 I would like welcome Vijaya Krishn to the virtual day of the midwife as our second speaker of the conference. Vijaya is a 30 professional midwife and the co-founder of the Healthy Mother Sanctum, the Natural Birth Centre, and the leading official Lamar's certified childhood educator in India. She teaches the Healthy Mother Lamar's accreditation childbirth educator programme in order to educate and certify Lamar's educators all over India and also runs the Healthy Mother Breastfeeding Support Network. So I'm going to hand the baton over to you, Vijaya. Thank you, Linda, and mute myself so I can have a proper cough. Thank you, Linda, for that wonderful introduction. I am so honoured and thrilled to be invited to this amazing virtual event and for this opportunity to speak with so many of you sister midwives and birth keepers and birth workers from across the world. Happy International Day of the Midwife to all of you. And before I begin, I think I want to take a moment to remind you each one of you of the amazing, awesome and life-altering work that you do every single day. Congratulations, Kudos. We are celebrating not only the International Day of the Midwife, but also 2020 as the year of the nurse and midwife. So while 2020 has brought some honestly odd sets of events together, I think we are in the year where Midwifery is actually being recognised across the world. So I think that's pretty cool. So before I begin, I would like to thank all the mothers and fathers who have given permission to use their photographs in the presentation. So yes, I am a midwife and I am the co-founder of the Sanctum Natural Birth Centre in Hyderabad, India. And it's a one-of-a-kind birth centre with a collaborative model of care, which is what we are going to be talking about a little bit more in detail later on in the presentation. So before, let me go right on. So it would be very appropriate at this time to recognise the contribution of all our traditional birth attendance across the world. We do come from a long tradition of Midwifery in the country, but traditionally 70% of the births were, at least over several decades ago, of course, almost all the births happened at home. But even a few years ago, there was at least 70% of the births that were happening in the homes because a large part of India is still fairly rural and suburban. But then, of course, government and those policies and initiatives, obviously, which have impacted the institutionalisation of childbirth, and while this presentation does not have the ability to go over all of that, we do have to still recognise that there are midwives practising and delivering excellent and extraordinary services in the country to the women where they need them. So, yeah, we do come from a long traditional of Midwifery until the kids at home advised were the keepers of birth in India. And one thing which is remarkable when I see this slide is that all the things that we talk about in Midwifery today, as we know it, keep the lighting dim, keep everything personal, ensure that there are women supporting other women. These women already knew what they were doing years ago. So, the ageless wisdom of Indian midwives was passed down generations from ancient times. And Janet Chawla, who has done some stellar work in the country with her organisation, Matrika, and the Jiva project where she has gone and looked at what traditional birth attendance and practices were in her book. She writes about midwives knowing that not to cut the cord and if the baby was not breathing at birth, they would heat up the placenta and then milk the cord to revive the baby. So, this ageless wisdom obviously has been there and it has been passed down generation to generation. So, but just in over a century, giving birth has changed from being there to here, which basically again tells us, you know, where Midwifery was with hands-on skills, palpation, women actually listening to women. And here we are with the current set of scenarios where essentially because of volumes, because of medical education, literally a woman gets into the office for an appointment and she gets five minutes and she's told to lie down. A scan is done. It's very, very hands-off and maybe there is a little, you know, a five-minute or two-minute conversation. She has prescribed medicines, prescribed tests and eventually that's where we land up with lots of interventions and perhaps this is the end section. So, of course, the medical system in its wisdom has decided that, you know, birth is essentially, and this is not just that doctors and hospitals are bad, it is just that the way of teaching the medical education generally looks at birth as an emergency, a disaster waiting to happen unless otherwise proven. And years ago, when we were just starting up in 2006, 2007, and when I was looking at births happening in the hospitals, there was a birth where I was just observing and, you know, an episiotomy was going to be cut and I said, why are you cutting the episiotomy? And the doctor actually chuckled and said, every baby has a big head unless otherwise proven. And that basically sums up the situation with the medical sort of education and the way they look at birth. So, there is an atmosphere of fear that restricts a woman's choice. There is family involvement which sometimes can be overbearing but sometimes is restricted. We still often see, although it is improving, we still often see that even the partners, the fathers or other, you know, significant other is prevented from entering the room for a checkup and especially for even scans. And I always often wonder, you know, what has the partner not seen before that we are saying don't come in, you know. So that sort of involvement is restricted. There is blind trust in the care providers. There is caregivers. There is fear. There is lack of knowledge. And therefore, suddenly we have come to the point where interventions have become like the accepted new normal. So this is the challenge