 If you want to start talking to your slides, introduce yourself, Linda, and then start talking to your slides. Thank you. I will start. Good afternoon. My name is Linda Pano, and I am the President in charge of the Obstetrics and Gynecology Award at the Eastern Highlands Provincial Hospital. I am also the President of the Eastern Highlands sub-grants of the Papua New Guinea Nibbifree Society. I would like to give you an idea of what midwives are doing in the province and the activities of the Nibbifree Society here. We are in Goroka, the capital of Eastern Highlands province, in the highlands of Papua New Guinea. The population of the province is approximately 600,000, including approximately 130,600 women of childbearing age who are having about 16,600 babies each year. The new planning coverage is 26 percent, and the fertility rate is 4.4 children per woman. 733 women die of maternity-related causes, say 100,000 life-threats in Papua New Guinea. There are many reasons for this, including geographical barriers. Women may walk three days to reach a health facility. Illiteracy. Many women have not completed grade one. So are unwilling to show ignorance and so fail to attend clinics. Some facilities are run down and sought of drugs. There is a men's power shortage within the health facilities, and some staff demonstrate negative attitudes towards patients taking care. There are high poverty rates and high fertility rates. Domestic violence where husbands do not permit women to attend clinics. This is usually to women having their babies in their village. The rate of birth unsupervised by skilled birth attendants is approximately 65 percent in Eastern Highlands province. This may cause the eight districts of the Eastern Highlands province. Each district has a health center except Goroka, which has a provincial hospital and Penantu, which has a rural hospital. In each district, there are a number of health sub-centers. The major road is the Highlands Highway, running roughly east-west. Most other roads are unpaved and often difficult to navigate due to heavy rainfall and landslides. Those sub-health centers in the southeast of the province are only accessible by air. All sub-health centers and health centers manage pregnant, betting, and post-natal women and their babies. Midwives are only working in the Eastern Highlands Provincial Hospital. Each of the districts has centers and some of the sub-health centers. Therefore, a large proportion of women who do attend health facilities for pregnancy and childbearing, health or child-bearing, breasting care, are managed by nursing offices and community health workers with limited skills and military. The maternity department at the provincial hospital consists of labor wards, obstetrics and gynaecology wards, and special care missiles. The labor ward has seven beds, and in 2013, 4,374 beds were recorded, an average of 12 per day. 240 sick-bearer infections were performed, 5.5% of the hospital beds. It is talked by 10 midwives and 3 community health workers. Some examples of the types of patients include little death in neutral, 101 recorded in 2013, rich, 82, severe pre-eclampsia 31, acclampsia 1, HIV properties, 75, vitran rapture 4, postpartum hemorrhage, 367, maternal death 8. The obstetrics and gynaecology ward had 21 deaths. About 7,000 women were admitted in 2000. About 20 every day. These included postnatal women, the ward is talked by 8 midwives and 4 community health workers. The special care nursery can manage up to 27 babies at one time and had 1,016 admissions in 2013. The nursery is talked by 2 midwives, 6 nurses and 5 community health workers. Some are antenatal clinics which is within the grounds of the hospital managed 3,970 new antenatal women in 2013. Over 300 a month. Intimatal consultations for new women, reattended, are conducted on 4 days and Fridays are utilized for sexually transmitted infections. It is not unusual to have over 50 women per day at the clinic. The clinic is talked by 3 midwives, 3 registered nurses and 3 community health workers. Luffa district is one of the 8 districts in the province. The health center there is talked by 3 midwives and it is fortunate enough to have a maternity waiting house. Women from remote areas can come there at the end of their pregnancy and wait for labor close to the health center. One of the top health centers in Luffa district is Lupuru. Also has a midwife, but this is unequal. So you can see that the midwives of the province have an extremely challenging job, caring for women and their babies. Rokessapet Proudy is an Australian midwife who was working in Papua New Guinea in 2010, investigating the quality and quantity of midwives in the country. We visited Goroka and we local midwives were inspired to develop a sub grant of the Papua New Guinea Midwife Society. In 2011 to 2012, we identified all the midwives in the province. In 2012, Tonya Korovi and myself decided to learn about midwifery societies. In August 2012, we gained approval from the National Office of the Midwifery Society to set up a sub grant in Eastern Highlands province. The sub grant of our aging age is to reduce the maternal mortality ratio in the Eastern Highlands province. We want to be a strong voice and advocate for midwives and midwifery in the province. Increased numbers of quality of midwives and ensure all women have access to midwifery. This year we have 102 members of which 88 are midwives. The others are affiliated members. 