 So I'm now going to introduce our speaker. Bavia Reddy is a public health researcher with expertise in global maternal health. She is a doctoral student at UBC's School of Population and Public Health and holds a Master's in Public Health from the University of North Carolina at Chapel Hill. Bavia has over a decade of experience with implementation research and multiple method research projects on gender and health. She has served as an external reviewer for the World Health Organization guidelines on antinatal care and a World Health Organization working group to synthesize evidence on strategies to reduce mistreatment in childbirth. She has been a faculty member for a course on gender and intersectionality in health policy and systems developed for the World Health Organization Alliance for Health Policy and Systems Research, where she built a case-based module on respectful maternity care. Using a social inequities lens, her research engagements have included risk assessment in pregnancy, health system determinants of maternal mortality and morbidity, and capacity building of community health workers in low resource settings. Since 2015, her work has focused on drivers of mistreatment in childbirth and barriers to evidence-based interpartum care. Hi everyone. It's wonderful to be with you today on the International Day of the Midwife. And it's great to see representation here from all over the world. As Heather said, I'm a maternal health researcher from India, and I'm speaking to you today from the University of British Columbia in Vancouver, which I acknowledge is on the traditional lands and unceded territory of the Musqueam, Squamish and Silvertooth nations. I'm privileged to live and work here. I'm here today to talk to you about the quality maternal newborn care research alliance, which I'm a new member of. I want to start by saying that my appreciation for midwifery is not just as a researcher, but as a mother too. I was very fortunate to have incredible midwives support the birth of my child, and it only reinforced my passion to make high quality midwifery care accessible to everyone. Which is what this research alliance ultimately aims to do as well. So the QMNC is an alliance of researchers, midwives and other clinicians, advocates and policy makers, and we're committed to conducting and promoting research to improve quality maternal newborn care. The members who comprise this alliance are mostly researcher practitioners and heavily researchers and midwives with some physicians. But this platform is open to anyone who is interested in contributing to three main research priority areas, which we'll get into later in this presentation. So the QMNC emerged from the seminal Landsat series that some of you may already be familiar with. In 2014, the Landsat published a series of papers that were hugely influential in establishing the strengths and the potential that midwifery has. The takeaway from the series is that midwifery is a vital solution to the challenges of providing high quality maternal newborn care for all women in newborns in all countries and all childbearing people. It is saying that when we have limited resources but need to reduce preventable maternal and infant death and suffering and provide high quality maternal care, the answer is high quality midwifery. Here are the four papers in this initial series and there was one follow-up paper that came some years later. I hope you'll can see this in the first paper. Mary Renfrew and colleagues synthesized a huge amount of quantitative and qualitative evidence through a systematic review. They spent a lot of time looking at how midwifery is defined, how different people define it and coming up with a clear and inclusive definition of midwifery. What they found is that midwifery, as they've defined it as a high quality form of care, can improve more than 50 short, medium and long-term outcomes ranging from clinical, psychosocial and public health outcomes. They also developed a framework that we'll discuss in more detail that lays out the components needed to offer high quality care and this laid the theoretical framework for the rest of the papers. In the second paper, Caroline Homer led a team that used a modeling technique called Live Saved where you're able to enter different information about the maternity care delivery system and model what would happen if you changed certain factors. So how would mortality or morbidity rates change if you modified certain aspects? And what they found is that by far the most effective way to reducing preventable death and suffering in maternal and newborn care is by implementing high quality midwifery care as defined by the first paper. What they also demonstrated is that if you added family planning to midwifery care then it could reduce mortality by 80% or more. In the third paper, this focused on country experience of strengthening health systems through midwifery. They looked at four different countries that started with very high maternal mortality and have seen very sharp improvements over several decades. And so some people understand this as positive deviance models where like why do these countries despite facing the same constraints why have they been so much more successful at reducing maternal mortality? And what they found is that along with the expansion of infrastructure and services and reducing financial barriers to care all these countries focused on the expansion and integration of midwifery in primary care. And they also included that we need much more attention to respectful care and reducing over medicalization. The fourth paper here is a high level synthesis of all the findings from the three articles and it ends with a call to action and it emphasizes that midwifery and midwives are central to achieving all national and international goals and targets in perinatal health. And there was a strong sense among these authors that this needs to be a starting point for action given that there's a lot of compelling evidence on what needs to be focused on. So this is the framework that Renfrew and colleagues developed that presents