 Okay. It's time now to introduce our, our facilitators or our speakers. They are two, as you can see on your screen, we have, and they're going to talk to us about a single belly Midwest care for freedom, mobility promoting a dynamic bath. So I, before I hand over to them, I will have to say something a little about their work. So we start with Inez. Please Inez, raise your hand so that they can see you. Hello. Good. Inez, Inez is Inez Rothman or works at the research as a researcher. So Inez Rothman works as a researcher. We can't hear you, Mary. Yes. Something went from briefly here. So Inez Rothman, can you hear me? Inez Rothman works as a researcher at the Flemish Association of Midwives, focusing on strengthening everyday based midwife care. She recently led a development of campaign move freely swing your belly freedom of mobility during labor and birth. In her own practice, lava yoga, Inez has been permanently supporting over the past seven years, parents and children with yoga, mindfulness and body and body work from preconception to the first 1001 days of postpartum. She is a certified perinatal yoga teacher and works intensively with the craniosacral therapy and perinatal Inez grew up in Germany, but has been living in Belgium for the last 16 years. So let's talk also briefly about our next facetier speaker that is Lee, please raise your hand so you can see you. Lee first worked in the maternity ward and delivers delivery room for the last 20 years. In 1999, she started a home birth practice as an autonomous midwife in Belgium. Her calling lies within a physiological birth and women centered care. Lee makes the connection between caregivers around birth to improve their human rights in child birth. Recently, Lee retired from the practical work. Lee has a deep knowledge of physiology in birth and a critical view of protocol and guidelines. She fights for deeper knowledge in physiology in birth, midwife related care, continuity of care and for the autonomy of wife and midwife. Thank you so much. That is a short introduction of our facilitators and I need to hand over to them so that they take us away, they take us, they continue with the presentation. Well, thank you, Mary, for this lovely introduction and were you assigning the presenter role to me? Yes, I have already given you the presenter role. Okay, because I can't move the slides, but otherwise I'll just give you a sign to move the slides further ahead then. Okay, well, thank you again, Liefa and I are very pleased to share some insights from our research which we've undertaken at the Flemish Association for midwives over the past one and a half year. And we've done that research together with a couple of colleagues which are listed here on the right. And we derived the findings, some of which I want to share today with you based on the campaign swing your belly or move freely. The starting point of our research was that we were fascinated by the fact that a woman, a wild woman, moved during childbirth. She, when a woman gets all the space to follow her instincts, a woman swings her belly and swings her hips. She may dance during childbirth and in order to deal with the labor pain sensations and to help her baby to move smoothly through her pelvis. And I'm sure you all have witnessed that as well. In practice, however, we see often that the healthcare context or the healthcare approach used may not always facilitate or hold that space for women to move freely. Sometimes women may feel ashamed to move freely during childbirth or they just don't know that they can or are allowed to move during child labor. And you probably also witnessed that and the labor wards that women tend to sit or lie down and bed and may not get out of it. So that's a pity because there are a lot of advantages of freedom of mobility and some of which I'd like to share with you in a moment. So what we would like to achieve with that campaigns when your belly is first of all to give that freedom back to women to move freely during labor and also to give that freedom back to midwives to hold the space for women to move freely and to apply their knowledge and skills to promote physiological labor. So how did we approach our research? Well, we focused, as you see here, on four questions. And each of those questions we tried to answer based on the four pillars of evidence-based research. First of all, we looked quite into detail into how do we define that concept freedom of mobility. Secondly, we tried to learn from the history of freedom of mobility. Thirdly, we looked at the effects it has on maternal and neonatal outcomes, including the birth experience. And the last question we tried to answer is what are then the factors, the barriers or the promoters of using freedom of mobility. And I'd like to share or answer question two to four briefly while I'll leave it later on. We'll also focus in much more detail on question number one based on her long-standing experience as an autonomous midwife. So what we've seen is that throughout history women have always moved during childbirth. They have used upright positions, flexible sacrum positions as you see here on these lovely paintings and drawings and other artworks. And traditionally childbirth has been a very intimate happening, a ceremony within the circle of women and supported by a wise woman, a midwife. And it was from the approximately the 16th century onwards that a number of developments led to the fact that our view on childbirth and freedom of mobility changed. Just to mention a few, the development of obstetric instruments of general anesthesia, the twilight sleep movement all led among others to the fact that we sort of more medicalized vision on childbirth emerged and that women suddenly all were lying down in birth and supine positions and didn't use movement that much anymore. And it was only half of last century that increasingly more evidence-based research appeared and testifies of the many benefits of medwifery lab continuity, care models, and also of freedom of mobility. And so we looked at that research evidence. What we did is we did a review of that literature. We included in our research six clinical guidelines, six systematic reviews to RCTs, and a lot of other qualitative studies looking at the birth experience over the past 10 years. And what we found there is that, not