Deborah Hughes
ARM has held the two UK seats on this committee since 1997, when it was discovered that the RCM were no longer attending meetings on behalf of UK midwives. This was the third meeting I have attended (the EMLC meets annually) and Jane Evans' second. We arrived separately in Dublin on the Friday evening as I had driven to Holyhead and taken the ferry whilst Jane flew over from Luton. (Jane's clients have a tendency to prolonged pregnancy and attending anything with her involves one in vicarious anxiety about this. However, all babies obligingly decided to savour the pleasures of uterine life for a little longer and awaited their midwife's return before emerging.)
The meetings are hosted by the various EU countries in turn and are arranged by the member organisations. This meeting had been organised by the Irish Nurses Organisation, which has a Midwives' Section (there is no separate midwifery organisation in Ireland), and was held in a Dublin hotel. There was an awful lot of food involved.
The meeting took place all day Saturday (09.30 -17.30) and Sunday morning (09.00 -13.00) and had, as always, an extremely packed but interesting and relevant agenda. The attendance at the meeting was very good. All 15 EU member states were represented with the exception of Portugal. The EEA (European Economic Area) countries can send an observer and Switzerland did so. Estonia and Cyprus, who are applying for EC membership, were both represented by observers. This brought the attendance to 29.
Saturday's agenda covered a very lengthy discussion on the future of the EC Midwifery Directives, which have been so influential in raising the standard of midwifery education and practice in so many countries including the UK. As many readers are aware, these are under threat and the Advisory Committee on the Training of Midwives (ACTM) that oversees their working is more or less defunct. This is due to the European Commission not wanting the expense of servicing the ACTM and the six other Advisory Committees (for nurses, doctors, vets, pharmacists, dentists and architects). The ACTM has not met since June 1998 and it was inquorate at that meeting because the Commission would only pay for a third of its members to attend.
We had put on the agenda the issue of what would replace the Midwifery Directives (aka the sectoral directives). We also took an information pack for delegates with us, which we presented. This contained a range of outcomes and competencies for midwifery education and practice. The aim of our presentation was to gain EMLC agreement as to the outcomes and competencies which could be put to all EU midwives for consensus approval. We want to have a document ready to present to the Commission if the sectoral directives are repealed.
My anxieties about this whole issue had been brought into sharper focus when I saw the competencies which the Advisory Committee on Training in Nursing are currently piloting. These are so woolly that a Martian reading them would not have a clue as to what nurses actually do. They are also very generalist in nature and some bright spark of an EU civil servant may think they might "do" (sic) for midwifery. Anyone who wants to get a copy should ask for Document XV/E/8481/4/97-EN dated 24.6.98.
Obviously this is a very complex issue and I am not doing it justice here, but I am happy to talk about it to anyone at national meetings or anywhere else. (I also wrote an article with Liz McAnulty of the UKCC on this very topic which appeared in December 1998's RCM Midwives Journal if you want to know more now). Suffice it to say that Mary Cronk has decided it is a key issue for the future of midwifery. (I don't think I had anything to do with this - she came at it separately and then rang me up to tell me I should be concerned!) However, this was in a sense reassuring, since Mary is invariably right when it comes to pinpointing what is going to be of imminent and crucial importance to midwifery.
Anyway, no consensus regarding outcomes/competencies was reached in Dublin but all members have taken the pack home and will discuss it with their colleagues nationally and it is the main item on the agenda for next year. Should the sectoral directives be lost in the meantime, an emergency meeting will be called by the EMLC. We are not alone in this fight - the six other affected professions are equally worried and representatives from the EMLC have met with their representatives and engaged in joint lobbying of the European Commission. Meanwhile, yet more letters will be sent to the Commission in an attempt to halt the rot.
Amongst the many other topics discussed on the Saturday were a proposed BBC World Service programme on European midwifery, and the pro-nursing bias of the WHO European Office that has many and various detrimental effects on midwifery in Europe. It was decided to monitor carefully the activities of the latest WHO Europe baby -The European Forum of National Nursing and Midwifery Associations, and particularly the new concept of `the family nurse' which is being strongly advocated by the WHO Europe Office at the moment. (The summer 1999 Health Care in Transition: WHO Newsletter for Nursing and Midwifery describes the role, inter alia, of the family nurse as: "visiting and helping the young mother with care for the newborn".)
The host organisation lays on an outing and meal on the Saturday evening. This year's was a trip to a restaurant to the north of Dublin bay, a lot of food, wine, Irish coffees that tasted 90% proof, and a band performing traditional Irish songs. The audience was not required to perform Irish dancing for which I was deeply, deeply grateful, having consumed more Bailey's cheesecake than was good for me.
Sunday morning saw Jane and me having a second pre-breakfast swim in the rather cold hotel pool and sporting the rather fetching bathing hats the staff insisted we wear. We had both slept like logs - for the five minutes that separated the end of the all-night heavy metal rock party in the bar next door and the commencement of the digging up of the road outside by a bloke with a pneumatic drill at 7.15 am.
