 Okay. And finally, we get to our wonderful speakers. So I'll turn it over to you, Maryam and company. Thank you. Good afternoon. This is Liz. I'm going to be the first speaker. It's about 2.30 in the afternoon here in Adelaide. So good morning, good afternoon and good evening to everyone else who is joining us and happy International Midwifery Day. I'm just going to give you a little bit of an introduction into how we're running the speakers. There's four speakers. So I'm going to do the first few slides. Then Maryam's going to come in. Nazrin's going to then provide some information on the Iranian context and then Roz is in the family issue and then Roz is going to look at the family issues in the Australian context and then we'll open it for questions. And I'm just having a change of plan because Maryam's going to go first. Okay. Now hand it over to Maryam then we're going to go backwards and forwards a little bit. Hello, everyone. My name is Maryam. And before everything, I think maybe I need to clarify my accent or where I am originally from. Although I live in Australia and I am Australian, I am Iranian as well and I am from northwest of Iran and the dominant accent which I have is Turkish. You might hear a bit different accent from Nazrin as she has just Persian accent. Now the plan which we had this plan with Lee's that Lee's will introduce how we are going to perform this talk then I will just give an introduction to the talk and then myself and Lee's we will go through slides together because you will notice we have different colours for Australia and Iran. In recent times, birth culture and tradition have been changed and challenged by rapid modernization everywhere in the world and so in Iran and Australia. Nowadays, medicalized and surgical births and the overuse of western technology are dominant everywhere. And this appears highly valued by some cultures and some populations especially by Iranians if we compare it with Australia and especially the Iranians who they can afford elective C-section surgery definitely they will adopt it. In this presentation, we will discuss some conflicting social influences and trend among women families as well as the impact of health systems and maternity services service models including accessibility, funding and social acceptability as well as that physiological and social event in which family members participate fully or let's say humanizing birth and humanizing culture to have healthier families and communities. This will improve health outcomes including physical, emotional, mental as well as social outcomes including gender equality, power education and also improved life trajectory for communities and families within countries in general which we will contrast Australia, we as Iran and here now myself and Liz will go through slides according to the color as you see I selected the Australian symbolic color this gold yellowish and the turquoise blue for Iran and just follow the colors and you will pick which one is for Iran and which one is for Australia. Okay there will be a slight delay as we swap over because we are actually presenting from the same room so we need to make sure each others mic is muted otherwise you will hear lots of reception is not good. Just let us know if that is for myself, Liz or for Maryam. So when we look at, we are not going to go through everything because you can read the slides but we want to look at two things in the privacy difference and companionship for birth and a physiotomy rate within looking at this slide. In Australia it is common practice that every woman gives birth in a private room and they can have companions, partners, family members with them. I have had one birth where we had 11 people in the room, it was quite interesting but that was what they wanted, that is what they found comforting to them and they felt safe having their extended family around them whereas some women you will get maybe one or two but it is very rare that somebody actually gives birth in Australia without having a support person with them whereas this is actually quite different in Iran. I will highlight other few issues although we suppose not to talk about what we have already put on slides but later on I decided I might need to explain a bit more. One was about the high rate of skilled birth attendants in Iran which I just want to emphasize that in Iran sometimes I call it over skilled because in Iran that low risk women, low risk births will be conducted by obstetrician as well which I am talking about here and the other issue which in this skilled birth attendance I like to mention is that lack of childbirth education in Iran comparing with what we have here in Australia. In Australia we have that routine antenatal classes if a woman is in need of breastfeeding education she will receive proper and one-on-one education and many more other sessions but unfortunately this is not happening at the moment in Iran in a very organized way that we have in Australia. Then for C-section rate in Iran I need to mention that at the moment the culture and tradition going to the way that if pregnant Iranian women most probably will decide to have an elective C-section with a well-known obstetrician in a private hospital if she can afford that and if it's not financially possible to have that C-section through the private system in the public hospitals which they are teaching hospitals the women will labor under different conditions as Liz mentioned for example that lack of privacy, lack of presence of any support person it's very obvious and I will touch on routine episiotomy that Liz mentioned and it's although according to evidence-based practice it's a kind of very old-fashioned maybe older than more than 30 or 40 years the evidence showed that we don't need to have that routine episiotomy but unfortunately that routine is at the moment continuing in Iranian hospitals and noliparous and even multiparous women in paratubes they receive routine episiotomy and there is a question here which says what percentage of babies are born out of hospital at home in Iran we don't have home births and just in remote areas and some tribes which they keep their tradition if a home birth is happening it's just because they don't have access to hospitals or skilled births otherwise even privately practicing midwives they are not allowed to provide home births therefore the births will happen in the hospital or in the remote areas and I will move to the next slide and I will give back sorry I just muted myself when we're looking at the types of people