 So today, it is with great pleasure That I introduce Halima Moussa-Abdol. She is a nurse midwife – a fellow of the West African College of Nursing – and a lecturer from the Department of Nursing Science at Armadw Bello University Zarya–Cod난ios State Nigeria. She started her journey into nursing in 1996, in the School of Nursing Armadw Bello University Teaching Hospital, Zaria, Nigeria. Where she qualified as a registered nurse in 2000 and proceeded to qualify as a registered midwife in 2005. In 2014, Halima gained a master's degree in maternal and child health nursing midwifery. And in 2012 Halima was registered as a public health nurse with the Nursing and Midwifery Council of Nigeria. Halima won an international student citizenship in 2016 to undertake a PhD study of the well-being of the Nigerian midwifery workforce based in Cardiff University in the UK. She has published articles in high impact factor journals and has also presented papers at both national and international conferences. It gives me great pleasure to introduce Halima to talk about her study on midwives experiences and prevention of workplace violence in tertiary hospitals in northern Nigeria. You're very welcome Halima. Are you able to unmute your mic Halima and then you have presenter role now. Are you there Halima? Thank you very much Ali for having me and thank you very much for that description of me. My topic, what are we talking about today, is a bit of finding out of my PhD journey and it goes this way. Even some of us were being slapped and then what do you do? It's just at the expense of your job. This is a bit of a verbatim extra of the quote from participants describing or explaining some of their experience that depicts workplace violence. And then here we go. I'm going to be talking about the experiences and prevention of workplace violence among midwives in tertiary hospitals in northern Nigeria. That's my name again, my supervisors, Professor Hunter Billy, Warren Lucy, who are all midwife raising Cardiff University United Kingdom. Now midwife has been reported as experiencing higher level of stress compared to other healthcare professionals. This is not surprising due to the nature of our work that deals with us dealing with women with a strength of emotion, emotion of joy, sadness and sometimes. And the experience of maternal death in some developing countries like our country Nigeria. In Nigeria and the midwife stress is further increased because of palpable shortage of midwifery workforce and a high maternal infant mortality rates, which I'll be talking about as we go through the slides. Still on the introduction. The shortage of midwifery workforce is a global phenomenon, including Nigeria. Nigeria is ranked seven out of 57 countries in the World Health Organization region. This World Health Organization region is the region of Africa, region of America, region of Southeast Asia, the region of the European region, the Eastern Mediterranean region and the Western Pacific region. From the cycle there, Nigeria, for those of us that don't know where Nigeria is, Nigeria is situated in West Africa. We have a population of over 200 million, which is generally about the population of Eastern Europe. We have one of the highest maternal mortality in the world. The official figure from Nigeria says we have about 512 maternal deaths by 100,000 live birth. But the UN United Nations Agency puts the figure of about 914 by 100,000 live birth. So whichever figure or statistic we are going to be using, this maternal death are highly phenomenal. And this puts midwife to more stress because they try to work so hard to make sure they save the life of mother and find a way of turning around the maternal mortality. Now, still on the stress issue or workplace adversity, many tertiary hospital is a busy unit in Nigeria. And I want to explain why we have that here in Nigeria. Tertiary institutions are facilities that are designed to assess referrals from primary healthcare settings, secondary healthcare settings and sometimes the private settings. But due to the low functionality of primary healthcare settings, in theory, the primary healthcare facility are designed as supposed to be the entry points for the women into the community to seek for help. And then when there are complications or issues arising, they are supposed to be referred back to tertiary hospitals for further management. Now, because of the low functionality of these hospitals, 60% to 90% of mothers are self-referred and served to tertiary hospitals, increasing the number of women using these settings and placing a high burden of high pressure on the frontline midwives. Still on that, shortages of midwife with harsh work environment characterized by frequent stock out of basic commodities. What I mean by stock out of basic commodities is that you find out that instances, some of the consumables that are supposed to use to support these women during childbirth are not available. This is a source of stress for the midwife because the midwife is ready to provide cable that items she's supposed to use is not there. So it's a source of stress for the midwife. Together with poor supply of water and electricity and the increasing rate of facility-based delivery notable in tertiary hospitals, like I've said before, result in a perfect storm for the midwife. Now, all those issues may result in moral distress, burnout, and the inability of the midwife to provide quality of care to the mothers because of all these issues. There is also a link between burnout and the mistreatment of women, and of course this may contribute to a poor midwife relationship as reported by many studies. This is a part of the midwife. Now, studies also reported that in Nigeria, the out-of-pocket expenditure, which constitute nearly 90% of health expenditure in Nigeria, places a significant burden on majority of the household, most household. Out-of-pocket system of healthcare finance has these inherent