 Okay, which is recording. So I'd like to introduce you to our speaker for right now. Her name is Marlis de Ope Lima. She did tell me how to pronounce that in the correct way, but I know that I would butcher it, so rather than attempting it, I'm just going to say that welcome, and thank you for being here. She's a midwifery professor at the University of San Paulo School in the Humanities Arts Science and Midwifery course in Brazil. She's also a researcher on women's health and quality of life, midwifery care and depressive symptoms and pregnancy. Prior to her position at the university, she taught and coordinated the School of Nursing at the Adventist University of San Paulo. She completed her basic nursing degree from the University of San Paulo postgraduate degree as a nursing midwife from the University of Santo Camilo. I hope I'm saying that correctly, and a master's and a doctoral program from the University of San Paulo. So welcome, Marlis, and I look forward to hearing the rest of the presentation. Thank you, Megan, for introducing you. First of all, I'm glad to be here. It's an honor to participate in this virtual International Day of the Midwives 2017 and to have the opportunity to share this project with you midwives around the world. The project upscaling midwifery education in four countries in Africa is founded by an organization of the petroleum exporting countries found for international development, OFID, and it is an partnership between the World Health Organization, the General Conference of 70-day Adventist Department of Health Ministries, and Loma Linda University. We all know that maternal mortality rates around the world are very different, and in some countries it remains a challenge to be faced by the government. It can be said that maternal mortality rates show how valid a woman is in her society. So high maternal mortality continues to be a problem in many countries in sub-Saharan Africa. WHO, concerned about this problem, established with the country's members sustainable development goal 3.1, which aims to reduce maternal mortality ratio below 270 by 2030. In order to reach this goal, WHO decided to partner with the General Conference of 70-day Adventist Department of Health Ministries that globally have more than 70 schools of nursing and midwifery. So as to improve quality of midwifery education in these countries, the established goal was to upscale midwifery education by facilitating the implementation of WHO midwifery educator core competencies by midwifery educators. To reach this objective, laboratories of change were developed to provide an environment for embracing innovation, new ideas promoting changes in attitudes. We are assuming that establishment of laboratories of change in these countries will transform midwifery educators by improving their knowledge, skills and attitudes. Ethical, competent and confident midwives can improve the health and well-being of women and girls across the lifespan. The project donor chose four countries to take part in this initiative, Botswana, Lesotho, Malawi and Camero. We are using a theoretical framework, the Change Theory by Kurt Liewing, which presents to us three cycle phases, as you may see at this slide. Phase one, unfreezing, make people aware of the need of change. We started by doing a capacity assessment of the midwifery educators from specific schools of these four countries and then we explained the project and the WHO core competencies. After that, the consultants and the educators get together doing a gap analysis and came out with the development of action plans with timelines. Phase two, moving to present innovations, the new approach. We introduced the theoretical foundations of competence-based education and active methods of learning through seminars. And now we are in phase three, refreezing, which means incorporate these innovations on a daily basis through implementation and assessment of competence-based education. Also, demonstration by the midwifery educators, the WHO core competencies and enhanced collaboration between them, focus on values. These slides show us the dates of all the steps we have been through since December 2014 and go on until March 2017, when we were able to do the capacity assessment in Cameroon. We started the capacity assessment before in the other three countries, so it's a little bit different from what you may see here from Cameroon December 2016. Actually, the data was March 2017. The project will continue until 2019. We work in collaboration with international, regional and country-based WHO leaders. WHO collaboration centers establish at universities of these countries with ministries of health and nurse and midwifery council leaders who are all engaged in facilitating change in the knowledge, skills and attitudes of the midwifery educators. Assessment of sustainability and accountability will be examined through indicators jointly developed by participants and consultants and by the ability to, one, integrate midwifery educator core competencies into their teaching and, two, incorporate competence-based education concept into their curriculum. The outcomes will be changed in the knowledge, skills and attitudes of midwifery educators that will be assessed using the WHO midwifery educator core competency gap analysis tool at the end of the project. The WHO midwifery educator core competency has 19 domains that we have to go through it and to show how they are confident, how they are competent in all these core competencies. The outcomes, by doing that, we hope to make a difference through midwifery education and decrease the maternal mortality rate in these countries. These are the direct participants of this project and you may see a picture of Dan in the next slide. Some of them from Loma Linda University are here with us and they will help me answer any questions you may have. Some of them, like Dr. Patricia Jones, are from Loma Linda University, WANSA and Kowani are from WHO, Jennifer Nayoni is from WHO Offsie, Africa Offsie and