 All right, so this is World Health Organization, session B, sustaining quality midwifery care in a pandemic and beyond. And we're so very, very excited to welcome all our speakers today to Virtual International Day of the Midwife 2020. I'm going to make brief introductions and then I'm going to have the speakers take the microphone. Firstly, I'd like to make an announcement. We kept Lastina Watula from Japaigo on the conference session. She sends her gratitude to all you all and blessings from Zambia, but she is unfortunately unable to attend today due to a family emergency. I'm just going to tell you a little bit about Lastina. She has vast experience in systems strengthening the education of health professionals through working with Ministry of Health in Zambia, Uganda, Botswana, Ethiopia, and Lesotho. She's included a lot of development, instructional design, work with HIV, AIDS, core competencies. She is a founder member of the Midwives Association of Zambia who contributed to the development of a continuing professional development system for nurses and midwives in the country. She's an emerging researcher and she's written and presented in national, regional and international conferences. So we hope she's going to listen in after this and we're sending blessings also back to Zambia, to Lastina, and we're sorry she's not here, but we're very excited to welcome on her behalf Anna von Horsten from UNFPA. She's going to be speaking in place of Lastina. Anna is currently working in the technical division of UNFPA headquarters in New York and is supporting the Maternal and Newborn Health Fund before coming to New York. She worked at the Bangladesh country office. Anna completed her Midwifery training in Hamburg, Germany, and thereafter moved to London, United Kingdom where she worked as a community midwife. She mostly supported births at home. She holds a bachelor's of science in Midwifery with honors from King's College and a master's in international health policy from the London School of Economics. And our third speaker is Professor Mary Renfrew who's a fellow of the Royal Society of Edinburgh in Scotland. She's professor of mother and infant health at the University of Dundee. She's a researcher, educator and midwife of over 40 years in the fields of Midwifery, maternal and infant health and infant feeding. And her research has influenced and informed policy and practice across the UK and internationally. And she has advised governments and international organizations. So it gives me great pleasure to welcome all our speakers to the next session. And I see they've shared their Twitter handles, so feel free to follow them and I'll make sure that we start. And I believe it's Professor Renfrew that's starting. So I'll make sure we give you the microphone, Mary. Hello everybody and thank you, Jane, for that introduction. And it's just wonderful to be here talking with you all. This evening my time and just saying, good evening, good morning, good afternoon and happy upcoming International Day of the Midwife to you all. We're really honored to be here, to be able to talk to you all and to be with so many midwives, educators, policymakers, regulators, I think as well, researchers and I'm particularly pleased to be talking to so many students today. So thank you all for joining us. We're going to be talking about sustaining quality midwifery care in a pandemic and beyond. We're thinking about what's happening for everybody right now, but we're also thinking that this is not going to go away quickly. And we have to be thinking about how we plan and how we really work together to have the best possible future during and after this particular crisis that is enveloping the world. It's a key topic for all of us in every country. We're all learning in this new situation. And I guess there's not many people who would at the moment count themselves experts in coronavirus and COVID-19. And I know certainly I do not because we are all learning every day more information about this disease and its impact. It's an especially important disease for midwives and for women and for babies because women and babies, you know, babies are still coming at the same rate they were before. Midwifery has not slowed down. Midwives are just as busy as they were and indeed even busier in dealing with the consequences of this disease. So the work of midwives goes on right in the heart of maternity services and of communities and women's lives everywhere. We've been hearing reports from around the world of responses to COVID-19 that affect midwives and women and babies and families. Some of those reports are very difficult. They're disturbing, they're challenging. Other reports are positive and inspiring about how people are responding and finding solutions to really difficult challenges. We're going to be talking today about both the challenges and the positives. We very much want to hear from you. We hope this will be quite an interactive session at least in the chat box because we're going to ask you for your experiences and your ideas as we go along. So please do share. It's a great opportunity for everybody to share their experiences and for all of us to learn. Just a little photograph of what we look like because we know you don't have a webcam tonight but here we are and we're sorry that Lastina's not with us but Anna and I are here to really talk with you this evening. And I'm now going to hand over for Anna to take us forward through the next few slides. Many thanks Mary, Jane, Chris and the whole team. I would like to say initially that this whole presentation although Mary and I are presenting it has been really put together by a group of people. For some reason I can't move the slides right now and it's coming right there. And this is a group of midwifery advocates and organizations. We speak usually once a month. Currently we speak a little bit more frequently to discuss the latest evidence and developments in midwifery related to COVID-19. And yeah, the members are WTO, UNICEF, UNFPA, ICM, Cardiff University, USAID, Jepago and Wide Riven Alliance. I'd like to give you a little outline of what we are going to talk about in the next 30 