 Okay, excellent. Now, it's with great pleasure that I'd like to introduce Gloria E. Sigbonar for volunteering to present her session on the SHE Campaign Innovative Obstetric Critical Care Training Program to reduce maternal and mortality and morbidity. Gloria is a UK obstetrician and gynecologist, educator and founder director of the Institute for African Women's Health and for the longest time she's been driven to do something about improving women's health. Ever since seeing a friend's sister and a cousin die in childbirth where one minute they're alive and healthy and the next minute they were gone, she later trained to become an obstetric fistula surgeon and was struck by the terrible injuries inflicted on mothers that left them incontinent and able to have sex or walk. The inequities of all this deeply affected Gloria and especially once she realized how many maternal deaths and injuries were totally preventable and could strike mothers at any time regardless of social status. She didn't want to do something that had no longevity or sustainability. She really wanted to keep African women healthy and hence the Institute was founded. The first interprofessional body where all key stakeholders have an equal voice and role, especially the women themselves who are at the centre and design of the programs and have equal validity. So nothing further for me. I'd love to hand over to Gloria for a very interesting session. Welcome Gloria. Thank you very much Gillian and thank you to the virtual team for allowing me this second opportunity to talk about the SHI campaign and maternal mortality and morbidity in Africa. So I've had a fantastic introduction. I don't have to say much about myself but I do want to talk about this concept which is SHI and I'm hoping that you will understand it as we go through the presentation. So SHI was ready started once I became an obstetric fistula surgeon. So an injury which damages mothers because of childbirth and I came across mothers such as this woman here who wasn't dead but for me she was as good as dead because socially and psychologically she'd been so traumatised by her birth experience and having taken this photo and having looked at it several times I just thought this is mad. This was taken I think in 2007. Mad stands for mothers are dying. How can mothers still be dying in this day and age when we know what to do to prevent it? So I found it completely crazy that we should still be in this situation and then what was also quite concerning for me was doing quite a lot of voluntary work in Africa. I come across quite a lot of women and quite a lot of institutions and in one such institution I came across a room which was very darkened and in the local language there were words written which translated meant the wards for those with no hope and when I went in there I expected to see women who were maybe lepers or had these really incurable diseases but there were these mothers who had given birth or maybe hadn't even given birth but they had completely preventable conditions but they've been pushed so far in terms of their physiology that nothing could be done for them and they were just left there to die and that was for me really troubling and really concerning. So having worked in this space for a number of years I finally realized actually I think one of the reasons why we're maybe not tackling what's happening in Africa and maybe the rest of the developing world at the moment and even in the US where maternal mortality rates are now going up is because we're seeing this as a really complex problem and for me as an obstetrician and gynecologist or even I like to call myself an obstetric midwife, for me the problem is really, really simple. The WHO likes to talk about the fact that women die because of ruptured uteruses but for me the ruptured uterus causes her to hemorrhage and that's the reason why she dies. They talk about obstructed labour, killing mothers but obstructed labour kills the mother because she gets an infection or she hemorrhages. Unsafe abortion or septic abortion is still a big problem because she has an infection and then you have all of these other conditions such as sickle cell disease, HIV, diabetes. All of them once again stem from the fact that the mother is dying because either she has sepsis or she has hemorrhage or she has preeclampsia or eclampsia and this is how she really came about because I felt well if I can collapse the reasons why women are dying down to three really simple things it should be really simple to address those issues. So she stands for sepsis or infection and you can see with the image sepsis at the bottom because usually it's an ascending infection which then travels up through the woman's body and causes morbidity and mortality, hemorrhage and then eclampsia or preeclampsia. So she for me was really significant and this really has been my message. I mean I've been working in this space for I think close to 15 years now but I think in the last few years since I've started using the word she it really has opened a lot of doors on so many different levels because people just get it. They understand that it can be really simple to prevent these things. So if you collapse the reasons why women die from a WHO point of view into those she conditions then you will find that roughly 27% of deaths and mobilities are due to hemorrhage or some sort. 33% are due to preeclampsia and eclampsia and actually if you look at it by institution eclampsia actually plays a bigger role than