 my colleague, Shanaz Shahid and she's going to talk to us about community midwife, professional training and strengthening knowledge and skills. Shanaz is a program coordinator and a senior instructor at the Aga Khan School of Nursing and Advisory in Karachi, Pakistan. I'm going to go ahead and mute my microphone and Shanaz it's over to you and thank you so much. Okay, thank you Jane. Dear all, hi, hope everybody is fine. I'm Shanaz from Karachi, Pakistan and it's 4 p.m. evening time. So good morning, good evening and good afternoon to all. So I'll start with my presentation. This talks about community midwives refresher training, strengthening knowledge and skills. So here are the objectives. The presentation will cover the background, purpose, methodology, findings, strength and limitations, conclusion and recommendations. In background, as maternal mortality is a major area of concern in most part of the world despite of several interventions still very high and Pakistan ranks third highest in the world with estimated number of 276 maternal deaths per 100,000 life births and to meet the millennium developmental goals to one quarter of its 1990 level or to 140 maternal deaths per 100,000 life births by 2015 is a bit big challenge. It was estimated that skill birth attendance will need to increase to 90% or higher in order for maternal mortality to decline to 140 in a country like Pakistan in developing world. And in Pakistan, 65% of births take place in homes where risk of death due to obstetric complications remains much higher. This is a substantial challenge given that only 48% of births were attended by a skill birth attendant. So mostly people living in rural part of the country, they go for home birth or you know for a birthing station birth, they don't go to the hospital and they are mostly ending up in having a traditional birth attendant to care for them. So assessment of community medwives in rural Pakistan by the Population Council showed substantial deficiencies in knowledge of various aspects of maternal and mental health. Hence, there was a need to improve their quality of service delivery. Thus, a training was organized by the Aakhan School of Nursing and Midwifery in collaboration with the Maternal and Neural Child Healthcare Program SIND. This training aimed to update community medwives knowledge and skills by discussing evidence-based practices and facilitate CMWs to provide safe maternity care to women and their newborn and ensure timely referral in case of any complication and enhance community medwives family planning, counseling skills and services. Moreover, strengthen their financial management skills to establish and effectively run their own birthing center independently. Since once they get the diploma, they go in their respective communities, so they are responsible to have their own birthing centers. So that's why the birthing financial management skills are very important. Methodology, where the participants were divided into three groups comprising of 14 members in each group and a five-week refresher training was conducted in Aakhan Maternal Child Health Center, Hyderabad SIND and the training comprised of an introductory session for midwifery modules, especially covering antenatal, intranetal, post-natal newborn care, and one specific module was focusing on the financial management skills. Data analysis was done by calculating simple percentages. A comprehensive review on management of childbirth complications and family planning skills was also done, but those were not tested. The sampling, as you see, there is the map of Pakistan and there is a circle showing SIND. So 42 community midwives were identified and selected from 11 districts of SIND. You can see on the side, this map of SIND is present and there are small circles in the districts from where participants were recruited. So it's almost spread all over SIND. Pre and post assessment of theoretical knowledge and skills was done by using the Steven Harvey tool and this tool was pilot tested on four of the participants and this was very important to do a pre-assessment so that we would know what to teach them exactly, what were their lackings. In terms of teaching learning strategies, a variety of strategies were used including discussions, lectures, role plays, simulations, demonstrations, group work, case studies, reflective diaries and energizers. The reflective diaries were very new for most of the participants as throughout their training, their academic life, they have never been taught in this way. So this was very new for them. Now the sessions, the modules, the introductory session, it was an introduction to the international and national midwifery organizations such as the International Confederation of Midwives, Pakistan Nursing Council, Midwifery Association of Pakistan and this session basically covered on the role of these organizations to improve the status of midwives in the world and in Pakistan. The MDGs, 3, 4 and 5 and their relationships with each other, major reproductive health indicators and challenges within Pakistan, the role of community midwives in reducing maternal and newborn morbidity and mortality. As I said prior, mostly the deliveries are conducted in the communities by traditional birth attendants. Those are untrained, they have learned through observations and they are, you know, called dyes. So they practice and the women are very comfortable to go to them. And once there is a complications, they can't handle it and at the very, very late stage the women is asked to now move on. Okay, so community midwives is a special caterer. They are aimed and they target to go into their respective communities where there is no doctor, where there is no clinic or a setup as such. So they run their own setups and provide care, maternity care to women and child. Now the antenatal module, the antenatal module was quite a bit descriptive. It covered the, to discuss about motivating clients for antenatal care. As in Pakistan, women usually don't go for antenatal care and they feel like everything is normal than what is the use to go to a clinic for checkups. So they avoid and they only go once or twice and that's it. And calculating expected rate of delivery and estimating gestational age and as you know the literacy rate is very low in Pakistan. So women, you know, they don't remember their menstrual dates. So they go with the mood and they go with the chronic calendar. They, you know, it was like mid-of-last month or something like that. So it is critical in assessing the getting more