 And so we are coming to the session. So I would like to introduce our speaker for this session, who is Isabella Gatt. Isabella Gatt is a PhD candidate at Charles Darwin University. She's a registered midwife with more than 12 years of experience as a midwife educator and a researcher. She's a fellow of the Ghana College of Nurses and Midwives and a member of the Ghana Registered Midwives Association. Isabella is actively involved in advocacy and currently she's a member of the action on preeclampsia Ghana. This is an advocacy group which is concerned with preeclampsia in Ghana. She is currently pursuing a PhD focusing on improving midwifery care for women who develop preeclampsia in Ghana. A big hand for Isabella as she presents to us. Thank you everyone for joining us today, wherever you are joining from around the world. And thank you Bupe for the introduction. Yes, I have worked as a midwife for over a decade and it's a job I absolutely love. I'm passionate about quality care for all women no matter their location. Far too many women die during pregnancy and childbirth. Meanwhile, there's so much we can do about it. The good news is, as frontline maternity service providers, midwives can avert a huge proportion of these deaths and save many mothers and babies. Isn't that incredible? Yes, it's really good to know. And like what was said this morning, if midwifery care was a vaccine, all women would be rushing for it. So let's follow the data and invest in midwives to ensure best equity for all. I'll be looking at midwives knowledge of preeclampsia management and this is a scoping review that was done in 2010, 2020, sorry. This is the outline of the presentation. Maternal mortality remains a global challenge and unfortunately many women die in low and middle income countries where rates are unacceptably high. Prevailing health disparities in these poorly resourced settings often make the situation worse. Preeclampsia is a hypertensive disorder of pregnancy and this multisystem disorder can lead to a rapid deterioration in maternal and fetal condition. Currently, it is the second leading major cause of maternal death. Preeclampsia leads to multiple short-term and long-term consequences, some of which include prematurity, low birth weight, still birth and for the mother, she can live with lifelong cardiovascular and renal disease. Also, the baby can have a lot of cognitive challenges later on in life. Preeclampsia is highly prevalent in low and middle income countries and usually the care for women is complex and centered on a multidisciplinary team-based approach. So this team must be highly competent and must be able to institute evidence-based interventions from guidelines. Now, the important thing to notice that in preeclampsia, prevention, early recognition and prompt treatment are important to reduce adverse outcomes and so the care that this woman receives must be prompt, must be concise and must be based on best available evidence that fits the context. Midwives are frontline maternity service providers in many nations and they are often the first point of call and so the midwife's ability to recognize and initiate timely treatment is very essential in maximizing the outcome. This means that the midwife's knowledge and her practice skills must be top-notch. In the literature, there's some evidence that in primary health facilities, health professionals find it difficult to assess, to diagnose and to refer women with preeclampsia whilst in tertiary health facilities, non-adherence to guidelines seems to be the issue and so although the literature shows that there's suboptimal treatment of preeclampsia and has linked this to inadequate knowledge in some studies, midwives have not really been studied and so this remains unknown. We currently do not have the evidence to support this. So previous research has focused on maternal and neonatal outcomes of preeclampsia and the biomarkers of the disease and admission trends. Some have also looked at women and community perceptions. However, a few primary studies on health professionals have been done and so we decided to take the scoping review to actually identify the scope of research by describing the nature of research, quantity and quality and also to document gaps in knowledge and make suggestions for future studies. So we asked what do midwives from around the world know about preeclampsia management and this is how we went about it. So we utilized the JBA recommended format for conducting scoping reviews and so based on the population, concept and context format, we actually identified studies we wanted to review. So our population of interest were professional midwives or nurse midwives and the concept we're interested in is that they are knowledge about any aspects of preeclampsia and we're also interested in studies from across the world from any hospital setting or primary health care setting. Because we wanted to obtain contemporary evidence, we put a limit of the last 10 years during which we reviewed the papers and also because of our language limitations, we only reviewed studies that were published in the English language. So how did we go about this? The recent question actually guided our search. So we developed such terms and we used a combination of keywords, free words and medical subject heading terms and we searched