 Okay, so now we are ready for Hiba, and Hiba, I would ask you to introduce yourself, please. Thank you very much. Thank you, Christian. Hi, everyone. I am Hiba. I am from Palestine. At the moment I live in Gaza Strip. I received a master's degree in midwifery last year from the University of Aberdeen in Scotland. And now I am working as a clinical instructor at some local universities in Gaza, and also working as a clinical midwife at a maternity hospital in Gaza too. So, this presentation is part from my master thesis, and I am happy to be here and to participate in this conference, and hope that everyone will enjoy this presentation. I will start now with my presentation. It's about women's experiences of a childbirth in the Arab world, a systematic review of equalitative and quantitative evidence. Sorry. This picture was on the day of my graduation ceremony at the University of Aberdeen. I am the second one from the right. The first one from the right side, she's my first supervisor. Her name is Lucia de Ambroso, and the third one, she's Helen Bidford, my second supervisor. And the fourth one, she's Alice Gajal. She's the external examiner for my thesis, and I am pleased to tell you that I was honored to win her prize for the best in the free nursing research project at the College. Okay, so I will start with some introduction about the Arab world. The Arab world occupies a large geographical area which comprises 22 Arabic countries. In the Arab world, marriage is considered the gate to childbirth because it represents the only foundation within which childbirth is allowed, as well as that childbirth is viewed as the purpose of the marriage. Childbirth is a major life event and a special life story and emotional experience for women. Women's experiences and their stories of childbirth are therefore relevant in developing evidence-based care on individual subjective narratives. So, there is an urgent need for women's experiences to be incorporated into health services and health policies toward improving the quality of care in maternity services. Just a simple notice. I am sorry about what you're hearing from my background. I cannot stop this sound. It's from an open area and I am absolutely lost the room and you still can hear the sound. Anyway, there's a report from the United Nations. Okay, thank you. There's a United Nations report demonstrated as a substantial discrediting rate among Arab women in most countries except Iraq, Yemen, Palestine, which is my country, Sudan, Somalia, Mauritania and commerce. The total fertility rate remains over four live pair women reproductive age for these seven countries that I mentioned which indicates continuing high rates of fertility for some poor and rural areas. The geopolitical status at the Arab world nowadays is complex and challenging due to state of the crisis and armed conflict areas such as Iraq, Yemen, Syria, Palestine and Libya. So, these circumstances undermine the health system and cause emergency health situation because of the occupation, internal civil strife and political tension. There are comparatively fewer studies addressing satisfaction and exploring women's reported experiences as an outcome of maternity care in the Arab world compared to Europe and United Kingdom. Therefore, it has been worthwhile in this paper to focus on women's centered care during childbirth experience to develop recommendations towards influencing health professionals and policy to improve health systems and make real change. So, the aims and objectives from this paper was to addressing these two questions. The first one was what are women's views and experiences of the flavor birth when accessing delivery services in the Arab world? And the second question is what does the evidence suggest for policy and practice? The methods for this paper was a systematic review accompanied by a synthesis of the quantitative and the quantitative studies describing women's experiences in birth and labor in the Arab world. The elements of textual narratives and thematic synthesis methods was used to analyze the data from selected study. Also, my experience and reflections of my professional background was also incorporated for the result of this paper to support the interpretation of the data. Now for the findings. Eleventh studies were selected for the review, three quantitative and eight qualitative studies. From the analysis, there were two overarching themes where identified women's centered care and medicalization of childbirth. Medicalization of childbirth with unnecessary technologies can be viewed to exist in direct opposition to centered care delivery with culturally sensitive care where women are empowered and otherwise lead care in childbirth. For the first theme in this paper, the women's centered care in the papers, many women would have appreciated the feeling of control during the childbirth process. Women indicated their need for families' emotional support and their mother's attendance during labor. However, it is forbidden in most public hospitals and actually this is the policy in most Arabic countries. For the second theme, medicalization of childbirth, women experience a number of routine practices that were unnecessary, harmful, and non-indicated of procedures during labor and birth. Those involved induction, artificial rupture of the brain, continuous fetal heart rate, nurturing a frequent vagina examinations, and epizotomy, enema, and shaving. The humanization of childbirth were so important in terms of lack of respect, care, poor pain management, lack of necessary information from childbirth assistance, and lack of privacy. The medicalization of childbirth was observed in the widespread use of unnecessary procedures which affected negatively women's control in the childbirth process, except in terms of demonizing childbirth. In conflict areas and during wartime, such as on Gaza in December 2008 to January 2009, there was no safe place for childbirth, as reported by Wick and Hassan 2012, women in this area reported multiple barriers to accessing a suitable birth place. They reported no mere safe place for childbirth or access to thereby health birth attendants and fear of unknown about their families and their labor status during the constant sharing. This is reported by the woman from Gaza that the woman had facing the war in 2008-2009. In addition, there was the impossibility of knowing when and where the bombing would take place and so safety guarantees were impossible. The wives also