 Okay, so now we are ready for Hiba, and Hiba, I would ask you to introduce yourself, please. Thank you very much. Thank you, Christian. Hi, everyone. I am Hiba. I am from Palestine. At the moment I live in Gaza Strip. I received a master's degree in midwifery last year from the University of Aberdeen in Scotland. And now I am working as a clinical instructor at some local universities in Gaza, and also working as a clinical midwife at a maternity hospital in Gaza too. So this presentation is part of my master thesis, and I am happy to be here and to participate in this conference, and hope that everyone will enjoy this presentation. I will start now with my presentation. The presentation is about women's experiences of childbirth in the Arab world, a systematic review of equalitative evidence. This picture was on the day of my graduation ceremony at the University of Aberdeen. I am the second one from the right. The first one from the right side, she is my first supervisor. Her name is Lucia de Ambroso. And the third one, she is Helen Pitford, my second supervisor. And the first one, she is Alice Kajol. She is the external examiner for my thesis, and I am pleased to tell you that I was honored to win her prize for the best in midwifery nursing research project at the College. Okay, so I will start with some introduction about the Arab world. The Arab world occupies a large geographical area which comprises 22 Arabic countries. In the Arab world, marriage is considered the gate to childbirth because it represents the only foundation within which childbirth is allowed, as well as that childbirth is viewed as the purpose of the marriage. Childbirth is a major life event and a special life story and emotional experience for women. Women's experiences and their stories of childbirth are therefore relevant in developing evidence-based care on individual subjective narratives. So there is an urgent need for women's experiences to be incorporated into health services and health policies toward improving the quality of care in maternity services. Just a simple notice, I am sorry about what you're hearing from my background. I cannot stop this sound, it's from open area and I am absolutely close to the room but you still can hear the sound, anyway. There's a report from the United Nations. Okay, thank you. The United Nations report demonstrated a substantial discredited and fertility rate among Arab women in most countries except Iraq, Yemen, Palestine and which is my country, Sudan, Somalia, Mauritania and commerce. The total fertility rate remains over four live pair women reproductive age for the seven countries that I mentioned which indicates continuing high rates of fertility for some poor and rural areas. As you know, the geopolitical status of the Arab world nowadays is complex and challenging due to state of the crisis and armed conflict areas such as Iraq, Yemen, Syria, Palestine and Libya. So these circumstances undermine the health system and cause emergency health situation because of the occupation, internal civil strife and political tension. There are comparatively fewer studies addressing satisfaction, maternal satisfaction and exploring women's reported experiences as an outcome of maternal care in the Arab world compared to Europe and United Kingdom. Therefore, it has been worthwhile in this paper to focus on women's third care during the childbirth experience to develop recommendations towards influencing health professionals and policy to improve health systems and make real change. So the aims and objectives from this paper was to addressing these two questions. The first one was what are women's views and experiences of the flavor birth when accessing delivery services in the Arab world? And the second question is what does the evidence suggest for policy and practice? The methods for this paper was a systematic review accompanied by a synthesis of the quantitative and the quantitative studies describing women's experiences in birth and labor in the Arab world. The elements of the actual narratives and thematic synthesis methods was used to analyze the data from selected study. Also, my experience and reflections of my professional background was also incorporated for the result of this paper to support the interpretation of the data. Now for the findings. Elevator studies were selected for the review of three quantitative and eight qualitative studies. From the analysis, there were two overarching themes were identified, women's third care and medicalization of childbirth. Medicalization of childbirth with unnecessary technologies can be viewed to exist in direct opposition to third care delivery with culturally sensitive care where women are empowered and otherwise lead care in childbirth. For the first theme in this paper, women's third care in the papers, many women would have appreciated the feeling of control during the childbirth process. Women indicated their need for family's emotional support and their mother's attendance during labor. However, it is forbidden in most public hospitals and actually this is the policy in most Arab countries. For the second theme, medicalization of childbirth. Women experienced a number of routine practices that were unnecessary, harmful and non-indicated of procedures during