these databases in April 2020 and we updated the search weekly even as we were writing the results. Now we also did a hand search in key midwifery journals like Woman and Beth and Midwifery to also see if we could find more papers and end notes was used to manage the data. And so after the database search was complete we actually retrieved 210 articles which we exported through end notes and after screening them for titles and abstracts we realized that some of them were not really relevant to what we were interested in to be excluded them and finally we had 35 papers which we now read cover to cover and excluded six. And the reasons we excluded the six was that they didn't mention any professional midwives in the sample. They were talking about some referred to lay midwives or lady health visitors and these are of non-professional cadre. And so at the end of the day we retrieved 20 research papers and nine guidelines. So how did we now retrieve the data from the papers? We used two data instruction tools. The first tool extracted data based on the country of origin, the study design, the data collection instruments and a summary of the findings and the second tool actually extracted data from the guidelines. And we actually used an approach where similar concepts were identified across the studies. We grouped these into categories and we compared them and we labeled them as themes. And we also wanted to know the quality of research that has been done. So we used the Hawker et al. 2002 tool to actually assess the papers for regal or methodological quality and we actually used a scoring system as you can see on the slide. So this is what we found. Okay, so just to give you a brief overview of the findings we actually realized that out of the 20 papers, 19 of them were quantitative and there was only one qualitative study. Now there was an dominance from the African region however we didn't identify any study from Australia, from the United Kingdom or the USA and these are all high income countries. As we performed the quality appraisal we realized that the research that has been done is actually a balanced mix of good and fair quality and we identified four key themes from the data. So let's take a look at the results a little more closely. So as you can see four studies were from South Africa three from Tanzania and three from Nigeria. And out of these five of the studies were thesis. So two actually were from South Africa from Tanzania and the so qualitative study was from Nigeria and it was part of a large multi-center trial. In the studies the commonest tool to assess midwives knowledge were questionnaires and some studies also had very small sample sizes. For example, in China only three midwives were included as part of the sample and in one Romanian study there were only 12 midwives as part of the sample. Most of the studies described the midwives had between one to ten years of experience and the studies were conducted in a variety of hospital settings that range from rural, urban, tertiary, specialist and in some cases they describe them as primary care clinics. So let's look at the first theme. Now this theme actually addresses whether midwives knew the theoretical aspects of preeclampsia and whether they knew about assessment techniques. So this theme had two sub themes and the first sub theme knowledge of defining features actually spoke about whether midwives knew the risk factors, the maternal symptoms, emergency signals, diagnostic criteria and future cardiovascular risk. In some instances midwives had inadequate knowledge on these aspects. However in other instances for example three Nigerian studies reported that midwives knew the risk factors, the signs and symptoms and were aware about future cardiovascular risk. Regarding correct clinical skills this theme actually addressed whether midwives knew correct assessment techniques and whether they knew about blood pressure monitoring, history taking, laboratory tests to diagnose preeclampsia and the required clinical checks. Now knowledge was lacking especially on blood pressure assessment. In some instances midwives did not know about arm positioning did not know the correct technique did not even know sometimes about the calf sizes and in some studies also midwives did not know when to begin blood pressure monitoring to obtain baseline values. Regarding antinatal visits in some instances midwives had inadequate knowledge about increasing frequency of antinatal visits for women at high risk of preeclampsia and health educating women on the worsening signs. Knowledge was also lacking on that aspect. However we found that women who midwives who went in urban centers sometimes had more knowledge and in an Indonesian study midwives in an urban area knew the required clinical examinations. The second theme treatment of preeclampsia had three themes. Let's take the first one knowledge of guidelines so this actually addressed whether midwives knew the guidelines and knew the content of the guidelines. In some instances midwives were aware of guidelines but did not know the content whilst in other instances midwives did not know the national or international guidelines as occurred in a Tanzanian study. However in South Africa on the other hand midwives knew the guidelines that should be implemented in severe preeclampsia but