 So we're going to go ahead and get started with Edith's amazing presentation. So I'd love to invite our speaker to join us. There we are. Hello again. Thank you again. Hello. It is my great honour to welcome Edith Mangindan. She is a doctoral student of Midwifery at the University of Iceland. She was born and raised in San Francisco, California in the United States to Filipino parents and she moved to Iceland in 2009 with her Icelandic husband. Her experience as an immigrant woman receiving maternity care in Iceland inspired her to become a midwife. Her research areas of interest include immigrant women, respectful care, women's autonomy and decision making, informed choice, mistreatment and childbirth, intersectionality and culturally sensitive care. She also works as a registered midwife at the anti-natal and postpartum inpatient unit at Landspital University Hospital and hold lectures on cultural humility for midwifery students at University of Iceland. She does more. Hold on. She does more. I don't think she's able to have any rest. In addition, she is also on the editorial board of the Icelandic Midwifery Journal and teaches childbirth preparation classes for English speaking. I expect some pairs. Let's go ahead and welcome Edith. Thank you so much. Welcome. Oh, thank you for that wonderful introduction, Jane. I'm so happy to be here with you all today. Happy International Day of the Midwife. My name, as Jane said, is Edith Mangindan and I am a doctoral student of Midwifery at the University of Iceland and I feel very honored to be able to share my work with you today. The title of the first article that I'm working on right now with the three articles that will go towards my doctorate is Migrant Women's Experiences of Respect, Autonomy and Mistreatment in Icelandic Maternity Care, a Quantitative Study. And on my PhD journey, I am so fortunate to have two very experienced and encouraging midwife researchers as my supervisors, Dr. Helga Gottfresdottir and Dr. Emma Marine Swift. But before I discuss my project with you, I believe that is important to let you know a little bit about my background and Jane has already started talking about it. So I'm just going to go over it. On September 3rd, 2009, my life completely changed the moment I gave birth to my first child, Ari. I had just moved to Iceland a little over nine months before this picture was taken. And as Jane said earlier, I'm born and raised by Filipino immigrant parents in San Francisco, California in the United States. And in 2009, I decided to move to Iceland. I left my job, my apartment, my friends, my family, all for love and adventure. But shortly after moving, I became pregnant with my first child in this new country. And it was such a beautiful time in my life, but still very challenging. It was a very, it was very challenging because my husband and his family were the only people I knew here. I didn't speak Icelandic. I was far away from my own family, my own mother. And I was a very visible foreigner, very much an outsider. But on the other hand, I was in a country where pregnancy is considered a natural and normal process. Women are encouraged to give birth without intervention, if possible. And I regularly went to a midwife who was very professional, warm and encouraging. And I enjoyed going to prenatal yoga classes to prepare myself physically and mentally for the upcoming birth. I also read all the books written by American midwife Ina Megaskin. And my husband and I also attended parenting classes held in English. I was very much prepared to give birth. And I remember every moment of my labor and birth. And I felt really well the entire time during this labor and the experience of giving birth in this manner, conscious, calm and free from fear was empowering for me. I felt I had regained faith in myself and my self esteem changed for the better. I also felt compelled to share my experience to help other women have the same experience, especially women of foreign origin. And this life experience sparked my interest in midwifery and I was deeply inspired. Although giving birth was empowering for me, I experienced the Icelandic healthcare system as an immigrant woman who was unfamiliar with the language, culture and systems. As a migrant woman, I experienced prejudice, loneliness and a sense of hopelessness, especially when I thought of my future in Iceland. And however, just two years after moving to Iceland, I was accepted into the nursing program at the University of Iceland and graduated in 2015. Throughout my studies and in my work as a registered nurse, I noticed disparities within the healthcare system, especially among immigrant populations. My experience as a pregnant woman of foreign origin motivated me to apply for the graduate program in midwifery in the hopes of improving care. And in 2018, I graduated with a degree in midwifery and in 2020, a master's degree in midwifery. Today, I work as a registered midwife at Lansvitale University Hospital, as Jane mentioned earlier, in Reykjavík, Iceland. I also am a childbirth educator, specializing in migrant parents, and I'm studying to receive certification as an internationally board-certified lactation consultant. So I hope to have more classes for non-Islandic speaking families. And in order to understand the context of my research, it's important to discuss Iceland. So here in Iceland, we have a population of over 360,000 people on the entire island. The fertility rate is 1.71%, the highest in Scandinavia. And we see about over 4,000 births per year on the whole island. There are eight different places for giving birth. Home births are about 2% of all the births in Iceland. Caesarean sections are about 16.1%. And this is considering both acute Caesarean sections as well as the elective Caesarean sections. The epidural rate can be anywhere from 46% to 55% depending on the hospital. And currently, 290 midwives are actively providing care over various settings. And some of the pictures that I'll be using are actually pictures of the Icelandic countryside of the island and with beautiful images or with beautiful pregnant models in them. They're some of my favorite images. And the background, equal access to quality care is a fundamental