labor and birth. Those involved induction, artificial rupture of the brain, continuous fetal heart rate, suffering, if equal, vagina examinations, and epizetony, enema, and shaving. The humanization of childbirth were so important in terms of lack of respect, care, poor pain management, lack of necessary information from skilled birth assistants, and lack of privacy. The medicalization of childbirth was observed in the widespread use of unnecessary procedures which affected negatively women's control in childbirth approaches in terms of demonizing childbirth. In conflict areas and during wartime such as Gaza in December 2008 to January 2009, there was no safe place for childbirth as reported by Wick and Hassan 2012. Women in this area reported multiple barriers to accessing a suitable birth place. They reported no near safe place for a childbirth or access to nearby health birth attendants and fear of unknown about their families and their labor status during the constant chilling. This reported by the women from Gaza that the women had facing the war in 2008-2009. In addition, there was the impossibility of knowing when and where the bombing would take place and so safety guarantees were impossible. The wives also reported trying to help laboring women with only simple and ill-prepared equipment. Now for the reflection of my experience in Gaza to support the result of this paper. In 2012, I was working in the largest governmental hospital. It's called H5 Hospital in Gaza Strip. The Ministry of Health in Palestine sought to employ midwives in maternity services with WHO in cooperation to build midwifery lip care during training the midwives with the basic and advanced skills. Midwives in Gaza are authorized to manage low risk cases of laboring women during delivery care as defined by International Confederation of Wives ACM. The midwives in Gaza are unable to order any procedure without reference to doctors in spite of WHO recommendations for midwifery lip care in Palestine. Their severe pressure worked with high case loads. For example, during my work there were more than 12 cases with only three midwives. One physician and one obstetrician. Doctors request oxytocin infusion for most cases and bisectomy used routinely for most primigraphida. Some doctors use their previous experience and their old knowledge without guidance according to WHO recommendations and evidence-based practice to deal with the emergency. The women also are restricted in mobility and drinking during labor. Therefore, the midwives and the doctors evaluated women's labor artificially by plant catheters. All women give birth in lighted homey position and I can say this is the only position women can have childbirth in the public hospitals in Gaza. And convenient support to attend labor is forbidden due to open area in labor world in which the patient's feet are separated by care turns or rubable walls. However, it's allowed in the private health facilities to have social support during childbirth. The overload of work results is insufficient with wifery support for every woman. To conclude, my experience in Gaza was relevant and consistent with the findings of this paper or this review, the medicalization of childbirth and using unnecessary harmful procedures in post-conflict region where also relevant to the two overarching themes identified in the results chapter. As a result, women's preferences are critical sources of knowledge to explore and consider in such situations. Now for the key conclusion. To counter the effects of intersecting lines of medicalization and technology power over women's experiences of childbirth in this context, health policy makers, decision makers with wives and other health care professionals need to work with this available evidence of women's experiences and narrative account of childbirth to achieve high maternity quality care. The indications for practice. It's important to involve all stakeholders including midwives, maternity care professionals and women in efforts to improve current practice and also to eliminate unnecessary procedures. There's a need to develop policy in Arab countries and update WHO recommendations with evidence on the subjective lived experiences of delivery and the childbirth to achieve high maternity quality care and women's satisfaction. Also, the decision makers need to empower midwives in their community either geographically or socially to be able to provide their care for marginal groups or in time of a crisis. Especially now, the situation in Arab countries is not stable. Also, there's a need for planning for emergency care is essential by mapping the availability place of midwives providing them with basic medical equipment and medicine at home and any clinics in order to facilitate their care to women's needs during a childbirth. The future research. We need a future research to focus on somehow to support women and supporting childbirth experiences from a few points of skilled birth attendants and maternity care staff. A future study could also explore in more detail the challenges of providing evidence-based practice to reduce medicalization of a childbirth in terms of legitimacy of subjective lived experiences. A future review and research which focus on whole childbirth experience including