 Alright, I will now take the opportunity to introduce the three speakers we have today. They are presenting on the contribution of the non-physician clinician midwives in improving access to emergency obstetric care to rural communities in Ethiopia. Atela Takele is a senior public health professional in MPH stroke RH and a chief midwifery expert. He has more than 18 years experience in maternal newborn and child health quality improvement in academia, clinical and development activities at different levels. He is currently working at the Ministry of Health as a technical assistant and is leading the second reproductive health strategic plan development 2021 to 2025. Our second speaker will be Beleta Belgu who is a chief midwife and a health monitoring and evaluation expert with over 12 years experience. He has previously worked as an academic dean, clinician, midwife tutor and midwife advisor. He is the monitoring, evaluation, research and learning manager of the Ethiopian Midwives Association. He has managed different project evaluations and researches. Our third presenter for this morning would be Mr. Fecado Alemu who is the public health specialist MPH RH and a registered midwife. He has more than 19 years experience of teaching midwifery and public health in Ethiopia and South Sudan. He's a consultant in management and clinical services, health systems establishment and strengthening, public health initiatives, strategic planning and development of midwifery and nursing. His research interests are in maternal and newborn health, health access and other health related issues like HIV-8 and PMTCT. Currently he's a senior advisor to the Ethiopian Midwife Association and a PhD candidate in MPH RH at Addis Ababa University. Welcome to Kellen. Thank you Katrin and Sylvia as well the audiences across the globe. So I will continue with my presentation and here is outlines and I will start with with the introduction. Maternal mortality is yet unacceptably high in the world and of the 295,000 days, 95% are in low and middle income countries. In Ethiopia there are about 14,000 maternal days every year which is also very unacceptable and again additionally about 2.6 million stillbirths and 2.8 million newborn days occurred per year. So distance from home to health service facility contributed for high maternal mortality rate particularly if the distance from home to institution is you know greater than four hours time. So just do we need really MSc clinical midwives in Ethiopia? So different you know researchers could try to answer all these things. So skill-based attendant with access to cesarean section decreased maternal mortality. Other research indicates that mid-level providers with surgical skill training avert the shortage of obstetric surgeons as task sharing activity. So Nigeria, India, Ethiopia, DRC, Pakistan, Indonesia you know accounts about 50% of all you know all the number of additional cesarean sections planned in a year about 2. I mean 3.2 million cesarean sections in a year. So in 2008 about 278,370 cesarean section need was calculated. However only 1% was achieved as research indicated. There is also high disparity access to cesarean section between rural poor about 0.3% only achieved and versus rural rich which is about almost similar 0.6% and is higher for urban rich community which is about 8.3% have an access for cesarean section. So generally there is less than 10% of facilities provided cesarean section anesthesia and blood transfusion in Ethiopia. Med need for emergency obstetrics is stagnated at 18% despite 100% goal for emergency obstetric and bone care in the world and in Ethiopia as well. Approximately 20% and 1% of the facilities provided cesarean section at urban rural facilities and and respectively as well. So there is a study in southwest Ethiopia. Comprehensive emergency obstetric care service was less than 2% in the remote areas that that there is such you know want to show that remote areas need a trained midwives in cesarean section and 6.6% is in in the in the urban district areas in general. So WHO recommended tasks sharing to address the rural health workforce with surgical gap. So just research you know indicates some some cost benefit analysis when compared to obstetrician and midwives with with surgical skill training. So there is a 30 year cost per major obstetric surgery about 38.9$ for trained midwives and 144$ for you know obstetrics and gynaecology per surgery. So you know trained midwives in surgical skill you know could be cost effective as as the research indicates. In terms of attrition rate of medical doctors about took three bucks after seven years of graduation almost 100% was you know leave their their actual work compared to 12% of of trained midwives and other healthcare providers. Therefore training as a conclusion of these research findings as a literature review training non-physician clinicians is less time consuming and less expensive than physicians do. Employing non-physician clinical costs less than employing physicians which doesn't mean that as as a detailed it says source which doesn't mean that hiring physicians is not recommended but you know hiring midwives in the rural area would be costly you know very interesting for for the community. Crucially non-physician clinicals tend to remain in rural and under-served settings longer in a greater number of than physicians do. So this is taken from a research by Bergsten in 2015. Thank you so much but later we'll continue. Thank you very much. The main objective of this study is to explore the situation of master's clinical training experience and also the current practice and challenges in Ethiopia and the specific objectives are to document the current practice and the related challenges and the second specific objective to examine the situation of the training and competency of clinical midwives in Ethiopia and the third one to identify the training and deployment related challenges of clinical midwives in Ethiopia and the methodology we use exploratory qualitative study with comprised of phenomenological studies and document review. We use this method because most of the clinical midwives were graduated but they are not working as they were trained so we further need to know what was the reason behind their practice or we use this method and the setting Ethiopia is divided into 10 regional state and two city administrations and also the state divided into 68 zones and 900 waradas a total of 4,230 government on health facilities among these 3,980 to our health centers. 