 a lot of project management and technical assistance support across various projects that we have at MSH. I work with institutions and with CSO organizations as well as communities in Africa, Asia, Latin American, Caribbean. And my areas of expertise are health planning and budgeting. I do a lot in health finance, cost revenue analysis and resource mobilization. And I'm now very happy to start entering into the world of advocacy. With that, I'm going to let my co-presenter Carla Berdichesky present herself and then she'll present the first half of this presentation. Thank you, Eliana. Well, I will introduce myself. I am Carla Berdichesky. I'm based in Mexico City. I trained as a medical doctor and I was always concerned about the inequalities in health provision. And that's why I went into public health. I have a master's from the London School of Hygiene. And for the past 10 years, I have been an independent consultant working for a variety of NGOs, UN agencies and foundations. And in these projects, I have designed and implemented a great variety of research and advocacy projects on sexual and reproductive health issues. Not only in Mexico, but for Latin America and the Caribbean, I'm very much focused on maternal health. And I have been involved in a series of projects on midwifery recently, and this is the fifth one I collaborate on. So I'm very happy to first give you an introduction on maternal health in Mexico. We can have the next slide, Eliana, please. For those of you that are new to the scene in Latino health in Mexico, our maternal mortality rate is not very high. It would not be too striking when compared to other countries in the region or in other regions. It is currently at 36 deaths per 1,000 live birth. However, when you analyze maternal mortality, rates dramatically increase in states with higher concentrations of indigenous populations or with greater poverty levels. And these are the states where our project is based on. And for example, in one of these states, Chiapas, the current maternal mortality rates more than double the national average. So a great majority of deliveries currently nationally are occurring within hospital settings. And they're actually high rates of skilled provider attendance. Average is 96%. However, public health services are oversaturated. There is a lack of personnel and their shortages in material and financial resources. There was an article published in the Lancet in 2016 by Miller. And Mexico is really characterized by this model of too much too soon provision of maternal health services. Where there is really a routine over medicalization of normal pregnancy and birth. And this description includes really unnecessary use of non-evidence-based intervention. As well as a use, sorry. Very happy to all the doctors. Thank you, Ana Clara, for doing this job with me. We are together physically, but well, we are in the same position as well. In the work that we are doing, we are in the same position of intervention. We are in the same group. Carla, I think we can continue. I think there is some disruption. Thank you. So the unnecessary use of these non-evidence-based interventions are really harmful when applied routinely and are overused. For example, caesarean deliveries in Mexico total more than 40% of births nationally weigh over WHO recommendations and can even go up to 80% in some settings. And as facility births have increased, they have overstressed available human resources. And this has also resulted in low quality of care that in the end translates into high prevalence of disrespect. Next slide, please. Under the MDGs, Mexico fell short of achieving the two-thirds reduction in maternal deaths. However, national and state-level governments have really remained committed to improve maternal health. And the Mexican national government has officially recognized midwifery as an important strategy to address maternal mortality. And there is an explicit goal from the MOH to include midwives at the primary care level for low-risk pregnancies, but with referrals to complications to the secondary level. And so in response to this government will, in 2015, a group of private foundations, NGOs, and UN agencies began looking into strengthening maternal health services through the integration of midwives. Specifically, the MacArthur Foundation made a strong investment towards increasing options for midwifery training, increasing recognition of professional midwifery and its benefits to maternal and neonatal health, and strengthening regulation and policy and efficient integration of midwives in the health sector. So there are many complementary efforts currently underway. As an example, UNFPA is partnering with four Mexican midwifery schools to improve training for midwives to a recognized international standard. And the program provides skills, building, and works to ensure midwives are supported and championed by their local community. Partners are also coordinating recruitment efforts between midwifery schools and local health institutions to ensure that graduates are fully utilized and placed in communities where they are most needed. So timing here is key. And investing in the training of midwives will have a lasting effect. By 2030, the target date for the SDG, the population of Mexico will have grown by nearly 20% to 143 million. And professional midwives can provide capacity and level of care that ensures a growing population can receive the care they need to ensure healthy women have those marks. Next slide, please. I'd like to give you a view of midwifery in Mexico today. According to the state of the world midwifery profile on Mexico in 2014, there were only 78 professional midwives that were dedicating 100% of the time to maternal and neonatal health. However, nurse midwives that total more than 15,000 professionals in the country currently spend a low proportion to none other time on maternal and neonatal health. The country has 23,000 traditional midwives that are often accompanying women as part of the referral chain, and only in some communities remain as only available and culturally acceptable health provider. Given the few numbers of their 3.5 million pregnancies a year, professional midwives remain very in position, and