 Just upload So Elsie perhaps you can start with introducing yourselves Okay, good morning everybody It's the start of 9 o'clock in the UK on a very great morning from where I'm sitting I am a clinical midwife I'm also very active in the voluntary sector mainly around mental health for women young black men and I'm also involved in working with our regulatory body on their patient forum This presentation that I'm doing today is just sharing the work that we're doing within a small team of midwives called Mimosa Midwives We've come together to work as midwives because we are passionate about our profession and we want to make sure that we make a contribution however small to helping women to work well The title of my presentation today is the power of cultural safety when different worlds meet and it's all about our work that we've been doing over the past few years within our team As midwives, we are privileged to work with women at a momentous and mostly beautiful time of their life It is also a time of high expectation of having to trust strangers and of the fear of the unknown As midwives, we are autonomous practitioners of midwifery We hold the responsibility of caring for each individual through a normal life process most of the time As maternity services and technology have advanced a normal process of birth has moved progressively into the medicalised hierarchical structure of the hospital rated according to the degree of risk they are able to handle Midwives have therefore to not only recognise we are normal and refer women appropriately but now we are more and more involved with treating the abnormal midwifery training and its education therefore has needed to extend to highly advanced technical and theoretical knowledge and skills and our statutory requirement for the maintenance of professional competence has also included utilising the requisite knowledge and skills that we need for our work Within the time constraints for the education and regular professional updating of the midwives we find that there is a real threat of the knowledge and skills within the art and craft of midwifery to be left behind and the hospital system and the set NHS target in the UK require that managers must find the most cost-effective way to deliver the most efficient service So what we have noticed in the UK is that slowly over time what was once by and large a growing profession has begun to show signs of slowing down in many different ways So recently this presentation is actually coming out of a request to share some work that we were doing within the local migration partnership working and they were looking at a more detailed focus on the area of migration in health within the area because the birth rates in England have risen over the last 10 years and we found that migration is one factor for the increase In England they noted that over one in four births was being to a woman who was not born in the UK So as providers and commissioners of maternity services we needed to respond to the changes in the local population We also had to take into account the different factors that impacted on the maternity and the different language and cultural needs in the UK health system and how people actually understood that Within the area in which we work in the West Midlands we also saw a significant change in the profile of women who make up the maternity services So the level of birth to non-UK born women is high in some places in the West Midlands They were also looking in this forum at the different challenges for women in the area and they were looking to see what the challenges were to consider the evidence on the outcome for women and look at examples that helped to improve the maternity care for women of these different communities So to go to my second slide our work is actually based on the international consideration of midwives definition of the midwives role and scope and it's there on the screen and I'm sure we all have an understanding of it in terms of what midwives do and how she works and where she may work But in our work our practice we actually try very hard to do that as much as we can We are freer as much as we are a group of private midwives we are freer to work to our code of practice because we are not employed by any NHS trust we're not employed by an NHS trust So our benchmark practice is the rules and the code of the nursing ministry council to regulate us as midwives and we have a second slide please So the first consideration we had was who is a migrant woman and actually defining this woman was a little bit contentious in as much as the definition is not conclusive there are many classifications of a migrant a migrant and a migrant woman depending on which angle you are looking at it so for example there are legal status for migrant women so for example in the UK we have undocumented migrants but basically from our perspective as midwives we take it to mean a person who moves from one place to another whether it's for work or for better living conditions and quite certainly in the area in which we work a lot of women come for education to better their education or they come with their husbands or partners too for working, for their working we also have quite a high population of women who are refugees and asylum-seeking women who are not actually entitled to have public forms so we have quite a wide number of women in Birmingham itself which is the main city to our work in has been termed super-diversity so we have people from all over the world actually living in Birmingham for one thing or another we have certainly more than spoken cultures to match and in fact we have quite a bit of mixed heritage women and families we also notice that there is a change a constant change actually in the profile of the population who live and work in Birmingham the issues from maternity care is one of the issues the things that we were focused on certainly in our work and what we found is the usual things like language and that would actually impact on informed consent we are required to give information to women in order that they can actually make a decision unless we speak the language of the woman we would have to use an interpreter and interpretation is one of the benchmarks of the services that are delivered we also