Thursday, May 27, 2010

Getting away from the Dunedin wind and rain

I have to say that I am very pleased to be leaving the country for a week on Sunday and getting away from the terrible weather we're having at the moment.

I'm off to Brisbane on Sunday for a week because I have been asked to speak at the National Community Care Conference about the eMentoring program I set up for Aged Care Queensland last year. I will also be popping in to see Mary Sidebotham at Griffth University and doing some development work on an online course in their undergraduate midwifery program.

It won't be that warm in Brisbane, but it will be 100% better than it is here......

Monday, May 24, 2010

The good news...and the very bad news

I have been looking around for a credible open access midwifery journal to submit a number of articles. I am committed to the concept of free, online availability of publications for midwives, especially for those who live in developing countries, and rural and remote areas.

The good news...
The good news is that the International Confederation of Midwives is starting up a new journal called the "International Journal of Childbirth" edited by Dr Denis Walsh and published by Springer Publishing. I don't have much information about it because its website isn't going live until October. However, it looks like it will be a fabulous international journal covering a range of topics that will interest anyone associated with childbirth.

...and the very bad news
When I emailed Dr Walsh to ask if it would be open access, his reply was that after much discussion with the publishers, the decision is that the journal will be by subscription. Members of the ICM who live in developing countries will pay a reduced rate.

Very disappointed
I am very disappointed by the decision for the journal not to be open access, especially considering it is representing the ICM who is working to service midwives on an international level. It is fair to say that I know nothing of the behind-the-scenes discussion so I should not rant on too much. However, I feel this is a missed opportunity for advancing international collaboration and communication, which surprises me considering the mission of the ICM.

Back to the drawing board
So, here I am, still on the look for an open access midwifery journal. I'm not having a lot of luck so far. But in the next few days I will talk about the journals I have found.

I am resisting the idea of starting up a open access journal myself because I know it will be a lot of work. But if there really is a need, it may be something I need to look at.

What are your views on this issue?

Saturday, May 22, 2010

Checking your security settings on Facebook

The online discussion about the security of your information on Facebook continues. If you have any concerns about how secure your account is, here is a website that will help you check your settings: Just follow the instructions when you get to the website.

I ran a check and found I had a couple of settings I could re-set to stop people passing on information that I wanted to keep to myself. So I do think it is worth running this check to see if there are any changes that are advisable for you to make.

Wednesday, May 19, 2010

Why I won't be leaving Facebook on "Quit Facebook Day"

The online buzz at the moment is the new security settings on Facebook and the discussion about how ethical the owner of Facebook, Mark Zuckerberg, is with our personal information. If you want to read a long summary of the issues involved, read what Danah Boyd has to say in her post "Facebook and “radical transparency” (a rant)". A shorter and less academic summary of the issues can be found on the post "Facebook Exodus Planned for May 31: Will You Quit?" written by Jennifer Van Grove.

What will I do?
After reading around the issues, I have decided to keep my Facebook account for the time being.

The main reason for this is I have found it is the best way to connect with midwives. For some reason, midwives have really taken to Facebook, more so than Twitter. You only have to look at the success of the Virtual International Day of the Midwife this year to see how effective Facebook is for communicating with midwives.

What will other midwives do?
I asked midwives on the Virtual International Day of the Midwife fan page if they will be leaving Facebook. Here are a few of the replies:

"my privacy settings are pretty private and I use Facebook more for my personal life, and some general midwifery chitchat/awareness/discussion/articles -confidentiality not an issue here :)"

"If you set your settings right there's no issue."

"i have most of my info public. i'm still not worried."

"Staying.. wonderful way to promote what I believe in.."

"Sometimes the only way i can keep up with what is happening with family and friends around the world and they my happenings! I get bogus cals from Skype but I just delete them not disconnect!!"

Mixed feelings
I do not have concerns about privacy because I have a very open online identity. However, I do have concerns about the security of my information - I want complete control over who sees what information. And I am concerned for people who do not fully understand the implications of privacy settings, or what happens to their personal information. Here is a comment that pretty much reflects the quandary I feel I am in with Facebook.

"At the International Day of the Midwife webinar session, I was a little surprised to learn that FB is not only for profit, but that they are selling my information to bidders everywhere (despite my privacy settings). It may not appear in a Google search, but my info and posts are being stored out there and someone paid good money for it all. I thought all my information would be safe if I stayed on the highest privacy settings. Not so.

Though I completely understand why many birth advocates are packing up and moving on, I'm torn on the issue of losing my daily connection to all my non-birthy friends on FB. Many of my non-techy and non-birthy friends simply are not yet willing to make the move to micro blogging. :(

Informed choice
For the time being I am going to watch and wait, and see where Facebook takes us. Until another alternative materializes that midwives fully engage with, I'm going to stay with Facebook. However, I feel it is really important for me (and you) to stay up to date with developments so I can make a truly informed choice about how I represent myself online, and the tools I use to do so.

In the meantime, here are a few tips I have put together for using Facebook.

How informed are you about your online identity? When was the last time you read the terms of use of Facebook or other social networking tool you use? How do you use your security settings?