52 midwifery teaching institutions are available in Ethiopia. Among these 31 are inverses from the this 31 inverse 6. Six inverses are providing MSc clinical midwife. As of July 2018 the number of midwife graduates in Ethiopia was 20,000 around 20,000 and the study population are all midwife working in the health facility teaching institution government and as well working in NDO and the other senior doctors and gynaecologists were participated and other key improvements from the ministrofiles regional health hospital heads the Dino for schools and the midwifery department heads were involved and the conclusion that I get a midwife participated in FSD were not included in the informant interview and the sample size we use is what sample size and sample techniques purposeful maximum variation sampling technique we are used and the data collection FZD and Ki were conducted from February 1 up to March 2020 and the interview and FGD with audio recorded and digitally transcribed with the consent of participants and Nadish in concurrent field notes were also taken and the meantime taken for the interview was 15 minutes which is ranging from 26 up to 85 minutes like the qualitative data we also assure the qualitative data by assessing the credibility that's whether the findings are plausible and true and also the data triangulation then also dependability and the third one is what transferability was and the findings may be transferred to another setting or context or groups so we check the quality of this qualitative data the data analysis we use at last i version 7.5 use the Ki and FGD data were audio recorded, translated and transcribed verbatism in English and the transcript analyzed using the pre-simple of thematic analysis all careful rate and reread the transcript of the interactive basis and then coding categorized data was done additional codes were created as a team in the coding process and the reporting the report presented uh thematically under each main time septemes brief overview were given and the researcher opinion is provided the discussion part of this research and further direct quotes were used to present the participants voice and the speech and ethical review board of the utopian midwife association grants is the ethical approval and the purpose and objective of the study was well explained to each participant and well informed and also consent for where gain and participation was participatory and the participants were informed so thank you so FGD will continue the result. Head fecado, fecado please unmute yourself and continue. Thank you very much the result was divided into three parts one is a document review and the second is qualitative interview and also on site supervision on document review the program started in University of Gondar in 2000 time after needs assessment done among the stakeholders including the ministrophes um at that time there was a need for to train these midwives to do this procedure as it has been seen by the faculty it appears a very big country with 112 million and with the inaccessible obstetric health service for that we need this mid-level cadres to cover a ruler and under served community so with that this curriculum was started since that the training over 329 clinical midwives were training since 2010 up to the training time up to the data collection time that is 2019 among this 329 clinical midwives master's debuts 30.7 were females this is a distribution with universities as you can see this is the highest number is from University of Gondar and the pink the blue one is male and pink ones are female and in addition the over the six universities which but let I mentioned there are currently 216 students so when we add up the two we have over 550 clinical midwives in the country and again among these one over third are females so among these graduated midwives when we see their status whether they're working actively working or not only 3.6 were providing full CMOC service which means including caesarean section majority of these are working in two out of 10 regions of Ethiopia however when we assess on document review whether they have any significant medical error or not we only found two postpartum wound morbidity but no case fatality and other complications so which means they are practicing safely the procedure safely and we also try to assess whether the students are doing with the standard that is a 15 caesarean section were recommended in the curriculum as the level of competency looking other countries experience so there were 15 css the students achieved more than that the minimum the average number of caesarean section performed during the study time was 25 with a standard division of plus or minus 7.4 the second part of the result was the qualitative finding well these are the distribution of our study participants we interviewed the ministrophiles we interviewed regional health bureau in some country where you are working they may be said state has ministers the others are obstetrician gynecologists who are teachers trainers as well as colleagues school deans clinical midwives the majority of them are males and their ages for most of them is about 15 and 44 team certified to 39 years and have an average of nine years experience so the first thing we were asking were whether this is a program is relevant in Ethiopian setting and can be also duplicated in other countries it has scaled up so almost all our responders to say this program is relevant and the reason they mentioned were that one discovery of a professional they can provide comprehensive care like this is a word from a regional health bureau head who says that in the in that region which have more than six million population the majority of mothers died from obstructive labor and pph so these midwives can provide a comprehensive care that is antenatal care up to preconception care and including post-natal care so in addition to the CS service they can provide quality care in different directions so they prefer these professionals compared to other mid-level providers the other point they mentioned on the relevance of this program was it improved