of the increasing cesarean rates. And unfortunately, the state that I live in, Telangana, which is towards the southern part of the country, is actually the sort of the, has one of the worst statistics as far as cesareans are concerned. It has, in the private sector, it has about 75 to 80% known cesarean rates in some of the hospitals. So cesarean rates, top 90%. And so essentially, unless a baby is actively falling out, there is a lot of cesarean that are being done. And the sad part is even the public institutions where traditionally the women because of whether it was volume, whether it was because of lack of resources, as in the doctors where the women were actually allowed to labour. And I hate this word allowed and I always use it with a lot of caution, but whether they were allowed to labour and give birth or at least deliver vaginally, if not naturally, even those rates are going up remarkably and Telangana today has somewhere between a 48 to a 52%. And in some by some statistics, even a 58% cesarean rate, even in public institutions, which is essentially the hardy low, low, relatively lower risk women are giving birth. So this is a study that came out recently. India might soon have the most cesarean section rates. And current estimates show that India has doubled the world's average of cesarean rate in the last decade. And those are some some sobering statistics. And I think it's all of us should sit up and take notice, whether it is public policy, policy makers or people who are in the midwifery world who are trying to push for better midwifery care, because we know that midwifery care can contribute to reducing these numbers significantly. So what is the nature of the problem? It is generations have not had a normal, but we have had women come into the come into the center. And after they've had their normal delivery after fighting hard to even come into the center to give birth, because we are still considered after 12 years, we are still considered an alternative care provider. And generation when they have the birth, they will say, you know, I'm the only one in the family who has had a normal delivery. And I'm really proud of it. And we will say, yes, you should be extremely proud because not only have you made a difference to your life, but now you're able to pass that wisdom of living in your natural birth to your daughter or daughter and daughter-in-law or a friend or other people in the community. So I think this is something which is very crucial. There is fear in families that is passed on to mothers. And it's just interesting that, you know, when you look at two generations back, for example, the great-grandmothers or even the grandmother generation, they usually will say, you know, yes, I was working at the home. I was working in the field. I had some contractions. It felt like pain. I felt it was gassiness or discomfort. And then, you know, I continued my work and I gave birth fairly easily to the one generation down where it is the mothers of these moms who are pregnant right now. And they also have many of them have had normal deliveries, but it has all been in the hospital. And then the current, you know, focus where there is all this medicalization of childbirth because they are seeing their nieces, nephews, wives, you know, their own cousins or whatever, give birth in the medicalized environment, there is so much fear not only in the antenatal period during labor and birth, but also in the postpartum period where even breastfeeding, a simple biological happen naturally for most women is considered like, you know, unless otherwise proven the mother has no milk. So there is a lot of fear in the families which is passed on. Listening to elders, the doctors become more important. And this is again a very cultural sort of issue because sometimes, you know, when we see the family for the first checkup, often it is not just the mother who walks into the room. It's the mother, her partner, her mom, her mom-in-law, maybe her sister or her sister-in-law. And we have suddenly five people into the room. Obviously, how is she going to feel even confident to speak her mind? And, you know, they'll expect like with folded hands sometimes say, doctor is my daughter, daughter-in-law well, and what can you say about her condition as if it is a disease process that someone needs to diagnose, you know, and it is just so heartbreaking sometimes to see that. And finally, when they leave the room, a lot of them will say, I'm putting my daughter into your hands. And I think these words ring in my ears because it is just such a way to sort of handle the mother and it's culturally we have to be so that and sort of try to break that in pieces where we say, you know, why don't you all go out? I've talked to you. I can't just say I will not speak with you because I know they will never come back to see me, but, you know, say, okay, I've heard all of you, but may I have some time with your daughter or daughter-in-law? And then eventually a lot of the women who understand this model of care and it has become better over the years. They will come in and they will talk and, you know, then they will bring that, you know, the elders or so on and so forth. But it is almost as if she is married, then she goes to her husband's home and then she's brought to for her delivery over here. And she's essentially like the child belongs to the family and she's a vessel to give birth. And there is a lot of that which also causes the problem to multiply. Superstitions are built through blind faith. And of course, from the doctors and obviously, though we all know that googling is not the best form of, you know, finding out the best information, again, they are ridiculed and questioned and saying, oh, you know, you google for five minutes and how are you better than me? So that's part of the problem. So, and then the other part of the problem obviously created by the medical profession, C-sections are the only options available