encountered different cultural practices which would impact on the care given and the care received by the woman and how she actually managed her pregnancy her childbirth and her post-natal period as well so in terms of for example one of the big issues are around diet there were many issues in terms of women depending on their status in society being able to afford nutritious food there were also issues about types of foods to be eaten within pregnancy depending on which culture you came from how you managed sleeping with baby many cultures closely which in this culture in terms of guidance closely is something that is encouraged in fact it is actively discouraged one of the issues that we came across as well was how systems work together or don't work together and working across systems we found to be quite difficult in terms of how the NHS systems are worked how they work or don't work together so an example of that would be trying to for example work as private midwives getting women into NHS systems so that they could actually access girls so one example would be something like a woman whose immigration status is not secured who is pregnant who needs to be booked by 12 weeks so that she can actually have her regular scans and she may want to access all the things that have been laid down as good practice English NHS so for dating scans she would need to book early so that she could actually access so whether she was able to pay for this or not there is still a difficulty actually getting her registered with a general practitioner to get her into the NHS system that is really quite difficult to achieve at times because the rules will change as to whether she has to pay not pay whether she has to prove her status or not prove her status so these are the sorts of difficulties we meet within systems when we are trying to work with women across sections and actually break down some of the barriers that are there and some of them are actually not intentional barriers but they happen because systems develop separately so we actually see some inequalities in access we see inequalities in terms of treatment and we also see inequalities in terms of outcomes so this is well known across the sectors that there are certain categories of women depending on where their racial origin that their outcomes will not be as good as the indigenous populations for example the triennial review of maternity services which happen in the UK shows that there are women of African heritage and Pakistani heritage those women are more likely to suffer poorer outcomes than women of indigenous population so how do we overcome these what we try to do is work to best practice as Mimosa midwives and the women we look after we are contracted to look after we deliver a one to one continuity of care simply because that is shown to be giving the best outcomes for women women per se but in particular the more vulnerable women the women that we are not contracted to look after who we actually support so for example women who with no recourse to public funds who do not actually they are not able to pay for their care and who have a very minimum style of care with the neonators we actually support them in terms of the other work that we do in the biology sector so they will come and attend our aquanatal classes and those classes actually help to empower women to feel good about themselves to take some exercise we support them in terms of advice given along diet post-mental exercises we talk to them about things like hegel exercises and just generally support their mental and physical well-being especially chance within what we are doing for the project that we are leading in terms of the evidence base that we use we try to stick to best evidence and the work that we use is based on David Sackett but also some of the other work that we've done with the independent midwives in the United Kingdom when we were looking at best ways of working so primarily evidence base to us to quote is a conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients and we can actually do that because we are working one to one with small caseload of women so to go on to quote the practice of evidence base medicine means integrating individual clinical expertise with the best available external clinical evidence from systemic systematic research by individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice which is reflected in many ways but especially in more effective and efficient diagnosis the most thoughtful identification and compassionate use of individual patients predicaments rights and preferences in making clinical decisions about their care we try to integrate individual expertise therefore with the best external evidence we use a bottom up approach primarily because that actually puts the woman at the centre of her chair and we use the external evidence to inform how we work but it doesn't replace our individual expertise as clinicians and we also bring our life experience to our work so that we integrate all of these things to help to help inform decision making for the women so things in the UK that help us so we use what we NHS will use as guidance so we just use it as guidance the Cochrane Reviews and the NICE guidance which actually helps to bring breadth to how we we work with the women but most importantly we use the values of the patients to help to help our approach and improve the care that we give to the women so our team in most of midwives who are we we're a small team as I said before we use one-to-one methods of working because that actually helps to produce continuity of care and developing relationships of trust and confidence which is really so important to the outcomes for women it helps them to make the decisions for themselves and as I said we use best evidence to actually inform our work our midwives are five of us in our team who work actively together to deliver care to women on the many different fronts that we work we have within the team a lactation consultant who is also an aromatherapist, an aquanatal instructor she's also had quite a significant number of NHS years of experience and laterally commissioning experience as well so she's able to she was a city lead for the breastfeeding in the commissioning sector and she's able to spend