 I would like to introduce to you Mrs. Katarina Montagnoli. She is a young midwifery leader from Italy and she works in Switzerland. Katarina is focused on reproductive health among migrants and she balances her clinical work with research. And she is a midwifery educator. Katarina, go ahead. Thank you very much, Yuri, for this presentation. And welcome everybody to this session. I am very excited and also quite nervous to be here. And well, first of all, happy International Day of the Midwife, everyone. So I'm glad that you tuned in for my presentation and this presentation actually is the result of my master thesis. And just before starting, let me... Yuri, can you please put me a presenter? Thank you. Let's start with... Let's start with a little quiz that I created and we will see the results of this little poll at the end of the presentation. So just to present you the outline of the whole presentation I will start by talking about life in Geneva and Switzerland. Why interdisciplinarity is the key process to conduct such a research. My materials and methods results. So these three parts. What is the stakes? So all the limitations and future studies. So just before starting back, I will show you again the QR codes so that you can take the time to take the picture and arrive to the poll. Okay, very well. Okay. So what are... What we're and what are my motivation? Why I am so interested in this topic? So being myself a migrant because I come from Italy and I live in France and I work in Switzerland. I felt myself how migration is a pre-scient issue of our time. Economic migration but as well why not climate change migration and all the different types of migration. We've been talking about migration internationally and global compact on safe and orderly migration which was approved in Marrakesh in December 2018 but one more time we failed to include irregular migrants and as we can see international migration is a phenomenon that continues to grow and very rapidly and just to tell you the very last data of our time in the first trimester of 2021 there has been the biggest number ever of people dying in the Mediterranean Sea just to let you know that the pandemic doesn't stop actually migration. So why migration in Geneva? So Geneva is a global magnet for migrants. There are full of international organization among other set of UN agencies the International Center for Migration, Health and Development where I did my stage and many many other international organization. They are CRC and many other. But unfortunately this magnet is not just represented by the multitude of international organizations present in the area but as well from the lack of formal network for families because families that move in Geneva most of the times don't manage to find a kindergarten for their children and other facilities that would allow them to just exploit regional services. And this is the other reason why Geneva is a global magnet for migrants because apart from the economic migrants or migrants coming with a direct contract with international organization there are many many other coming for like filling the gap of the lack of a formal network for families, for sustaining families. And this was really very much let's say recognized by the state of Geneva when in 2016 it launched the Papyrus operation which was a massive operation to globalize irregular migrants who were living in the area for more than 10 years in an irregular situation but who somehow also met a certain type of criteria. And the University of Geneva at the same time launched the parchment study where I also had the opportunity to work in to analyze from an economic and health care and social point of view how regularization actually impact on the life of irregular migrants. So I did this internship experience and I also worked as an activist in the past five years. And most of the times I was at the Kansko unit which is a primary health care unit financed by the Kenternal hospital which is a health care unit dedicated to people without health care insurance. And as you might well guess this Kansko unit takes care most of the times of irregular migrants. So for going next I decided to really reply to this question of mine with an interdisciplinary scoping review to see what are the results in literature with regards to social science, anthropology and health care in general about irregular migrants access to reproductive health and their clinical maternal and reproductive outcomes. Overall I found 92 studies which I included in this scoping review and there are some additional data which I gathered personally during my hospital activity and internship as an activist at the Kansko unit. So to go forward these are the very first results in the sense that I really wanted to start as a health care professional from the health care point of view and in the literature I found that doesn't matter really the acidity of anti-Natal care attendance when it comes to pregnancy outcomes for irregular migrants. So and this is a result of a research done by Hans Wolf and his team in 2008 and performed in Geneva. So this paradox in the literature was very surprising to me because of all the rest of the literature I've been reading so much in these years which states exactly the opposite. So irregular migrants as people without legal status actually are more prone according to the WHO and to other international organizations, the RCRC and so on and are more prone to have worse health care outcomes, medical outcomes but especially because they are more vulnerable population but when it comes to Geneva this is not true. So the acidity of access to anti-Natal care and regularity to such anti-Natal care services it does not impact upon pregnancy outcomes. And looking a bit further in the literature I found that there were some other studies that were prospecting and presenting such data and which took into consideration other variables than the simple access to anti-Natal care but as well for example in the case of Canada and Kalano in 2017 the ethnic course for populations of interest. For example Ethiopian people living in Canada or when it comes to the US Mexican migrants living in New York and for what concerns the US this phenomenon since it was very much linked with the