an antenatal or intrapartum or postpartum period are recommended. A greater effort and evidence is also called for women's rights of safe birth, a respectful healthcare and accessible and available access to care during complex and wartime. Now I just put some pictures. It was taken by Al Jazeera. This picture was in the last war. The last, I can say, Dalash-Australia attack on Gaza in 2014, exactly in July 2014. The first picture is from the Shifa Hospital Maternity Unit. During wartime, we can expect 25 to 50 women over a 24-hour period. And also, the medical supplies are running short due to ongoing Israeli offensive on Gaza. In other meaning, Gaza is still under blockage by Israel. So this blockage also limits the medical supplies and we have these chances in basic equipment. The second picture from Shifa Hospital too. As the ambulance made its way to the hospital, this lady called Hanan El-Mahifrim, continued to bleed and was rushed to surgery, to see a surgery where her baby gear was delivered by a caesarean but unfortunately died at birth. After her condition, Hanan was not told the news of her daughter's death until a day after the surgery. Hanan said, when they told me, I feel like I couldn't breathe. I wanted to cry but I was too tired. I think this is the last picture. Mariam joined it, 39 years old. It's a mother of eight and now she's expecting her ninth child. As I mentioned in the introduction, the fertility rate in Gaza is high. I can say it's 4.6 baby women. And this is the difference. Now I can say, oh, I finished. Now I am happy to hear any questions or any comments. Thank you very much, Hiba, for your interesting presentation. There was one question in the chat right in from Monika. Can you ask if women's mothers are allowed during birth in the hospital? Yes. Actually, this is a policy in the governmental and public hospitals. They cannot bear birth companies, mothers or any relatives. Because the area of the hospital with the leopard women is very crowded and if the hospital allowed for every woman to have hair relatives, it would be more crowded. So this is why they avoid this. I can say there's another reason. I think it's for cultural, it's related to cultural beliefs. Some husbands maybe refuse to attend the childbirth. Maybe they are shy or something like that. So maybe this is the, I can say this is the reason. Yes. Is there another question? So I would like to ask... Is the answer clear for everyone? I hope the answer is clear. No, no, they will ask if it's not clear. So I ask our participants to put in more questions to Hiba while our participants are in... Ah, okay, Margaret is asking do all women go to hospital for birth or are there a birth at home? Okay, actually we have two systems. We have public hospitals and private hospitals. At the moment we don't have a home birth except for women. She cannot go to the hospital and suddenly have birth at the home. But till now we don't support the home birth in Gaza and I think this is bad. But for my side I think it's good to support home birth. But to answer your question, at the moment the woman can have birth at a public hospital or private hospital. Okay, thanks, Margaret. Okay, so please put in other questions for Hiba. I would like to ask the question what is about the breastfeeding rates in your region? Yeah. What is about breastfeeding? Hiba? Yeah, sorry. Did you ask about breastfeeding? Yeah, breastfeeding, the rates of breastfeeding in... Yeah, the rate of breastfeeding in Palestine is actually high. It's 96%. Yeah, it's considered high, I think 96%. That we have cultural beliefs about breastfeeding. So if the mother at the beginning has or facing difficulties with breastfeeding, her mother or her relatives will support her to breastfeed her baby. So, okay, Akita is asking in the rate of caesarean sections in your region, your country. Okay, actually I don't have accurate person about caesarean section rates. But I can say the normal phasional delivery is more than caesarean section. And usually the women prefer phasional delivery. And just for urgent reasons or accidental reasons, the women refer for CF. But I am afraid I don't have accurate number. So, but is it often in your experience or do women ask? For CF? No, it's not often. Because we usually refer the women for normal childbirth. But for some reasons, for example, if the women have at the barter of marriage or accidental marriage, the lady should be referred to CF. Yeah, it's a good question. Are there any wife-led care units at all? In my country, there is Norway. It's called Norway. It's a project supported by Norway. It started last year to support with wife-led care unit in Gaza. And it started just in one hospital. It's in the Chippa Hospital because it's the largest hospital in Gaza. And I think they started in this hospital because if this project succeeds in this hospital, they will follow other hospitals with the project. This project is actually just for law-risk cases. Wives can care with women. With women, law-risk, considered as law-risk, the women don't have any medical problems. Wives can care with it without any interruption from the doctors or obstetricians. The midwife in this unit don't use oxytocin, don't use abyssaltony. And the midwife using birth-deep exercise, full