 All right. It's my pleasure to introduce to you Ellen Blix. Ellen Blix is a professor of midwifery science at Oslo and Akerhus University College in Oslo, Norway. She was educated as a midwife in 1986. She attained an MPH in the year 2000 and a doctor pH in 2006. Ellen Blix has worked as a clinical midwife for 20 years, most of the time in a small local hospital in northern Norway. She's also worked in bigger university clinics as a community midwife and in projects in Lebanon, the West Bank, and Cambodia. Her research areas are place of birth, duration of labor, fetal surveillance, and normal birth. Ellen, turn on your microphone and away you go. Thank you. Thank you very much, Lorraine. Is my microphone on now, Lorraine? Yes, it is, and you sound good. Thank you. So thank you very much for inviting me to speak at this conference, and congratulations with the International Midwifery Day. And I want to invite you to Norway during this talk. And we have just been to Romania. And thank you to Elisa and Irina for a very interesting and almost heartbreaking presentation from Romania. And this is another story in Norway. And in case you didn't know, Norway is in northern Europe. It is stretching from very far towards the north. And we are a part of the Nordic countries, together with Sweden, Denmark, Iceland, and Finland. And we are all rich countries. Norway is one of the richest countries in the world. We have good health systems, and we have health registries, and we have very good birth registries. And Norway, Sweden, Denmark, and also Iceland. We have a common history, a common culture. We are the same ethnic group. And we have almost the same language. In Norway, Sweden, and Denmark, we can understand each other when we talk. Norway is a very big country with few inhabitants. We are a little more than 5 million people in an area of more than 304,000 square kilometers. And that is 10 times the size of Belgium. We have a few cities, and we have huge rural areas. Here on the photo, you can see all those big blocks there. That's the barcode area in Oslo. It's the newest and most modern part of Oslo. And down there, you can see a part of the Lofoten Islands in northern Norway. We have less employment than other countries in the area, and other countries than Europe. And we are rich also because we found a lot of oil 30 years ago or 40 years ago. And most women, also those with the children, are part of the work stuff. They are working outside their homes. The breastfeeding rates are among the highest in the Western world, and we have paid parental leave. And mothers and fathers can stay at home until their child is one year, and they will have some money for it. Most inhabitants are ethnic Norwegians. But we have one indigenous group, and you can see a photo of a mother and her baby and the grandmother up there in the left corner. And it is about 40,000 Tami people, and they are living in the northern part of Norway and in Sweden, Finland, and Russia as well. And they are declining because of the influence of the majority, and only a third of those who say they are Tami people, they can speak the Tami language. But it's still a living language. We have a growing immigration population, and 15% of all the inhabitants in Norway are first or second generation immigrants. But they are unequally distributed along in the country, because in the Oslo, the capital area has more than 30% immigrants, while other areas have very few. But most of the immigrants come from Poland, from Somalia, Sweden, Lithuania, Iraq, Pakistan, and of course we have refugees, though, from Syria and from Afghanistan and also other countries. All health care during pregnancy and childbirth is free of charge. And also illegal immigrants are granted emergency health care. And pregnant women who are, for instance, asylum seekers who have not got the permission to stay in Norway but who still stay illegally, they are granted maternity care without risking to be arrested and deported. We probably all agree that there is a need in almost all countries for a new model for maternity system that focuses on optimizing biological, psychological, social and cultural processes and strengthening women's capabilities. And I think that most of you are familiar with this model or framework from the Lancet series on Midwifery from 2014. Now I will tell you about Midwifery and maternity care in Norway, but we should have this model in mind. And in the end of the talk, we can see what is working well and where there might be need for improvements or change. And about the... We should also think about if our practice is in line with evidence-based recommendations. We have strong evidence for recommending continuity of care. We have strong evidence for recommending intermittent auscultation in low-risk births. And we have strong evidence for one-to-one care during the active phase of labor. We are about 3,000 registered midwives in Norway. And we work at the most countries in antenatal interpartum and postpartum care, most of us. I know a little about midwifery education. Almost 200 years ago, we had the first midwifery school in Norway. And that is a school where I am working now. So we have educated midwives for almost 200 years. And we will have a big celebration in 2018. As in many other European cities, there was a public maternal hospital where poor women and unmarried women could be cared for free. And midwives and medical students could be trained. And 200 years ago, to be trained as a midwife, you should not be younger than 20 years old and not more than 30 years old. And married women with own children were preferred, with experience from childbirth. And they were supposed to be good women. So they had to go to the priest in the town or the place they came from. And he should recommend them. And it was not necessary that they could read in that time. But it was an advantage. But to become a midwife today, you have to be a qualified nurse first and have a bachelor in nursing. And with minimum