 It's my pleasure to introduce Cynthia Pitter. Cynthia is a registered nurse and a midwife for over 20 years. She's a lecturer at the University of the West Indies School of Nursing in MONA. She holds a master in nursing science from the University of the West Indies and is doing doctoral studies at the Institute for Gender and Development Studies, where her research and publications are focusing on gender-based violence in pregnancy. Currently, she represents the Jamaica Midwives Association at the board level at the Nursing Council of Jamaica. She is an educator and a trustee for the Caribbean Regional Midwives Association and one of two coordinators for the Young Midwifery Leadership Program in the English-speaking Caribbean. Welcome, Cynthia. We're looking forward to your presentation. You have the microphone. Thank you, Cecilia. Good morning, everybody. It's morning in Jamaica, warm sunny Jamaica, happy International Day of the Midwives, and it's my privilege to be here. And I just want to say thank you to Linda for inviting me and thanks to all the Midwives around the world and in Jamaica in particular. Our national project that we are doing for the International Day of the Midwives in Jamaica is to pay our President, at the moment, at the largest maternity health facility in Jamaica. That's the Victoria Jubilee Hospital. She's been a characteristic call to all the women that are there, all the models, and she will make a presentation to the two first babies that were born this morning, and also she will be awarding the Midwife that has been working the longest at that institution. So like Cecilia said, I am from Jamaica, beautiful island of Jamaica, and we are known in the Caribbean, that's Jamaica in the pink where the hour is, and we are known around the world for our legend, Bob Marley, already an artist and I'm trying to navigate. Okay, we are very honored to tell you that we have the fastest woman in the world and also the fastest man, that is Jamaica is the home of the fastest woman and man in the world. Kingston is our capital and we are a resort country. As a matter of fact, we were around the third island in the world and the first in the Caribbean. This is my school where I work, the U.S. School of Nursing, and the teachers that you are seeing on your right is our president, Mrs. Vester. She visited us in January and she had a public lecture and that's the executive body of our Jamaica Midwife Association. We have over 300 direct entry midwives in Jamaica plus midwives who are also registered nurses. My focus today is to inform you, to talk with you about respectful maternity care. That's the other, our word, maternity services. Cynthia, can you speak a bit closer to your microphone so that you're louder? Okay, this project, I became interested in this project when I started reading about it and realized that USCID has done many work in other parts of the world on this topic. And then I started to see how can we do something about it in Jamaica. So my object is for today where I will look at some definition of terms and hopefully generate some discussions around the respectful care in maternity and also give an outline of the proposal that I'm working on in Jamaica. Respectful maternity care is not something new but it started to emerge. We started to coin the world in the 1970s and 1980s. It was brought to national or global attention in 1985 when Maine, along with Rosenfield, brought it to an international conference, the World Respectful Maternity Care. Since then we have had the safe motherhood in 1987 and also the international conference on population and development program action in 1994 as also initiated this concept. That was from the 1970s of until now. We are still having that problem because a meeting was held in Rwanda in just November 2015 and from that meeting we can say that we are still having the problem around the world. Out of that meeting, individuals were talking that we are teaching Midwest to good vaginal exams but not to be kind. They believe that respect maternity care is sometimes framed as a soft issue without the same urgency as emergency obstetric services but the consequences of mistreatment can be serious and far-reaching. The participants at that meeting agreed that more work is needed to achieve high-quality care that is both safe and respectful. WHO also has declared universal rights of all women as an essential component of quality care. Respectful care, I believe, is an essential component in achieving the maternal health goals of the Sustainable Development Goals for the 2030 agenda. It is an urgent priority. In defining the term respectful maternity care universal rights of childbearing defines it as an evidence-based practical model that focuses on the interpersonal interaction that a woman encounters during labor, the legal and postpartum. Emphasis is placed on the respect for women's basic human rights including respect for women's autonomy, dignity, feelings, choices and preference including choice of companionship wherever possible has proven to be effective in reducing maternal mortality rates. Disrespectful care, on the other hand, in childbirth is an interaction or facility conditions that local consensus seems to be humiliating or undignified and those interactions are conditions that are experienced as are intended to be humiliating or undignified. These definitions prove a platform for various groups to unite and challenge unaccepted social norms and poor health system practice. A growing body of anecdotal and research evidence are now pointing to a disturbing future of health workers such as Midwest. Disrespectful abuse and women and girls worldwide in maternal disturbance. Disrespectful care knows non-geographical boundaries and such is not confined to any particular class or institution. A study that was done in Tanzania shows that 19 to 28% there's a prevalence, shows that it's a health crisis, you know, and the study was prompted by the number of facilities of women attending facilities to give birth. They realized that there was a