exercise. And they ask the women to choose which position they prefer to have a childbirth. But most women, as I can see, they choose a light-atomy position. I think because they think, because as they use to have a childbirth by light-atomy, maybe they think this is the best position for them. But we try to learn from them that you can choose any position you like. Okay, thank you very much. Now, let's see if there are any more questions from our participants. So, what about the education of midwives in the Gaza? Are there enough possibilities to get well educated as a midwife in your region? Okay, we have two colleges that teach midwifery programs. The midwifery program is in Gaza for four years. For example, at my side, I have a bachelor from the Islamic University of Gaza. And my bachelor was four years. I started a clinical training in the hospital from the second year. And so continued the training in third and fourth year. Then after graduating, we have a period called the Eternalship Period, like 300 hours. This period to make sure that I am good with wife after graduating. And I cannot take the certificate without finishing this internship period. So in Gaza we have two midwifery programs in Gaza. The first one was started in 2001. In the College of Palestine, called College of Palestine. And the second one started in 2008 at the Islamic University of Gaza. And also we have another program for midwife. It's called Practical Midwife. The midwife can be a practical midwife for two years. It's called the Bluna Midwife. I think maybe the word Bluna is different for you because the Bluna is known for certificate. The Bluna in Gaza means that the midwife has learned for two years to be a midwife. And actually the practical midwife who has two years, she can deal with women, support women. But for example, she cannot provide help in childbirth. Just she can help in both NATO and NATO units. That's it. What about midwives associations in Gaza? How are you organized in your region? Okay, actually we don't have a special organization for midwives in Gaza. We have association called nursing association. This nursing association can cover the midwifery issues. So we don't have a unit or organization special for midwives. And I think this is a weak point for the midwives in Gaza. But for example, if I need help in some issues, I can go to this association or I can go to the Ministry of Health in Gaza. I can see another question in Christian. How long do women stay in hospital after childbirth? Okay, for women, for women has no childbirth. If the woman is pregnant, she can stay for like four to six hours. And after that ask to discharge for the multi-gravity. Women usually actually stay just for two to four hours. And most I can say, most women stay just for two to three hours after no childbirth. But after if the woman has CS, she should stay at least for two days in the hospital. And she can go home at 30 or 40 days. And do midwives help women at home, like visiting them at home in the first weeks after the birth? And is it for the women? Okay, having childbirth in public hospitals, it's free. No paid, no money to pay by the families, it's free. But in private hospitals, it isn't free. For the supporting women after they go home, yes, we have community midwife, the community midwife working in the postnatal clinics. And they have regular visits, the midwives have regular visits to women's home to support women and to provide some health instructions about childbirth, about caring baby, caring herself after childbirth. And also if the baby needs vaccines or something like that. Yes, that's it. So there's a question, it's about how is the bonding and the skin to skin supported? I would like to say that we support bonding and we support the skin to stick to skin contact after childbirth directly, we have this. And before do this, we ask women that we would like to put your baby in your abdomen. Some women fears at the beginning, some women's, no, they used to have that. And for the bonding, I can say we have breastfeeding at the first hour of childbirth, most women breastfeed their babies. Because I said this is a catcher of beliefs about breastfeeding. I was going to ask you, but you said that the units get really, really busy sometimes. And how do you cope with that when you're flooded with women? Christine. Hello, can you hear me? Eva, do you hear us? Okay. Sorry, Christine. No problem. Christine. Please put again the question. Christine, can you hear me? Can you hear me, Eva? Eva, do you hear us? No, sorry. What's your question, sorry? Please repeat your question. I think I had an interruption in the disconnected intellect just for a few seconds. What did you ask, Christine? Oh, sorry, I said, you said in your presentation that the units often get very, very busy. How do you cope with a midwife with a sudden, with lots of women coming in? Are you able to see more stuff in? I'll get you, host. Are there anything? Please type in the question. Okay, okay. Sorry, I think I had disconnected it just for a few seconds. Okay, let us ask the question. What are the women's or our own experience of typical midwifery care in both the midwife, midwife, midwife and public hospital? Okay. Actually, we need to study, we need to do study and