 Okay, now it is time to welcome our speaker of today with the topic Factures influencing the implementation of midway flood care in low and middle income countries and mixed methods systematic review. This is by none other than Sanghi Manjini and Andaraj. If you want to know Sanghi father, Sanghi is a third year PhD student in the department of midway free at King's College London. Her research is on midway flood care being implemented in India and research has always been an interest and interest to Sanghi and this made her to register in 2018 as a master of research student at King's College London where she continues as a post graduate researcher and the focus of her PhD research is to explore the views of women about midway care, care-led in India. Sanghi has a specialization in maternal health nursing, she has worked in academic as well as in clinical settings, her career started as a midwife and she had worked in all clinical settings such as home, community, maternity wards and in hospitals. In academia, she started as a clinical instructor and later became a lecturer in the midway free department. She had worked in academic institutions for 10 years in India as well as in Oman, Muscat. Sanghi is a registered midwife in the nursing and midway free council in the United Kingdom. Sanghi, you are most welcome with your presentation, that's what we say in Kenya. Thank you. Welcome. Thank you. Thank you, Margaret. Happy to present at the VIDM conference. Thanks for the VIDM committee for selecting this topic. Before I start with the presentation, I just would like to put off my camera so that there is good connection as well as clarity in my presentation. I'll just get back my camera by the end of the presentation. So I welcome you all to the presentation titled, Factors Influencing the Implementation of Midwife Lead Care in Low and Middle Income Countries, a Mixed Method Systematic Review. The systematic review is a part of the PhD study and has been conducted under the supervision of Dr. Maria Duvosa and Dr. Sean Walker. In this presentation, I will take you through a brief introduction followed by the research question, then we'll state the aim of the systematic review and the methods. To match with this year's VIDM conference theme, Midwives Together We Care, this presentation will highlight the review findings from the midwife's perspectives. Following the findings, the strengths, limitation and the conclusions will be presented. As this review is part of the PhD study as mentioned earlier, the next phases of the study will also be highlighted. Welcome to the current situation about maternal health. The state of the world's midwife free, that is according to Xiaomi report in the year 2021, it states that globally around 810 maternal deaths occur each day. Out of this, nearly 94% of these deaths are preventable and are found to happen in low income countries. One of the main reasons for these deaths that happen in low income country is just because there is no qualified health professional for a pregnant woman during her childbirth. And this was reported in the year through 2017 by the World Health Organization. So how is the situation right now? Now, according to the global estimate, according to the SOMI report in 2021, it states that still one in five women are having their childbirth without support from a skilled health worker or health professional. The same report is also showing that once we strengthen the capacity of midwives, then the access to get a healthcare professional for a pregnant woman during pregnancy as well as childbirth can increase and thereby maternal and newborn deaths can be prevented. So to prevent maternal deaths as well as to provide high quality maternal and newborn services, midwives are pivotal. Further, a modeling study from 88 low middle income country estimated that universal reach of midwife-led care would prevent 67% of maternal deaths and 64% of neonatal deaths. Midwife-led care has also been recommended as an ideal or relevant model of care by the International Confederation of Midwives. So based on these evidences, strengthening the midwife workforce and bringing in midwife-led care in low middle income country has come in the global agenda. It's gained more attention in low middle income country. Although this model gained more of attention, resistance to implementing midwife-led care in low middle income country remains. And this was given by the Lancet series in 2015. Further, when the World Health Organization clearly states that there are challenges implementing the intervention in low and middle income countries, even studies from low middle income countries indicate there are certain factors that are influencing the implementation. So though primary studies on midwife-led care from low middle income countries exist, there has been no systematic review focusing on this topic and that's why this research question came up. It states, what are the factors that are influencing the implementation of midwife-led care in low and middle income countries? What is this review aimed to? The review aims to identify, to synthesize and report all the factors that facilitate as well as hinder the implementation of midwife-led care in low and middle income countries. So coming to the methods, this is a mixed method review which was conducted using Prisma guidelines and it's reported following the Prisma feed checklist. The review protocol has been registered in Prospo 2020 and the reference number has been given for your review. How did we, how did this method go about? So the first thing in this review, we started as the inclusion and exclusion criteria were identified using the PICO's element, which is the population, intervention, the context, outcome and the study design. Coming to the search strategy, the searches were conducted using seven electronic databases such as Medline, M-Base, Sinal, Psych-Info, Midris, Global Health and Web of Science. Searches were done up to July 2021 and the search was limited to English and Spanish languages. The data was extracted from the studies using the supporting the use of research evidence, which is commonly called as a shoe framework. The shoe framework was used in this review because it provides a structured guide to identify and address the barriers to implementation of healthcare interventions. The methodological quality of the studies was used using the mixed method appraisal tool, which is the M-MAT tool and the data was synthesized using the framework thematic synthesis. The coming to the results, so initially a total of 6,605 articles were identified on screening by titles and abstracts. Some records were excluded. 