quite a bit of time supporting us and the mothers in terms of breastfeeding outcomes for the moms themselves and also for the future generations we also have within the team two people who are qualified to teach and one who is actually completing her teaching so we have quite a significant expertise around education, education of students but also our own education so we spend a fair chunk of time sharing our updates and making sure that we are fit to practice in that way we're supported by a very she was a very senior midwife within the NHS and she's out on retirement instead of going back into the NHS to do banquet, temporary work she's chosen to join us and she was a very senior in terms of her leading she led a team of midwives when the continuity of care was being piloted in the NHS she's now working with us and she coordinates quite a bit of our practice within her level of seniority within the team also we have a considerable amount of expertise of working in the volunteer sector so one of our midwives who is now working in education had worked with us about developing groups around post mental depression she worked with young mothers fathers doing things like baby massage to help them to connect with their babies a significant number of our midwives also indulge in alternative therapy we all use all our skills to actually work with women not only in a medical fashion or a midwifery fashion but also we bring our social skills to our work to support women to prepare to birth well and to move on with their lives in terms of looking after their children we teach acronym classes we also deliver paragraph classes on a one to one or indeed on a group basis as well we're very fortunate in as much as our supervisor of midwives is very woman centered and midwifery orientated she works within an NHS trust as a senior manager and has been a midwifery supervisor for quite some time now she supports our practice making sure that certainly we meet at least once a year but quite often we meet more than that and she supports our practice to make sure that our equipment is up to date and that we are continuing our learning professionally and personally so that we are able to function or as autonomous midwives that we want to be so how do we gather our evidence base our evidence base actually came from a variety of different sources and all of the members of the team so for example I had an experience of looking very closely at what was happening in New Zealand to improve maternity care and out of that experience we have chosen to embed the concept of cultural safety within our practice because we found it to be the simplest and most effective way of working as a one to one but also as a team and just to share with you some of the concepts around cultural safety for those who've never heard of it it's about an environment which is safe for people where there is no assault challenge or denial of their identity of who they are and what they need it's about shared respect shared meaning shared knowledge and experience of learning together with dignity and truly listening it requires a consideration of issues of power and not just the imbalance of power between a patient and a medical professional but the wider origins of that power beyond the hospital consciously or unconsciously such power reinforced by unsafe prejudices or demeaning attitudes and wielded inappropriately by health workers could cause people to be stressed and avoid the health further it also develops the idea that to provide quality care for people from different ethnicities than the mainstream health care providers must embrace the scale of self reflection as a means to advancing a therapeutic encounter and provide care congruent with the knowledge the vital values and norms of the patient are different from she or her own and for us that just encompasses all the things that we want to deliver as midwives working on our own outside of assisting in fact what we're doing is develop assisting of our own the other evidence base that came to us was one of the midwives who was working within a class was actually asked to look at the journey she was asked to map the journey of the patient through the system that the trust was using and what she found basically was that the women who were termed vulnerable migrants in terms of high social risk or high medical risk were the ones who had the most fragmented care and the ones that midwives found very difficult to look after subsequently within the pressurized environment that they were being cared for and the fragmentation meant that their outcomes were poorer that piece of research was actually mainstream within a trust to improve the care that was being offered to women vulnerable women and the outcome was that they had employed and supported one midwife to actually lead on that the third piece of evidence that we used within our team was a piece of research done in a particular area of Birmingham where a midwife who a community midwife who was trying very hard to get a one-to-one scene up and running she decided to look at the areas of continuity and discontinuity of maternity care for the women in the area and her revelations showed basically saying that the discontinuity actually didn't help the women either physically mentally and they felt very disadvantaged by the care that they were offered and that they received happily I have to say that within that area now there is a home birth team that's been set up and is being evaluated and so far it's running really well in about 2006 the commissioner, the local commissioners did a set of reviews of maternity services to look to see how it was that they could actually improve the perinatal mortality rate for the area because they actually acknowledged that there were significant problems for the locality and again based on that they made certain improvements in how the maternity care pathway should run but having said that they didn't make any changes in terms of how midwives were working with women so it was more of a sort of strategic change rather than a front line rather than it going down to the front line so there was no bottom-up approach to that myself as part of my update I attended a Red Cross meeting for the first time ever really looking carefully at what was happening