 Hello. So thank you very much for the great honor of being allowed to speak at this meeting. Today I want to talk about critical help early for women in Africa or in shorthand terms. It stands for Tua. And I need to sort of give a big thanks out to Naomi Sangaya, the midwife who runs the critical care unit for women's health in Malawi where I started the program, Sylvia Matango, who's one of her colleagues, and Andrew McWinja. My name is Gloria Sabona and I'm an obstetrician and gynecologist. And currently I have founded and I'm directing the Institute for African Women's Health, which is a multidisciplinary think tank to really bring everybody involved in African women's health together underneath the same umbrella because at the moment it seems like the African woman has been dismembered in terms of her needs. So we have midwives working on one side, doctors on the other, policymakers doing something sometimes completely different. And I felt there was a real need to have an umbrella or platform where everybody can come together to try and improve women's health for the better. So the objectives of this talk are to talk about this critical care program which I started in Malawi and to get people to understand why it's so important. So I want to talk about why critical care. So by critical care I mean the close constant watch of women with life-threatening conditions as a result of pregnancy or other women's health-related conditions by a specially trained person. And I want to be able to hopefully establish why I feel the midwife has to be at the forefront of that. And I want to talk a little bit about how I went about setting it up and then what the outcomes were and what the challenges were that we faced. So I start with why. And for why I usually like to use this term which is mad. And I always say that it's really bad that babies are dying, but it's completely mad that in 2015 mothers are dying in childbirth or from women's health complications. Completely mad because we've known for years how to treat and how to prevent these conditions but women still continue to die. And they die of three main issues based on my experience working for more than 10 years I would say in the African setting. They die from what I call the she condition. So the S stands for sepsis, hemorrhage and eclampsia or preeclampsia. And the reason why I set up the critical help program was that I felt greater understanding of those conditions would really, really help to make a big dent in maternal mortality and mobility. I'm really, really passionate about stopping women from getting so advanced just because of simple pregnancy conditions. I always say that it's mad that mothers are dying and there's more than one way to kill mothers. You can kill them physically and we all know about the stats of one woman every minute or 800 women a day. But for me, based on the experience I've had for the past 10 years, there's more than one way to kill women and women are dying in their droves from physical, social and psychological complaints. So the critical help program was really a way of trying to make a dent into that. So it really tries to tap into what I call the preventable conditions and we hear a lot about the preventable. And I think those things are really important but at the same time we have to appreciate that there's also the unavoidable conditions that women are faced with. So it's not a simple case of that we can prevent women getting sepsis or preeclampsia. In the most part we can but sometimes it's unavoidable they are going to get those conditions just because of their makeup and we have to be ready for them. And then of course there's the attributable. So the attributable means the things that we contribute towards making a woman sick in terms of not having the right equipment, not having the right staff. From my experience working in Africa, we have a huge number of women for instance that have preeclampsia and it almost seems as if the African woman is more sicker than woman anywhere else in the world. But it's not that. If we start looking back at their history we actually find that we're not picking up their blood pressures early. So they're going through the whole of the antenatal period not having the blood pressures picked up until the very last minute and then they come to us very sick. And if we don't have that critical care approach for them they are going to die. So we are trying to sort of work within these three main areas. And I feel that the midwife is really, really important to working in the critical care field just because we know that mortality goes up when you do not have enough health workers. So the WHO says that health workers should there should be a ratio of 230 as a bare minimum per 100,000 of the population. And this will enable you to give at least basic care. But we know that in most African settings you're lucky if you have two doctors and then maybe 37 or 40 midwives per 100,000. So we are way off the mark and it should not be any surprise that we are having the really, really bad numbers that we're getting especially in the rural communities. So we have to be really innovative in how we're going to tackle maternal mortality and morbidity. And I feel for my experience especially having trained midwives from close to 10 years now in different African settings, Nigeria, Ghana, Kenya, Malawi. The midwife really is key to that. I mean the Malawian midwives are extremely, extremely highly intelligent people. And you know as midwives they do this kind of constant watch of the patient anyway in labor. So it's in their psyche. They have the empathy to do it. So I felt in