human right. And it's considered a key issue in healthcare here in Iceland, with a change from a homogeneous population to a multicultural society with 15.6% of immigrants. It is important to address the health status and needs of childbearing immigrant women in the country and their access to the healthcare system and experience of maternity care. The design and delivery of maternity care plays a crucial role in ensuring good outcomes and positive experiences. The World Health Organization standards emphasize that outcomes of high quality care include experiences of autonomy, respect, dignity, emotional support, and client-led informed decision-making processes. I've often thought about access to healthcare in patient equality or equity. Equality means sameness. It's giving everyone the same thing. It only works if everyone starts from the same place, right? But if we're talking about equity, that when we talk about equity, we're talking about fairness, access to the same services and opportunities, we must first ensure equity before we can begin to enjoy equality. And the number of immigrants here in Iceland has increased dramatically in the last two decades. 20 years ago, immigrants accounted only for 2.6% of the population. But today, as I said earlier, immigrants make up over 15% of the entire population, and that's about 45,000 residents and growing. The three largest groups of immigrants here in Iceland are from Poland, Lithuania, and the Philippines. This influx of immigrants has dramatically changed the racial and ethnic makeup of Icelandic society within a relatively short timeframe. And foreign-born women here in Iceland are a huge, are a growing group. The largest group of women comes from Poland, with over 7,000 Polish females living in Iceland, and 3,400 Polish women are of a childbearing age. Nonetheless, of the 290 midwives working here in Iceland, only about 2-3% are of foreign origin, and this is including 2 midwives working in Iceland that are of Polish origin. Now, throughout the world, healthcare systems are placing an emphasis on encouraging and embracing cultural diversity within the workforce in order to mirror and better serve a changing population. A lack of diversity within healthcare professions can lead to disparities in the provision of services for very diverse groups. It's always good to have this in mind. And the Icelandic maternity healthcare services, here in Iceland, there is universal healthcare. Prenatal visits are conducted at the local health clinics in each of the neighborhoods. The woman attends the clinic that's in her neighborhood, and high-risk pregnancies are recommended to be taken care of at the hospitals. 7 to 10 antenatal visits during pregnancy are under midwifery-led care, and midwives and obstetricians work together if complications arise during pregnancy or in labor. 74% of births occur in a hospital setting, and the woman receives 5 to 7 home care visits in the 10 days after giving birth. Although foreign women are generally satisfied with the care they receive, a growing number of studies is shedding light on the difficulties and challenges that they experience. In a qualitative study in Iceland in the year 2011, so exactly 10 years ago from this year, seven women of foreign background were interviewed about Icelandic midwifery-led maternal healthcare services here. Results suggested that immigrant women in Iceland often had different cultural views towards pregnancy causing conflict in maternity care, had inconsistently effective communication with healthcare professionals, and were more likely to experience isolation and depression after birth. Now studies from other countries have shown similar results. Difficulties in communication, insensitive remarks, stereotyping, prejudice, unfamiliarity with the healthcare system, lack of information, for example, educational materials and websites aren't available in many languages, interpretation services are lacking or of poor quality. Some women are unaware of services because of this lack of information, and isolation and depression after birth can be very common. On the other hand, healthcare professionals also experience challenges when providing care for for migrant women and their families. Attempting to understand the experiences of women in this vulnerable group can be very demanding, as many of us have experienced. And many studies suggest that language barriers are a very common challenge that healthcare professionals encounter. There are varying levels of health literacy for each woman, and different cultures and subcultures make learning about culturally competent care very difficult. A lot of foreign born women require more emotional support because of the many stresses that they experience just moving to a different country and adjusting. Also, some foreign women are more likely to experience pregnancy complications. And there are many differences in maternity care between countries. Like I experienced myself as an American moving to Iceland, the two different healthcare systems are just like black and white. For example, like with the Caesarean section rates. And also not to mention the many systematic barriers that healthcare professionals can encounter, although a midwife wants her to do her best to provide care for a woman who might, for example, not understand the common language spoken or is living in difficult social circumstances. These there are certain systematic barriers that that hinder from the providing the high quality care that these women deserve. And so my research is as follow question is as follows. Do migrant women experience less respect and autonomy and decision making and more mistreatment in maternity care than native born Icelandic women? In order to research this question, I've designed a survey called the maternity care and Iceland survey or MCI for short. The survey is I incorporated so 88 to 100 survey items, depending on how the woman answers the questions. And I ask about socio demographic background, birth intentions and outcomes, as well as incorporating standardized instruments into the survey. The participants were women over 18 years old, who were pregnant and had given birth in Iceland between the years 