I was astonished to find the experience of women who were refugees on asylum seeking women within the city what was happening to them that their care was less than everybody else was having and this was the impact of the immigration system for example they would be not seen they would be coming from another area and then they would not be seeing a midwife straight away there was no food pathway transferring them from one area to the next consequently they would fall through the gaps in the system and perhaps women at 36 weeks pregnant would turn up in a hospital and then go into labour and just land on the doorstep of the nearest hospital with very few maternity and of course the outcomes of such women are not as good as women who have had the opportunity of care or indeed of carer within a system that knew who she was what her issues were and so on subsequently to that within the area in which we work the maternity alliance which is an organisation set up in the United Kingdom to support maternity care and in particular focused on undocumented migrants seeking women and so on they decided to have some practical training around the policies, the immigration policies and what people were entitled to have etc so our team was actually invited and did take part in the training so we gained some knowledge about what the policies say pregnant women need to have and should have and the laws but in fact what happens is that as a result of legislation there is quite a bit of changes and sometimes it's very difficult to discern what people are entitled to so for example just to clarify that it used to be that women are entitled to be registered with a youth general practitioner in order to access maternity services and at this moment in time as a result of recent legislative change there is no such requirement to accept women onto general practitioner lists so the implication for women women who have whose immigration status is not clear means that she may or may not get onto a GP list and she may not be booked for quite some or indeed booked at all and just end up turning up at the local hospital when she's in labor or if there is a problem just turning up as accident and emergency so these are the sorts of things that impact in the UK there are patient committees known as the maternity services liaison committees these were set up in statutes some years ago and each NHS trust was required to have such a committee set up in order that the voices of patients and service users informed how the service was run and the service that they received this is no longer the case but most hospitals in fact have kept their committees now so quite a lot of the information that's fed back to hospitals that are creating pathways for all their patients quite a few of the hospitals have kept their committees and they're quite useful because we glean quite a bit of information and we're able to input certainly sometimes it's very difficult for women who do not have English as their first language to input so our team there are two people, certainly two people on our team who regularly attend the local MSNC committee to input on behalf and to advocate for the services for women who are not able to just speak for themselves clearly or who might even be afraid to speak for themselves and then we have national reviews which are ongoing from time to time the confidential enquiries and maternity services have been very, very useful to tease out the problem so for example there were years when hemorrhage was the main the main cause of death and we were able to actually do something about remedying that at this moment in time the things on the agenda are herinatal mental health and there is an ongoing maternal review or review of maternity services, a major review of maternity services which has just started now to look at how it is that we can improve maternity services for all women so in terms of how we work as MIMOSA midwives we want to continue working with this model so the continuity of care is a holistic model we work in partnership we've actually achieved a good way of team working we're learning quite a bit about maternity funding and we're certainly delivering a lot in terms of the satisfaction for mothers and for midwives we have seen that the women are more satisfied all round particularly in terms of their support for breastfeeding and because we have a social focus we're actually able to help women to prepare themselves for birth we support them to birth but sometimes we do that in the home sometimes we do that in hospital but whatever it is we are there for them at all times as professional midwives but certainly being a very more social, midwifery social approach to our work and we will stick to our principles in terms of cultural safety so just to take a phrase from the Welsh Assembly in 2002 and I think to be quite honest the UK does try to work very hard towards supporting good midwifery practice but for us it's like the Welsh Assembly has said birth is not a patient episode it's an event of great social and emotional significance and that is the way we will actually go forward for women as again using the benchmark of the cultural safety so looking to the future then there's still clearly quite a lot to be done we are a small team we are looking to grow we have quite a few people who are actually working who are looking to work with us and we are looking to actually develop into a larger team and to work nationally to help others to set up in this way using national policy because the policy in the main or the policies in the main are fan practice policy but it is something that actually prevents them to come down to the working level we seek to work in partnership and we do that ourselves with the gender local general practitioners, the health visitors, the social workers general and the GP other midwives so working with a woman for example who we work in hospitals so she might want her antenatal and post-natal out of hospitals but we also work with the NHS to help her and support her within the NHS for her birth and then franchising is one of the things we are looking at to see how it is that we can spread our model because we think actually it is a very good model in the midwives way of working in terms of the mothers they certainly