they were not too familiar with guidelines for mild to moderate preeclampsia or their country's recommendation because according to the international society for the study of hypertensive disorders preeclampsia should not be categorized as mild, moderate or severe. The second sub theme knowledge of appropriate treatment actually addressed whether midwives knew the medication and the side effect profile and essential midrify care such as monitoring. Although guidelines differ on the choice of first, second or third life anti-impertensives midwives could not differentiate between routine anti-impertensives and those given in emergencies and this is a little alarming also midwives in some of the studies did not know that aspirin or calcium is given for preeclampsia prophylaxis so at risk groups. Knowledge was also lacking concerning the indication the root of administration the dosage, the signs of toxicity and the antidote in terms of magnesium sulfate so these were all knowledge gaps that we identified. However, in some instances midwives knew about treating eclampsia and in Afghanistan the midwives knew that they must call for help position the woman left to natural administer oxygen protect her from injury and check the fetal heart rate so that's very good. The third sub theme knowledge of inappropriate treatment actually from the data two drugs were repeatedly mentioned in the literature and these were diazepam and egomension it is quite interesting that about 60% of midwives across studies cited the need for intravenous diazepam although standards and guidelines were strongly advocate for magnesium sulfate as the drug of choice. Again, in a Romanian study midwives mentioned that they would give egometrine and this is a little alarming because egometrine can actually exacerbate hypertension and is contraindicated. The third theme emergencies emergency procedures actually had two sub themes in some instances midwives knew about preparing for emergencies and they actually knew about essential drugs and supplies to stock for example, some midwives mentioned that they needed IV fluids they needed suction cutithers and oxygen face mask and sometimes they also mentioned that they knew that the blood pressure apparatus must be regularly calibrated. However, regarding the management of emergencies only 20% of midwives in a Tanzanian study were knowledgeable about safety during emergencies and some of them mentioned that they would actually leave the woman alone to request for an ambulance. In Afghanistan 50% of midwives did not know about stabilizing the woman before referral to a higher level facility. Now the last theme factors influencing midwives knowledge. We realized from the data that where with whom the midwife worked and how long she had worked influenced her knowledge. So we identified three groups of factors work related factors pre-service education related factors and continuing professional development related factors. So midwives who went in larger tertiary hospitals in urban centers, those with a high midwifery caseload those who had an appropriate skill mix at work meaning that there was a very good balance mix of experience and novice midwives working together and those with more experience had more knowledge. For example in Tanzania the midwives who worked in the urban areas knew about what to look out for and then the required clinical checks. We also found from the data that midwives with baccalaureate degrees had more knowledge than their non-degree counterparts. And lastly regarding the continuing professional development, we found that three quasi-experimental studies actually reported that before training knowledge was lacking on several aspects but after training the midwives knowledge increased profoundly and this they attributed to the material or the content they had been exposed to during the training. In fact in one such Romanian study the midwives knowledge increased significantly one week and one month after and that study used a blended technique of lecture, of video case studies, clinical tests, vignettes and practice and more of like discussions. Also in Indonesia midwives who were regularly supported with physician visits had more knowledge possibly because of interprofessional learning. So we set out to find what do midwives from around the world know about preeclampsia management and what we found were studies from low and middle income countries that showed that midwives had inadequate knowledge on several aspects of preeclampsia management. However we must also extrapolate findings cautiously because some of the studies had very small sample sizes and unclear reporting about data analysis procedures and in some studies the context was also not well described. Again more of the studies did not focus on areas relevant to midwifery practice like health assessment health education management of acute emergencies in fact health syndrome was not mentioned at all labor and postnatal care. And so although the scope of midwifery practice differs across countries, per the ICM's recommendation midwives are involved or should be involved in complication management and therefore it means that the midwife must be knowledgeable and so we need to take pragmatic steps to strengthen midwife's knowledge in these settings and one of such steps is clinical mentoring