 Thank you so much, CO, and happy International Day of the Midwife to everyone out there, and I appreciate you coming to my presentation. So my presentation today is entitled Baby Proyecto, which in Haitian Creole means Baby Project, and it's about obstetrical and midwifery simulation training at FCO School of Nursing in Laogan in the Republic of Haiti. And I would like to thank my colleague Brent Sybel, MD, who is my colleague from the University of Florida in Jacksonville, who also assists me with this program there. So thinking about Haiti, as a child growing up in Scotland in the 1960s and 70s, and I'm sure all of you heard a lot about Haiti, and I'm not sure whose microphone that is making the noise, but it's not mine. So Haiti in historical context. If you think about Haiti, it's a very interesting place and a very interesting republic. It was the first black republic in the world, and it was the first country in the Western Hemisphere to abolish slavery completely. And on January the first 1804, Jean-Jacques Desireen, who was an African-born ex-slave, would declare Haiti independent, but unfortunately since then there's been a lot of problems in Haiti, and of course not least of which was the devastating earthquake in 2010. And one of the things that happened at that time in Haiti is, especially in Laogan and the surrounding where it was the epicenter of the earthquake was, many of the healthcare providers, including midwives, either died or were seriously injured. So the whole healthcare system basically at one fell swoop was wiped out. And at that time, Metsans en Frontier did a great job, they came in to help with emergency care, but up until now there's been very piecemeal work. So we're attempting to assist there with simulation training, which I'm going to talk about today. What where is Haiti and why should we care about it? So this is a little map here, so you can see Guantanamo peeking in at the top left-hand corner there. And if you just look further up on the map, you'll see the little part of Florida that sticks out there into the sea, so really not far away from where I live in Florida. And Haiti shares the island of Hispaniola with the Dominican Republic to its east. And for me to get to Haiti from Miami just an hour and 20 minutes. So why should we care? Well we know from studies that Haiti has devastating outcomes for women and babies. And the maternal mortality rate last year was 359 per 100,000 live births. And if we compare that to where I live in the United States, this number is 14. So to think about that in perspective, you go an hour on the plane and you've got completely different outcomes for women and babies and families in fact. So how did this study come about? And this is an ongoing, this is ongoing work that my team and I do in Haiti. So I was invited to Leogand to do a needs assessment for another health center in 2013. And my colleague was there and we were looking at traditional birth attendance and what were the options for women. And I actually had an appointment with the dean of the school there, Dean Hilda Alcindor. And she invited me to go and visit with her over at, it's called FCL, it's Faculté des Sciences infamière de l'Université Episcopale and we call it FCL for short. So I'm going to be referring to FCL. So we had a very interesting conversation in 2013 and she requested that I think about coming over to teach midwifery and obstetric training classes to bolster what was already being taught at FCL school. FCL is the only baccalaureate nursing program in Haiti so it's got a very important part to play in the healthcare system in Leogand and all of Haiti actually. We do know that obstetric and midwifery training is vital to empower nurses and midwife to be effective healthcare providers for women and newborns in Haiti. So what did we do? Well, I asked Hilda Alcindor what she would like and she asked if we would consider bringing the team that I already had at the University of Florida, would I consider bringing that team over to teach at FCL and I thought, well, why not? I think this is a great opportunity for some learning and we could bring our equipment there and work. So we began there three years ago and at first we had 45 junior and senior nursing students who were identified by the faculty to attend the training and we had a pre-selected sample of 41 more female, four more male and they were all full-time enrolled BSN students at FCL and here you can see us, we're in our suturing lab actually so we bring all the equipment with us so that it's fully self-contained. So what did we do? We used a qualitative method to see how the students were learning. We used direct observation and evaluation. You're probably all familiar with Mamma Natalie, it's a layered old device that's wearable. We do have, we've purchased two of them with our grant that I'll talk about at the end. We take those with us and actually they live there now, our Mamma Natalie's actually live in Leogun and then we bring the rest of the equipment with us. These were devised for low resource environments and it's interesting actually we use the same devices when we're working in simulation labs in the USA. So that's what we did, that was the design of our program that we have there. So what did we do? And it's very interesting we actually do a simulation lab Monday to Friday from 8 to 5 and we have a lot of different experiences. So we hold daily labs for between 9 and 12 students because we know that's about the most effective number and