51 studies were screened by full text and assessed based on the eligibility criteria. As 20 articles did not fit in the eligibility criteria, those studies were excluded. One article got identified through reference list search and so totally 32 studies were included in this review. So out of the 32 studies, 24 were qualitative, six were quantitative and two were mixed method studies. Coming to the, this image shows exactly the 21 low-middle-income countries from where the 32 included studies were taken. We had major studies like five studies from Pakistan, two from Afghanistan, Bangladesh, Nepal, Mozambique, Nigeria, Kenya and Malawi. And one study from Morocco, Benin, Brazil, Cambodia, Guatemala, Iran, Lavo, Palestine, Peru, Rwanda and Ethic mini-district in South Africa, Uganda and Vietnam. So these are the 21 low-middle-income countries from where the 32 included studies were taken in this review. Regarding the participants, a total of 17,589 participants belonging to three key groups such as care recipients, care providers and stakeholders were included. Based on the settings, 11 studies were done in urban setting, 16 were done in rural areas and five studies included urban as well as rural areas. At the methodological quality of studies, looking at the methodological quality, it was found that 23 studies had a high score of 4 to 5, eight studies had a moderate score of 3 out of 5 and only one study was scored low with a score of 2. But none of the studies were excluded based on the methodological quality. So the review findings, this review identified many factors that influence the implementation of midwifelite care. To match this VIDM conference theme, the review findings will be presented using three levels. That is the care provider's level or the providers of care level. The level two would be health system factors, level three is social and political factors and all the findings will be presented from the perspectives of midwifery professionals. Coming to level one, which is the providers of care, watch by the barriers for the providers of care. The first main barrier was inadequate knowledge and skill among midwives but considered as one of the major barrier to implement midwifelite care in low and low and middle income countries. This barrier is directly linked to the education and training that is received by midwives. Midwives in this review, 13 studies in this review have reported that the quality of midwifery education was so low that they were unable to handle even normal pregnancy. In certain contexts, midwives have stated that even if the education was up to the standard, the midwifery educators who had trained them were not found to be skilled enough. So, due to these factors, midwives have stated that the knowledge and skill to practice midwifery was inadequate. Indeed, in a study which was done in Vietnam by Doyen in the year 2018, one of the midwives have stated that she cannot do much because, just because her competence is low. The other barrier was the inability to recognize complication, especially during the intrapartum period. This barrier is connected to the previous one which was inadequate knowledge. And from this review, it was noticeable that many of the midwives did not have the capacity to recognize when patients come with complication. So, this is quite evident from a study which was done in Guatemala by summer in the eighth year 2017 wherein midwives have reported they don't have knowledge if patients come with complication. So, due to this inability to recognize complication, midwives failed to refer women to tertiary hospitals at the right time. Inadequate knowledge, skill, as well as the incapacity to identify complication at the right time, totally decreased the confidence of midwives working in low-middle income country. And this was the third barrier for providers of care. According to this review, decreased confidence was most obvious among midwives while performing midwifery procedures or practical skills. So, all these three barriers are interconnected which made the care recipients to negatively view the midwifery services. And hence the implementation of midwifery care was adversely affected in low-middle income countries. So, what then facilitated? So, the facilitated factors, the first factor is according to the midwives, they have reported that when midwifery education is provided by qualified clinical educator and supervisor, then it was found to facilitate implementation. Poor study in this review showed that midwives specifically have indicated that certified, experienced midwifery educators provided efficient practical training and also taught them how to handle obstetric emergencies. And that increased the confidence of midwives while performing their skills. This created a positive image among care recipients about the midwives as well as their services provided by them and thereby it enhanced the implementation of the intervention. The second facilitating factor was midwifery education and training. When midwifery education and training is given to global standards based on international recommendation, then that was considered as a facilitator. But additionally, midwives have also reported that the training should also be relevant to the local context. 