previously suspected. And then here this is not a misprint. The S isn't missing. I use the slide just to illustrate that when I go around and I talk about she people often tell me well you don't have sepsis in my institution that's not a big issue for us it's hemorrhage and eclampsia but around the world people have started to realize that sepsis is a big killer even in the west countries they've now started their world sepsis day and they've got the sepsis campaigns. People are beginning to realize how it can sometimes be such a big killer and it underpins so many other conditions so that's the reason why we have the underscore and the she campaign just to signify that sepsis has to be thought of as part and parcel of what's going on with those conditions and it really plays a big part in hemorrhage and eclampsia. So this is an example as to why I feel the conditions are really significant and why they really do need to be handled and tackled and understood together. If you think about a woman who has high blood pressure but then she hemorrhages and she hemorrhages because she's got high blood pressure maybe because her clotting is off she's more likely to hemorrhage. The two conditions go together. Let's say for instance she hemorrages but her blood pressure is so high that you haven't recognized that actually her blood pressure is now dropping. It's also become significant. It's known that sepsis can sometimes initiate preeclampsia. Studies have shown that it's known that women that have chronic hypertension have a greater chance of becoming preeclampic and eclampic and the progressional sepsis for those women are higher. So this is just to illustrate to you how important these conditions are and how they all relate together. So the aim of the she campaign is that we really want to stop women being pushed to the physiological limits. We know in Africa and in most other settings one woman come and they die because we've pushed them so far that even if we put these women with sepsis hemorrhage and eclampsia who are really sick in the best unit that there was around the world they still would not make it because they've been pushed too far. So the aim of my campaign really is to really recognize these women quite early and catch them early on before they get pushed too far and then you can't bring them back. The way that I have done this since 2013 is with a matrix or algorithm called Tua which stands for critical help early for women in Africa. And I developed a matrix because having worked in this space for some time I often like to use this term which is the problem that we have with research in maternity care is that we often talk about sensitivity that a woman have a condition. You have to know that women have problems with maternal mortality and morbidity but that seems to be the rampant cry. We focus so much on the fact that yes we've got one woman dying every minute or now it's one woman dying every two to three minutes and the whole rhetoric is really really sensitive which is important. We need to draw attention to the issue but then the specificity often is lacking because you know we now have a specific problem. We have to be really specific about how we're going to tackle it tackling it with just saying women are dying and how we have to be really sad about it is not going to work and that's the reason why we still have so many women dying in Africa today. So I said we need to move away from too much sensitivity and let's start getting more specific about what we need to do and that's what the she campaign really is about. So I wanted to deliver critical care within the African context for these women that were really sick, sepsis hemorrhage and eclampsia who were coming and they were dying because staff thought they didn't have the equipment they didn't have the knowledge and how to manage them they didn't have intensive care and I knew that opening an intensive care unit even in the biggest hospitals would not be possible it wouldn't be feasible so we need to have a very low resource system where we could deliver critical care for these mothers so that they didn't die and their babies were more affected and then also we needed a system whereby we could start to recognize these women really talk about the physiology because that was really important and also manage the women and then also really importantly think about prevention because I'm not about picking up the pieces I'm tired of sitting down as an obstetrician or an obstetric midwife waiting for women to come damaged sick when I know I could have prevented it out there in the community so I'm really about prevention and this is what Chua and she is about as well so to achieve this it was very clear that we needed processes and pathways by which women would be identified and sent to the right place we needed the right team of people talking to one another it had to be an interprofessional team and the midwife was key to being part of that team and then we needed good documentation and communication pathways so this was what we developed with the Chua matrix so in critical care you who are up to date with how we kind of manage resuscitation situations we'll know about the A, B, C, D, E A stands for airway B breathing C circulation D is damage E is exposure and then I've added into Chua F which stands for fetus because for me the biggest killer of these mothers sometimes can be their babies we haven't done something to maybe deliver the baby and give the mother the best chance but equally mothers