birth weight of the infant of the newborn was described as the birth weight paradox. And I asked myself why is there such a paradox in the literature why acidity of access to anti-Natal care does not correspond to the better outcome better pregnancy outcome. So I responded myself by saying that there is an historical process and it is also current in Western country and this historical process has this trend has set itself to medicalize pregnancy. So pregnancy is very much assumed for the general public as a condition as a condition which might which should be cared for by specialist gynecologist or an obstetrician. In Italy for example the first question you would ask not myself but the first question you would ask to a pregnant mother is so who is your gynecologist and who has taken care of you during this pregnancy. And I responded myself that is a very cultural mother very much cultural mother rooted in our cultural Western in our Western culture and this is also one way to justify the lack of benefits arising from the assiduous medicalization by anti-Natal care access for undocumented migrants. And of course adding to the ethnic specific curves that the migrants effect and the effect that we are considering pregnancy at the very basis as a physiological state of being. But let's go a bit further and like put it in prospect with the current the current pandemic we are living in. So the paradox can also be explained somehow in this Covid period through the fact that we had to we were forced to during lockdowns all over the world to re-understand access to reproductive health and maternal health care and to reorganize it restructure it according to the needs of every person. So in the US it was at least very easy to have up to 22 visits in person visits during pre-Covid pregnancy while in a very recent study which tried to understand the benefits of telemedicine these visits were able to be reduced and compacted to eight visits in the whole pregnancy. And if we think about WHO guidelines on access to anti-Natal care services they also rather propose a minimum of eight anti-Natal care visits. So we have experienced as midwife has professionals as students why not how telemedicine can be a good substitute for lowering in present contacts and how restructuring anti-Natal care services is important to comply with the clinical distancing need and somehow how useless how little of use were like the over-medicalization of pregnancy proposed in this pre-Covid area. To go next I wanted to state these four points that go a bit out of the topic and like outline the fact that clinical distancing and referral to primary health care centers has been a very primary step to comply with the lockdown and with the general measures due to COVID that women became real partners of the health care providers especially in case of complication during the pregnancy let's think about like diabetes, gestational diabetes where mother had to are still taking their glycemia and referring to their general practitioner or medical doctors and how midwives really led this transition to over-medicalization to physiology why not also through telemedicine through the mean of telemedicine and this is where I also talk about how much it matters interdisciplinarity so access to reproductive health in general is just not a matter of health it does not include only health care professionals as we just stated it includes first of all women that are their partners and it includes as well a set of determinants of health such as for example in the case of telemedicine all the administrative procedures and why not all the IT procedures all the IT help to set it up these telemedicine options and this other set of determinants of health include among others of course migration the state of the person, the knowledge of the language spoken in the welcoming country the social and legal status, the culture of variables, personal visions, personal experience and economic possibilities so now I pass to the social science point of view because we just realized how social determinants of health can be important in accessing health in accessing antinatal care and I wanted to understand as a student and also as a scholar where can we locate the pregnant body of irregular migrant socially so I've been looking in the literature and the very first obstacle to access antinatal care was the cost, the expansiveness of antinatal care in Switzerland and it is also a reason why irregular migrants often lack healthcare insurance even though it is a compulsory thing for a regular person living in Switzerland and then still looking in the literature I found the description of these deservingness and entitlements situations where a person becomes a biological citizen because of his or her needs in this case it's rather her needs but in the Petrina book published in 2013 the author describes this process of deservingness and performing illness to access health but also legal rights in the case of the Chernobyl nuclear disaster and I really found a sort of parallelism between what happened at the time actually 26 years ago and what is happening now not only in Switzerland but also in the whole of Europe where we only provide rights to the person in need when we realize that they are really need when they perform what they allow us to understand their biological need and their biological citizenship and there's also actually all over Europe a law that entitles people to access free of cost care in general emergency care and this is also the reason why I particularly liked this parallelism between biological citizens and health rights and then another social determinants are the lack of knowledge the lack of networks so the fact that recently arrived people doesn't know where to go where to look for care for free of cost care and it was the case of course in the health care center where I worked and as well the fact that as a person without legal status you don't have any social protection because you're working as we say in French you have a black contract in a sense that you don't have any rights just to continue with the fact that people most of the times recently arrived people don't have a network the Cannesco health care center is one of the points of reference for people without