problems. Now, the effect of catastrophic health expenditure in child among other factors, literacy, ignorance, and many other factors may result in patient aggression as reported by other studies at the slightest provocation and they may transfer the aggression to the healthcare workers. Now, all these events collide in the labour room and may further result in the experience of workplace violence. The National Institute of Occupational Safety and Health defines workplace violence as the act or threat of violence ranging from verbal abuse or physical assault directed towards a person at their workplace or at duty. Understanding how midwife navigate through this phenomenon while providing quality care to this woman is very, very important. Originally, the study was carried out to explore the characteristics and the phenomenon of workplace adversity. This is an accidental finding that workplace adversity could be caused by workplace violence as experienced by the midwife and that brings me to share these studies with the participants with the audience. Resilience has been reported as the key for coping with workplace adversity. Resilience is the ability to respond positively and consistently to adversity. Now, understanding how women navigate and survive and thrive in such environments is very, very important for Nigeria midwifery. The course study has documented that a well-motivated midwife is able to reduce four out of five maternal mortality, four out of five maternal death. And that is what we are all fighting for to achieve in order to achieve the universal, to achieve the sustainable goal number three. Still on the slide, it's taking a little bit to come up. The research objectives of the study originally was to explore, this is just a bit of the research objective, is to explore how the phenomenon and characteristics of workplace adversity are experienced by midwives, and to develop a compelling grounded theory of midwife resilience which can be transferable to other settings. Still on the slide, I'm sorry, the slides are taking a little bit slower to come up. Now, the methodology and methods. The research design, of course, is a qualitative research design because we are looking at, we're trying to explore the experiences of midwives. The constructivist's grounded theory methodology was adopted. There are five traditions of qualitative research. We have the phenomenological, we have the ethnography, we have the case study, we have the grounded theory, and we have the narrative research. The grounded theory methodology was adopted. Why? Because this is obviously the fourth study that is trying to explore the adversity of midwives, specifically to midwives alone, working in maternal health care centres and unit and tertiary hospitals. And the concept of resilience has not been studied anywhere. The first concept, the first study of resilience was conducted in United Kingdom in 2014. But that study used a descriptive qualitative research to explore the meaning of resilience among the midwives there. But in developing countries, considering the nature of our own adversity, it becomes very pertinent to explore how midwives working in such areas develop resilience to survive and thrive and give compassionate care to mother. And that brought us to the study. And because the concept of resilience has not been explored in our own region, grounded theory was the best method because nothing is known about the concept of resilience. And there's no study has been developed using a grounded theory to develop a compelling theory explaining how midwives survive and thrive in the face of adversity. The area of study that I've mentioned before a tertiary hospital, and I tried to provide the reason why tertiary hospitals, the midwives working in tertiary hospitals were used for this study. The method of data collection or the methods we are using interviews, feed notes, reflexive diaries and reflexive journals were used. Initially, focus group discussion was supposed to be held among the midwives, but it was almost impossible for these women to be bring together to form a focus group because the nature of the world, their overwhelming workplace. Even at a cost-free glance, you could feel that these midwives are on the CH. So focus group was not used. So interviews, feed notes and reflexive diaries were used as a method of data collection. The population of study in the two tertiary hospital were a total of 108 midwives working specifically in maternity head unit that is obstetric and gynaecological work. The sampling technique was a purposive sampling, which is usually done in a grounded theory. In most grounded theory studies, two samples are used. The first sample is a purposive sample where participants who are believed to have an experience or understanding about the phenomenon on the study are being approached for data collection. After the data is collected, it is being analysed all through using the grounded theory methodology process, which will be discussed in the subsequent slide. Now to ensure good clinical practice in medical research, ethical approver was sought from three sources, one from Cardiff University, two from the two tertiary hospital where the studies were to be conducted. In vivo 11 was used for organising the data and to ensure credibility of the results. Now the theoretical sampling. Theoretical samples is the method of sampling that is specific to grounded theory methodology. The theoretical samples are those participants that the researcher feel they have information, they have information rich information that is necessary for theoretical generation and so their approach after due consideration for subsequent data collection. I want to let us know that the data collection of grounded this study was in two phases, which lasted for the period of 12 months. The first phase lasted for four, five months. After about five months, the data collector was analysed. When the theoretical samples were