 Okay. So I'm going to go ahead and Isabella, I'll make you presenter here shortly. I just, I do want to introduce you first. All right. In keeping with this year's VI-DM theme, Earth Equity for All, I am very pleased to introduce our speaker today Isabella Smart who will discuss with us Teh Wairoa and Mana Kitonga in Midwifery. Isabella, who is Scottish member, changed her career at 40 and received a degree in Midwifery in Nottingham in England. She worked for six years in the community as a midwife in socially deprived areas and with asylum seekers and migrants before relocating to Aotearoa, New Zealand in 2008. There, she worked as a clinical midwife specialist and diabetes for seven years before becoming a midwife manager for public health community based maternity services in South Auckland in 2016. Isabella is committed to tackling health inequities faced by pregnant women, particularly Maori Wahini and women from the Pacific Islands by providing innovative midwifery services. Thank you so much for being with us and sharing your experiences Isabella and I will now turn over the microphone to you. And there you are. So I'm just waiting for my slides. Oh, do you see the, down at the bottom there? Remember the little arrow if you push it forward. Yeah, I didn't do that for you. There you go. Thank you. Thank you. Kia ora koutou katoa. My name is Isabella Smart. I'm a midwife manager as been explained in South Auckland in New Zealand. I want to share with you some of the work that we've been doing in our community midwifery service, which is part of what's called a district health board. So attached to a hospital and providing community midwifery. Te Wai Ora is a term that was gifted to us by one of our Maori social workers, and it's really about having a healthy life. And Manakitanga is a Te Reo Maori for a concept that is translated in our DHB's values as being kind, but it's actually much more than that. It's about understanding women's needs, wrapping care around them and reacting and providing what women need to get the best outcome in pregnancy in this context. In case any of you are unfamiliar with where I'm speaking from, this is an interesting infographic that shows Aotearoa, which is the Te Reo name for the country, New Zealand. It shows the two islands superimposed across Europe to give you an idea of the geographical size of New Zealand, and the population is just under 5 million. So we have limited and varied maternity health resources, but we do have a system where the health authorities and the Ministry of Health fund self-employed midwives. So the majority of care is provided to women by self-employed midwives who claim money from the Ministry of Health for the care of women, and women can choose the midwife that cares for them. The work that I do in South Auckland is providing care for women through employed midwives, and I'm going to tell you a bit about those women as we go on. Further information for all of you that may be unfamiliar, New Zealand is a bi-constitution, a bi-cultural nation, and in 1840 the Treaty of Waitangi was signed by Maori signatories. Not every Iwi that's equivalent of a large tribal conglomeration signed this with the British Crown, but the idea was from the understanding of the Treaty of Waitangi that Maori would not cede to their sovereignty, and that there would be protection, partnership and participation. Obviously colonisation followed, which meant that these principles were not fully realised in any way, shape or form. So as a consequence the impact of colonisation on the indigenous population is similar to the same experience throughout the world, so I don't really need to go into that in any great depth. I'm sure you'll all be able to have familiarity in your own countries or from knowledge of other countries about the impact of colonisation on health, on maternal health, and on going into generational effects of that situation. So that you get a little bit of background from my perspective and the perspective of Midwifery New Zealand, we're about promoting well-being. We're about trying to enable the best outcome for women from a physiological process of being pregnant and birthing your baby. These are some of the influences, which is always traditional in any presentation to talk about your sponsors and influences and all the rest of it at the beginning. So the College of Midwives, my health board, Counties Manukau Health that employs me, the Midwifery Council here and the Ministry of Health, also the International Confederation of Midwives. And that's just a selection of views of the types of facilities we have and the women we care for here in Oteroa. Now interestingly enough, in terms of striving towards equity, because there's great health inequity at the moment, the Midwifery Council and the College of Midwives in New Zealand have our standards both in English and also very specific standards in Te Reo Maori. So the Turanga Kaupapa, these are standards which clearly outline and inform Midwifery practice in relation to the rights, needs, wishes under the treaty for Maori wahine. Wahine is the Te Reo Maori word for women. I'm very happy for all of these slides to be provided afterwards because it's always attempting to put a lot of information on the slides, but you don't have time to talk about it all. But I'm very welcome for everyone to have this information afterwards, particularly if you can't see some of the very small print that's there on the screen. This is to give you an idea of the context for Midwifery in South Auckland in New Zealand. This is from the latest Quality and Safety Health report by our local health board for our area. And on the right hand side of the screen as you look, you'll see a 36%. And that really is in our area, the geographical area that we provide Midwifery care, 36% of women live in high socioeconomic deprivation. So that's almost one in two children in South Auckland are living in poverty and they're living in sometimes relative, but absolute poverty. And we are twice as many as the next highest health board in New Zealand. So it's a particularly economically deprived area. And if you look to the right of the 36, there are some bar graphs. And it explains that Maori, Pacific women and Indian populations are overrepresented in the most socioeconomic deprived areas. And these are areas that we cover here in South Auckland with our Midwifery Service. Our population in the area is roughly 16% Maori, although I'll show you in the next slide, we birth more percentage of women than that, than higher than that. Sorry, I think I've gone one, two forward, excuse me, this slide here. What makes our women unique and it means that we need to look at how we deliver services and make them relevant is that we have about 20% of our birthing population are Maori women. 