13 studies in this review, midwives have reported education should be based on global standard, but at the same time, it should also meet the needs which is applicable to the daily practice. So the last facilitating factor for providers of care level is adequate clinical supervision. Six studies in this review, it was noticed that provision of sufficient clinical supervision improved quality of care for care consumers. The studies additionally suggested that midwife let care had greater implementation success in low middle income countries when regular supportive supervision is given particularly for newly qualified midwives when employing her in any clinical settings. So these three are the factors that facilitated at providers of level. Coming to the second level, which is health system factor. There are three factors which acted as barriers. The first foremost factor was lack of resources. This includes both human as well as financial resources lack. Coming to the human resources, staff shortage was considered as a major barrier to implementation, especially in remote rural areas of low middle income countries. Midwives in 17 studies reported that staff shortage resulted in exhaustion that were leading to poor standard of midwife care. Besides insufficient workforce resulted in stress, dissatisfaction at work. Managing work was really difficult for midwives because of insufficient staff and midwives felt always that they were overloaded with work. This work overload led to absenteeism, high turnover, thereby affecting successful implementation of midwife-led care. The next barrier is linked to the previous barrier. This lack of facility was directly linked to lack of financial resources. Midwives in 7 studies reported that due to lack of financial support the infrastructural facilities were very poor in the midwife-free units. For example, the midwife-free units in low middle income countries did not have a proper delivery bed, or even adequate beds were not there, no proper watch were available, no privacy, and also no delivery kits. So because of the lack of these basic facilities or supplies, it was difficult for midwives to provide quality care. Further, midwives in 3 African studies have also highlighted that lack of water and electricity facility is the main problem for poor service. Because of these lack of facility as well as lack of financial resources, women were not attracted to visit the midwife-led unit, and therefore the implementation of the program had to be discontinued halfway in many of the settings in low middle income countries. Coming to the third factor, lack of authority was considered as a barrier in low and middle income countries. Executing midwife-led care was really challenging for midwife-free professionals as they had no power to act in the health system. In a study done in 2017, and by summer, it clearly says that the healthcare system is highly hierarchical that affords only primary authority to physician. So this shows clearly that there is medical dominance. And because of this medical dominance, the midwives had very low level of autonomy to practice, and this hinted implementing midwife-led care in low and middle income countries. Further, midwives in eight studies had reported that the independent practice was not at all achievable. Independent decision-making was really very hard. Many occasions, midwives were just as passive observers. They did not have the authorization to act at all. So these are the barriers. So coming to the facilitators, what then facilitated at this level? The first thing which facilitated at health system level is leadership and management. It was found that midwives with decisive leadership, good managerial skills, facilitated the execution of midwife-led care. Midwives as decision-makers, getting involved in policy dialogues, enhanced implementation. Presence of midwife-free representatives in policy-making and support from professional organization increased the likelihood of gaining authority. The second factor which facilitated at this level was communication, which includes both internal as well as external communication. From this review, it is noticeable that communication increased coordination which helped in smooth working at all levels of sectors. For example, proper communication system interacting among health professionals by easy at be district or provincial or national level. So this communication strategy along with information continuity was found to ease the implementation of midwife-led care in low and middle income countries. The third facilitating factor was quite important and it is funding. It was highly considered as a facilitating factor to implement midwife-led care in low middle income countries. This is because funding improved the basic facilities or structure in midwife-free units. 