minutes. Our goal is really to demonstrate that midwifery are at the heart and center of primary health care and therefore universal health coverage. We will use stories and examples from across the world. We are all in this together. We are all learning from one another and therefore we haven't separated high income countries and low and middle income countries. As Mary said, please share your experiences. We want to hear from you. We are really keen to hear what you're sharing in the chat box. We want to discuss the consequences and changes for societies but also health systems. What has changed for women and newborns as the receivers of our care but also the viewers as midwives and our allied health care professionals? What are the key strengths of midwives and also the key challenges for all of us? How can we sustain quality care and epidemic and most importantly, how to build back better? Our first case study of good practices is from Zambia. This is something that Leskina has shared with us and I'm now honored to present on her behalf. The story has been shared by Gepego in Zambia. Please note that we couldn't find a better photo showing use of PPE as such because it takes time to get permission to use the photo. Therefore, this will do in the meantime. The Republic of Zambia is a landlocked country in southern Central Africa and has been facing challenges before the pandemic in the Bifri that many low income countries have. For example, insufficient number and coverage of midwives, quality of care problems that can have to do with the level of training or sometimes with supplies for life-saving medicines such as magnesium, sulfate, or sodium, and so on. If you want to find out more about Zambia in maternal newborn health and midwives in the Bifri workforce in Zambia, I encourage you to go to the UNFPA website and look for the states of the world in Bifri Report from 2014 and read the Zambia dashboard. The story is about the midwife in charge of one of the first level hospitals in Zambia. She has been trained in responsive management of COVID-19 and is now deputy commander reporting to the local commander for the catchment area. Her involvement is administrative as well as clinical management using COVID-19 checklists that have been adapted from the Department of Health in the Philippines, how to organize screening of women coming to the hospital. And in my opinion, this is a great example of South-South collaboration. In Zambia designated hospitals have been set up to care for pregnant women with full preparations and equipment to transfer any suspected cases appropriately, ensuring continuity of care. For example, if a pregnant woman with suspected COVID-19 infection presents, she will be immediately tested for COVID-19 as well as malaria as a differential diagnosis because symptomatically that's very similar. The team will be informed and the woman will be transferred in a COVID-19 designated ambulance to a health center that is prepared to manage individuals with COVID-19 infection. All staff that were in touch with this woman would be immediately quarantined while waiting for the results. And if the results are positive, then the staff continues to be in quarantine for the next 14 days and released upon having two negative tests. If positive, then they are sent to a COVID-19 designated hospital for treatment and monitoring. Obviously, this requires a lot of careful planning of the human resources needed because if you send staff on quarantine for 14 days, this is going to have an impact of safe staffing levels. PPE, especially masks are available now for all staff and anyone in the entering in the health facility. And the president of the Republic of Sambia gave a directive two weeks ago for all citizens to use a nose mouth cover in public. So now we are seeing that women arrive with a mask or a nose mouth covering at the hospital. The midwives and the labor boards now have additional PPE and full equipment to cover other body in the uniforms, particularly in the urban areas where COVID-19 has began to show increased numbers of cases. I'd like to point out that here in this specific example, the national COVID-19 crisis management team has received training how to remain calm and help dispel anxiety of midwives, provide psychological care, continue support and how to build the capacity that means training for readiness in the community as well as the health facility. In addition, use of virtual platforms in Sambia, this is e-learning and there's a model called the ECHO model, provide opportunities for midwives to learn about the latest evidence and updates on maternal and urban care in COVID-19. And the Sambian Midwives Association in collaboration with American Pediatric Society Association, I'm sorry, are also holding ECHO sessions specifically for midwives on how to respond to issues in midwife care. With this, I will hand over to Mary, who will take us further through the presentation. Thank you, Anna, for that. And it's a great case study to start with and think about what every single country is having to go through just now and the level of the changes. And although different countries are at different stages in this pandemic, we've all either been affected already or we're likely to be affected in very important ways. And currently over a hundred countries are in lockdown. So this strange experience of sitting on our own and talking to our computers and you sitting on your own and visiting to your computer is a very common experience right now across the world. So what is changing? Now, you will all have your own experience because in every context this manifests differently, but we are all seeing some manifestation of these changes in our broader societies. So please use the chat box to tell us what's happening for you. But in broad societies, we're seeing health systems, economies, communication, transport, supplies, education, family life, all changing in ways that we have never seen before. This is a completely new situation for the world. We're seeing physical distancing and infection control measures out in public as well as in healthcare. We're seeing concern and anxiety and fear and stigma and