some of the others are participants of this project from the school, from the International Consulted also. Here you may see the picture from the part of the group, the majority of them are here. We want to say thank you to RFID once again for funding this project and thanks to all of you who is attending this presentation. I know we have more time for some questions and I want to open this time for any questions that may you have and thank you again, Megan, for introducing me to this presentation. Wonderful. Thank you. This sounds like such an enormous project. I think the slide from me that really hit home was the one where you had all the dates on it and it was like, wow, this is a lot of work here and I know that Dr. Pat Jones is here and able to answer questions as well so I would leave it over for you guys to negotiate the questions that are coming in but let me know if you want me to help in any way. I think for me, one of the things that it brought up was what was one of the hardest parts in doing all this, like what were some of the things that came up that you were surprised that were difficult you weren't expecting or even that you were expecting and that was one of the struggles. Well, for me, the most challenging thing was to put all these people together and to have our meeting and to try to speak the same language for the whole project. I mean, it's a big challenge because they want to work in a competence-based way, in a competence-based education way but they don't know really what it is about or how to really use this in their teaching so working with them about this is really challenging for us also because we are working in a different countries with different cultures and different realities although they are all in the same continent as African continent but there is some differences between them. For instance, in Botswana, they are more developers than the other countries so they have more support for doing these changes but in Malawi, they face huge problems to use these new ideas, the new approach to their teaching so it is wonderful to have these differences between these countries and to deal with different realities even though we are at the same continent. Awesome, thank you. What are some of the things that helped overcome the struggles? Did you have interpreters to help with the different languages or was it something that you just kind of all got through together because there were enough people there that knew languages? Well, actually all of them, they speak in English so the kind of universal language is English but they all have also tribal languages and other national languages but we use only English to the classes and at school actually at the middle high school and at the university they all use English, not other language, not local language so it is easy for us at least to try to talk to them at the same language. Wonderful, I can see some people are starting to type some questions that are sort of coming in but until they come in I am going to sort of keep asking if that is okay, I feel like I am overtaking your thing, oh here is one that is coming, has there been a difference at all, i.e. a drop in the MMR in any of these countries during the project so far? Not, it is not our goal to decrease, direct the maternal mortality rate through our project. Our project is to enhance the teaching through the competence based education for midwifery and then through skillet midwives help to decrease the maternal mortality rate so it is not a straight goal for us or we may not say that we are really improve the maternal mortality rates at these countries but we hope doing so through our job but there is no straight line for that right now, at least right now. Talking about schools and I know for me I am working in America right now, the international students have, it is kind of a hot topic for American students to go international to get experience. Is there some, I don't know, I want to say use but that is not what I mean, that is not the word that I mean, can you see a situation where students from countries like America can be useful within the scope of this project? Actually not, if I understood correctly you were asking me about the students to go to these countries to working with us in this project, is that correct? Yes, we get a lot of students in our school who want to do work overseas as part of both their students experience but also their ongoing midwifery experience and I was, it is a bit of a controversial topic right now as to whether this is an appropriate thing for students to be doing or not and I was interested in whether you felt like it is appropriate within this project or it would not be appropriate within this project. Well actually we are not working with any students at this project, we are more like consultants so we have some background about competence based midwifery education and I am aware about this, it is a controversial issue right now but particularly at this project we are not using any foreign students at Africa, it is just for the midwifery educators and with us from WHO, local leaders, consultants from the University of, like WHO, Collaborations Centers and from Loma Linda University and some international consultants but not, we don't have right now any students from the United States or from any other country participating in this project right now. Wonderful, thank you. I see some other people that are typing some questions so I will just allow a little bit of time for them to do that or alternatively you can raise your hand and I can give you the microphone if you would like to speak. Now so, I want to ask Dr Pat Johns or Sabine Dumbard if they want to share more ideas about the project or say something more maybe you can contribute also. You both have microphones if you would like to talk, I think you just probably have to go up to the top of the screen and make sure that the microphone there is green but by clicking on something, something that I want to say is all the Sub-Saharan