 So now it's my pleasure to introduce Ruth King. Ruth is a mother, a midwife, and a midwifery advisor for the Australian College of Midwives, the professional body who have midwives at the heart of everything they do. Ruth gets to bring her passion for her profession to her love of education and policy development. In her seven years in this role, she has seen a number of fabulous changes, including midwives being recognized as a distinct profession. In this COVID-19 pandemic, she can see the true nature and professionalism of the midwifery workforce being realized. Despite rising challenges, midwives have stayed true to their practice and continue to have women at the heart of their care. Women will continue to have babies and they all deserve to have access to a known midwife. Ruth has been engaged with the Papua New Guinea Buddy Leadership Program since its beginning and has seen the progress from idea to reality as midwives from Australian and Papua New Guinea connect and grow together. I'm going to turn slides over to you, Ruth. Thanks, Asiria. And there you go. Brilliant, thank you. First off, thank you for having me to present in this 2020 Virtual International Day for Midwife Conference and thank you to everyone who has come along to hear about this fabulous program. I feel really honoured to be representing my colleagues and presenting to you about the P&G Buddy Program. As per the abstract that I submitted, I want to share with you a story of development and achievement through successful partnerships between professional organisations and the midwifery members. But before I begin, I would like to acknowledge and pay respect to the traditional custodians of the Australian nation, particularly of the Ghana people on whose lands I'm presenting from. I acknowledge the continuation of cultural, spiritual and educational practices of Aboriginal and Torres Strait Islander peoples, their continuing role in maternity services and birthing and in the Australian College of Midwives. And I pay respect to their elders past, present and emerging. And I note from the responses that we got to that survey that there's lots of people from Australia. So I acknowledge all of the traditional custodians who you'll learn as well. Okay, so before we begin on the story that I'm here to present about, we must look backwards a little as it is from these beginnings that the seeds of the story were harvested. Inter-country twinning has been used as a means of collaboration and networking to address a lack of clinical capacity in countries. Twinning can also be an intervention to address the social barrier of isolation for professionals working in low resource settings. The intention of twinning is usually to build relationships based on equality with shared power and responsibility to plan, conduct and assess a common project between organisations. In 2011, the International Confederation of Midwives established a global twinning program because they understood that two were stronger than one and that by working together, countries could achieve greater outcomes and mutually strengthen their respective midwives societies. Before the ICM twinning program was established, the ACM were already working with the midwives in Papua New Guinea to re-establish their professional society. Where the midwifery, where the P&T midwifery society had initially been established in 1988, similar timing to the Australian College of Midwives, for many reasons, midwives engagement in the organisation had declined and the subsequent leadership midwives were looking for had waned. In Australia, the ACM had continued to grow in membership and had a number of very active and passionate leaders who were leading the midwifery discussions. In 2010, with assistance from the Australian College of Midwives, the P&G Midwifery Society was reborn. They joined ICM in 2011 and established a formal twinning partnership with ACM. Midwife numbers at that time were estimated at around 100 for the entire country. From 2011 to 2015, a National Maternal and Child Health Initiative was funded by the Australian Aid and brought on the ground support from a team of Australian and New Zealand midwives to be based in Papua New Guinea. In late 2015, an expatriate midwife was employed through the Maternal Child and Health Initiative to specifically provide mentoring and support at the Port Moorsbury General Hospital where the Midwifery Society and P&G had the head office. In November of that year, P&G Midwifery Society held their first National Midwifery symposium in Port Moorsbury. This was a milestone achievement as over 240 of the potential 800 midwives registered attended. And I wonder if you've noticed in that time the rise in their midwifery membership and midwifery registration from 100 to around 800. This period of growth for the profession also saw developments and improvement for the society. However, in December, funding ceased and all the expatriate midwives who had lived there and provided much of the needed mentoring were required to leave P&G. Since that time, ACM and P&G Midwifery Society have continued to work together on leadership programs, creating connections and friendships and developing opportunities to grow and learn together and from each other. In 2016, the Papua New Guinea Midwifery Society realised that they needed to improve outcomes for mothers and babies and believed that this was best achieved by the strengthening of