mental health challenges for the public at large, as well as for women and babies and for health professionals. And we are seeing an astonishing pace of change and some of that we're going to talk about, some of that pace of change is bad, some of it is good and helpful as people work really hard to mitigate the effects of this disease. Some things stay the same while other things are changing and in our world, of course, women still get pregnant, babies still get born, families live their lives and more women become pregnant every day. And that statistic that Fran shared about the number of women who will not have access to family planning really gives us pause for thought about that. It's our workload will be going up certainly. All women and babies still need skilled, knowledgeable, respectful, compassionate, midwifery care because without that care, other things will go wrong. COVID is not the only threat that women and babies face and it is our skilled, knowledgeable and respectful care that keep them safe and we have to keep as many elements of that as we can. Midwives and other health workers are still working hard to provide care, in fact, harder than ever. And there are wonderful examples of positive developments across the world, but also midwives are under a great deal of stress. Midwives are working in circumstances that are difficult and dangerous for them. Midwives are getting infected as well and getting sick and they are dying as well. And so we have to keep in mind how hard this is for midwives and for women across the world. And of course, we still need evidence to guide us in what we do. All the decision making that's going on right now, whether that's at local level, whether that's at national level, whether that's at the global level with the WHO guidelines, has to be grounded in evidence that those decisions are the right ones. And so evidence generating that new evidence, analyzing existing evidence, remains incredibly important. So what is changing specifically in health systems? And here we want to know what is changing in your health system at the moment. So please do tell us. There is, of course, an overriding need for infection control, hand washing, and personal protective equipment, PPE, that is about keeping everyone safe. Staff are working beyond their normal capacity and in many places and particularly for midwives, staff workforce was already limited and staffing was already limited. And this is coming on top of that increasing stress. There's a focus on critical care that can override everything else. Of course, with very sick patients now with COVID needing intensive care. And that focus tends to take the spotlight away from other services and it can have a really negative effect on other services, including maternity care. Health service configuration is shifting. In many places, services have been centralized into hospitals and out of community. And that, of course, can have a negative effect on women's experiences if they have to move from an expected home birth or an expected community birth through to hospital birth where they might have a bigger distance travel, transport may be a problem. Women may be afraid, they may be afraid of getting infection. They may be moving to a hospital where they don't know their midwife anymore. So a lot of change, a lot of uncertainty for everyone. Some services are closing community services, for example. Transport problems, of course, for women traveling to those centralized services, travel during lockdown can be particularly complicated. And, of course, emergency transport when ambulances are often deployed for transporting very sick COVID patients. The staff sickness, the staff themselves get sick or staff have to self-isolate if family members get sick or if they've been in contact with a woman who's been sick. Others are being redeployed out of maternity services and into other services. And so maternity, again, is getting its staffing reduced in that way in some countries. And indeed, there's particular problems for health workers who are sometimes attacked in public. There are ports of health workers being attacked in public for fear of the fact that they've been in touch with people who are infected and people are afraid that they themselves, the health workers will become a source of COVID infection. So there are lots of very serious challenges in health systems across the world. At the same time, there are some very positive rapid developments happening of new knowledge, of new evidence informed guidelines and indeed of tremendous developments and rapid solutions being found to these problems. So what changes are affecting women and newborns and families specifically? And again, you are going to know this from your context much better than we are going to know this. But we are hearing stories of limited range of services and access to service provision, that moving out of community and closing home births being one of those. Limiting options and imposing interventions. So the choices that women might have normally to have their companion of choice, to avoid if possible unnecessary interventions, to avoid unnecessary caesarean sections. In different countries, those interventions are now being reported to be imposed. Sometimes companions at birth are being very limited or indeed completely restricted. We're hearing reports of mothers and newborns being separated at birth, not always for justifiable reasons. And again, that causes huge harm for women and babies. And we're hearing reports of women avoiding healthcare settings altogether for fear of infection, for uncertainty and for not knowing the caregivers who are likely to be looking after them. At the same time, we're also hearing reports of quality care continuing in this difficult set of circumstances with lots of innovative options. And we're going to be sharing some of those later and looking forward to hearing some of what's been happening that's been positive in your setting as well. So I'm now going to hand back to Anna who's going to tell us a case study of what's happening in Madagascar. Thank you, Mary. I'd like to share a really empowering and inspiring case study that we