identified, I went back to the field and did another data collection that lasted for about five months and then the transcription and data analysis subsequently took to about 12 to 15 months entirely. Now to select the theoretical sampling. The snowballing method was used and the long years of experience was used as a yes to consider the midwives as those necessary to form the theoretical sample after due consideration and discussion with the participant. Sorry, the slide is taking some seconds to come up. In grounded theory methodology, the grounded theory methodology is both a method of data collection and analysis. It has about 12 steps which must be considered when collecting data and analysing the data. For most grounded theory methodology, it is pertinent for the researcher to identify those that will form the proposed sample and what I did here identify the midwives. How were these midwives met? I met these midwives at the hospital. The two tertiary hospitals have dedicated where the midwives come together with the senior members of the midwives in the hospital. They have a meeting every Monday. I presented the study just to simulate them and let them know what the study is all about. Those that indicated interest were given a participant's information sheet which explained why the study is needed, what they need to know about the study and those persons that were interested to participate were asked to give a call or send a message for me to come back. When I was contacted, I met each one of them with a consent form and everybody signed all the participants. The majority of the midwife were all willing and happy to participate in the study. The consent forms were all given to them. The consent form was filled and signed by the midwives and was returned before the collection of data. The steps here for data collection and analysis are about 9 to 10. That is both drawn for the proposed samples and the theoretical samples. For each sample, an analysis is done for the proposed sample. After the analysis, you identify the participants who you feel they have reached information that is necessary for theory generation. And they are met for the second phase of the data collection and those participants will form the theoretical sample. And then you collect the data from the participants and run the same method of data analysis until data theoretical saturation. The theoretical saturation is when you feel the new data that has been collected from the participants sparks no theoretical insight. Then you can categorically say your epistemological hunger has been satisfied and then you can stop and begin the process of theoretical generation. Now ensuring regal in qualitative research. Regal is thoroughness in qualitative research. Before process identified by Lincoln and Guba is the credibility, dependability and conformability and transferability. For credibility, concurrent data analysis was involved. And this was done by collection of data and immediate analysis of the data so that it will inform the subsequent interview guide for new information. Of course triangulation of method was used. The feed notes, the feed notes, the reflexive journal and the interviews were used. The interviews lasted, I forgot to say that before now, the interview lasted between 45 to 1 hour 30 minutes, 45 to 90 minutes. It was a long interview and the media were ready to talk about all the experience. The data was transcribed by media researcher. And then it was analyzed subsequently. And then to also ensure credibility, theoretical saturation was achieved when new data generation does not spark theoretical insights. Therefore dependability and conformability, peer debriefing by the supervisor, part of the interviews that were transcribed were sent to the supervisors who double check across the audio to be sure no data was missed. And they also analyze some of the data, some of the transcript to check for consistency of the codes. And then to also ensure dependability and conformability, I remain reflexive. All information collected during the data collection, all ideas talked about by the participant were noted on the reflexive journal, which I use extensively, why doing the analysis. And that supports the reasons for many actions are the period of data collection and data analysis. Then for transferability, of course, for qualitative research, we have usually very small sample compared to quantitative studies. But because of his agranded theory methodology, two tertiary hospital was utilized to ensure rich data necessary for theory generation. Now the tentative results and analysis, I called them tentative results because for granted theory, you are not done until you submitted your thesis, you generated your theory, and then you can say fine, and that's all. The first category we have there is experiencing workplace adversity and perceived effects. And then we have this health subcategory, which I'll talk about in the subsequent slides, the meaning of resilience, managing and driving, strengthening coping are all the four categories related, major categories related to the study. Now, for this session, for the purpose of this presentation, like I said earlier, the first category, as mentioned in the first slides, was talked about experiencing workplace adversity and perceived effects. Mind you, I said this study, the experience of workplace violence was an accidental finding from this study. I thought about, because of the number of violence experienced by the midwife, I thought that it was better for me to discuss this as a research opening of this magnitude. The first subcategory was the nature of adversity experienced by the midwife, and the second subcategory was responses to the adversity and the perceived effect as described by the midwives. Now, now I have about eight of the sub teams working in difficult workplace was discussed, having poor collegial relationship, difficult midwife patient relationship, grappling with