34% are women from the Pacific Islands and about 16, 17% are women of Indian descent. So that might be Fijian Indian, or as we say, Indian Indian, because that's what the women tell us to help us understand that they've migrated from the subcontinent. Although 20% on this graph here says European and other in the birthing population actually in South Auckland in the care that we give. And the two and a half thousand women that we care for a year, we have very, very few European women. It's in single digits. Most of our population that we care for is overwhelmingly Pacifica, Maori and Indian. About 25% of our population, birthing populations Indian, probably over 60%, around about 50-60% would be Pacifica and over 30% Maori women. Now one of the things that I wanted to share with you today and in the outline that I sent in for the presentation was family violence. The background to this is in 2017 or 18, between those dates, the New Zealand police looked at their response to family violence. So that's some people would refer to that as intimate partner violence, but we use a wider terminology of family violence because it might not be violence from an intimate partner, but it might be within the family unit. And the police looked at how they were dealing with this because statistics weren't changing over time and their reactions were typical reactions of calling it a domestic, dividing women up, pulling out the perpetrator, helping usually it's male, helping him to calm down, I don't know, sometimes arresting him, sometimes leaving him in the street and then walking away. That's a very wide and generalized sort of overview, but those kinds of reactions where it's a domestic problem between a couple or people in a family and there's no reason, if there's no crime committed, there's no reason for police to get involved. So they looked really seriously at how they were dealing with family violence, and as I say in 2017 or 18, they came up with a completely different approach. They changed their terminology in how they dealt with family violence, they changed the code name that they use when redoing in, so it's no longer domestic. They then trained their police officers to do an overall view and assessment and to write a report after each call out to a family violence incident. Then they set up what were called safety assessment meetings and they involved health authority and other organizations in looking at each family violence incident and looking at what could be done to offer help, support and to ensure safety of the victim. Involved in the incident. And because of that, in 2018, they approached the district health board and said, we realized that quite a few of the women that we're doing reports on for family violence incidents are pregnant and we'd like to let their midwives know that something's happened so that they're aware that women may be at risk and may need some other help and assistance. And the NGOs, so there are a variety of culturally specific NGOs who work alongside the police to give help and support. They would like to get in touch with the midwives and try and work together to help women in these very complex situations they can find themselves in. So at that point I then took responsibility for working out how with the self-employed midwives and the employed midwives, we would find a way that was following our privacy laws and disclosure laws to be able to share this information and to update midwives who might not be aware that an incident occurred because of lots of reasons of women not sharing it through fear or shame or other reasons. So I didn't really know how many were going to be involved and how much work was going to be involved at that time but that's why I say it's about brave, odd and brave collaborations at some stage if you're interested in trying to address equity issues you have to be brave. You have to say yes I can do that even if you've got no idea how you're going to do it and what it's going to lead to I believe and you can start exploring it. So this was almost like action research. I said yes start sending the referrals to us and we'll find a process for notifying people and dealing with the outcomes of it. So we started on this graph the very left hand side as you look at the screen is 2018 and we had about nine or ten in the first month and we thought that's not bad we can kind of manage this. And as you can see what has happened between now and the end of that graph is 2020 is that the numbers are just exponentially grown as the police have sent us referrals and we've been willing to take referrals for women who disclose to the police an incident that they are pregnant but they haven't got any mid we can't find any midwifery care logged for them we then go out and look for those women we contact them and we offer them midwifery care. So numbers this is easier for you to see numbers per year started off with our first first cohort when we started in July to September 2018 was about 11 or 12. And then there was a bit more over the Christmas period and then from 2019 the numbers have just grown they've grown and particularly in 2020 highlighted in red is April to June. That was the time of our lockdown in New Zealand because of our COVID response and we had a number of different levels of lockdown and they we knew in advance that it was likely to be triggers for family violence. People stuck in the house is unable to get out and use the usual safety methods for getting themselves away from their partners. People unable to work people affected by intake of alcohol there was huge amounts