Sunday, May 16, 2010

Google Documents versus Open Office

I have just bought a new lap top and refused to pay for $200 plus for Microsoft Office. So I have been using Google Documents, and now Open Office for all my "office" work. Both systems are free and are worth considering if you do not want to buy into Microsoft Office. Jerry Brockmeier has written an in-depth comparison of the two systems "Small Business Software: vs. Google Docs". Here are some thoughts I have from my own personal experience.

1. How can I integrate Google Docs and Open Office with Microsoft Office?
The main concern I had about moving to Open Office was how I was going to manage the huge amount of work I have in Microsoft Office formats? And further more, how can I collaborate with people who are still using Microsoft?

The beauty about Google Docs and Open Office is that they convert Microsoft files into formats you can work on, and then convert them back to Microsoft. And I think (but don't quote me before I check this) that you can now save files in an Open Office format in Microsoft.

2. Google Docs and Open Office are integrated
The beauty of both products is that you can switch back and forth and save documents and presentations in formats that can be opened in both Google Docs and Open Office.

3. Google Documents is portable
This means you can take your work wherever you have Internet access - this is particularly useful if you move between a number of computers. The downside to this is you're stuck if you have no Internet access. In contrast, Open Office is embedded in your computer, as is Microsoft. So you have to install Open Office on every computer you work on.

4. Which is more secure?
Any data you store in Google Docs is hosted on a server somewhere in the world. This means that if the server goes down for whatever reason, you will not have access to your data. I have to say that I have never had this problem in the two years I have been using Google Docs but the potential is always there.

The other potential problem is that your data is not as secure in Google Docs as it is when it is stored in Open Office on your own private computer.

5. Which is best?
I think that Open Office is better than Google Documents for what I call 'long term' work. It has more functions and is easier to manage. But Google Docs is brilliant for collaborative work - more than one person can work on a document at the same time which gets rid of emails going back and forth with track changes and so on.

What are your experiences of using Google Docs and Open Office? What would motivate your move to Open Office? What do you feel are the benefits of staying with Microsoft Office?

Resurrecting my old lap top

I have had my Toshiba lap top for four years and I have been thrilled with its performance. I have dragged it around the world with me, and I used it as a PC - far more hours than is recommended for a lap top. But over the last few months it has been driving me mad - it's been really slow and I had to keep re-booting every five minutes. So in view of the advice I received years ago that lap tops only last three years, I thought I was justified in buying a new one, which is what I did.

Ditching Windows
I have to confess that before I forked out $1000 for a new lap top, I had a chat with Wayne Mackintosh who is a strong advocate of open source and open access resources. Wayne suggested that I strip Windows off my lap top and install Ubuntu, which is an operating system the same as Windows, but it has been developed over the years by the open source movement. But I was too nervous to do that, so chose to buy a new lap top with Windows.

Testing Ubuntu
Instead of throwing out my old lap top, I thought I would have nothing to lose if I installed Ubuntu on it, just to see what it looks like and how it works. The first thing to say about Ubuntu is that it is free and was painless to install.

How I am getting on
I hate to admit it...especially to Wayne who will only say "I told you so" old lap top has a new lease of life. In fact, it is operating faster than my new lap top. I have to confess, I wish I hadn't wasted my money on a new lap top....but there you are...I'm living and learning :)

Introducing Open Office
The other advantage to installing Ubuntu is that Open Office was also installed. Open Office is a free alternative to Microsoft Office. In my next post I'll talk a little about why you should think about trying out Open Office, especially if you are a non-profit organisation or student, and in the position that you cannot afford to buy the latest version of Office.

Do you use Linux or Ubuntu? How do you get on with it?

Saturday, May 15, 2010

Talking about an open access midwifery journal

I have been thinking more about the possibility of starting up an online open access midwifery journal and as a result have started a little research into the notion. This has resulted in a really useful chat with Dr Eric Repphun of the University of Otago. Eric is one of the editors of a new open access journal called Relegere: Studies in Religion and Reception. Several things came out of this conversation that no doubt will lead to further discussion.

1. Open access journals is the way to go - people just cannot afford to subscribe to print journals any more.

2. Online journals can have a much quicker turn around of review and publication than paper journals, which is a good selling point for authors.

3. I need to do my homework. There's no point in setting up an OA midwifery journal if the need is already being met by other online journals.

4. Need to think about how to show credibility right from the start ie how would I attract a quality editorial board?

5. Need to be patient - it takes time to build up a solid readership and reputation.

6. Can be done very cheaply. There is a free open access journal software that I could use called "Open Journal Systems" - I would only have to pay for a domain name and local hosting.

7. Would I want to be aligned with an institution or be completely independent? How would that impact on perceptions of quality and credibility?

8. Need nine to 12 months lead up time to call for papers. This could work out really well and tie in nicely with the Virtual International Day of the Midwife 2011. We could ask midwives to submit conference papers (this would be voluntary) which could become the first issue.

There are a lot of other things to think about so I'll continue my research and see where things take us.

What do you think of the idea of an online open access midwifery journal? If this something you'd read...submit articles involved with as an editor or reviewer?

If you are interested in the idea of an open access midwifery journal, please let me know. I'd also be really interested in hearing from people who are involved with open access publication and authoring.


Thursday, May 13, 2010

DEANZ conference 2010

In all the excitement of the Virtual International Day of the Midwife, I forgot to talk about the Distance Education Association New Zealand conference I went to in April. This was the first education conference I have been to since I moved out of midwifery and into staff development, so it was really valuable to meet other people doing similar work to myself.