who are present within a birth we have generally the midwifery group practice model in Australia we have shared care which is shared between midwives and local GPs and we have private obstetricians and we have obstetricians who work in the public sector as well so depending on which model of care a woman is going through will depend on her flexibility to walk around to have water births some end up being on the beds as opposed to being able to adopt any position of choice we've got every birth that occurs in Australia has a qualified skilled birth attendant there be it a midwife or a obstetrician and we're finding that dollars are increasing as well and we've got the increasing group practices and most of our group practices have a waiting list that's actually longer than their physical capacity to take women into their records to actually give birth and once with the records and the evidence research supporting midwifery lead care as well we have quite a lot of obstetricians who are really quite woman friendly with working with the midwives to allow their decisions in helping the women advocate for the women and the health care costing is through the we've got a universal health care system in Australia and so they can choose to be in the public system or the private system where they pay and home birth is different but Ros will be able to talk to you more about that because that's very much her area of practices regarding the system availability of childbirth and different maternity care system in Iran usually it will be just a private system or public care system there is no way of shared care or opportunities for example GP or midwife working together although what I am presenting in these slides is from published literature and later on Nasrim will explain about the new efforts that at the moment is happening by some efforts through government and also Ministry of Health and also with that private practising midwives in Iran we have private practising midwives which their number are almost maybe less than few hundred and considering that we don't have that midwifery lead clinics in Iran midwifery profession and context of midwifery practice that lack of professional autonomy and also power within the mainstream health system puts a bit of let's say extra pressure on pregnant women, on bursing women and in most of the time in private hospitals and even in most of the public hospitals diverse will be controlled and guided with obstetricians and all of these lack of providing different opportunities or maternity models for women pushes pregnant women to accept that C-section is the best and easiest form for her to go through so when we're looking at the demand that's coming from women the Australian health care practice both in especially midwifery group practice but also in our public settings is very much woman centred and we're having increasing continuity of care models and it's something that our student nurses and also our student doctors especially in Adelaide and through the Flinders University are having and encouraging the continuity and understanding that the care of the woman is increased when you know that woman when you've got that rapport with that woman and we've got increasing women wanting to have what they deem as natural birth experiences low intervention, we have an increasing hypnobirthing community that is very much trying to reduce the interventions from when they start though we still have a high intervention rate with induction of labour and depending on where you go through there is some negotiation over post-states that you can negotiate when you're induced however with some private obstetricians and in some public venues then they have policies that they will not go over 10 days post-states and you will get induced regardless and that's an agreement that is usually done there midwifery group practices most of them are connected with the public hospital so yes then that's going to be coming from the policy sorry I've just seen a student nurse term that was my error I did mean student midwives my correction I teach both nurses and midwives and so that's my mistake so we it's very lucky here though the caesarean section rate is still 30% in Australia and some hospitals have lower and our private hospitals have higher and some obstetricians will have differing rates as well and that is very much on their way of practice and it is very much different each hospital and also each state as well I can read some of the questions in the chat box which they asked about the culture and also continuity of care before explaining the parts which I am going to do for this slide I just going to mention that yes the culture over the last 30 years why or for what reason the culture in Iran changed dramatically is one of the I think thriving factors for that high level of C-section as over the last 30 years yes medicalized birth models for healthy pregnant women is equal to a dominant care model which the good example is that C-section and also about continuity of care model in Iran unfortunately it's not possible for women to go through for example mid-degree care model and have continuity of care if she wants to have continuity model it's just through private health system and just via obstetrician but in Iranian system even when mother is prepared for normal births unfortunately the health care environment and health providers are not ready or able to provide for women needs and the thing is usually obstetricians will insist and ask women to use that quick, safe and easy way and not to suffer a pain which later on Nasrin will talk about some family issues in childbirth culture in Iran and as I mentioned already in Iran only women who can't afford the high cost of C-section now have to go through the pain and unfortunately in Iranian culture at the moment natural childbirth has somehow become synonymous with social stature for some women So as you can see that the caesarean rate in Australia over this 10 year period which the latest results that we could get has stayed fairly stable with a slight decrease in non-instrumental vaginal births and a steady increase or steady rate of vaginal births and when we go to the next slide this kind of makes a little bit more sense when we break it down into maternal age, remoteness and socioeconomic we're seeing an increase in the age of women having children and also an increase in the comorbidities as well and so that's making with pre-existing health conditions with increasing body mass with increasing congenital heart diseases for example with