47 at the Provincial Hospital, 6 at the University of Goroka, 9 within church health services, 3 at the Papua New Guinea Institute of Medical Research, 22 in the district government health centers and sub health centers, 6 at the Highlands Regional College of Nursing, 6 working for non-government organizations and 3 in other settings. So far the sub grants has managed to produce a constitution which 88 midwives in all districts of the province. The society has encouraged and supported the staffing of labor ward and obstetrics and tenagogical exclusively by midwives. Previously, general nurses were working in this area with fewer members of midwives. The society has formed close linkages with the Bachelor of Midwifery programs and students from the University of Goroka. We have formed a strong relationship with Australian College of Medicine. In 2013, we arranged the local telephone service provider, Telecom, to connect the internet to the hospital mess and gather the members of the midwifery society to participate in the online conference. The society has encouraged 70% of midwives in the province to attend emergency obstetrics care training and encourages midwives to perform research in their own clinical settings. The future is exciting. The society will elect a new executive in 2014 and in-service training program will be developed at a provincial hospital. The society will assist with essential obstetrics care training for midwives and other rural health staff here planning a provincial midwifery conference. The society will also collaborate with the Open Union Nursing Council to expedite the registration of graduated midwives with a Bachelor of Midwifery program for ways to improve quality of care within the clinical area. The Eastern Highlands sub-brands of the Papua New Guinea Midwifery Society will continue to investigate ways to motivate all midwives to provide best practice care to our women. I would like to thank the Visual International Day of Midwives for the opportunity to share our experiences and vision with other midwives around the world. Thank you. Thank you so much, Linda. That was great. Lovely and clear and well-paced. A lot of information in there. So I just wondered if you wanted to share what the picture was at the bottom right-hand corner, which I thought was so interesting the other day. These women are dressed in their traditional costumes? Yes, yes. Sing Sing Group. In Papua New Guinea, we call it a Sing Sing Group. And a Sing Sing Group. Yes. They are dressed in their traditional costumes. You look beautiful. Okay, thank you. There will be probably questions at the end. So if we can now ask Waneth if she is ready to present and her presentation should come on behind this. Are you right to go, Waneth? Yes. Yes, Lynn. Lovely. You can start now. Good afternoon. My name is Waneth Koran and I am a midwife at the Eastern Islands Provincial Hospital in Goroka, Papua New Guinea. I trained as a nurse graduated in 1993 and trained as a midwife in 2007. Since that time, I have worked in the labor ward of the hospital. The Eastern Islands Provincial Hospital is located in Goroka, the provincial capital and is the only speciality facility in the province. It takes research from the one rural hospital to urban clinics in Goroka. It sells centers and 26 curfew centers in the province. Curfew centers may return initially to a health center or a rural hospital at Kainanti, but some research directly to the Eastern Islands Provincial Hospital. During my years working at the hospital, I noticed a large number of referrals arriving and the burden of this extra workload on the staff and resources of the hospital. I decided to conduct this research to explore the issue. The study aims included assessing the appropriateness of the condition of the woman being reset, recording the referral outcome and the level of healthcare present at the delivery, recording the cost involved in transporting the woman to the hospital and who met the cost, highlighting the issues in the provincial health system with limited resources, manpower and logistics, identifying strengths and weaknesses in the system for future planning. I performed the study as part of a research training program for health workers at the hospital with support from the Papua Museum Institute of Medical Research. I sought approval from the hospital administration and the Provincial Health Authority concerns what are seen from each woman. Others who had been reset to the hospital labor ward were assessed on arrival and monitoring delivery. I collected information from the referral letter, the labor ward register, and by interviewing the mother. I collected that information about 96 obstetric referrals from 22 health facilities between October 2012 and May 2013. This number did not include every referral to the hospital. Only