 Now this is obviously the wrong slide set. Hang on a minute while we get the right slide set. It should be the right set. Wonder if you want to go to the next one. It's got Niagara's set. No, that's fine. Don't worry. We'll nip through these quickly. Oh, we're in the same place anyway. That's interesting. Okay. We've had a couple of blips today, I have to say. Okay. So let me tell you a little bit about the background here. I visited Iran in October last year. I was invited to go to speak to as a result of the VIDM actually from this from last year I was invited over because the midwives and the government in Iran are trying to promote more physiological birth. Now there was a presentation during the night for those of us in the UK which is recorded and I will put the recording up shortly onto the website that you could go to at which they talked about the background and differences between Australia and Iran actually but the differences are similar if you're talking about any developed country. So there is a very medicalized maternity services. There are many more obstetricians or what they call gynecologists there than there are midwives and they are in charge of all births but the government are wanting to promote physiological birth because they're wanting to encourage an increase in the population size which has become a bit stagnant and with so many people having cesarean sections they are choosing to have smaller families. So there's a big move on there to introduce physiological birth. So I was invited over to Iran and I run with another midwife friend aboard a workshop introducing the concepts of physiological birth and water bath. So as a result of that Fatima was at that workshop and when she went back to her own city which is the city of Koramabad in I think southern Iran she wanted to practice this physiological birth particularly water birth. So this is the story of her water birth. So Fatima Aras Hussaini has got a master's degree in midwifery and this is the case study of her water birth and this is Fatima you've seen that picture up as well very pretty don't you think? She is an experienced midwife she's done a variety of courses she is a teacher as well she's been a midwife for 12 years and she works in a governmental run maternity hospital they are both governmental and private hospitals. The medicalization of the private hospitals is worse than it is at the governmental hospitals. So as she has told us here childbirth in Iran is very medicalized with gynecologists in charge of all the births and I've told you a little bit more about that already. I'm not too sure I had some conversations with gynecologists in Iran and I think they're part of the system too in that they're having difficulties seeing beyond the medicalized side of it. It is a powerful match isn't it? There's a nice one to offset that when we get towards the end of the presentation. So it's very medicalized in Iran and also and which makes it a lot worse is that the midwives are given very little responsibility there they are what in this country we would call obstetric nurses they just do what the obstetricians the gynecologists tell them to do. Although they have a four-year degree course to become midwives they don't have accepted responsibility for the women that they care for. They do run private clinics they do have private clinics and they do take on private patients so to speak or women clients. I found it difficult to understand exactly what the place of that clinic was because I believe that even in their clinics they then have to negotiate with the gynecologists to be allowed to manage the woman's birth. Can women be gynecologists? Well I didn't see any men I only saw female gynecologists which to some extent surprised me. Maybe Fatima you could text me and tell me how many if there are men gynecologists because as I say I only saw women and I saw quite a few. So caesarean sections are very common women tend to think in Iran that a caesarean section is an indication of wealth and they also consider that this is safer a less painful birth and there is the issue of the vaginal bypass I was told by some in that it does retain the integrity of the vaginal canal. So for all those reasons caesarean section reaches 90% in some hospitals and of course there are there's increasing evidence that caesarean section is not a safe option and there are many complications and I suspect that that will also reduce the number of babies the women have. So about eight years ago the government began an initiative yes it is to promote physiological birth the problem with that is you can't just say everybody else everybody's got to have a nice normal birth now that you've got to change people's attitudes towards this and this could be this is something we were going to ask all of you there are there's the gynecologists there's the midwives and the women so how do you think we we can have that we can suggest to the the midwives of Iran would be a good way of encouraging women and midwives and gynecologists that physiological birth is a good option what do you think how do we change society's views number of children what do you mean by number of children all right so to explain to everybody that and that of course is from what I understand and I only spent nine days in Iran and I have been talking to Iran almost nonstop ever since from what I gather that is the reason for encouraging physiological birth the government seems to be on board with that but it's everybody else you've got to get on board education education education yes yes have community outreach programs yes the government's got to be behind it while I was in Iran we were actually asked to go and speak to the government it was a very interesting meeting we had just got off the