 Before we go to the speaker of the day and the presentation, I would like to introduce Halima Musa-Abdi, who is a nurse, midwife and lecturer from the Department of Nursing Science, Amadubela University Zaria in Kaduna State, Nigeria. She won a Cardiff International Studentship in 2016 to run a PhD program with a research focus on the midwifery workforce in Kadiff University, UK. Her presentation is titled, Why Study Resilience Among Nigerian Midwives? It is a preliminary report from a grounded theory approach. Welcome Halima and take us through. Thank you very much Catherine for the introduction. You're welcome. I want to use this opportunity to welcome all the great midwife in the house to the virtual International Day of the Conference. I wanted to sit back, relax and enjoy the presentation as it lasts. Thank you very much. Now, my study is talking about why study resilience among Nigerian midwives. There is a growing evidence from research suggesting that depression, burnout, post-traumatic stress disorder, compassion fatigue are prevalent among nurses and midwife. This account for a quarter of sickness absence is elsewhere in the world. Though mechanisms have been put in place in some of the developing countries to be able to ascertain the course of sickness absence among midwife. For now, this is not recorded in my own country. For now, what mechanisms have been put in place? Now, staff ill health results may result into medication errors and matriotic patient safety. And so that is quite very unhealthy. Midwife, on the other hand, are exposed to a higher level of distress due to the nature of their work that deals with emotion. Emotion like joy, happiness, sometimes grief in the case of maternal death. So midwives, midwives are, sorry, I can't see the slide any longer. Nigeria has the highest maternal mortality in the world with about 814 per 100,000 live births. Nigeria is situated in Africa. On the picture here, this is Nigeria. It's situated in Africa in West Africa with a population of about 190 million. It has one of the highest maternal mortality in the world. This translates that midwives have the tendency of being exposed to attending to traumatic birth, which has been believed to be a documented course of stress for the midwives. Another addition to that is the shortage of midwifery workforce has become a global issue, including Nigeria. Nigeria has ranked seven out of the 57 countries in the World Health Organization regions. These World Health Organization regions, which are the African region, the region of the Americans, Southeast Asian region, European region, the Eastern Mediterranean region and the Western Pacific region. Nigeria is ranked seven. Then down to the country, nation level, Nigeria is ranked second after Ethiopia with a shortage of midwifery workforce. That translates to more stress for the midwife because they need to provide lots of services to midwomen requiring their care. So they are exposed to more stress. Then the tertiary hospital on the other hand is the busy unit in Nigeria. The tertiary hospital is served as a referral center for both the primary and secondary healthcare facility in Nigeria, but because of the low functionality of the primary healthcare centers, models are being referred from primary and secondary health centers to tertiary hospitals. This means increased women using this facility and thereby creating more pressure for the midwives. Now, together with the highest maternal mortality rate we have, the fact that the midwife are being exposed to the, I have the tendency of being exposed to providing care or experiencing traumatic, but alongside with the shortage of midwifery workforce, create pressure for this, create pressure for the midwives. Now, midwives are responsible for two lives, but it becomes more challenging in the Nigerian context where direct obtersury causes of maternal death, such as high-potensive disorders are very prevalent, coupled with socioeconomic factors like delay in seeking medical health, would translate that models are rushed in lately to the tertiary healthcare institution and the midwives are forced to provide care to save the lives of this model. This models, this results into workplace adversity and stress for the midwife. The midwives have been reported to be emotionally overloaded, helpless and even frustrated. The stress the midwife experience in Nigerian are likened to this plant here, which is growing and surviving in the cracked surface. This plant is obviously experiencing adversity, but you could see this plant is surviving and thriving. One of the biggest, one of the biggest reason for this that has been documented from study is resilience. Resilience is the ability to respond positively and consistently to adversity. Now, two previous study that have been conducted in Nigeria has demonstrated the prevalence of stress. This study is actually building on this previous study demonstrating that has demonstrated the prevalence of stress among nurses and midwives, but there has been a specific study demonstrating stress among midwives and how this midwife are able to survive and thrive. Now, some midwives are able to adjust and cope with stress using some resilience strategy. We could see this midwife in the picture here. She was awarded one of the best resilient midwife providing care, can get all mother care to the mother. Understanding more about how such midwife withstand workplace adversity and remain positive and motivated to benefit the midwifery profession in Nigeria. And it is believed that the water organization has such a well motivated midwife has the tendency to reduce three out of four maternal dead and that is what we want in Nigeria, how we can find a way of turning around our unacceptable high maternal mortality. The objective of this study is one to explore how the phenomenon and characteristics of workplace adversity are being experienced by midwife. Like I said earlier, there is no any study that is specifically looking at midwives resilient or looking at how the phenomenon of workplace adversity is