 Felly mae'r rhaid i gael gyda Grace Daniel. Grace is a lecturer at the department of nursing science in the University of Midwife for the past 17 years. She has published about 20 journal articles, both nationally and internationally, with a passion for maternal and child health and humanised midwifery care during labour. She has worked both at the bedside a o lectora ar y cyfnod 17 oed. Rydyn ni wneud am ymddiadau mewn cyfnodol ac gyfnodol gyflwyngol yma ar y Cymru. Rydyn ni wedi mynd i gweithio i'r ffrindiau, hunain, a gŵr a'r gweithio ar gyfer. Grace wedi'r rhanau'r gwanedlai argyflwll yn 2017 a chyfyddo'r bwysig o'r darllen yma o pergyrchunio cyfnodol a adnodd y Lleidon ni wedi'i gymryd HIB positif. Mae'n aelio'r sefydliad honno yn ysgrifennu afrikanol a'r gyfrifiadau ac mae'n ddweud. Dwi'n rhan i'n gweithio i gyd, ac wedi gweithio i'r hyn o'r gweithio'r gweithio'u'i modd. Mae'n rhan i'n gweithio i gyd yn rhoi'r rhain. Mae'n gweithio. Rhaid i'n gweithio i'n gweithio. Rhaid i'n gweithio i'n gweithio i'n gweithio... I've been introduced already, so I wouldn't spend too much time talking about myself. Grace Daniel from the University of Joss. I'll just go right away into the presentation. The topic is knowledge and attitude of major free students regarding respectful maternity care in Joss, presented by me, Grace O Daniel, from the Department of Nursing Science University of Joss. The outline goes thus. We'll be talking about the background of the study, we'll be looking at the problem, the study purpose and research question, methodology, findings, discussion, recommendation, conclusion and acknowledgement. That's all we're discussing through this. Let me just take my video off so that the screen can be a bit bolder. Okay, so the background of the study, pregnancy, childbirth and their consequences are still the leading cause of death, disease and disability among women of reproductive age in developing countries. Nigeria is still a developing country, a third world country, and so we find ourselves experiencing pregnancy, childbirth and its consequences, which has led to high maternal mortality in Nigeria. Maternal mortality is highest in South Saharan, Africa, where the maternal mortality ratio is 100 times greater than developed regions in Nigeria. Maternal mortality still remains high. It's about 576 per 100,000 life births. The lifetime risk of a Nigerian woman dying during pregnancy, childbirth, postpartum or post abortion is 1 in 22. So in contrast, the lifetime risk in developing countries or developed countries is 1 in 4,900, which means that Nigeria is at the verge of collapse because maternal mortality is so high. A key strategy to address this high maternal and newborn mobility and mortality is to increase the proportion of births attended by skilled births. However, WHO has raised concerns that improving quality of care is paramount to reducing maternal mortality in Nigeria. For us to talk about improving quality of care, then we have to talk about respectful maternality care. Respectful maternality care refers to the human and dignified treatment of a childbearing woman throughout her pregnancy birth and the period during childbirth. It respects her rights and choices through supportive communication actions and attitudes because disrespectful and abusive behaviours and environments degrade the quality of maternal care, maternality care. Addressing disrespect and abuses is an important component of cultivating respectful maternality care in health facilities. One of the most challenging components of graduating fit for purpose respectful providers is the regular provision of an exposure to clinical practice settings in which respectful care is modelled at all times. There's a big challenge of modelling respectful care during labour and that was a cost for concern and that's what spurred me up to do this study. The challenges of role models both on the teacher's side and even during in the clinical areas is a problem and that's what spurred this research. So factors like knowledge and attitude play a significant role in influencing the behaviours of these students towards their clients in future. Knowledge provides a foundation for human action while attitude towards behaviour is the extent to which a person has a favourable or unfavourable appraisal of that behaviour. So an understanding of major free students' knowledge and attitude towards respectful maternality care is important for planning effective educational programmes in the universities. So the problem is basically disrespect and abuse of women during childbirth. Disrespect and abuse of women in health facilities continues to be a prevailing public health issue in many countries and it violates the human rights of women to be treated with respect and to be free from harm. Numerous adverse consequences of disrespect and abuse on women's health and well-being has been reported including increased risk of birth complications, poor self-retired health, sleeping problems and signs of post-traumatic stress disorder and the reluctance to use health facilities. Furthermore, lack of respectful maternality care may reduce access to appropriate interventions even among patients already within the facility for delivery care by reducing patient provider communication. Even though I didn't write it here