sustainable midwifery leadership and advocacy skills within their membership. They had a kindred spirit in Judy Brown, former midwife and current Rotarian of the Morialta District. Judy had an inspiring midwifery history here in Australia and around the world, including in the ITM. And she was able to see not only the value but also the importance of the opportunity for her Rotarian community. Rotary have a long history of undertaking humanitarian projects and this aligned perfectly to their goals for improving healthy health outcomes for women. Through her Rotary and Midwifery work, Judy had an existing connection with midwives in P&G and could see the challenges they were experiencing in maintaining the traditional twinning engagements. As noted previously, some of the previous partnering had it created a model where the development was dependent on in-country support of midwives from Australia and New Zealand. When funding was cut and the midwives left, the support was disrupted. Added to this were the existing communication challenges related to often unreliable, inaccessible and in most cases, expensive telephone and internet services. In addition, there were cultural challenges related to the style of communication asked of the P&G midwives who typically used oral and hands-on techniques as opposed to the written format that is required for emails and documents. Judy's lifelong connection with the Australian College of Midwives and understanding of our existing relationship with P&G meant that it was a logical connection for her to reach out to ACM to be a partner in this project. Judy wanted it to be more than just a twinning project sure that there was an opportunity to build on the existing twinning partnership structure but to take the focus from the midwifery professional organisations and turn it to the midwives with the intention of building a buddy partnership that would support the P&G midwives to develop enduring leadership skills. Fundamental to her idea was the concept that midwifery leadership is vital in addressing the sustainable development goal targets for maternal health. For example, goal three, reducing global maternal mortality rate. To have a clearer understanding of why this relationship was so essential, it is important to understand a little more about maternal health care and midwifery in P&G. It is well known that women and babies die in large numbers in Papua New Guinea. Papua New Guinea has the world's highest maternal mortality rate, one of the world's highest maternal mortality rates and is the highest rate in the Western Pacific region with most attributed to causes that are typically thought of as preventable in Australia. Much of this may be reflective of the lack of skilled birth attendance in Papua New Guinea as Papua New Guinea continues to experience significant work for shortages specifically within the maternity sector. In short, there are not enough midwives for women. To give you some greater clarity of the challenges faced by the midwives, more than 80% of the people in Papua New Guinea live in rural and remote isolated and hard to reach places. There are an estimated 250 births in Papua New Guinea per year, or approximately 642 per day, and most of them are in the rural areas. The Papua New Guinea government has a policy of having a midwife in each child centre by 2020, and there are definite efforts being made to achieve this, but the numbers are still low and the challenge is to retain the midwife in their role after they have been trained. For example, in the past four years, more than 300 midwives have been educated in the four midwifery schools, accounting for about half the current midwifery workforce in the whole country, taking the estimated number of midwives to 1,000. 60% of these midwives are members of the Papua New Guinea Midwifery Society. Despite the increase in midwifery numbers, the rate of skilled attendance at birth is still less than 50%, which means there are about 110,000 unsupervised births annually, where there is no midwife or other health professional present. The increased numbers and focus on maternal health has seen the maternal mortality rate decreasing in recent years, from over 470 per 100,000 in the early 90s to around 145 per 100,000 today. However, there are still challenges as the sustainable development goal is to reduce the maternal mortality rate to fewer than 70, with no country greater than 140. And they are still a far crowd from the Australian rate of 6.8 per 100,000. P&G may have a way to go, but they are definitely heading in the right direction. Rotary Papua New Guinea Midwifery Society and the Australian College of Midwives all agree that strong midwives and strengthen midwifery equates to strong mothers and strong babies. We know that midwives are the most appropriate caregivers for childbearing women. We know that access to midwifery care saves the lives of mothers and their babies. We also know that midwives need to be educated, regulated and professionally supported and that they benefit through a connection with their professional associations. And to inspire the next generation and support the existing midwives, they need their own leaders to connect with and aspire to. One of the big challenges midwives and Papua New Guinea faced was their lack of ongoing professional support and access to continuing education. These are essential to maintaining skills and providing respectful and