have better physical outcomes and we have certainly impacted on them in terms of their mental outcomes and their emotional outcomes because whether she has a vaginal birth an emergency delivery section or whatever sort of experience she has through her birth continuum we always go back at some point to be brief and to share and many of the women actually keep in touch with us over lengthy periods of time so that's us any questions that you might want to ask thank you very much Elsie we have one question Nata asked do you use interpreters in your services or any other tools to overcome language barriers well we don't actually employ interpreters or we do have access to interpreters via the NHS if we are working within the NHS if we are working with women who are for example somebody comes to our Acquinated class who doesn't speak English then we utilise the forum that they have come from so they may come from an organisation that supports migrant women they will have interpreters so we use their interpreters so we don't actually employ interpreters at the moment but we use what there is in the systems that they are coming from to support them any other tools to overcome language barriers well we use a lot of smiling positive gestures so if we are teaching an Acquinated class for example to a woman because we have that on a regular basis to a woman who who doesn't speak English then we will use certainly in the Acquinated class we are using gestures we are demonstrating the movements but we would also combine that with explanation for the class so we have to do an assessment of the woman's status before she joins the class and we would do that in conjunction with the worker who brings her because generally the workers will bring the women to the class so we do that assessment whilst the worker is present and then we will talk through we do perfect floor exercises in the pool when we are in the pool to do the perfect floor exercises when the worker is present so that when we get to that point in the pool the woman knows exactly what this issue is supposed to be doing yeah we just do the best we can with what we have got really so Sarah is also putting in the laughter is helping much and Julia also touch and patient is very helpful yes do we have any other questions so put in there is one about the challenge of the midwife franchise thank you very much so franchising is the method that we have aspired to there is in the United Kingdom and to improve maternity services by using small groups of midwives now that has been accepted by the new lead of NHS England who is leading on service and within the document it is called a five year forward plan if you want to look it up within that document for the first time we have been doing this official support for small groups of midwives to develop ways of working that improve the maternity outcome and what we would like to do is to work with and in fact we started working with a national team of midwives who are developing franchises because we believe that is the way to go so if for example we have small groups who are working to the same principle who are being supported it is quite expensive to fund a maternity service the way things are now it is quite an expensive business but if we have a central body that develops a franchise and is then able to give it out to little groups of midwives across the country so we are all working to the same standards to the same principles then we have a better chance of succeeding as far as giving and the receiving of care is concerned rather than it being this huge organisation that is working at the top level but somewhere down the bottom it doesn't meet the needs of women so the barriers to franchising I think at this moment in time are helping groups of midwives to realise that they actually have the power to work in this way it is challenging yes but they can be overcome it can be hard work we have to be prepared to build small good working teams and then we need some money which is always the biggest talent we need huge amounts of funding to actually develop the structure that will help midwives to work in this way and then we have the men in grey soup who largely dictate policies and we have to convince them that this is the way but that in itself is not so bad it's about helping women to understand that we have to come together in order to improve the service and this is one way that we can actually achieve it okay perhaps one last question the work you are doing at the moment how is that financed how do you get money for your work well some of the work we are paid for so we may pay us to look after so we look after all women to be honest and some women are quite wealthy they will pay us to look after them antinatally or postnatally or both we have to work with an organisation that set up it has professional indemnity insurance and it gives that to us to look after women for the birth section or indeed the whole pathway because the UK is now required as I guess every country in Europe we are all required to have indemnity insurance sufficient professional indemnity insurance for for birth the actual birth rate is extremely expensive and we are required to have insurance to the level of million three million has been quoted ten million has been quoted and that is quite difficult you need to be a company an organisation in order to access that whilst we are working on our model we have to use an organisation a company to deliver the birth aspect we also get money from the other work that we do there is not a lot of income from the Aquanatal but we get a lot of support from the people who host her there is not a lot of income at the moment but I think our passion for the profession and our passion to improve the lives of women whoever they are keeps us going okay thank you very much for that answer I think we are at the end of the session and our time so thank you Elsie very much for your contribution I put some links about mid-lifery in the UK and some the information about refugees in the UK in the chat box so perhaps that is helpful so thanks everybody for joining this session and the question is now I think we have some feedback so is it true yes that is true I will post the link in the chat box it is there now so I will turn off the