but Nigeria has a high level of disrespect and abuse. It's as high as between 23.7% to 98% prevalence of disrespectful care during childbirth and these are what students will go and face this issue and the main thing that now comes out of it is that these students see it as normal normal practice to disrespect a woman during labour. When we talk of disrespect we talk about verbal abuse during labour or childbirth we talk about shouting at a woman, lack of privacy, not honoring the woman, not valuing the woman. Those are things that are prevalent even in the labour ward and it causes so many havoc at the end of the day to the woman and these are what students see and at the end they try to emulate it. So the purpose of this research was to assess the knowledge and attitude of middle-free students towards providing respectful maternality care during childbirth in just plateau state Nigeria. So the questions are what is the level of knowledge and attitude of middle-free students towards providing respectful maternality care during childbirth. It's a descriptive cross-sectional study design and this cross-sectional design was used because the participants were selected during one period for data collection. The setting it was done in the University of Joss Nigeria and the University of Joss is a federal university that is located in Joss plateau state part of Nigeria. It's located in the northern part of Nigeria. It's the only federal university in Joss and the Department of Nursing is located in the main campus of the university. The university has different campuses and one of the campuses houses is the Faculty of Health Science and Technology where the Department of Nursing Science is under. So the department trains students to give nurses and midwives. The students start middle-free courses at 300 level. They however go for their obstetrics and gynaecology clinical posting at 400 and 500 level. So at the end of 500 level they are expected to sit for their final qualifying mid-free examination, qualifying them as mid-drive. So they get exposed at 400 level and normally they will have two clinical postings, one in 400, one in 500 exposing them to obstetrics and gynaecology. They go to different units and the labour ward is part of the units that they have to go for postings. So purposive sampling was used. Since it was just two levels that were dealing with 400 and 500 level I felt that the whole students should be able to participate. So they were all given the opportunity to participate in this study. 400 and 500 level middle-free students with a total number of 236 were selected as a sample size for this research. The data were collected online. The middle-free students assessed the Google form using a unique link on their phones, laptops and iPads. It was a Google form. They were able to fill the questionnaires on the Google form and submit everything was done online. Ethical approver was sought from the university. The head of the department of nursing also gave approver for the conduction of the research. Each student was also given full information about the study and consent form was signed if they wanted to participate in the study. So data analysis. All the questionnaires were checked for completeness. An Excel software package Microsoft Office 16 was used for analysis. Descriptive statistics such as mean, percentage and standard division were determined. A total of 24 stem questions were used to assess knowledge with one point allotted to every correct response and zero mark for incorrect or I don't know response, giving a maximum attainable point of 24. Thereafter, a percentile graph was plotted against the score and scores corresponding to the 58th percentile and above at judge as good knowledge and those below the 58th percentile at judge as poor knowledge. The attitude of the students measured was measured with like a skill with the option including positive or negative attitude. Test of association was carried out using a chi-square. So this is just the summary of the analysis. So the findings. Findings for knowledge we will see that the students had good knowledge on respectful maternity care. We actually had three objectives. One of the objectives, the first objective was to assess their knowledge on respectful maternity care. The second was to assess their knowledge on the rights of a childbearing woman. And the third was to assess their attitude towards providing respectful maternity care. So our first objective you could see that the knowledge they had was good 90.7 percentile knowledge and just 9.3 had poor knowledge on respectful maternity care. The knowledge of students regarding the rights of childbearing women. We also see that they also had a high knowledge, good knowledge, 77.5 percent knowledge on regarding childbearing women's rights and only 22.5 had poor knowledge on that. And then regarding attitude towards providing respectful maternity care, which is the third objective, we see that about 88.6 of them had negative attitude towards respectful, providing respectful maternity care. Only 11.4 had positive attitude towards providing respectful maternity care. Some questions that were asked in this case were questions regarding what would they do if they were to provide care for social condition and probably women was not cooperating. What