Background: to evaluate the effectiveness of external cephalic version (ECV) without tocolysis or epidural analgesia, the complications associated with the procedure and the association between the number of ECV attempts and cephalic presentation at birth and caesarean section.Methods: retrospective cohort study of all (n = 924) ECVs carried out between 1996 and 2000 in a specialised midwifery centre in the Netherlands. After bivariate analysis, those variables with a p value under 0.05 were considered statistically significant and were tested in a logistic regression model using backward stepwise selection. Analyses were carried out separately for first ECV attempts and second ECV attempts.Findings: in total, 958 ECVs were analysed, 889 first attempts and 69 repeat attempts. Seventy per cent of all first ECVs were carried out before 37 weeks, but half of those were carried out between 36 and 37 weeks. The success rate for first ECV was 41% and for the second ECV 29%. Bivariate analysis showed that the success of the first ECV was positively influenced by parity, non-Dutch origin, higher birth weight, higher age and longer duration of pregnancy. After logistic regression, parity (odds ratio [OR] 2.8, 95% CI 2.1 to 3.7), non-Dutch origin (OR 1.8, 95% CI 1.2 to 2.8) and birth weight (OR 1.7, 95% CI 1.4 to 2.0) remained factors that independently influenced the success of ECV. The odds ratio for duration of pregnancy at first ECV was borderline significant: OR 1.2 (1.0 to 1.4). After an unsuccessful first ECV, only 13% of the women received a second ECV. The prevalence of cephalic presentation at birth increased with 3% after a second ECV. Three cases of complications were reported during or very shortly after the first ECV, and these did not result in serious complications. No complications were reported after a second ECV.Conclusion: ECV without tocolysis is a safe procedure for pregnant women and their babies. Repeat ECV increases the number of cephalic presentations at birth and should be considered after an unsuccessful ECV. (c) 2006 Elsevier Ltd. All rights reserved.

For 86 years—since its founding in 1919—the International Confederation of Midwives (ICM) has been representing, advocating for, and advancing the profession of midwifery worldwide. Today, 86 autonomous midwifery associations from more than 70 countries are members of ICM. The American College of Nurse-Midwives (ACNM) was admitted into ICM membership in 1956, just 1 year after the founding of ACNM! Since that time, ACNM has been one of the leading members of the ICM—both in sharing key documents for developing global initiatives and in taking on many leadership roles within the global arena. On the 50th anniversary of ACNM, the leadership of the ICM is pleased to offer a brief commentary on the ICM's important role in promoting the global agenda for women's health with midwives as key partners. The mission of the ICM is to “To advance worldwide the aims and aspirations of midwives in the attainment of improved outcomes for women, their newborns, and families during the childbearing cycle, using the ICM midwifery philosophy and model of care.”1 These words are worth a moment's thought because they enshrine a concept that forms the basis of the unique midwifery ethos: the aspirations of midwives are inextricably connected with the health and well-being of the women and babies who come to them for care. The vision of the ICM (updated1999) also supports this principle in proposing a future in which both midwives and women are educated, autonomous, self-determining, confident people, respected in their communities and societies. In addition, of course, midwives are qualified health professionals with a particular expertise in the skilled support of women during their reproductive years, with an emphasis globally on care during childbearing. The ideals described in the overarching mission and vision are, in turn, supported by more detailed documents, which have been debated and agreed upon by members of the ICM over the years. They include the following: 1) The Definition of the Midwife (updated 1990), 2) The International Code of Ethics for Midwives (updated 1999), 3) The Essential Competencies for Basic Midwifery Practice (2002), 4) Global Strategy Goals (updated 2005), and 5) more than 30 position statements on topics from promotion of vaginal birth to debt cancellation in developing countries. Each of these core documents and position statements are guidelines or tools that are used as needed by member associations working with governments and civil society to strengthen the profession of midwifery and the use of the midwifery model of care by all who provide health services for childbearing women. The first 3 core documents, in particular, do exactly what their titles say they do. As such, they are in frequent use by midwifery associations and individual midwives to establish and maintain the status of midwifery in their country. The fact that the World Health Organization (WHO) and the International Federation of Gynecologists and Obstetricians (FIGO) have endorsed the “Definition of the Midwife” since 1972 gives the international definition even greater force as a policy tool in country-level consultations. The knowledge that these statements have been adopted in an international forum is a powerful tool, which has been used time and again to lay down and cement together the blocks that build the structure of midwifery as a profession. The fact that Patricia Riley et al.2 in the editorial of this issue suggest that the ICM has not gone far enough in moving the midwifery agenda in some position statements is clearly a reflection of the difficulty in negotiating global statements with more than 150 delegates using a minimum of 5 different languages. This reality underscores the need for ACNM and all member associations to make sure they submit needed agenda items at the Brisbane Council in July 2005 for discussion and action. The Global Strategy of the ICM is a framework that supports the work program of the Confederation and is, therefore, primarily an internal document. However, its structure demonstrates clearly the 3 parts of the work that ICM sets out to do. The Strategy is made up of 16 goals that fall into the categories of 1) addressing women's health globally, 2) strengthening the midwifery profession, and 3) promoting the organization internationally. Each goal is associated with a number of objectives, activities, and expected outcomes, so that evaluation can easily be carried out, and progress toward the goals can be charted.3 Midwives, while retaining their autonomy, are familiar with collaboration in practice with doctors, nurses, managers, and policy makers, and most importantly, with women. At the global level, the pattern remains the same. It will be no surprise to ACNM midwives that some of the ICM's most successful and effective projects have been carried out in partnership with other organizations. At its best, partnership halves the workload and doubles the value, because the results are disseminated throughout both groups. As the only international organization with formal recognition by United Nations agencies, the ICM is afforded increasing opportunities to partner in key policies, events, and activities