 Now it's my pleasure to introduce Leticia Bissei. Leticia is a midwife from Cameroon. She's working in a medicalized health center in the far north of the country and she's been doing that since 2015. Leticia is from the first batch of midwives trained in the country and she obtained her state registered midwife diploma in 2015. She earned a bachelor's degree in 2016 and most recently, a master's degree of public health in 2018 from the Catholic University of Central Africa. She's a member of the Cameroonian Midwives Association and the Anthropology and Public Health Community. Thank you so much for joining us today, Leticia. I am going to make you the presenter and you will have control of your slides. Thank you, Leticia, for the introduction. At first, I've planned to present in English, but I'm seeing a lot of people very excited to have it presented all talking French. Then I will do it in French. And since also the French is my first language. OK, our study is entitled the Determinant of the Historical Violence at the Maternity of the Okotá Center of Yaoundé. I must say that the Maternity of the Okotá Center of Yaoundé is an Okotá of four levels in the system of reference to the Cameroonian Midwives Association. It is a maternity that welcomes every year more than 3,000 people and receives a lot of medical students, women's teachers, nurses, nurses and others. These are the reasons that motivated us to bring our students into this structure. And at the base, we wanted to talk about humanized care. But as we mentioned in the literature review, we discovered the term of the object violence. And I personally admit that as a woman, I was a little shocked by the term because I said to myself, there is no woman, or there is no medical personnel who, when they wake up in the morning, comes to serve you, is it possible to be violent? We see a woman who comes to lie down. And this is the reason why I put this term into my research. And with reason, because all the personnel I had to deal with were really skeptical about this term. So we're going to go back, first. I'll select the second slide. Here we go. We have a plenary of our presentation that will introduce some elements of the context, the methodology that we have used to bring this study, some results, a synthesis of these results, a conclusion and the suggestions that we have formulated in regards to the concerns. First of all, in terms of introduction, in our literature review, we have seen that the global strategy presented by women, children and adolescents was aimed at 2030, the reduction of maternal mortality to at least 70 for the 100,000 living births. And that one of the strategic goals of this objective was the assistance of the international women to qualify before, during and after the treatment. This is one of the reasons why countries that did not have the training of their own women, especially African countries like mine, decided to introduce this training in 2011. And it is also said that the essential skills for a caretaker must be both clinical, cognitive and rational. But we have considered that the presence of a personal barrier between the caretakers and the patients are presented as an interface in the increase in the number of treatments by a personal caretaker. Because it must be noted that here in our context, in urban and rural areas, even more than 30% of the treatment is done in non-specialized structures for this. So, from the results of the WHO, we have learned that in the world, many women, if not only in the case of African countries, many women experience non-respective treatments and non-treatment in caretakers. And the Argentine, which is well advanced in relation to many countries, whether in Europe or in the Americas, has already recognized the right of women not to be victims of violence, of caretakers in caretakers. Like you see it? Yes, I see it. Yes. Can you give some of your points in English? You had many listeners who were hoping to hear some about Cameroon in English. Okay, when I will reach the level of Cameroon I will talk in English. Okay. Okay. At this level, we are saying that Argentina has recognized this right in a legislative way and even now, even if there are scientific data suggesting that the lack of respect and the lack of treatment are experienced by women, there is still no current consensus international on the matter of the country that should be defined and measure the lack of respect and the lack of treatment in Africa. It is in Africa. In 2016, the government and one NGO conducted a study entitled Etude Exploratoise Religious Effect of Women in the Service de Santé. And from that study, we realized that more than 40% of women are complaining, accompanying the care they receive in the health structure. In Tanzania also, they conducted a study on the prevalence of the... the respect and the abuse in the health centers and also in urban areas. Because most of the time we think it's only in the rural area that we can observe those treatments. But some studies show that even in rural, urban areas, even more than 50% of women, as in Tanzania, are complaining of the care they receive. Actually, in Cameroon, what we can say about it is that our strategic evaluation of the health sector is showing that the results that are presented, due to the poor results that are presented, due to, first of all, the lack of a certain number of material in the health structure, but also due to the fact that patients are not happy or are not complaining with the quality of their welcome in the health structure and some practices, like because, you know, in Cameroon, there is not health insurance. Most of the time patients are paying from their pocket. And for it, there is a lack of observance and some health