evidence-based care. The Papua New Guinea Midwifery Society has the responsibility to support the development leadership skills within the profession, along with mentoring and support, all of which they believe and no know have seen has a trickle-down aim of addressing mortality and morbidity. By reaching out to Rotary and the Australian College of Midwives, they were aiming to provide the required support for their midwives. They wanted their midwives to develop skills from an additional foundational partnership but also wanted them to end up as leaders who were self-sufficient over time and who in turn could nurture their own local midwifery community and future leaders. This was about capacity building for the future. Despite challenges in distance between Australia and Papua New Guinea, initial brainstorming between the parties identified the core aims, the funding requirements and engagement responsibilities of a partnership to progress. Midwives would be drawn for both ACM and Papua New Guinea Midwifery Society membership. In Papua New Guinea, there was also a requirement for the midwife to come from a well-functioning branch of the Midwifery Society to make use of existing communication channels. The existing relationships in Port Mosby and Garoka would form the basis of the program as relationships in a country like Papua New Guinea hold a great deal of weight and are essential to achieve further change. Funding was sought and gained through the Rotary Australian World Community Service Grant or ROKS. It's a grant that has been provided for a three-year program. This required a collaborative approach to develop and create a grant application with a supporting budget and project timeline. After funding was approved, Rotary Moriata and ACM undertook an essential two-day exploratory mission to P&G. It was vital that they went to personally understand the requirements needed to further progress the project to ensure that nothing was missed or misunderstood due to communication challenges. From this work, the development of a learning structure began. It was agreed that it would need to be a program that provided the midwife buddies with access to support, opportunities to increase their confidence and gain a greater understanding of the professional identity as well as expand their understanding and ownership of their own professional development requirements. The hope for outcomes included improvements in the health systems that resulted in better clinical practice and outcomes for both midwives and women and a vibrant leadership community. Strong midwives equating to strong mothers and babies. The ACM sought an independent curriculum developer who had experienced teaching and facilitating in this space. The draft program was jointly agreed by all parties and would consist of three workshops over a two-year period. The initial plan had been to have a three-day workshop with day one being a train the trainer, drain the facilitated day with days two and three for the midwifery buddies to connect and learn about leadership. It was soon recognised that the volume of content that all parties wish to be included would require a longer workshop structure and so the design was changed to allow for three days of joint buddy workshopping. One of the outcomes agreed was the development of a joint project specific to the Papua New Guinea midwife buddy and their place of work. Each three-day workshop would take place in Port Moresby as that was the most central location in Papua New Guinea with access to the services required for the workshopping. Each workshop would consist of six big wives from Australia and six from Papua New Guinea. As noted, there will be an Australian facilitator as the primary lead with a corresponding Papua New Guinea midwife facilitator. The P&G midwives would receive a per DM as set by the World Health Organization to support their engagement in the workshop and the Australian midwives were all volunteers. Each group of midwives would be asked to commit to the program for 12 months with the hope that the relationships would develop and continue after the formal period was over. Within that time, they would attend the workshop, engage with their buddy via an agreed communication channel, keep the facilitator update on progress, jointly work on the project for the P&G midwife and undertake the evaluation process. At the end, there would be 18 pairs of buddies. It was believed that this would create sufficient critical leadership mass in Papua New Guinea to ensure ongoing in-country workshops and pairing of further cohorts of buddies. And through their leadership and learning that the P&G buddies would be in a position to help to guide and develop continuing professional development opportunities for their colleagues, as well as working to improve local practices. Recruitment for the Australian facilitator and first cohort of Australian buddies drew so much interest that the midwives for the second workshop were also identified. Professor Helen Hall from Monash University accepted the facilitated position and quickly engaged with her counterparts in Papua New Guinea, Jennifer and Julie, as well as the project team being led by Rotary Morialta and the ACM to ensure that the planned workshop would deliver the desired outcomes. A few changes were identified such as the need to include an immersion day within a Papua New Guinea health service so that the Australian midwives