plane having traveled all night we hadn't had much to eat for the last few hours and we were going to meet them over breakfast but breakfast was some fruit but they were telling us that they they have a large amount of money that they want to put behind an empowering woman project in order to empower the women to become entrepreneurs actually and start thinking about running businesses etc etc so education has to be part of it interestingly enough I did speak to one of the lecturers who at the university where they train them midwives and she told me that they only have one textbook I don't know whether this is totally true remember there's a big big language barrier here too she said that they just use one of the American obstetric textbooks and that's the only way the only way in which the midwives are taught so they are already getting a medicalized a medicalized culture of coming through their education something like Sweden's public commercial but appropriate for that culture has Sweden have they have they developed some kind of education I don't know about that yes I agree I'll you I'll you family that some women in some countries are not terribly keen to face the challenges of physiological birth and to be honest we have a speaker later on who's going to talk about the media and how the media has influenced that because I don't know about in your country but in my country there are lots of programs showing childbirth as it is like one born every minute and they show a very skewed version of childbirth where women scream and are very frightened and it's very frightening to people so I think you're a little bit unfair in some extent olufemme but it's not um you're not wrong either a bit of each jame what's your thoughts you got any ideas how we can hear me okay sorry can you hear me okay you're a bit faint can you hear me so don't worry if you sorry can you hear me now yep a little bit better yeah yeah let's just wonder any thoughts about how to um how to encourage women and obstetricians and midwives to accept physiological birth rather than a medicalized birth well I think it really feeds into our talk last night it's all about the and saying intervention is important in the right place but we need to have you know at least 80 percent of our population should be able to have normal physiological birth with low intervention and being cared for by midwives so I think knowing um knowing what's normal and knowing what's not normal and then having services that all work cohesively together I think that's important yes yes indeed and ginger ginger ginger is that how you pronounce it what do you mean by less people at the birth ah okay are most of the people present a caesarean male or female well again I don't really know I know that in Iran um the husband is not encouraged to be present at the births so that's one male out of the way and as I've already said all the gynecologists I met were female so um it's possible that's true as well um I think part of the problem is that they the the women in Iran from what I saw and what I gathered are used to submitting to whatever is thrown at them they don't seem to have an awful lot of empowerment so we're back to that again of course you can post a link please do it's in the chat box so that would be wonderful if you would like to do that how long there's there been a history of caesarean section um so what I gather it's at least 20 years or something like that we have male midwives in this country too so there's a few suggestions there for Fatima to mollover and her midwife colleagues anyway so um and I've already said this is part of what I've already discussed that um the women themselves believe that caesarean section was better than a normal birth so this is this is us in Iran with Fatima this is me in the middle and to my left to the left is Allison who is a wonderful midwife from here in Scotland who is a midwife led unit midwife so to speak and in fact was my daughter's midwife and that's why I took her because she was fabulous and on the right is Fatima so she's we had this workshop there were something like 30 odd senior midwives came to the workshop to um to discuss and consider how to change the different maternity hospitals in Iran to consider physiological birth so after that workshop Fatima says she was thinking about water birth a lot and she thought about how can I do that how can I find a mother to speak to her about it because in my country mothers do not have enough information about water birth and then about two months after the workshops a mother was referred to her own private clinic or her own clinic and um this mother was 23 years old a primagravada and was at 34 weeks of pregnancy I will answer that question Becky yes there were a few gynecologists popped in and one which one of them we were talking about episiotomy at the time which is mandatory for all primagravadas in Iran do you remember when that used to be the case here in the UK um and um she agreed with us that episiotomy was not necessary so some people some of the gynecologists do not agree with the kind of standard care there's um family size tends to be quite small but that's I don't understand too much about that one and I would have to ask for more information about that so anyway so Fatima saw this woman and thought that maybe she was an ideal candidate for a water birth and the woman told her that she was really frightened about the label the label pain um and the episiotomy um and I suppose was swithering about what type of birth she would have now I don't really understand despite asking her several times why Fatima chose this one in particular although I do know that she was low risk or didn't have any um I shouldn't say that we're trying to get away from the risk word