Second Life presentation
I gave a presentation about the virtual birth unit. There was not the interest I expected but having said that, I had some good one-on-one discussions about the work following my session. I felt the presentation didn't go as well as it could have done - what I should have done was play the YouTube video that explains how the normal birth scenario works. I have tried to do this before at conferences, but when there is little or no Internet access this can be a disaster. Suffice to say, we were at Te Papa which had excellent Internet access.

Meeting Terry Anderson
I sound like a bit of a groupie when I say the highlight of the conference was meeting Professor Terry Anderson. Terry is a Canadian who works in Athabasca which is the Canadian equivalent of the Open University/Polytechnic. Terry is world renown for his eLearning work, and his book "Theory and practice of online learning" is my is open access and free to download.

Connectivism made easy
In Terry's keynote speech he talked about the history/phases of eLearning and put things into words of one syllable which made a lot of sense to me. At long last I understand the difference between behaviourism, constructionism and connectivism:

Behaviourist - self paced, individual study
Constructivist - learning in groups
Connectivisim - learning in a network

What comes first...the chicken or the egg...?
The other thing that Terry discussed which rang a bell with me was the relationship between technology and pedagogy. I have heard the mantra "the pedagogy comes first" many a time, and I have said it myself, often as a means of apology...feeling I have to apologise for my interest and love of technology. I have never had the nerve to voice my thoughts...that we would not have the choice of pedagogy without the technology.

Terry sees technology and pedagogy as ying and yang...doing a dance. He said that technology sets the beat and the timing...and pedagogy defines the moves.

Here is Terry's presentation which I hope you enjoy as much as I did.

Tuesday, May 11, 2010

Tips for using social media to organising and facilitating an online event

Here are a few tips I learned from facilitating the Virtual International Day of the Midwife using social media.

1. If you choose to use social media to organise and market your event, do not expect it to be a free form of advertising. Social media is about being social - if you use it as a one way marketing tool, you will fail to connect with people and ultimately you will not attract people to your event.

2. If using Twitter, aim to tweet at least once a day, and even more frequently as you approach the event. If using Facebook, post messages at least twice a week and more frequently as you approach your event.

3. Always respond to people when they leave you a message or comment

4. Use a Facebook fan page as opposed to a group - people can see your fan page without needing to join Facebook. If you force them to join Facebook, you will set up barriers to people engaging with you.

5. Integrate your social network sites eg set up your Facebook page so that when you make a comment, it automatically gets sent to Twitter.

6. Ensure someone has the responsibility to 'run' social networking sites for the event. That person needs to understand how social media works.

7. Using social media to organise an online event takes times - think of it as an investment but remember the old adage "There is only one thing worse that no social media campaign and that is a badly run social media campaign".

8. Be consistent across the various websites - use the same logo and branding.

9. Distribute information in as many places as possible,,,YouTube, Slideshare, Blip.TV,....

10. To be sustainable as possible and increase branding, use an identity that be used every year eg use "Virtual Day of the Midwife May 5th" but not "Virtual Day of the Midwife May 5th 2010"

11. Use a logo or account name that is short and easy to remember.

What tips would you pass on?

Further reading:

How to organise an event on Facebook -

The Mashable Facebook guidebook -

The Mashable Twitter guidebook -

Sunday, May 9, 2010

Walking the 'open education' talk

For some years I have been talking about open access and open educational resources. I think it is essential for midwifery sustainability, growth and professional support to make as much of what we do and teach open to all in the online environment. By working in this way, we foster collaboration and communication with midwives all over the world, as well as improve communication with pregnant women and families. This is why Deborah Davis and I have developed the concept of the Virtual International day of the Midwife with the format it has - open and free to all midwives.

Recently I have challenged myself about my practice, and realised that I do not necessarily walk the talk, especially in relation to publication of my work. So I have asked myself this question:

I talk about open access and open access journals, but how ethical am I being by submitting my work to closed midwifery journals?

Where should I submit my work for publication?
This question has come to a head over the last few months for several reasons.

Access to journal articles
The first reason is my ongoing frustration about the difficulty of accessing journal articles. I have talked about this issue more than once, recognising the difficulty midwives have in accessing evidence-based information, especially if they are geographically isolated or do not have access to medical libraries or databases.

There are a number of open access journals that midwives should find useful, but all of the main midwifery journals are closed to all but subscribers. And for many midwives, subscription is prohibitive.

Here are a few online journals that may be of interest to midwives:
Role Models
The second reason I have started questioning my practice is the influence of strong role modelling that I see around me. The Second Life Education Project, Leigh Blackall and his open PhD and Wayne Mackintosh with his work in Wikieducator have all got me looking at how I can be a role model to the midwifery profession. My open work and research in this blog has been noted by other midwives, but I feel it is time to take a real step of faith into open access publication.

Open access does work
I spoke to Professor Terry Anderson (a professor who specialises in education) a couple of weeks ago at a conference in Wellington and he told me he only published in journals that had open access. Of course, he has the luxury of being able to take this decision - he has the international name and resources to support his work. Nevertheless, he has put his money where his mouth is, and published a number of open access books that have reached far larger audiences than those he published using conventional methods. It goes without saying that I am barely on the same planet as Terry, but I do feel I can contribute in my own way. I believe that if we all do our small bit and move to open publishing, closed midwifery journals will be forced to respond.