being experienced by the midwife. This is the first study to demonstrate that after its finding to explore what is the meaning of understanding of the construct of resilient and resilient strategy and to further develop and explain a theory explaining how midwife survive and thrive in the phase of adversity. Now, the research methodology and methods. The research design is a qualitative research design. Why? Because information, in-depth information is needed to understand how the midwife experiencing adversity in this area develop resilience. A constructively grounded theory was method was utilized. The reason will be provided in the next slide. The area of study, like I mentioned, area at tertiary hospitals and I've provided reasons why tertiary hospital was taught due to the nature of their environment. The method of data collection was interviews and feed notes. Initially, focus group discussion was taught but due to the nature of the work of the midwife, it will be very difficult to bring the midwife into a group to form focus group discussion. So interviews were later taught to be used. Interviews were used for the first and the second phase of the study. The population of study is about 109 midwives. The sampling techniques was propulsive sampling. Grunder theory is characterized by theoretical sampling but then you need an initial data for you to get across to those that will form your theoretical sample. Then for that reason, you must use a propulsive sample as required in most qualitative study. Ethical approval was sought to ensure good clinical practice in medical research. Ethical approval was sought from three sites. One from the School of Healthcare Sciences, Ethical Committee, Cardiff University, United Kingdom and the two tertiary hospitals that were utilized. For the participants, presentation was made to the participant and their concept was sought. Midwife were extremely willing to participate in the study as soon as they consented to participate for the study. In vivo 11 was used to organize the data. Before that the interview were transcribed. After transcription, in vivo 11 was used to organize the data for the first and the second phase of the data. The second phase of the data was theoretical sampling. For the second phase of the data, the theoretical sample were used. This theoretical sample were gathered after the propulsive sample in the first phase of the data. The theoretical sample were made up of 11 participants who were also part of the propulsive sample but were recognized as resilient midwife. After the initial analysis, longer years of experience were sought to be a reason for being resilient. And for that, noboli method was used to get across each and the next participant that formed the theoretical sample on the theoretical saturation. Now for this slide, I'm going to talk about the grande theory methodology. Why was it used for this study? The grande theory methodology is a method of qualitative inquiry. Of course, we have five traditions of the qualitative inquiry, which is the case study method, the phenomenological, the ethnography, the narrative, and the grande theory. The grande theory methodology is used where the two or nothing is known about the phenomenon on the study and the concept of resilience is not known in Nigeria. There has been no study demonstrating that I have talked about how midwife developed resilience and even how the phenomenon and characteristics of workplace adversity has been experienced by midwife, despite the issues in the available evidence about the issues in their workplaces. Grande theory method is both a method of data collection and analysis. The end product of the grande theory is to develop a substantive theory grounded in the data generated from the participant. Like I said earlier, nothing is known about the concept of adversity and resilience, specifically among midwife and thoughts. Grande theory method was thought to be appropriate. In the next slide, I'm going to take you through the steps of grande theory methodology because it is both a method of data collection and analysis. The first step in grande theory, of course, is for you to do a purposeive sample. After the purposeive sample, you still run the grande theory method across the interviews or transcript generated from the first purposeive sample. The first one is initial coding using line-by-line codes. The initial coding is a heuristic device that helps the researcher to interact with the data. Before I proceed, I want to talk about the many. I want to explain what coding is. Coding means giving meaning to words. And grande theory is loaded with different level of coding. Initial coding, which is the first, like I said, is a heuristic device that helps the researcher to interact with the data because it involves line-by-line coding, coding line-by-line on the transcript using gerunds. Gerunds are verbs that end with ing, which signifies action and processes. The next step is constant comparative analysis. In constant comparative analysis, as you collect the interview and data, is the process of comparing one data to the next data. Looking at for similarities and differences, and that will tell you what to look at in the next data or the next interview. In vivo coding is another level of coding in grande theory method. It means using participants' special terms and naming the codes after that particular term in the particular word you wanted to code. It is also called verbatim coding. It is very, very important in grande theory because as much as possible, participant words and voices are often needed towards generating the grande theory. Then the next level is the focus coding. Focus coding, just like the word signifies, focus are those number of codes that appear in the initial codes. The researcher is needed to focus on that code and is believed to be necessary for generating the theory. Exact coding is another level of coding, it's an advanced level of coding, but according to Katy Shamas, this may not be necessary during the analysis. Then the theoretical coding. The theoretical