to, like, you see if our patients are having difficulty hearing you. Have you done something different? Have you moved your mic away from your face? No, you're very, very distant. What have you done differently in the last few minutes? Is the mic a long way away from your mouth? Could you bring it up nearer to your mouth? Yeah, it's near my mouth. No, that's perfect. That's fine. That's lovely. On you go. Yeah. Okay. So should I continue? Yes, please do. Okay. So I was discussing regarding the antenatal modules, antenatal care modules. So management of minor disorders was also taught since women have so many disorders that can be treated at the midwives' end. So it is very important they should know how to manage those disorders and interpretations of lab investigations. It is very crucial, some tests and basic investigations, a midwife should conduct at her site and those are very critical for making the plan of care of the women. These were discussed in detail and you see some pictures. These students, the participants are, you know, listening to the people have sound trying to hear. They did an examination, an abdominal examination and they were practicing and developing EDD ops calendars for them as they have never saw it before. So they were doing it. We shared samples and we taught them how to do it. Now in the antenatal care module, the concept of normality was discussed and normality in here in Pakistan childbirth is seen most of the time. Right, you've gone again, Shanaz. Hi. You're very much in the distance again. Are you turning over some papers which you're following? Because maybe you're knocking your mic away from your mouth. There's a lot, sorry, no, I can still hear you just, but it's still very fuzzy as somebody has described it. Can you speak to me again? Right, thank you. You're still very, very faint compared to what was before. I know you don't have a brilliant internet connection. I can hear you, but there's interference as well, but you're very faint. There's nothing, none of your clothes are touching the mic or anything like that. The mic is still just near your mouth. Right, okay. I think everybody will have to turn up their volumes on their computers a little bit. It might well be your internet. No, he's still very faint. Would you like to try turning your mic, try turning your mic off and then on again. Okay, okay, am I back? Hi there. Oh, I can hear you better, but there's still a bit of interference in the background. Have a go and see how you're getting on. Okay, so should I continue? Yes, please do. That's fine. Well, that's okay now. Okay, so I was discussing regarding the internet, intranetal care modules. So in this, we discussed the concept of normality. And as I discussed, pregnancy is seen as a disease in our context most of the time. And the healthcare professionals are mostly, mostly getting panic attacks when the women is going to deliver. So remaining the normality of the physiological process is very critical. So that we talked to the students and history taking again, review of the records, maintaining the partograph. That is very critical since they are in an area where there is no nearby any transport services or any other facilities, so they should be given to every other women in our part of the world. So delivering without epistheology is a choice where the choice that they can say is not to do it, but it's needed. Would you like to interrupt your tonight? Your sound is buried at this moment. We can't perhaps hear you. There's just a lot of noise. So could we ask you to do the audio set up with the test once more and be careful to check that your microphone, it is the right microphone. It sounds like there's a lot of noise around what you're saying. So it's very difficult to hear you at this point. Sorry to interrupt. So you need to click in the upper left corner on meeting and then choose audio set up with the test and then do the test. And to the audience here, we're sorry, but there seems to be some problems with the Sianas audio and speak, but she will be back just in a minute. She just needs to check her settings. Absolutely fine. Start off with Annette and then it kind of faded and then it started coming back again. And then it faded and it got really bad. So thank you for that advice. Hello, Annette. I did it. Yes. And there's still noise. I don't know. Yeah, we can hear you now. It's a bit better than before, but it is still a bit noisy and it might be your headset. I don't know if there is any problems with that. But try to go on and then we'll see how it goes. Okay. So now the next post mental care module. So they in this basically we discussed about the active management of first stage of labor and the importance of it like until examination. This is very critical post mental assessment and introducing concept of skin to skin contact. So this is a very new concept in our part of the world. So we discussed with the students with the participants the importance of the skin to skin contact and breastfeeding. In newborn care, basically we discussed provision of the immediate newborn care and newborn examination and then immunization also. Now in management of boarding centers, we discussed about the how to initiate a small scale business as the advice had to run their own setup. So they should be able to know how to initiate a small scale business and what is the importance to develop a business plan and how the marketing should be done and what is the significance of the marketing strategy and moreover networking since they had if they had to refer a women to someone they should have a proper network system developed. The participants demographic the data shows that you see 40.5 percent were below 25 years of age and 33.3 percent was between 25 to 30 years of age whereas 26.2 percent were more than 30 years of age. So less than 25 was the highest participants age distribution. Now the working status if you see this, this slide shows that the 90 percent of the CMWs were working and only 9.5 percent were not working. So that means they had their boarding centers but they were not successfully running it. They had problem with it. This slide shows the knowledge assessment of the participants in terms of entrepreneurial, entrepreneurial, post-school and newborn care, free and post. So free is the blue one, blue bar and the post is the red bar. If you see there is an increase in the post test in all the modules and although we use the Stephen Harvey tool but still the participants were not able in all the components to achieve the level of competencies