The third reason I have started thinking about this whole issue is that I have recently had several invitations to publish articles. I also have a back log of work to publish including the work I have done with eMentoring, Second Life and the Virtual International Day of the Midwife.

The problem I face is that because there are no specific international open access midwifery journals, I don't know how I can get my work read by the wider midwifery audience in an academic, peer-reviewed way that will give me the brownie points I need as an academic.

What's good about open access journals?
A couple of things stand out for me about open access journals, especially if they include an open access review process. The first thing is that the review process will be more transparent and rigorous. The second and most obvious, is that open publishing increases access to information, which goes some way to support disadvantaged midwives.

Benefit for authors
As an author, my question is "will my work be cited more often if it is in an open access journal?" It looks like the answer to that question is "yes", although as you can imagine, it is quite a complex issue. Alma Swan has just reviewed a number of studies that has looked at this issue and found that the majority of studies found open access increased citation impact ie if you publish in an open access journal, you are more likely to have your work cited in other articles. But... let's face it, if my article is rubbish, it won't get cited wherever it is published!

Where does this leave me?
I have just declined an offer to write an article unless it is published under a Creative Commons licence. I am concerned that taking this stance will restrict my publishing opportunities and reduce the opportunity to get my work out to 'Mrs Average Midwife'. However, I am so committed to the philosophy of open access that I am prepared to take that risk.

The obvious answer to my problems is to start an open access midwifery journal....I'll just quickly do that after lunch!!

Seriously, if anyone is interested in discussing this further, please let me know.


Swan, A. (2010). The Open Access citation advantage. Studies and results to date. School of Electronics & Computer Science, University of Southampton. Retrieved 9 May, 2010, from

Wagner, A. (2010). Open Access Citation Advantage: An Annotated Bibliography. Issues in Science and Technology Librarianship, Winter. Retrieved 9 May, 2010, from

Image: 'untitled' db*Photography

Saturday, May 8, 2010

Organising and facilitating an online event with social media

In my previous post I gave a brief report on the online conference for midwives that I organised and facilitated this week : The Virtual International Day of the Midwife. Within a few minutes it became obvious that the conference was going to be a great success, especially compared to last year's conference - last year we had an average of 6 participants per session...this year we had an average of 50 participants per session. So what made the difference to the success of this event...this year?

Last year my main method of organising and advertising the VIDM was by using email discussion groups. But as I have already indicated, this method of advertising wasn't particularly successful.

This year I focused on social media to market, plan and facilitate the VIDM, in particular Twitter and Facebook.

There are a number of concerns about Facebook, including the attitude of the owner to people's personal information, and the difficulty in deleting an account. Whilst I understood these concerns, I cannot ignore the fact that an increasing number of midwives are using Facebook to connect and share information - at the time of writing this post the Virtual International Day of the Midwife page had 2,486 fans.

Connecting with people
What I found was that Facebook gave me an immediacy of access to people, especially during the event itself. I was able to post information about events, answer questions and queries, and keep a record of people's comments and feedback. Whilst you can do that on email groups, I always feel that I have to be very careful what I say and how often I send emails for fear of overloading people. I don't have the same concern with Facebook.

The provisional results of the event evaluation survey show that Facebook was the most effective in marketing VIDM - 69% people heard about VIDM through Facebook compared to 13% of people who heard via an email group.

I also set up a dedicated VIDM Twitter account as well as a hashtag #IDM2010. My impression is that midwives are only just getting their heads around Twitter. What I have noticed is that Twitter is used extensively by pregnant women and mothers, especially mums who are campaigning for better maternity conditions.

At the time of writing this post, the Twitter account had 161 followers - 9% of the online survey participants had heard of the VIDM via Twitter. At this time, Twitter is not an effective communication tool for midwives, but I still think it is worth engaging with Twitter. I used it very effectively for seeking synchronous help from my non-midwifery network , especially when I had urgent technology problems that needed solving. I also used that network for psychological support as during the event.

Blog and Wiki
Whilst I used Facebook and Twitter for connecting with people, and passing on the latest news about the VIDM, I used this blog and the VIDM wiki for processing ideas, making plans, gathering feedback and consulting with the wider community. This is a great way of engaging and including the community you are serving, as well as making use of collective brains and resources.

In my next blog post, I'll pass on some practical tips I learned about facilitating an online event using social media.

Further reading:

How to organise an event on Facebook -

The Mashable Facebook guidebook -

The Mashable Twitter guidebook -

Virtual International Day of the Midwife 2010. All over for another year!

(Thanks to Deborah Davis for photo)

The Virtual International Day of the Midwife is over for another year. Here are a few quick personal thoughts and initial impressions about how it went.

We still have a couple of things left to do. I have to sort out the recordings and put them on the VIDM wiki - I am planning to make them available in a number of formats so they can be disseminated as widely as possible.

Deborah Davis and I will be writing a formal report which will contain feedback from participants and the results of the online evaluation survey. We'll also be making some recommendations in the report about next year as well as more general observations about online professional development for midwives.