coding is another name called conceptual category. When you have summed up all this coding and you have gotten to the level of the theoretical coding, it's to begin to link up your concepts and link up the concepts. Linking then one to another towards the generation of the theory because theory is the linkage of two abstract ideas towards the generating of a particular theory. Memorizing. Memorizing is an important component of grande theory because the researcher is advised to record or write down every decision he or she would have taken. And we fall back to that because grande theory method takes a lot of time and sometimes decisions taken at a particular time may be forgotten and it's required that the researcher writes down reasons for every action and reasons for naming a particular code at every stage of the data collection. At this stage, the researcher is advised to select a core category that is very, very important to be linked together towards generating the particular theory. The next one is theoretical saturation. The theoretical saturation is when subsequent data collection does not spark any theoretical insight. Then the researcher would categorically say this is fine. It is when this epistemological hunger has been satisfied it is believed that you have attained theoretical saturation and hence you're supposed to stop or terminate data collection at this stage. I have this theoretical sampling because it is also a part of the grande theory methodology which I've explained earlier. After the theoretical saturation, you begin to do your theoretical sorting, diagramming and integrating and finally generating the theory. Now, the grande theory methodology utilized for this particular study. The whole method was utilized with the exception of the axial coding. The axial coding was not used because it is believed that it is not actually needed for the theoretical coding. And as such, I move on to the level that is the theoretical saturation, the diagramming and integration. I want us to know that that is an analysis in grande theory methodology is an ongoing process. So this is a preliminary report of the body because analysis is still ongoing until theoretical saturation. Now, I have the tentative results for this. The tentative analysis results are here. The first category is this, experiencing workplace adversity and perceived effects. Now, these four categories are believed to be the resilience strategies the participants utilize, but this is still ongoing because data analysis is still ongoing. And just like I mentioned earlier, this is a preliminary report. This fourth category here demonstrates the experience of workplace adversity and also the response and perceived effects to the adversity experienced by this participant which will be discussed in the subsequent slide. Now, the first category which is also the theoretical code have some group of focus code underneath which is the first category is experiencing workplace adversity and the number of focus codes that were clumped together into that particular category are one, working in difficult workplace environment, having poor collegial relationship, having difficult midwife patient relationship and grappling with difficult emotions. These are the analysis, these are the experiences of workplace adversity among the midwives participants. Then the second subcategory under the category one is responses and perceived effect of adversity experience and under this we have losing it and overreacting by the midwife, developing fiscal challenges, delivering poor quality of care, then being out of balance. These are some of the responses and perceived effect of the adversity experienced by the midwife. But the purpose of this presentation I shall be discussing the experiences of workplace adversity as discussed in the first subcategory before this particular slide. Now, working in difficult workplace environment. In this place, the participant talked about how they are being faced in working in difficult environment, self-shortage, increased high patient workload and working in a facing health research, facing with some available unavailability of some facilities in the head centre cause a lot of stress to them. Now, the first one is one of the participants, Aisha, who works in one of the hospitals. This is, I want to remind us that all these names are pseudo names, they are not actually the name of the participant. When she talked about, she can imagine there was a day a patient was brought in with routine placenta after 24 hours full in, but she was bleeding and that day I was the only midwife in the world. The other midwife had gone to get a patient from the theatre, had to start running up and down to look for the doctors on that same day. I had two other patients who were already on second stages. It is usually so stressful when this patient come at late stage and also annoying is something that could have been prevented and resolved easily when they report much earlier or if they had delivered in the hospital. The midwife are faced with women rushing into the hospital very, very late and they are forced to provide care to save the life of this mother. This was thought to be, to create a sense of adversity to the midwife. Another midwife participant, which is typical of many, talked about their workload. Sometimes it pulls them to try to provide care to about 10, 15, 20 patients. You see other patients again waiting for your help. Plenty of patient models are lying down for you to check them. They are just coming for you to admit them. A clamped patient again, at times it is so frustrating and very exhausting. This was said by another midwife in the same facility. All this creates a sense of adversity and is typical of many of the participants in both of the tertiary healthcare institution. Still on working in a difficult workplace environment, the special care baby units, which one of the participants talked about that. Sometimes the midwife is required to quickly take a baby to that unit. You find that sometimes there is no light source for