have received from the UNFPA Madagascar country office. Madagascar is a beautiful island in the front of the shores of East Africa and over 60% of Madagascar's people live more than five kilometers from a health center, often in very, very remote and difficult to reach areas without roads or communications. Health personnel are unevenly distributed across the country and drug medical supplies are often thrown to stockouts and are unavailable in some areas, which is why Madagascar is a good example to promote a centralized care at least until a further planning has happened for more community-based care. If you want to find out more, again, I encourage you to check out the state of the World's Madagascar dashboard on Madagascar with all the data that you might be interested in. I'm going to turn on you one half, Madagascar, and this can be found on the UNFPA website. As you can see on this slide show that it shows a little ambulance. The public transport has been suspended in Madagascar due to COVID-19 and following a collaboration of the Ministry of Health and UNFPA. Now a free transport is provided for pregnant women to come for antinatal care and intrapartum care. This has been advertised on Facebook, which is a common means of communication in Madagascar to promote health services. Additional social media campaigns have been published and have been going on in Madagascar to counsel women that services continue and that they will be provided a mouth-nose cover when they come to the facility. There are also other countries that have set up really empowering and inspiring initiatives. For example, Laos has set up a hotline for women to get information whether their clinic is still providing services if it's safe to come and so forth. And some countries are working on psychosocial support services for women as well as midwives. We are frequently seeing that midwives are being redeployed into nursing roles, which is beyond our scope as midwives really. Some of us have nursing backgrounds and still midwives must stay in these really essential services of antinatal care, postnatal care, intrapartum care. Midwives getting familiar and gaining experiences with new service models. For example, how to use PPE correctly, how to use telehealth, work in a new GR system, et cetera, is maybe something that is affecting midwives as well. Many midwives report that they are stressed and anxious because they feel they don't have enough information or means to protect themselves or have a much, much higher workload because the new service models can be more time consuming. This is for example, if there's a new GR system in the hospital or if the labor ward is divided in a COVID-19 ward and all the other remaining women in another ward. Many midwives also have shared concerns with us that there are fewer midwives working in their respective labor wards, leaving women and their babies more vulnerable to the whole too little, too late and too much to soon syndrome. We have seen an increased rate and encouragement by some countries to conduct inductions, plants are there in sections. That really depends on the country context and the resources. The intention behind that is to manage services and to plan the labor ward activity, but we all know that this can backfire really severely and may extend the hospital stay for the women. Midwifery students and aspiring students have told us that they're not sure if they can apply from the different education programs and those that are currently enrolled have remote learning opportunities, but maybe tricky depending on the context, which for example, they may not have access to IT equipment or a stable internet connection. I think we can also agree that quality midwifery care can only be learned hands on and not remotely. In the meantime, there's extraordinary commitment from midwives to adjust as quickly as possible in order to continue to provide quality care. What do midwives bring? The key strengths. This is a summary really that kind of justice to the enormous key strength that midwives have and but I would like to point out some of them. A wealth of competencies, how to make sure that women and newborns are well and remain well and remain well and kindness and women's mental care has always been at the core of the midwifery-led model of care. Midwives know their communities extremely well and have a unique connection with the families and the women in the community. Midwives are adapting extremely quickly, which comes with the nature of being a midwife, I think. If there's unforeseen or unpredictable problems or complications, we just deal with it. And finally, to point out the photo from a campaign from the National Health Service in the United Kingdom that you can see on the bottom right, midwives are fostering trust and reassurance for women and their families that quality care continues even during a pandemic of a highly contagious virus. Key challenges for midwives. What are your key challenges? The main challenges for midwives around the planet right now, including many of you who are listening, are that, for example, an unsafe work environment and lack of personal protective equipment. This has partially to do with the missing representation of our occupational group and decision-making at a higher level, such as in national emergency planning and response groups. Midwives and women are also disproportionately affected during this pandemic, as shown by the gender lens paper published by UNEFPA, which can be found on the UNEFPA website and I encourage you to check it out. Furthermore, and very worryingly, as Mary already mentioned earlier, midwives are being pulled away from maternal newborn health and full focus is given to intensive care for very sick patients with COVID-19 infections, which is unless we have a background in nursing and critical care well beyond our scope of practice. Many midwives have reported that they are fully informed about the correct infection and prevention control measures and guidelines, or I'd actually like to say have not been fully informed as it depends. We have received reports on both sides. Some feel really supported and some feel very lost in how to