most of them have independent practices supporting home-based deliveries and only a few work within the health system. Regulation is open to professional midwifery, but must be strengthened. For example, labor coasts permit the employment of professional midwives. However, national and state policies are currently lacking a definition of the role and competencies of a professional midwife. Professional midwifery schools are relatively know and have restricted capacity to a few hundred graduates per year. And university nursing programs have recently reviewed and strengthened midwifery competencies and training, and will soon be graduating professionals with a full set of ICM competencies. Efforts on association are underway and newly established Mexican Association of Midwives have recently officially been recognized by the ICM. As described earlier, this MSH project is part of the MacArthur Foundation efforts to strengthen midwifery in Mexico and runs from November 2016 to December this year. The project goal is to strengthen the advocacy capacity of midwives and see stakeholders to make compelling arguments that are sensitive to and effective within Mexico's political context. This supports the three pillars of the project. The project focuses geographically on five states that are highlighted on this map of Mexico. They were selected as they combine high levels of maternal mortality as I explained earlier, but there is a strong political commitment to improve maternal and neonatal health. And they all have strong institutional capacity and human resources to build on in order to conduct activities to promote the inclusion of professional midwives. My colleague Iliana will take over in a minute to describe the detail of our advocacy course that is one of the main activities of the MSH project. But I would just like to take advantage here to highlight that there are a series of complementary activities that are also taking place. For example, we have produced a documentary of the midwives that has become an integral part of the maternal health team in a rural health center of Dalbo. And also for the state of Dalbo and in coordination with health authorities, we have produced this state level midwifery profile that is on the slide to be used as an apple. Next slide please. Finally, and before passing the presentation back to Iliana, I have a review with this post that illustrates the motivation of Carolina, one of the professional midwives that is part of the advocacy training exercise and works in the state of Chiapas. One of the first states in the country where access to quality maternal health services is often available to a very few. Iliana can you take over now please. Yes, thank you so much Carla. We'll go to the next slide. Okay, so now let's take a deeper dive into what this advocacy course looks like. The purpose of our advocacy course is to build the skills of mid-level health professionals to effectively advocate for programs and policies that integrate midwifery into the state and national systems. So we're offering this advocacy course in four phases. The first phase was a virtual phase where we offered five to our virtual seminars. During those two hour virtual seminars we had different guest speakers come in from the central level Ministry of Health. We had people from some of the network organizations like the Safe Motherhood Committee, the Association of Professional Midwifery in Mexico, and we even had some people from other countries, midwives from other countries that wanted to talk about their success stories. And during this virtual phase we also asked that the participants do an assessment of what midwifery looked like in their states. So how many midwives they currently have professional midwives and what their maternal mortality is for example, what kind of midwifery associations exist policies. And so they completed those assessments in that first phase. In the second phase we held a one week in-person advocacy planning workshop where we actually got all the participants together and in teams they worked on evaluating the results of their assessment to see really what those midwifery gaps were in their states. And then based on those gaps they created an advocacy plan for the following six months. And then we moved on to phase three which is the phase where we're in right now where they're currently implementing their advocacy plans in the six month time period. And then we'll eventually move on to phase four which will be in October where they're going to have a results workshop. We plan on inviting people from the Secretaries of Health again interested CSO organizations, network organizations and possibly other health professionals to hear about the results and the outcomes of the advocacy plans that the teams have implemented. During the in-person advocacy course where we taught them how to do advocacy planning, I just wanted to put a plug in that we use the IPPF handbook for advocacy planning as a basis for our content for that workshop. It was absolutely great to use that. We are currently offering this course to six teams with a total of 22 participants. The teams come from the states of Chiapas Guerrero, Hidalgo, Morelos, Oaxaca and San Luis Potosí. We designed this course for not just midwives, but midwives, nurses, doctors and other midwifery advocates that are committed to strengthening midwifery in Mexico. And the reason we included not just midwives is because we thought it was really important that we have other cadres support midwifery in these advocacy plans. And the goal really in Mexico is to see these midwives working as a team with the health professionals in the different hospitals and health clinics and what a perfect opportunity for them to start working as a team doing advocacy planning for midwifery in their states. We also found that the teams, the participants in each of the teams already work together on midwifery in their stage, which was a huge added value because we already had a group of people that knew each other and that were delivering or managing midwifery in their individual states. So during the virtual part of the program and then also throughout the rest of the phases, we created a group on our leadernet platform for