her to see or even take the baby to this particular unit and this is believed to be a source of danger to even the midwife and the baby because there is tendency the baby may even drop from her hand causing trauma to the child. Another one one other findings is having pop-collegial relationship. Some of them referring to the senior midwife, they will just relax like senior ones. This is from one of the senior midwife. When you are working with them they will just relax. They do most of the work without no supervision. It is believed that it creates a sense of adversity to them because they feel very tired and exhausted plus no supervision from the senior midwife and the work feels relentless for them and thus creates a lot of pressure for them. Still on pop-collegial relationship one of the midwife participants also talked about that it may not really be a shortage of staff that is the problem. It may be that your colleagues are not putting in the way you are putting in at work. So it affects what you give to the patient and it also affects how the patient relates back to you. This is very very important. This participant is trying to say having pop-collegial relationship in that midwife patient relationship and of course the particular midwife during the work may not be able to give what is necessary to the patient and of course that will create stiffness in their relationship and may even affect for that affect the access of using intrapartial services by this particular patient. The next category, the next focus code that I was talked about under the first category is having difficult midwife-patient relationship. Mostly the patient-relative are always very aggressive and anxious. Immediately they bring the patient all they want you to do is to stop all whatever you are doing and attend to them and the participant. If you have a case that needs more attention than the patient, they will feel like you are neglecting them and you are not giving them the attention. So they will become angry and verbally aggressive. These are all believed to create a sense of adversity to the midwife and this is because of many of the interviews. This is just one among what the participant have said. Now still on the same issue another participant talked about another participant talked about now due to distress you are not able to put yourself in a comfortable position. What she is trying to say here because of the stress midwife is experiencing even her facial expression tells that she is stressed and she may not be able to relate very well to the patient and for that reason they may at the end of the year have a difficult midwife patient relationship where the women are not able to express themselves and tell the midwife what she actually wants. Now the last slide is grappling with difficult emotion. The midwives here tried to talk about how they are being faced with maternal death, feeling of guilt and responsibility was was filled up in their expression because most of them feel that they are even sometimes they feel bad as if they are the cause of the death they go home feeling very depressed some of them even cry in their place of work like this one she said the most awful one is when it is fresh still but it is painful I know that for me I was feeling very bad that why should she give back to a fresh but after nine months she went through all this discomfort I took and the first time she took this delivery I went home feeling so sad as if it was the cause of that death. This all adds up and creates a lot of pressure for the midwives. Still on grappling with difficult emotion now instead of looking for how to bring the women to the hospital they left her with the bat attendant at home and the bat attendant came to the hospital she kept on on tea she became paper white this woman was rushed into the hospital she died leaving behind five children the witness reported that she had to cry so much on that day and even after work this creates a lot of pressure as I have discussed earlier to the midwife and it creates also a sense of adversity now having discussed all these findings which was categorically looking at the experiences of workplace and like I have mentioned earlier that this study is a preliminary report and the study is still ongoing findings from this study has demonstrated that midwives are faced with workplace stress and adversity which is tough to influence the decision to stay in the profession and we need more midwife to be able to help us turn around our maternal mortality statistics we need to find a way of supporting midwife so understanding how midwife develop resilience is important to Nigeria midwife to ensure the provision of compassionate care compassionate care is necessary to increase access to quality intra-pattern services when you give compassionate care to mothers you have highly motivated midwife the midwife the mothers will develop passion to have even utilize the intra-pattern services in Nigeria and of course we help reduce our maternal mortality finally I would like to say thank you very much for your complete attention the midwife here is one of the resilient midwife in Nigeria and I have a picture here and that brings me to the end of my presentation so thank you all yeah friend could you please unmute your microphone and take the questions yes thank you very much for that so Halima as I said and we are ready to take questions so if you have a question to ask you can type it in or you can raise up your hand so that I can give you the right to ask the questions alright Halima I will start you off with the first question okay what is the government doing to curb the shortage of midwives in Nigeria thank you very much for that question mechanisms are being put in place to see how more midwives how women will be enlightened on why midwives are necessary especially in the rural areas young ladies are being motivated to come into Midwifery and as a mid what we call the midwife service scheme which has been developed to have mobilized retired midwife to go to rural areas to support support models