a much deeper and more comprehensive conceptualization of quality. You have clear divisions of roles and responsibilities that are based on needs, competencies and resources. And it's not just about having a care provider but providers that are organized in a particular way with a certain skill set and you want practitioners that combine clinical knowledge with skills and interpersonal care and that includes respect and cultural competence. And the philosophy using expectant management and using medical interventions only when indicated. So if your system is organized in a way that everyone sees an obstetrician you will have much higher intervention rates than where everyone sees a midwife and some people will receive care from an obstetrician. We're given the audience here that's preaching to the choir. In terms of values, it has to be driven by respect, communication, preserving community knowledge and an understanding that people closest to the problem are also closest to the solution. And the ability for care to be tailored to personal circumstances and needs. And coming back to the organization of care, you may have dedicated providers who are well trained and have a strong philosophy and value system but if they operate in a dysfunctional system that's poorly organized you're not going to see the results we want. And up at the top we're looking at practice categories. That is the ability for clinicians to do all of this, to do the preventive care, education, information and health promotion. So for midwives it's not just about catching those babies, they're involved in health promotion, assessment screening, care planning and prevention of complications. And all providers need to be able to do all of those things. Then we get into the more medically complicated procedures and so for all childbearing people these three things are needed. And then for some childbearing people we'll need first line of management for complications that need immediate response. And so it's important to note that here that midwives need to be equipped to handle the first line of management of all complications. So it's not just about transferring clients to another provider or a high level facility for that first line of management for say a hemorrhage or a baby that's not breathing these things need to be managed right away and midwives need to be trained and empowered to carry out that first line of management. For midwives to be effective they need to be able to carry for instance anti-hemorrhagic drugs, have training in neonatal resuscitation and so on. And then in the last box on the right is medical and obstetric neonatal services. These are for really medically complicated pregnancies that require either an obstetrician or a paeniatologist or a neonatologist. And most recently members, two members of the Research Alliance led the development of this framework into an index to measure quality of maternal care. And I can post information on that article in the chat later if anyone's interested. Now, what we want to point out here is this circle and that's the true scope of midwifery care. It's everything but those medical obstetric and neonatal services for complicated cases. And in reality in some practice contexts midwives do handle high-risk clients as well. So you see there's a little bit of an overlap in that last box because there are systems where midwives, for example, will assist exasarians and so on. And just to emphasize that is the care that only a few people need. So this is what midwifery provides, everything but that little box. And there's a dotted line because sometimes they also contribute to those services. Here's the problem. Almost all current funding and research goes to that little box. The set of services that the smallest proportion of people will need. So the goal of the QMNC Research Alliance is to bring the focus back to everything else captured here. The research funding and implementation needs need to be directed to all of these other areas. And that's the goal. So after those first papers were published a few years later a group came together that were a mix of the authors from the first series and some emerging scholars as well. And the authors of this paper drew from that Lancet series as well as a research prioritization study that was with the WHO that had 11 priorities developed and what they did is condense those down to three research priority areas. And the idea was to synthesize it and have a smaller set of priorities that you could actually build a platform around. And it calls out the fact that for decades funding has gone to this narrow area and has not done anywhere near enough to improve the lives of mothers and babies globally. And we'll get into these three priorities but that's what the alliance is oriented around. So this is a 14-member steering committee that got together to set the strategic priorities for the alliance. I won't say much on that. Okay, so the Kermansi's vision is a world in which equitable and quality maternal newborn care for all is advanced through the promotion, conduct and translation of research that examines the contribution impact of midwifery. What it's saying is that we'd like to see maternity and newborn care be driven by equitable research. And it was deliberate to say midwifery and not midwives because we want to stress that every kind of provider can provide high quality midwifery care, not just midwives. And the mission is to collaborate in global research that promotes, generates and translates knowledge particularly of the integral role of midwifery in order for women and childbearing families to survive, thrive and transform. And again, this language is deliberate because there's a lot of focus on survival along with that research funding focus on that narrow area and keeping people from dying but what about thriving and having a birth experience that's positive and transformative. So we consider survival as the floor and not the ceiling of what we should be trying to impact. And we want to see people thrive and transform by the kinds of care experiences they have. There's also