decline, so the study was done and it shows that women describe their abuse as non-confrontational. They resign once they're to abuse because they are being abused. They stay away from home, stay away and stay at home or they simply accept their abuse or they return home or bypass certain facilities or providers. Mayor Respondent described more assertive approach like the fathers on the other hand would request better care or they pay a bribe or lodge a complaint and in one case assaulted a provider. Also in Mexico, disrespectful care was documented. In Kenya, 20% of the women also reported disrespectful care. They found that the study that was done found that non-confrontational care was very pronounced, was very significant, non-dignified care, some women report neglect or abundance or non-consensual care are either physical abuse and some have to pay. They were detained because they did not pay their fees. A qualitative study was also done in South Africa where it found that negative interpersonal relationship with caregivers was one of the themes along with lack of information, neglect and abandonment and absence of labor companion. The patient provided a relationship and an antinatal care uptake at two referral hospitals in Malawi also documented disrespectful care. What are the types of this respectful care? Bros and Il reported that physical abuse, for example, sitting, rock-forcing legs apart, condom pressure for normal delivery, non-consented care, non-confrontational care, non-dignified care, discrimination-based and specific patient attributes, abandonment of care, detention and facilities. In another study done by Manawa, absenteeism or unavailability of providers, corruption, poor communication and willingness to accommodate traditional practices, authoritarian or frightening attitude was also documented. The question is asked, are midwives part of the problem? Skill-birth attendants such as midwives, behavior and attitude are critical components at its release, the best practice in maternity services. Health care providers are more likely to value and adopt professional caring behavior and to obtain skills and knowledge to practice respectful maternity care. Midwives usually work diligent, treat women with compassion and even use their own resources to assist women in the referral in case of life threatening. Emergency. The model that we use in midwives model of care has deep respect for normal skill-birth and the uniqueness of each child-bearing woman and her family. The model is characterized by caring, empathy, support, trust, confidence and all those positive words. As a matter of fact, the International Confederation of Midwives and the International Council for Nursing also mandated their constraints to protect the rights of their clients. The midwifery curriculum in many countries needs all of us threatening in the areas of human rights and respectful care. There are many documented stories and narratives that have implicated midwives and we can make reference to the White Ribbon Alliance. Also in Jamaica, we have our own. A lot of some women reported disrespect and abuse. So we can safely say that midwives are a part of the problem. There are other potential contributions to disrespect for care, however. For example, at the individual level, some women become normalized. They accept their views. They don't talk about it. Lack of community engagement and oversight, financial barriers, lack of autonomy and empowerment on the part of the women. In terms of laws and policies, lack of human rights in some countries, ethics, principles at the national level, lack of environmental, national laws and policies, lack of legal redress mechanisms and lack of regulatory bodies. In terms of governance and leadership, lack of that we are also lacking in that area. The service delivery in many of our practice areas, they are lack of standards and leadership, supervision for respect and non-abusing childhood. Lack of accountability. The provider, sometimes they have prejudiced, provided as the standard a result of training, provided demoralized shortness of human resources and poor professional development opportunity and provide a status and disrespect. What do we need to do? The literature in the United States when we look at the needs assessment speaks to women of color. That's what I found documented is usually women of color or immigrant women who would report disrespect and abuse which is often due to poverty and lack of health insurance. Their maternal rate at that time was 28 per 100,000 which is trending now I think it's on the 14th. All governments are legally obligated to protect respect and fulfill the care of women. We found that lack of information about sexual health discrimination in the healthcare system lack of access to sexual and reproductive healthcare and poor quality of sexual and reproductive health information and services. You heard Karleen just spoke about adolescents are also affected as studied down by Mary Stanton shows that refugees women are also affected it's usually women in low and middle income countries women age 20 to 29 years old women with more than one children. Women who are unemployed have limited education also are disrespectful, disrespected. The characteristics of the abuser lack of information about sexuality and sexual health discrimination in the healthcare system lack of access to sexual and reproductive healthcare. Poor quality of sexual and reproductive health information and services and of course overwork staff poorly paid and erratic schedule create a stressful environment that can underline the respectful care. Of course, respectful care would have impact. One woman's negative experience may be enough to dissuade her family, neighbors, or friends from giving birth in a facility or the day seeking care. It can also impact the maternal and mortality rate. Many patients feel difficult or ignore where the healthcare workers pay to feel demoralized. Disrespectful care is a recipe for dangerous delivery practice normalization of abuse by healthcare providers