diabetes that this is contributing to the increasing in caesarean section rate for the older women and interestingly enough the remoteness doesn't make that much difference when you're looking at the major cities where about 80% of Australians live within an urban sitting and looking at our very remote and with a lot of our remote areas they are actually directed into bigger centres for their care between a week or two weeks before their due date so that they've got that coverage there and we have a similar caesarean section rate between the socioeconomic levels though we have a slightly increased rate with natural birthing in the lower socioeconomic rate which is comparison to the next slide which is about Iran Here is an example, a public hospital it's from this paper which is published in 2012 and the rate of caesarean in private hospitals is higher definitely due to that economic incentives for the medical profession as you see almost 30 years ago just 10% of children were born by c-section in Iran and now it appears to be a very normal way although from 2015, few years after 2009 the Iranian Ministry of Health and Medical Education announced that natural childbirth would be free in public hospitals in the hope that to promote that physiological childbirth as well as the main reason was to increase the fertility rate but many women now see vaginal births as outdated and they prefer the convenience of c-section The lack of a transparent system for public reporting of health information in Iran is very obvious and it made it impossible for me to access the recent childbirth data but according to UN Women's Reports in February 2016 the average c-section rate in Iran was 78% and in public hospitals it was 100% and when I was talking with Nasrin in this regard she said oh no, she read in some reports that it's 50% but apparently they are not approved reports and Linda here asked what was the government's reason for promoting natural childbirth it's better not to go maybe in that area but apparently they feeling that Iran has the capacity opportunity to have population of 150 million not 80 million and also they are I think they don't care about the for example income, education, anything else they are just at the moment considering the population and they started to encourage childbirth and increasing fertility from that but the other issue for encouraging physiological childbirth I think it was the reports from Health Organization about the high c-section rates in Iran which I think they asked Iran to decrease c-section rates or Iran will not get support from WUHO and they started to do some stuff but how successful are they in this motion Nasrin will talk about that but it's in very early stages at the moment and as you see there is another issue in maternity system in Iran and might be one of the main reasons to have that high c-section rate and it's the mild distribution of workforce and this is again public hospital and as you see the ratio of obstetricians to midwives it's very strange we have higher obstetricians in that hospital comparing with midwives and further or the other main issue on top of this mild distribution of workforce is that neither midwives nor obstetricians they don't learn midwifery models of care or even they don't witness physiological childbirth and in Iran midwives their textbooks are the same as textbooks that obstetricians they use them for during their study and practice and therefore all that they learn is medicalised childbirth so when we're looking at the continuing on about the education of midwifery in Australia we have four year education course for direct entry midwives we also have an abbreviated RN entry course for those who won't become dual degree and that gives you a bachelor of midwifery however that doesn't mean that you can work you need to be registered with our national authority and get a practicing certificate to be able to practice within Australia our graduates who come out currently are also need to do some external postgraduate work and then they can apply to do postgraduate studies to become endorsed to give medications we aren't prescribed as from initial graduation though there are some universities that are looking to include that but at the moment it's mostly postgraduate and the training is independent to our regulatory body and it's separate from the government body which is very much different to Iran and we've just had recent changes in the number of continuities that students are expected to do in their training and also how many births so normal vaginal births and complex births and neonatal assessments and that is the same regardless of whether you do a direct entry course or whether you do an RN entry course and abbreviated it's a very very busy time for RNs coming through but it's once again the qualifications that you end up with are different due to the governing bodies Okay in Iran from 1980 since the integration of healthcare delivery with medical education and the establishment of the Ministry of Health and Medical Education it's been the responsibility of University of Medical Sciences to train midwives and place them in health centers, clinics and hospitals in Iran with free education is direct entry for almost the last 40 years which is a four year course and the regulatory authority is Ministry of Health and Medical Education as I said this ministry they train midwives and they put them in the practice and opposite to Australia until recently in Iran just graduation from the course was enough to practice as a midwife we didn't have to have registration although we had mid-be free registration body but we have many midwives in Iran which they are practicing at the moment but they don't have registration number because the Ministry of Health they know exactly who's graduated from there and opposite to Australia I think when a midwife is graduating from this course she has the prescription rights for small formulary, mid-be free formulary they have the qualification and the skills to do episiotomy and to do suturing as we routinely use that in Iran as well as for example IV cannulation which here in Australia midwives they need to have further education training for being able to do this extra let's say skill and what else about but the main thing I think for mid-be free practice in Iran will be that this institutional verse medical control, hierarchical relationship as well as the way that we get trained under the authority of Ministry of Health it limits midwives autonomy and severely challenges the promotion of normal