now she had didn't have any um history that would stop her from having a physiological birth so she um Fatima realized that this might be a lady who would be uh susceptible to some conversation about her choices including that of water birth so she asked her did she want any any information about water birth shall we have a talk about it shall we educate you about water birth and she welcomed the idea and that was why Fatima decided that this was an option for this particular woman and she said that she wanted Fatima to talk to her husband and her mom um and uh this Fatima did at 36 weeks and they explored the whole process of water birth and as Fatima said she she tried to give her a very balanced view about what all the benefits and complications are about water birth about a normal vaginal delivery as she's put here about cesarean sections and she showed them some films about water birth now it that's just reminded me actually um we had a speaker last year called Layla who was the in fact the one who invited me to Iran and she um she works in the private maternity system and she does water birth and to native classes and she and her colleagues had produced some advertisements which they put onto the tv to promote laboring in water so there is an ongoing changes in the um in Iran okay so Fatima said that she told them quite honestly that this was her first experience but she would do this and she had been educated about this and the woman and her family decided that they would trust her and she was very proud and honored that um they would trust her to um conduct their first her first water birth with them so this is the facilities and we were discussing this last night their their physiological birth room which is an interesting concept is quite small and it does not appear to have many of the things that we think would be useful in a physiological or physiologic birth room that we would like um i asked if the lights could be dulled and she said that um no they can't um that they're stripped lights and so you can't do much about that so they're very much at the beginning of the whole process of um offering physiological birth so um this is the room and that's the water pool that they've got and you can see all the facilities like that there so when the woman rang in her 38th week she called her to tell her that the pains were starting and um and then of course she uh she examined her to make sure all was normal and she made sure all her equipment was ready um for this birth now someone has asked physiological birth medicalized birth and water birth and i'm missing the difference um medicalized birth is one that is managed physiological birth is one that is left to um work left to um to be very natural and follow the hormones of birth and a water birth is kind of a subset of that so this is the equipment that she had for a water birth sorry i'm still here i was just i'm still here it was just that i had um some students popped in so i just had to explain to them what was happening okay so this was their their uh facilities that they've got in her hospital anyway so the mother came in at 38 weeks and um Fatima makes the point that she was actually quite an obese slave at 93 kilograms but she was admitted at nine o'clock at night was four centimeters dilated and she spent her labor educating her and her grand and the grandmother of the baby about um using breathing exercises movement in the water pool using the birth pool and using massage etc um she she made the point she told me last night that the grand that she the woman chose to have her mother with her as an attendant attendee um and i heard previously that um the partners the men are not allowed in but it did seem to be an option for this woman so that might not be the case everywhere and one of the biggest problems of course is to get um reliable information and Iran is a big country and they do not um they do not have protocols and procedures anything like we do in the UK and in many other countries that kind of direct um how maternity care is given anyway where are we so oh no i wanted to say so what do you all think about the fact that this woman was 93 kilograms in weight and was for a water birth yes i know i agree jane um i i uh this is an issue for many people and in fact my daughter as well was um my question was merely what does anybody think about the fact that the woman was 93 kilograms and was considered a good candidate for a water birth especially one that was the first water birth um Fatima did tell me that she had absolutely no history whatsoever that would uh mean that she was not a suitable candidate really for a water birth so she was quite happy to go ahead with this water birth and as someone said just then um it does make um a lot of difference to people if they are quite heavy it seems to be an advantage really well it doesn't seem to be it is an advantage to them it still needs to be low risk yes i know i know is there a better word i have no idea and yes the bmi above 35 is an interesting concept because um it might be above our protocol but i don't know what country chatting girls in i'm guessing in the uk but we do follow the rules that women are entitled to choose their place of birth um and with negotiation well not negotiation but with um full discussion they should be able to give birth input in water even if they are outside the so-called protocols and that's another story for another day of course day go that's a very good good point that joy has put there that um the risks of a caesarean section are greater from a caesarean section than it would be from a normal birth so i also feel that uh water birth would be idea ideal well sorry so we've agreed really that uh this woman there was no reason why this woman should not