we have US trained faculty, there's six of us that go. There's four midwives, one Haitian American, RN and one physician and here you can see Brent, he's demonstrating blood loss to the students there. The learning scenarios include normal births, postpartum hemorrhage, which we know is a big problem in Haiti. We also talk about infections because those are the two highest risk things in Haiti are hemorrhage and infection and we do suturing of simple lacerations because these students they are, these ones we're talking about just now are nurses and they will be expected to repair simple lacerations and we do review normal anatomy and physiology of pregnancy and birth. So we give them objectives to complete prior to beginning the workshop and these are written in Haitian Creole and French because even though the school actually teaches in English most of the students are more comfortable obviously in Haitian Creole and in French so we do have it translated so that we can all understand what we're all talking about. All the students rated the program as good or excellent and they felt that the training was very useful and they would be able to apply their new knowledge because these students actually fan out in that area and work in the local health centres and in the local hospitals there in Leogun. They did not make any specific improvements in the course and the students continued to reinforce their training with the use of the simulator devices and the equipment which was donated to the school. We do communicate regularly with the faculty and we have a lot of ongoing meetings there to provide support and then we also provide annual in-country trainings and online support as well there. And thank you Celine that would be very helpful and you can email me I'll give you my email after she's saying she could go there she speaks French and that would be very helpful. So the students felt really validated and empowered I think one of the things is when we go to Haiti we're not there people ask me they say how many births did you do in Haiti that is not our role we're not going there to take over our role there is to educate so that this can be a self-sustaining program run by the faculty and staff there and we will provide annual training so that the faculty there can take over this training program and the students were able to learn and document their new skills. It is obviously difficult to assess the impact in the local community but we do know that the students are very involved and most of them want to stay in Haiti and in Leogand to work as nurses they do not wish to leave Haiti they actually want to stay and help in their own country. There are further simulation experiences planned at FCO and we're also going to expand the offerings to include other local midwives and traditional birth attendants. So I always think of midwifery as serendipity. It was serendipity that I went to Haiti in 2013 with my colleague and it was serendipity that made me meet with Dean Allison Dorr and interestingly enough and I'm very excited to announce that Frontier Nursing University is developing an initiative with FCO school and we've been tasked with assisting them and it's going to be their program so FCO will have a midwifery program and it's going to be starting this year so that's very excited to announce that at International Day of the Midwife. We're working very hard on the curriculum and we're going to be enrolling our first midwifery students who are all going to be graduates of the nursing program at FCO. They'll be enrolled in fall this year so it's extremely exciting for us. We're going to keep offering the annual training for the students because there's really strong demand and now we're actually seeing the students again. We've seen them one year and then we do a higher level course for them the next year so it's very nice when we actually have students there more than one year. We've got to know them so they're really coming on and their skills are really excellent. We did add our Haitian American nurse and that was really a big plus for us. We're not very strong in French or Creole but we do have translators there with us from the faculty but bringing our colleague Esther Lien was a big plus for us because it really helped the students learn more effectively and it was very engaging for them so we really enjoyed that. I would like to thank the American College of Nurse Midwives Foundation. The Jeannie Reisler Award really helped this program get off the ground and I really have great support from Frontier Nursing University and the University of Florida for making this educational initiative an ongoing project and you can see here all the students are very excited to receive their diplomas and we had another successful simulation project. So here's my contact information I'd love to hear from any of you that are interested in this program and I'd love to take some questions. We have good time for questions and Jane I have a question to begin with. The program that Frontier Nursing University will be offering to the nurses once they graduate is that a certificate program? Is it Frontier's usual program or are you specially crafting a program to meet the needs of the nurses? That is a fantastic question and thank you for bringing that up. So at the present time is my understanding that it will be a graduate level certificate which will follow the ICM competencies for midwifery so we've basically gone to the ICM which for all of you that are interested in