labour and births because we will be trained in the same hospitals as we have that obstetrician students as well and therefore everything gets to be medicalised and under the control of obstetrician team now from Nazrin we'll talk about women and her family issues in Iran as well as the new efforts and what's happening in promoting that physiological childbirth I know Nazrin and some midwives they are very active in promoting physiological childbirth and she will talk about their success and the challenges that they have Okay, hello everybody thank you for introducing me Maya, I guess I will go on with woman and her family issues in Iran as Maya mentioned from 2014 government tries to increase the fertility rate by promoting normal and physiological births however in mother Iran there are new cultural issues leads and influences within the women and within the woman and from her family which impacts women's attitudes towards childbirth some examples are severe fear of labour pain lack of childbirth education plans, CSI, medical staff access of human rights in childbirth and lack of social support at childbirth but many women many women in Iran are turning away from natural childbirth despite policy efforts to increase rates to free government services from physiological births in this part I will highlight some issues around improving and facilitation physiological births in Iran which hope gradually will contribute to cultural changes in childbirth here are some suggestions to reconnect with physiological birth and facilitate normal childbirth in Iran which is the iron childbirth education modifications improvement in midwife free education implementing midwife free education models and importantly changing obstetrics income stream and we tell human rights we believe that none of the above strategies will work but what about recent improvement in childbirth in Iran here in Iran mother can have childbirth at birth these days which is interesting here in Iran somehow it's unique I think in Iran most of the laws are midwives because mother prefers midwife who monitors her pregnancy during nine months accompanying her in labor work as well it shows how much trust and emotion between them begin to grow between them I meant mother and midwife during pregnancy control and the second is changing woman attitude towards physiological birth midwives nowadays are way of power of educational education and they now they have to put time and effort for educating women for physiological birth and I can see every single midwife here in Iran is trying to be a physiological birth promoter also they can legally establish a center as a midwife free and physiological birth consulting and instruction and instruction center they can get this permission legally and start for training women for physiological birth in the private midwife free consulting center and the third is facilitating physiological birth like decreasing physiothermia rate choosing a birth position by mother which we didn't have and as a midwife season I remember that we rule the mother and we told her to what position is better for her but nowadays choosing birth position is with mother with mother opinion I think and decreasing CS rate down to 50% in some centers and the attendance of family has been at first as well which we didn't have it but nowadays we do have some even public and centers and also private centers and one of the attendance asked why you use the midwife free because we have the special faculty as midwife free faculty and it is not here in Iran nurses are in different faculty and midwife students are in different faculty as well and we are graduated as midwife not as a nurse as midwife so I think I finished my part if there is any question I will answer this Thank you very much so we are up to questions now do we have any more slides Okay can everyone hear me well I hope I'm going to be welcome and happy midwives day everybody I'm Ross from Australia here in sunny Queensland I'm going to speak to our last three slides quickly so we can have some time for questions I guess the thing to say from Australian midwives perspective is that pregnancy and childbirth is a public health issue that is profoundly affected by social determinants of health we have a very good national data collection set in our country and we can see that clearly from the data we have so therefore we would argue that public health initiatives to address chronic disease prevention must take account of social determinants of health and the intergenerational effects of early life influences and pregnancy birth and the post-natal period are all critical times for adopting strategies that can optimise a healthy start to life the example provided in this slide is in relation to one of the issues the rising public health issues for midwifery and pregnant women in Australia and it's only one so the biophysical issue relating to increasing body mass index nearly 50% now half of all women in Australia suffer from what we would see as a perhaps a disease of affluence, lifestyle affluence and large BMI results in significant pregnancy complexity and complications for these women and their babies this includes the increasing risks of diabetes and then also for the offspring or babies of those families across their life course and life trajectory and despite our overall low maternal mortality rate in Australia we have very significantly different outcomes for different groups of women and babies related directly to ethnicity to first nation status our Aboriginal and Torres Strait Islander mothers and babies and outcomes on all indices are significantly poorer for these groups they include high mortality and morbidity particularly higher rates of preterm birth low birth weight and death up to the under 5 year age group tobacco smoking is also an associated risk for women and significantly large numbers in these groups also have this particular challenge so studies by several large research groups in Australia the Murdoch Group on the Eastern Seaboard and the Telethon Institute Professor Fiona Stanley's Group on the Western Seaboard also show that culturally and linguistically diverse women have reduced equitable access to services and rural and remote indices also show this for women who reside in geographically challenged areas of our country. The other thing I want to emphasise particularly because it's not spoken about very often but a significant growing psychosocial issue is the burden of suicide in pregnant women and women who've given birth. In Queensland now where I'm working