can sometimes be the biggest killer of their babies as well so F had to be there and so with the algorithm we teach people to think about each of these sections of the airway breathing and circulation systematically so you have to deal with the airway first because of course if the mother doesn't have an airway and she's completely blocked off no oxygen then there's no point trying to mop up the blood because she's coming with hemorrhage you have to be really systematic so we teach that we teach in a really logical way which is okay what are the critical observations that you need to think about and the critical observations for me there's several but the three key ones are the respiratory rates, pulse and the temperature and the reason why these three for me are really important to start with is that you do not need equipment and in Africa sometimes especially in the health centers where people say there's no batteries, no equipment it stops them from doing basic observations that would alert them that the woman has a problem so always they start with these basic observations and then do something about it so you want to help the woman and you want to help her by just thinking about giving her three main things that she's going to need she's either going to need oxygen, she's going to need some form of fluid or to have fluid taken in the form of blood or she needs medication or drugs of some sort so just think about those three things and then E stands for early intervention so how early do you have to give these three things and what do you have to do with them, do you have to open the airway to give the oxygen do you have to position her, do you have to physically give oxygen if you can do that or do you have to adjust the fluid, stop them all together, do you have to take blood do you have to give her medication, stop the medication so it was a very simple matrix to introduce midwives who started on this program to critical care in the way that they could really start to build their knowledge we were trying to get them to deliver critical care competencies in four to five days instead of the usual six to twelve months that it takes around the rest of the world and that's what we've managed to achieve in three hospitals so it does work then the rest of the matrix really is about what comes after so it's not about these women coming and then saying okay fine we've saved the mother we really want people to start thinking about why did that happen, what's underlying the change in the physiology so it's kind of like self reflection, why did it happen, who was involved when did it happen, was it an antenatal problem, was it post-native, was it interpartum and then the A stands for you know what's your goal so for instance we might have an audit meeting looking at all of the pre-eclampsics within four weeks you want to basically look at the critical observations you know what help was given what was the intervention you want to think about who was involved when did it happen and then you want to say okay fine for the next month before we come back this is what this is our goal we want to try and reduce the mortality and mobility rate by this amount and we want to allow we need to allow certain things to happen you know so for instance maybe it's because we didn't have an anesthetist or maybe we didn't have a midwife or the midwife wasn't allowed to work because she wasn't paid what do we need to allow and then all of this goes into an audit so this is a really simple overview of the matrix I don't have time to go into it in great detail but this to give you an idea of how we start to break down understanding of the she conditions and how to manage them so like I said we have delivered this within three hospitals across Africa to date Queen Elizabeth Centre Hospital Malawi and this was the first program in November 2013 and the unit is still going strong having saved hundreds upon hundreds of women and their babies and then recently she and Chua has now gone to Pumwani which is the third biggest maternity hospital in Africa it delivers about 100 babies a day and then after that Lagos Island Maternity Hospital which is nicknamed the baby factory of Africa so this picture is from Lagos Island Maternity which I really count as one of my great success stories just because the team that came along and this is a bunch of midwives here were so proactive in taking it forward and really realizing that vision for she so hey you can see why it's helping one another with resuscitation a key part of each of these units where this has been set up is what we call the early warning score so the early warning score is a way of recognizing the woman based on their observations if you look on the left hand side you can see ABCDE so the observations broken down and then you basically take the observations on the mother and then from there decide whether they're normal or abnormal and you give a score so for instance if she had a post of 69 you so okay she's got a score of zero so this is a really quick way of scoring the woman and the problem that we have in Africa is that sometimes the ratio of staff to patients can be so great sometimes you have two staff to a hundred patients so it's not possible to go to every single patient and score them and of course you might not have the equipment for instance to do an oxygen saturation so what I say to people is that look just start by saying does the patient look unwell does she feel sick are you worried about the patients and that's how