international work, the ICM actually has basically your work done for you. They actually have a curriculum printed already that you can actually adapt for any situation so we're using those competencies and we'll be adapting them for the program there so at the moment we're thinking it's going to be approximately a two year program for the midwifery students and for them the days that work best are Friday, Saturday and Sunday because all of these are working people so they'll have classes Friday, Saturday and Sunday taught on the ground and we will have input online so we'll have an online connection there we will supply all the support and the teaching materials and that will be taught in English but it will be translated because we have a lot of support from our Francophone colleagues so they will be assisting us with that but it's a lot of work but it's a really exciting avenue for us to pursue and Jess Bentley asked when you go there how long do you stay? Well it's such a beautiful country but we do because we all work and it's interesting because we take exactly the same process as what I teach in Lourdes so we actually just go there for one week a year but we do keep in touch with them frequently on email and on Skype. Is there a direct entry program? Celine says yes there's training and I don't want to speak to this because I'm sure Midwives for Haiti would speak to this so there is training by Midwives for Haiti but that would be something that they would address there and Linda was going to ask about online teaching so we are going to have online teaching but we are going to actually have it be like brick and mortar school now there will be like textbooks and you know papers and things like that because sometimes the power can be a little temperamental so we don't get power all the time and then Jess thank you I had another commitment my colleagues already went to we actually have three students from Frontier who live in Haiti and work there and they will be planning to assist us as faculty so sorry I did not attend the women's conference because I actually had a previous engagement but the president of our university Sue Stone was there along with some of our Midwifery students who live in Haiti. Gloria and hello Gloria it's nice to see you from last year I was Gloria's facilitator last year we are looking to partner with other institutions that would be great I'd love to hear from you and so that's Hiromi in Japan asks about perennial suturing and that is a great question thank you for bringing it up yes it's a problem because unfortunately we have a lot of we have a lot of learning we have to do in Haiti women are still having routine episiotomies there so yes it is a problem because we're having a lot of perennial trauma still so it's a lot about education for midwives and providers there so this course doesn't mean this course is offered to registered nurses the course that we offer basically is just to bolster their education that they're already having just to to improve their knowledge and skills it's not to provide a midwifery training per se but the midwifery program obviously will be providing that is there not perennial problems in all cultures to some extent yes Linda and probably for all of you as seal points out I'm originally from Scotland and I'm of the age where we still did we had to do a certain amount of episiotomies in our training so obviously I only do about three episiotomies a year now it's very rarely that I'll do them so we do need to spread the word on perennial integrity and the importance of it but the students also the reason we do teach about suturing is that they are asked to do simple suturing as well because you know if there's an accident or whatever they'll be in the they'll be in the setting in the hospital where they might have to do simple suturing so they can do hand ties and they can do instrument ties and they can identify the anatomy so that's why we include suturing Cecilia asks how many midwives means frontier hoping to educate annually when they're up and running so we're hoping in the first class about 15 so and they're former students from the school so they'll be about 15 in the first class and then we'll probably admit by annually so that means every two years we'll have about 15 and we do have we are working with different partners to find suitable clinical sites for that so I'm going to cough that's a great question Celine and I don't like to answer that question Celine asks will midwives be autonomous I think that it depends where they work and I'd like to have I think Jess obviously works in Haiti it depends where you work in Haiti how much autonomy you have I do believe in the hospitals it's difficult because a lot of the what there are not a lot of physicians there but birth tends to be the actual birth not the physical care of women and labour but the actual birth may be taken over by the physician but we do know most healthcare in Haiti is provided in rural areas so that means that the traditional birth attendance and local midwives are doing most of the care themselves so that's why it's important to reach out and make sure there's an excellent training for these people in that area so we are looking into that training as well but we do know that midwives for Haiti provides excellent training as well yes suggests agreeing that it really depends on where you are in the country so yeah there's autonomy if you're in the rural area otherwise if you're in a hospital I think it's quite controlled