one-year work experience as a nurse. So we do not have direct entry in midwifery schools in Norway. We have five schools. And two of them offers midwifery education at the master's level. And that is the one in Oslo and Intensberg, number four and five. The others are working towards master's programs. And it takes two years in the midwifery school to become a midwife. And a total of one year is clinical practice and the rest is theory. As in other countries, the role of the midwife is supposed to be that she is an autonomous practitioner in pregnancy, childbirth, and post-natal care. And we also have a role in women's sexual and reproductive health, even if midwives that, even if few midwives are working within these areas. But you can be a counselor in the contraception. And give advice to women with problems in their menopause also. And the organization of maternity care in Norway is that antenatal care is both in primary and secondary care. Birth care is almost only in secondary care, apart from a few home births that are taken care of by independent midwives. And postnatal care is also in primary and secondary care. And now, in this lecture, I will just talk a little about antenatal and postnatal care and concentrate on intrapartum care. And in antenatal care, women are cared for by midwives and GPs. And we have national guidelines from the health authority. And they are very good. They are evidence-based. They are a bit old. They are from 2005, but they are under revision now. And according to these guidelines, the women should be able to choose between a midwife or a GP. Or she can go to both and mix you to that they share the antenatal care. But many places, there are too few midwives employed to offer midwifery care to all women. And there are also some professional tensions or conflicts and who is going to be the lead carer in antenatal care. And for the time being, it is more or less a GP. And healthy women will have a routine ultrasound screening at the hospital, but the rest of the checkups and will be in the primary care. And midwifery practice in antenatal care is like many other countries. As you can see here on the list, and what is special in Norway is probably that we have midwives working with preventing tick leaves in pregnant women. I don't know if that's so common in other countries. And that is that big organizations or municipalities, they will employ a midwife. And she will go around to ensure that the pregnant women working there have a good work condition so that they don't go early on in the tickly. And that can be things that they can have a good chair to sit in or the possibility to have a five-minute rest every hour and put the legs up. Or maybe she should do something else than her usual tasks. And this has been a success. A lot of the rates of sick leave in pregnancy have declined very much since this was introduced. It's not everywhere, but it is many places. And then postnatal care that women are usually offered a very short stay in hospital. And some hospital offer postnatal care at a patient hotel where the woman can have a room where she can stay with her husband or partner and see who she wants. And she can have help if she needs that. And the rest of the care should be in the primary care. And some years ago, we had a health reform indicating that women and also other patients should stay as short as possible in the hospital. And then the follow-up should be done in primary care. But when it comes to maternity care, the women are discharged from the hospital early. But the municipalities who should take the primary care have not been staffed up to take care of the women in their home. But it will hopefully improve. And also we have a national guideline for postnatal care. They are very good and they are evidence-based and very good, promoting women's own abilities and promoting breastfeeding. What is probably special about Norway is our high breastfeeding rate. And we have a long tradition of that. And we also have a national advisory unit on breastfeeding. And this is financed by the health authorities. And their tasks are to increase knowledge and establish and monitor best practice standards. And that is the baby-friendly hospitals and baby-friendly neonatal units and baby-friendly health stations and so on. And to do research, and they give advice to health authorities and health care providers, not to mothers. And they are staffed also by midwives and others with special education on the breastfeeding. We do not have any representative users' organizations for maternity care. And that's the pity, and I hope it will come. But we do have a strong users' organization for promoting and supporting breastfeeding. And they consist of mothers with experience of breastfeeding and special training in counseling. And mothers who have the problems or questions can call or send an email, and they will get help. And they also work politically. And then I will talk more about intrapartum care. But first, I would like to say that Norway and also the other Nordic countries are good and safe places to give birth and to be born, compared to other places in the world. We just heard how it was in Romania, for instance. We have access to free health care during pregnancy and childbirth, and they are well-organized and they're free of charge health care and vaccination programs for all children. Mothers and also fathers can have a leave to take care of the new child. And we have access to clean water, to safe and good housing. Everybody can have an education. And there are rights for women. There are rights for employees and for children. There is, for instance, it's forbidden to beat and hit children in Norway. And in general, we get decent paid for our work. And when we get old, we can retire it and we still have money to live for. But everything is, of course, not perfect. For example, there is a small but increasing group of poor people here in Norway, as well as in other countries, falling outside the society. And