needing the help of the midwife and also those midwives that are unemployed will also mobilize to these areas to provide care to women at the rural areas in a way of helping the maternal mortality in our country alright thank you for that there is a question or comment from Margaret she is saying she is interested in the spirituality part of being resilient what do you say about that like I said earlier the findings is still ongoing but what the participant actually talked about in the spirituality which I said for the purpose of this conference I am only talking about the experiences of workplace adversity the other four categories I said research is ongoing data analysis is ongoing but one of the biggest reasons they said is that one of the things that keep them motivated is that they believe that midwives are only going to be rewarded by God they feel strongly attached to that and because of that they feel strongly motivated to provide more care but that finding is still coming up because analysis is still ongoing I believe that at the end of this study I am going to talk about that but for now those are tentative results and tentative categories alright thank you for that any other questions to Halima Halima another question for you okay is there a way to redirect people to the primary and secondary centers instead of them going directly to the tertiary centers which you indicated are for referrals thank you very much the only way that they can be redirected is that now because of the universal health coverage midwives medical doctors are taking turns to go to the primary healthcare centers to provide care on a particular day so that mothers will be able to utilize that center and they will know that okay we have coming to this center to provide care and so they will want to use that facility thereby it will go a long way reducing the number of people going to the tertiary hospital so that is the mechanism that is being put in place okay thank you alright Halima there is a comment there from Joe he says I am a remote rural midwife in New Zealand and have similar challenges here working very hard to prevent maternal and maternal mortality we have cold icy roads I appreciate how hard it must be for you our women here are well healthy women with access to good nutrition and it is still difficult Halima I am not hearing anymore I am a person about typing you are not hearing anymore no I didn't hear the last bit can you say that again sorry it just went smooth say it again please there is a comment in the chat box you can read it I can't read it here okay it says I am a remote rural midwife in New Zealand and have similar challenges here working very hard to prevent maternal and maternal mortality cold icy roads I appreciate how hard it must be for you our women here are well healthy women with access to good nutrition and it is still difficult so what is it that what is it that is difficult I didn't get that bit sorry she is saying that they have healthy women and they have good access to nutrition but it is still difficult for the midwives there although they have these good facilities so she can only relate how difficult it must be for these women in Nigeria so is that a question or a contribution no it is just a comment okay okay thank you very much it is really difficult more in Nigeria because nutrition is also an issue because some of them may not have enough to feed so it is also an issue but the midwife is tasked with a lot of responsibility to help educate to serve as an advocate to talk more to the midwife to the mothers on how they can use locally available food to provide nutrition while they are pregnant and even to the other members of the family and you applaud the work that you are doing so we can take one or two more questions because we have about four minutes any more questions for Halima there is a comment from Margaret she says perhaps it would help to have more education for the mothers what do you say about her comments yeah that would be very very important and it becomes the role of the midwife to sensitize mother to sensitize the mother at the alternator clinic to collaborate with non-governmental organization to see how they can use medias to sensitize mother on the need to use the facility and importance of taking the prompt decision to report to facilities at the right time because it will go a long way on reducing maternal deaths in Nigeria thank you for that comment in an earlier presentation we had about twinning and we were informed that this is a concept that has been adapted in Nigeria can you tell us a bit about it and how it's improving the life of midwives in Nigeria well the twinning is kind of the twinning is bringing the is a concept that brings two workers in two different countries to be able to share resources that will help like that will serve a source of collaboration and will also solve some of the five problems in the country I don't really know much more about twinning but I attended a conference that I talked about it briefly and somebody is actually currently talking about the session and the session before my own before my session I didn't really admit the last bit of the presentation I would have been very grateful if I would get part of the presentation and she said she was going to send a link or she will email us an article about the twinning I'll be very pleased to read about it and when I go back to my country I'll be able to join forces and see what the twinning is much more about but I believe it's going to go a long way because any knowledge cut in is going to be wasted it's going to add more knowledge to the midwife it's going to go a long way in reducing maternal death or creating more knowledge to the midwives which they will in turn use to better the life of mothers in Nigeria all right thank you very much Halima for that do you have a last word to tell the participants before we move on yeah I do want to say I hope they did enjoy the presentation and I wish all of us a great virtual international day of the midwife thank you very much thank you Halima