would they do? And most of them replied they would shout on her. That was the only way they could get her to cooperate. So it only tells us that these are things they have seen while in the world. And once they see such things, these are the things that they will practice. These are the things they will emulate and move forward even as they practice, as midwives. So in looking at the association, the test of association, we looked at the test of association between knowledge and the selected social demographic factors. We looked at their class level, we looked at gender, we looked at marital status and religion. So we picked each objective. And for objective one, it was only gender that seemed to be significant. So there was the hypothesis that was put up, was that there's no association in the level of knowledge of respectful maternity care and selected social demographic characteristics. And we see that gender seems to be significant from what we had. Even though I didn't put it in the slide, we had more of female, the female gender, you know, more than the male gender in the class. In both classes, the females are more. So it's possible that it's tilted that way because of the gender inappropriateness. Okay, and then the second one was the association between students' knowledge of child and rights and selected social demographic factors. We also found here that class level and religion was significant. The class level was just two classes. So class level was significant and religion was significant. And in the third one, where we looked at the association between their attitude and selected social demographic characteristics, there was no characteristic that was significant in this. So our discussion, we realized that practice based on knowledge not only reflects systems thinking, but is one of the hallmarks of a profession. And in the case of media free reminds us of the link between theory, inquiry, evidence and practice. That's to say that knowledge is very, very important when it comes to training students and impacting the right knowledge to students will help them to move the theory into practice. And as I went, students, when we as teachers have to teach students, then we have to emphasize what is right, what is evidence based, what has been inquired and has been proven right. And these students will tend to move it such teachings into practice. And the teaching should shift from fact based to value based. If we really want to improve respectful maternity care, then our teaching has to be more of value based. Since from the findings of this study, we see that their attitude is negative. And that's because they have seen the models of media free or child birth to them is on the negative side. And so they have built their value towards the negative. And so as teachers, as as lecturers, we have to ensure that our teaching is more of value based. And if it's value based, they will go on to impact some values that even when they get out there, when they start practicing those values will remain in them. Secondly, recent publications note that exposure to disrespectful care during media free training can be common and eventually becomes justified by students contributing to the normalisation of mistreatment in facility based childbirth. Okay, so publications have come out to say when these students are exposed to disrespectful patient care during their training, it becomes a norm. It is seen as everything is normal. And it becomes normal to shout at a woman during delivery. It becomes normal to slap her laps. Now they call it therapeutic slap. It is normal to give a therapeutic slap to a woman just to make her cooperate. It's normal to expose her and not use consider her privacy. Okay, so when students come out with that idea, it becomes it's not good because by the time they start practicing, they will see it as normal to do all these things. Developing caring attitudes and meaning occurs through one's lived experiences of caring, as well as through learning human caring acts by studying, self-reflecting and observing members of one's profession. So these three are very, very important and we have to as lecturers emphasise that in students that it's not all about, you know, just going, taking a delivery, the head comes out, you just bring out the baby. You still have to do so many other things for women and that's why we have to study. We have to study to be good and then there must always be self-reflection. What did I do that was wrong? What did I do that, you know, was this woman satisfied with the care that was given if she was not satisfied? What went wrong and what were the things we were supposed to do that we did not do? This self-reflection helps to, you know, reorganise things and helps to have a better experience, you know, in other deliveries and then observing members of one's profession is very, very important. These experiences and external sources combined with the more internal understanding of oneself together will enhance the caring capacity. So, recommendation. Modelling is, modelling what is right on the part of the midwives to these students is highly recommended. I've been, I'm doing a study and the study is on promoting respectful maternity care and from this study I'm looking at the perspective of midwives and the women and you could see