 Thank you very much Tim. My name is Jennifer and I am a PhD candidate at the University of Nottingham, the School of Health Sciences. I'm also a midwife and an educator from Ghana and happy International Day of the Midwife to everyone, wherever you are. Thank you very much for joining me. This afternoon here in Nottingham, but whatever time you are on, thank you very much for coming. I would be presenting on the topic respect is relational, a fractured midwife-woman relationship, a focused ethnographic study of midwives views and beliefs about respectful maternity care in Ghana. My presentation would be based on my research, the research I've carried out as part of my PhD. So for this presentation, I would be looking at the evidence surrounding respectful maternity care. I would talk through my study and speak on the aims and objectives. I would go through the phases of data collection and analysis of my data. I would talk about key findings and then acknowledge the people who have helped me through my PhD journey. So within the Ghanaian context, respectful maternity care or the treatment of women during childbirth is not new. It is actually, it is something that has been spoken of for more than a decade. However, the international attention to the treatment of women during facility-based childbirth became internationally known after the landscape analysis by Bowser and Hale, where they explored the evidence surrounding disrespect and abuse of women during facility-based childbirth. During that landscape analysis, they categorized the abuse of women under seven categories. And after that, there has been several typologies that have been used to describe the treatment of women. Some of them included the humanization of childbirth, obstetric violence, disrespect and abuse, respectful maternity care. But these typologies have been used based on perhaps how researchers feel about the violence that is very much integral to the treatment of women or to the care that women receive. Disrespect and abuse or the treatment that women receive during childbirth is a complex problem because it takes different shapes and forms based on the context that is being studied. Several studies have since Bowser and Hale been carried out into disrespect and abuse or into respectful maternity care. And whichever category is spoken of during these studies as context specific. So for instance, Baranowska and her colleagues who analyzed the experiences of women in Poland found non-consented care discrimination, lack of privacy and physical and verbal abuse. These were part of the typologies by Bowser and Hale. And on the other hand, in Pakistan, the researchers found all the seven types of abuse in their findings. And so it is very much context specific. And within the Ghanaian context, the studies that have been carried out have also found all the various types of disrespect and abuse. And these researches that have been carried out have resulted in the White Ribbon Alliance developing corresponding rights to the categories of disrespect and abuse that have been identified. And so for instance, for physical abuse, the corresponding rights was freedom from harm and ill treatment. And so a lot of attention has been drawn to the fact that the mistreatment of women is a human rights-based concern. Within the Ghanaian context, however, practice is so very much abusive towards women. A lot of research continues to be carried out which identifies the abuse and disrespect of women. So in 2018, the WHO released their recommendation for intrapartum care for a positive child birth experience. And in this recommendation, one of the integral parts was the definition of respectful maternity care. And the WHO defined respectful maternity care as care that is organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality and ensures freedom from harm and mistreatment and enables informed choice and continuous support during labor and childbirth. This definition has several components and this was used as a vignette in my study to simulate discussion with midwives. So the focus of my PhD was to understand midwives' views and beliefs about respectful maternity care and how respectful maternity care is actually enacted, how it is influenced and how it is experienced within the everyday practice using a focused ethnographic study. Within the studies that have been carried out, a lot of the typologies that were developed were based so very much on women's views about the issue of disrespect and abuse. There is still a lot that is lacking or there is still a very wide gap with regards to the views of midwives who have been portrayed as the perpetrators, mostly of the care that women receive. And so harnessing their views on this issue was very, very important, particularly in shaping the concept of respect that could be applicable within the particular context where the study was carried out. So the main objectives of my study was to understand what RMC meant to midwives and how they were actually enacting it in everyday practice and to most importantly explore the factors that influenced the provision of respectful maternity care and then to access the facilitators and barriers for the provision of this care. As I indicated earlier, I carried out a focused ethnographic study and so my data was collected in different phases. I first obtained ethics approval from the Ghana Health Service Ethics Review Committee and then from the University of Nottingham Faculty of Medicine and Health Sciences, the Ethics Review Committees in these two institutions. So for data collection, I first carried out three weeks of participants' observation and this enabled me to determine how RMC was being enacted by midwives in actual practice and to identify the facilitators and barriers for its provision. Going through the participants' observation also enabled me to actually obtain a case study which I used as a vignette for my focus group discussions. So in addition to the WHO definition for Respectful Maternity Care, I also based on my observation developed a case study which I used to simulate discussions during my focus groups. So I carried out as well 15 focus group discussions on Respectful Maternity Care with a total of 16 midwives. These midwives included rotation midwives who were newly qualified midwives. They included qualified midwives as well. Midwives who had been in the system for a number of years and also