surprisingly, upright and flexible sacrum positions do improve the birth experience, in particular the women's sense of control and autonomy and confidence. They also sooth labor pain sensations. They shorten second phase of birth, they decrease the risk of instrumental birth, and they promote better fetal positioning due to the many biomechanical effects of birthing positions, and they decrease the risk of abnormal fetal heart rates. So all that research evidence is very encouraging and positive, and we need to share much more that evidence both with parents and healthcare providers. Our review of literature did find somewhat uncertain evidence concerning other outcomes, like the rate of C-section, perineal trauma, epiosotomies, postpartum blood loss, as well as maternal and neonatal outcomes in case of epidurals. But I have to say that if you look on an observational study level, we do find many positive effects, whereas on a meta level we couldn't, while the evidence was uncertain. What is important, and I'd like to point out that many of these studies have quite some limitations, especially with respect to the freedom of mobility, just to mention a few. The first one is that we hardly can sort of capture the freedom of mobility concept by randomizing women to one or two positions. And because women move in and out all sorts of different positions all the time, and we can only know once in labor what positions may be beneficial. And those studies can, well, it's very difficult to capture that complexity in a randomized controlled trial. Another limitation of the research study is that the healthcare context, the healthcare approach was very different across the studies. And we sometimes just didn't know whether Medwifery-led continuity care models were used or whether women could actually follow their instincts and be wild, or whether the physiology of labor was supported. So what we then did to do is to do some further research, because as we've seen, as I said on the one hand, women want to move if they follow their instinct throughout history, women have always moved. The research evidence is positive concerning the benefit. So why is it then that women still do not get sufficient space to move freely and intuitively? So we looked at all sorts of factors, barriers to using freedom of mobility promoters. And maybe given the time, I'd like to mention just a few. One of the most important barriers is also not surprising is the over-medicalization of births. For instance, continuous electronic fetal monitoring limits freedom of mobility, unless you're maybe a rope jumping champion. But if women are hooked to a monitor, obviously the wires limit the woman to move freely. Sometimes women just don't know or feel obliged not to move if they are attached to a monitor. And so we looked at the clinical guidelines and also research evidence of fetal monitoring. And all of them actually recommend in a low risk labor and birth to use, not to use continuous electronic fetal monitoring, but intermittent escultation. And still we see that increasingly being used in hospitals. Another one is epidural anesthesia, obviously depending on the dosage women are less mobile when you have an epidural. And here in Flanders the rate is 71.2% of women use epidural anesthesia. We do see a trend towards using lower dosages and a bit more modern technologies. But overall the majority of women do birth with an epidural. And what is important here to realize is that we still have a lot of opportunities even with epidural anesthesia. We need to encourage women to move also with an epidural. And there are possibilities if we adapt birthing positions and if women get much more support by their partners and the healthcare providers to stay mobile. Maybe just to mention others, of course, route to an application of hospital protocols or protocols which do not focus that much on physiology. Another barrier, the beliefs of healthcare providers is another one to if we are not used to watch for waiting, then we may feel more comfortable intervening in a situation which may not need management at all. Another barrier is that students midwives but also practicing midwives have a limited knowledge of the biomechanical effects of birthing positions. They just don't get enough opportunities nowadays to observe what is a wild woman and what kind of signals does a wild woman give in labor. How do we interpret that? And we could turn those barriers into promoters. Of course, other promoters are, for instance, midwifery-led continuity care models at the Flemish Association for Midwives. We also just published a report on maternal and neonatal outcomes in case of births which were supported by autonomous midwives. Very interestingly, we also see there women at home birthing at home or supported by the midwife more mobile using all sorts of positions. Also, more home-like birth environments and hospitals are interesting using birthing bars and birthing balls and birthing bars, ribosomes, stint lights, things like that, promote more mobility to the labor. And also multidisciplinary scenario trainings with other healthcare providers are very interesting in this context. And last but not least, of course, we also need to reach the parents and raise their awareness on freedom of mobility. And that's why the Flemish Federation of Midwives developed that campaign, Swing Your Valley, to take home some of these messages to both parents and healthcare providers. Then I'll pass on to Felita. Okay, I was asked just to tell you some stories about freedom of birth, stories of women who give birth. And when I want to talk about it, I see a lot of women pass during my years in my career. And I see, for instance, a little woman, she was a very small woman from Asian origin, and she had a mass belly, and she gave birth at home. And when I arrived there, she was running through the apartment from the one side of the apartment to the other side. And the only thing I had to do was stay aside so that she had the room to move as she felt she had to do. And she started running with every contraction, and after the contraction she takes some rest, to breathe, and then she started running again. And at the end, she ended in a door opening, and she was standing there with her hands supporting herself with her hands. And she was half squatting, and then she