that promote the shared goals of healthy women and healthy newborns/families, wherever they live. By far, the most significant partnership to date in the global arena has been with WHO. When the global Safe Motherhood Initiative was launched in Nairobi in 1987, the ICM was there.4 Since that time, the ICM has held collaborative triennial workshops focusing on the midwife's role in Safe Motherhood activities, capitalizing on Barbara Kwast's well-known mantra that the midwife is the “lynchpin” in all Safe Motherhood activities. Partnerships with other United Nations agencies are crucial for technical support, funding of selected activities, and worldwide contacts and influence. In 1999, the ICM was added, along with FIGO, to the InterAgency Group (IAG) on Safe Motherhood (the founding group for the Safe Motherhood Initiative). In recognition of its leadership role in childbearing care globally, the ICM was named co-Chair of IAG in 2000, and now co-Chairs with the World Bank the Steering Committee of the Partnership for Safe Motherhood and Newborn Health.5 In the last 2 years, the ICM has forged a hugely successful alliance with FIGO to promote the prevention of postpartum hemorrhage, which has resulted in media events, external funding, and professional workshops being held on 3 continents. Another key partnership is with the International Council of Nurses (ICN) in campaigning for more widespread and accurate birth registration. Both midwives and nurses are well aware of the devastating consequences of a baby going unregistered, especially if that baby is separated from close relatives during war, natural disaster, or epidemic disease. Current collaborative work with the ICN focuses on regulation of the professions of nursing and midwifery, which will be carried forward globally, emphasizing the importance of professionals controlling regulatory matters. A new position statement setting forth the characteristics of midwifery as an autonomous profession will be considered by the ICM Council in July 2005 and will be useful, along with the current Framework for Midwifery Legislation, adopted by the ICM Council in 2002, to move the regulatory agenda. Although interdisciplinary work is often the most effective in addressing health issues for women and newborns, the task of strengthening midwifery cannot be so easily shared. An example of a project ICM is taking forward is the “Young Midwifery Leaders” program, begun in the America's Regional Meeting in Trinidad in April 2004. Five young midwives and their chosen mentors are following a pioneering course, climbing the steep learning curve of leadership and advocacy skills. The meetings are run on something of a shoestring budget, but the commitment of both mentees and mentors is inspiring. Five years ago, the United Nations chose the significant moment of the dawning of the third millennium (by the Western world's counting) to announce the Millennium Development Goals.6 These 8 ambitious goals are visions of a world in which the division between the developed and the developing nations will disappear. The first is “Eradicate poverty and hunger.” This gives you a sense of the type of obstacles that are in the path to obtaining these goals. But the fourth is “Reduce child mortality by two-thirds,” and the fifth is “Reduce maternal mortality by three-quarters.” Midwives are crucial figures in the work toward both of these targets. Women need the care of a skilled attendant to ensure good outcomes following pregnancy and childbirth. True public recognition of this fact is very recent. In November 2004, a landmark statement on the importance of skilled attendance at birth was jointly issued by ICM, WHO, and FIGO, endorsed by ICN. The focus of the statement is the importance of a person with midwifery skills being present during a woman's labor and delivery. The statement represents official recognition at the global level that this presence is the highest priority in the drive to achieve safe motherhood, and in particular, the fifth Millennium Development Goal. It will be no surprise to the readers of this journal that the prototype skilled attendant is the midwife! The joint statement, “Making Pregnancy Safer: The Critical Role of the Skilled Attendant,”7 clarifies the long-debated issues of who and what a skilled attendant is and provides evidence-based guidance, so that work in countries to build the level of human resources needed can continue on an assured basis. World Health Day on April 7, 2005, had the theme “Make every mother and child count.” The accompanying publicity highlighted the “invisible crisis” of maternal deaths and child deaths and their impact on family and community. The Partnership for Safe Motherhood and Newborn Health, the Healthy Newborn Partnership, and the Child Survival Partnership worked together on a common agenda for maternal and child health at a meeting in New Delhi following release of this report. These partnerships are a model of the importance to maternal and child health of UN agencies, donor and bilateral agencies, and professional associations of mid-wives, physicians, and nurses working together at country level. As noted in the 2005 World Health Report, we must take action together to implement the knowledge that will avert the many avoidable deaths of mothers and young babies and for “all families [to] have access to a continuum of care that extends from pregnancy (and even before), through childbirth and on into childhood, instead of the often fragmented services available at present.”8 Thus, the global spotlight is on partnership, collaboration, and continuity of care to achieve safe motherhood and newborn health. And midwives, indeed, are at center stage. This year, when so much is already happening to make midwives the focus of world attention, the ICM is holding the major series of meetings, which regularly renew its 3-year cycle of governance, work planning, and professional interchange. Delegates from many of the member associations will meet in Brisbane, Australia, at the International Council meeting to debate new position statements, elect new officers, endorse changes to the ICM constitution, and deal with other essential components of organizational business. After this meeting, the midwives of the world gather for the Triennial Congress, a 4-day presentation of all that is innovative, exciting, perceptive, creative, and groundbreaking in the science and art of midwifery. For those involved with the planning and carrying out of these events, reaching that time seems like the scaling of a lofty peak—an achievement—a time to stop, drive a stake in the ground, and fly the flag in celebration. Indeed it is; but there will then be the need to turn and look upward again, not back down the path we have climbed. Far off are other peaks, higher still. It is daunting, but we have the tools we need. As midwives, we have the most essential equipment: our hands, our heads, and our hearts. We have climbed so far. What is to stop us now? With strong member associations, the ICM will continue to be a force to be reckoned with, and women will reap the benefits of this force for health. Congratulations, ACNM, on reaching the 50-year milestone! Keep up the good work in the United States as well as in the world!