implement those new guidelines. In some places, we see that the proposed reorganization of services is done in a not women-centered way and might jeopardize the relationship between the wives and the women they're killing for. We also see the power issue of power balance that we have been seeing for decades. In some countries, PPE was distributed to doctors but not to other occupational groups. And surely everyone that keeps providing essential healthcare services has to be protected. The same is true for danger pain, for example, that traditionally occupation groups received that have a bigger and more powerful lobby. Going forward, simple changes can help and we will be discussing solutions in the next part of our talk. And you can start thinking of solutions that work in your setting for when we get to that point. Please post them in the chat box. The State of the World's Midwifery 2021, I have a couple of times mentioned the State of the World's Midwifery, SOMI for short before. SOMI is a joint project and the core group is formed by ICM, WHO and UNFPA and then many other civil society organizations and academic institutions that work with us on this project. And the SOMI is an important advocacy document and exercise to analyze shortfalls in unmet need of the sexual reproductive maternal newborn and adolescent health workforce that is including midwives, but not only midwives. In short, the aim of SOMI is to provide data and evidence which can be used for advocacy and to stimulate policy discussion at a national level with a focus on the workforce. And we had two previous SOMIs, the last one in 2014 and there were also several regional SOMIs, for example, in the Pacific, in the Arab States region and in the East and Southern African region. SOMI 2021 is going to be published next year. We have just finished the data collection and this year, all countries around the globe were invited to participate industrial nations as well as low and middle income countries. Midwives associations have played a very significant role in the data collection due to the ICM member association survey being one of the two main data sources next to WHO's national health workforce accounts. Two knowledge papers and peer reviewed papers will be in the main report. One will be focused on the impact of midwives as a specific occupational group on society and the other paper will be on the return of investment. The rest of the report will look at the wider team to acknowledge that midwives like all occupational groups can only be effective as a part of the team. I feel personally that SOMI at the moment is also really important because the shortfall in numbers of midwives globally was known before and there's a risk that this pandemic makes the workload challenges worse. This is a sample profile that was used last time in the state of the world midwifery this time, the layout will look a little bit differently but just to give you an idea. The risks and consequences of COVID-19 for women and new ones in midwives. What is the impact of the pandemic? As mentioned earlier, peer anxiety within the midwifery workforce is a big theme. Worrying about their own health and the risk to infect their families as well as to continue care safely. Women may be avoiding health facilities out of fear for infection as Mary already mentioned earlier or fear of being separated from their baby. There can be transport problems to reach care or the staff gets redeployed. There may be restrictions and limitations to services and unnecessary interventions. As I said earlier, for example, plan C sections, inductions in the belief to better manage the activity in the labor board but we all know again that the evidence shows that the same in the hospital following these interventions may well be extended. In short, for these reasons, we foresee an increase in maternal newborn mortality and morbidity through decreased access to services and quality of care. These trends have also been sadly following the Ebola outbreak a few years ago. Also for aspiring midwives, there may have been major disruptions in their learning and development plans and depending on the context, they may not have received personal protective equipment or they require supervision how to use it correctly and keep themselves safe, making them perhaps very, very vulnerable. Now we would like to discuss a few points in the category in the good news and I will hand over back to Mary. Thank you, Anna, for that. Now, up till now, I think we've been measuring most on the negatives of this but we want to turn our minds to how we create sustainable quality care in the pandemic and beyond, thinking about midwifery care and not forgetting, importantly, our students. There's some lovely pictures here from Bahar in India and Uganda where colleagues have absolutely worked out solutions for transport supplies and quality care, for example. Now, can somebody move the slide forward for me please? Because I don't think I've got that back at the moment. Thank you. So we've thought about some positive outcomes. Now, these may be potential and they may be real but there are things that absolutely could happen and are happening in some places and please in the chat box, please tell us about positive outcomes that you are seeing. Fran was talking about the recognition that midwives are at the heart of universal healthcare and primary healthcare and it's becoming really evident globally and in many, many countries that this is the case and that care could not be provided without midwives and how essential that is. We're seeing that new ways of communication could possibly lead to improved outcomes and there are stories I saw some of them in the chat box a minute ago that new ways of communication could actually, for example, improve breastfeeding rates as women are getting virtual support and they can have three or four contacts a day instead of possibly one visit in the first 10 days. And that quiet time as well now with lockdown that women are at home with their families with their babies quietly without having to do too many things could actually be causing positive outcomes. So this recognition of the value of midwives