that the midwives have their own complaints and talk about how the women are not cooperating and the women also have their own part and complain that the midwives don't understand with them. They are the ones in pain. So, we have to come to a point where these midwives have to be trained and retrained. They have been trained, that's why they are practicing, but they need to be retrained and emphasis must be put on providing respectful care despite all odds. Even though disrespectful care is a multifactorial problem, it has issues all around. There are issues with midwife salaries, there are issues with even the antenatal care. There's the issue of women not getting the right education during antenatal care and so when they come in for labour they don't want to cooperate with the midwives which is a big problem and when students see these attitudes they just invite them because they feel they are right. So, we need to, our main target will now have to be the midwives who are practicing in the labour words. They have to be trained and retrained on respectful maternity care. So, and that encompasses the modelling that we are talking about. So, training and retraining midwives regarding the promotion of respectful maternity care. We also emphasise collaboration between the medical nursing and media free councils to embed principles of respectful care within professional standards including mechanisms that support and enforce implementation of respectful care standards. When we talk about mechanisms most some hospitals have a mechanism where when a woman is maybe not treated well or she's not satisfied she can report you know to a higher authority and the authority will pick it up probably calling the nurse or the midwife to order. So, the essence of this is that when there are mechanisms that are set up these mechanisms help to control midwives from you know maltreating women or abusing them in any way. There should also be a focus beyond immediate cost of mistreatment. According to some researchers the focus should not be on the immediate cost of mistreatment because most of us will look at what actually costs this mistreatment but our focus in this case should improve teaching on professional ethics and work towards producing respectful healthcare providers. So, our focus is now going to shift back to we the teachers we have to invite professional ethics into our students. We must teach them what it means to be professionally to do things in an ethical manner and when students know how to do things in an ethical manner they will stick to that because the likelihood of them having issues at the end of the day would be ruled out. So, the essence is focus on teaching and when you focus on teaching it would teach a respectful maternity care it will reduce the effects of maltreatment in healthcare providers in the future. So, in conclusion our research has shown that majority of students have good knowledge about respectful maternity care and knowledge of the rights of child bearing women but they have negative attitudes towards caring for women in a respectful manner. So, student-faculty caring relationships combined with role-modelling during the educational process are the best possible ways to help students learn professional caring. I must also emphasise that we lecturers, we teachers, we should also be role models it's not just the midwives that are working in the hospital. We as lecturers if we respect we respect people then they would also respect us if we respect our students they will also respect us so it's easier for us to teach tell them about respect if we respect them and it will go a long way to solve this issue of disrespectful care during maternity care or during childbirth. I must acknowledge the head of department nursing university of JOS and all the students study participants from the department they were of great help to help actualise this study. Thank you very much. Thank you for listening. Thank you Grace for sharing that so needed research. There has been lots of studies in the more we know about this then the better I think for women and midwives to do better. So, we've got chance now for some questions just 10, 10, 15 minutes or so. So, if anybody has a question I think most people are listening only so if you would like to write it in the chat box then Grace I'm sure would be happy to answer any questions. Is there any mentors within practice for students to have as support in learning that kind of respectful care and what should and shouldn't be taking place? Okay, yes we do. We do have clinical instructors who visits the students during their clinical postage. Even though we have the issue of a large number of students and just few clinical instructors and so the clinical instructors choose to visit them part-time and see them doing their clinical postings and these clinical instructors are midwives. They are nurses, they are midwives and they have been in midwifery for some time and so they are able to train these students while on the word. The only issue is like Labour word. It's not everyone that is allowed into the Labour word. Okay, so it's not, they do visit them there but not as often as they will in other areas too. So, there are people that will serve as clinical instructors to instruct them while during their clinical rounds. That's