could have a better understanding of the context of maternity care for the Papua New Guinea midwives and the challenges they may be facing in their roles as leaders and clinicians. This meant the workshop went from three days to four and it was agreed that the immersion day would be best placed in between the more formal learning. The workshops and topics were further developed and speakers from both Australia and Papua New Guinea were engaged to help share experiences and learning opportunities across both settings. The Rotarians from Morialta District were organising magicians, coordinating travel, visas, accommodation, the workshop venue, a welcoming event and launch and all aspects to require the support of the midwives but most especially the Papua New Guinea midwives. In March 2019, the first cohort of 12 midwives met in P&G under the guidance and support of Helen and Julie as the facilitators and Judy as the Rotary contact. They were in very safe hands. November 2019 saw the second cohort of midwives connect. The Papua New Guinea midwifery society faced a few startup challenges in regards to recruitment of midwives for the first workshop. As midwives were having difficulty getting support to attend and take the time of work, the first cohort of midwives therefore were predominantly from Port Moresby. After the success and positive promotion of the first workshop with the health officials, health services and midwives in Port Moresby and the whole of Papua New Guinea, the recruitment of the second cohort of midwives resulted in many more midwives coming from the remote provinces. The remoteness however, bought its own challenges related to travel and time away from home and then after workshop connections. But they are challenges that the team are working together to address. Each workshop provided a number of opportunities for the midwives to work in their buddy pairs and with the group as a whole. They would learn together about maternity care in Australia and Papua New Guinea, comparing the differences and celebrating the similarities. They would review the state of the world's maternity care and maternal and infant outcomes worldwide to put a perspective on their own places of work. Together they would define what was required for a strong midwifery community and strong and confident leaders exploring elements of self care, advocacy, goal setting, communication and the elements of quality care. Their learning would include videos, group tasks, brainstorming, trust exercises, presentations and the clinical immersion day. Once they had the basics, they would identify their projects and flesh out the details for commencing and then working out a plan for progressing and maintaining communication when the Australian buddies returned home. The midwives jointly identified what they hoped to find in the midwifery buddy and how they wished to work together. In their buddy partnership, they identified their strengths and weaknesses and areas of interest and expertise. Together, they worked on identifying a project that would address an issue that the Papua New Guinea midwife wanted to see changed in a community. The first cohort seemed to have the easiest time in staying connected. It is thought that this was because they were in the majority from Fort Moresby and so more able to stay connected after the workshop as they were all local. The second cohort had faced more challenges as they faced a sense of isolation when they returned home. Even though they were from areas where there were existing Papua New Guinea midwifery society branches, the lack of existing leadership across the country was being realised. In addition, the second cohort are now facing the coronavirus pandemic and this is challenging the way they are able to connect with their Australian colleagues in many instances due to the breakdown in communications across the country due to health-related lockdowns. And there are also huge changes in the way that they are practising clinically. The Papua New Guinea midwifery society, Australian College of Midwives and Rotary are all working together to determine how best to support the midwives and ensure they can remain connected. At this stage, the Australian buddies continue to reach out and connect and a number of ideas are being reviewed to assist the midwives to maintain communication in these challenging times. It is recognised that when the pandemic-related restrictions are released, this may become easier. Despite the challenges to maintaining connections that have been identified, because the buddies had established mutually agreed communication channels and rules that they are working to, even if delayed, they are progressing their projects. The most common communication channels have been Facebook, Messenger and WhatsApp and communication in the majority has been maintained. Overall, the feedback from the midwives who have so far been engaged with this program have been overwhelmingly positive. They are feeling connected and excited by what they are achieving for themselves and their communities. They can see that change is possible and achievable and that they can create it. To date, 12 of the planned 18 buddy pairs have connected. The plan had been for the third cohort of midwives to meet in August of this year, but due to COVID-19 pandemic, those plans are currently on hold. Evaluation has commenced and the results are pending, but from the status of the