terms of the numbers even though they're very low in Africa per 100,000 of the population in terms of numbers and also in terms of the inherent skills to deliver this intensive care. The midwife is the ideal person and I call her the madwife. And in the UK if you use the term madwife it's not really seen in positive terms. But for me in Africa with the experience I have I think madwife should be seen as a more affectionate term. You know we need more madwives in Africa, madwives who are really upset and angry that mothers are dying and really want to do something about it. And I feel that if we have more madwives or midwives who will help them with CPD it will help to improve the environment in which they work which is extremely poor and of course will help with motivation and retention. So how did I go about setting up this critical care unit in this hospital in Malawi? Well it was done in four days and even now I still can't believe that it actually happened within that four day period. But we started in a central hospital in Blantyre which is the commercial capital of Malawi called the Queen Elizabeth Central. And this hospital has sometimes as much as 15,000 deliveries a year and for those 15,000 deliveries they're lucky to have 35 midwives in total caring for those women. So the midwives are really working flat out. The hospital has a forbed intensive care unit which is for the whole hospital not just for women's health and often we cannot get our patients in there. And of course that was leading to a high number of maternal deaths because many of the health centers were referring their patients into the central hospital and of course they were arriving in really poor condition. We couldn't get them into ICU. There was no specific area to look after them in the hospital. So there were 12 maternal deaths when I started this program in November 2013. And if we use the ratio of every woman that dies they are maybe about 20 to 30 who are severely injured then that basically equates to about 360 near misses or morbidities. And then we were losing about 60 babies a month. So I went out with Miata Kapaka who's a HDU trained or critical care trained midwife from the UK to help deliver the initial training. You can see here on the left we have Ellen Sherwa who's the director of nursing and midwifery, a very visionary passionate director of midwifery. And we collaborated together to start this program and she invited midwives in Queen Elizabeth Hospital but also representatives from the 25 health centers who feed in to Queen Elizabeth Hospital and send the really bad cases to us. And we started with the premise that these people they're experts. So I didn't want to stand in front of them you can see me on the right saying I know everything there is to know about critical care and I'm going to tell you how to do it. They really had to work out things for themselves. So we started with three basic questions at the beginning which was why do we need a critical care unit? And they quickly realized after lots of discussion that there was not a need for something like this which was lots of staff lots of equipment because of course they couldn't reach that level. Why did I need a critical care unit? What does it involve? And what would it look like? So what they decided was it was not enough just to have a unit or an area within Queen Elizabeth Central Hospital. We needed to be able to feed into the health centers feeding into Queen Elizabeth because what was happening is that women were coming extremely sick because they were not recognized or treated quite early on and then Queen Elizabeth couldn't cope with them. So we really wanted to establish a network feeding around Queen Elizabeth. So the philosophy that we started with was the midwife decides if you live or die and that's such a profound statement the midwife decides if you live or die and we went forward with that because you know the midwife quickly understood that she stood between the woman dying or staying alive you know if she didn't take those initial actions she's with the mother she's by her bedside all the time she doesn't take those actions to recognize and then intervene and refer then that woman is going to die. So the midwife immediately took ownership of this critical health program and another principle is that we tried to instill in them was what we call the art of critical health. So you know what we were trying to do is not just sit down in a unit and wait for the woman to come to us really really sick we wanted them to understand that you know we do not want to push babies and mothers to their physiological limits so the art of helping these women was to stop them getting pushed so far that the limited resources that we had at Queen Elizabeth for instance was not enough to sort of meet their needs. So it was really about anticipation or prevention and this is the reason why the health centre midwife was so important anticipate prevent these horrible conditions but then if a woman is becoming sick recognize early so we can bring the woman back from extremists quite early on and then timely intervention and that basically stands for art. So we gave a quick pre-test just to see where they were in terms of their knowledge you know not just advanced critical care knowledge but even this basic thing such as observations what's the normal blood pressure what's the why is the respiratory rate so important as the first indicator the woman is sick and that pre-test actually was extremely low it was three percent even when it came to things such as you know what's the normal blood pressure we were getting values such as 210 over 