2015 to 2021, and were proficient in either Icelandic, English or Polish. Yes, the survey was translated and back translated and then reviewed by community leaders and women from the different communities to ensure accuracy, which that in itself was a lot of work, but I think work well spent. And to collect data, I've used convenient sampling and to better distribute the survey among women. I designed a website as well for to include information about the survey and links to the survey in different languages. The survey was regularly advertised on social media platforms, Facebook and Instagram, which are most commonly used by this demographic from April 1 2021 until April 30 2021. So I just finished collecting data. And I incorporated these the following instruments into the survey. The mothers on respect index score will measure the respect mothers experience in their care. The mother's autonomy in decision making scale will measure the mother's level of autonomy while making decisions about her care options. And the mistreatment by care providers in childbirth indicators will measure the level of mistreatment that the mother's experience while receiving intrapartum care during birth, right? And I will discuss each of these instruments further in the following slides. So Maury or the mothers on respect index. It was originally developed in British Columbia. Maury is a client informed quality and safety indicator that can be applied across jurisdictions to assess the nature of provider patient relationships and access to person centered maternity care. It was originally a 14 item scale. And it can be administered with a six point like response format with slightly different questions on branching pages for specific populations. It assesses the nature of respectful patient provider interactions and their impact on a person's sense of comfort, behavior and perceptions of racism or discrimination. Because of the focus of this study on immigrant women, I have decided to use the adopted 17 item Maury scale, including perceptions of racism, which was adopted for this use in the United States. There are four questions, number 11, such as I felt discriminated against. Item number 12, my care provider use language I could not understand. And item 17, how often have you felt treated unfairly because of your race, heritage or ethnic group have been added. MADM or the mother's autonomy and decision making scale is an instrument for assessing the experience of decision making during maternity care. The seven item scale was developed and content validated by community members representing various populations of childbearing women in British Columbia originally, including women from vulnerable populations. The MADM measures women's ability to lead decision making, whether they're giving in given enough time to consider their options and whether their choices are respected. It reflects person during priorities and reliably assesses interactions with maternity providers related to a person's ability to lead decision making over the course of their maternity care. For example, it asks that the care provider help the woman understand all the information when receiving maternity care. And the third instrument I incorporated into the survey is called the MCPC or mistreatment by care providers in childbirth indicators. I have decided to include these indicators because they measure other domains that align with the World Health Organization's typology of mistreatment such as stigma, failure to meet professional standards of care, lack of informed consent and loss of autonomy. This adaptation of the survey has been used when conducting research in the United States and items are patient designed and patient validated to measure mistreatment in childbirth. Because foreign women are considered a vulnerable population, asking them about mistreatment during childbirth can give us a more complete picture of their experiences. For example, it asks, did your midwife or doctor ask you what you wanted to do before any of the procedures were done such as episiotomy, continuous fetal monitoring or screening tests? Or did healthcare providers ignore you, refuse your requests for help or fail to respond to your requests in a reasonable amount of time? And some ethical considerations. This study received approval by the Icelandic Bioethics Committee on October 20, 2020. And women were asked to read a consent form available, of course, in Icelandic, English and Polish, and were requested to provide informed consent before they began the survey. All participants were able to take a break and stop participating whenever they liked, and all answers were anonymous. Participants were directed towards resources that would provide them with support through lend me your ear or in Icelandic it's called which is a service provided by midwives to give women an opportunity to discuss their difficult birth experiences in case the survey brought up difficult issues for them. Or women were told about the women's shelter if they indicated that they have experienced mental or physical abuse. The information about these resources was available, of course, in Icelandic, English and Polish methods. For the methods, we decided to have exposure value variables, the country of origin. So it's dichotomous. So we were going to split the two groups into native Icelandic women and then other so women of foreign origin. Outcome variables will be will be calculated from the three instruments that we talked about earlier. Experience, respect will be calculated from the Mori score, experience autonomy and decision making from the MADM score, mistreatment in childbirth from the MCPC indicators, and childbirth experience will also be considered. Covariates will be parity, maternal age, residence status, marital status, education, employment, language, year of birth, mode of delivery and newborn health. I am currently I just finished collecting the data. So currently I'm going to start analyzing the data, which is the fun part, right? And so I'll look at background factors. We'll use descriptive analysis, student T tests, Fisher's exact exact test, child square test and logistic regression. And hopefully I'll be able to publish my