projects and the feedback from Papua New Guinea and Australian buddies, we are already seeing midwives from both countries reporting a sense of fulfilment and accomplishment. They are proud of what they have achieved together and are talking about the future and how they will continue to connect and grow. And I know that on this slide, I just have the images or the logos for the Australian College of Midwives and the Papua New Guinea Midwifery Society, but I think it's really important that we also recognise that this partnership and this particular work that we're doing has been based on the amazing support from Rotary here in Australia and also Rotary in Port Moresby. They have provided the backbone and being some of the most passionate workers on this and without them, the amazingness that is being created with the Australian and the Papua New Guinea Midwifery Society members probably wouldn't have been realised. So just a little bit about the projects so far. I've got details here for the first cohort and the projects that they've been addressing have included the creation of a pamphlet for partners with information about family planning, antenatal care, nutrition and labour. A leaflet on the advantages of guardians during labour and the development of education for staff on the use of guidelines and screens for privacy. They've been addressing prevention of anemia by looking at nutrition intake and whether iron supplements can be useful and are taken by pregnant women. They've been introducing positive changes in labour ward environment by incorporating respectful care maternity models into the labour ward through staff education. They've been investigating the support and resources needed for cervical screening by midwives. They're looking at developing audio visual education packages on sex education for students in both English and Pigeon languages so that they can reduce unwanted pregnancies due to lack of understanding. These projects are all being led by the Papua New Guinea midwives and so they are relevant to the communities and healthcare settings where they work. The outcomes that the midwives are seeing are all positive. They're seeing increased engagement with their midwifery community and with the women and uptake of the information. And the midwives themselves are making plans for where they are going next, which is one of the aims of the process to create continuing professional development and to create leaders who are self-sufficient. Another fabulous outcome from the first cohort is that one of the midwives has decided to continue not only looking at the cervical screening but to travel to Australia and to enroll in a midwifery degree here in South Australia. She's currently being supported by Rorya Moriata and her Australian midwife buddy. And she is also presenting at Virtual International Day of the Midwife later today. She is session four, social determinants of the late presentation of cervical cancer from one at one o'clock, I'm saying in the morning, UTC time. So that's Nancy. It would be fabulous if you could go along and support her as well. Together, Rory Moriata, Papua New Guinea midwifery society and the Australian College of Midwives have created an opportunity for midwives to connect and bonds to be formed. We have built on existing relationships and strength and ties. Together, the midwives have faced and overcome their own challenges, be it communication, technology, resources or something else. Together, they have grown and learned about themselves and each other. Together, they have identified common ground and a project to work on. Together, they have laid down the foundations to a lasting relationship based on mutual respect and understanding. Even as we all face the coronavirus pandemic, together, they continue to connect as they are able, sharing their experiences, worries and achievements. Together, they are planning for their future. We have one final workshop to complete and a group of buddies to support. So we will continue to learn from and adapt the program based on these details. For example, before we commenced, we changed from a three-day workshop to a four-day one to enable the clinical immersion day. We have also increased the preparation for Australian midwives for the immersion day and revised the timing of the days to ensure that we can best support the Papua New Guinea midwives in regards to their travel, to and from the workshop and also reduce interruptions to their paid employment. We have also implemented ongoing buddy engagement meetings to keep everyone engaged and connected and assisted with opportunities to promote and disseminate progress and achievements. And a big shout-out goes to Helen Hall in that regard because she has been unfailing in her support of all the midwives over the last 12 months and we know that she will continue to do so. The next and final stage of the project is to undertake and complete the formal evaluation. Through a process of reports, surveys and semi-structured interviews with all buddies, a big picture of this initiative will become known. The evaluation process will be completed in stages as we need each cohort to complete their workshop and year of engagement. However, we are already gathering data from the first cohort and who completed in March this year. The progress of their projects is testament to the value of the partnerships and the ongoing plans reflect the bonds that they have