for anything where there seems to be a slight slightly off from the norm, gestational diabetes, low AFI, high AFI. And because there is not extraordinary protocols and because there is not an oversight that is available hospital to hospital and there is no need to declare numbers, it is just some hospitals might say I will wait for two hours, some hospitals might perform internal exams starting 35 weeks. So there is really no standardization and everything ultimately lands up. If you have a cross tie or a bent toenail along with your pregnancy, you might land up getting a C-section. C-section is directly suggested many times for twins, cord around the neck, a huge problem, a huge problem, because they will bold it saying, they go in for their multiple scans, they will bold it saying that you have a cord around the neck and you know what's even more funny. Sometimes they will say the cord lies near the neck and they will bold it and so all these fears come into the woman and then she eventually lands up having unnecessary interventions and of course this is their intersection. The due date myth, huge, you know, cross your due date, you have an induction or a C-section, vaginal exams, baby not high, inductions for no valid reasons, I talked about that. So is a healthy baby all that matters, women grow babies? Without a woman at best, the baby would not exist, right? So and the argument across, I think, but of course I'll talk about that, but your baby is healthy, why are you not happy? And 2013, the birthright survey was done in the UK and those who experienced care that they perceived as disrespectful, abusive or negative were far more likely to have negative feelings about themselves and those memories were vivid for a lifetime. Similarly, listening to mothers, there were three surveys done, the last survey, there were high levels of interventions, 68% were still confined, and experience completely optimal healthy birth practices and this is, you know, in countries where actually there is some transparency of care. And here, when we talk about India, we don't even know what these numbers actually might look like. So birth has its dangers of course, but the privilege does not need to be paid for by foregoing rights to dignity, autonomy and choice. So what is respectful care? Factory line care can become inhumane? Yes, we do have large numbers and yes, we always have to look at how can we make it scalable? But essentially, I always feel that midwifery has to be the frontline of all of this care because midwifery is care is more personal, it is more individualized and it is meant to not be for large numbers, but when there are larger number of midwifers, they would take care of smaller cohorts of pregnant women and hopefully make it one-on-one personalized care. But generally, when we look at what is happening currently, there is no dignity, no privacy, pubic shaving and enema have reduced over the last few years. Government is putting, the Indian government has put across many programs and some of these practices which should have been relegated into the 1920s and 1940s or which never have started in the first place are now getting, that's being stopped and even the government institutions and so on and so forth. The internal exam, women will tell us very often when they come for the second delivery to us or when they come for a wee back, they will tell us that the pain of the internal exam was more than the pain of labour and birth and what are we doing to these women? That's the, ultimately, when we look at even midwifery in larger practices, I've had students come from across the world and sometimes they will point out to me that this is the midwifery care that we learned in textbooks, but now we don't practice it anymore because of the volumes, because of, you know, shift and because of other things that come into play, induction and augmentation. In fact, all interventions, almost all interventions have no informed consent. It is, you know, you can tell somebody, you know, by starting the drip, you can have a baby in three hours without telling her ever, you know, about all the risks that, you know, induction and augmentation can, you know, cause. Food is withheld still, many hospitals will have a list of small number of things that they can take, including some water and maybe like a very light meal, but still really not allowing the woman to eat as much as she want, lying on the delivery table for hours. Stidups are becoming less, but still many places it is used. Epizotomy still very routine, even for in most hospitals for a first time mom and Epizotomy rate is between 90% to 100%. Fundal pressure cord is clamped and we call this an uphill. So a little intervention here, a little intervention there. I'm sure all of you have, have, have experienced at some point or another, or some of you have experienced at some point or another this kind of care where the baby is essentially pulled out of the mother and that the face that that is over here is sort of exemplified and how she feels about the birth. It is a trauma. There is nothing joyful about giving birth and I love this quote from Rhea Dempsey that it might seem counterintuitive that an activity experienced only by women. Women are nonetheless pushed to the bottom of the power hierarchy and are treated so appallingly, but this is the case. So can a mother labour in peace? Of course we know she can. This is a woman who is ready to push her baby out and she is in the tub squatting with her husband next to her. You can't hear anything? Any better? Okay. All right. Is birth without cutting anything possible? Of course it is. Is birth directed pushing possible? Of course it is. This is a mum who travelled from Delhi to give birth with us. She was a wee back mom and and she had had a very, very traumatic birth experience and this time she landed up almost catching her own baby. You do see my hands as the baby was born in the call at the very bottom right