you start your hand over any patient that you're worried about that's the patient that you should try and score as completely as you can so this is what staff has started doing in each of these units now and I think this is the reason why their mortality has really really dropped because they are recognizing the woman early stopping them being pushed so far in their physiology and bringing them back and then managing them with the resources that they have so you can see here observations which are higher than they're supposed to be have higher scores and then observations which are lower than they have to be also have higher scores so sometimes you can have a patient that comes in with a score maybe of nine so she might have a respiratory rate of 24 her blood pressure might be 160 that gives her a score of four she looks extremely sick that gives her a score of two so she has a score of six maybe she looks really confused another score that gives her eight and maybe her temperature is really low less than 36 that gives her a score three so that's a score of 11 so she has a score of 11 and also what's really unique about this score so this early warning score system is something which has been used around the world in many obstetric units and even non obstetric or maternity units as a way of recognizing the patient but what they did in Lagos Islands maternity in their critical care unit that they call Limku or their service was they also put symptoms on there they recognize that sometimes patient staff did not take the observations either because they were busy or they didn't have their equipment but symptoms were very easy to score so they actually put symptoms on there and I think this will make a really big difference in our she campaign going forward because we aim to go into the communities to use this kind of score system with people who have no clinical background whatsoever and we want to kind of make it very visual and based on symptoms and get them scoring the symptoms that way and know where to refer them so that insight that I got from Lagos Island maternity has been really great in sort of establishing a sort of new way forward for the she campaign so once they've scored the patient what they do they now use what we call track and trigger to now decide what happens with the patient so if the patient has a score of zero to two as you can see on the left then it's okay this patient is fine she can go home but if the patient now has a score of three to five this is well patient and basically they're triggered to do something so either in the hospital they're told what the who needs to go and see the patient or if they're outside the hospital in the private hospitals they're told how soon they have to get the patient in and this is really significant because one of the reasons I'm sure many of you have heard about the three delays one of the reasons why many women die is because there's been a delay in getting them the help that they need and even when I went to Lagos I was quite surprised to find that there are many private providers who still sit on these women for hours and hours if not days before referring them in quite late to places like Lagos Island but that time it's too late to do anything for them but we thought with numbers it was like a common language everyone could understand if you're sitting on a woman with a score of six to eight you know that the chance that that woman is not going to make it or the outcome will be bad is quite significant and we have no excuse for not referring the patient so we want people to really start talking with a common language and in numbers and that really is making a big difference so to sit on a patient with a score of 15 is completely unacceptable and in Lagos Island now they've started to audit their figures for the past month and they're finding that the patients who are coming to them now have scores of 15 but quickly with intervention they're actually bringing those scores down to nine to six to eight so it's making a big difference and before they were having significant numbers of deaths because of late referrals actually for the past few weeks those deaths have gone down by 90% with the Tura and the Shea system so as I explained to you the reason why this Tura system and having that score system and really concentrating on Shea is really significant is that you can quickly pick out those women who are really sick so for instance in this world which is really overcrowded how do you know a woman is sick when you're the only midwife looking after 50 women it can be really difficult but when you start with that question is there any woman that I'm worried about any woman that's sick let me just go and pick her up let me just do what observations I can do it makes such a big difference so that's what has started to happen in the free hospitals so this picture illustrates how we pick up some of these women so I happen to have a post-soxymeter where I can sort of test the oxygen levels in the woman's blood and you can see here her oxygen level is 85 which is way way too low you can look at the urine which is what I call coke colored so that's another way that I sort of teach people to identify the sick patient does the patient look like coke, phanta or sprite this was a patient who was very very sick with sepsis and also had preeclampsia as well she luckily made it because we picked her up quite early now when we deliver the training we are very hands on and very practical we do not believe in sitting these