the last three year review of perinatal statistics show that the leading cause of maternal death is suicide and that's significant. Some of these suicides related to post termination of pregnancy and for other women the suicides were during the antinatal period while the women were pregnant and for a number of other women they are associated with perinatal mental health conditions in the first 12 months after giving birth. The other issue that is also a significant issue is domestic violence it is a growing problem in Australia and it cuts across all socio demographic sectors. So as you can see we probably have some different challenges to other areas of the world although some of these things may be more common that are just not spoken about and they involve gender equity issues and women's rights essentially. So the other thing just back to the models of care you can see listed on the slide the overuse of analgesics in labour especially epidural which relates to our high medicalisation of birth in this country. Childbirth education is a variable quality for some families. Some would argue it's more a socialisation exercise in some facilities rather than a true education for women. In Australia most women's partners men do attend the birth as this is a cultural expectation of most women. Another significant factor I must emphasise is the very different intervention levels between public and private maternity care models in Australia. We have a universal health system as Liz mentioned so our funding is varied about 50% of people have private health insurance but we have universal access for all while the majority of women do give birth in public facility hospitals about 70% of upward and greater if you go to a private hospital to have your baby your risk of having a caesarean doubles automatically. So there are significant variants in the rates of medicalisation and iatrogenic interventions in different sectors in this country. I guess we would just emphasise as well that social support at childbirth is expected in this country it's variable across different models of childbirth but as midwives we know that respect and kindness are core values for providing women centred care and that often happens best through the social model of birth midwifery, woman partnership and relationship that is developed over the course of a pregnancy the support during childbirth and then during the postnatal period. So whilst Australia often is seen as a lucky country pregnancy and childbirth are still very much political issues and very more so for different groups of women because funding of maternal and infant services in Australia is not necessarily optimised care equitably for all women and groups. In an area where I'm living and working at the moment in the southern metropolitan area of Queensland one in ten women have little or no contact with health services during pregnancy i.e. they actively avoid mainstream service delivery because there isn't access to culturally safe care. We have large numbers of Aboriginal and Etsy women large numbers of Pacific Island and Maori women and also increasingly large amounts of women who come from other areas of the world who do not find the services on offer palatable or offering them culturally safe care. So this is a highly significant issue for us in terms of providing safe quality and alternative services that are going to affect the life health outcomes of these children and their families. Improvement strategies I think certainly like Emma's been mentioned by our Iranian colleagues, promoting the benefits of physiological vaginal birth as a public health strategy is critical. We need to implement evidence and government policy we need a midwife for all pregnant childbearing women and we need to expand access to the midwifery maternity model because only 8% of women get access in Australia and certainly we need to ensure culturally safe access to the midwifery model for vulnerable and socially disadvantaged women. So in concluding the presentation I think our concluding point is that midwifery is a public health strategy which will improve intergenerational health of families for women wherever they live in the world. It has short and long term health benefits which can offer significant public health gains, save the health system a lot of money and lead to higher satisfaction and healthier communities and families. I'm going to finish now so we can have some time for question. Thank you Roz and thank you to your team. It's a wonderful demonstration of how fabulous this software is because we not only have participants listening in from all over the world but we have presenters that were in different locations presenting together. So we have time for one very quick question if someone would like me to give the mic to you. In particular you can put your hand up or you could type a question there. We will only have time for one because we've got to get set up for the next one. Thanks Roz. Happy midwives day to you too. You can raise your hand if you can find it up the icon in the top tab Dale's still got a tick to say you like something. I'm not sure what. We've got a lot of people typing so I'll just give them one moment hopefully a question will pop up there. Maybe it was thank yous that everyone has been typing. Someone's just clarifying I think that you said the leading cause of maternal death was suicide Roz. I think people are shocked by that. Do you want to make any further comment on that? Sorry I was typing that's right. I forgot I've got a microphone. Yes. It's not what we expect to hear. It certainly varies around the country but in Queensland yes when I was looking at the maternal mortality review of the 40 deaths across maternal deaths across a three year period and our maternal mortality is low because of suicide and the other eight were actually related to other chronic health conditions and malignancies so it's not what we expect but I think it's related to again these social determinants of health and issues that are not very visible often which relate directly to women's rights and the relationships and their access to resources and power and support or social services often or not. Thank you. Alright we will wind it up there but that's really a sobering point to end on but thank you for an absolutely fascinating session I think the differences and the similarities are just so fascinating. So thank you once again, thank you to all the participants I've just got a couple of slides to finish with here Thank you. So I'll be turning off the recording now.