of the picture, but she almost caught her own baby. So yeah, I think that's the power that we have to let women experience. Can the baby get to know her mother before touching others? I'm sorry. I don't know whether this picture is looking elongated, but on my slide it looked okay when I did the presentation on my computer. So excuse that slide. And this couple actually had a normal delivery at another hospital for the first birth, but she wanted a more untouched, a more gentle birth and chose our care and they caught their baby in their water birth with four hands. And yes, there is such a lot of oxytocin in that picture, right? Oxytocin and love. That's the circle of love. Can the baby be born gently? Yes, of course. Can the placenta be honoured as the baby's nourishing G? G means life. So can that placenta be honoured? Can it be honoured? Yes, of course. This is that moment of pause that we talk about, right? Where we don't touch, we don't prod. We let that woman experience that minute of birth in whatever emotion she wants. The mum here is experiencing it really quietly. The mum here is elated, but let that woman have that moment of pause and none of us talk or move or do things to disturb that moment and then unless there is an emergency, of course. So what is an autonomous midwife? I don't want to belabor this because most of you over here do understand this and it is, she is the clinical care provider who is the expert at normal birth. It's what she would do, what a hospital would do in a typical hospital setting and she provides the antenatal checkups counseling, one-on-one labour support and everything to help the mother baby and she is also able to recognise complex needs and complications and refer to the OBGYN on the team when it is needed. So there is absolutely the WHO recommends midwife-led continuity of model of care. It supports a woman throughout her antenatal period, intra-partum and post-partum period and supports healthy parenting choices. So what do women want? They want a supportive caring relationship with a midwife or a small number of midwives. They don't want to be hurried. They want to have a woman-centric approach and this approach actually improves their confidence and we will talk about the numbers and our statistics, but it actually improves their confidence in their own bodies to give birth. There are no strangers in the room and there is less fear and these are all the, for the continuous labour support, which a midwife offers, which doulas offer as well and there is so many findings that we should not be ever looking at birth without that continuous labour support. So where we did come in was in 2005 and 2006 I was teaching Lamar's classes and what we would find is while the couples initially, well it was actually a pretty unknown quantity at that time because whenever we talked about classes people thought that it would be some kind of exercise program or they would come in with a question mark as to what we were going to teach. We would start teaching individual couples one at a time like one on one and then sort of talk to them about what, that they did have a choice about the way they gave birth and they were like, what choice? What do you mean choice? And anyway, as we went through that process when we started getting our first bigger classes like four people, five people, six couples in the, in the class, 90% of them landed up with a cesarean section because the last mile failed them. They would do all the things and they would talk to the doctors but when they would go in they would find that they were back in the same maternity environment which then did not respect their choices. Nor did they even know, I don't think the medical care provider even sort of acknowledged what these people were talking about. So, where, so what we thought what would happen if we could create a new model of care, where the woman would be at the center of the care universe, access all the benefits of the midwife led continuity of care and continuous labor support and still have access to the safety net of access to the emergency medical interventions and cesarean section and not only that, this is there all over the world but what would happen if it were in the same premises? And that's where in 2008 we actually decided to change the status quo and my backup of Cetrician, Dr Jain Tiradi, she has had an immense contribution to this entire, you know, birth center model in the country which is unique in the country but also only a few across the world where it is an autonomous midwife led independent model of care but has the emergency backup infrastructure services in house. She has been a tremendous champion of that and so we created this model. We would talk hours on end as to how it would work. We would say, you know, what would be the protocols? When would we look at transferring and because this was an unknown quantity we decided that we would rent one room within her hospital and we would start working on the protocols and start working on, you know, what we knew would work best with the midwife led model of care but then also look at what would be the circumstances under which we would transfer but the beauty of this was that this was already a maternity, maternity hospital where they had all the infrastructure that was available for both the cesarean section as well as all the stuff that was there. So that's where we started out one room and then it became two rooms and our office initially was so small that if one person walked in one person would have to walk out and then we were two people we would still do all the payments in cash which is really funny because now when we look at it we don't be in this current COVID situation nobody handles cash and we sanitize the credit card and use gloves to handle you know anything so it's it's really kind of funny where we have come and how far we have come from but that allowed us to perfect the model over eight years that we were inside of