difficult emotion, losing it and overreacting. What leads to disrespectful midwfricare, then developing physical challenges, delivering poor quality of care and poor work and life balance, which they mentioned as being out of balance. Now, for the purpose of this presentation, I'm going to be focusing on having difficult midwife patient relationship, which may result into the experience of workplace adversity when considering the definition of workplace violence as discussed earlier. Now, I will quickly run through this slide, having a difficult midwife patient relationship. Most of the codes were blocked codes. Why? Because the midwives have given some sort of narrative. We don't talk shortly here. We need to explain a particular phenomenon until the meaning is being defined. Here, one of the midwives talked about, there was a day, her experience. There was a time I came in to take over. I saw a patient who was trying to beat a colleague of mine, so I had to intervene, but they wouldn't listen to me. They were very aggressive. We had to lock the midwife in an office because they were ready to hit her. This is a situation where she attends to a mother with a postpartum hemorrhage under her care before she attends to them, because the mother they brought was stable and was not showing any sign of contraction, yet it was just a few minutes for me to come in. That is the midwife talking about it, but they weren't listening and blamed the midwife for lack of concern about their patient. They were all yelling at us and screaming on top of their voices. This supports other findings where sometimes patient's relatives felt the midwife had an unconsignable thing and that brings about aggression and sometimes the display of workplace violence. Still on it, another slide depicting the experience of workplace violence, a mother and relative tried to abscond after childbirth with heart pain, their hospital B and I tried to stop them. The woman's relative and the woman started insulting me and were threatening to hit me for standing on their way because they have no money to pay. Many of the issues this patient talked about was largely due to either lack of funds which result into abusive relationship or difficult relationship between the midwife and the relative, and this was experienced by almost all the participants. The next slide will be talking about the prevention of preventing workplace violence as described by the participants. These are some of the points they mentioned on how this can be curtailed and will increase the number of women using the facility because studies have reported that currently in Nigeria only 39% of women deliver in the hospital facility. In the facility, why 59% of mothers are still delivered at home without the support of a skilled but attendant. One of the reasons they pointed out was the attitude of the healthcare workers. So now, one of the response the participant gave were preparing mother on what to expect of labor and births, building interpersonal relationship, knowing oneself, calling for help, evaluating the free maternal and child health care policy. Now preparing women on what to expect of labor and births. Now one of the midwife, the name there are student names, these are not the real name of the participants. They are false name in one of the hospital and she said, due to a shortage of midwife, we don't have time to give all the information to the mothers at the antenatal clinic. You can imagine six midwife attending to 260 women at ANC, you can't see everything, but it's very important to tell them what to expect and what they need to know when giving help. Educate them on label and how they need to cooperate with the midwife. I take my time to talk to these women. I tell them the financial implication and the hospital routine requirement when she present a label. I emphasize on being prepared for birth. All this is talking about preparedness for births. I keep reminding them to buy this, leading at subsequent antenatal visit. I don't get tired. This is pointing at preparing the woman of birth preparedness. Now the next slide is talking about building interpersonal relationship. Majority of the midwife mentioned the importance of this as very important in creating an excellent midwife client relationship. Sometimes, like I said, they do a lot of, the codes were largely block codes. Sometimes you can have a patient relative wanting to hit you as a midwife. You have to be patient. Make them understand because by the time they bring in their patient, both the patient and the relative are always anxious. Sorry, I have to read it out. So you have to take your time, tell them what to expect and come then. Try to be kind to win their confidence so that they will believe and trust you in order to develop a good relationship with you. The midwife, you have to be very, very diplomatic and patient in dealing with this remain and their relative. Majority of the, this is just one among the data from the participants. Majority of them emphasise on the importance of building interpersonal relationship. The next slide is talking about knowing oneself. In fact, I think majority of the participants talked about knowing yourself and working on your attitude. And one of them said, but the truth is I know myself. I used to be highly temperamental. I told myself, look, this is one of your attitude and is not good for you as a health worker. If you want to achieve something, you have to work for it. You have to give your clients confidence. I've worked for over 15 years in the labour world. I now found out that women need somebody they can confide in. I said to myself, Maria, you have to work on your temper. So when you get irritated easily, they can't confide in you and you will not get results. Or you may both lose it and start exchanging words. So knowing yourself and changing your attitude is 150% important as a midwife. This is by Maria in hospital A. And most of them talked about the