170 is normal so that helped us to establish where people were in terms of their knowledge this is an example of one of the questions that we gave them and then we just went straight into physiology and pathology and as I said we focused on the she conditions so sepsis hemorrhage and eclampsia preeclampsia because we felt these were the main reasons why women are dying if you go to any African hospital you know if anyone bought me their stats and asked me to look at why women are dying these are the three main reasons I know we've got other issues such as obstructed labor unsafe abortion but they all fall under these three main conditions we really want to concentrate on this because we felt if they understood how to manage these conditions they could manage more or less anything that came their way from a critical point of view we wanted to move away from doing something really complex like this because midwives even though they're highly highly intelligent even as a doctor you get flawed trying to learn all of this information within four days so we needed to sort of come up with a simpler framework that they could start to build their knowledge on so we introduced things such as this within the book that I've written such as you know when a woman comes with altered level of consciousness or temperatures high or low or she has high breathing or fast breathing or slow breathing low blood pressure high blood pressure pain bleeding we introduced a book full of algorithms so that as soon as a woman came their way and they picked up an observation was wrong or worrying they could actually go to the book or to the guidelines and immediately start step by step to manage the woman we also simplified all of the observations just down to these three observations so pulse respiratory rate and temperature and which I thought was really important BP of course we covered and we covered during output but we focused a lot on these three observations because one of the issues we were having in Malawi was lack of equipment so I told you before about woman coming with eclampsia preeclampsia and it's because their BP is not getting done because there are no batteries BP machines are not working we all know from a physiological point of view that the BP is one of the last things to go off anyway and these observations here actually give you a lot of information quite early on and you don't even need equipment to do these observations you don't have to be clinically trained to do these observations so we focus on these three observations and of course focus on the other things as well such as the urine output so we use novel things such as you know knowing whether a woman was dehydrated or was passing urine okay by equating it for instance to soft drink so Coca Cola means that yes this woman is really dehydrated it goes sometimes along with eclampsia preeclampsia sprites usually means that she's well hydrated so we use really innovative techniques to really get them thinking and then one of the big innovations we had was thinking about the management so when we think about managing preeclampsia or sepsis sometimes the algorithms can be quite complex for people to get their head around so you really want to make it quite simple so what I said to them is you only have to think of three things when it comes to the management just like you have to just think of three observations you don't have to think about three three interventions that will help the woman is either that she needs O2 she needs something to be done fluid wise and she needs drugs and if you've got these three things in your head it's very easy to use this as a framework to start putting things on to those for those conditions so this is an example of what we came up with so those of you that are familiar with this basic resource will be familiar with the left hand side which is the ABCDE and how when someone comes critically um well you have to go for that algorithm so we stuck with that but on top of that we had the anticipation part of it and then we had the recognition so the recognition had all of the observations underneath and then timely intervention was oxygen fluid and the drugs so if we go to the next slide I'll just give you an example of what I mean by giving somebody oxygen so it doesn't physically mean you have to give oxygen because of course in the health centers in the villages there is no oxygen but there are other things that can be done to ensure that that woman has good oxygen delivery so if she's pregnant we know that we have to tilt the mother 15 to 30 degrees that will help to give her oxygen or you open the airway if she's obstructed and from a fluid point of view we were talking about IV fluids or giving blood or whether the patient was bleeding or not so you want to think about maybe giving her fluids if she's very dehydrated or she's septic stopping fluids or restricting fluids for instance in the pre-eclampsic or clamptic and taking fluids by way of blood to ensure that you know where what you're dealing with and where you're going and then for drugs it was you know do you have to give drugs you have to stop drugs so just having this framework I mean it seems very very simple but having this frame really helped people to start understanding how they could start managing the she conditions and then it was from there very interactive so they had the framework they understood that they were the experts they understood that they decide if the woman is going to die or live and then they started giving them scenarios really and step by step on that first day they started working out using that framework how to manage