the hospital and many people would wonder how does one maternity care hospital exist in another maternity care hospital but it became a very energetic relationship and what landed up happening as a result of that initially the doctors they would not understand who we were because remember in this country there is only the the A&M who is basically an oxalurin nurse midwife or she's called a multi-purpose health worker and she has perhaps about six weeks of obstetric nursing as a training and or the graduate nurse midwife who has the you know the the about six months of obstetrical nursing of course then there is the BSE nursing and all of those things but generally the the people who are working under the obstetricians in the obstetric led model of care they did not understand what autonomous midwifery was and so for them it was like some high-priced hand-holding service and to educate them and to say that we are not bringing in trainwrecks to see you when we refer people and we understand where the risk here you know the where the higher risk women are and we will refer to you in time and so that really actually thank you Linda so I will I will speed up my presentation so that actually led to a lot of you know a work and then in 2006 we landed up moving into our own independent birth center which has the collaborative model of care led by independent midwives supported by in-house OBGYNs and medical specialists have on on on board with us on an ass need basis positions and as that is we have pediatricians to complete that continuity of care and provide the same gentle care and gynaecologist who provide infertility and other gynaec related things so we are basically created an entire co-existing system within our system and emergency infrastructure which basically means a an operating theater a level one and I see you and because in the country we don't have a birth center as a as a recognized entity what we have and basically we also wanted people to access insurance we have what we have is a is classified as a level three hospital and therefore it takes care of all the regulatory and licensure requirements as well so this is our birth center I'll just go through a few photographs and it's a labor of love and we have created it to look like a home as much as possible simple every room has a water tub and we use waters water very regularly almost 90% of all our women use water for a quadradural for pain relief and quite a number 30 to 40% any given year have water but sanctum is the garbagriha which is the home of the womb and that's where the diet he resides in a temple women are goddesses and the womb the holy place where the birth happens so what have been our results this has been our cesarean sections have been at 10% since inception currently they are at 7.2% the 10% from inception has been because like I said for the first two to three years it took time to perfect the model of care where people where the obstetricians it we cannot be like a bull in a china shop saying this is the only way we know and this is you know we we would like for x y z to happen and it took some amount of you know back and forth before we could perfect the model of care where they will be comfortable attending the birds which were even a higher risk so that's where the that's where we started off at and the hospital where we started had an 83% cesarean rate when we started slowly they started saying if healthy mother sanctum can do it so can we and currently they are at a 53% cesarean rate which is still pretty high but I think we have impacted the community as well so by the numbers this is uh we have medical inductions because we also take the higher risk women it is not just the low risk women we have gestational diabetics we have high blood pressure we have breach births we have which have happened twin birth so and so because of that we have had medical inductions but we also use a lot of natural induction methods whenever appropriate and available so our medical inductions are under 5% epidurals are 0.8 that is eight out of 1500 births vacuum deliveries at 0.5% five out of 1500 births four sub deliveries at 0.2% two out of 1500 births and epizioctomy rates at 6%. I want run through everything because I know I have a limited time our premature births are less than 1% readmission rates are almost zero and we have breastfeeding rates of 100% at six weeks and this chart this past year there have been a couple of women who have struggled and especially when they have transferred to a tertiary care and ICU so I think currently if I do the rate for today it might be more like at a 98% but still pretty good rates I would think. A VBAC success rates I think these we are very very very honored to and that we are privileged to support VBAC any given month because of the high number of primary caesarian rates one third of our case load happens to become VBAC and we have we have an overall 90% VBAC success rate and some years we have had a 96% VBAC success rate and VBAC A to C we have a 98% VBAC A to C success rate that tells us something that women know how to give birth babies know how to be born and we have to be there to support them this is again I'll go through this at any of you who want to look at this presentation can do so later but we have had you know many many births where we have had you know preterm births 1.57 was our smallest baby that was born our biggest baby was 4.31 in this in 2018 in 2019 we had a 4.6 kg baby born to a four feet six inch woman so he has birth works and like this this slide again goes through a quite a bit of you know like detail but basically we have all the women who have had natural birth with complex needs women with previous loss women with IVF and assisted reproduction but essentially they are told oh this is a precious pregnancy plan your baby at 37 weeks have a C section IVF assisted reproduction women have also given birth and many of them at 42 weeks complete twins we have had nine sets