An International Perspective


The 22nd Congress of the International Confederation of Midwives (ICM) opened on October 7, 1990, in the city of Kobe, Japan. The English word “Japan” is derived from the Chinese words meaning “land of the rising sun.” Founded in 660 BC, it is a country of ancient civilization and old traditions that value education and hard work. Despite its scarcity of arable land and natural resources, it is an industrial country with modern technology; today, it leads the world as an economic superpower. Japan's population density is the highest in the world (with about half of the population of the United States), and its infant mortality rate is the lowest (five deaths for every 1,000 live births). Japan has 23,000 nurse-midwives, an enviable number as compared with the United States.

The theme for this year's triennial Congress was “A Midwife's Gift: Love, Skill and Knowledge.” The opening ceremony was a splendid and memorable event. Sumiko Maehara, President of ICM, along with the Japanese Nursing Association and Midwives Association, warmly welcomed the 6,000 midwives gathered from all over the world. The crowded assembly reverberated with an air of anticipation and excitement. Although many participants came from different corners of the earth, each with a diverse culture, tradition, and language, there was an unspoken bond among us—a feeling of unity and a sense of shared purpose.

Princess Mikasa of Japan was among the many featured speakers. She reminded us that despite “the benefit of scientific progress which we are able to enjoy today, mothers in all social environments share alike the joys and trials of maternity.”1 She further stressed that “society continues to place deep trust in mid-wives as guardians of mothers and their babies at the most important and vulnerable moment of their lives.”1 However, a legitimate concern was expressed by many: Will all mothers in the world be able to reap the benefits of scientific progress at the dawn of the twenty-first century? Dr. Barbara Kwast, in her special address, entitled “Midwives' Role in Safe Motherhood,” lamented that “the right to enjoy successful pregnancy and childbirth and to regulate fertility safely is still denied to millions of women today. The magnitude of maternal mortality and morbidity is witness to this social injustice.”2

As we are about to enter the twenty-first century, the responsibilities and the tasks that midwives face toward the reduction of maternal morbidity and mortality pose real challenges as well as opportunities that do not offer easy solutions. The World Health Organization (WHO) estimates that more than 500,000 women die each year as a result of complications in pregnancy and childbirth, most of which are preventable; 5 million women are permanently handicapped each year as a result of childbirth; and 50% of women who give birth in the developing world do so unattended by a trained health worker.3 Certainly, there can be no nobler task than providing every woman a safer passage to motherhood and a better future for her children and family.

The reduction of maternal morbidity 2nd mortality is a formidable task that confronts health care providers around the globe. However, the marked disparity between mortality and morbidity rates of women from the developing and the developed countries is especially alarming. For example, WHO reports that maternal mortality is 50 to 200 times greater for women in developing countries than for women in the developed world.4 The major direct causes of maternal deaths are attributed to obstructed labor, eclampsia, hemorrhage, sepsis, and complications from both spontaneous and induced abortion. This is only part of the story, however, other contributing factors, such as substandard health care, nutrition, housing, education, sanitation, water supply, and social and economic conditions, can have a direct adverse effect on maternal and infant health and well-being. Therefore, to reduce maternal morbidity and mortality rates, mid-wives need to look beyond the obvious causes of maternal mortality and morbidity.

It is apparent that midwives alone are not able to assist women to reach their goals of safe motherhood. In the developed countries, it takes the cooperation of providers, health centers, hospitals, and health departments to deliver maternity services according to local priorities and legislative needs, while identifying those most at risk. In the developing countries, traditional birth attendants and midwives may be the only available personnel providing primary care to women in rural areas. To further compound the situation, medical resources are often lacking, and assistance from the government and referral services for high-risk women are not easily accessible. Despite such roadblocks, midwives around the world must work in concert with other providers, local communities, and governments to come forth with national as well as international programs of action on safe motherhood.

In recent years, partnerships between midwives and national governments have begun. Their efforts are being supported and complemented by international organizations in striving toward local problem identification, as well as formulation of plans of action targeted toward the improvement of maternal and infant mortality. For example, in February 1987, a conference jointly sponsored by the World Bank, the United Nations Population Fund, and WHO took place in Nairobi, with the purpose of establishing a call to action on safe motherhood. A list of activities were identified using a comprehensive and multisectorial approach. This involved actions and commitments from communities and governments, as well as from nongovernmental organizations to prevent disability and the tragedy of unnecessary deaths of women dying in pregnancy and childbirth.3

Another concrete plan of action for safe motherhood initiatives was set in motion at the August 1987 special collaborative ICM/WHO/UNICEF Workshop held in the Hague, Netherlands prior to the 21st International Congress of Midwives. The outcome of the meeting was a worldwide pledge by midwives to take collective action to accept wider responsibilities for maternal care services and to assume a leadership role in reducing maternal mortality with other care providers.3

On September 29 and 30, 1990, the first World Summit for Children was held at the United Nations headquarters in New York City, with representatives from more than 70 nations in attendance. The primary objective was to undertake a joint commitment and to make an urgent universal appeal to give every child a better future. Similar to the Safe Motherhood Initiative, the outcome of the World Summit for Children was a 10-point action program for protecting the rights of children and for improvement of their lives. World leaders agreed that they will work together in international cooperation, as well as in their respective countries, to carry out their commitment for child survival, development, and protection. Among the many aspects of the plan of action, affirmations were made by participating countries to reduce by a third the number of infant deaths in the world by the year 2000, to halve the number of women who die in childbirth, and to guarantee that children everywhere will have access to clean water, sanitation, and basic education by the end of the century.5

More attention has been paid to maternal and child welfare on the global basis in recent years than ever before. So what stands in the way of making our heads of government and public officials take actions on the improvement of maternal and child health? It is well known that women contribute to more than half of the world's labor and carry most of the responsibilities for childbearing and childrearing. Yet, women have the least power in terms of decision making and social status in the society. Changes are unlikely if men continue to make all of the decisions concerning which systems of maternal and child health care are needed as well as the extent and content of services to be delivered. In most countries, health planning is done at the ministry level, where women are not well represented, if at all. In order, then, to effect real change in maternal and child health care policies, it is imperative that women be involved in policymaking. It is the responsibility of midwives to empower women to become actively involved in changing the political, social, and economic system so that women's lives can be permanently transformed.

Unless the system changes, no substantial reduction in maternal and infant mortality rates will occur. It is essential, therefore, that midwives seek cooperation with all of those involved directly and indirectly in the work of maternal and child health at the local, national, and international levels. The word “midwife” means “with woman.” and midwives now, more than ever, need to develop the essential sociopolitical knowledge and skills to motivate and work with others in developing and implementing action plans for improving women's health.

For centuries, midwives have been with women, giving them the gift of love, skills, and knowledge during the most vulnerable times of their lives: pregnancy, labor and delivery, and the postpartum period. Strengthened by training in political action, midwives around the world will be able to influence policymakers effectively as well as empower more women to become policymakers themselves so that real changes can occur in the lives of tomorrow's women and children. The conference on a Call to Action for Safe Motherhood in Nairobi in 1987 concluded: “Perhaps most important of all, this Safe Motherhood initiative must create an awareness that something can, should—indeed must—be done, starting with the commitment of heads of states and governments.”6 Without the positive action and support of governments, the midwives' love, knowledge, and skills will only be a token gift to women.