How many people attended?
During day time hours (New Zealand time), the average number of seats filled was 50. During the night, we dropped down to 30-35 seats. That does not tell us how many people 'attended' overall, because I know of at least three places (including a maternity unit) where more than one person was watching one computer. At the same time, we know that a number of people attended more than one session. Nevertheless, this is a huge increase compared to last year when we had an average of six people attending which included the speaker and facilitator!

Who attended?
The provisional results from the evaluation survey (75 responses so far) indicate 25% of participants were midwifery students, 21% were midwives, 15% were midwifery educators and 5% were midwifery researchers. Five per cent of participants were parents and 16% were 'other'. These results will be adjusted once the survey has closed.

This survey is still open so if you'd like to complete it, please do. We're also interested in hearing from midwives who did not attend - the survey will give you the opportunity to explain what prevented you from attending, and help us understand what needs to be done to support you to attend next year.

Where did participants live?
The majority of people came from New Zealand, Australia, USA and Canada. We also had visitors from Norway, Sweden, Slovenia, Brazil, Holland, UK and Portugal.

How did the technology work?
I do not like to promote one product over another especially when the products are proprietary. Ultimately I would prefer to use a free web conference tool. However, we were sponsored by the Otago Polytechnic Educational Development Centre who gave us free access to a virtual meeting room called Elluminate which worked extremely well. The only technological problems that I was aware of was on the participants' end. One speaker in Cyprus was unable to connect which was a disappointment, and I know institutional firewalls were a barrier to some people accessing Elluminate.

So how did it go?
I was blown away by the number of people who attended and their enthusiasm for this form of professional development and networking. It became addictive...a number of people said they couldn't leave because they were afraid they would miss something and consequently stayed up all night. Even in the three sessions when speakers did not turn up, we were able to have general conversations in which people took an active part.

All the speakers were brilliant and shared an amazing range of topics, information and resources from personal stories about clinical practice to PhD research. Three main themes emerged: how to keep birth normal, dealing with recruitment and retention issues and how to be an online midwife.

"thanks so much to staff members, although I can't attend in the all sessions, but I have been able to feel how the midwife in the world can reconcilable in an event, without having to leave our chair.. ^_^"

"I am so excited to be able to access the sessions I missed. I especially want to hear the ones about informed choice and how place effects birth. Thanks for this great resource."

thank you so much for this wonderful event, can't wait for next year :-)

Thank you so much for oranizing this event! It has been wonderful!!

What an awesome thing you have done Sarah and Deb! Fantastic effort, brilliant outcome, so many happy midwives and a feast of great input for everyone to share and enjoy from now on! Whoooot! Thank you so much for your organisation, coordination and stunning vision. Exceptional. Hope you're sleeping well after the 24 hour labour of love.

One of the most exciting comments made to me was by Merrolee Penman, who is an occupational therapist, education and researcher. Her colleagues and she have been so inspired by what we have achieved that they are going to put on a similar event for the World Federation of Occupational Therapists International Day in October.

Thoughts about next year
I thought it would take five years to get to a point that we have arrived to now (in only two years). I think a lot of the success of the event is because of the way we integrated social media into the planning, marketing and facilitation of the event...more about that in my next post.

We will definitely put on the event next year but it has got too big for Deborah and I to manage on our own. So we will be looking for volunteers to join an organising committee to help us out. One of the things I will be keen to do is enrol more facilitators so I do not have to stay up all night :)

The other thing I would like to look at is how we can share the recordings and resources with midwives who not have access to the explore how we can use mobile devises as well as disseminate CD materials.

My personal thoughts
I am extremely proud of what we have achieved and how successful the day was - this is the first of its kind in international midwifery. The numbers of people attending match and beat those of other very famous virtual conferences I have attended in the past. Now we need to look at how we can increase midwives access' to events like this, and also encourage face-to-face conferences to integrate virtual events into their more traditional formats.

My personal learning has been about online facilitation...not so much in learning about it, but rather gaining more experience with it...knowing how to support people...having the confidence to handle unexpected difficulties...being creative when speakers do not turn up...making sure people feel included...

(If you would like to learning more about online facilitation, please feel free to join me on the online course "Online Facilitation" which starts in July).

Next post
In my next post I will talk about how we used social media to plan, organise and facilitate the VIDM, and why I disagree with those people who are leaving Facebook.

If you have any thoughts or feedback, please feel free to leave a comment here. What would encourage you to attend online conference and professional development activities? What would stop you?

Saturday, May 1, 2010

Formation et Pratique de sage femme dans le monde: situations et défis

This is a guest blog post by Atf Gherissi who is a midwife in Tunisia. Atf wrote this discussion paper as one of the events of the Virtual International Day of the Midwife 5 May 2010. The English version of this discussion paper can be found here.

Formation et Pratique de sage femme dans le monde: situations et défis

Aperçu de la situation de la profession de sage femme dans quelques regions du monde

Ma modeste expérience acquise à partir de quelques contributions notamment dans les pays d’Afrique francophone et dans les pays Arabes - que ce soit au nom de la Confédération Internationale des Sages Femmes, de l’UNFPA ou encore de l’OMS/EMRO - m’encouragent à partager quelques idées pour décrire et analyser la situation de la profession de sage femme.