and there's still there's still it's it's it's quite sad there's still a lot of improvements to be made Leo Ghan used to have the best hospital in Haiti the Opital San Qua so the Red Cross Hospital it was supposed to be one of the best and it's it's quite difficult now it's very under resourced and they're having a lot of issues so it's still very unstable so we have to deal with a lot of political issues as well as other issues when we go there yes the healthcare system is broken so we're trying to we're trying to make a difference as midwives and physicians and we're going to do our best on that so thank you for all your questions I think Hiromi's asking another question here she says in our birth centre we do not perform a piece of autonomy and we do not suture even with a tear we rarely have problems it heals very well spontaneously and Japanese midwives are not allowed to suture legally so good work Hiromi I do recall in Scotland in my training and this was 25 years ago that we were allowed to cut a piece of autonomy but we weren't allowed to suture so I had to learn my suturing when I went abroad so I did not learn to suture until I left Scotland I believe now that midwives in Scotland learn suturing Jane while other people are typing is there a midwives association in Haiti that is providing some social support and that might work toward more favorable regulation well that's a great question Cecilia and thank you for asking there is there is the Haitian midwives association but they're based I believe they're actually based in Miami we have a big diaspora in Miami and in Florida in general is a huge diaspora that provides support to Haiti speaking about midwifery in Haiti I do know that there's there is licensed midwives in Jack Mel and all around which are American trained licensed midwives and there's midwives for Haiti but again it's very peace and you know so there isn't as far as I'm aware and Jess can probably speak to this as well I'm not sure that there's I'm not sure there's a national coalition of interested people there was just the there was just a tour on of women's health provision last month which my president of my university attended Sue Stone who's also a midwife to see what was available for women in regards to women's health and midwifery care but I don't believe that there's a national coalition at this time so so Jess is saying and in Port-au-Prince yeah there is midwifery training in Port-au-Prince but it's there's no kind of national national coalition I'm aware of so it's quite difficult because we're all kind of doing things here and things there so we're trying to advertise this you know this program that we're going to be offering and then going annually to empower the students that are there even if these folks are not not midwives at the moment they're midwives in the making so they're very very interested in women's care because we do know that you know if we have strong women and strong educated women and men that will have much greater improvement in health outcomes very quickly if we can empower them as quickly as possible so thank you we are well ahead of schedule if there are other questions for Jane please don't hesitate to ask I see a couple of people are typing in so Jess asked have I worked with midwives for Haiti not in the formal sense the informal sense that I have a lot of links with the folks that work there but I have not one of our students is actually going to be doing her clinical practicum partly in Port-au-Prince and Haiti so with midwives that are working for midwives for Haiti so this organization is an American organization that provides midwifery care and training in in many areas in Haiti so I do have informal links with them but not in specifics to our attendees you aren't high question about the panel oh yeah you aren't tied to typing into the chat box we can open the microphone for you if you raise your hand the little icon at the top of the screen sorry go ahead yeah so I was I was wanting to ask her all me about and her how she Jane is such an Adobe pro she read her questions before I got to read them back to her she can read the chat box and her screen at the same time yeah I use them this kind of format for my students and no one likes to use the microphone so I always was used to them typing in the chat box yeah well I've been doing this for a while so and I'm interested to hear from Celine I'll look forward to your email Celine it's very it's very fascinating working there in Laodan it's so hot there's no air conditioning and the students are there the women wear skirts and hose and dress shoes and the men are wearing long pants and dress shoes and socks and it's very hot in there and no one ever asked to take a break we're always working we work right through so it's quite inspiring is this only for nurses and Haiti which are you talking about this the training program I guess you're talking about the training program Olivia yes because it's for the school it's based in the school I mean we've had folks we had actually some students from Boston College that stopped by and then they came and joined in if there's people there they can certainly come and join in but this is particularly to provide provide a support for FCO and the training and the education that goes on there and currently the the midwifery program it will only be open to nurses Jane trained at FCO until it gets bigger because it's quite an undertaking for our school to take this on so it's a lot of work and I'm sure in the