15 studies in this review showed that increasing the funding increases the supplies in hospital and this in turn increased the demand for midwife-free services. Further, it was obvious from this review that national as well as international funding is quite required to continue midwife-led care program as planned. So regular on-time monetary aid or support was found to facilitate the implementation of midwife-led care in low and middle income countries. Coming to the last level, the social and political factors. So the barrier with regard to social factor was the practices in relation to culture and tradition. That is cultural, traditional as well as religious practices that existed within a community acted as a barrier to implement care by midwives. Because of the local practices and beliefs in a community, women, including their families were hesitant to accept the midwife as well as the midwife-free care. This barrier was more prominent among women living in remote rural areas wherein they followed certain customary practices which is more pronounced during pregnancy and these practices hindered implementing midwife-led care because it was a big challenge for midwives to overcome their practice and render their services. Coming to the political barriers, there are two factors. One is political instability as well as corrupted political system. By political instability, it refers to the frequent changes in the government which is very common in most of the low middle income countries. Because of the political changes or uncertainty, authorizing midwife-led care program as well as approving any plans from the ministerial level got delayed. So this consequently helped, this consequently hindered implementing midwife-led care within a timeframe according to the plan and also most of the time government initiated midwife-led care program had to be deferred often. The corrupted political system was another factor which acted as a barrier. So apart from political instability, employing the right talented midwives in midwife-led unit was not possible because of the corrupted behavior of decision maker. This was quite evident in a study which was done in Benin wherein the midwives have said that holders were appointed by politicians which in turn affected the functioning of hospitals. So it is quite noticeable from this review that many posts got filled in by incompetent midwives that affected professionalism and again it became more difficult for the care recipients to accept care from midwives and this adversely influenced the implementation of midwife-led care in low and middle income countries. So what then facilitated? Three factors acted as facilitators. One is government legislation and regulation. The two was long-term thinking and contracts for midwives. So government legislation, it clearly says midwives from a study in Morocco that when the midwife-led care program is being based on national strategy then that facilitated the implementation. Even additionally, government regulation rules legislation for working condition of midwives is being implemented then the program would have a smooth implementation process in low, middle and country was evident from this review. Coming to long-term thinking and contracts this was more related to increasing the credibility of midwife reprofession as well as sustaining the implementation program. Policies, plans on recruiting midwives on permanent contracts were found to facilitate implementation because it reduced turnover, increased job satisfaction and retention of midwives especially in remote areas. So these are the barriers and facilitators related to all the three levels such as providers of care, healthcare system factors and social and political factors. What were the strength and limitation of this systematic review? The strength of this review is that using the SHURE framework for extracting the data was the strength of this review. This is because as I mentioned earlier the SHURE framework was designed to identify barriers when a healthcare intervention gets implemented in low income countries. The other strength is all the 32 included studies assess the factors that hindered or facilitated the implementation of government initiated midwife reprogram and this is another strength of this review. The limitation is there could be a possibility of missing some relevant studies because there was no grade literature involved or included as part of the search. Coming to the conclusion, so from this review it is evident that for greater implementation success in low middle income countries, drive free education and training needs to be to global standards. Advice as leaders and policy makers are crucial. Professional organizations supporting midwives to gain authority is very much imperative and an enabling environment with adequate facilities resources to practice is very much essential and government legislation and regulation to develop autonomy and accountability to be in place prior to the implementation of midwife healthcare in low and middle income countries. So what does this review lead to? So what are the next steps? So this review identified, it reported the barriers and test data from three key group members such as care recipients, care providers and stakeholders. Most of the identified barriers as well as facilitators are also pertaining to the Indian context. From the review, which was very much clear that many studies had care providers as well as stakeholders point of view. And if they included women, exactly what women want was really very scarce or studies pertaining to what women want or what are the needs of women or how women can be involved in this health decision making process was really few. And that is the reason why this review has led to this current study which is on what are the attitudes and beliefs of women towards the implementation of midwife healthcare in India. These are some of the references for this presentation. And thank you very much for listening. For any further question, you can contact me through the email ID which I had given. Thank you for listening once again. Thank you very much, Siangi, for that detailed presentation. It is really a valuable presentation, particularly to low and medium income countries. I believe they will put it into practice. Now, just to summarize before I ask certain questions from your presentation, I have seen that for midwife-led care to be successful, we need an enabling environment. An enabling environment that starts from our government and the whole system should actually be involved. And I've also seen from your presentation