Dans les pays d’Afrique francophone

Avec le soutien de l’UNFPA, la FASFACO (Fédération des Associations de Sages Femmes d’Afrique Centrale et de l’Ouest) a conduit une enquête par email auprès de ses 13 associations membres pour un diagnostic de la situation des sages femmes dans ces pays. L’exploitation des données des questionnaires remplis par 9 associations a mis en évidence un ratio sage femme/habitants très loin de la norme définie par l’OMS (1/5000 population).

Durant sa première session sage femme tenue à l’occasion du 5ème congrès de la SAGO (Société Africaine des Gynécologues Obstétriciens) à Kinshasa en 2007, la présentation des résultats de cette étude a impulsé un débat qui a permis d’aborder les problèmes qui caractérisent les services et la profession de sage femme en Afrique Centrale et de l’Ouest:

· La disparité des curricula de sage femme en termes d’accès et de durée

· La prolifération des écoles de sages femmes (privées et publiques) où les normes de qualité de la formation ne sont pas considérées

· La baisse du niveau de qualité de la formation des sages femmes comparativement aux promotions précédentes (encadrement, nombre d’étudiants en inadéquation avec l’infrastructure de formation)

· La concentration des sages femmes dans les villes comme le résultat d’une gestion inadéquate des ressources humaines (conditions de travail, motivation, isolement) et de l’absence de volonté d’exercer à l’intérieur du pays.

· L’absence de plan de carrier de sage femme. Démotivées, les sages femmes finissent par abandonner la profession

· Le nombre insuffisant de sages femmes formées par an : 115 au total pour 9 pays

· La création de structures de santé dans la communauté sans recrutement de professionnels qualifiés.

Ces discussions ont abouti à des recommandations opérationnelles dont certaines ont principalement porté sur la nécessité de réviser et d’harmoniser les curricula de sages femmes, d’élaborer des plans de carrière pour les sages femmes, d’améliorer la formation initiale et continue ainsi que les conditions de travail des sages femmes. D’autres recommandations ont insisté sur l’importance de planifier les ressources et d’identifier des mesures pour une distribution équitable des sages femmes dans les provinces (mesures incitatives, stage professionnel obligatoire à durée déterminée). Une autre recommandation clé a porté sur le besoin vital de renforcer le partenariat entre les sages femmes et la communauté afin de ré-établir la relation de confiance avec les femmes.

Dans les pays Arabes

La situation devrait être similaire avec toutefois une difference de taille créée par l’existence d’une formation de sage femme à entrée indirect, soit après celle en soins infirmiers. Ce système dérive de celui des pays anglo-saxons sachant que, dans la plupart des pays francophones, l’accès à ces études est direct.

La stratégie de responsabiliser des professionnels à profils divers pour prodiguer des services de santé sexuelle et reproductive aux femmes - en particulier dans les gions difficiles d’accès – parait être une option définitive alors qu’elle doit être considérée comme une option transitoire le temps que le pays soit couvert par un effectif suffisant en sages femmes diplômées. Parmi ces professionnels, on retrouve les sages femmes diplômées, les infirmières sages femmes, les infirmières obstétricales, les sages femmes communautaires, les infirmières spécialisées en soins maternels et infantiles et les cliniciens non médecins …… en Tunisie, en raison du manque flagrant en sages femmes au cours même de l’année de l’Indépendance (1956), le Ministère de la Santé Publique opta pour une formation express (6 mois) en obstétrique au profit de 11 infirmières diplômées d’Etat qui furent les premières sages femmes diplômées avec le titre d’infirmières obstétricales. Un terme a été mis à cette approche en 1979 en raison de l’atteinte d’une couverture suffisante du territoire en sages femmes dont la formation à entrée directe avait été démarrée dès 1967.

Parmi les effets négatifs d’une telle approche, il est important de signaler que ces professionnels ne sont pas toujours recrutés comme au Yémen où les sages femmes restent toutes inactives une fois diplômées. L’Association des Sages Femmes au Yemen a mis en oeuvre un projet soutenu par l’USAID pour former des sages femmes à assister les femmes Durant l’accouchement dans le cadre d’un exercice de libre pratique.

L’autre effet négatif porte sur le fait que si tous ces professionnels ont leur mission e commun, ils diffèrent pare leur pré-requis et surtout par la qualité des services qu’ils fournissent. Dans certains pays, il arrive que ces professionnels soient amenés à exercer dans une me structure de santé. Leurs relations inévitablement conflictuelles aggravent leur crédibilité, celle de la structure et du système de santé aux yeux de la communauté à desservir. Pire encore, aucun système de passerelle n’est prévu pour assurer la mise à niveau de ces professionnels et, bien sûr, aucun plan de carrière n’existe.