reported trying to help laboring women with only simple and ill-prepared equipment. Now for the reflection of my experience in Gaza to support the result of this paper. In 2012, I was working in the largest governmental hospital it's called the Chiffa Hospital in Gaza Strip. The Ministry of Health in Palestine sought to employ midwives in maternity services with WHO, cooperation to build midwifery healthcare during training the midwives with the basic and advanced skills. Midwives in Gaza are authorized to manage low risk cases of laboring women during delivery care as defined by International Confederation of Widwives ACM. However, the midwives in Gaza are unable to order any procedure without reference to doctors in spite of WHO recommendations for midwifery healthcare in Palestine. Their severe pressure worked with high case loads. For example, during my work, there were more than 20 cases with only three midwives. Every shift, one physician and one obstetrician. Doctors request oxytocin infusion for most cases and physiognomy used routinely for most primigraphida. Some doctors use their previous experience and their old knowledge without guidance according to WHO recommendations and evidence-based practice to deal with the emergency. The women also are restricted in mobility and drinking during labor. Therefore, the midwives and the doctors actuated women's labor artificially by playing the paper. All women give birth in lighted homey position and I can say this is the only position the women can have tried birth in the public hospitals in Gaza. And companion support to attend labor is forbidden due to open area in labor world in which the patient's feet are separated by curtains or movable walls. However, it's allowed in the private health facilities to have social support during childbirth. The overall work results is insufficient with wifery support for every woman. To conclude, my experience in Gaza was relevant and consistent with the findings of this paper or this review. The medicalization of childbirth and using unnecessary harmful procedures in post-conflict region were also relevant to the two overarching themes identified in the results chapter. As a result, women's preferences are critical sources of knowledge to explore and consider in such situations. Now for the key conclusion. To counter the effects of intersecting lines of medicalization and technology power over women's experiences of childbirth in this context, health policy makers, decision makers, midwives and other health care professionals need to work with this available evidence of women's experiences and narrative account of childbirth to achieve high maternity quality care. The indications for practice. It's important to involve all stakeholders including midwives, maternity care professionals and women in efforts to improve character practice and also to eliminate unnecessary procedures. There's a need to develop policy in the Arab countries and update WHO recommendations with evidence on the subjective lived experiences of delivery and childbirth to achieve high maternity quality care and women's satisfaction. Also, the decision makers need to empower midwives in their community, either geographically or socially to be able to provide their care for marginal groups or in time of the crisis. Especially now, the situation in the Arab countries is not stable. Also, there's a need for planning for emergency care is essential by mapping the availability place of midwives providing them with basic medical equipment and medicine at home and any clinics in order to facilitate their care to women's needs during a childbirth. The future research. We need a future research to focus on somehow to support women and in supporting childbirth experiences forming a few points of skilled birth attendants and maternity care staff. A future study could also explore in more detail the challenges of providing evidence-based practice to reduce medicalization of childbirth in terms of legitimacy of subjective lived experiences. A future review and research would focus on whole childbirth experience including antenatal or intrapartum or postpartum period are recommended. A greater effort and evidence is also called for women's rights of safe birth a respectful healthcare and accessible and available access to care during complex and wartime. Now I just put some pictures was taken by Al Jazeera. This picture was in the last war the last, I can say, the last Israeli attack on Gaza in 2014 exactly in July 2014 the first picture is from the Shifa Hospital Maternity Unit During wartime we can expect 25 to 50 women over 24-hour period and also the medical supplies are running short due to ongoing Israeli offensive on Gaza another meaning Gaza is still under blockage by Israel so this blockage also limits the medical supplies and we have big chances in basic equipment. The second picture from Shifa Hospital too as the ambulance made its way to the hospital this lady called Hanan El Mahinfin continued to plead and was rushed to surgery where her baby care was delivered by a caesarean but unfortunately died at birth offered for her condition Hanan was not told the news of her daughter's death until a day after the surgery Hanan said, when they told me I felt like I couldn't breathe I wanted to cry but I was too tired I think this is the last picture Maryam joined it, 39 years old it's a mother of eight and now she's expecting her ninth child as I mentioned in the introduction the fertility rate in Gaza or in Palestine in general and in Gaza it's high I can say it's 4.6 baby women and this is the references now I can say, oh, I finished and now I am happy to hear for any questions or any comments Thank you very much Hiba for you Interesting presentation there was one question in the chat right in from Monika she asked if women's mothers are allowed during birth in the hospital Yes, actually this is a policy in the governmental and public hospital they cannot bear birth companies, mothers or any relatives because the area of the hospital with the leopard women is very crowded and if the hospital allowed for every woman to have hair relatives it would be more crowded so this is why they avoid this and I can say there's another reason there's another reason I think it's for cultural it's related to cultural beliefs some husbands maybe refuse to be to attend the childbirth maybe they are shy or something like that so maybe this is the I can say this is the reasons that's another question so I would