been an assumption especially in LMICs that thriving is the bells and whistles and that interpersonal aspects of care is something that is unfeasible that focus on it is unfeasible in resource constrained contexts and we assert that it's possible to be lifesaving and high quality and focus on these other aspects. Okay, so in the steering committee laid out the values that guide the Alliance this is what they focused on maximal impact. We want to impact as many people as possible not just those who experience complications answerability, community involvement and sustainability and using an equity lens for all of these areas. So here are those three priorities that I mentioned. The first one to investigate the impact of quality newborn care and in particular the contribution of midwifery on maternal newborn and related outcomes across diverse settings. It's to study high quality midwifery models of care and to know as much we can about those models to understand what's core, what's non-negotiable what are the most valuable components that need to be implemented in all regions and we say this with very clear acknowledgement that those components are going to be adapted for different contexts to suit the needs of those communities. So we don't support a one size fits all approach we want to find out how we can be translated and adapted for different regions, countries and communities. And I think the key to this is having research that is representative not taking a model for instance that works in a high income setting and assuming it'll work in an LMIC setting without careful consideration of the health system context, the socio-political history of how those professions evolved and a whole range of factors. Second priority is to identify and describe aspects of care that optimize or disturb physiology for all child-bearing people and anyone's. This research priority focuses on physiologic birth. This is for people who are interested in core scientific research on what is physiologic birth. Birth has been intervened in for the last 200 years. We don't have the data on what normal physiologic birth looks like. For instance, if you want to know how long labor is, if it's not interrupted and medicated, we'd have to look back to the 50s before births were regularly augmented. We have a much better understanding of what medicalized birth looks like and those consequences then we do physiologic birth. That is research priority 2. The third research priority is determining which indicators and measures and benchmarks are most valuable in assessing quality maternal newborn care across settings and including the views of those who bear children and develop new measures to address identified gaps. This is about being really cautious and thoughtful about how we measure what we measure and how we measure it. Core standard indicators like mortality, cesarean birth rate, breastfeeding, all of those are going to be absolutely critical but we can't be limited to it. It indicates the basic things in a system that's not going to describe a system where people are thriving. Here we need to figure out what is important to people and be able to measure it. The birthplace lab out of UBC where I work has co-developed a number of person-centered measurement tools on respect, mistreatment, autonomy and decision-making in prenatal care and these were co-developed with communities which started with understanding what service users and communities want to know and share about their experiences of care. The QMNC is committed to this global research agenda and we want equity to run through all these efforts but when you look at where research is coming from it's not like regions are absent per se but there's a terrible asymmetry if you look at who is leading the research and what kinds of research gets published. A lot of research is about people from LMICs but it's not written by people from LMICs and this alliance wants to try and change that. We also know that positionality really matters and how we see things and any research that is produced is imbued with the researcher and it's one interpretation of the picture based on the data that the researcher had available to them so in order to have a comprehensive understanding about what's going on in very little care you need as many voices and perspectives included and so asking the questions, collecting data and analyzing it we need more people involved and right now we don't have that and these power asymmetries and how research is produced are not going to become equitable on their own these unequal balances will keep perpetuating so this alliance is trying to do things differently and we're trying to build a global platform that is accessible in places that have accessible issues for example like China and try to use technology to create an online community with clear intentions about power sharing and mentorship and how it works. Some of the initial funding to develop the platform went to conducting a listing campaign where participants who join the platform were interviewed and part of focus groups to understand what are some of the shared needs that perinatal health researchers around the world are experiencing and are those different across regions and what would this platform look like if it were able to develop one that would serve as many needs as possible and right now this data is being analyzed and it's going to feed into the strategic plan and so that the plans that the alliance has isn't just the views of that 14 members during council but researchers all over the world working in perinatal health and so this table here shows us where key informants were from and we can see that they cut across regions and different stages of their research career and some new members and long-term members of the platform. The hope is that this web-based platform will draw members from all over the world and that discussions and research priorities that emerge from this are really representative of different views and different positionalities and that will build a stronger research product. This just shows you a little bit about what