The meeting started with the election of Anna Monaghan from Ireland and Karin Gottvall from Sweden as President and Vice-President respectively of the EMLC. It continued with reports on midwifery in each country. I shall just pick out some of the most interesting points raised, as I saw them:
Germany has 12,000 midwives of whom 700 work independently. There is some conflict between the two groups of midwives, brought about by changing roles and boundaries. German midwives are working on some leaflets based on the Informed Choice leaflets produced in the UK.
Ireland is about to get a new Nurses' and Midwives' Act and a statutory committee for midwifery will be established. Currently the two year post-nursing midwifery course has only 13 weeks theory and there is some hope of getting this extended to 26 weeks.
Italy's first degree midwifery students have just graduated. However, one of the Italian representatives teaches in a university and told me that he has to spend most of his time teaching medical and psychology students, whilst the midwifery students are taught for a lot of the time by doctors.
Austrian courts had recently found in favour of the EU which wanted to have deleted a paragraph in the relevant Austrian statute, requiring midwives to work in a hospital for a year before being allowed to work independently. The Austrian Midwives Association (the OHG) wanted this paragraph retained and is now trying to find other ways to keep this requirement. There was a lot of discussion about this at the EMLC with most present arguing that the principle of competence at the point of registration is an important one and that the OHG should reconsider its position. This will be revisited next year when the whole issue of competencies and outcomes is debated.
Belgium and Spain had many problems when I first attended the EMLC in 1997 but these have gradually resolved in favour of midwifery through both national and international lobbying. It is heartening to realise that things do improve for midwives somewhere!
Finnish midwives are still trying to establish their role in antenatal care, the majority of which is done by public health nurses who have very little appropriate training.
In France, independent midwives are fairly numerous and work in their communities providing antenatal care and education and domiciliary postnatal care. They are rarely involved in intranatal care as this is invariably hospitalised and medicalised. The French representative, herself an independent midwife, told me that it is considered unacceptable practice in France for a woman to labour without both an intravenous infusion and continuous electronic fetal heart monitoring. The evidence regarding these practices apparently interests neither the obstetricians nor the courts. Only one midwifery school in France (Grenoble) has access to medical/nursing/midwifery databases and it is very difficult for most midwives to find out about any research at all.
Greece has 100,000 births a year and 300,000 abortions. Women are allegedly dissuaded from using the IUD and the pill by doctors who emphasise their side-effects in order to maintain their incomes from abortion (Greece has too many gynaecologists for its population). The caesarean section rate has risen to 35% and midwifery is viewed with great hostility by the medical profession.
Dutch midwives' insurance premiums doubled last year and they are aware (because we've gone on about it so much at the last two meetings of the EMLC) of the problems the insurance market may pose for them in the future. They have been in contact with the European Women's Lobby (an apparently powerful EU group in Brussels) about the insurance matter, arguing that it could reduce women's choices and the rights of midwives. Meanwhile they are overworked, and still expected to attend 150 births a year despite the fact that screening and other technologies, as well as women's expectations, have increased their workloads hugely since the time this quota was laid down. One practice in north Amsterdam has closed and homebirth is no longer an option for women in that area. They are also having trouble keeping a tab on their statistics as these are no longer being collected centrally, though the two representatives felt the homebirth rate was being maintained at 35%.
The word "midwifery" does not translate into Swedish and so midwives have had to find another name for their academic discipline and have settled for "reproductive and perinatal care". They do seem to attach a lot of importance to their role in general reproductive health and family planning and some also run menopause clinics.
Estonia began to register midwives in 1993. Whilst midwifery had a long history in Estonia and Estonian midwives had even belonged to the ICM before the Russian take-over, that history had completely disappeared from view during the 50 years of Russian domination. Midwives in Estonia are now rediscovering their history. Midwifery has many problems in Estonia such as midwifery education being done mainly by doctors, no professional autonomy or responsibility, no identity, no status and very low salaries, but their representative appeared to be very optimistic! Overcome with sympathy and admiration, Jane and I promised that we would get the Estonian rep's name added to the Midwifery Matters mailing list! The EMLC also decided to have a very low subscription for poor countries and to try to find some cheaper hotels to meet in, so that more midwives from applicant states in Eastern Europe would be able to attend the meetings. It was good to hear that the Estonian rep thought that the EMLC meeting had been the most useful, informative and constructive one she had attended internationally. Jane also reckoned that it was a welcome change to her experience of the ICM (see Midwifery Matters, 82).
Next year's meeting will be in Antwerp and will mainly address the issue of the midwifery directives and moving towards competencies or outcomes (as recommended by the SLIM Report), and the role of user groups in member countries and their relationship with midwives (the former are not viewed particularly positively in parts of Europe). The EMLC is the only properly functioning group representing the interests of midwives as EU citizens and as an EU regulated profession. It is refreshingly lively and it is good to see midwives from such a wide range of countries and situations sharing a common vision and purpose. When ARM took on the two UK seats, it wasn't clear whether this would be a good thing to get involved in or not. It increasingly appears that it is.
Deborah Hughes, September 1999
AH updated 8 February 2000