as given by the Stephen Harvey. This is the skill assessment finding. We again entry into our post and newborn the blue ones are for the free and the post are in the red bar. So again this graph shows there were improvements in their skills once they were done with their training. And additional modules as we discussed since the CMWs are practicing there they should be knowing how to handle some critical complication emergencies during childbirth like shoulder dystocia, PPA. So they should be able to manage women at their level and then refer them and moreover the family planning knowledge also. So we gave a training on childbirth complications and family planning and we taught them how to perform the skills also and we asked them to practice in the pictures you see they are practicing and they were signed off but they were not tested as such for that. Now these strengths and limitations for this study is like it's although the strengths first of its kind in Pakistan such training for the community midwives have never been conducted before and mostly practicing you know CMWs participated in this training. So this was very important very good because they shared their experiences their live experiences that helped to learn and you know gain information to all and participants were of different strategies. So we tried to use different strategies to teach them different concept different childbirth concept. Limitations you know they have only 18 months training they have not been in any other professional education so their attitude their communication was a bit polite impolite and their attitude was harsh at times because they resisted change you know the sample was confined to one province so this was sort of a pilot we could call it a pilot because we just tried to do intervention at one province and then replicate if things go fine and CMWs you know they were resistant to unlearn things since they were with the TVAs as I discussed the dyes so they most of the time did and learned what they were doing although it was without any evidence based knowledge but those were harmful practices at times which was very difficult for the facilitator to make them and unlearn such incompetent things you know and the length of the training. So as I as we showed that the participants most of them were working they were having their own burden center so once they were here for a pilot training so they felt their clients were you know lost their clientele was decreasing so they suggested that the length of the training should be minimized or it should be in you know different brain. This training although it was a new initiative it was a significant effort to enhance some of the minimized development and it was the first of its kind to this training CMWs were able to review the important critical registry concepts and skills and this training enhanced their knowledge and made them competent. Moreover CMWs learned part of the strategy skills that is useful to sustain their services as being independent entrepreneurs and I just show you the in a bubble there is a quote of a participant he actually learned and practices practice much more than what we learned in our training so this was a very pro or positive thing for our team. In recommendation it was suggested that internship opportunities in the community should be given to the community midwife since they have to go there and practice there so it is very critical. Moreover inclusion of financial management skills should be part of the curriculum as the community midwife are you know trained to go and practice in the respective communities so it is very important they should be having those skills. And follow-up of the training participants it's not a one-time thing if you have done it after six months maybe you should go and just have a follow-up of how they are doing and give them a refresher so that that would be effective and useful for them and again as I discussed the duration of the training so it should be looked into a bit smaller or in pieces you know a two-week and then a break and then a two-week some sort of that. So it was a learning point for us. These are the references and thank you. The advice I require for better tomorrow it will be you know our training model so thank you all. I hope you have listened. I know there was so much distraction I can see in the next session most of the people were saying I'm not able to hear and not able to hear. Thank you Linda. Thank you Jane. And as Linda you are asking are you planning of carrying out this yet? We are planning to have such type of training in other parts of the country also and most probably within this year we are going to cover another program. So again we are going to replicate and we are going to take care of the lessons that we have learned from this initial training. Okay as Fiona is asking do the advice get funding to set? There is you know the advice just get the equipment, the delivery kit sort of thing to have to conduct the delivery and they get 2.5,000 to 3,000 you know every month as their incentive but it is not effective for the community advice to run their setup. It's very low for them so they have to definitely generate their own business and serve and earn money on their own. Are the advice class as independent advice? Yes these advice according to the TMC Pakistan Nursing Council they are eligible to conduct independent normal vaginal deliveries and if there is any complications they should refer. But usually they don't have to pay for this training because it is like completely they are trained and they are you know provide funds from the government they don't have to pay but once they are deployed in their respective communities so then they have to you know run their own business and set up and sustain their services. Shanaz your sound is getting quite poor again your sound is getting quite poor again how do you feel about turning off your sound and answering the questions in the chat box okay fine how should I type it yeah just like mute it yeah now you can just write the answers in the chat box to the questions if you like not sure how far we got down the list of what the questions were there now have you answered the one about whether the CNWC them what the CNWC as their greatest challenges sorry it'll be a bit slow but at least we'll know the answers that you're giving Shanaz we're just going to wait for a couple of more questions before we wrap this up okay okay we'll just get this final question answered from Shanaz and then we're going to conclude this presentation