because this can actually promote critical thinking and encourage reflective practices. New entrants can also shadow expert colleagues and learn by observing them. Another thing is that we also need to increase in service training opportunities for midwives especially those in primary health facilities. Guidelines are lengthy and from this review we found that some of the guidelines are inconsistent across board and seem impractical. Also there's the issue of visibility. Sometimes the guidelines exist but are not visible at the grassroots level. Midwives must be sensitized on the use of evidence to inform our practice and shorter versions of guidelines can be adapted for the midwives use. In this review we did not clearly identify the barriers and facilitators of midwives knowledge. We need to bear in mind that midwives lack of autonomy, scope of practice limitations, educational preparation, as well as workplace demands can negatively impact on what the midwife knows about preeclampsia. Task oriented care models that midwives adopt in their day to day work could also limit their knowledge on preeclampsia because they are focused on performing that task and they actually become masters of a task and not like giving comprehensive care to the woman. Again, burnout from being overwhelmed at work because of immense workload pressure could also impact the midwives interest in seeking continuing professional development opportunities. In the literature we didn't find any validated instrument that was used to assess midwives knowledge and so there's an urgent need for this. So what are the implications of the findings? Well policies on capacity building for midwives need to be updated or redesigned to include blended models that have both a theoretical content and a practice based content because from the literature we realize that blended models that combine innovative software approaches and other non didactic methods actually improve the midwives knowledge. Again, we also need to prioritize adding like more policies that will actually strengthen or support midwives to adequately perform their function and governments must show commitment to prioritize spending maternal health and investing in midwives. Clinical audits can also be conducted to identify gaps in care and institute measures that we can actually go about changing things that are wrong to ensure that the care that we provide is evidence based and is of high quality. There's also a need to strengthen midwifery education to ensure that we have high quality education and just to address what was said at the pre-conference this morning we need an agent investment in quality midwifery education. Future research is also very much needed and future research can examine the barriers and facilitators to midwives knowledge on preeclampsia and other obstetric emergencies. Future research from high income countries is also important and observational studies can also identify if knowledge and practices are congruent and also the suitability of post qualification training programs. So in conclusion midwives in some low and middle income countries have knowledge deficits on some aspects of preeclampsia management and we need research to explore the creation and implementation of interventions that can improve midwives knowledge. We should remember that knowledgeable and highly skilled midwives can turn the tide around and save many more mothers and babies especially those who experience preeclampsia. These are our references. Thank you very much for listening. I also like to thank my wonderful mentors those who have mentored me in the past those who mentored me today and those who continue to inspire me and will possibly mentor me in the future. Thank you very much to the audience. Bupe over to you. Thank you very much Isabella for a wonderful presentation. Indeed preeclampsia is a major public health concern especially in low middle income countries where resources are inadequate and so I would like to open the floor to questions so any questions that you have to Isabella can either be typed in the public chat or you can just unmute and ask Isabella. Feel free to ask from the presentation that she's just given she's very passionate about preeclampsia and indeed we need solutions to this life-threatening condition. We've seen a lot of women dying after having been diagnosed with preeclampsia and the complications that come thereafter to both the mother and the baby. So any questions people? Hello I can see some people are typing. Oh great Raleo Miriam says thank you very much Isabella for the comprehensive research presentation on preeclampsia. Indeed it is a public health problem. Thank you very much Raleo. Let's continue the conversations. Feel free to unmute and talk. Ganyo says very educated. I'm glad to attend. Perfect. Thank you very much Ganyo. Do we have any midwives from Indonesia? Isabella said you had no knowledge on the geometric news in hypertension. We need a midwife from Indonesia. We want to hear from you. How about you Bupre? Do you have a question? Yes Isabella Hello Isabella, yes My question will definitely go to the Indonesian midwives because according to your findings literature you finding they didn't have enough knowledge on the use of egometry in hypertension and as a midwife we are trained and we know to say egometry