of alcohol bought prior to lockdown in New Zealand. And that really demonstrated that you can you can make good guesstimates based on previous information and other research to enable you to have a response that's positive. So we changed our response slightly then and made sure that we up updated all of the women's electronic record with information. Whether they had an unemployed midwife or a self employed midwife during COVID and we've carried on doing that now to help communication. Those numbers are also going up endlessly and we're targeted to reach over over four between four and five hundred referrals a year. And remember we care for only about two thousand two and a half thousand women a year. So it's a large proportion of police incidents where the where they're called. So just to give you an idea of who we are and and how we deliver our services. Coriro is a discussion. So community midwifery there's around about 60 staff in total. We have geographical teams. We offer a service all day every every day of the year and we offer anti-natal and postnatal care. We offer some interpartum support in certain circumstances but that's not what we are funded to provide as community midwives. We've got a variety of team leaders that help to support our midwives that are operationally working and they tend to take more complex work. We have specialty teams who offer their midwives with postgraduate qualifications in diabetes or maternal fetal medicine. We provide a service to the women's prison which is located in Mangere in South Auckland. And we also provide the midwifery service to the refugee resettlement centre that's also based in our area called Mangere. We have three social workers and we have community health workers and they're really vital for the work that we do in making our work in helping midwives to be able to do midwifery and not feel that they're trying to work as unqualified and best of intention social workers and distracting them and taking them away from providing midwifery care. But it's impossible to be able to provide midwifery care when there are other priorities in a woman's life that need to be addressed like she's living in a car or sleeping in someone's floor or she has no food. We have lactation consultants and I also manage a breastfeeding and nutritional support service with what we call kaitipu ora workers. So they're support workers who help women with information anti-natally and breastfeeding and provide practical support postnatally as well as running classes on healthy cooking and infant nutrition. We also have a maternity assessment clinic that runs five days a week and that looks after women who have complexities and they see a doctor and they get a joined up plan that we put on their electronic record. The DHB that I'm employed by has certain values and we really try and use those values in our daily work. They're both English and Tereo Maori in description and the one that we are focusing on today with the work we do is a malakitanga which translates as kind but as I explained earlier on is a much more complex concept in Tereo Maori. This is an article and I know you won't be able to see this clearly but this is an article by Pauline Dawson and others about the barriers to equitable maternal health here in Aotearoa, New Zealand and one of the key things that it stresses is that we know there are barriers there are societal barriers as the effect of colonisation, poverty, dislocation, relocation, migration all kinds of things that can impact on inequity and maternity services but she clearly says that initiatives that appear to be working are adapted to the local context and involves self-determination in research, clinical outreach and community programmes and I use that as my research base really to justify the fact that we can work with a national programme we can work with our standard traditional ways of delivering midwifery care or we can look at new ways of working that are very specific to our particular needs may or may not be transferable, elements of them might be transferable but we need to be proactive in really looking and self-examining ourselves, our biases, our assumptions and to listen to women and to be flexible enough to change our services to meet their needs wherever possible so in relation to the work that we do with women affected by family violence and other social economic deprivation we developed the Te Wai Ora model and that's the model that involves all of the support workers I've already talked about and we think it's culturally congruent, these are community health workers who do a lot of work with us so they engage the women in the first instance, talking to them on the phone, explaining what our services are finding out what their preferences are and previously we were just getting paper referrals allocated to midwife appointments sent out and expecting them to turn up at clinics because that's how we would traditionally have run the service so we find that using the concept, the Te Reo Maori concept of Faka Whanangatanga which is about getting to know people, really understanding them in the world view helps us to engage women in a service that they would perhaps not see themselves represented in or feel that it was relevant to their needs at that time so for women who have really complex health and social needs we use the Ministry of Health model of multi-agency group support plan and the idea is that we talk with the women, she consents to our involvement more than just a midwife doing midwifery care and we led by the midwife and the community social workers and community health workers we listen to the women, we talk to the women about what their needs are it might be housing, it might be food, it might be an alcohol and drug issue it could be anything really and we work alongside the women she doesn't often, we don't hold big meetings we tend to contact individual agencies and get commitment and you can see here we involve anybody that we need to involve so for example we might have on a referral women may have or appears to have an intellectual disability and then we go and we look to see where is it, what kind, what is it how can we work with her, how does she