this particular course. In this group we've been able to post all of the recordings from our virtual sessions. We also have forums where we have the participants discuss the topics that were presented in the midwifery, I mean in the virtual sessions. And then we also right now that they're in their implementation phase, we're using this forum to allow them to update us on how the implementation of their advocacy plans are going. One thing we did find about doing this first virtual phase is that I think the participants were a little timid in the beginning to participate in the virtual sessions and even in the virtual platform. I think that maybe while in discussing with them during the face-to-face workshop I think they found that it was not necessarily a methodology, the virtual platform that they're used to using and so it took a little bit of warming up for them. So that was good feedback that we got and we also decided to put strict homework assignments and deadlines for when they need to listen to the virtual sessions if they weren't able to attend in the live sessions. And I think we also had a lot of discussions with the teams just behind the scenes, which little by little they became a lot more active and warmed up to the platform and started becoming incredibly participative. The only other thing I'll say about this virtual platform is that right now we're hoping at the end of this course to transfer all of the content and the material to a platform that the investigative, well in Spanish it's investigación en salud en demográfica. Inside it's a local consulting group in Mexico that created a midwifery platform for Mexico. And so the idea is that we're able to transfer this onto their platform so that in the future this course can be offered. We'd like to package the methodology for all of the phases so that people in the different states could eventually offer this or maybe even the Institute of Public Health or the UNFPA in Mexico could replicate this for other states. It's right now we're only working with those five. So just to give you a sense of what the advocacy plan topics are. We have advocacy plans that are focused on decreasing obstetric violence, some on increasing municipal funding and support. Some to develop midwifery champion groups and then others to establish standard operating procedures for once a midwife graduates, how you insert them into the overall health system. What we found was interesting actually with this group of participants is that it took them a while to really really understand what we meant by advocacy planning and what advocacy was all about. And I think what's been great about the way we designed this program is that they got a lot of theory during the virtual sessions and even the face to face workshop. And now that they're actually doing the implementation, they're really seeing not just what advocacy is but what it looks like in the implementation phase. And they're really starting to see how important it is to have constant follow up of your advocacy activities, how to be persistent and resilient in the face of adversity. And so I think that's been a very valuable part of this course. So moving on to the next slide. These are our formal expected results that we're looking at in the short and the long term. We want to see that, you know, our participants complete the course and that they were able to develop and successfully implement their advocacy plans. And in the longer term, we'd like to see that out of all of the, oh, I'm sorry, this is replicated, but in the longer term what we want to see is that whatever focus they have on their advocacy plans. That they're able to actually influence policy and influence their environment over time. We understand that in a six month implementation period, we're probably not going to see a whole lot of policy changes in that time period, but there's still a lot. I think that we can see in terms of like the capacity building that we're doing for these midwives and for these participants. And the other thing I would just like to say is some of our recent results have been just seeing that the different groups from the different states are for the first time really communicating across states and sharing knowledge and experience. And that was very valuable in the in-person session. And now that they've all met each other in person, it's great to see them discuss virtually, you know, just what their experiences have been so far. And I think that a lot of the states have very similar challenges when it comes to midwifery. And in fact, some of the advocacy plans are similar across states. And so this whole initiative has just really been great for them to share those kinds of experiences and lessons learned. We also have some states that have less midwifery in their states than others. Some are a lot more advanced in terms of the degree of midwifery integration into their health system. So I think it's also been great for those teams or for those states that are a little bit more behind to really learn from other states that are more advanced as to, you know, how they made all those successes happen. And, you know, what are the different activities that they're currently doing to continue building midwifery in those individual states. Currently right now, what pretty much all the teams have gotten is they went back to their states and they've obtained local buy-in for their advocacy plans and obviously getting more and more stakeholders on board. They've continued to revise and perfect their advocacy and M&E plans as they implement them. And a lot of them are just starting with all of their stakeholder meetings and really starting to influence policy, which has been really great to see as well. So we have quite a few lessons learned before I end. So the selection process was, it took a bit of time, but we realized I think after having gone through it how important it was to spend a significant amount of time identifying the right participant profiles to ensure that you're putting together an effective team. In some states we saw that we had a great variety of participants. We had the representation of midwives. We had some very high level people from the Secretaries of Health and we had a lot of people