shouldn't be used in hypertension. So I would definitely like to hear from midwives from Indonesia if we have any or do you want to Indonesia but I think I can actually speak to this. Sometimes it's about what is available and we don't like I said the context were not well described so we do not have like the full picture so maybe that is what is available and so that's what they have consistently used and you know sometimes the way practice is if you don't update your knowledge and you constantly do something kind of becomes robotic you don't really think through what you do and so it could be that that is what is available and so sometimes like the policies or the guidelines or logistics are not available and so midwives have to adapt to using what is available however we should always bear in mind that quality of care is also about making sure that we are actually giving care that meets the standard care that is safe care that bears in mind the risk and how to mitigate those risks and so sometimes we cannot solely put the blame or say that midwives have inadequate knowledge when we haven't studied other contextual factors that could actually contribute to inadequate knowledge Thank you very much Isabella for that response Perfect so if we don't have any questions or I have a question hello Hello Hi okay my name is Koywa Koywa Viofoswapia and I'm from Ghana and great presentation Isabella it was interesting to see I only have one question I wasn't sure whether the research in terms of was based on one particular country or it was a representation of what has happened globally or yes I wasn't clear on that and so maybe you can clarify that and just to throw it out there that I think it's very important when it comes to the knowledge that midwives have to acquire when it comes to preeclampsia because you know after the diagnosis all that the doctor needs to do much of the time when it comes to monitoring is under the care of midwives and so it's very important that they know all this and being a four-time survivor myself and having only one baby out of four conceptions it is not something that we should joke with and so it is very important that midwives are up to dating up to have the relevant knowledge at every point in time always stay updated on how to manage preeclampsia, its conditions and all that comes after it and so thank you again Sabela and if you can clarify the research representation for me I'll be grateful Thank you Koywa for the question and Koywa is actually the CEO of APEG Ghana so thank you very much APEG Ghana for joining us today and this was a scoping literature review so what we did was we compiled research that had been done on midwives knowledge of preeclampsia from around the world but what we found where most of the studies or the research that we found in this endeavor were mostly from low and middle income countries so that's not what we set out to do we actually set out to find globally what do we know about midwives knowledge concerning preeclampsia but then we actually found studies that were mainly from low and middle income countries with an African dominance and then as you mentioned yes it's really important that midwives are up to date regarding preeclampsia management because as I mentioned at the beginning is currently the number two cause of maternal death but in fact in Ghana preeclampsia is actually a leading cause of maternal death and so we need to have uncomfortable conversations about this because it's only when we identify what is wrong that we can get measures or create measures to fix it if you don't know what is wrong you can fix it so this study is just one in the drop of a big ocean but it gives us a good idea that maybe midwives practicing midwives are not having these CPD opportunities maybe practicing midwives are not having the right logistics to work with like there are so many things that we need to consider and this study actually forms part of a broader PhD study that seeks to explore the multi-level factors influencing the management of preeclampsia by midwives so thank you very much Coywa for your submission and for your presence and follow up so even though you set out to find out something globally and then your research says you found more on low middle income countries what does that tell us about the data available or what does that tell us about the condition in itself and its prevalence rate thank you very much and Bupe asked the same question yesterday during a trial session we had so this actually tells us that first of all it's important to know that as part of the risk factors for preeclampsia there is women of African origin are more predisposed to preeclampsia again it's also about scope of practice so in high income countries the scope of practice is different from that of low and middle income countries for example in high income countries women who develop complications have more of obstetric lead care while in low and middle income countries although the management of preeclampsia is supposed to be in a tertiary facility before the woman gets to that tertiary facility it is the midwives they are the frontline service provider so she's likely to come in contact with those so that is why perhaps we found more studies from low and middle income countries than high income because of scope of practice differences