personnel. And most of the time, the health personnel are, like, taking money from the patient and axing them more than what is supposed to be. With the GIZ, we realize, we realize a, we realize a, I don't know how to say it, a cool, cool, a short film that was for the students, for the student and their wife. And the aim of that film was to sensitize them against their role in the maternity on what they should not do. And more recently, on one French media, France Venkat, they show from one interview women that in our maternity is here in Cameroon, and especially this maternity, we work in that many women are still marginalized and they are, okay, they are still marginalized. And most of the time, they even hold in the health structure when they can't pay their B after delivery. Sometimes they even return their babies to conduct this study. We, as I said already, it was in one maternity of, maternity of the Central Hospital of Yaoundé, which is a fourth category maternity. And which is receiving most of the medical, midwife, nurses, students of the town. And our target population was the health practitioners, the parturists on the new models. And we included, we included in this study the health practitioners and also the women that were coming in the maternity for the delivery or who were in the post-natal world. At the end, we had 29 health practitioners that participated in our study. And seven, we interviewed seven women and we did 18 observations for the delivery. We have to precise that we use an observation guide, which is not from us, but from the White Ribbon Alliance. We use also an interview guide to collect information from women and also from the health practitioners. And from there, we realized that we had several types of determinants that were at the origin of obstetrical violences in that structure. First of all, institutional determinants, they were the most common and most of the violences observed were depending on them. First of all, we have the workload. We can observe that in that maternity, the health professionals, especially the midwives, they are working in two shifts. Then we have the morning shift and the evening shift. They are working in a team and each team for a maternity that is having five delivery beds. We have two midwives working per shift. It is too much. After we rediscovered that the social professional category also because from our discussions with the health practitioners, we discover the gynaecologists were more happy with their work than the midwives and the nurse. Let's say in our context here, the midwifery or nursing are not considered as category apart. They are still like depending on the medical practitioners. The medical practitioners are the one giving them orders on what to do and not what to do, and it's creating some frustration. Then most of them are not satisfied with their work. Also, we discover that the way they are welcoming people is not standardized. The hygiene also, the women are complaining for the hygiene. We observe that the hygiene was not that good, and even the health personnel is complaining from the hygiene in that maternity. The patients, they don't give the time to the patient to... In fact, they are not even giving the information to the patients. Most of the time, patients are not asking. I think that also has an origin that is the educational level because most of the patients are considering that the health practitioner is like a god. What he said is what should be done. Most of the time, they are not asking for information, and even when they are asking, the information is not given to them because the health personnel are considering that they are not... Maybe they can't understand what is done. They are not asking for the consent before carrying a procedure on a patient and also, they are returning patients, women that cannot pay their bills. They are returning them into health structure. And those determinants are also psychologic because we discover the way most of the health personnel are perceiving their relationship with their patients like difficulties. Also, the patients are not developing with their midwives a delivery plan. The central hospital of Yaounde is a referral structure. And most of the time, women that are coming for delivery are coming from some other structures of low levels. And they are coming that maybe they started to carry some procedure on them in those places where they were, and the procedure failed, then they referred them to that level. Most of the time they come, they don't have money. Most of the time, they come that the situation is already bad. And this affects the quality of the relation they have with those midwives. The midwives also abuse the women and from the women. And according to women, according to mothers, let me say mothers or new delivery women, the female midwives are more harsh than male. They don't pay me to them to have a companion during the delivery. And also the privacy is not really observed. So there is a room with five beds and they consider that every health professional that is coming has the right to see or to do. The women cannot ask for privacy. In fact, it's really difficult at that level. Psychologically, most of the time they consider in our context that women should deliver in the pain. Then when one woman is really shouting or crying, instead of maybe coming beside her and trying to alleviate her pain, they are most of the time shouting on her and asking her to try to do like others and stop shouting and making noise, which is not good. And also for the social, cultural aspect. As I was saying just before, they consider in our context that a woman should deliver for pain and every woman is the one that is very happy without crying or without shouting. And