quite complex real-life conditions that we've picked up on the world and then we talked them about recess so it was very interactive and hands-on now a number big part of what we had to do on that first day and this continued throughout the three to four days was we had to teach them about communication by way of documentation because one of the big things I found training in Africa the documentation or the paper paperwork is not fit for purpose so without that paperwork it's very difficult to communicate and of course to see that trend of when the patient's become an unwell or getting better so they had to get their head around being better with their communication and their documentation and once again because we really wanted them to take ownership I didn't go to them with this is the documentation you are going to use instead what we did was we downloaded lots of examples from around the UK and we then also asked people from around the UK to sort of send us their guidelines and we stuck them around the training room and we said okay look you've got 10 or 15 examples of observation sheets 10 or 15 examples of medication charts we want you to have a look at it look at what you like and what you don't like and design something which is fit for your own context so they spent time doing that and it was really enjoyable seeing them sort of looking at in their groups looking at each of the observation charts and the medication charts and working out how they could design their own for their purpose and I think this was really important and I think I think it's the reason why since November 2013 this unit continues to thrive even with just four full-time midwives continues to thrive because they designed everything themselves bottom up bottom up so for instance they designed the early warning score which is used quite a lot in the west but in Africa still when needs to take off they designed something like this themselves from scratch worked out what the normal observations were and what the abnormal variants were and like I said they designed it by drawing on paper Chester here who was a midwife and one of the furthest health centers is very good with computers he designed it printed it off so finally it looked like this where's them going where you can see here from Bangui health center who's now head of the safe motherhood program was on her knees designing an observation chart which would help or aid communication between the health center and Queen Elizabeth central hospital so this is what they've the the first edition of the observation chart looked like we're now currently on version four they continue to improve it time and time again and then one of the biggest challenges that we had to overcome really was the place because we knew in the hospital 15,000 deliveries there were sick mothers everywhere from the labor ward to the postnatal ward to the Guiney ward their woman just languishing languishing in bed not because the staff didn't care but when you only have one midwife looking after 100 patients it's very easy to overlook what's going on with them with the mother so there really was a need to really have this central place I was very lucky when I arrived that companies such as rotary and old mutual had actually rehabilitated and redesigned a space next to the labor ward for a critical care unit they had been sitting empty for some time and that was because they felt that there was a lot needed to open up that unit and it couldn't be open let's say in the next few months or so I was quite low to do training with midwives in a room knowing that there was sick mothers up and down the hospital and I had as far as I was concerned 19 experts in front of me from a midwifery point of view who were being trained in critical care but we couldn't use this space so one of the first things that the midwives agreed on that first day we're gonna we're gonna almost do like a coup and we're gonna open the critical care unit and there was resistance but the midwives were very strong instead fast and they decided to open the unit so they divided into four teams and each of those teams made up a bed ready for a patient to go into and while they were making up the bed and trying to source equipment for each of the beds myself and Miata the midwife from the UK went around the hospital trying to find the patients that will go into the critical care unit for the first time and it was very difficult because we find the patient and we think yes that one definitely needs to go into that unit but then an expert or somebody even sicker so it was it was a real challenge but we finally settled on four very sick women one with sepsis one with hemorrhage two of hemorrhage and one with eclampsia preeclampsia and we started putting them in the bed so we then set to the teams by their beds you've made up your beds now you've got your equipment half of your team needs to go and collect your patient that we've identified and bring them to the bed and the other half needs to stay by the bed and get ready to admit the patients and so using that process they worked out how to design documentation to aid transfer from one area to another and also how to stabilize the patient on the ward so here you can see a picture of team A which I fondly refer to as my best team the A-star team because they were so good you know assessing a patient on the ward who was very sick 10 days postpartum with sepsis after cesarean section so she was transferred to the bed and then day two to four was really very much bedside teaching they didn't see the inside of that room again the room where I put all of the documentation around because