this causes unhelp. Also when it comes to maternal and neonatal outcomes. And maternal death is death in a woman during pregnancy and within 42 days after birth or abortion. And the maternal mortality rate in Norway is 7 per 100,000 live births. And we just heard that it was 31 in Romania. So that is much higher. And this is about four women every year in Norway. And most midwives are so lucky that we have never experienced that their mother died. And the rate is varying widely across the world. From the lowest is in Singapore with three and the highest in Chad with 1,100 per 100,000 live births. If we in Norway had the same rate as Chad, almost 700 mothers would have died every year. And that is two mothers every day. And perinatal deaths and stillborns are stillborns and deaths in the first seven days of life. And it is 3.5 in Norway and that's among the lowest in the world. And this has been stable for about the last 10 years. And this means in crude numbers, it means that we have about 230 perinatal deaths every year. The global perinatal mortality rate is 20 per 1,000 births. And it's 47 where it is highest. So while medicalization of normal birth is a serious problem in Western countries, the problem in poor countries is the lack of access to medical care and, of course, poverty. Because poor people are carrying the heaviest burden here. I am so lucky that I have grandchildren. And when my daughters-in-law and my daughter were in labor, I was not worried about their lives or the lives of the babies. I was worrying about if they got good support from their midwives to manage labor pain, about unnecessary interventions. And I was very worried about early clamping of the cord and matters like that. If I had been living in Chad, for instance, I would have been worried about the life of my daughter or daughter-in-law and about the child. When it comes to intrapartum care, it is mainly in hospitals. But there is a midwife attending absolutely all births. Also, if there is an electric caesarean section, a midwife will take care of the woman before the caesarean. She will take her down to the operation theater and take care of the baby afterwards and make sure that the woman can have the baby as soon as possible. And remember, I told you about the guidelines for postnatal and antinatal care. We also have guidelines for intrapartum care, but they are not made by the health authorities. They are made by the association of gynecologists and obstetricians. And they have taken some midwives with them while making these guidelines. But not users and the quality could have been better. So I hope that the health authorities will also make guidelines in the future. And Norway also has a principle of differentiated maternity care. And that is a parliament resolution from 2001 and again in 2009. The aim is to offer women individual and appropriate care and to avoid medical intervention, having little proven benefit in low risk labors. And we have 46 birth institutions and almost 60,000 births every year. And maternity care is organized at three levels. I will talk about that a little later. This map shows birthing institutions in Norway. There are 40 of them are in hospitals and six are freestanding midwifery units. The freestanding midwifery units, they are organized under a hospital. So they are in secondary care. And there are also four alongside midwifery units in hospitals. The number of birthing institutions has declined over time. It is, in 1980, it was almost 100 institutions and now it is 46. And now about the three levels of care. It is specialised units in bigger hospitals and it is units in smaller hospitals and then it is midwifery-led units and we also have home births. And level one, it is specialised units in bigger hospitals and they usually have more than 1,500 births annually. And there are midwives of statisticians, pediatricians and anesthesiologists available all the time and they have a neonatal intensive care unit close to the delivery unit. And there are also some other rules, they are both equipment and that they should do research and so on. And the next level is level two, that is delivery units in smaller hospitals. And they usually have between 1,500 and 400 births annually. And there will always be a midwife present and the obstetrician and anesthesiologist will be on call. And some of these hospitals also have a pediatric service but not an intensive unit. And there are selection criteria, women with some special conditions will be referred to a level one hospital. And within our hospitals, within level one and two hospitals, we have differentiated care within the unit. And that means that at admission, when the woman comes to the unit in labour, the attending midwife will make a selection and she will decide if the woman is low risk or if she has a higher risk for complications. And low risk women are often called green group women and those with risk for complications are called red women. And then they are allocated to green or red care. But they will be in the same unit. And obstetricians will not be involved in the low risk women, the green women. And low risk women should, for example, not have a TTG going on, that would be intermittent auscultation. And then the selection process will, of course, go on through all the births. So the woman will be allocated to a red group if there will be some complications or if she has an epidural also. And we have a few alongside midwifery units in Norway and they are all in bigger university hospitals. And we have had, we used to have two more, but both of them are closed in spite of good results. And they're closed for political reasons and economic reasons. And about 7% to 8% of all births in Norway are in alongside units. And water births are quite common in these units and also in some hospital units. And two of these hospitals to have alongside units, they have decided that all low risk women should start labor in the alongside unit. And the idea behind this is that it may will