of twins who have been born with since inception of course a lot of the twin mums don't even touch as they go to the routine hospital but we have had nine set of twins who have been born naturally only two sets of twins since inception have actually had a CZN section for both of them for high blood pressure P I H with twins breach we have had nine a breach babies born and the the one of the mums had both of a breach babies with me and this is really funny I kind of love to tell the story a first baby was born breach at 35 weeks and her second baby was born breach at 43 weeks complete and that gave me some gray hairs just digital diabetes just digital hypertension high BMI low BMI we have had women 37 kgs give birth and we have had women with 127 kgs give birth naturally pesky Edd 41 weeks complete 100 42 weeks complete 98 43 weeks complete 100 percent so yes women again women know how to give birth so what are what are the other interesting facts to note the couples attend the mask classes we essentially make that one of the absolute essentialities for giving birth with us though we really don't want to force people I feel very strongly that unless there is education unless there is opening out of the minds unless the fear gets reduced there is no point in us standing up on a podium and saying natural birth is great the women and their partners have to believe so once they attend the mask classes a lot of them will actually say wow that was the game changer now we have become players in our own births and I think that's so lovely to hear couples who have felt that continuity of care helped of course 100 percent what are the secret behind the numbers relentless focus on continuity of care and every antenatal checkup the first checkup lasts for an hour hour and a half where we touch upon every aspect of the pregnancy you know and then every checkup lasts 30 minutes informed consent 24 seven labor support partner and family are fully involved in every aspect of birth just yesterday we had a wee back mom who because of the COVID situation her partner is quarantined in the Middle East and she is here and we did Skype the partner in at birth and it was amazing to see his tears flow she was fine but his tears were flowing so yes I think it's it's amazing it's absolutely essential to involve laser focus on diet and exercise throughout pregnancy we have a well wellness wing as well which is called a well mom and where we work on prenatal yoga starting right from the first trimester go on with the mask classes go on with prenatal aerobics which I have designed I in my past life I was also a physiotherapist and that helps quite a lot for me to work with the fitness aspect of it and so we have designed our prenatal aerobics program which people enjoy a lot and it's amazing to see women doing jumping jacks and military crawls and after 36 and 37 weeks lemas healthy birth practices again I'll forward that education like you give back we said the lemas classes there's all our prenatal yoga aerobics and this mom on the right she is a yogini herself and this was taken just few days before she gave birth and look at her that's a strong confident woman who is ready to embrace birth and I cannot tell how beautiful and how overwhelmingly you know soul satisfying it is to see this women transform into this kind of you know embracing the pregnancy and their childbirth experience so what do women want they don't want consultations they want good counseling there they don't they don't want to be told this is your only plan they want permission before touching or performing procedures and I think we have had gynaecologist give birth themselves we have had emergency care physicians give birth with us even my my back my partner doctor gently's own daughter-in-law gave birth with us and one of the things that I remember the gynaec when she was in labor and I asked her permission before touching and doing an internal exam she said to me oh this is how an internal should be done and yes I think that's where she she understands what that feeling is in her own body where she is now going to go back into the community and she said it has absolutely changed the way she sees women and you know how she treats women in you know who are under her care right now no fear in the birth room calm and quiet environment let the mother lead and I think that's so important let the mother lead respect her wishes support her emotionally and avoid invasive practices and that leads to a memorable and happy birth outcome what would a mother want this or this women want natural birth and a good birthing experience like Sudan says it's not either or it is that and this natural birth and a good birthing experience at the moment there are only two autonomous midwife led birth centers in India the numbers are huge cesarean sections are three times higher and this not only is escalating the cost and I think for people the you know the money actually does talk and I think everyone of us who is who is involved in the process to bring change has to say that cesareans escalate the cost not only the cost but also the burden of the care that is provided to them and of course you know we all we know that there are 33 other outcomes that are poorer when there are cesarean sections respectful maternity care with good informed consent and of course in India we have both the two little too late where there is still maternal and infant mortality because of that and too much too soon where like we said in the urban hospitals that we see there is way too much intervention and cesarean sections so what has birth happened and how has birth happened in corona times I cannot end this presentation without talking about this a little bit India has been on a complete lockdown we are still in lockdown in our state until the 17 this is the third time the lockdown has been extended everything that midwifery has always known is now having to be embraced by the obstetric community no multiple