research about this point, about the experience of typical midwifery care in both the midwife, the unit and public hospital. But I just can give you some highlights points about that. I can say sometimes you find women satisfied about her childbirth if she has any complications. And some women, maybe, yes, dissatisfied about her childbirth. If she's having complications or problems like fairly old cares, postpartum homelage or these things. But in general, I can say it's maybe half-half. I think I can say it's maybe half-half that the women sometimes are satisfied about the rule of the midwife and the public hospital. But sometimes, really, I think it depends. I hope it is clear for your question. Thank you. So, please put in other questions for Hiba, for a fantastic guest from the Gaza Strip. I would like to continue the question. What is interesting for me, while I'm googling, I just found midwives with the organization Midwives for Peace, which is a grassroots organization. Do you know about it? Sorry, I didn't follow your question. The organization Midwives for Peace? Uh-huh, organization for, yeah, Midwives for Peace. I have no idea about this actually. No problem. Okay, so we have another... Sorry about that. But yeah, I think it's good to have a look about it. We have another question. How do you cope with the increasingly busy unit, as you said, that can be up to 40 to 50 women in 24 hours? Yeah, thank you for this question. It's a good question, actually. It's a very overall work. We try to manage. We try, if need help, we can call midwives from other units or midwives who's in the call. We try to organize the work with the women. For example, we just take the women, so we have words, as you know, we have antenatal words, interpartum words, postpartum words. So, usually the antenatal words. I mean the antenatal words, the women who they are in the first stage, I mean who they are in the first stage of labor. They are in antenatal words. This word department, this word is usually busy. So, we just take the women to the labor room, who are nearly to be fully, or the women, for example, seven to eight. This is one of the methods just to organize the labor room and to organize the first stage word. And as I mentioned before, sometimes for just away, the women just stay after childbirth from two to four hours. So, after two or four hours, they're dispatched for another woman. So, by this simple method, we can just organize and control this overload and the pressure work. And also, the physicians and the obstetrician, they help us in the high risk word. So, to reduce this overload pressure work. So, we have another question from Julia, who is asking what is the midwife to patient ratio? Okay. I know internationally it should be midwife, one midwife per one woman. But in Gaza, I can say one midwife per seven to ten midwives, sorry, one midwife to seven to ten patients in maternity departments, intranet and intrabartum, antinatal and bostecal. And maybe you think that we have shortage of midwife, yes, we have shortage, but also we have graduated midwives in Gaza. But because of the economic status of the Ministry of Health, the Ministry of Health cannot avoid more and more midwives because they have problems with their funds. So, they just stay both, for example, and that we have actually two midwives per every shift, sometimes two or sometimes three. In the labor room we have three midwives per every shift, first stage work, postnatal work, obstetric ICU, we have obstetric ICU, gynecological department, high risk departments, we have just two midwives per every shift. So, yes, this is what I mean when I said overload work. Do you have a separate assessment unit or is this included with the same unit? Sorry, can I ask you what do you mean with a separate assessment unit? Is that you mean the assessment for the midwives, the midwives differed from the doctors' midwives, that what do you mean? Initial phone call. Do you have a separate assessment unit or initial assessment of presenting women? Yes, we have initial assessment in the reception. If the women, for example, come with labor pain, they will come to the admission department and their women, the midwives in the admission department will assess the lady and if the lady in labor, if the lady has cervical irritation more than 4-5 cm, they will admit it to the first stage work. This is what I mean with the, this is what I have, but is that what do you mean with the initial assessment? I'm afraid we are at the end of our time. I would like to thank you very, very much for your input and for answering the questions. I wish you everything the best for your work on a very hard situation and all the best for you and for your family. Thank you very much to be part of this and I want to be thankful to be, also that I had a chance to get to know you. Thank you to everybody here in this room. Now I will give over to Sarah once again and everything good from Austria. Okay, thank you, thank you very much. Brilliant, Christian, thank you so much for that. Right, I'm just going to do a little bit of housekeeping and save all the chat. And you are welcome to pop off and have a 10 minute break and stretch your legs while I tidy up this room. We will start again at the hour. Okay, thank you.