midwives that you can see here and Miata who was my trainer from the UK a critical care trained midwife we don't believe in sitting them down in the room for four to five days and teaching them by PowerPoint it doesn't make any sense they need to be out there because we know as we're sitting in that room there are women languishing around in hospitals that need help so we were very very hands on so this was in Malawi Queen Elizabeth very very hands on in teaching them from day one how to manage the patient at the bedside the other thing that they had to do and the midwives are so great at this you can see here on the left the medical director in Lagos Island maternity Donald who's been such a fantastic champion and then one of our young midwives who is now staffing the the Lagos Island maternity critical care unit and service looking at all of these observation charts that I bought from around the UK because I was very mindful of the fact that if you want people to use things they have to understand it they have to design it themselves and it has to fit their context so I never go into any of these hospitals and say look this is the documentation you're going to use this is how you have to communicate they have to work at that for themselves because then they're more likely to sustain it and that's what they did in Malawi it's what they did in Kenya and it's what they've done in Nigeria and I think this has been critical to making such a big difference you can see them ready looking at all of these observation charts and working out how to design their own observation charts here's a consultant anesthetist and two he's left you can't see there's a midwife to have a midwife and a doctor sitting side by side designing guidelines it's not something that happens very often in Africa especially if you're not like a senior matron or you're not in a school you just don't get that opportunity to sit down share your experience and work on something with a common agenda but here the team actually have to sit down together and build the algorithms and the guidelines for managing these patients and that makes a big difference and you can see here people building guidelines on the wall so this is a pharmacist working with midwives to build the sepsis guideline and to help them I just bought lots of guidelines that I got off the internet told them this is what this hospital does in the UK this is what they do in the States this is what they do in Australia this is what they do in Sydney this is what they do in Italy look through it cut and paste stick them on the wall and come up with your own guidelines and this is the reason why they're able to do the documentation and the guidelines and everything else really quickly within three to four days because they're building it themselves from scratch in a really simple way similarly here you can see in this picture a midwife who is now head of the safe motherhood unit in Malawi on her hands and knees building the observation chart that would aid referral from the health centre to the main hospital Queen Elizabeth so it really is a very hands-on interactive program and this slide basically just demonstrates what a critical care unit looks like so this is the one in Lagos Island where they've got four beds and they've broken the beds down by the score of the patient and then opposite those four beds they have patients who are maybe not scoring as highly but need to have a closer eye kept on them just so they don't sort of get worse but in Lagos Island they quickly realised because they get so many bad referrals they quickly realised that they could not just offer a unit and this is the reason I loved the team so much they said no Gloria we have to offer a critical care service at the bedside so that we can give that service to women wherever they are in the hospital so that's what they did they designed pathways and flow charts so that even if you were not critical care trained you could step by step know what to do for the mother and that really has made a big difference so I'm really really proud of the Lin-Ku unit which has been staffed and headed mainly by Chief Midwife and her team but with support from the obstetrician and the anesthetist and you know a key part of she and Chua is like I said prevention we really want to prevent these women getting sick in the first place and the key part of that is avoiding caesarean sections as an obstetrician I have to say that especially when it comes to coverage avoid the caesarean section like the plague because the chances that you get sepsis especially if you have HIV or you're diabetic or you're sicker is this so high I've seen so many terrible cases especially among very young girls that I try my best to really implant the prevention of those conditions on the labour ward intrapartum so I'm very pro vaginal where it is safe, where it isn't safe caesarean section and then even then the process has to be quite tightly regulated so these are just a few more pictures they're showing you she can see her mother and child you try and keep mother and child very close together for me that's really really important and I think this process has really I mean I don't think it's something you can teach you know to have empathy for your patients but you can see her Sylvia and Betango in the Malawi unit the empathy that she's displayed for her patients I mean she's still working there now since November 2013 sometimes she does 24-48 hours she is so strong and she's such a good example as a midwife