that participation of women is key in this because they will be able to highlight their concerns, their needs, and to be taken into consideration. But in real sense, we have found that women are left out which is making the whole thing not really useful to them. So their participation is quite key here. And also in policy formulation, we need to have policies that really take care of women taking care of their needs, particularly midwives and the women who are giving birth. We have seen also that training is key in this and training has to be to the global standards so that at least we have a comparison. And when doing this, we only have to consider the local context because remember you talked about the retrogressive cultures which we have to know how to deal with. So I think those are the key issues that I got from there before I asked my questions. Okay, we have seen that resistance still exists, particularly in these low and medium income countries. So now your research is very good. It will help like policy makers to kind of review their system. So how will you ensure that the results of this research are accessed by the government of India, particularly in this context to be able to put them into practical use for sustainable solutions towards improving the status of midwives in that country and also the women who give birth? Yeah, I think disseminating research would be a good idea of giving the results and then making the particular government know like what women are thinking about this and how it can be implemented. So this nation either through conferences or through any other, I mean publication as well as even dealing with directly talking to the organization, the professional organization. Like for example, in India, we have the nursing and midwifery council. So giving the report to them and telling them what is required from the women's side should really help in bringing up the policies and plans. But above all to me, I think having a decisive leader is quite very important. And that leader should be from the profession, from midwifery and nursing profession who could be supported further by the associations and so that she can bring up as a government legislation. Because studies in this review had given good examples wherein when the government gets involved and when legislation has been passed either even a bill or a policy is coming up with then the implementation process is really successful in low-middle income countries. Thank you so much for that. My second question is, we are dealing with patriarchal societies, particularly those who value these cultural and traditional practices that are still retrogressive and really entrenched in our communities. So what would be your recommendation on how these low and medium income countries should handle the issue of retrogressive cultures and beliefs to enable people embrace modern technology in midwifery care? And what systems should those low and medium income countries put in place to deal with those cultural issues? Yeah, it's quite difficult as far as cultural issue is concerned, especially in remote areas. People don't say no to you but they very well can stop you if you're not respecting their culture. And this was evident when as you said I just wanted to pick out a study which Pramar review itself, one of the Pakistan study which was done in the year 2017 and it was done by Ahmad. The study clearly states when you work in a community, especially in rural areas, one of the community midwife had clearly stated that providing culture-based care is quite important so that you get accepted first and then you can overcome the cultural barriers. So that is one part. And second thing is coming to the gender inequity which you're talking about. I think gender is always even in our review we had from the women perspectives just because women were not decision makers, it adversely influenced the implementation. So most of the time it is the husbands or the father-in-law or the in-laws were deciding on behalf of the women where she must give a child birth and that adversely affected. So I think this research, that's the purpose of this research like involving women as decision makers in their health and really finding them what really they want, what do they think about this that wife-led care should really help in successful implementation. Okay, thank you very much. I've got a question. I don't know whether I mean someone who wants to ask us a question. Anybody who has another question before I ask? I can see a question by Ella on midwifery education. She wants to know exactly what is happening in India. Yes, Ella, there is in Telangana state in India, they have started with the midwife-led care program successfully and they have brought UK midwives to educate them and they're also following the ICM global standard midwifery education. So with regard to your question, India is definitely following the ICM standard as well as trying to bring in midwifery education to global standard. But the only thing from my review, which I'm very much concerned is that all the review have stated they had good education but the only problem was how far they were able to apply in the practical setting was a question. This is because when we get practice from the institution, we have all the equipments, we have the delivery kits, we have all the settings in place. But when these midwives were left to the practical setting in low middle income countries, it was really very difficult for them to get into the real practice because they did not have the delivery kits also to perform. In some areas there were no delivery bits, some did not have even blood pressure machines. So it was quite difficult for them during those situations. So I think along when the midwifery educators educate the midwives, it's quite very much important to take