health care insurance and it really works via the snowball techniques of the mouth of words words of mouth sorry and over there there is very much discussed the problem of for especially in the case of pregnancy of how to balance access to health and the fact that you are relying only on you don't have any social security system behind you that covers all your needs all your health care needs and the fact that you're relying only on the entries on the salaries that you are perceiving as a person without a normal contract without a white contract if we want to call it that way and to continue this is the very last part of my presentation I also analyzed this aspect in an anthropological way this picture is very important to me because it represents the way Ticuna people understand their health in relation to the world so the social and personal and anthropological actually let's say anthropological understanding of health and the Ticuna are a population living in the Aboriginal population living in the Colombian Amazon and over there I had 21 days of ethnographic experience let's say living with them and thanks to these I really understood somehow the cultural self does not always reflect the cultural of the place you're living in so in non-western countries pregnancy is more a social than a biological event whereas as we said at the very beginning of the presentation in western country pregnancy is a biological event so you're pregnant and there are a set of visits that you have to do, the international care so it's very an event, a condition that follows a biomedical model but as I understood through thanks to this ethnographic experience and to reading thanks to the read of the literature the reproduction itself involves both physical so the physical self and also behavioural change and when associated with changes that migration imposes it is important to consider also the results going back to the study of a Mexican migrant mother in the US it is described how Mexican migrant mothers accessed somehow international care not regularly, not as seriously as the western model wanted but to complement, let's say to complement to fill the gaps of the western models they also referred to their cultural roots and they're solved little problems also with a different approach than the biomedical model and another aspect that could be a great obstacle to access international care in these western countries in our western countries is the fact that the person, the migrant, the regular migrant doesn't have a familiarity with the concept of self in the receiving society what are the dues and dons of cultural dues and dons of a pregnant woman in a western country so to describe this phenomenon of reproduction and anthropological self as Mitoka in one of her articles defined this state of being their reproductive habitus so the reproductive habitus as we can read are the modes of living the reproductive body the bodily practice and the creation of new subjects through interaction between people and structures as intended as institutions and I asked myself what are these interactions between people and institutions here in Geneva when it comes down to reproduction so as described in a later article published in 2018 by Fognoli people, irregular migrants have this problem in accessing reproductive healthcare because they have fear because they are blamed for their irregular access because they are stigmatized because of the little compliance with the western rules because they are blamed because they have a greater realization of an unplanned pregnancy that people want to continue rather than go to an IVG and because they have what is called inadequate access to antenatal care but at the end of this presentation I want to ask myself and yourself from which perspective can we say that access to antenatal care is inadequate so before going to the conclusions I would like to talk about all the limitations of this research as a real scholar so first of all the data published by Wolf are kind of limited in the sense that we don't have a lot of participants and data anywhere are quite old with respect to some more recent literature another important limitation is the fact that the migrant population is a very heterogeneous population and we can't really say that one thing fits all so people might come from western countries people as me people might come from other countries which don't have this western culture in medicine and then another limitation that I wanted to highlight is the fact that yes western countries I believe the most of the times pregnancy physiological pregnancy is somehow over-medicalised but anyway standardized model of care we have seen it our lives saving and work exceptionally well when biological equivalents in medicine are needed let's think about transplants and the COVID vaccine what are the future directions so myself I am looking for funds for doing maybe another study taking into account the different determinants of access to material care in a participative way and I would like to continue with this topic and merge qualitative and quantitative clinical and personal and from different prospective data to really continue to study the subject and somehow reply to this question of mine but internationally we have seen how there has been a cultural shift in medicine towards the personalized medicine and which is taking steps in 2018 the WHO interpartial recommendations suggested to seriously take into account cultural as much as biomedical models of care and in this way we have seen a sort of transition and in recent period as well the transition to telemedicine is also very much taking steps and I wonder if a mobile health tool would allow a better communication and a better access and a better understanding of the process of access to antenatal care for irregular migrants and very recently the WHO published new guidelines on virtual access to antenatal care and I think that there is some room for research in this domain so finally the first conclusion we have to gain, it's our responsibility to gain a better understanding of this paradox and why people don't access that seriously antenatal care and what can we do to fill the gaps the cultural gaps of antenatal care and by understanding and being