like the answer was clear for everyone I hope the answer is clear they will ask if it's not clear so I ask our participants to put in more questions to Heber while our participants are in ah ok, Margaret is asking do all women go to hospital for birth or are there a birth at home? Ok, actually we have two systems we have public hospitals and private hospitals at the moment we don't have a home birth except for women she cannot go to the hospital and suddenly have birth at the home but till now we don't support the home birth in Gaza and I think this is bad but for my side I think it's good to support a home birth but to answer your question at the moment the women can have birth at a public hospital or a private hospital just ok, thanks Margaret ok so please put in other questions for Heber I would like to ask the question what is about the breastfeeding rates in your weekend? yeah ok, about breastfeeding Heber? yeah, sorry did you ask about breastfeeding? yeah, breastfeeding rates of breastfeeding yeah, the rate of breastfeeding in Palestine is actually high it's 96% yeah, it's considered high it's 96% that we have cultural beliefs about breastfeeding so if the mother at the beginning have or facing difficulties with breastfeeding her mother or her relatives will support her to breastfeed her baby ok, Akita is asking in the rate of caesarean sections in your region, your country ok, actually I don't have accurate person about caesarean section rates but I can say the normal vagina delivery is more than caesarean section and usually the women prefer vagina delivery and just for urgent reasons or accidental reasons the women prefer for CF but I am afraid I don't have accurate number so, but is it often in your experience or to women ask for CF? no, it's not often because we usually refer the women for normal childbirth but for some reasons for example, if the women have at the Bartam homerage or accidental homerage the lady should be referred to CF yeah, it's a good question are there any wife-led care units at all? in my country there is Norway it's called Norway it's a project supported by Norway it started last year to support the wife-led care unit in Gaza and it started just in one hospital it's in the Chippa Hospital because it's the largest hospital in Gaza and I think they started in this hospital because if this project succeeds in this hospital they will follow other hospitals with that project this unit actually just for low risk cases the midwives can can care with women with women low risk consider as low risk the women don't have any medical problems the wife can care with it without any interruption from the doctors or obstetricians the midwife in this unit don't use oxytocin don't use ebusutony and the midwife using birth deep exercise full exercise and they ask the women to choose which physician usually prefer to have childbirth but most women as I can see they choose light atomy position I think because they think because as they use to have childbirth by light atomy maybe they think this is the best position for them but we try to learn them that you can choose any position you like okay, thank you very much now see let's see if there are any more questions from our participants so what about the education of midwives in the Gaza are there enough possibilities to get well educated as a midwife in your region okay, we have two colleges teach midwifery programs the midwifery program in Gaza it's four years for example at my side I have a bachelor from the Islamic University of Gaza and my bachelor was four years I started a clinical training in the hospital from the second year and then so continued the training in third and fourth year then after graduating we have period called Eternalship period like 300 hours this period to make sure that I am good with wife after graduating and I cannot take the certificate without finishing this Eternalship period so in Gaza we have two program two midwifery programs in Gaza the first one was started in 2001 in College of Palestine called College of Palestine and the second one started in 2008 at the Islamic University of Gaza and also we have another program for midwife it's called Practical Midwife the midwife can be a practical midwife for two years it's called Diploma Midwife I think maybe the word Diploma is different for you because Diploma is known for certificate Diploma in Gaza means that the midwife has learned for two years to be a midwife and actually the practical midwife who has two years she can deal with women support women but for example she cannot provide help in a trial period just so she can help in both natal and natal units that's it what about midwife associations in Gaza how are you organized in your region? okay actually we don't have special organization for midwives in Gaza we have association called nursing association this nursing association can cover the midwife free issues just that so we don't have unit or organization special for midwives and I think this is a weak point for midwives in Gaza but for example if I need help in some issues I can go to this association or I can go to the ministry of health in Gaza I can see another question Christian how long do women stay in hospital after trial period okay for women for women has no much help there if the woman is pregnant she can stay for like 4 to 6 hours and the woman then after that ask to discharge for the multi-gravity the woman usually actually stay just for 2 to 4 hours and most I can say most women stay just for 2 to 3 hours after no much trial period but after if the woman has CS she should be stay at least for 2 days in the hospital and she can go home at 30 or 40 days and do midwives help women at home like visiting them at home in the first weeks after the birth and is it painful? yes we okay having trial period in public hospitals it's free no paid no money to pay by the families it's free but in the private hospitals it isn't free for the supporting women after they going to home yes we have community midwife the community with midwife working in the postnatal clinics and they have regular visits the midwives have regular visits to women's home to support women and to provide some health instructions about childbirth about caring baby caring herself after childbirth and so if the baby needs vaccines or something like that yes that's it so there is a question it's about how is the bonding and the skin to skin supported I am pleased to say that we support bonding and we support the skin to