students midwives who were in the study sites at the time I was collecting the data. Then the third phase of my data collection involved semi-structured interviews with stakeholders who were involved in the provision of maternity care within the settings that I had chosen for my study. So these included labour ward managers, the deputy directors of nursing and midwifery services, quality control officer. I interviewed one chief nursing officer and one medical director who was the overall head of the facility. And then I also interviewed the head of the nursing and midwifery council in that particular region. So my data was collected from three different sites. And it included a regional hospital and two district hospitals. The regional hospital was very relatively well resourced as compared to the district hospitals that I collected the data from. The data I collected was transcribed. They were transcribed, the beta. And I analyzed my data using a Brown and Clarks thematic analysis. I conducted a reflective, inductive approach to thematic analysis using the NVivo software. I generated codes and these codes were based on the semantic content of my data. So similar patterns were collapsed and merged into categories. And these categories were further matched to develop potential themes. The subcategories were then also put together to generate overarching themes which I use for my writer. So for my findings, I would talk through two major findings from my data. So the first major finding I would want to talk about is the fact that midwives envisaged respect to be relational. So they talked about the fact that respect was reciprocal and so took a relational approach to respectful maternity care. This approach involved two major aspects and the initial one, the first one was the initiation of the midwife-mother relationship. And the second was maintaining the relationship through a woman or family-centered approach to care. So in initiating the relationship, midwives established rapport with women during the initial contact. Within the Ghanaian context, usually women going into labor were meeting their midwives for the very first time. So unlike in other contexts where there is continuity of care, and so the one midwife or a group of midwives would take the woman through both pregnancy, labor, postpartum and up to the end of that period. In Ghana, midwives usually met women for the very first time when they came into labor. So that initial approach was a very important phase of establishing that relationship in a respectful way. And so establishing rapport was very, very important. And midwife utilized various care ethics in addition to both cultural and religious values. And so sometimes midwife perceived women or treated women as though they were family members, or they treated them as they would treat relatives. So these kind of care values, in addition to certain cultural values, were utilized to initiate that relationship. Furthermore, midwives also maintained that relationship through a woman-centered approach to care. And this involved the provision of privacy, confidentiality, or within a conducive environment. Communication was really important. And the provision of information in order to enable women make informed decisions and choices concerning their care. In addition to that midwife perceived care to be individualized and non discriminatory. And this was particularly important for midwives in this context, because where they were working, the community in which they were working was multi-tribal. And so they spoke various languages, they had different cultures. And so making it very non-discriminatory was a very important aspect of respectful maternity care, which midwives conceptualized. And the final aspect was providing support during labor and childbirth. However, midwife also interestingly perceived respect to be reciprocal. And so in as much as they were offering women care that was respectful, they also expected to be respected in an equal manner. And so respectful, respectful maternity care, though have been conceptualized in this manner, was very theoretical. According to the data I collected, this was not the actual practice. And so for midwives, some midwives perceived that respectful maternity care was a mutual relationship between a midwife and the pregnant woman, so that at the end of the service, at the end of the service the midwife provides, no one will be, everyone will be satisfied according to a focus group discussion, one of the focus group discussions that I had. So the participants stated that both midwives and women needed to be satisfied with the care. This kind of a session was premised on the high maternal mortality rates within the care system for which most midwives or midwives have been blamed. So during the audits, the maternal mortality audit process, the blame, regardless of the contextual nuances and the systemic challenges that midwives encountered, they faced the blame for the mortality that occurred. And so they perceived the satisfaction with the birth process as something which was not vital for only the women, but for the midwives as well. And that was one of the reasons why they perceived respect to be reciprocal, or to be the perceived respectful maternity care to be grounded on a mutual relationship and a mutual satisfaction. Again, midwives also perceived respect to be reciprocal, because according to one of the participants, if the woman does not respect the midwife, she ought not to expect respect from the midwife. According to midwives, they had also been abused by women and their companions during the process of care provision. The challenges within the system was such that it was very, very much ripe with violence. And so women physically abused midwives and their companions physically abused midwives as well. And so midwives perceived respect to be reciprocal. And so as I indicated earlier, though they had, they had conceptualized or idealized a concept, a relational concept of respectful maternity care. In practice, it was not, that was not the case. And so several factors influenced that concept of respectful maternity care, which midwives had conceptualized. And so I developed a conceptual model for the factors that influenced respectful maternity care. For lack of time, I may not be able to go through these concepts, the components of this model. But I would like to very much talk about one