 Now with that while you guys are getting that all typed in I'm going to go ahead and introduce you to our speakers Keshet and Saban. Keshet Khoram is a research researcher who focuses on obstetrical violence in general and specifically in the maternity rewards in Israel. Her previous work examined the connection between traumatic childbirth, motherhood and shame. Her childbirth rights, she is a childbirth rights activist, a former publicist and a PhD student in the University of Haifa, Israel in the gender and women's studies program. Now, Saban Linehart currently works as an ER nurse while doing a PhD at the medical science faculty in the University of Tel Aviv, Israel. Her research focuses in the field of bioethics from different aspects and perspectives. Her current work examines women's choice during the pregnancy period and childbirth. I am going to turn presenter polishes over to Keshet and turn off my camera and thank you guys. This is going to be a great presentation. Thank you so much Kimberly. Thank you for introducing us and this is so excited to see how many people have joined us from all over. This is a very beautiful format of doing a presentation. So thank you so much. And I will start. We will discuss today about how can we improve maternity care in Israel? Sorry. Yes. Okay. Sivan, unmute yourself. Sorry. So we're going to see today how we can change maternity care in Israel and we go we will go through different topics starting from how maternity care is operating now in Israel. The results of our survey concerning what women want during their pregnancy childbirth and postpartum period and see the gaps they are there is today from the needs to the desires and the reality of the maternity care in Israel. We will see the gaps that we have in terms of equality in maternity care and see how we can go through them. Okay, so what's interesting to see in Israel is that in terms of an OECD country is the leading one in terms of fertility. We are talking about 3.1 children per child. Most of childbirths are occurring in hospital knowing it's a public healthcare service and only one to two percent of women give birth at home. Home births are highly regulated and remain a private service in Israel. It's important to understand how women, pregnant women and childbirth women are taking care of during in a healthcare perspective. All the prenatal visits are performed by an obstetrician and not by a midwife. This option does not exist today in Israel and the prenatal care is done by a staff that is different from the staff in hospital meaning there's no continuity between the different teams, medical teams. During birth today in Israel, midwives are taking care of three laboring women simultaneously, on average. If we talk about figures in Israel, we can see that third of the births are first birth women. The use of epidural is about 60 percent. We have 22 percent birth inductions. Women that had a previous caesarean section give birth vaginally afterwards in 80 percent of cases when they try to to have a vaginal birth afterwards. Six percent of birthers are instrumental births and we have 16 percent of episiotomy and about 17 percent of caesarean section. It is important to mention that those rates are in fact averages. You can see also the range from the different hospitals, minimum and maximum of all those interventions. It's important to know that in Israel, this information is not publicly available, meaning that a woman giving birth in such or such hospital does not know what is the intervention rate in that hospital. Also important to know is that because Israel is quite a little country, women can choose where the gift to birth in which hospital, mainly if they live in the center. But if they live in the north or in the south, the choice is very limited. For example, in the south, there are only two or three hospitals. So I stopped the video. I wanted to know if it's it's easier to see the screen that way or not. Siobhan, do you prefer to leave the video on? Let's see. I think it's bigger like that. Okay, so I'll keep it that way and we'll open the video when we have a question. So this is actually the research we are conducting in this past two years. This is an online survey when our aim was to create a database of women's expectation and experiences of childbirth. You wanted to promote new policies to adapt care and to train medical staff. As Siobhan said, most women in Israel will go through childbirth more than one. And this was actually the first time that a survey that big was conducted when women actually were being asked, what do you need? What do you need in your pregnancy? What do you want postpartum? A lot of the responses we've got from women were that this is the first time they stopped and thought about their needs and their desires. So our inclusion criteria in the survey was women who gave birth in a hospital in the past five years and pregnant women who plan to give birth at a hospital. The reason why we examine only hospitals and maternity wars is because, as Siobhan mentioned, the majority of childbirth are happening there. So who are the women who answered this survey? So above 3,000 women answered and the average age was 30, the majority were married. They were born in Israel, 86% of them, 40% gave birth before and 60% of the women who answered that was their first pregnancy. 70% of all the women who answered was aiming for a vaginal birth and 60% wanted to give birth at the same hospital they did before. As of their history, 31% had a miscarriage and 8% have been through IVF treatment, 3% had the stillbirth before. The majority of women described themselves as heterosexual, they spoke hyperfluently, had a bachelor degree or a master degree, more than the average percentage in the population, and only 30% of them are earning less than the average paycheck in Israel. Most of the women that gave birth before had a vaginal birth, and when we asked about past experiences of sexual assault, we wanted to give women an option to answer not only a yes or no, rather to give a scale. So 7% answered and they agree if they been through sexual assault before, agree in a mild way, 9% said they agree in a slightly way, and 22% say they agree in a very slightly way. So when we go through the results of our survey, we can see that during pregnancy follow-up, women were talking about the preparation to pregnancy and childbirth, the availability of medical teams and information they would like to have. We can see in terms of source of information, it's interesting to see that women mainly got an information from informal sources as internet sites or