when someone cannot cover the pain and it's just like shouting and expressing her pain, the health person, the health personnel, is that shouting on her, which is not good and favoriting obstetrical violences. And the relations, the relations between the health personnel and the patient also is not symmetric. They consider that the health personnel is on top and the patient is down and is supposed to respect and understand all what is said to him. There is not really some norms and regulations. And most of the health personnel don't even know the right of the patient. Okay, from those institutional determinants, I don't know what to do because here I take some messages from our interviews with the women as one of the women we interviewed said to us, l'accouchement est trop coûteux. Je peux prendre le cas de ceux qui sont coincés là-bas. On a trouvé une qui avait déjà fait plus d'une semaine parce qu'elle n'avait pas d'argent. Donc si sa famille ne lui vient pas en aide, elle va faire un an là avec l'enfant. Edouard Ossi et l'intervention. This was a case where one lady was returned in the hospital. That was more than one week after the medical practitioner has signed her discharge because she can't pay for the bill. She was still in the hospital. And another one was like begging for her and asking that, so are they able to keep her for one year if her relatives don't come to pay for her bill? They should try to understand the population, in fact, people. Another one was saying to us, la majeure a demandé un signe de retirer la perfusion et de trouver mon dossier. Mais c'est où? Elle a parlé jusqu'à Bavadé, jusqu'au comment on l'aide ici parce qu'ici c'est facile de m'oublier. Mais personne, est-ce que c'est normal? This was a case where a lady came in the hospital and the place was bounded. So they kept her in one place and almost forgot about her. When I went to her and she was explaining to me that the doctors said to a nurse to look for a better place for her. That was more than one hour already and she was still there. Nobody came even to give her any information, even to talk to her. And she was really disappointed with that situation. For the psychological aspect, one of our interview revealed one lady that was saying, dans la salle d'accouchement, il sort de l'école. Non, il y a une façon de travailler qu'on leur apprend. Je ne sais pas si c'est aux patients de leur apprendre ça. Je me dis qu'ils sont censés nous accueillir, nous d'en louder parce qu'accoucher c'est une quasiment. Je peux sortir de la vivante ou mode. Donc je ne me suis pas sentie rassurée. Mais bon, j'entrais là-bas en guillivière. Je savais déjà ce qui m'attendait à l'avance. This was also a lady that complained about the care gave to her. And she was wondering if the nurse and midwife that were in the maternity not received during their training, the technique and the way they are supposed to manage women that are coming to deliver. So she was saying they should pay them because the delivery is like she is almost alive at the end as she comes to bed. So she was not very reassured with the way people attend to her. But she was coming, knowing already what was waiting for her. You understand that women are coming to us but with already something in mind. And that is most of the time due to all the patients that came before and who explained to them out of the health structure how the care is rendered in that structure. So when she comes she has already in her mind that people are not nice there. They will not pay her. They will not attend to her the way. So she's coming prepared for it already which is not good. Also another one, I don't understand. I don't manage because I didn't have a job. I am on the same level. You do the same here. You send her to the room. That's the other woman who came. So this one that was a woman that came and she was not having money. And she said that the person was talking harshly to her and abusing her. That what are you even doing here? You are keeping space when other women are coming to deliver. Look for money and go out. And also from one of our observations where a lady had it there after the delivery. Then the doctor came to repair that there. As she was crying and shouting and trying to retain them. The nurse that did the talk to her and telling her, if your heart still touched me, I will slap you. You can take her. Let us finish with you. But you are shouting, shouting. If the doctor leave you, that will be bad for you. That's the way one nurse talk to one lady that just gave birth and had it there in front of me. Okay, in conclusion, as we said, our objective was to look at the determinant of obstetrics at the maternity. Then from there we discovered that there are some determinants that are coming from the institution. They are pursued the way the interact first of all among them, her personnel. The doctors are not respecting midwives and not respecting nurse. Also the workload for those midwives when they should be two for one shift, working from 7 a.m. till 5 p.m. and working from 5 p.m. till 7 a.m. the next morning. It is very, very heavy for two persons and sometimes per night they can attend to 10 or 15 women, which is too heavy and also from the psychological aspect. Women are coming because the hospital has acquired already a bad reputation. Women are coming already prepared in their mind that people will be harsh with them. They should not ask anything. They should be quiet. They don't feel at ease when coming because they have already those ideas in their mind and also they don't pay me to them. The configuration of the maternity room is not permitting to them to allow the birth companion to be in the rooms, which is not helping women psychologically and from the social