pushed, and she pushed three times, and I had a baby in my hands. So it was a very nice story. It was a baby of four kilos, and he came right away. So she birthed very easily because she had those mobility. When she didn't have the chance to move, it could have been a very disastrous birth, but it was a very smooth birth. Now, another story that I see is when a woman was giving birth to her third child, and she was in her bathtub. A large round bathtub, and she had a lot of place to move, and she was on her knees. And then at the moment that she started pushing, she started to turn around and from her knees on her back, and then back to her knees. And then, when she was on her knees again, the baby was in the bath. So she needed to turn out of her baby instead of the baby spiraling out of her. She turned it around. Another woman I see, she was a really big woman, a tall woman, she was a big woman too. And when she moved through during all the labor, it was her first child. And at the end, she was also standing right up. And that's what my experience also is, is that a woman who is taller than usual or bigger as usual, she has much more comfort by standing up positions to give birth. What I think also is very important is that as a midwife, you get so much signals on what's happening in the woman herself with the birth when you are just watching her to move. The movements that she does tells how the baby is in her belly, what the baby is doing, in which stage the baby is and how imminent the birth is or not. So what's the role of the midwife? It's just looking and watchful attendance is a very good term to do. Just being there and watch the woman and support her in what she is doing. So what the supporting was with the woman who was running through the apartment was just keeping aside. But sometimes you see that women are freezing in positions that they felt comfortable on a certain moment in their birth, but then a lot of things change in their bodies and they are afraid to change what they were doing. So then the role of the midwife is very, in a gentle way, trying to get them to move again. So my question is then sometimes do you feel you need to go to the toilet, for instance, and then they move. And during that movement, they feel again what they need to go on with the labor. So that was my little story at the heart is a white woman. The next stories I can tell is sometimes you see that the labor is going into maybe in the direction of pathology. And then it's very important that you can recognize what is normal in a bird and what's not normal in a bird. And that you can only learn by being there, being there, sitting there. I'm knitting midwife. I love to be knitting midwife. So I was with women. I slept with women. I knitted with women and I worked with women as well. So once I had a bird and the heartbeat of the baby was too high. The baseline was too high and I was thinking what could be the problem. And so I say we are going to try something if necessary, we go to the hospital, you know, but we try something, sometimes a thing. And I let her lean forward. And I did shaking the apple tree with the reversal because I suspected that the baby had a hand in his against his head. And it was pushing against the beans here and then the baby will give a higher heart pressure heartbeat. And so we did shaking apple tree and with the reversal. And after a while, we help her again upright and baby was fine. And he was bird at the bird. He indeed he held his hand against his neck, but it was not pushing anymore that he or something at a baby was very fine a bird. Then another bird I had, I remember it was in the hospital and the woman was giving birth. But she she was on the bird chair and her husband was set before her and I was behind her. It was a little bit of switching of positions, but I trusted that the baby will fell good in the hands of the father. So but at a certain point when she was pushing and the head was nearly to be born, I felt that I had to say something to her. And I said, very softly, when you feel that you have to go on your knees after the birth of the head, go and do it. Just feel what you need. And then the baby's head was born and the mother let me go behind her and she went on her knees. And then the shoulders became without problem. And after one she asked me, how did you know that I would feel that I didn't know. Yes. So I think also in Labour said, going to pathology, we can do a lot of things with movements and with helping the mothers to move. Then the third, the third part of what I think is very important is that we have to recognize the value of rest. When I hear midway speaking and run when I follow courses and so on, it's always going about doing doing and going on and stimulating and so on. And I think rest has so much value. So I think then of a birth of a first child and it was a straightforward Labour and then she was feeling hers to push and she started to push. And then we felt that the Labour was going to was slowing down. And at a certain point the mother says, I don't feel it anymore. I don't know what to do anymore. She said, what do you want? I want to go lay down and take some rest. She said, I said, okay, you can do that. And she went to lay down on her side and she fell asleep. And I was sitting in the kitchen and I was reading at that point. And then after a while I felt that energy was changing and I went to her and I was sitting near her. And then I was reading again. And then at one point I looked at her and at that moment she opened her eyes and she says, the baby is coming. And she went again on sitting on the bird chair and they became and that was it. So we don't have to push women forward. We have to recognize the value of rest. I have just looking. I had another woman and she was also in hospital and she was on hand and ease in part. And I saw beautiful how the promise of Michaelis was coming up and the purple line was growing. And that's the easy thing of women on hand and ease. And then they feel safe enough to be naked. So I saw that I'll have happened and I thought, okay, the bird is coming on. And then we saw that the labor was also very, you know, the surges were strong. And then we saw that the contractions slowed down. And I saw that the promise of Michaelis disappeared and the purple line was also disappearing. I