would be nice to think that it would manifest in improved remuneration as well as improved status and recognition of the mental and physical demands of midwifery might lead to more psychosocial support for midwives as people really understand how challenging the job is. And indeed new ways of learning and teaching are absolutely developing at the moment as students and educators get very creative about how to do this. Here's just a little insight. I'm sure a lot of you have had this Zoom experience over the last few weeks as everybody has to meet virtually. This is a high level meeting with the WHO with Dr. Tedros there and the ICM and the ICN all discussing global developments. So some of us have been developing what we are calling the key principles for quality care in a pandemic. A group of midwifery professors have been working together over the last few weeks and it's about maintaining sustainable quality care. And so in the next couple of slides I'm just going to go through those and we'll be really interested to know what you think about these as underpinning principles. Continuing to provide evidence-based, equitable, safe, respectful, compassionate quality care for the physical and mental health of women and newborns wherever and whenever care takes place. Protecting the human rights of women and newborns. Ensuring strict hygiene measures and social distancing when that is possible. Ensuring birth companionship. Preventing unnecessary interventions. Not separating mother and newborn infant unless absolutely necessary. Promoting and supporting breastfeeding. Protecting and supporting staff including their mental health needs. And planning for life after the pandemic to develop COVID relevant solutions for maternal and newborn health. So what must be done differently? We thought of some COVID relevant solutions but I'm sure there are many others. A midwives voice in decision making and messaging at all levels so that the right decisions get made and we're starting to see that happen now in places where it didn't happen before. Reassessing all guidelines for care in the light of COVID-19 and good international examples for this exist. Social distancing, hand washing, cleaning protocols in all contexts with face masks and appropriate PPE. Monitoring and reporting disrespectful and harmful practices and deviations from evidence-based care. Like unwarranted instrumental birth separation of women and babies. So speaking up, escalating concerns and really making these things clear when challenging them when you can. Strongly promoting and supporting all women for access to care, for no separation, for breastfeeding. Being alert to the increase that is likely to happen in gender-based violence and child abuse particularly in lockdown situations. And again, reporting that and escalating that. Tackling misinformation and rumours and countering that with fact and trying to get those messages out. Other COVID relevant solutions are collaborative and evidence-based work. This is really, really increasing at the moment. The tremendous increase in collaboration across the whole kind of science space and evidence space is tremendous. No sidelining or ignoring of midwifery and maternity services. Innovative and adaptive solutions for care and for education and training. Working out context-specific solutions. Listening to women and communities because they themselves will have solutions that work for them. And listening to midwives because midwives again will know the solutions that will work in their context. In summary, I guess in these slides what we're asking for is to find solutions to guard against being pushed backwards into what we might have recognised as maternity care in the 20th century. To centralise services to unnecessary routines to the rights of women and babies being ignored and to the role and scope of the midwife being limited. So these are COVID relevant solutions that I hope together we can work out over the next few months and years. So what innovative solutions are you seeing? We are certainly getting reports of community informed solutions to all sorts of things. Using hotels and schools as community-based services, different transport solutions, using taxis, using army vehicles, for example. Digital communications, I've mentioned, already is actually making it easier to talk to women. Proactive use of third sector and voluntary groups aligned with self services. And in the UK, that's working incredibly well to provide breastfeeding support for women, for example. Sourcing supplies for hygiene and PPE, there's lots of local solutions to this that have developed in many countries. And for staff, finding solutions for housing, safe transport, better rotations, digital communications and community-based services for them to have services close to where they work. So that's examples. And we're asking you to put your examples out here because, as I said, we're all learning together. We wanted to really take as our final case study the contribution of academic midwives and colleagues. It's maybe not obvious at this point in midwifery care where the focus is very much on the frontline care of women and babies. How important it is for educators, for researchers, for people who disseminate information that they are all involved in this enterprise and they absolutely are. So for educators to continue to educate and support students for the current situation for after, and it's been amazing to watch how education colleagues have turned around so quickly when they're offering really good quality education online, as well as supporting students who are being put out into the frontline much sooner than they might have expected. Developing national and global alliances and networks for sharing knowledge and learning, that is happening really quickly, right across the disciplines. There are new studies starting on maternal and newborn care and coronavirus all over the world. Funding agencies have turned around their priorities. The scientists and social scientists and midwife researchers are setting up new studies very, very quickly, much more quickly than before. Studies are being published as well as started and rapid