it was very much bedside teaching there's no point having sick mothers of critical care and you're sitting looking at PowerPoint so it's very much bedside teaching with myself and Miata teaching them at the bedside how to manage the patients and using that they started to work out their guidelines so what was the outcome of that four days training well of course at the end of four days we met quite a number of challenges but at the same time we found things such as the post test improved from 3% to 93% which was huge and these were not easy questions it was questions such as you know what's the circulatory disturbance in preeclampsia so they were quite advanced questions for midwives who were not used to thinking from that point of view but the test actually rarely skyrocketed from three to 93% and a number actually got 100% on the test the midwives were so excited they danced they sang you know they printed t-shirts such as this because after just four days this critical care unit which people had dreamed of for like several months or if not years was finally open and when I sort of looked at the data and I just give you a brief overview of the data after just one year so we started in the 18th of November 2013 the same time last year 2014 411 women actually have gone through that unit and been successfully discharged and as I suspected there were three main conditions the she conditions which were treating and managing woman force so it was a sepsis hemorrhage and eclampsia preeclampsia and of course there were a few other conditions that had to go for the critical care unit as well so those ones with cardiac or with epilepsy but these were the three main conditions and I can say as a result of that critical care unit the mortality rate actually dropped by half at least so whereas we were maybe losing between 12 mothers sometimes higher than that per month from these referrals coming in from the health centers and of course we're having a lot of near misses where women were extremely sick but they were not dying we actually reduced quite a number of those bad outcomes and deaths by 50% where we find that mothers are still dying so now instead of losing 12 mothers a month maybe we were losing one or two where those mothers are dying it's just because they have not been referred in early and they come in so advanced that even the ICU cannot manage these patients so this is something that we need to work on but from a critical care point of view and then midwitery point of view they have really impacted on outcomes and another thing which I you know I'm so proud of is just the empathy demonstrated by the midwives I mean I've been training midwives for close to 10 years in different African countries I love love love the malaria midwife I mean all the midwives I've trained in every country they're absolutely wonderful people but the malaria midwife I mean especially here Sylvia metango who's one of the key core staff in the critical care unit she is I don't know so empathetic I mean this picture is the front of the book that I've written for critical help early for women in Africa so empathetic and I was really stepped up to the plate so I'm really really glad I sort of demonstrated that people do care about their people and the midwife really is at the forefront of that the midwives have continued to demonstrate their CPD and to improve the unit by continued to develop the documentation and the care that they've given and they've also started to recognize that prevention is key so they've been really really key to try and stop six sick women coming to the unit and trying to scale up critical care competencies across the whole of Blantyre and then they've started to write their operational guidelines because once the unit opened it was amazing people from around the country asking for guidelines from that unit and asking the midwives how do you manage preeclampsia how do you manage sepsis so they really have stepped up to the mark the other thing that was really really fantastic in the black in the middle you can see here Wese Ngungwe who you saw on her knees designing the observation chart she's now head of the safe motherhoods department in Blantyre and she was so impressed and empowered by the training the initial four days training that when I went back in January to start phase two training she said Gloria I really want us to train all of the health center midwives especially in the in the early warning alarm or the early warning score I think it's really important so can me arrange training I've spoken to the district health officer he's agreed to sponsor them to come for training so using our help we actually managed to train 84 health center midwives and I think that this really has also impacted on the outcomes at Queen Elizabeth because now they're not coming as sick as they were before so the midwife for me has really really stepped up and I think if we can really start to take the midwife at the forefront of all of these initiatives in Africa I think we will start to see a big difference of course there are always challenges so we're dealing with a system where antenatal care is still not that brilliant we're still missing the fact that patients are anemic I showed you that Venn diagram at the beginning where I said that sometimes it's unavoidable or we attribute to the fact that these patients will become sick so you have patients coming with a HP of 1.6 we know that women are going to bleed hopefully not more than 200 300 meals but even with that amount HP of 1.6 of course she's going to be pushed into that critical level so there's a lot that needs to be done antenatally