into consideration the place where they are going to work and how they can bring in quality in such situation should be ensured. I hope it answered. Any other person with another question? Anybody who wants to ask a verbal? Okay, my last question is... There are other ones in the chat, Margaret, if you have a look. Pardon? There are other questions in the chat. Oh, yeah, one is going to... Okay, Xiangyi, can you respond to this? Shayla? Yeah, I think the midwifery education, I just said. Yeah, but now I could see another question from Shayla. Yes, you're very much right, Shayla. Like midwife is... As far as I've started with phase two quantitative study, I could clearly say the term midwife is not even clear among women. You're very much right. So what we want to know is through... What is the understanding about midwife? How well do they differentiate a midwife from a nurse? That's quite important. So we just started with the quantitative phase and even the term midwife was not well understood by them. So through this research, I think it should at least bring in an awareness that there is a group called midwife and what are their roles? What do these services include? Those things will be mentioned or at least known to the Indian population through this research I mean. Okay, I can see Bope Mwamba has raised their hand. Bope, can you talk and say your comment or your question? Yes, so thank you very much, Sanghi, for this systematic review. Bope, you have just a question with regards to what you mentioned following through your presentation, where you spoke about midwish-related units in lower middle-income countries not getting to their establishment because midwives didn't have the autonomy. I'm a midwife trained from Zambia and worked in South Africa. And so I'm just wondering what exactly you mean by that because if you happen to go to one of the lower middle-income countries where Malawi, most maternity care services are handled by midwives. So what exactly do you mean because the number of obstetricians are very few. So we can't say it's managed by obstetricians. So I'm not so certain what exactly you meant by saying midwives have no autonomy because they are the ones that do most of the work. Fewer obstetricians can't handle the entire demand in maternity care. So did you approve further what this meant exactly? Thank you very much. Yeah, thank you. Thank you for your question. Actually, this question has to be answered from the education side itself. When the midwife-free students were selected and taken to certain settings, like for example, they grit their practice from hospital sites, even it starts from there. When these midwife-free students were trained, even to practice on women to whatever they have learned from the nursing institution or midwife-free institution, even that was difficult for the midwives. Even in that setting, as a student itself, they have stated that they cannot practice or they cannot conduct a delivery because of the presence of medical students who are given more importance. That is one thing. And this was from a review which was done in a study on midwife-free educator and midwife-free students from Bangladesh. And number two, in Afghanistan, the study which was done in Afghanistan, which has been included in this review, this states that it's not the community or the midwife who's working in remote or rural. You should also think about the other units, like midwife in hospitals, working in hospitals. So many of the midwives who get trained from the low-middle-income countries, they are not only placed in communities. You should also think simultaneously what is happening to those who get employed or get deployed in the hospital site. They really are facing a lot of problems. They cannot practice independently just because of the presence of an obstetrician is what I meant. If I was not clear on the review, I'm sorry, but this is what the review findings gave. I hope I answered, yes. You have a question. Yes, so it's a follow-up question with regards to that. So I'm just thinking that this being a systematic review, I think it was going to be very important if you grouped the low-middle-income countries because me, myself coming from a low-middle-income countries, I had no issues with regards to practice. Whether it's at the hospital or in a rural place, we had all the autonomy because of the fewer obstetricians. So I think it's country-specific. It can be low-middle-income countries, but some low-middle-income countries have midwives as the majority of maternity health care workers, and hence midwives have the autonomy to practice. I don't know if you are getting my point there because the way it's coming out, it's coming out like wherever you go in low-middle-income countries, it's a similar trend. I'm sure that's the same pattern of practice even in Malawi and other countries where midwives are like the majority of maternity care workers. It's a different story in countries where we have a lot of obstetricians. I totally understand, but from my own context, not all of them may have that pattern. So if Afghanistan and Bangladesh have that, it was going to be good to categorize them to say some of these low-middle-income countries like Bangladesh, like the way you had come out, then generalizing to say in low-middle-income countries it's difficult to practice. Thank you very much. Yeah, thank you, Vibhava, for that point. But I just want to put in forward that this review just put the top barriers as well as Wesley's data. And this may, like in one country, it happens. It doesn't mean that it is happening in all. It's just a review, and it's just brought in the most commonly stated things, like how many studies reported about this. I hope you understand what I'm saying. But it's good to know that in your place you have the autonomy to practice.