promote more normal births. And we have a few freestanding midwifery units. And most of five of them, we have six units and five of them are in northern Norway. And in the northern part of Norway, almost 10% of all births are in freestanding units. And as I told you, Norway is a very big country. And northern Norway is almost half of the country, but there is only 10% of the population are living there. So it's between four and 5,000 births in northern Norway. But they have six, five freestanding midwifery units and five hospitals there. So there are a lot of institutions, but few births. And these freestanding units, they are usually connected to a health center or a small local hospital without obstetric unit. And there are about 600 births on these six units annually altogether. And there are usually long distances to the nearest obstetric unit from 16 to 28 kilometers. And sometimes that involves a ferry or a mountain passage also. And the Norwegian health authorities do not organize home births. And the woman herself must find a midwife willing to assist the birth. But the health authorities will pay the midwife for assisting the birth, but not for being on call or for transport to the woman's home. And home births are most common in and around the biggest cities and not the very common in rural area. And we have national guidelines for planned home births. And they are quite good. And I will say that they are evidence-based. I was in the group making these guidelines. But it's quite a pity that so few women are choosing to birth at home. But there are few midwives willing to attend home births. And it is not common. And many women have never heard about home births. So as I told you, we have a decentralized system in Norway, and we have many small institutions. But if we look at the total births, we can see that half of all births they were happening in five hospitals, five bigger hospitals. And 28% of all births were in eighth and medium big hospitals. So three quarters of all births are in 13 hospitals all together. And then 17% of all births were in 11 institutions with a size from 500 to 1,500 births. And a small proportion in 22 institutions, small institutions. So we have small hospitals also. And we have a few planned home births. We have more unplanned home births than planned home births at ULA. And we also, of course, have some births happening under during transport to the hospital. Our Caesarean section rate is about 17%. And we have 10% of the operated vaginal deliveries. But the Caesarean section rate varies between institutions from 13 to 26%. So there are variations. And here is the showing variation. But this is not between institutions. This is between regions. So it's quite big differences. There is on the western part of Norway, where you see this yellow line. They have only almost 14% of Caesarean. And there are hospitals who have even a little less than that. And other interventions in labor, we have an increasing rate of induction of labor. And it is 18% no. We have 16% effeceotomy. And oxytocin augmentation, they are at least 35%, probably more. And one third of all women have effeceoral analgesia during labor. And these are interventions when not induction of labor. But effeceotomies, and oxytocin, and also effeceoral analgesia, the midwark can influence much on that. And effeceotomies are usually cut by the midwark. And we can see there are great variations in effeceotomy rates also across the country between different regions. And they are varying. And this is the variation in oxytocin augmentation rate. That is also varying quite a lot across the country. And we have this differentiated birth care. But what are the effects of the differentiated birth care in Norway? And what is evaluated? In the different kind of unit. And as I said, Norway is one of the richest countries in the world. And then I think also we have a responsibility to do research, to spend some of the money on research on our health care system. So I have tried to find out what is done in evaluating this different kind of unit. And these are studies on midwifery led alongside units in Norway. And we have only three studies about that. And these three, they are all led by midwives, these studies. And the first one, Lukaster, that is an observational study describing the transfers and outcomes of women who plan to give birth in the ABC unit, alongside midwifery units in Oslo. And the next one is a cohort study comparing healthy prima parrots women who started labor in an alongside unit with a comparable group who gave birth in the conventional obstetric unit in the same clinic. And the third one is a randomized controlled trial where women were randomized to three different units and the outcomes were compared. And we have found, and these studies report the same what we see from other countries, that there are less interventions in labor in women who start their care in midwifery led units. But we could not, none of, neither Ada or Barnett could report significant differences in operative delivery. And that is probably because we have a quite low Mediterranean section rate in Norway. And then it is this midwifery led freestanding unit. And there are only two studies who have looked on them. And both of the studies are quite old, from 2001 and 2002. And both of them are observational studies. But this first study is Jan Hoft and co-workers. They evaluated the results after the small obstetric unit in Lufoten Hospital in the northern Norway was reorganized to become a midwife managed unit in 1997. And this was what we called a modified midwifery led unit as it was possible to perform caesarean sections there in cases where transport to the central hospital was impossible because this hospital is on an island. And it can be quite harsh weather conditions there. And they found that 70% of the women in the catchment area gave birth in the unit. And 94% had uncomplicated birth and the transfer rate was 6%. And the other one is Nina Smith and co-workers. They