneurs and also at a profit level that will be would engage their interest to stay on we need to look at acceptable midwifery care and quality of care needs to be critically looked at as we provide the enabling environment and of course research is very critical i am very sorry i see you flicking through your slides so that's also me know exactly what i'm going to say so as we look at midwifery into the next generation we need to look at midwifery leaders the power of synergy and the power of togetherness we need to look at purpose if african advice can come together and have be the same purpose and advocate for one direct entry to midwifery across the continent i think it would be worthwhile we need to also be able to bring out the the contracts between nesting and midwifery and to see it as a two independent profession but very much working together and supporting each other that will be helpful than to see midwifery as a subset of nesting and i believe that if we work together in the end it will be well worth it and the mothers of Africa and the children of africa can can can stay alive and we can achieve our mdg targets our targets for 2030 thank you very much for listening it's been a great pleasure keeping you thank you thank you very much drzany same for you that was an amazing presentation and i could tell it there was so much more that you could share with us if we had more time i'm disappointed that we didn't but i really enjoyed everything that you could share with us today and everything that we learned we have run out of time for questions i'm really sorry so i won't be opening stuff up there for questions but there is some wonderful comments and information in the chat box to have a read and to share with everybody and again i just thank you so much for your presentation i think it was fantastic