aspect of the model that has been very, that has been missing in the data coming out on respectful maternity care. And that is the influence of the care being provided by other health professionals. So what midwives perceived was that in the provision of care, in the provision of normal childbirth services, the focus was on the midwife. However, when complications arise, other health professionals like doctors, lab technicians, pharmacists come into play. Midwives often struggled in putting these, these health professionals together. And these health professionals often undermined midwives decision making. They were also verbally abusive towards midwife, towards the midwives and this influenced the midwives relationship and the midwives interaction with women. So for instance, during one observation in a facility, the midwife was trying to put doctors and other health professionals together for an emergency caesarean section. She called several and nobody responded. When they finally responded, they requested that she made arrangement for a car to come and pick them up. During this time, the relatives and the companions of the women were giving the midwife a lot of pressure. And so that led to argument, it led to misunderstandings between the midwife and the companions of the women. And so this such instances or such discourses affect the relationship that midwives had with the women. And there were certain contextual and health system challenges as well. For instance, institutional policies and practices made it very difficult for midwives to provide care that was grounded on the philosophies that they had articulated. For example, in one of the facilities that I visited, they had a policy of having bed companions. However, these policies determined the type of bed companions the women were to have. And so even though the midwives encouraged this to happen, it was the hospital policy that determined the type of persons. And so if the, for instance, the woman wanted to bring a friend, she couldn't do that. But she had to let someone who was a close relative according to the policies in the health facilities. And so this very much affected the kind of interactions that midwives had with the women. Again, there was a lack of political will in the provision of resources for the midwives to work with. In one of the facilities as well that I observed, a woman in labor fell from the delivery bed because the delivery bed was broken. And according to midwives, they had, they had complained so much about that particular bed, but it had fallen on deaf ears. And in that particular facility as well, one midwife was managing the labor ward, she was managing the postnatal ward, which was a 35 bed capacity, which had a 35 bed capacity. And she was also receiving babies from the theater. And so this put immense pressure on midwives to provide quality care. And the frustrations and the stress that they accumulated during that provision of care had strong impact on their interaction with women. With regards to the midwives themselves, they also embraced a philosophy of care that was very much grounded on the medical model of care. So midwife perceived themselves as a result of the gap in knowledge between them and the women. They perceived themselves as the, as, as having, as knowing what was best for women, as having the knowledge that was best for women. So usually they fail to offer women the choices that women wanted, because the midwives felt that they were more knowledgeable than the women. And so they imposed their knowledge, their childbirth knowledge on women, their authoritative knowledge became the philosophy with which they cared for the women. And so even though they had articulated a very relationship based approach, this was not in practice. And there was also a lack of identity acceptance of midwives. A lot of women perceived midwives to be too young. And they, they perceived that as a result of the age difference between them and their care providers, they they could not provide competent care. And so they refused care from these midwives. And they were very rude and sometimes verbally abusive towards the midwives providing the care for them. And so based on these concepts, midwives felt respectful maternity care was very much system shaped. And so they described it more in terms of structural violence than them being the perpetrators of care and women being the effectors that the structures within which they were working were so impoverished. And they lack the basic necessities that they needed to provide care. In addition to that, there was there was a lot of risk aversion. There was a lot of fear of litigation. There was a lot of fear of adverse outcomes. And based on based on the causative mechanisms that were identified using critical realism, sorry, using critical realism, I identified three major causative mechanisms that had resulted in the lack of respectful maternity care within the context that I studied. So I utilized critical realism as my philosophical underpinning during the conduct of my research. And so using retraduction, I arrived at three major causative mechanisms. And one was the high dependence on midwives ability to navigate through the challenges within the healthcare system. So as I have indicated earlier, there were a lot of challenges, challenges with resources, both material and human and challenges with acceptance of the status or the identity of midwives. And midwives were expected to navigate through these challenges. However, the support that they needed had not been provided to enable them navigate through the challenges. So for instance, in one of the facilities, women were expected to donate blood in anticipation for its need. Even for women who were going through normal pregnancies who had no complications, they were expected to donate blood. And this was the responsibility of midwives. Midwives had to ensure that women had provided the blood. And so it created a lot of conflict between women and their midwives, especially when women had not been able to identify persons who would donate the blood. Again, midwives were the ones who were expected to ensure that women had settled their financial obligations to their facility. And during the discourses that ensues between women, midwives and their companions, a lot of conflict arise. And so that kind of dependence on the midwives' ability to negotiate through these challenges