Je souhaiterais revenir à la question de l’accès direct/indirect aux études de sage femme. Mes échanges avec des sages femmes diplômées en de Grande Bretagne, en Australie et aux Etats Unis méritent d’être partagés. Diplômées infirmières, elles assument leur identité en tant que telles, mais une fois diplômées sages femmes, elles assument leur nouvelle identité et considèrent “qu’elles n’ont plus rien à voir avec les infirmiers”. C’est loin d’être le cas dans les pays Arabes où il y a surtout des infirmières sages femmes. Dans ces pays, les sages femmes sont confrontées à deux obstacles : la domination infirmière et celle des hommes puisque la profession infirmière est surtout masculine quoique qu’un équilibre émerge depuis quelques années. A titre d’exemple, aux Emirats Arabes Unis, un long plaidoyer n’a pu aboutir qu’à la création d’une section sages femmes sous l’association des infirmiers. En Palestine, les sages femmes ne peuvent se mouvoir librement parce que fusionnées avec les infirmiers. Récemment, une sage femme a créé un comité national de sages femmes qui œuvre pour la création d’une association de sages femmes.

Durant une précédante réunion organisée par la Confédération Internationale des Sages Femmes, une infirmière en chef à l’OMS fit une presentation dans laquelle l’infimier et la sage femme sont considérés comme une entité unique et fusionnelle. Elle annonça fièrement l’ouverture de perspectives citant en exemple la mise en œuvre d’un Master en Sciences Infirmières au profit des infirmiers et des sages femmes. Le concept est clair pour l’OMS, l’infirmier et la sage femme sont une seule et même entité à maintenir. Le problème est que, fondamentalement, ils sont différents pour deux raisons au moins: l’infirmier a pour mission de soigner toute personne en situation de maladie tandis que la sage femme a été créée par les femmes depuis des siècles pour les accompagner durant la séquence à la fois la plus précieuse, la plus heureuse et la plus douloureuse de leur vie. Leurs identités s’en trouvent systématiquement totalement différentes et les philosophies des programmes de formation ne peuvent qu’être différentes. Lorsque changer de casquette est facile comme en Grande Bretagne, aux Etats Unis et en Australie, le problème ne se pose peut-être pas. Mais lorsque ce n’est pas le cas, maintenir cette fusion est une confusion qui étouffe la sage femme en termes d’identité et d’entité. Le Master délocalisé établi au Maroc par la Faculté des Sciences Infirmières de l’Université de Montréal est prisé plus par les sages femmes que par les infirmiers, heureux tous deux de l’ouverture d’une perspective d’évolution notamment vers un doctorat. Cela signifie toutefois qu’en optant pour cette voie signifie quitter la profession de sage femme. Nos collègues en sont certainement conscientes mais ont-elles seulement le choix de faire autrement?

Maintenant pour convaincre les décideurs, nous avons besoin de mener un plaidoyer convaincant basé sur l’évidence, c’est-à-dire sur les données de la recherche. Un arguement pourrait ne pas avoir à attendre à être prouvé puisque former des sages femmes selon une voie d’accès indirect équivant à disposer d’une promotion de diplômées au bout de 5 au moins, tandis que les former selon la voie d’accès direct garantit aux décideurs de disposer de deux promotions de diplômés en même temps : les infirmiers et les sages femmes

Cette analyse rapide n’est certainement pas exhaustive et je suis convaincue que les discussions de la journée aborderont des problèmes au moins aussi pertinent. Mais je voudrais conclure que la sage femme doit être émancipée de la profession infirmière aujourd’hui plus que jamais et sous tous les aspects (formation, règlementation, plan de carrière, conditions de travail ) et se doit de se prendre en main. Les programmes d’études doivent être revises selon une approche paradigmatique qui articule le paradigm éducationnel avec ceux socioculturel et disciplinaire (Bertrand & Valois, 1992), (Hatem-Asmar, Fraser, Blais, 2002), ainsi qu’avec le paradigme systémique (Gherissi 2008). Une telle approche devrait produire des sages femmes compétentes dont les services fournis devraient suivre et répondre autant aux besoins des femmes en matière de santé sexuelle et reproductive, qu’aux priorités des systèmes de santé, qu’aux règles et aux ambitions de la profession elle-même.

Atf Ghérissi, CM, MSc, PhD. Maître Assistante Universitaire, Sciences de l'Education. Ecole Supérieure des Sciences et Techniques de la Santé. Université Tunis El Manar. Tunisie

Please feel free to leave comments and join the discussion here about this very serious problem that faces midwifery both at a local and international level.

Shortage of midwives; situations, solutions and concerns

This is a guest blog post by Atf Gherissi who is a midwife in Tunisia. Atf wrote this discussion paper as one of the events of the Virtual International Day of the Midwife 5 May 2010. The French version of this paper can be found here.

Shortage of midwives; situations, solutions and concerns-Practice and Education Highlights on the midwifery situation in some regions

According to my modest experience and contributions in francophone African countries and in the Arab countries, whether for ICM, UNFPA and EMRO, I would like to share the following information and ideas regarding midwifery services and profession.

In the francophone African countries

An electronic survey has been conducted in 2007 by the FASFACO (Fédération des Associations de Sages Femmes d’Afrique Centrale et de l’Ouest) and supported by UNFPA among its member associations. A questionnaire sent to 13 midwifery associations was filled by 9 of them. Despite its limits, this survey highlights a serious shortage of midwives with ratios very far from WHO norm (1/5000 population).