that were managing midwifery in their states. And so I think when in those cases we had a very strong and effective team where we had a variety of people that could cover those different roles that were going to be needed during the implementation of the advocacy plans. In other states they weren't as varied and so I think they have really faced challenges in how to move their advocacy plans forward. We didn't quite nail getting those high level people that could really open doors for those participants or for those teams once they go back into their states. And what we're seeing right now is that we actually have those teams integrating more and more people that aren't necessarily in the course but just really getting buy-in for what they're doing and really getting that support locally to help them open those doors. But I think definitely spending more time really getting to know what the participant profiles are and making sure that we have a diverse team was very important. It also was very important for us to work in teams rather than having individual trainings. Over the years MSH has really promoted this form of training mostly because it's much easier for a team to go back to a work site or to go back to their states and really promote and implement the work that they're doing or learning in the training sessions versus having just one individual. And like I said earlier it's also great that these are teams of not just midwives but of doctors and nurses and it's great to hear all these different voices supporting midwives in the advocacy plan implementation process. The other thing that we learned about the virtual sessions is not all participants had great connectivity especially our participants from CHAPAS that are from more rural areas. And also we saw that because you know we were working with a lot of doctors, nurses and midwives that their schedules varied from week to week. And so we were trying really hard to nail down a two hour time period where we could have our virtual seminars and we did Saturday mornings but still a lot of people were either on call or working at the time. And so it was difficult for everybody to participate in the live sessions. And so one thing that we've been considering for the next iteration of this program is to actually have the sessions pre-recorded and uploaded onto our site so that people could listen to them at their own pace. And what we would do is probably just have homework assignments for each virtual seminar and have a deadline for when they have to listen to the virtual seminar and complete the homework assignment so that we know they listen to it. And then also the homework assignments are basically discussion questions on our forum to really generate discussion across the different participants. And so that was just another lesson learned that it would be great to just give them that opportunity to have more of the self-paced virtual sessions. The other is the that we learned is in terms of expected results versus the time frame that we had. So this is a one year course we started in October. And last year and we're going to end in October of this year. However, the implementation period for the advocacy planning is only six months. And so our expected results really had to change thinking about that. What we're really trying to accomplish here is that we increase the capacity of midwives to be able to advocate for themselves and for the services that they offer. And so I think that in that six month time period we can definitely measure that the degree of capacity building that we achieved. But like I said earlier in our results page it's it's going to be difficult for us in the six month time period to see things like policies changing in their states it who knows it may happen and that would be amazing. And I'm sure there are other things that are going to happen like them being able to create a more enabling environment for midwifery by creating more champion groups for example. But definitely you know if in offering this you really want to see that policy change as a result of the advocacy work it is important to give a lot more time during the implementation period of their advocacy plans. So that was another lesson learned. And then also the elections are going on right now in Mexico and we didn't really foresee well we just didn't know that it was going to fall within our time period and so that was definitely something that the participants have seen as a challenge because they're trying to influence a lot of policy makers but right now they're not sure which policy makers are going to be in their states after the elections. And so that has definitely halted the implementation of their plans and so it'll be really important for future just to kind of for future reference to look at these types of events like elections and see you know possibly how they can impact and compensate for that by maybe adding more time or maybe adjusting your start date of the advocacy course. And with that, I just want to end with this quote from one of our participants. Her name is Issela Barrera Cortes she's a physician. She's this one right here and I really like this quote because it really shows you the motivation behind why those who participated are in the course. And she says I decided to participate in the advocacy course because I see how midwifery improves the quality of maternal health services for women and their families. Because of this since 2016 I've been advocating for midwifery in my state. And definitely this was something that I saw across the participants and talking to them about why they were interested in this. And they were really committed to improving the quality of maternal health services and maternal health outcomes in their states and I think that's why all of them are extremely motivated enthusiastic and participative in this program. So thank you very much again for listening this is the whole group of us. There's Carla and there's me. And then we have all of the participants here. This was during our in person workshop. We are going to have about 20 minutes I believe a question and answer and I are more than happy to answer any of the questions about just the context in Mexico or anything related to our