and health facilities and of course it can lead to barriers to countries achieving international goals. We have known data on the cost but I can just imagine when a woman complains and sometimes these cases would end up in the courts and they have to be compensated, it can be very costly. A study was done in the Caribbean in Domenica and Domenica they have a 98% of deliveries that are done by skilled workers it shows that there was overcrowding and there was understaffed and experienced staff uncomplicated labor and deliveries were over medical life, emergencies were not dealt with in a timely fashion and providers suffer from compassion fatigue, demoralized and overwork. Quality of care was lacking and the labor and birthing process was the worst. So we see we have that documented but we don't have a study done in Domenica so we want to look at the Domenica experience. Our maternal mortality rate at the moment is 89 per 100,000 live birds nationwide 96% of our birds are hospital and 90% of our birds are conducted by skilled attendants including women. Domenica like many other countries in recent times have several reports of abuse by healthcare workers including midwives. Mothers never return to a particular hospital after claims of inhumane treatment. Three women have declared that they would never give birth at that hospital again after they said they were abused and mistreated by doctors and nurses one reported that she became suicidal and had to sweet professional medicine. She was told by the doctor that she was the reason for her death as she was too fat and too lazy to push out the baby. I was slapped, laughed and I was in a note of consciousness and that doctor looked at me and said how can I sleep so I must have sleep after that. So some of these are just un-dotal notes that our women are experiencing. A 16 year old claimed that she bore twin recently at the hospital and alleged that one was stolen after birth. I must say that there is usually an investigation and the chief usually follows where they may but most times the publics are not informed being mistrust for the system. The theory that I've not yet coined any theory but the area that I want to look at is central to having any discussion and this is the kind of abuse there should be and how midwives are predominantly women treat other women especially vulnerable women such as those during the birthing process. Midwives are engaged in struggle to assert their professional and middle-class identity and in the process deploy violence against patients as a result of creating social system and maintaining fantasy of identity and power. We can look at patriarchy as one of the theory that we could use the theorem and to give it a theoretical framework on the proposal that I'm working on. So the aim of my study will be called an exploration of respect for maternity care in middle-class practice and I believe it's a conduit for achieving the maternal health for the 2030 agenda in Jamaica. In this study I hope to examine the level at which respectful midwifery is being practiced in maternity care in Jamaica. So I will explore the mother's perception of care received during childbirth because what a woman perceives as disrespectful probably is not so. We have to do an investigation and we also want to examine the midwives perception of care for women during labor. We'll be using a cross-sectional study design using mixed method approach. We are going through the ethical approval process at the moment and we hope to start in September and November. So for the mother's the quantitative aspect of the study we'll do a telephone survey using a questionnaire which was developed by the International Literature and for the midwives with your qualitative study where we do in-depth interview using a semi-structured interview guide. The women that will be included are mothers who were delivered by midwives during the month of September and November. Mothers who gave informed consent, mothers who were 80 and over. Midwives who have worked in the area and midwives who gave informed consent. We'll exclude mothers who are below 18 and mothers who have had zero infection. We'll also exclude midwives who are on a part-time basis and midwives of course who are only during those two months. So we'll be doing our study at two public facilities that offers maternity care in the Kingston metropolitan area based on a 75 million person living in that area. These two institutions are both teaching hospitals and therefore they're more like we open to accommodating research and using the finding. Both institutions of a midwifery program and midwives are rotated through the labor world every six months. Because we have to try the tools that we will be using. It's new so we'll be pre-testing the tool at another hospital which has similar patients and that serves similar populations. Sorry. I believe that this study is relevant to Jamaica because it will strengthen the practice of respectful maternity care in Jamaica. It will also educate models of their rights to be to respectful care inform the midwifery curriculum develop standard that is tool to measure the prevalence of disrespect and abuse in maternity care and also inform future intervention on respectful maternity care. This study will also support the systematic review being currently conducted by WHO in which they hope to identify all forms of disrespect and abuse experienced by women during childbirth in facilities where the way forward. What do we need to do? We need to create we need greater support from government and develop development partners for research and action and disrespect and abuse initiate support and sustain program designed to improve the quality of maternal healthcare with a strong focus on respectful care as an essential component of quality care. We also need to emphasize the rights of women to dignified, respectful healthcare throughout pregnancy and childbirth involve all stakeholders including women in effort to improve quality of care and eliminate disrespectful and abusive practice generate generate