we're having to reuse a lot of our equipment so ambu bag bags the oxygen masks especially the ones with the bags all of these things we have to re-sterilize dry and then use again because it's very difficult to get equipment but despite that people such as name Sangaya who you can see here on the left and Silvia Mitenko that really empathetic midwife are continuing to make strides in that unit I mean as it stands at the moment the unit is run just by four people Naomi on the right Silvia on the left or vice versa actually on the left Naomi and Silvia on the right Andrew McQuincher absolutely fantastic midwife and Esther Malanga and that's because with 35 midwives in that department of 15,000 they cannot spare any more to work in the critical care unit so sometimes people like Silvia will work 24 hours they will work 36 hours it's absolutely amazing but they're so dedicated to what they're doing and they don't really ask for anything for themselves other than this really basic things like Gloria next time you come from the UK can you bring us scrub suits because we don't have scrub suits so you can see them here wearing scrub suits embroidered with their name and how proud they are to have simple things like that and to be to be recognized so now they've been elevated to quite a high level and I think that would really help their CPD this is one of the very first patients in that four days who was discharged she was the patient who was so sick at one point we were up with her all night and I actually thought she was going to die her respiratory rate was 50 blood pressure was in her boots and post was 155 I really didn't think she was going to make it sepsis after serine section and it was amazing that day five having gone through that critical care unit and intensive intensive care by Andrea Miquinja and Silvia Mutenko you know that she's actually here today she has a live baby and she still has a uterus so we are now trying to scale up this critical help early for women in Africa in other African countries the book is more or less written now and we hope you can get funding that we can actually start to push out these very simple basic but advanced principles across the whole of Africa and the midwife as far as I'm concerned even as a doctor have to be at the forefront of that initiative thank you very much Gloria can you see that question would you consider introducing this training in the UK um yes I mean I think they do have um training in the UK um not specifically for all midwives but I think midwives who are trained from a critical care point of view and who run the high dependency units um do undergo this training so I think a number of universities such as kins college do offer a critical care program but I think it's important that every single midwife should understand critical care because critical care doesn't just happen in a place it happens everywhere um and I think this rarely is um one of the key areas that will really help to reduce maternal mortality and morbidity even in the UK so even though our numbers here are very very low um we are still losing sometimes 10 to 12 mothers per 100 thousand and no mother should die if it can be prevented so I think definitely there's there's a need to scale critical care um and even if they don't go to four more qualifications such as at kins college I think a program like this would really help them and you can do those other comments Gloria yes I can um so I'm not asking um they would like to get a copy of the book so my details are there so you can email me and I'll see how I can get a copy um to you um and then there's a comment here about the lack of interest in the respiratory rate um I think even in the UK um the respiratory rate really has been overlooked as the first marker that a woman is beginning to go off and I think it was only when the confidential enquiries um highlighted it I think a few years ago that people have now started to go back to that but um I think the respiratory rate is so important and like I said with the other observations such as temperature and post you don't need specialized equipment you don't even need to have specialized training anybody can do it so I think it's such a shame given that is the first marker that the woman is beginning to go off and there's sometimes that time to intervene that we don't pay more attention to it so I'm very hot on that when I do my critical care training that the respiratory rate has to be seen as that gold standard or the benchmark for what's happening with the mother um and then in terms of whether the training can be delivered in other languages I mean my first language is English um but you know I'm mindful of the facts for instance in Africa that we have francophone Africa um and I've had people approach me for instance from Niger and Senegal um interested in the program um but their main concern is that um it needs to be in French so I am looking into um interpreting the training materials into French and Creole and I'm also looking into I mean it's only one of me um it's a lot of work to do the training even though it can be delivered very quickly within three days um but I'm looking into establishing trainers on the ground so for instance I've got like a cohort of midwives now in Malawi who are more than capable of taking this program forward by themselves um and then in terms whether the package has been developed um so a trainer can access it um as director of the Institute for African Women's Health um I'm looking to develop quite a lot of online materials and downloadable materials that people can sort of access because I think education should be