friends, then books, and only then by the primary obstetrician, childbirth courses, and then Facebook at last. Most importantly for women, they were wanting professional consent to see in terms of availability, but also in terms of informal way of communication as emails or phone. Only then they were interested in the partners involvement, having ultrasound checkup as per request, birth preparation courses, maternity ward meeting before the birth itself, and emotional accompaniment. It's interesting to see that although for most women it's important to have availability of professional consultation, at the end they receive their information from informal sources as internet as I said before. In terms of assistance during pregnancy and in fact all the follow-up and checkups, women were interested to have these made by midwigs. As I said before, this option does not exist today in Israel, and only then by female obstetricians or male obstetricians. When we look at how women choose the hospital they want to give birth in, they talk about the different possibilities of consideration and the staff. Most importantly they look at the staff professional skill that the treatment they have received before in a previous visit or a previous birth or the maternity ER visit. The option for zero separation, it's important to know that in Israel it's not an option that is available in all hospitals and for all women there are certain conditions and only certain maternity ward that offers it. Then they were looking at one-on-one midwife continuous care and as I said earlier this does not exist today in Israel in the public service healthcare. One midwife is treating three birthing women in parallel. Only when women choose to have a private service or home birth then they have this follow-up with the midwife and having one-on-one care. They were also looking at the natural childbirth approach and the rates of medical interventions. When we look at what a woman meant during the childbirth itself and not only choosing the place that would give birth they're talking about the staff, again the possibility and the consideration and also the privacy. We can see that they were looking at being informed about the childbirth, giving informed consent before medical interventions, the availability of midwife during the childbirth itself and also being involved during the childbirth process and having respectful treatment. It's interesting to see and it's important to mention that we can see that choosing the hospital the women focused on professionalism of the staff but during childbirth they were focused about the treatment and the quality of human relation they would receive during the birth itself. Here again we can see that the women would have preferred to have the assistance of midwife during the childbirth. In Israel it is constructed in a manner that it is true that the midwife are the main professional actor during birth but there's always an intervention of an obstetrician so first they would like to have the assistance of a midwife then a female obstetrician and only then by male obstetrician. As per if we look at the postpartum period we can see that women talk again about possibility which is something that is redundant during all the different periods. The baby breastfeeding, sleep, night, silence and food which are in fact basic needs that we all need but especially in this challenging period for women. If they look at the maternity ward after birth most supposedly they would like to have their partner and the escort present during the night also. Here I will mention that in Israel this is not occurring in most or even all hospitals the partner or the doula or the escort or someone that is with a family cannot stay at night only in very very specific cases and specific hospitals. Then the women were interested in encouraging breastfeeding through available consultation and also the number of women in the same room. In Israel we are talking about four to five women in the same room after birth and also the availability of nurses during their stay. So throughout the questionnaire throughout the survey we asked women about their emotional state. We asked them how was their emotional state during pregnancy during the childbirth itself and after. So what we saw that women who experienced emotional difficulties during pregnancy were more interested in continuing continuous midwife-led care as Yvonne mentioned this option does not exist in public health in Israel. Also we saw that women who experienced worsening in their mental health state after childbirth wanted postpartum follow-up visit with the midwife or the OBGYN that treated them during their childbirth. In general what we saw that the preferences related to postpartum visit was towards the primary OBGYN the one that the women saw during their pregnancy after that we saw a preference of seeing the person who assisted them during childbirth and then their primary care physician. Again as Yvonne mentioned this is not an option right now to see the staff that actually actually treated you during childbirth only at the childbirth itself. So what we also saw that women who seek mental assistance during pregnancy or experience sexual assault in the past were more interested in having an out of hospital birth. Again this is something that has been legally discussed and for now is not an option in Israel. Women who experienced sexual assault wanted to give birth at home or at an independent childbirth center or before water birth. Again this is water birth is an option that is only available in a very strictly hospital and under very strictly pregnancy related issues. As for past childbirth experiences when we asked women who gave birth before we asked them what is the guidance and reference to treatment that they got from the hospital staff. So 78% said they received information about need of medical consultation. Red flags they need to take care of as of their physical condition. 90% visited gynecologists in their recommended time and 81% received no information about the need for mental or emotional assistance. 38% of the women who answered the survey said they felt their mental state has worsened than before birth. 37% were concerned during their childbirth and 60% said they seeked mental assistance during pregnancy. Again when we look at the numbers of women that said that they felt their mental state has worsened and then we see the 81% did not receive any information about what to do what is the red flags about their mental situation. This is a very concerning matter. One of the most important thing we wanted to know in our survey was about how was the treatment they received from the medical staff. We asked them about the communication and the treatment experience they've been through. So 76% of the women said that staff spoke to them in a respectful way they treated them nicely. 