data related to respectful and disrespectful care practices and this will ensure some system of accountability and meaningful professional support are also required. The fundamental right for respect for high quality healthcare should extend beyond the perinatal period to accommodate women throughout their lives and development of a tool to measure women's perception of respectful maternal care in public health facilities. We need professional development opportunities and quality of improvement program for example free and in-service program for midwives who are already in the system and of course we need to adjust shortage. Very importantly we need to celebrate those midwives who have given selfish work so we need to recognize them even where the problem of abuse are uncovered and this picture shows last year in midwives of the point in part of Jamaica were celebrated. In summary, while respectful maternal care primarily emphasized the absence of this respect and abuse healthcare providers and other staff it also advocates positive and supportive staff attitude and behavior that increase women's satisfaction with her birth experience. The theme of the midwife, women and newborn the heart of midwifery this is where it's all stuck with us that midwives of the world continue to work hard every day to ensure women and newborns to see the quality care that we deserve. The end and I want to thank you for listening and Jamaica no problem. These are some of my references. Thank you. Any questions? Thank you so much Cynthia. You have a couple of questions. The first one is why did you exclude birthing mothers who were under 18 years old from your study? I did that specifically because in Jamaica we are very protective of our teenage mothers and they have to get a different types of consent. So at the moment we just want to focus on the adults and then in the future we hope to do that data so we can make a comparative data. And then Nicola is asking does anyone know when whose systematic review will be published? Yes. WHO has done a lot of work and you can Google it and you will get information. They mostly focus in South Africa, Uganda, Tanzania, Mexico. So there is the data out there from WHO already. Other questions for Cynthia? Remember to speak on the microphone. If you raise your hand I can open up your mic and you can speak instead of typing. We'd love to hear from you. Cynthia have you collected any of the data yet? We have not. We just have anecdotal notes. That's actually what I'm after. I'm after some of the expressions of others about the disrespect or the abuse that they were subject to. And anecdotal records, yes. And I've highlighted some. So those that are highlighted are the ones that was made public in the print media. Oh, Nicola is asking you to expand on what you have based your questionnaire on. The change project. I don't remember the mean of the acronym. So there are two projects that are supported by UNFPA and USAID. The change project and the traction project. They have done studies and what we have done was to modify their question here. For example, the studies that they have done, they have three tools. One that will observe the midwife well. He or she is giving cure. One that they will ask the patient about their perception of cure. And one that will ask midwives is her perception of cure. So the questionnaire focus on the nine types of abuse, like physical abuse, family giving support or physical need. And then I will turn it around and modify. They gave me permission to modify to ask the questions of the models. So if you base on the change project and the traction project that was done in other parts of the world, they have given me permission to use. And those, like I said, they are focusing on the types of abuse according to WHO and ICPD rights of the women in child care. So, Nicola is asking are you looking at issues of poor practice, medicalization, or only straightforward disrespect and abuse issues? And I think you've given us an idea about that. Yes, because we are focusing on midwives. We could do study to extent on health care providers, but at the moment we believe that midwives are predominantly women. And we believe that women are to be women, but we know that that is not so. So that's why we are focusing on midwives at this moment. As midwives, we want to let our voices heard in Jamaica. So we are embarking on a series of studies looking at other areas to get some attention or some traction in Jamaica in terms of creating our own knowledge. Cynthia, even before you collect data, do you have an idea once you've identified some systematic problems that might be creating disrespect and abuse? What you might use as some corrective actions? Yes. We start looking at the curriculum first. As all the midwives, we need to be a model for the younger midwives. We have annual symposium like a conference in Jamaica each year and Respect for Care is one of the topics that is presented each year. So we are working on it. And whenever issues should come up, we usually attend to those issues immediately. So we are working on a course straight-in on a super-visory and our leadership role in the practice area. Do we have any more questions for Cynthia? I'm sorry, I've just come back. Did you answer the question about what you based your questionnaire on? The questionnaire was based on other things that was done. We used their tools. So we have modified those tools for our cultural preference. And it's based on the types of abuse that are identified by the ICPD and the White Ribbon Alliance. Okay. Thank you very much. Okay. So I think we've run out of questions. So I think we have to say for coming today all the way from sunny Jamaica. I actually live in Scotland where we have sunshine today and I was sitting in the sun for a little while. Just to make the use of it, we don't get sun all that often. So that's a lovely presentation. Thank you very much. I'll just run through these final slides so everybody knows we do each session. Okay. So just a reminder for me to turn off the recording.