brought a lot of fractured their relationship that existed between the women and their midwives. There was also a competing demand between safety and satisfaction, resulting in fear and risk aversion within the Ghanaian context. There is a very high maternal mortality rate. And this has been used as justification for the abuse and disrespect of women. The high maternal mortality rate causes a lot of fear of adverse outcome. And so when midwives envisaged that women were either going to refuse emergency interventions, or they were going to refuse care that they midwives perceived as being good for women, they tended to use abusive means to ensure that women agreed to the interventions that they were being given. They also became very risk adverse. So for instance, during one observation out of distress, a woman requested for a caesarean section, even though there was no indication for it. The midwife agreed to have the caesarean section done. But on further consultation, she realized that there wasn't a team to do the caesarean section for the woman. And immediately, the midwife became very apprehensive, because at that point, at the point the fitters became distressed, the lycop became a conium stained, and the midwife became afraid that this was going to result in a fitter distress. And so she began to shout, and she began to use abusive means to ensure that the woman went through a normal process of labor. And so the demand for safety and the blame that is put on midwives, when that safety is not achieved, causes midwives to become very risk adverse. And this becomes a precursor for abuse of women. The third one is that the midwives philosophy of care. Midwives in this study did not base their care on the midwifery model of care. It was very much a matter of doing to women, rather than being with women. And this also points back to the perception of risk, because they had become so risk adverse that they were more interested in doing and in achieving outcomes than in meeting the needs of the women they were caring for. So based on these, I made some recommendations for practice. And one of it is a revisit to the philosophy of midwifery practice, which is based on the with woman philosophy. It is based on the midwife-woman relationship and a woman-centered approach to care. These were conceptualized by the midwives. However, it was in theory, but not in practice. So it is important that within the Ghanaian context, the midwifery philosophy of care is revisited. And as I indicated, there was a lot of interprofessional conflict within the care center. So there is a need to ensure interprofessional learning to promote collaboration so that in enduring emergencies, women are able to receive a multidisciplinary care. And midwives also need to gain more training in care provider interaction to enhance their ability to communicate with women, even when there is language barrier. Again, midwives also need to be supported to navigate through the challenges within the health system, because even though they have been highlighted as the perpetrators of abuse and disrespect, it is very much a systemic problem. And so midwives need to be supported to navigate through the challenges, whilst strategies have been put in place to improve their system, they need to be supported to navigate through the challenges. They also need to be very strong leadership within midwifery practice to ensure that there are role models and midwives are able to obtain the supportive supervision that would enable them reinforce practices that are inherent in midwifery. Finally, I want to thank my supervisors, Professor Helem Spivey, Dr. Kashwin Evans, Dr. Phoebe Palotti, and then the University of Nottingham Vice Chancellor's Scholarship for funding my PhD studies. Thank you very much for listening. Jennifer, Jennifer, thank you very much indeed. A virtual round of applause to you from all of us around the world for a fascinating presentation there. Very much appreciated. And while you were talking, there's been quite a lot of chat in the chat box, sort of confirming what you're saying there and people talk about their own experiences. There are a couple of questions and we've got just a couple of minutes if you can answer these relatively quickly for me. In light of the dynamic cultural context in Ghana, how did the midwives conceptualise disrespect? And did your study identify any forms of psychological abuse? Psychological abuse was not just of women, but of midwives because I would say so because as I indicated earlier, the challenges within the system has not been improved. And yet, though they have affected the high maternal, they had led to the high maternal mortality rate, midwives have been the targets of blame for these abuses. And so they have been traumatised, which has not been as yet identified in the literature in relation to respectful maternity care. And so based on the trauma, based on the blame, based on the challenges within the system, they reproduce the control by abusing the women in their care. And so the psychological trauma, the psychological abuse was not just to the women, but to midwives as well. And so more or less I would identify this as structural violence and not simply disrespect and abuse of women. Again, there were certain contextual nuances that were conceptualised by women. So for instance, utilisation of religious values, utilisation of certain tenets within the culture, for instance, considering the woman as a relative or treating the woman as a relative or as themselves, are certain facets within the culture that was inculcated into the provision of care. Jennifer, one more question, if we can just we've got two minutes before I have to close us out. But another question here is about how about the midwives knowledge on RMC, what did you find? That the midwives knowledge on RMC was was very minimal. However, I was able to simulate some discussion using the WHO definition of respectful maternity care as a vignette. So I used that definition and I used my own observation during the initial phase of data collection to develop a case study, which I used as a vignette to enable midwife articulate their opinions on what respectful maternity care was. However, like I indicated earlier, for them, it was shaped by their relationship with the woman. And so that led to the development of the relationship-based approach to the respectful maternity care concept.