those I was personally aware of were able to interview. The mother's age ranks from 16 to 40 years. Seven were less than 18 years old, 79 were between 18 and 35 years, and 10 were older than 35 years. In fact, many women, particularly in rural and remote areas, do not know their age. Many may have been born at home with no record kept for their birth, or their parents may have been illiterate. Recorded ages could be assessed by the patients or health staff. The largest proportion of referral mothers were pregnant. There are a wide range of reasons for reserving women. In 18 cases, there were more than one reason for reserving. All are included in the table. Some were reset as a precaution due to high risk factors, such as multiple pregnancy, post-pregnancy, malpractice patients, and such a nature of the women. This woman may or may not have been in labor. Others were reset when complications had occurred, such as anti-pattern hemorrhage, physical distress, and arm problems. Major reasons for referral was for prolonged and obstructed labor. Many diagnosed by reserving health workers as CPD, or PayPal, or Calvic, is proportioned. These slides show less common reasons but include one logistical problem. No light. Solar out of order. There is no electricity supply outside the larger towns in the province, so most health facilities rely on solar lights at night. Uncooperative mother is a common diagnosis of an illness and often indicates a lack of knowledge, both in the woman and the health care health worker caring for her. Three-quarter of the referrals ended up with the general delivery, either normal general delivery or vacuum extraction. One quarter were delivered by caesarean section. Doctors mainly managed those mothers requiring caesarean section. There were 22 and three of the vacuum extractions. Health extension officers are highly level health workers who receive four years training and work in hospitals and health centers at a higher level than nurses and midwives. They managed two of the normal the general delivery. Midwives in Papua New Guinea have a broad range of students and their role extends to performing vacuum extraction. Midwives perform 10 of the 13 vacuum extractions and 49 of the 59 normal general deliveries. Two sets of the referral cases delivery when booked or managed by midwives or staff supervised by the midwives such as midwifery and nursing students and community health workers. 28 of the 96 referrals came from Kainan to Role Hospital. Although there is at least one doctor working in this facility it does not have the capacity to perform an experiment. 43 referrals from several centers bypassing health centers may approach to and arrive directly to the provincial hospital. This may have been because the health center was closed, particularly at night or because of the agency of the referral. These three health centers may be staffed by health extension officers midwives, nurses and community health workers. Several centers are usually staffed by nurses and community health workers. These health workers do not have the skills necessary to manage women with complicated pregnancy and labor. The maturity of women is said to travel to the hospital by ambulance. Some arrange their own transport by public bus or private vehicles. One came by hair. Some of the most distant health centers have no road access to the provincial hospital by plane. Although the majority of others were transported by ambulance, only one quarter did so at no cost. Half of the research spaces have to pay more than 50 kena a equivalent of 20 Australian dollars, 18 US dollars or 13 euros. This cost was paid by either the woman herself or one of her relatives. There are few midwives in the risk of health centers. Most staffed by nurses and community health workers whose knowledge and skills are inadequate to manage death in humans. An example of the lack of adequate use and knowledge is demonstrated by the 18 mothers reserved for obstetric, obstructed labor and kefal or pelvic dyspropositions. 14 of these mothers delivered the generally and only two thirds of all the reserved cases were managed by midwives in the hospital. The actual problem is the lack of skills and knowledge in addressing and managing women and labor. The fact that two thirds of all the reserved cases were managed by midwives in the hospital supports the government's aim to place a midwife in every health center and sub-health center by 2020. Replacing midwives in the hospital would be decreased substantially. Although most reserved are transported by ambulance from health center facilities most of them still have to change. Sometimes a significant amount of death transport is supposed to be free and most people in rural areas are subsistence farmers and do not have much status. This may impact on people using health services and needs further investigation. Health services do not have a budget to transport patients so some of that money may be being used for other purposes. Interest structure in Papua New Guinea is likely. The lack of solar power for life is one health center highlights the need for a reliable source of power in health