70% said they were asked about for consent before medical interventions. I remind you the thing Sivan has mentioned about what important for women in their childbirth. More than 90% said that to be given a consent to be informed was the priority for them and then we see here that only 70% were asked for a consent so 67% of the women said the staff introduced themselves, staff respected their wishes, 66% felt involved in the childbirth process and received an explanation and information before interventions. Again this is of course there are countries that are saying worse things about mistreatment and abuse during childbirth but 35% of the women answered by no at at least three of the questioning. Again this is something we wanted we wanted to put on the table when we approach now after the survey with the results to medical staff and decision makers. So we know that our survey and research is certainly mutation and one of them is in fact the language barrier. We know that we lack of access in terms of language but also in terms of social media to minority groups of the survey and we would need further research about minorities population in Israel as well as specific geographic location as I said earlier the north and the south has more limited choices in terms of a hospital or in terms of birth choices in general. What we can see for sure during from the results of our survey is it's very important to empower and support need wives as well to listen to women needs in relation to their maternity care and that can bring a big change in terms of experience and growth outcomes. So from the results of our survey we can see main changes that can be brought especially in terms of midwife free let care continuity of care and out of hospital options. We see there's an urgent need to change policies to make midwife let care more available to have more women midwives working at hospital meaning that they will not have one midwife for three breathing women but tend to have one on one care and also have more access for out of hospital versus for women but also for midwife to attend them. Of course the aim is to allow breathing women to access quite the public health care with no relation to their ethnicity or geographical location. So the main um matters that we can highlight in terms of a why we would like to expand the options we would like to expand for women we are talking about continuity of care during pregnancy and childbirths including of course involvement of women during these periods and also taking into account the emotional and physical support in the postpartum period. In fact expanding the options means that we expand the community-based care and support all midwives to expand their activity in community but also in the hospital. So we wanted to give to give a few acknowledgment we want to to thank Kieran Briao partners Sarah Tankman and Mitaal Banshoek that were a part of this survey and a part of this research and our graphic designer Michal Shemla. Thank you so much. Thank you. Well welcome back everyone let me get the recording paused here. Lorraine says turn your recording back on. Well I did we have to move that slide. All right so do you guys have any questions at all for Cassette and Savon this was a wonderful presentation. I'm watching him. Let's see anyone at all. I'm amazed at this accomplishment I mean that was this was phenomenal and if you guys can actually get some changes made within the facility and the the organizations and just get people thinking about this is incredible so congratulations to you all this is just amazing. I think that was the main thing when we saw the results when we thought about the survey I think we wanted to give as many options but we didn't necessarily thought this is what women will say they want because these options are not available not everyone knows this is something you can actually want. All right well you guys um I don't see anyone else typing here. I'm typing my email if anyone uh want to stay in touch or to ask something afterwards maybe Sivan will want to write her email also. Let's see you have a few more messages below here. All right guys well this has been a wonderful presentation and um I guess uh since we don't have any questions right away we can email Cassette and Savon if in fact um we have if we have a need uh looks like Rola Lorraine has mentioned that uh Seal is typing so we don't want to leave anybody else uh and Seal says in the US most hospitals are for profit hospitals are required by insurers to survey patients following a hospital birth hospital mid-wise physicians and nurses are exhorted to treat well so they the survey results are high. That is to say all of the staff are urged to provide respectful and compassionate care to clients so that the survey results look high. Hospitals that have high ratings on respect and good treatment actually receive a bonus payment from the insurance companies. That's interesting it's very interesting because um in Israel a lot of the times when we approached the the um health ministry and said that women are um actually uh complaining about treatment uh we were giving the response that women can choose whatever um maternity war they want so if they choose they can if they did not did not like the treatment they can choose another hospital um but saying that as Sifan has mentioned the the word choosing um we we really you know need to um to keep a safeguard from that because a lot of the times women cannot actually choose uh where to go to um so not only the the dollar sign the you know be um be the reason for a good treatment uh rather than seeing um child birthing women as a person. Yes also a lot of information in Israel is not publicly available so as Keshad said it's I mean it's very difficult to really choose uh in a in a consent way let's say or informed way the the place where where they give birth. Um do you guys know will your uh results be censored in any way? Are you going to be able to publish your full results? Well we we do we are not related to any I mean we did not do this survey uh related to any hospital or to the ministry of health we did it in a free way I mean uh academically pure academically way uh related to the university uh and the organization uh Karen Brea that Keshad mentioned so it should not I mean I don't see any reason it would be uh censored but you know who knows.