evaluated outcomes from birth in old freestanding maternity homes in Norway in a two-year period. And they found that less than 2% of the women ended with an operated delivery and 10% were transferred. But they found that 35% in the catchment area could deliver safely in the freestanding maternity home. So that was a different finding that the first one, they found 70%. And data for these studies, they were collected more than 15 years ago, almost 20 years ago. And since then, thousands of women have given birth in freestanding maternity homes. And the results should have been documented. Because all births in Norway are documented in the medical birth registry. But the problems with birth in midwifery units and also home birth are that the transfer are not recorded. So if the woman is transferred, the birth would be registered as a hospital birth. So it's difficult to evaluate by using the medical birth registry. And then it is this practice with differentiating care within the obstetric unit. And then we have, I found three studies about that. But it's only one who compares, who is a comparative study. And that is the first one near same. And she compared outcomes of two obstetric units in a hospital in Oslo. And the units were identical. But one of them implemented a special protocol for management of low risk labors. The others did not. And the new protocol led to a small but statistically significant increase in rate of spontaneous vaginal deliveries in primiparous women, but not in multi-paros women. And the two others were observational studies. And they just did how many low risk women when they came to the unit. And that was about 60%. And 40% of them again turned to be high risk during labor. And I have done a study evaluating outcomes as the planned home birth. And we find the same as they do in other studies from Europe and from the Western world. That it's less interventions in women that plan to give birth at home, compared to low risk women in a hospital. And then it's the questions. I know which mid-wise autonomous practitioners. And I would say yes and no, because within the frames of guidelines and laws, we can practice autonomously. We can be leaders in most of our practice areas and we can influence on policy. But the medical paradigm is dominating and there is an increasing focus on risk. And in intrapartum care, we are very focused on risk. And it is getting more and more. And the question is how can we find the balance to take care of those who have complications and in the same time promote normality for all the others. And there is also another challenge I want to mention. And I guess you have it in other countries as well. And that is that the midwives are losing some authority among our users. And there are midwives very active on social, and not midwives, but there are women very active on social media. And the demand and the craves are that they should decide themselves to have a caesarean section, to have epidurals. And it is like they want to tell what they want and they want obstetricians and midwives to deliver what they want. And this is a challenge, I know that. And it is important to meet that and to discuss. But I think this is a difficult matter. It is not so widespread in Norway yet. I have been involved in some of these discussions. So we had some discussions about epidurals and if all women should be offered an epidural and so on. And it's not so easy to take these discussions always. But then I tried to look where the Norwegian model may improve. And I found that we have excellent first-line management of complications and medical obstetric and neonatal services. But I think we can improve in all other areas in this model from the Nancy series. And I think especially in philosophy. And I think that we have that in common with many other Western countries. And also evidence, we don't really follow evidence-based practice. There are lots of CTG monitoring when there is no reason for it. And we have a few models of continuity of care, but not many. And in the big hospitals, there is no chance of having a midwife present during active phase of labor, not usually, at least. And the principle of evidence-based care is weak in the periphery and obstetrics in Norway. And evidence-based guidelines may be accepted, but not necessarily believed in and followed. And interventions are still introduced without proper evaluation of its effects. But it is still so in Norway that midwives still belongs to one of the most respected groups. The women want us, they choose us, and most of them are satisfied with us. And there are, we have far from the situation that you have in other countries. But there are some professional methods and who is going to be the lead carer and so on. But midwives are the only experts of the normal birth in Norway. To become an obstetrician, there is a requirement to have 30 assisted vaginal deliveries, 15 bridge deliveries, 30 caesarean sections, and no requirements to assist at normal deliveries. So thank you for listening to me. And thank you, Ellen, how informative that was. I've gathered a number of questions. And if you have other questions, please put them in the chat. We have about five minutes or so for a question. And Misaki, if you just want to wait one minute, I have some questions that I'll put in chat first. So first of all, Salin had a number of really good questions. And the first had to do with was there any move or lobby for direct entry education for midwives in Norway? Move a lobby. There are a lot of midwives who would like to have direct entry education. And there was a serious try a couple of years ago to have that in Tromsø University in Northern Norway. But it failed. And the problem is also that the nurses have a very strong association and a lot of influence. And they are very much against that midwifery should be a direct entry education. All right, good one. And I'm going to collect these ones. They're all related, again, from Salin. And she wanted to know...