good that they've got that support and that network of people that they can have as role models. Do you think that women are becoming more empowered to speak out when they feel they're not getting the care that they deserve or need? Well, in Nigeria, Nigeria it's not all women speak out. Women that feel they are disrespected, some of them will just, they don't speak out because the mechanism of telling someone this is what somebody has done, that mechanism is not there and so some of them feel bad, they just, they just keep it inside of them and say this is, they say it to maybe their friends and colleagues and in just a way of saying don't go to this hospital, this is what the midwives did to me the last time I was there and so they will not complain to any, because there's no mechanism in the hospital but they will complain to other people outside which tends to make people not want to go to the hospital again and then secondly for most women they don't feel anything is done. Like I spoke to one woman and I asked her, did they cover you when you were in labor? She said no. Did they use screens? She said no. I said ah so you were exposed. She said yes, every woman was exposed so everybody that what was in their mind was just the pain. So they are carried away by the pain of labor and not even minding the privacy issue. So for women, for some women it's now becoming a norm that is normal for you to be shouted at. The midwives are just trying to help you and that's what's, that's the idea, ideology that most women carry. But I'm doing a study and I hope at the end of this study that things would take shape because it's basically on improving respectful, promoting respectful maternity care and still working on it and hopefully when it's out we'll be able to bring out something that would help both the women and even the midwives at the end of the day. I think it's really important that so I am from the UK and I think often midwives in the UK maybe even other well resourced countries feel that this is a problem that's not theirs. But from my experience women in UK hospitals also experience disrespectful care and a lot of the research around this is in African countries and I think we have a lot to learn from your research. So it'll be really interesting when this research is finished and you have some clear way forward to improve the education and I think it's really important that all countries really take a look at this research and see how they can improve their care and their education. In the UK we have so many women that come here from other countries and the British people are very poor at learning languages and this sometimes results in disrespectful care because they don't have the facilities or even look for the facilities to help women when they don't understand the language or it's acceptable to get an interpreter and explain everything that might happen to them in their labour and consent them for everything at the beginning when they've just come in in the beginnings of labour and expect that woman to take it all in and to understand it and then to remember it if her labour doesn't progress or she needs some help and assistance and it's not really respectful and understanding throughout the whole of her labour and somebody that communicates with her. Yeah communication is an important aspect even in Nigeria we have the issue of communication from what I've gathered from my research some women feel the midwives don't talk to them they would check them probably do a vaginal examination and instead of telling them madam you've gone this far they would just you know remove their hands and tell the other nurses or their counterparts oh this woman has gone this far and it's like they don't communicate directly to the woman how far she has gone and how she's doing well or not doing well or something they just ignore her and if we want to relate it it has to be a person-centered care every care that we give must be person-centered you have you have to involve the woman even in decision making and the issue of Episciotomy we discussed AXDAT and nurses the midwives don't even inform the woman that they are going to give them a cut the women just feel a cut and it's at the end that they tell them they give them a cut and that's not respectful at all so these are the things that is being done and students see them and it's not encouraging at all that students see these things and they will end up practicing it you know the way it's being the way they see them and that's just the essence we are trying to push for movement against this respectful care and in a country or in a in a locality where it seems to be a norm to be shouted at and everything and even the women are accepting that if a woman said the nurse is just trying to help me that's why she did that and it's now becoming a norm and so we should we should not accept that as a norm shouldn't be that's interesting how the women are now normalising it and and justifying yeah that really thought provoking presentation i think it will stay with with us for a good time afterwards and hopefully we can reflect on our own practices and and and and really think about the care that we give women and keep on going with your research it's it's good to have people like you fighting for these women's rights thank you thank you