facilities. Whether it is central supply generator or an alternate form such as solar. There is a general lack of maintenance of health facilities in the province. This is a system of referral there is a system of referral within the province and women have been transported to hospitals but there is an agent's need to improve decisions. Difficulties include the health center staff, lack of knowledge and skills about caring for women and women in difficult terrain and lack of good roads. More research required in this area and there are already more studies being undertaken in the province. I would like to thank you all for the opportunity to present my research today. Thank you Wanis that was wonderful and amazingly how clearly we heard you considering the internet issues you have been having and how difficult some of our practice sessions today. I would also like to thank who has been working in the background to help Linda and Wanis come to this session and to present today. Thank you very much and let's see if there are some questions for you. You have a lot of really good comments down the side. You might like to read through some of those. The effort you have made to come and talk on the VIDM and also the strides you have made in improving things for women in Papua New Guinea. You can feel really good about that. Do we have any questions? Some of them have been answered as we have gone through the session. Are there any other questions that someone must have one that you want to ask in people typing? You used an amazing number of vaginal words, wasn't it incredible with such a small staff? While we are just waiting we talked the other day about the women who came and who waited to go into labour at the health centre and I wondered how long would they come for? Do they come for a day or two at the first inkling that they are in labour? Towards the end of pregnancy they come and wait. They come and wait maybe a week for their delivery. So you would have a lot of women actually waiting around and about the health centre at that time? Yes. Not so much at the hospital but at the health centre. Yes. You know, in the places round about. Uh-huh. So how far would some of these women come to birth at the health facilities that you know of? How far would they have to come? It takes two to three days to walk to the health centre. So they wait around for their labour. It's quite a challenge, isn't it? You would want to get there early, wouldn't you? And one of these... Yeah. Sarah has asked, do they receive postnatal care when they return home? You surely know. At the health centre probably overnight and they are gone. Right. So then they walk back with their new baby? Yes, they do. They walk back with their new baby. And I was noticing too that you had high numbers of problems from PPH as well. And we just heard from the midwives from India and they were saying that one of the main problems that caused women to bleed and to be so at risk in delivery was the rate of anemia. Is that the same for Papa when you're getting? Yes. We have the same problem here too. There was a question raised on volunteers. We don't have volunteers here with us. So if anyone is interested to come as a volunteer, you can write to them, the hospitals, to the Eastern Highlands Voluntial Health Authority. So did I hear you write that you do or you don't take volunteer midwives? They can write to the Eastern Highlands Voluntial Health Authority if they want to come to volunteers. And volunteers are allowed to accept volunteers. Right. So they may well get an opportunity to share some of your some of the issues that you're facing over the year. Yes. We do that volunteer. So Essie, are there any other questions for Linda or Juanus? I'm just scrolling through to see if I've missed any. You must have satisfied all the questions and answered them. Okay. So I'd like to thank you so much. I think you've done a wonderful job of presenting and it's just wonderful to hear from Papa and Yagini. We know what some of the struggles are there for yourselves and for the women and it's wonderful to hear what you're doing in there and to be able to do some research as well that will help out with hopefully addressing some of those major challenges in your country and how beautiful it is and how beautiful people are. So thank you very much. If there's no further questions, I'll just close. I'll shut the recording down. Hello, Jean. Yes, hello. Linda here. I saw a question on the Australian Government or the DIPAD. The Australian Government DIPAD has, for the last few years now, they have sponsored mid-free training here in the country. That is why now we have plenty, we are coming up with plenty midwives now in the province. I appreciate and we thank the Australian Government for the scholarship they have they are offering to Papua New Guinea for the scholarship for mid-free training in our university. That's wonderful. Thank you. I'm sorry I didn't capture that because I picked off the recording but that's good to know. Thank you. I'll just hand. Thank you. It's lovely to hear you and it's good to have gotten you on line without too many interruptions.