and I think she's the one that really spurred me on to keep going and now my plan is to use her as a trainer for other midwives across Africa to really embed this so she has really made a big difference for mothers mothers are really making it you can see this mother here who you know I actually thought we were going to lose her she had sepsis I thought she was she wasn't going to make it but actually mothers are now making it because of the sheave system where we have just concentrated staffs understanding and management on just those three conditions so as I said before I've delivered this in three units Queen Elizabeth in Malawi Pumwali in Kenya and Lagos Island Paternity in Nigeria they're seeing great results the big issue they have is just the late referral and this brings me on to the next part of my presentation and I'm aware that I don't have that much time so I just spent five minutes talking about the next part which for me is the next part of the sheave campaign prevention prevention and early recognition so recently in the Royal College of Surgeons and Islands conference they spoke about the fact that hospitals are for repairs and the community is where health is built and I really do believe that I believe that women are essentially healthy and the aim of the institute is to keep them healthy so in order to do that we have to really work at the community level we can't sit down and wait to pick up the pieces with these women because there's only so much capacity that these hospitals can accommodate so we have to deal with the late referrals which are really significant and she has really helped me to start tackling that late referral and the empowerment of women at the grassroots level so she has really helped me to tackle newborn mortality and the champions of newborn mortality and mobility and I say look the biggest killers of these newborns or their babies are their mothers and I don't say that in a bad way but actually most of the babies that are in that neonatal unit or the ones that die come from those mothers that have sheave or mothers that have not had their sheave managed carefully in labour at all so if we can tackle that we can actually have a knock on effect for a lot of those mothers so a lot of these babies in the neonatal unit or the deaths are due to pre-term sepsis so if the mother has a temperature we know the baby temperature would be one degree higher or a six year so if we start to tackle she we will start to really tackle what encompasses she as well which is the newborn mortality so think about it 23% complications from infections can be reduced if you start to tackle she the six year rate which is really significant I think it's even higher than 23% in some of the hospitals you can see here a CTG or CTG at the back horrible, horrible decelerations with this baby because the mother has sheen it's not being managed appropriately and then prematurity so I spoke about F in my algorithm in the matrix and I'm a big fan of delayed called clamping or what I call placental resuscitation the tendency is when you have a baby that's distressed or we're delivering the baby as an emergency we just want to clamp the cord straight away forgetting 70% of the baby's blood if not more is still within that pre-center so I have a big there's a big push for me now to say do not clamp that cord even if the baby is really distressed you have the best chance or you can give the baby the best chance by not clamping the cord and that also has really made a big difference with a lot of these babies in the newborn unit so this baby here that was extremely white actually had ended up having a blood count of about 2.5 when it should have been maybe 12 or 13 so I advocate just in Africa but even in the UK if there's fetal distress please do not clamp the cord you can resuscitate the baby on the cord and try and get as much blood into that baby as possible that really is what is needed for resuscitation so she has really helped to open doors for me when I started nobody will talk to me especially when I spoke about training midwives they were not interested but with that she campaign and also the gains or the impact that I've shown in Malawi doors are starting to open so in Lagos for instance you can see here the medical director Donald Imosemi a fantastic proactive leader who galvanized a very senior team to come for training and on the left hand side the director of medical services for the Lagos State Commission who is so passionate about this and wants us to sit down and work out a Lagos state strategy to try and reduce mortality across the whole of the region she is really well aware of the fact that death is just the tip of the iceberg if there's one death we know that there's 30 times as many nearnesses where women don't go home when they should when they're in intensive care and even greater than that morbidity in the community is huge many of these women that have preeclampsia go home with no follow up they come back again with preeclampsia maybe the second time they don't make it they're losing their babies so we have to tackle this at a community level and to tackle it means that we really have to think about the state of our healthcare workers midwives for me are key because they're so close to the mother but we still have a great shortage of midwives within Africa I think just today I was reading an article that said that we're going to have 12 million healthcare workers short by 2035 especially in the poor urban areas or in the rural areas