it has impact on quality of reproductive maternal and childhood service by saying this improves the quality of care because this student this level of progress they can supervise and they can train and coach and mentor the junior midwives and bsc midwives and also diploma midwives in in there when they are assigned there with so they can provide the service in general that is another relevance the third one is they provide holistic care to the mothers they provide continuum of care and they provide also non-traumatic delivery like when midwives are doing the the operations they they try to give chance more to non-traumatic interventions like an instrumental delivery spontaneous vaginal delivery before they go to see the reinsection compared to other providers so the this is another quality and relevance the other is in the where these professionals are assigned unnecessary referral to higher centers were reduced so that the mothers and the community are not wasting their time by by by traveling longer distance and by by by traveling to higher centers which are busy and uncomfortable to mothers and like this is a word from a TGD participant they said in their health care capacity they were managing 23 deliveries before the arrival of the clinical midwife but after the arrival of the skin care patient rating 130 per month because the community preferred them and are satisfied with their care service and then the other importance of these professionals they said is timely decision making midwives as they have like accumulated experience in their practice and education they make timely decision especially differentiating normal from abnormal and that is important like when they decide the caesarean section or other interventions they make it timely and they save the baby and the mother the second point next to the relevance where we were as try to assess whether this training is quality up to the standard or not so overall the opening end seems like the medical doctor students and and deans they said that the students are trained in in quality because one of the reason is there is no significant in wound infection and other complications compared to to other providers and in document review we were trying to assess 3100 operations from that document and then from this we only found two complications and it is in an acceptable range and we said the number of professionals which was done by the the midwives in their service area where they are assigned it outnumber the the performance by medical doctors or integrated emergency surgical officers so a minimum of 1000 the minimum caesarean section was seven with the recently assigned clinical midwife to a maximum 1000 was done and then then except to postpartum morbidity no case study was recorded however we found some issues which need to be corrected one is a surgical and theoretical clinical skill needs to be increased to three years in Ethiopia the curriculum is two and a half years but the participants they recommend they it is better to increase two and a half years and sorry half a year a year so that one we can use this the additional half year for internship program in busy hospital this is a word from all the obstetrician and gynecologist in northwest Ethiopia which recommended that this can be used the added half year can be used so that they will develop confidence and then the other is they need more general surgery exposure like they are when the gynecologist and others assess the the the competency of these professionals they say they are very good in obstetric procedures definitely but the abdominal procedures like managing injured bladder managing injured rectum rupture rectum in that case they may need more skill so one they need some surgical exposure in addition to the obstetric one more surgical exposure and the other this can be achieved in busy hospital so if the training can be increased to three years after the basicity the second is in in the visited schools among the six one some have very good skill lab up to the standard the others they they they have no complete instruments like to practice before they go to the actual surgery they they have to practice in a skill lab in a simulated setting so at least it has to be harmonized harmonized among all the schools the other is the student enrollment my my the index where coming from universities but the participants suggested especially this obstetrician and gynecologist from north in Ethiopia he suggested if they come from the practical area they have more like health centers and hospitals they have done universities they have they have more interest more eager for the to learn the skill and also they can go back and serve the community another challenge is the it comes from the professionals themselves they said they even they have agreed to work with with any condition but the minister of health doesn't support them with proper jg and scope of practice so they are they are forced to work under the scope the practice of the license of obstetricians and gynecologists so these were say good morally as well as also professionally hurting them and they are not also getting the benefit why what they have to get and then also the another challenge is organization and health system challenge one there is no proper scope of practice given to these professionals according to their competency in Ethiopia we call it in in some countries it is called job description in Ethiopia we call it jg is not where the formulated and given to this professional and so they have an issue when they go to the practice there so the management the hospital management you have no proper practice you have no proper jg and they are not getting their benefit their professional also responsibility so it is not well understood by the health system both at the at the regional and federal level that is also another challenge in conclusion from our finding we said there is high client satisfaction and the program is highly supported by all stakeholders however even though this there is a consensus that this experience that we drive can be back become imok providers by being taught all the skills needed to undertake advanced obstetric procedures such as the section however lack of policy and regulatory document from ministrophes especially the scope of practice jg job description and proper