reviews of evidence to inform guidance are being done very quickly. Now, we know a lot about that at the moment because a group of us midwife researchers in the UK have over the last few weeks been putting together what we're calling very rapid reviews, not just rapid of key topics in the context of COVID-19 to inform the new guidelines that are joined between the Royal College of Obstetricians and Gynecologists and the Royal College of Midwives. And we've done rapid reviews on service provision, for example, centralization versus community services on induction of labor, on companionship and labor, on breastfeeding and mother-baby contact. And those rapid reviews are now informing those new guidelines. And so the midwifery voice has been brought right into the heart of decision-making and interdisciplinary guidance and services. And we know this is happening in a number of countries across the world, the same kind of collaboration and very active involvement of academic midwives. So please do tell us if it's happening in your country. And so I'm going to hand over to Anna to just finalize the end part of our talk. So Anna, back to you. Are you there, Anna, or will I keep going? I'm here, I was talking to myself. Now, okay, building back better. I'm really happy that I get to present this part of our presentation. I am a firm believer that there are many, many opportunities for us to step systems that will benefit us in the future. And it's about building a new normal and building a bridge as our governor, Andrew Cuomo says here in New York State. Let's take advantage of the innovations and the past pace that things are changing in right now. Let's identify more efficient ways to provide care such as telehealth for some, but maybe not all or definitely not all, not maybe, antenatal care and postnatal care appointments. This is really depending on the context. In many contexts, women will never be able to achieve the recommended number of antenatal and postnatal care appointments, for example. So this is an opportunity. And providing women with stock of supplements instead of having them come back to the clinic to pick up iron and folic acid and so forth. Also regarding referral links, particularly in lower soil settings, maybe used in the future to strengthen links between primary and tertiary care facilities which has been traditionally some of the weakest links to improve maternal and new one health outcomes. Health monitoring systems are currently established in a very fast pace. I'm referring to electronic monitoring systems which may open many doors for us to track data tomorrow. For example, the number of midwives in a given area, case, hospital, spotting, hemorrhage, for cancer and so forth. So we could do it in any day that we wanted, but we need the system to be up and running for that and to start the collection of the data. And I see that now that we have contact tracing and so forth, these systems are being established. The same sort of supply chains, perhaps the mechanism is established now could also be used for medication and PPE. Could be used tomorrow for the supply of essential and life-saving medications which again is a challenge in many parts of the world. And now we are developing tools to model, plan and to cost certain services which includes safe staffing and hopefully we can learn from that and use the tools for advocacy in the future. And one final point I would like to add that's Northern Slides is again referring to students and I have seen many great comments on this already. We must have students to develop that they can develop the key competencies of quality care even in this context. And we have to think about the future we really need whenever. I feel like someone else is talking here but maybe it's just in my line. Even though the learning environment and modalities may have changed and I saw in a comment about British Columbia, I think but this is actually a real advantage now. It's crucial that midwifery education is carried out and keeps continuing to be taught and we really have to appreciate the level of flexibility and adaptability and willingness for ongoing learning of all midwifery students as well as educators all around the planet. Personally, I would like to add something that I feel Midwest are one of the most essential healthcare professionals in this time and women are pregnant now and more will be pregnant tomorrow. Babies continue to be born and the services that Midwest provide is one of the most essential services there are in the health system. And we salute them as part of this group that we are speaking of on behalf of in solidarity every single day to ensure the best possible outcomes for women and newborns. Safer together, respectful maternity care during COVID-19 pandemic. This is a beautiful graphic shared by the Wide Ribbon Alliance developed by the Wide Ribbon Alliance. I encourage you to go to their website and their Twitter profile. It's a campaign that specifically focuses on the element of respectful care in this time and it's a really beautiful approach and absolutely essential to quality care. A little overview again for you what are the global players? What are they doing for midwives? Here are examples from the International Confederation of Midwives. Examples from UNFPA that has developed several technical briefs how to reorganize services and some social media slides from WHO that I feel they should be shared all around the world and I think they have been and also WHO has developed so many technical guidance briefs, papers and online courses that are all free to access. As we're coming to the end of our presentation I would like to bring your attention to all the resources that we've used and all the references that we made and with that I would really like to say thank you. Thank you, thank you for being here for keep providing quality care to all those women and newborns out there keeping them safe. Please stay safe yourself and share with us whatever you would like what your experiences are in the chat box and I'm handing over to Mary. And just to say thank you from me as well the chat box looks incredibly rich I'm looking forward to reading it