African countries, they are looking for a competence-based midwifery education, usually they are nurse midwife, there is no direct entry fee for midwifery there right now because they think that it is important to have both knowledge, nurse and midwifery so they don't know how really to implement this so they are trying, they are struggling to implement this for the whole universities and the whole schools of nursing and midwifery in these different countries so this project is a really, how can I say, it's really trying to make this difference, helping them, helping the government, helping the nurse council leaders to implement it and to transform the competence-based education for the school of there so we are really being like a consultant helping them to do this. So it's sounding like the schools are making their own plan of education but your role really is to just help and kind of oversee and provide assistance where you need to, is that right? Yes. Okay, awesome. I can see some questions have come in here. What is the response from the teams you are working with? Are people finding it as making a difference to how they are handling the students? This is from Jinga, I hope I'm saying your name correctly. She is from Uganda and they have direct entry midwifery but often people want to have both training since they can be in isolated situations and need more knowledge. Oh that's your town, it's a town. Just pronounce ginger, I'm so sorry. I should be better but I'm very sorry. Well, it's not an easy task to change your vision, your ideas and to adopt a new approach to teaching. So there are different levels of acceptance between the sites. There are some of the sites that they are going further and they are in braces, they are understanding better than others. But it is the same for us. I mean, usually at the school you have the students with different levels of knowledge, of acceptance, of new ideas. So at the end of this project we will be able to see how it is really working for the teachers and for the new students and how they are being able to incorporate these new ideas and these new approaches to the teaching on a daily basis. So for now we are still implementing, we are still working with the professors there to get confidence, to start implementing the competence-based midwifery education. So right now we don't have yet any reports about how they are reaching the students, how they are doing the things in a new way. But we hope that very soon, we hope to have these reports very soon. We have these data. But we now, we are feeling that we are getting more and more in this. There are different levels of acceptance, different levels of using this new approach, these new ideas. But we hope at the end, all of them will have the same level, they are all using in the same way or at least in a common level, may I say. Awesome. I can see Sabina's typed, I'm getting over Laryngitis social type. It has been encouraging to see that the midwives from different sites have formed relationships and are eager to collaborate with each other. That's really interesting to me as well. Can you elaborate more on that? So the groups that you have been working with, they are starting to talk to each other and maybe share resources. Do you find they share similar, is it similar between the countries or is it quite different between the countries in terms of how they have set up their curriculum? Yes, they all have different curriculums. So we are trying to work with all the different types of curriculum that they have to these four sites. But they are starting having some meetings together. So they have been able to change, to share the reports, to share new ideas, to how to implement this competence, these midwifery education. So they have this opportunity to share the experiences they have been through. And this is very wonderful because they can have the opportunity to share these situations and the challenges, situations they have been through. So they can learn off each other's experiences and what worked for them and what didn't work for them and that kind of stuff. That sounds like it should happen much more throughout everybody, you know, in terms of both in midwifery but also in midwifery education as well. That sounds fantastic. Taro Meti, I hope that I'm pronouncing that correctly. What are the timelines after implementation will you be able to see results? So I guess from here on out what's your kind of timeline looking at? So our final report will be by 2019. So we have more at least two years ahead to continue following the implementation and look for the results of this project. What kind of measures of results have you got coming out of that? Is there something that you're going to, is there a specific measurement that you've got or is it both sort of a feeling that you're going to be able to see the results? Is there a specific measurement that you've got or is it both sort of a feeling from the teachers as well as a quantitative measure? We are more working in a qualitative data and also we have the gap analysis tool from WHO core competencies that is more quantitative data also. They measure how they feel competent about the top and how they feel confident to put it in practice. But the results are more qualitative and we are seeing that our major challenge is really to change attitudes and behave as an attitude, to change values, to make them moving forward, change the old habits about teaching or about how the value need free education. So it will be indicators more related to the qualitative data and we have part of it, quantitative data about the gap analysis tool. Wonderful. Monica says the curriculums are usually set by the government. Pat's saying we anticipate the hardest change will be in the area of behaviors and attitudes. Knowledge and skill will be the easiest to change. Can you talk some more about that? In terms of behavior and attitude, are we talking about other medical professionals in the area or are we talking about people, women and