deployment policy from federal as well as regional levels state level is hindering this professional utilization even the regions which allow them to practice they are not practicing with with jg and they are not even motivated according to the standard or in in comparison with other professional there is a gap in coordination among the ministrophes ministry of science and higher education in curriculum harmonization so that there is some difference in curriculum some mongoose schools and this is not not good to have the same level of training and the same quality of service gap related to availability and adequacy of skill up also well noted especially surgical skill up and the length of practical stay also has to be increased there is a gap uh so we have given this recommendation based on our finding one there is a need to properly recognize clinical midwife with defined scope of practice as imok service providers by the ministrophes there is a need to prepare jg as stipulated in the curriculum and stated competencies there is a need for clear policy document for their recruitment therefore their deployment and have to be motivated and their career paths we have to be clearly stated by the ministry as well as minister of higher education and the region there is a need for collaboration so that a standard training and coordination among the intake and output has to be organized for regional health bureau for state health departments we said the region has to own the program so that they can give proper support especially when these students are going to regional hospitals they will get proper support so the region has to own this program there is a need for pre-regional plan especially a policy document how to recruit and send these students for training and how to recruit them back when they they trained finish their training and their deployment after graduation has to be clearly stated motivation scheme and career and after graduation supervision proper supervision and pull-up and upgrading mechanism has to be needed for training institute for the six universities and additional one which are coming soon so there is a need for curriculum harmonization and standard decision among all training institute so that same output quality assurance scheme such as a skill assessment and deployment in hospitals with client type law is also recommended their entry is mostly from universities has to be revised and more chance has to be given for those coming from service areas why the training institute has to integrate teaching with practical so that the train the trainers has to go to the practical areas and then the practice with their students so with this we are we acknowledge Ethiopia Midway Passive Session who organize and sponsor this training the federal administrators who support us in all process during this training regional health bureau training institute specialist senior obstetrician gynecologist friends and clinical midwives all those give us important training pro first Stefan from Sweden he he gave us an important input and he's also the founder of this program in Mozambique so we want to thank all of you and our our viewers and then the listeners thank you very much thank you very much Fekedu Takele for this wonderful presentation Sylvia you can go on yes another thank you to our presenters Mr. Takele, Mr. Fekadu and Mr. Belete yes indeed your presentation really ties in with this year's theme follow the data investing the midwives with this kind of researchers they give us new evidence that is going to help spearhead the global and regional as well as the national efforts to engage in reproductive maternal and newborn child outcomes worldwide so thank you very much for this very insightful presentation we are now going to allow for some questions from the public if you anybody has questions kindly type them in the public chat alternatively unmute yourself and please ask your question we are reserving merely three minutes for this part of questions while we are waiting for some questions i'm just going to read some of the comments that were said that are posted in the public chat Halima Musa Abdul says great study and presentation and then Getahun says good findings Tena Noiwok, Teneza says great findings good tasks for all the team Gati Lake says well done Feki and the team at all thank you for your nice presentation and Mihiretu Mola and you say salut to Feki and the team interesting findings thank you so much this is from Animo Taghele and then Catherine Shimechero wants to find out how come there are more male midwives training in the universities I think Tefeka too okay thank you very much Catherine for the question generally this is a problem in it's not only in midwifery but in all parts of the training in Ethiopia because you know like in Africa where patriarchal society and more males have access to educations and females so generally the higher education when at the elementary level it's almost the same but reaching at higher in-institute level when you see a degree level and above there more males are represented than females and this is the same for midwifery so but in diploma levels there are more midwives the more diploma middle more females than males but when you see when it go up the more males are represented so that is why there are more males in Ethiopia midwife but in Ethiopian mothers they have no problem with having service with more male and female thank you for the response another question from Jinja another question from Jinja midwife are the men accepted by women giving birth I think this will be our last question okay may I continue yes hello okay uh uh in answering the first question here in Ethiopia there are no the community has no any problem just getting the service from male midwives and males are equally preferred by by neighboring mothers pregnant women and other other part of the community coming for health seeking but even there are other other parts of the like eastern part of of the country uh maybe the community may prefer um female midwives than male midwives and you know the region trained more female midwives than male midwives in that uh in that part of the community otherwise as as a country there is no uh preference of female midwives and uh male midwives okay thank you very much uh that concludes our session on questions