results by the end of the year. But it's really nice to tell you that the total of 2370 mothers participated in the survey. And of those 1,829 answered in Icelandic, 327 answered in English, and 214 answered in Polish. And this survey here in Iceland, it's it's most of the surveys about, for example, healthcare or maternity care are in have been conducted in Icelandic. And they have failed to collect data in English and Polish. So this is one of the first studies that's able to do this when we're looking at maternity care here in Iceland. And, yeah, like I say, hopefully I'll have really interesting results to publish late in the later months. And as part of the discussion, I'm sort of very much looking forward to see how these results, you know, of whether or not migrant women experience less respect, less autonomy and more mistreatment in the native born Icelandic women. And also especially I would like to look at and discuss factors such as the duration of women's residency here, their immigration status, their level of education, job status, level of income, the language proficiency, and even being a person of color, whether any of these sort of play a factor in women's experiences. And it is my hope that this doctoral study will give healthcare professionals, administrators, and policymakers insight into the experiences of migrant women within the Icelandic maternity healthcare system. At the 72nd World Health Assembly in May 2019, the four guiding principles in the resolution on health of migrants and refugees included, one, the right to the enjoyment of the highest attainable standard of physical and mental health, two, equality and non-discrimination, three, equitable access to healthcare services, four, people centered migrant and refugee and gender gender sensitive health systems. In Iceland, the inability of the healthcare systems to provide care for the quickly increasing immigrant population has created a gap of disparity in healthcare between minority and majority populations. And shedding light on the experiences of this vulnerable population is the first step in improving maternity care for these women and their families. And I would like to end my presentation with a quote from Birth Matters, a mid-wise manifesto written by the inspiring Anna Megaskin. The way a culture treats women in birth is a good indicator of how well women and their contributions to society are valued and honored. And with that, I would like to thank you so very much for spending your time with me and listening to the work I've been doing. And I would love to answer any questions that you guys may have. So feel free. I think there's a question. Can I see a question from the chat? Reena is asking, why aren't these tools more widely used? Wish they were widely used in public. Do you have any suggestions for Reena about Birthplace Lab? Yes. Exactly. I have in my, let me back up here. Oh, sorry, forward. Here in my references, you can check out the amazing studies, Sova Dam and Stoll, they run the Birthplace Lab. And here you can see, if you look at my references, you can see the papers that they've published about their work. And also you'll see if you Google even the Birthplace Lab, you'll see the work that they do. And you can have access to the instruments, to sort of research in your own settings. Really great work. And actually, Catherine Stoll, who you see is one of the writers of the articles, she is actually in my doctoral committee. And it's been invaluable having her input when I'm collecting the data and how I'm analyzing the data and things like that. So, and they're very, very, very open to collaboration. And I know these instruments have been used in other countries as well. Canada, the United States, the Netherlands, Sweden, and more and more countries are using these instruments. And Cindy Farley is asking, I understand Icelandic language is challenging. How are you doing with that? I think in my situation, Cindy, that's a really great question. It was a sort of sink or swim situation. So, because the Icelandic, like I told you guys in the beginning of my presentation, I attended nursing school actually here in Iceland. And the curriculum and everything, the teaching and everything is done in Icelandic. So, I just had to be really good about attending all the classes, looking at all the slides, and translating from English to Icelandic to English and making sure I understood everything. And then also just listening to how proper Icelandic is spoken and reading Icelandic articles and the material in Icelandic, I sort of slowly, but surely picked up the language and learned. And so that was, and I also, as a nurse, we do, and in midwife, we do a lot of practical training. So, I was able to practice my Icelandic with my colleagues, nursing students, midwifery students, my patients. And so slowly, but surely I was able to get Icelandic done. So, yes, I am fluent today in Icelandic, but I've also lived here about 12 years. And I think Anika is asking, I'm wondering if you think change can be implemented based on your research. That is a wonderful question, Anika. And I'm so glad to see you here. I think that is my hope. I hope it can be. But change can only happen if we, you know, sort of get the right people to listen to the work that we're doing and also to demand it. And so just to sort of spread the awareness of the research, what, because I don't have the results yet, but hopefully the results will shed some light on the situation. And from there, we can continue to present the data, to present the research and to present our sort of suggestions and recommendations. Because if change does need to happen, it's good to have the research and the evidence to back it up. And so that we know which way we should go and what needs to be, you know, what needs to be addressed. What is causing the inequities in our healthcare systems? Where should we start? Great question. And just looking back to the birth lab information, Dr. Vadam was one of our keynotes last year. So if you go, you can access all our recordings. So if you'd like to go to, seems like a long time ago, 2020, Saris did a lovely job talking about birth lab and utilisation of tools, et cetera, et cetera.