Shared and discussed during the first FASFACO midwifery session held alongside the 5th SAGO (Société Africaine des Gynécologues Obstétriciens) in Kinshasa in 2007, with UNFPA and ICM support, these results opened a debate that raised the following issues regarding midwifery services and profession in Central and West Africa:

  • Disparity of Midwifery Curricula in terms of access and duration
  • Proliferation of Midwifery Schools (private and public) with no regard to the norms of quality of Education
  • Decreasing quality of Midwifery education comparatively to previous batches (tutoring, number of students not in adequacy with the education infrastructure)
  • Midwives gathered in the city as the result of an inadequate management of human resources (work environment, motivation, isolation) and absence of willing to practice inside the country
  • Absence of Midwifery career plan. As a result, midwives, demotivated, abandon the profession
  • Insufficient number of midwives trained per year : 115/9 countries
  • Creation of health facilities in the community without recruitment of qualified professionals

Operational recommendations derived from the discussions and mainly focused on the need to revise and harmonize midwifery curricula, to develop career plans for midwives, and to improve Education, Training and Work environment for midwives. Other recommendations emphasized on the need for establishing human resources plans and for identifying means to ensure adequate midwives distribution in the provinces (incitative measures, compulsory professional training with fixed duration). Another key recommendation concerned the vital need for strengthening partnerships between Midwives and the Community to re-establish the trust relation with women.

In the Arab countries

The situation should be the same but with an important difference in addressing midwifery education as an indirect entry program in conformity with the Anglophone education system knowing that in the francophone African countries, this education is mostly direct entry.

The strategy of assigning professionals with multiple profiles to provide SRH services to women mostly in remote areas looks to be a definitive option while it has to be considered as a transitional option meanwhile the country will be covered with enough certified midwives. These professionals count certified midwives, nurse midwives, auxiliary midwives, community midwives, nurses MCH, non physician clinicians…… In Tunisia, because of the sudden shortage of certified midwives during the Independence year (1956), the MoH provided 6 months intensive obstetrics training to 11 nurses who were the first qualified midwives in the country but having a title of auxiliary midwives. This option has been stopped in 1979 as the country was covered by certified midwives whom the direct entry education program was launched since 1967.

Among the negative outcomes of such a strategy, it is important to highlight that these professionals are not always hired such as in Yemen where midwives are trained but don’t work once certified. The Yemen Midwifery Association developed a project with the support of USAID to train these midwives to serve women as private providers of maternal care.

The other negative outcome is that all of them have in common their assignment but are different by their background and by the quality of the services provided. In some countries, it happens that these professionals work in the same health setting, but in a conflict situation which alienates more the credibility that each of the system, the setting and themselves, don’t have enough in the community supposed to be served. Moreover, no bridging is planned to ensure a scale up for these professionals and, of course, no career plan exists.

I would like to come back to the point related to the direct/indirect midwifery program. Talks with midwives from the UK, Australia and the US make clear that being graduated nurses, they keep their nurse identity but once graduated midwife, they keep the new identity and “have nothing more to do with nurses”. This is not the case in the Arab countries where there are mostly nurse midwives. There, midwives face two constraints: nurse domination and male domination as most of the nurses are men even if a balance is emerging since a few years. As an example, in the UAE, a long struggle conducted to create a midwifery association could only set a midwifery section under the nurse association. In Palestine, midwives can’t move freely without being merged with nurses. Recently, a midwife created there a national midwifery committee hoping that they will be able to create their own midwifery association.

Moreover, the WHO nurse chief scientist in Geneva made a presentation in a last ICM meeting, addressing nurse-midwife as a twin entity, and announced proudly the implementation of a Master in Nursing Sciences in Morocco for both nurses and midwives. The concept is clear; nurse-midwife is merged and should be kept as it is. The problem is that, fundamentally, they are different at least for two reasons: the nurse exists to care any person in a sick situation whether the midwife has been created since centuries by the woman to be with her during the happiest, most precious, physiologic sequence of her life. So, their identities are systematically and totally different. When changing hats is made easy as in the UK, US and Australia and other countries, it is not a problem. But when it is not the case, keeping them merged stifles midwifery identity and entity. The Master degree established in Morocco by the Faculté des Sciences Infirmières of the University of Montreal recorded lots of midwives happy to have a perspective to evolute and get a PhD. However, that means: exit midwifery. And they don’t have another choice.

Now, to convince the decision makers, we need to make a strong advocacy evidence based. One argument may not need evidence as training midwives through an indirect entry education program equals to have a batch after at least 5 years whether training them through a direct entry education program equals for them to have two batches available at the same time: nurses on one side and midwives on another side.

This brief analysis is certainly not exhaustive and I am sure that the discussions you will have will address others issues at least as relevant. But I would like to conclude that the midwife needs to be emancipated now more than ever in all its aspects (education, regulation, career plan, working conditions…) and then to take its own lead. Education programs should be reviewed and updated according to a paradigmatic approach that articulates the educational paradigm with the sociocultural paradigm, the disciplinary paradigm (Bertrand & Valois, 1992), (Hatem-Asmar, Fraser, Blais, 2002), and the systemic paradigm (Gherissi 2008). Such an approach should allow producing competent midwives whom services should meets women SRH needs, health system priorities and the professional rules and ambitions.

Atf Gherissi, CM, MSc, PhD. Assistant Professor, Education Sciences. High Schoold for Sciences and Health Techniques. Tunis El Manar University. Tunisia

Please feel free to leave comments and join the discussion here about this very serious problem that faces midwifery both at a local and international level.