cultural aspect. Here from women, the obstetrical variants are too frequent, extremely frequent. So sometimes when you decide to conduct a study like this one, they even see it as a strange phenomenon to talk about it because for them all what they are doing is already in their practice and is almost normal. Okay. We suggest that we identify some problems, specify the causes and consequences and we suggest some recommendations to the the main actors like all those dysfunctions we observe in the maternity room. We said this is due to the insufficient lack of material, the also the disponibility of drugs and the health product. And these are some consequences because the procedure, most of the time are rupture when you have to send a patient to the pharmacy to go and bring you maybe a catheter. That the time the relative is going to the maternity, what will happen to the woman that is there in need. And that also frustrates the patient, but there is no, there is no, there's no stock of drugs and product for the maternity just beside that they can take and maybe set the B at the end for the patient for every single thing. They have to send a relative to the pharmacy, which is not good. This was addressed to the Ministry of Public Health and also for the administration of the hospital for the workload. This is due to the lack of personnel. And as a consequence, the small number of personnel that are there available cannot give, render the care that patients expect and they cannot do the individualized care at that moment. They need to recruit personnel and to define a good politic of recruitment. Because in that health structure also most of the time some students are after their training, they are coming for the perfection amount, like to perfect their skills before entering and even those who cannot take care of them. When that is a good source of human resources for the maternity, they can use them for that time they are coming for to perfect their skills after their diploma to enhance the work and to complete their teams that are working in the units and render better care to the people. There is insufficiency in the organization of the care. I think they lack competencies, they lack motivations, and these lead to disorder, first of all, in the way that they are tending to people, they should reinforce the capacity of the health team and really reinforce it, not only without making a highlight, but also following a variation of their personnel in a permanent way. There is insufficient communication in the team, first of all, with the administration and also with the patients. I think this is not because they don't want, but they lack competencies in communications. They are not taking the consent of the patient and I think they really need to be reinforced in communication and this is the role of the Minister of Public Health, the administration of the hospital, and also the associations like the midwife association in Cameroon. Leticia, I think you are close to the end of your presentation. We have about yeah, we have about five minutes left. Can you maybe summarize and then people might have some questions. Okay, let me summarize. Your suggestions were actually good summaries. Okay, thank you. So, our study aim at the identification of of the care violence is determined at the central hospital maternity of Yaoundi and also to contribute to the understanding of the way Patreon and the women who are recently given the place, if they care given to them during that particular dedicated stage of their life. So we use a mixed approach and from that we realize that the lack of human resources on quantitative and qualitative aspects are for more in the manifestation of these violence. And also the educational aspect both from the health care givers and the patient side, although it was not taken into consideration there seems from our result to be from a great impact in the poor quality of care given to women in labour. Okay. Okay. Thank you for this opportunity you gave me to do this presentation to you. Leticia, I think we have heard a midwife leader of the future for you to be able to go back and forth French and English is a real skill. I can only imagine that your midwifery skills are as great. Elena is asking she's wondering if you have plans to present these findings to the people you have identified. For example, the Ministry of Health and others. Actually, I've been able to present it to them because there is a lot of procedure to access to that level. And I think you as personally as individual is almost impossible. But if you are carrying by a structure that is really representative for the Ministry, maybe at that time you can have that opportunity to be heard if you present this. Excellent. What about getting the information out to midwifery journals in English, Leticia? This study was conducted, let me say at the end of the year 2018. Then when I saw the opportunity to present it first of all to the virtual conference, I thought it was a first step to make people to see or to appreciate what is done or what people are living here at my level. So if there are some other opportunity to present this study, I'm ready to take them. Leticia, in the chat box, Elena Ateva, who's from White Ribbon Alliance, I believe, says she would like to follow up with you. And she's given her email address at the White Ribbon Alliance. She says you can write in French. And I think she is going to help you spread this information. Okay. All right. Leticia, again, thank you so much. I don't know if the listeners know, but we lost our French translator at the last minute, and Leticia was brave enough to speak in English. I hope, Leticia, you'll consider joining us in future years and updating us on what your work is doing.