thought, okay, baby is going up again because he's not ready and not all right in the right position. And so I asked the woman what she wanted to do and she wanted also to take rest. So she came out with a bed. She went on bed to take a nap. She slept for half an hour or something. And then the contractions started again. She went in the boat again. The promise of Michaelis coming up again. The pink line was there again. And then she gave birth in a normal way. So I think we have to look at women and see what they are doing, what they need. And rest is rest and taking the time. Also in every time, every moment of the labor, we see that the pattern comes. We all know the rest and be thankful stage before pushing. But I think those stages are more than once in a labor. So we cannot have in early labor, we cannot have half the labor and so on. So we see that there are rhythms in birth as well. And I think it's important that we recognize those rhythms. So that's where my stories. I give the word again to Ines. Thank you, Lisa. Just to sum up maybe here and to continue on Lief is lovely birth stories. I think we can obviously find a lot of information in the research, but the real wisdom is in the birth stories and observing the woman and what happens during labor. And then we were thinking, okay, what can we do at least here on the Flemish side? And maybe that's something which sounds recognizable also on your side. We think that how can we as midwives hold the space for women then? So what needs to change? And these are maybe just a few points which we came up with. And as Lief has said, the watch for waiting, the knitting midwife being with the woman, that's so important, observing the woman in labor and being there with a beginner's mind every time. And reading those signals, interpreting those signals to evaluate labor progress. Another one which is maybe more on the skills level is that we feel that we maybe as a student midwives, as practising midwives need to learn more about how to do vaginal examinations when the woman gets all the space to be wild when a woman is maybe in a different position than lying on her back. And fourth, we think also generating or sharing that knowledge on biomechanics of labor and worst position is very important, especially in the cases as Lief referred to when there may be suspected labor distortion. And for us at the Flemish Association of Midwives, we also developed a website, obviously that's in Dutch, but to raise the awareness about freedom of mobility. And if you are interested in learning more about the research which we've done, which you've tasted here today a little bit, if you want to share your experience with this topic with Lief and with other colleagues at the Flemish Federation of Midwives, you can either reach us through our social media accounts here listed. We've also developed a social media challenge dance to help us spread the word. So if you want to do that with us together, post your own moves during labor or do this dance which we've posted here on social media and to get a little bit of the vibe, the dancing vibe up and running. Well, that's from our side, I think, what we wanted to share. Mary, maybe let's see at the chat whether there are any questions. I saw the comment of Sheila and she said what she does with students and that's what I did also when I had a student in my practice. They went with me and we had a little paper and I posed questions on the paper and what you hear, what you feel, what you smell, what you think, what you feel you want to do and why should you do that and then the student answered also on the paper because I didn't want them to speak to me. We learned chatting but we talked through the paper and that was very interesting also afterwards to reread and to evaluate whatever they were thinking and evaluating. I think our time is almost up. Mary, you give us a sign when we have to stop. Is there any other question? Molly O'Brien, thank you for your comments. I'm a follower of you and I admire all what you share of knowledge. Thank you. Margaret says we need to collect all these positioning stories. Yes, that's my dream to collect all the stories on the birds I attended. In 40 years it was more than a lot that I can tell. Thank you all for your kind words. You were a little nervous but I think it was okay. Thank you. Thank you, Liz and Inez for the wonderful presentation. Thank you so much. I think it's time to wrap up. We have already gone through some of the questions that have been highlighted on the chat. I don't think there is any that is not answered but at the same time just to wrap up in a few minutes it's important to have freedom of ability during childbirth. This is basically from the evidence shared with our two sisters that freedom of mobility improves the birth experience. We have it also soothed labor pains. It's shortened second phase of birth. It decreases the risk of abnormal birth. Some of the factors that have also been highlighted in the discussion include barriers and promoters. Maybe I can share a few. We have over medical some of the barriers include over medical over medicalization of birth and then limited knowledge and experience. We also have the promoters integrating knowledge into the curriculum and also awareness raising targeting parents which is one of the very key points. The experiences shared and the short stories shared by you ladies were awesome and then it's also important to take time to check on any woman who is in labor. You also need to monitor the stages especially during birth and also this was one of the parting short. Wisdom is in the real stories and of the observation during that time. Maybe I'm answering. Yes, go on please. I just wanted to say that because I see in the chat that there are a number of questions about the presentation and the research. If participants are interested in getting all the underlying research articles and the stories and other materials we collected, we're very happy to share that. I put our email in the chat. It's info at fruitfrauen which means midwife in Dutch.be. If you send a message or you just contact us on social media then we are more than happy to share that but also if you feel like talking or chatting more about those birth stories and sharing through that the wisdom will be more than happy to do that as well.