we don't have anywhere near where we should WHO said that we need 230,000 head of the population in some countries in Africa you're lucky if you have 37 100,000 and two doctors it's not enough so we have to do a lot more and this is where the she campaign of fellows come in so the she fellow campaign is saying that let us start using our biggest valuable resource which are the women themselves and especially the adolescent girls who are more likely to get she conditions and also to die from the she conditions let's start to use them as community health workers at the moment we have community health workers who are tackling every single condition under the sun and they're doing a fantastic job but I think that we could do a lot more if we were more specific as I said before and not just sensitive target these adolescent girls teach them about their health what they're more likely to die of they're more likely then not to go down that route and they can also help other mothers as well they're young they're fit they can go around they can identify these mothers really simply these she fellows I keep saying they may be ignorant let's educate them but they're definitely not stupid they're more than capable like this group here who I was teaching about the obstetric fistula they did not know what the fistula was they're just been repaired we're about to go home I put my laptop on the floor and I said this is what your fistula looks like and I showed them photos and videos and they were fascinated and the discussion they had was one of the most academic discussions I've actually had the privilege to sit in on so I feel that we can really start to use these she fellows women and especially adolescent girls to really out there and start preventing and managing recognizing these conditions and helping the women so all of these mothers that I delivered I think potentially could be she fellows of the Institute the Institute is an academic body but it's not just for the professionals these women also have to be fellows of that Institute so I think she can really do a fantastic job I think she's able to do a lot of prevention I think she's able to avoid a lot of those conditions and she's educated and I think she can really start to tell us the reasons why women find themselves in these situations in the first place at the moment we are very sensitive we are not specific about what the actual issues are on the ground because we think we know in our infinite wisdom in our academic institution but I think we need to really start getting close to where the problem is and using these women to tell us what the issues are because then we can start to build sustainable programs so I feel that these she fellows they can't read they can't write they haven't gone to school they can actually start to work and it's really hard to reach spaces in the rural areas in the poor urban areas that qualified professionals they want to go to and they can really be a great asset to our service they can do simple things like identifying anemia so you can see my thumb at the bottom and you can see it's launched a little bit because I'm pressing down on her eyelid but even then it's not completely white this woman has completely white membranes she's anemic this is something that she knows have started picking up for me themselves they've got eyes they can see this is sepsis and this is a what I like to call a she fellow a relative who was a quite a young adolescent boy who was dressing his mother's wounds with brown sugar so this is something that can be done in the community because one of the big issues I found is that when you have a woman with sepsis the tendency in some hospitals is that they say okay she's got sepsis we're going to go in and do an operation again they cut her open even if they find nothing they think oh the sepsis must be coming from the uterus the uterus comes out she has a hysterectomy sometimes at the age of 17 and she has a dead baby to boot as well so I'm very keen on avoiding the sepsis but if she gets sepsis let's try and be conservative and conservatism can actually be achieved within the community as well so brown sugar has been known for decades to treat infections and the way it works is you've got bacteria eating away at the skin give it sugar to feed on instead it leaves the skin alone, desiccant to heal so brown sugar is what a lot of relatives are using now to good effect a number of the programs I've set up and it helps a lot and of course they do a lot they look after these babies anyway just teach them don't keep them ignorant about keeping the baby warm keeping the cords okay they can do a lot so there are many things that these she fellows could do to contribute towards the system and I think she will do that she needs something and at the moment community health workers are left in limbo we don't pay them they're volunteers and of course they have to survive they have to eat so they often do other jobs and therefore it means that sometimes they overlook sometimes the symptoms and signs that these women have my aim is that these adolescent girls actually should get paid they should get some kind of salary they should get some kind of security and along the way understanding what these she conditions are and helping these women to recognize and manage them they get to understand their health they contribute to the health system and also get an education at the same time because what we will be given them is health literacy which is almost like a gateway