consumers of midwifery care or are we talking everyone? No, we are talking about midwifery educators. Because for them it's a challenge to change with the resource that they have. Sometimes they think that it's not possible to change the things the way they are. They were because or they are because of the lack of resource. But it's not true. It's not true. In reality we can make a difference. We can make a huge difference through education without lots of resource. So we are facing this challenge to make them believe that they can incorporate this changing without doing or without meeting lots of resource. And the government of these countries are really interested in to implement competence-based midwifery education. But they just decided which will be the curriculum, but they don't give the government, usually the government, they don't give to the teacher the tools how to make the changes in their teaching. So this is a challenge for us. So if I'm hearing you right there, you just said the government has the resources, but they don't pass it down to the teachers. Did I hear that right? No, no. The government went by law or by set the curriculum to every school using competence-based education. But the government is not given the way how they can do it. I mean, they are just demanding from the midwifery educators to change, but they are not given to them how to do it. So they have to do it by themselves or looking for themselves how to change. So now we are trying to help them to reach this goal to using competence-based education and to give to them the education, the knowledge, the skills and the attitudes to be able to implement, really implement that at the classroom. Because something is wonderful sometimes at the paper, but it's not really happening at the school, at the classroom. So we are trying to help them to make that a course at the school, at the classroom with the students and improving the quality of midwifery education through this. So that makes sense. So the government is saying we want it to be different. It needs to change, but they're not telling them how to change. That's where you guys come in. You're the ones that are kind of helping them with changing what they're doing in order to meet the curriculum that's been set. But that a lot of the times it's the instructors that are kind of feeling a little bit like, I'm not sure we can change. This is how it's always been. And I know that I fight that and even in my school here in America, we fight that fairly often too. So I can only imagine what it would be worse with less resources than what we have, which is plenty. All right, I'm just going to go on and keep reading here. Monica says, attitudes affect everyone. If the attitudes of healthcare provider is negative, it affects the willingness of clients to access care. Attitudes on behalf of the clients can also be affected by family and tradition. And Pat's saying, in these countries women have had negative experiences with the care by midwives and don't want to go to the SBAs for care. That's birth attendance. Remind me what the first word is, skilled birth attendance. This is often related to cultural and traditional practices. Midwifery educators admit that their role models have not always demonstrated caring attitudes towards women giving birth. And this is hard to change. So the question is, how much training or are we talking midwives? So I'm thinking, yeah, what is the length of the training for the midwives? Well, as I said before, usually they first, they take it on two or three years to be a nurse and then more two years to be a midwife. One to two years to be a midwife. So it takes like five years to be a midwife, but they are not a bachelor degree. They say they are, what is the right word for that, license, but it's not a bachelor degree. To get a bachelor degree, they have to go to university and there are a few at the countries. So they are nurse three, two or three years previously as a nurse and then one to two years to be a midwife. And is there any training here that's directed towards the birth attendance rather than the midwives? Not that I know, not that I'm aware. Only they have doctors, obstetricians, and they have the nurse midwife to attend in the birth. I don't know if you have any TBA, traditional attending of birth, there probably they have also. But when we are talking, we are talking about the skillet birth attendance. Awesome. We've got comments five years is a long time and Pat's saying in many countries they are RNs first and then registered midwives for example in Botswana. Do they have a direct training or is it post basic midwifery? So are all of them nurses first or is there any direct entry midwifery training? As far as I know for these countries that we are working in only post basic midwifery, not direct entry. Awesome. I can see there's lots of people typing right now so I'm just going to give time and space for the stuff to come through. There's a question, they don't combine the training, do they do both together? No. Now they go just first for the nursing school and then take the midwifery course. They are not combined. Wonderful. I think there's a comment coming through from Pat. The programs we are working with do not have direct entry. WHO uses the term SBA to refer to all levels of health professionals who provide birthing assistance. Wonderful. Okay is there any final questions or any other topics that people would like to discuss or address? My lease I want to say thank you very much for your presentation and for all the work that you and your whole team are doing. I found it fascinating and I think that it would be such a challenge to be working with different countries and trying to come together to create solutions that work for everybody. Obviously not the same solution but solutions that still go ahead and work for everyone. So thank you for your presentation and for being here at the day of the midwife and happy day of the midwife to you. I'm going to turn off the recording button now.