advocacy course. Thank you, Eliana. That was an informative presentation. I love your last slide in the quote at the end. I certainly can appreciate here in the United States that collaborative piece where during your advocacy planning stage you made sure to include not only midwives but doctors and other healthcare professionals. I think that's just such a key piece of this whole plan and can certainly appreciate that part of it. I have other comments but I want to make sure that we have time for questions from any of any of our participants. Please feel free to use the chat or raise your hands for questions or comments about the presentation. And Eliana if you can throw the presenter piece back over to me. That would be great. Sure. And I couldn't help but when we were listening when I was listening to think about the similarities at Frontier Nursing University. We have distance based community community based distance education and so a lot of our students are in rural areas. And certainly have some connectivity issues for the online piece of their didactic coursework. And so I had that question for you. How did participants overcome the connectivity barrier if there is one but you seem to have answered that. And the other piece of that was just thinking about working professionals and how do you kind of adjust for that time and place bound piece of that work. Just because they're in clinic and they are busy. So how do you get them all together to be able to collaborate in person or face to face. So this I think falls in one of our lessons learned in terms of our selection process and really being very careful about the participant profiles because in some of the teams we were able to get people from the same like groups to apply within the same state. So for example in San Luis Potosí we have a team of people that work in the same hospital and they're in the same office. And so that makes it really easy for them to come together and to find time to work on their advocacy plans. But then in other states like for example Morelos like they're all working in different parts of the state and not necessarily in like a central location. So it is a little harder for them to meet although they're very motivated that group and they every Sunday find a central location where they meet. But that's just an example of how it's easier when you select people that are already in one team that are like in one location to work on those advocacy planning activities. And then in terms of the connectivity so we did have quite a bit of trouble with connectivity especially for some of those states that don't have great connection. And as a response to that we did record all of the sessions and then just give them the link to how they can stream it and then they would just go online and complete some discussion questions. And so that really helped a lot and I think that's why this lesson learned about you know making the virtual part a little bit more self paced came out because I know that these are clinicians and that they're very busy and sometimes like even when they're not working they're on call. And so giving them the opportunity to participate at their own pace I think would be really important for future offerings. Yes, that's great. Related to connectivity but not specifically responding to the question. It's it's been key to maintain motivation within the groups. So we've, we followed we followed up on the phone by email and really made efforts to keep motivation high and feedback to these teams that are now off back to their state that working really on their own and within these really creative groups but it's been key to follow up with them periodically. Yeah, and I would add also. So in the beginning I know I mentioned that they were very timid especially on the virtual platform and participating in the seminars. And I think that took a lot of like follow up to to really get them engaged in the platform and in the course and we had very strict rules for like who can proceed into the in person face to face workshop so it was you know people who completed their assignments who attended or listened to the virtual seminars. I would send like weekly updates to the entire group and then to some groups to the entire participant group of participants and then to separate groups and then, you know, if I saw that there was an individual that was active or participating I would have you know my own call with that person or I would reach out to that person to see you know how best we could support him or her so that they could you know be more active and some people just realize that they really did not have the time and they dropped out of the course but it's good to see that they're actually a lot of them are still supporting their teams and some of the implementation activities that they're doing. And so yeah I think I agree with Carla like it did take a lot of persistence and a lot of following up and like she said not just over email but also over the phone over whatsapp so it did take a lot of that. Thank you both for that for that insight that the pearls of wisdom from your this process and it will be special part of this presentation for viewers does anyone else have questions or comments for the presenters. Well I certainly do want to thank Eliana and Carla for their work and for presenting I know the long term results of this will have a greater health impact. It will be interesting to be nice to hear and update later and see how the groups are doing and it's such special work so certainly thank you both for that. If there aren't any other questions I'm going to stop the recording now and we appreciate everyone's participation. Yes we do and for those midwives that tuned in we so appreciate all of the work that you do for women children and families all around the world so thank you very much for that. Thank you very much Carla we appreciate your time this morning also. Thank you for the space it's been a very rewarding experience to see these midwives and these midwifery groups empowered and moving on towards new goals in Michigan and Mexico so thank you for the space and we'd welcome any further questions after this talk if there are any. So thank you for having us. Thank you so powerful.