skin contact after childbirth directly we have this and before do this we ask women that we would like to to put your baby in your abdomen some women fears at the beginning some women's they used to have that and for the bonding I can say we have risk feeding at the first hour of childbirth most women risk feeding their baby because I said this is a catcher of news about risk feeding okay so I was going to ask you but you said that the units get really really busy sometimes and how do you cope but how do you cope with that when you're flooded with women Christine I like to hear the hear Eva do you hear us okay sorry Christine no problem Christine please put again the question Christine can you hear me can you hear me Eva Eva do you hear us no sorry what's your question sorry please repeat your question I think I had interruption in there disconnected internet just for a few seconds what did you ask sorry oh sorry I said you said in your presentation that the units often get very very busy how do you cope as a midwife with a sudden with lots of women coming in are you able to hear my staff name or I look at your house I thought you were coming I think please write type in the type in the question okay okay sorry I think I had disconnected internet just for a few seconds okay what's that question what are women's or our own experience of typical midwifery care in both the midwife with great and public hospital okay actually we need to study we need to do study and research about this point about experience of typically of typical midwifery care in both the midwife the unit and public hospital but I just can give you some highlights points about that I can say sometimes you find a woman satisfied about her childbirth if she had if she has sick childbirth without any complications and some women just dissatisfied about her childbirth if she's having complications or problems like family health care hospital home or these things but in general I can say it's maybe half-half yeah yeah I think I can say yeah it's maybe half-half that the woman sometimes satisfied about the rule of the midwife and the public hospital I think it depends I hope it is clear for your question thank you so please put in other questions for Hiba fantastic guest from the Gaza Strip I would like yeah continue question continue continue what is interesting for me while I'm googling I just found midwives with the organization midwives for peace which is a grassroots organization do you know about it sorry I didn't for your question the organization midwives for peace organization yeah midwives for peace I have no idea about this actually no problem okay so we have another sorry about that yeah we have another question how do you cope with the extremely busy unit as you said can be up to 40 to 50 women in 24 hours yeah yeah thank you for this question it's good question actually it's very overall we try to manage we try if need help we can call midwives from other units or midwives who was in the call we try to organize the work with the women for example we just take the women so we have words as you know we have antenatal words interpartum words so usually the antenatal words I mean the antenatal words the women with who they are in the first stage word I mean who they are in the first stage of labor they are in antenatal word this word department or this word is usually busy so we just take the women to the labor room who are nearly to be fully or the women for example 7 to 8 c.m. they dated this is one of the methods just to organize the labor room and to organize the first stage word and I mentioned before sometimes for just away the women just stay after childbirth from 2 to 4 hours so after 2 or 4 hours they are there to space for another woman so by this simple method we can just organize and control this overload and the pressure work and also the situations and the obstetrician they help us in the high risk word so to reduce this overload pressure work so we have another question from Julia who is asking what is the midwife to patient ratio ok I know internationally it should be midwife one midwife per one woman but in Gaza I can say one midwife per 7 to 10 midwives sorry one midwife to 7 to 10 patients in maternity departments in Interabarta and the alternator and maybe you think that we have shortage of mid-flood wife yes we have shortage but also we have graduated midwives in Gaza but because of the clinic status of the of the Ministry of Health the Ministry of Health cannot employ more and more midwives because they have problems with their funds so they just they both for example and that we have actually two midwives per every shift sometimes two or sometimes three labor room we have three midwives per every shift first stage work personal work obstetric ICU we have obstetric ICU gynecological department we have just two midwives per every shift so yes this is what I mean when I said overload work do you have a separate assessment unit or this included with the same unit sorry can I ask you what do you need what do you need with a separate assessment unit is that you need the assessment for the midwives the midwives paper that what do you mean initial form call do you have a separate assessment unit or assessment of presenting women yes we have initial assessment in the reception if the women for example come with labor pain they will come to the admission department and they their women their midwives in the admission department will assist the lady and if the lady in labor if the lady has cervical irritation more than 4 cm more than 4 to 5 cm they will admitted to the first stage work this is what I mean this is what I have but is that what do you mean with the initial assessment about you and so I I saw the sorry I'm afraid we are at the end of our time I would like to thank you very very much for your input and for answering the questions I wish you everything the best for your for your work on a very hard situation and all the best for you and for your family thank you very much to be part of this and I want to be thankful also that I had a chance to get to know to you thank you to everybody here in this room now I will give over to Sarah once again everything good from Austria thank you very much brilliant Christian thank you so much for that I'm just going to do a little bit of housekeeping and save a chat and you are welcome to pop off and have a 10 minute break and stretch your legs while I tidy up this room we will start again at the hour thank you