the platform looks like and some of its features. I won't spend too much time on this. Here's a map that shows currently where members are from. There are 85 countries represented. The highest density of membership is still in North America but there is a good distribution across regions and here if we look at participation which right now is tracked by who is starting or responding to discussions on the platform there are a lot of early career researchers from LMICs and they're also engaging with it for mentorship and research opportunities. It's just another way of looking at the density in membership by high, middle and low income economies. Here are some of the ongoing activities that QMNC has. There are monthly newsletters with research updates. There are facilitated discussions where you can hear and be part of these discussions on the latest research in perinatal health and it's usually quite a small about under 25 people and quite an intimate sort of environment and you can talk with sort of these PIs and leads on these big research projects and if you're in places where you can't access research because of the paywall it's a way to still learn and engage with the latest research and it's also a way to have cross-cultural conversations and push the envelope and challenge each other's assumptions. We also track QMNC at events and conferences so if you remember when you go to a conference you can meet other members at these events and the QMNC track will label certain presentations that are in alignment with one of these three priorities so if you're working on priority two you know about all the presentations at that conference or event that correspond to it and can meet up with other members who are working in that area. There are six fellowship opportunities one for each WHO region. Most positions in the cycle are closed but there's one spot for the Mediterranean region that's still open if their listeners were interested and this just lays out the organizational structure and who the research leads are for the three priorities right now. And so the process has begun for producing pilot publications in each of these areas on midwifery care, on child bearing physiology and on measures and benchmarks. There's also going to be another piece on global equity in birth research and finally a piece on the process of bringing this platform together and working collaboratively across these areas and what worked, what didn't work in really capturing the process. So that's it from me. This is where you can reach the Alliance. I see that Jodyne is here in the audience who can also help with questions if people want to know more about how they could get involved. And yeah, I think I'll hand it to you Heather if we did have a discussion question in mind or if there are other questions that have been coming up I haven't looked at the chat. Thank you. Thank you. Okay, does anyone have any questions that they'd like to start with? All right, well then I'll start with one. So I am curious, what kind of barriers do you see to midwifery led care in your context or country and what has supported the expansion of midwifery in your country? And that could be a question for everyone really on this session and perhaps Baria could give us some insight. Yeah, I mean, so I can speak on some of the barriers in India in the context that I know best and I think India isn't unique in this. It's been an obstetrician led model of care for a long time and there are powerful groups, professional bodies that are threatened by the expansion of midwifery and the scope of midwifery and I think a lot of the work there is in working to break down those professional silos and improve communication across and really engaging doctors and obstetricians along the way, making them feel part of the expansion of midwifery in a way that supports them to handle the kind of cases that they're really trained to and letting midwives do the rest. I think I saw someone's hand up. Yeah, I was curious about what other people are experiencing in their country context in terms of the position of midwifery and the status of midwifery in some ways. Margaret says that it's the same in the UK as what you were just describing and then she wants to know how do we get the OBs on board? That's a million dollar question. I think having some OBs, some sympathetic OBs to begin with is great because having OBs talk to other OBs is one way. I think these are quite sophisticated approaches that are very context specific and culturally and you know, but tune to what works to communicate and be heard in those contexts. So no, there's no magic bullet. Yes. And Nidhi says that she's excited to engage with QMNC Research Alliance as she is beginning her midwifery research career. She's a PhD student in the US researching midwife-led models of care in the US. That's great, Katie. That's wonderful. And I think there are different ways to get involved with the Alliance. The facility discussions are now called Calabash Cafe. There's some meaning to that, some background to it, but really a wonderful way to engage with these research in these really small groups which a lot of, you know, that get lost in larger conferences. This is so incredible that ViDM has a 24-hour program. Yeah, so KC Katie says, I'm not familiar with this, Katie, but I'm going to note this down and how would I reach you to share this? Let me follow up on it because there may be others in the network who know about this. I'm afraid I'm not familiar with anything off the top of my head, but there should be people who can have the answer to that. Could you maybe reach out to me directly? I'm happy to put my email down here. Well, thank you so much, Babia, for your... Oh, Katie raised her hand again. For your lovely presentation and the work you're doing for all of us to improve midwifery-led care. Yeah, thank you all for listening. Like I said, I'm a new member of QMNC and I'm still, you know, finding my way and figuring out how best I can contribute to the Alliance. So I hope this has piqued people's interest to look into it and consider becoming a member.