created. Whilst this project aims to build on the twinning structure by focusing on the midwives as opposed to the midwifery organisation, the ICN member association capacity assessment tool or MACAT will be included in the assessment process as an end for outcome of this program was also to increase the viability and strength of the Papua New Guinea midwifery society through the growth and support of the midwifery leaders. Using the MACAT evaluation tool will also increase the validity of the outcomes and aid in the translation to other countries. From the passion of midwives in both Papua New Guinea and Australia to support change and development of a dedicated midwifery program has been established. The outcome so far has seen 12 midwives in Papua New Guinea from both central and more remote areas connect, develop and maintain respectful relationships with Australian bodies resulting in projects aimed at improving maternal health outcomes in Papua New Guinea and raising the profile of the midwives through leadership capacity. The aims of the project are being met and strong leaders are emerging and creating local communities of connected midwives. It is hoped that the learnings from this initiative can be applied to other low income countries who face similar challenges for the midwifery community. Together, we are already planning the future and have been investigating ways to keep this program and the projects that are underway going. We are looking into grants here in Australia and overseas and we have received additional funding from organisations and individuals most especially through many rotary organisations here in Australia. The buddy program has so far been supported by the RAUX grant and has a donation page within that space. So if you would like to support the RAM or any of the initiatives that are underway by the Papua New Guinea midwives you have that ability you just have to go to the ACM website to find out more. In wrapping up, together we are stronger and together we can create and support strong women and strong mothers and strong babies. Happy International Day of the Midwife. Thank you, Ruth. What a wonderful project. We have time for questions for Ruth. You can type them in the chat box. Ruth, there was a question that I saw. One of the participants was wondering about unattended births. As in how many are unattended? In Papua New Guinea, yes. Yes, so at the moment the estimate is that is around about between 44 and 49% of births are attended which means that there's more than 50% of births that are unattended and that's not through lack of desire from the midwifery community. It's mainly down to the lack of there just isn't a big enough workforce. So back on one of my earlier slides I think I had some information on the number of midwives and I think it's where we've oh no I didn't put it there. There is a statistic which shows that it's like one midwife per 200 or something. It's quite a significant shortage. That is really small. Other questions? Oh, Sarah's asking was that one per 250? That could be the number that I'm trying to recall. I had the details but I've put all my, I've tried to clear my desk because I've got someone coming in to present here later today. So I've moved it over there. But that does sound about right. Let me just see if there are any other questions. Are there other questions? Yeah, so Sarah's saying she missed the stat. I didn't actually put on a stat. I just said that there were around about 110,000 that were missed per year and there are only 1,000 and Jan has noted quickly there are only 1,000 midwives in Papua New Guinea. So there's a lot of women who just don't have access to midwives and especially in those more remote areas. If they don't have midwives who are in those spaces, travel is very difficult. Jan is asking, when will the third group go to Papua New Guinea? Okay, so we originally were having the third group going in August of this year but because of the COVID restrictions and all that's related to all of the travel we aren't actually in a position to be able to say when we can take that third group over. We're working with the midwives in Papua New Guinea and keeping an eye on all of the travel arrangements. And when the restrictions are lifted then we will definitely be looking to get that group over there as soon as we can. So Charlotte has asked if the ACM are considering similar projects in other regional countries with similar birth statistics such as Team Allist. Charlotte, I think that's a fabulous idea and yes, we would love to be able to do something similar. I think probably if we focus on this project and get it finished and get some really good results and then we'll be able to determine whether there are changes that need to be made to the program so that it can be more supportive of the midwives. But I think definitely in the future having the ability to move this and to be able to work with other midwives in other areas to support midwifery leadership can only be for the betterment of the midwifery worldwide midwifery. Thank you, Ruth. Before we lose table, I unintentionally erased the chat box responses to what countries you all were coming from. So would you take a minute now and type in again which countries you're attending from? Thanks so much. I'm seeing countries I didn't see on the first go around. Turkey, Bulgaria, Nigeria. Yeah, it's a fabulous representation from around the world. Yes.