future it will be very successful and expand it Jane you might tell our listeners a little bit about frontier so they can imagine how frontier might take on a program in another country the way you're doing the per name but it heals well of course we transfer third-degree tears to the doctors okay great yeah sorry sale go ahead okay so for those of you that are not American nurse midwives our school was started in the 1920s by a woman called Mary Breckenridge and she helped with the reconstruction of France after the war she was an American trained RN nurse and when she went to France she discovered people called midwives and when she was there she thought well that's interesting that's a really empowering profession so after the war she went to London and she saw women in London that were nurses and midwives at the same time and she thought this was a great model that could come to America so she was the first American woman that became midwife in London she did her training in London and then she actually went up to Scotland to do part of it like an internship to learn about midwifery care and rural communities so she brought British nurse midwives over to Eastern Kentucky and at that time the women in Eastern rural Kentucky were very poor and had very poor obstetrical outcomes and with her midwives and nurses they looked after the whole family and they took care of all these women and they actually had some of the best outcomes in the whole of America at that time so the Frontier Nursing Service developed into Frontier Nursing University which is now an online university and we have students all over the world basically mostly obviously in the contiguous United States but we also have in Asia we have in Guam in Japan Saipan and also in Europe in Germany and the UK we also have students there so we've been doing online for a long time we have a lot of experience in delivering and remote education and it's if you have an internet connection basically you can be at Frontier as a midwife because we can provide your training with local you have midwives in your local community providing your clinical care and we also have family nurse practitioner and we're about to start mental health practitioner training as well so it's very exciting I actually was just in Guam a couple of months ago so we had a very good time there so I should have waved to Hiromi because I see she's in Japan I did get to stop in Japan for a little time so I'm glad Shari's here shout out to Shari so proud to be a Frontier midwife great and Celine says oh we're talking about the sutures again yes we were we have distinct tears that were sutured in the ones without suture and Hiromi says do you have an entrance exam what is the standard of the students basic competencies I think Hiromi that's a question why don't you email me because that's a question that would be best answered in in an email so I can speak to that very well because that's part of my job thank you Ori Gatto so I will I will look forward to hearing from you and I'll look forward to talking with Celine as well I'm looking at your comment Linda about a perennial suturing would be a great workshop and I would very much like my colleague Brent Saiboh come he's the one of the top teaching obstetricians in Florida and he's fantastic so Crystal says it is our practice oh sorry it is our practice to not stitch first degree tears and leave second degrees up to moms but great majority choose to stay home without sutures there is the thought absolutely crystals mentioning poor fall-up nutrition and infection control and Haiti and that you've got that exactly right nutritional nutritionally a lot of these patients can be very deficient so they're not going to heal normally like somebody that's well nourished say in America or the UK or in Canada or whatever they're not going to heal as well but yeah I mean I think most of us now realize that first degree tears can be left alone and second degrees perhaps maybe one stitch or whatever just to take care of him and Linda's thinking about a perennial suturing workshop for next year and I'm just trying to get my head around how we would do that online we're straying far from Jane's topic on Haiti but leaning on her expertise we have about five minutes left I was just saying we've we've strayed far from your initial topic on Haiti we have about five minutes left any other questions for Jane hello can you all hear me we can hear you again Jane all right sorry my internet I got kicked off for a minute so yeah I think it sounds like we should definitely provide some suturing workshops next next year that's a great idea so and Michaela said telling us that there was information about the midwifery conference from Haiti in March 2013 and there was just a conference like last month as well so oh thank you so it's 2016 so I will look that up as well thank you all all right coming back I am going to and thanks CEO for facilitating thank you so much yeah thank you so much this is actually my first time facilitating so you were my practice Jane thank goodness it was you for all of our listeners Jane and I go back a long time Dillian Jane gave us wonderful information about I'm not sure if SEAL is having issues Chris but we're not hearing SEAL so I don't know if she's speaking but I was wondering if I'll see if I can turn off the record oh I am speaking I can't remember how to do that I am speaking and now you can't hear me okay I can hear you we're all offering to do it now I will turn it off and he's