need us to provide our service and for example one woman in particular that was not it hadn't been diagnosed, it was just people's opinion that had become fact in notes so we got assessments for the women we pressured agencies to provide assessments and the cost of assessments found out how we needed to present information to her and she was perfectly able to with support look after her baby and have a good outcome the same with drug services, drug and alcohol services here residential services are very expensive so sometimes it takes us to put pressure on other agencies rather than to say the baby should be taken away and looked after by family because the woman has a drug problem for us to say no the mother and baby have basic human rights to be together and the mother wants help so we would like her to have the opportunity to be placed somewhere along with her baby so that the best outcome for both so those are the kind of work that we do really Isabella just letting you know we just have a few minutes so just so that we can have some more questions as you can see here we have plans that are highly developed with key people that are responsible and we enable everyone to do what's required of them because often when you're disadvantaged and powerless you might know that you're entitled to housing but you might not be able to get it yourself we use their support systems we look at the women's world view and we try to coordinate and enable things to happen for the women we use models that are culturally consonant so these are two teo Maori models of health so that we're not using European and inappropriate health belief systems and models to come up with plans that essentially will fail and then the women will be blamed for them failing we really want in the midwives role is support, advocacy and enabling I'm going through these quickly now but the concepts are the same it's really important advocacy is a huge part of the international midwife role for women being proactive and helping the women to make the right decisions for her and that's the hardest part for us and the hardest part for women because often their voice is not heard and then midwife is vital for their voice being heard we have to be brave the last phrase there to stand up and walk alongside the women and her whana and using our professional privilege to bring about change we have a tremendous amount of power and it's using it in the most appropriate way to support women to get the best outcomes and just finished with what we've achieved really we've reduced our child protection referrals women being stereotyped and women that their assumption that their babies would need to be removed and placed elsewhere we've been able to enable women to achieve their outcomes to feel supported to access services that have meant that better outcomes have been achieved for all our midwives have been better educated in understanding the difference between need and risk and therefore not having defensive practice but having enabled strengths based practice so we're always trying to work in a humane and culturally consonant way with women so that staff midwives community health workers, social workers and everyone involved in them feel confident to help women to get the best outcomes from their pregnancy Okay thanks Harold There we go, thank you Alright so I'll turn off the record actually let's ask a few questions first if you really have any questions you're welcome to put them in the chat or if you want to raise your hand I will keep an eye out for that with those icons as well what an amazing discussion and what achievements you guys have made for sure let's see I noticed a couple of comments one was they've never seen the map of New Zealand exposed on the EU that gives us a good idea of the area that we're looking at let's see things are coming in let's give folks a little bit more I have a question for you Isabella is there an active campaign to recruit and train more Maori midwives for that culturally congruent care what has been the response around that yes we have Maori midwives, specific midwives working in our service and also throughout the DHB there's been a recognition that they are underrepresented so starting a few years ago they created a second training campus it was generally on the north shore which is a really equivalent of an hour and a half drive out of the area to train they've been working on the campus in South Auckland and have been inundated with local women local women who want to train as midwives and I heard, I was at conference yesterday to celebrate International Day of the Midwife a bit early and they have I think the lecturer said 70 Maori students on their intake for midwifery training across the university at different stages of training for Maori and Pacifica and there's been a recent agreement that the Ministry of Health is going to fund specific help and support for Maori and Pacifica students to get into university to be financially supported because often they're from the most deprived areas and also to get cultural support because it can be very difficult to train in an area where you may already be facing systemic and institutional racism and bias and unconscious bias so there's been a lot of work in that area and it's looking really positive really positive Beautiful, it looks like Tammy Heap from New Zealand mentioned that Maori midwives is doing an invitation for support for a Maori my apologies for my pronunciation Maori Bachelor of Midwifery Programme Are you with us? Yes, we had discussions yesterday at our celebration of midwifery I've got to show you my t-shirt apparently the Chief Midwife here said I have to show you my t-shirt but yes I think certainly Namaya and the Pacific Midwives Association I think are all involved in getting everyone together so it's not coming in from outside from people like me that are full of good intentions, it's actually coming from the people that it matters to that are involved in it to define what the support network should be and what it should look like to enable success and hopefully dozens and dozens of Maori and Pacifica and Indian midwives coming into our services to meet the needs of women Beautiful