early scans you know e teleconferencing women are not being put on prejudice on or at least less of them are being put on it less tests less scans less doctors visits but now because the community has only known of pregnancy as a risk and get a pianistic visit the doctor there is a lot of confusion and anxiety about these multiple consultations and scans and I think slowly hopefully this model of care will be embraced you know as we go along that it's okay to not have too many interventions especially early on some hospitals unless a woman is a multiple and I know we have heard from colleagues we've heard from different care providers that because of unknown fear of corona in some hospitals unless a woman is a multiple and at five to six centimeters everyone is getting a c-section even if they show up in labor which is to me unconscionable labor support which already was non-existent in many hospitals has been further disallowed c-section rates are dramatically further increasing at the sanctum we have been using what we have been doing so far to to sort of work in the same model of care that we have worked below we have been using our ambulance to drop up and pick up essential staff as public transport is completely closed and most of the nurses and the other housekeeping staff and even the admin staff depend on the public transport and so we have been using our ambulance which has not never been or very less been used for other things now to pick up our staff and we have instituted 48 hour on call chips for our midwife 24 hours for nurses so that we can reduce footfalls in the community and because we have the collaborative model of care and in-house OT and ICU and this is a typo over here our cesarean rates actually since the beginning of the lockdown has is at 4.2% including mothers with high risk so i think it's possible we have had actually one cesarean section over the last two and a half months our continuity of care has enabled good follow-up from the antenatal to the postpartum period so as frontline caregivers midwives can provide care with empathy and like Sheena Byrom says kindness costs nothing empathy costs nothing and love comes back to you 100% and i really really believe in that midwifery model of care is woman-centric and it can allow for an empowered birth and the solution i think wherever you are across the world with good independent midwives can be an autonomous midwife led care establishing partnerships with the OBG violence and other you know medical care providers in the community and implementing a collaborative model of care and look at that picture that says it all mother and father looking at each other baby nursing peacefully and that's what we want to all of us want to see isn't it and with that i'll end my presentation and thank you for listening patiently and thank you for all that you do for mothers and babies every day and i'll leave this as the last slide so that if you want to know where we are at you on the media and the digital platforms you can definitely look us up thank you very much for listening patiently many many thanks for jaya that's a fabulous presentation and i let it run on because i think you are answering the questions that people were asking so we really don't have much time for questions does anybody have an urgent question otherwise i suggest that you contact the jaya through her website or facebook page or on instagram any urgent questions i've got a quick one if you can answer it answer it um well it's not really a quick one um in in india do women have the right to say no legally i think they have a right to say no of course they have a right to say no but uh but i think the more important question to be um you know asked about is do they know that they have a right to say no absolutely that's that's really the question because i think when especially when women are always being in a dependent state where they have been you know their partner may have been chosen for them when they then there is a certain cultural norm about women being more you know like a part of the family and the baby uh you know is a is like the is being made for the family so to speak i think it becomes really hard there is also this whole thing about you know there is not enough sexual education reproductive education there are many women who get married and have maybe like have had one um you know um it maybe have had sex once with their partner and have got conceived and then there is all this conception and then she is uh you know told that you can't have sex in the pregnancy all through the pregnancy and then eventually culturally she goes off to her mother's place the husband is at his mom's place or by himself and you know in all this there is no coming into her own you know how does she feel about herself how does she feel about her pregnancy how does she feel about um you know bringing a child into this world is that an is that an option that is given to her or is she expected to celebrate because making a baby is the social thing to do I think it is just there are so many layers to this that I don't think I have an answer but yes they have the right to say no but I don't know how they exercise that right thank you very much I think we'll need to stop it at that point it's just I agree with you that um it's whether or not they know that I mean that applies here in the UK as well even now we know that people don't understand that they have the right to say no but I don't think in all cultures legally they have that right which is the reason I was asking and I knew it wasn't a very easy question to answer but there you go okay so thank you very much indeed Jaya and well I hope that we can work together some more because your message is relevant to everybody in the world not just in India and the resource poor countries um but also many of our developed countries could well well listen to what you have to say as well and all student midwives should listen to this it will