in more detail and hearing your questions and having that discussion. It's so clear to us, I mean, I think many of us have known for a very long time how important midwives are but over the last few months the core absolute contribution of midwives to health survival, well-being of women and families is absolutely crystal clear and I think it's really clear now to write up through the global level and out through various countries. So thank you to all of you for the work you're doing and I'm really looking forward to the questions and discussion. Thank you Mary so much. This is Jane again the facilitator and we thought this is such a fantastic interactive discussion that we'd love to talk about some of the themes and some of the themes I've seen are can either of you talk about what happens in low-resource countries in relation to PPE? I know that Halima who lives in Nigeria responded that they lack PPE and also how is it for everyone in relation to doctors being given PPE and nurses or midwives being ignored? So can either of you take that question, those questions? I'm happy to respond to this Mary, unless you would like to. No please go ahead Anna, that's great. It is exactly the problem that I have been referring to earlier it is correct in many countries and even within a country sometimes it's depending on the region midwives are totally forgotten in the response plans that are referring to PPE, information sharing and so forth and this is really going back to the power imbalance the lack of representation at the decision-making table and global national response teams and I really encourage the Midwifery Association and anyone any champion that's the ministries of health to make sure that someone is representing the Midwifery workforce at those tables to make sure they're covered when they're planning a procurement of PPE and also any capacity building and how to use PPE correctly how to reorganize services correctly and safely and yes, it is true. We still see this in many countries the examples that we shared today from Zambia Madagascar Iran for example, see on the last slide show as well the midwives with the baby and the mask is on the left side as a photo from Iran. They have done a good job but we have to keep pushing it's because an incredibly vulnerable group right now because they're essential providing an essential service and they are neglected. That's correct. Advocacy is so essential right now. I think all I would add there is yes it's a critical problem in low resource settings but it's also happening in high resource settings and it's extraordinary to see systems getting stressed and supply lines getting stressed even in high resource countries and it certainly in the UK it has been a really difficult problem to get PPE to all staff so they can stay safe. So yes, I think we're all being challenged all countries at the moment in doing things faster and more than we've ever had to do before. And there's a couple of questions infections from the skin contact who would take that? What's the question? What are the questions, Jane? Will the newborn not be infected through skin to skin contact? Is that the question? Correct. Well, I guess we're all learning things and nobody's giving very hard and fast answers to those questions at the moment but what my reading of the evidence is that that is not a risk. If the mother is infected then hopefully she will be in contact with her baby practising proper hygiene measures according to the protocol and Fran went through that helpfully in her presentation and there's WHO guidelines around that but she should be washing her hands wearing a mask when she's dealing with the baby. Skin to skin contact has so many positive effects physiologically as well as psychologically but it's a really important thing for us to continue to do. Separating mothers and babies is not a small intervention. It's a very important intervention with short and long-term effects and it really should only be done if it's absolutely essential. I would like to point to this. It depends really again on the context and I all heartedly agree and I think the evidence is very compelling that it's a severe intervention to separate the mother and the newborn and it has to be really considered carefully on a case-by-case basis but in low-result settings the separation of the mother and baby is the worst thing that can happen to this newborn. It would mean that the baby will not be breastfed or will not be breastfed in time and it will receive something else in breast milk and if we look at the most frequent causes of neonatal mortality it is these are diarrheal diseases and in so many factors in the world clean water is not available no alternatives to breast milk are available in addition to all the health properties of breast milk obviously but if you separate the baby from the mother if the virus doesn't kill the baby the separation will and this is just in addition to all the benefits in terms of the microbiome and the warmth and the heat and all the other benefits the skin-to-skin benefits but it's really important to keep them together to assure the health and well-being of the newborn. I think you know Anna this is a good discussion about exactly our theme tonight which is sustaining quality care even in a pandemic because if we don't sustain the key elements of quality care mothers and babies will suffer in other ways they may be protected completely completely from getting COVID although I don't know how you do that but they will suffer in other ways and so separating mothers and babies or not having a birth companion or stopping continuity of care schemes or medicalising birth all of that has an impact on women's on survival on health, on well-being for both the mother and baby and so we have to find COVID relevant solutions where we respect if you like the infection control measures but we absolutely maintain the quality care that women need and babies need. I really think that was a perfect perfect note just to finish this fine presentation and thank you so much for your attention to all the wonderful participants and thank you for all that you do I'm going to go ahead and turn off the...