importance of working on their attitude for the purpose of building an excellent relationship with their women. So doing the difficult relationship will be prevented and the workplace violence will also be curtailed there by bringing more women to utilise healthcare facility for delivery. Still on preventing workplace violence, calling for help. Now some of them were even slapped. They said that this was mentioned among 50% of half of the participants that formed the theoretical sample. They talked about the importance of calling for help instead of calling for help. Instead of talking to the patient directly, it's better they call for help for security personnel to draw the attention of the clients that is trying to. Talk to them partially then evaluating the free maternal and child health policy. Now this policy has been put in place to provide services for models in the states. The essence of this was to ensure that models come to the healthcare centre, have their antenatal, have their intrapartial services as well as postnatal services without paying the time. But you find out that the services are not providing care as described by many of the participants. And then this participant said there is a policy on free maternal health services available for women using maternal services. In reality, these services are not in place due to inadequate funding as most time consumables and other materials are not available. Making these women to purchase it out of their pocket, placing on bearable financial burden on them. Sometimes they have no money to pay and will be at loggerheads with the midwife. I think stakeholders should monitor and evaluate with only to make the system work better. This is by one of the midwives who is trying to advocate for the free maternal health and child health policy to be monitored. Because if this policy is monitoring some of the aggressive relationship that comes up will be avoided. Alema, we've got eight minutes left for finishing in questions. I'll see you at your conclusion so we should be okay. Thank you very much, Ali, for the notch. Now, in conclusion, preventing workplace violence is paramount to promoting a healthy midwife-women interaction. This interaction may enhance an excellent birth experience for women necessary for sustainable use of former maternal health services. Of course, in Nigeria, where the maternal mortality is unnecessarily high. Finally, I will say thank you all for your complete attention and welcome to the virtual internationality of the midwife. Thank you, Alema, for a really comprehensive explanation of your study for your PhD. We do have a little bit of time now for some questions, so if you have any, please feel free to write them in the chat box. Daki asked earlier, Alema, what proportion of a family's income does it cost to have a baby in Nigeria? Say that again, please. What proportion of a family's income does it cost to have a baby in Nigeria? Okay, thank you very much for the question. Now, to have a normal birth, it depends on where you're going to have the birth. In hospitals like tertiary hospitals, they charge out of pockets. Sometimes they charge about, it depends on what that particular family are earning. The basic salary scale in Nigeria, I think the minimum wage in Nigeria is supposed to be 30,000 naira. That's about 15 pounds. Sorry, that's about 60 pounds. If you have to go to the facility to give birth, they may charge about 20 pounds. That's roughly 40% of the salary. It's a bit expensive for people that are earning below average on their normal salary scale, minimum wage. Thank you. There's two questions which may be combined. One is about the percentage of home births in Nigeria, and the other one is about do women engage in hospital birth in your area? Sorry, I didn't hear the last word. It just went mute. Say that again, please. So the percentage of home birth in your area and do women engage in hospital birth in your area? Do women engage in hospital birth in my area? Yes. Yeah, they do, but most time they call the attention of probably a traditional birth attendant to assist them, but not the midwives. Sometimes they avoid hospital because of lack of funds and the difficulties, or even assessing the hospital or going to the hospital. So they prefer to call the traditional birth attendant in their community to support them. I think you've answered Ginger's question that one of the reasons they do avoid the hospital birth is because of the cost. Yeah, it's because of the cost. Like I said, our method of healthcare funding is largely out of pocket. Sometimes to stay away from spending out or incurring and a catastrophic health expenditure, they prefer to use their valuable chip birth attendant in their community to support them while they deliver their baby. Is there anything that the Nigerian government is doing to deal with this problem that you've highlighted in your study? Yeah, recently the social, recently they are beginning to talk about making the services, making the women enrolled in the national health insurance scheme. That is the community part of it to support them. And then when they do that, of course it will take part of their bills away and then they won't be able to pay the catastrophic health expenditure will be less. The extra money they will have to pay out of their pocket will not be as if they are doing it completely, 100% using the out of pocket method of payment. Halime, you have been wonderful. I have really enjoyed hearing about your study and I know some of the other delegates have been really keen to hear about some of the background to the methodology of your study as well and found a really good understanding of how you've explained it. And I think you have opened our eyes to the conditions that midwives have to work in in other parts of the world. So thank you. Thank you very much Ali. I can see some questions in the community. Thank you so much. Thank you Jane for that notch. Thank you all.