open to understanding irregular migrants' behavior towards reproductive and paternal services and this is I really much believe is totally in line with 17 SDGs but most of all with the third SDG that is good health and well-being and finally as a global health professional I want to also highlight the importance of interdisciplinarity of a different multi-level point of view of thinking of systems for the analysis of human rights and access to health as a human right and the fact that solutions must be sustainable and innovative and adapted to people's needs so before thanking you well I finished with my presentation but before thanking you I would like to get back to the quiz results well we have just four responses I'm afraid that I didn't really actually let you have the time to reply to the questions so I would like to go back to the QR code let you maybe reply to the questions and in the meanwhile let Yuri take some questions and continue talking about this very interesting topic with you thank you for that okay thank you Katarina thank you for your eye-opening and inspiring lecture so please colleagues can you fulfill the little quiz via the QR code and if you have any questions you can raise your hand or you can put a question in the chat box it was a very great nuanced discussion appreciated Rona O'Connell hi Rona how are you she mentions the ORAMA program maybe you can you want to share something with us so I was really impressed by your presentation Katarina I was also reflecting when you had a slide about where do we locate irregular immigrants what do you think about or what is the challenge about health literacy because I have the I think but maybe I am wrong I think that maybe health literacy of irregular immigrants is limited and I mean by that do they have enough insight in the structure of healthcare like in Switzerland in Geneva and also do they have access to the internet because if you say I want to consider the transition to telemedicine that's okay but do they have the means that's a reflection so thank you already for this question Yuri you are actually totally right so there is not a lot of literature on the subject and the biggest reason is that irregular migrants since they are somehow persecuted for their irregular status don't want to appear most of the time remain in the shadow and this is also another reason why network is so important to them for accessing antinatal care and care in general so I've been reading a lot about what are the most important obstacles for as well a healthcare worker to provide access and provide quality access, quality of care to people that lack of for example documents let's think about not only legal documents but as well documents of the pregnancy why not and for example lack of birth certificate and how can we better even allow from a legal point of view access for these people so when I was in Paraguay volunteering as a midwife I found well I was in the city of Incarnazion I had this very little experience that I wanted to report to you because it lasted just six months but by the end of the day by the end of the experience I realized how midwife are so central in the process of not only health rights but human rights giving when people don't manage to access regularly antinatal care and why not also pregnancy care and childbirth care and for example deliver alone in their delivery room they don't have access to a birth certificate they don't have access to an identity to a recognized identity for their children and when it comes to a a scolarization period then your child doesn't have access to school doesn't have access to education and so there are a set of processes that start right from the moment we we decide to take care and to fight for this human right access to health for vulnerable people and or not so well thank you for your question thank you Katarina do you have some results because we only have two minutes to go do you have sorry do you have some results yeah sorry so talking about the poll that I asked you to fill so most of the people 85.7% think about one thing about irregular migrants think about asylum seekers and it's very interesting this reply because if we think about asylum seekers they have a very precise profile in all countries and they are somehow more protected than irregular migrants asylum seekers are protected by the law even here in Switzerland they have access to care free of cost they have access to courses to language courses to integrate the culture with the population so this is somehow it's not false but it's very interesting this perspective because actually as a matter of fact asylum seekers and also refugees which were the two most selected answers are the people most followed by the authorities and they have more access to health in general and then for the open question what do you think is important studying why do you think it's important studying migrants access to maternal and health in general so I think is I really like this reply I know who surprised was that but I wanted to read it to you so it has displaced people with fragmented health care and lack of family support it is vital that migrants can access maternal health without fear and this is I think what we can really sum up to by the end of this presentation so as health care professional it is important to let people understand that we are not we are not there at the hospitals to take care about their legal status or anything else but we are there to care about them and to take care about them so really the most important message that we have to pass is that we care for the other person just because it's a person and it doesn't matter their legal status or anything else and then for the last question do you know how your country deals with ensuring access to health for irregular migrants so 75% of people responding to the poll yes but still there is 25% that doesn't know so I really invite you to inform yourself because as a health professional you have not only the right but also the power to allow people to access or not health so I really want to thank you for your attention and this is my email address feel free to connect and I look forward to continue discussing with you about this topic okay thank you so much Katowina thank you Yuri