open source and it should be free um I don't think we should when it comes to women's health we should be putting a barrier in terms of money um between knowledge um and getting help for the woman so um I'm looking to sort of get a lot of these materials online for free um but if you email me um I can add you to the mailing list and once that's available um I can get that to you and I think if there are no other questions I think one of the key things I mean that term Mad Wife I think is really important I think we have to really start getting mad I think you have to start using quite how can I put it um language which rarely tugs at people's emotions that this rarely is mad so I mean critical help early is one of the programs that I've established I've established the Art of Delivery um training program um because one of the big problems I find going to Africa I mean in the UK we still have that problem as well but it's not as bad going to Africa women still flat on their backs in labor um and then we're wondering why the baby gets asphyxiated um we wonder why we have bad conditions why the mother ends up with a caesarean section even that full dilatation so Art of Delivery is one program and then recently I've just come back from Malawi again where I've started a training program in ultrasound for the midwives um and I've been I wouldn't say accused by the doctors but you know there's a lack of understanding why is a doctor am I focusing so much on the midwife well in terms of numbers it makes a lot more sense um and then secondly I just find that the midwives rarely do get it um and I think we need to have more mad wives or more specialist midwives that have these high level skills because like I said they will stop the woman getting so sick we do not need birth for instance to become a disease where we allow the woman to get so sick and then we now develop big institutions around how to deal with it that is absolutely and completely wrong so for instance we've got fistula surgery now which is now becoming a speciality in its own right fistula which is so preventable um we are now allowing the woman to get to that point where they have these horrible holes within their anatomy and then we're now saying yes we now have fistula specialists that's wrong um and the same thing with um ultrasound allowing the babies to die and then developing a big specialty around it so we need to really start dealing a lot with the prevention and I feel that midwives get that preventive aspect um a lot more can you answer the question about the changing life attitude um I can't see that question where is that um I think training to change attitudes rarely it has to come from the grassroots people often say that we don't want top down approaches and that's true um they feel it should be bottom up for me my understanding is that it should be bottom up until it meets the top halfway in the middle and so that really means that you have to I don't know really tap into the hearts and minds of those people at the grassroots those people at the front line tap into their understanding and you know what's in it for them and why is it so important empower them that their voice will be heard and that their solutions actually make sense and then I think you actually find the attitude changes so in this particular hospital I have done so much work not just from a critical care point of view but on the labor ward where we were getting so many bad outcomes and then recently ultrasound training guiney ward postnatal ward and a lot of it has come about by really inviting the midwives as experts as an example and telling them that look do you think there is a problem what problem do you think there is and how do you think we can go about tackling things and giving them a voice for the first time so we've done quality improvement um workshops with the midwives where they have designed solutions so I mean this particular unit really has started to change in just a few weeks because the midwives have now felt empowered to actually start changing things and I think that's the only way to go really I don't think you can foist things on people and then expect their attitude to change they have to understand what the issues are and they have to understand that it's within their power to change it and why it should be within their power to change it and then I think you will find that the attitudes and the empathy naturally comes from there so in that critical care unit for instance the midwives have rarely taken ownership of that unit it's the cleanest place not just in that department but in the whole hospital I mean when you walk into the critical care unit you think you're in a completely different world and this midwife see it as their area these are their patients it's part of their job to ensure that the mothers come in and go out in one in one piece and they're not mechanical in what they do either there's so much empathy there's the caring and the feeding and the washing and the cleaning and I think like a lot of that has come from them feeling that they have designed that whole program by themselves and I think this is the way forward for training I think not just in Africa but anywhere else in the world it really has to be learner centered and they have to drive the training because then whatever outcomes come about will be sustainable well I think we all really want to thank you so much Gloria that was some cash that thank you so much the slides are brilliant and as we tell you the slides will be available for viewing later so thank you again fantastic presentation thank you very much I'm now going to turn off the color