sometimes for them in becoming literate in other areas as well so salary health and education also spell she and that's our aim now to work with partners to start coming up with community health programs employing these adolescent girls almost as interns either a few years if they want to continue going to become midwives or continue as community health workers that's fine but it gives them a gateway and an understanding and a contribution towards their societies so that's the aim of the she campaign and my question to you is what do you think she can do because you know we've got lots of ideas of how we can start to fund this campaign and get these social enterprises started get these women paid get them generating their own incomes in the community and at the same time they're delivering a vital part of the health service but we need ideas and we need your support so my details are here I'm happy to have a discussion with you now about how you think the she campaign would work I'd be happy to speak to you privately by email you can follow us on Twitter or follow me at my personal Twitter thinking box and please tweet about what we're trying to do the she campaign we really tried to build this movement I think it has great relevance not just for Africa but I think all over the world where people are struggling to finance the health system and I think community support and prevention is key I think to really keeping our populations healthy so I think if this really takes off and I think it will take off it can really have a knock on effect I think for just how we deliver health in general. Thanks Corrie that's an absolutely wonderful presentation do you want to just finish up I just wanted to acknowledge the people who I mean I couldn't have done this by myself obviously so I've had quite a number of supporters who've really believed in she such as Miata, Chimma, lots of MDs from different hospitals my UK colleagues such as FIO and of course organisations such as the Virtual International Day of the Midwife are giving me this platform which Medical Association couldn't have done it without them and I think if we all start to collaborate together we can really start to make a big difference so thank you very much. Thanks very much Gloria as I said at the beginning of the presentation there's just so much information that Gloria had to give there and we could have easily done two or three sessions so I know certainly from the comments that everyone's really enjoyed it is there any questions just we might take one or two Corrine I completely agree with you I think that's the same here in Australia it would be great if we could concentrate more on the basics instead of the piles of paper work that we have to do. I was talking to Gloria about the CUMU charts you know the early warning charts that we use here and I think a lot of time is spent on them rather than actually looking at the woman so I certainly think that going back to basics is very beneficial. Okay I can see a question here from Cecilia about resuscitating the preterm newborn while still attached to the cords. This is not routine in the UK at the moment especially when there's fetal distress optimal cord clamping has had fantastic champions in the UK and it's really starting to spread in terms of sort of waiting for white waiting for the cord to go white after three minutes if possible. So I think it is starting to spread I think my issue is that the key group that really do need what I call placental resuscitation are the ones that are not getting it and they're the babies that really have fetal distress and especially the preterm babies we tend to just cut them off straight away and that's one of my big campaigns now which is number one slow delivery of the baby is really important but definitely keeping that baby attached to the cord as much as possible because I've found especially in Africa it really helps resuscitation. I've had babies who have come up with meconium really really sick and just a simple process of delivering the head really slowly putting the baby on the mother's tummy and then not cutting that cord is enough to the baby self resuscitate itself even the sickest babies and it gives the baby the best chance so I think there's a lot that we can still do in midwifery and I'd like to say I'll take credit for the placental resuscitation but of course it's working with fantastic midwives, my sister's a midwife and I've got lots of midwifery friends and colleagues just observing what they do sometimes I feel we don't understand what we do but we do it because it seems logical it makes sense but having now researched it scientifically it makes a lot of sense as well so I think in the UK we still have a long way to go in terms of dealing with a distressed baby for the baby that's not distressed I think people already started to take up that message do not cut the cord until it's turned white. Yeah we're finding the same thing here in Australia it seems such a logical thing to me I'm really unsure of why there's so much resistance so I think we're probably experiencing the same thing all around well thank you very much Gloria I think the she campaign and that acronym too is just a really really easy thing to remember and I think we're all going to go away with that implanted in our brain she can, she is able and I think what was the third one she is she has and she can. Thank you very much for that Gloria okay so we'll just finish off with a couple of the final slides I'll just end the recording