have a water birth so this woman is just this is this woman's first baby and i was quite surprised but pleased to see that uh the she delivered it or she gave birth i'm sorry at midnight she came in at nine centimeters nine o'clock remember four centimeters star eight a damn it was born at midnight now this is that baby i asked that last night this is that baby um at the moment of birth just after birth uh 3.6 kilogram baby 36 centimeter head circumference and everything happened within the water the mother didn't need an episiotomy but had a little laceration that she repaired with five sutures and so it's absolutely wonderful to hear that the birth went so well and it's also very nice to see the picture too there are so many questions i would have about things like delayed cord clamping and about um you know um what kind of cares were given during the process of birth but i think um the language side of it makes it difficult to ask those questions um and it does worry me a little bit about things like the depth of the pool and such like yes because you'd expect the water to cover the abdomen etc so there's a whole load of things that we've been able to get to within the UK for example we've been able to develop fine tuning such as optimal cord clamping etc um but they're not ready for that yet so i'm good for them to be trying to um encourage physiological birth okay so that was her story about how about her first water birth and she tells me that she's had another one since then which also went um very quickly and she's very pleased with her experiences on giving women this choice and the fact that the women trust her to um to support her throughout this she says that she feels that god is supporting her in this um pursuit of physiological birth and water birth um but how to actually expand this within her practice and within Iran is another issue um she was telling me that the people she works with thinks that she's um she should not be um promoting physiological birth um because it's not safe i was just looking at the comment here about allowing the cord to pulse anti-physiology yes it's like um in the third stage whether or not you ask the woman would you explain to a woman about active and physiological third stage because actually if you just are going to do a physiological third stage why explain an intervention unless it's necessary so rather than say would you like an active or a physiological third stage because this is this and this is that well do you need to have that conversation at all unless there's a reason why you might need to say okay so it's not working physiologically um therefore we do have to think of an option and what we could do is do obstacles and blah blah blah yeah no physiological birth is not unsafe provided the woman is well supported and has good midwifery care from educated people are you femi so you're quite right there is it's not unsafe the problem is that people can people see childbirth as being um something that needs to be managed and yet women have been having babies for donkeys years from eons quite successfully and the the um mortality rates are quite low so it's our intervention that are causing the problems really so that's um Fatima's story have we got any questions and i'll ask if she wants to add anything can i ask a question of course i'll ask if i can i don't know how is my cell is it really quiet again it's it's audible it's fine i just wanted to know uh all the wonderful midwives and birth attendants that are here um who actually uh participates in water birth uh on the call here today and who's able to actually provide this care for all our wonderful women we could just talk maybe chat in the text box about that so the question was how many of you out there get involved in water births that do water births multiple people balance it claudia has families in washington becky in virginia katie in detroit this year we we do a lot of water births in the uk um we have many midwife led units now in the uk and water birth is generally um offered in all of those places standard care in chatman chatom i'm assuming chatom the girl you are from chatom okay so katie page says they don't currently offer water birth in the hospital okay so you don't because you haven't got a policy and you haven't got your staff training oh jill hi jill okay so um is there other plans in um whatever va is what is va in the us i'm not very good at my us states katie is their plan to train up people and um start offering water births of virginia sorry i probably should have known that katie so are you planning water birth what if a woman comes to you and says i want a water birth does she have that right it's possible to begin to change the culture yes jill you you should be the person to be able to answer some of these questions and i'm sure you have a sense of the difficulties that the midwives in iran must be happening i keep saying to them we need to need to make changes in small small chunks because um i feel that uh going straight for water birth is maybe a little bit quick and maybe they should be thinking about the environment of birth and reminding themselves about hormones of birth and um i feel that i would like to go back to iran now that i know more about it and do a different kind of workshop from the one we did in which water birth would be a very small part of it and the most of it would just be about um providing the perfect environment to um to support the women and um and encourage physiological birth so katie says that uh they try to get women out of the tub before birth to birth on land but if they don't well they go and if they do give birth underwater then um they um they have to fill in forms et cetera this was the same here i might add um just what i know 15 years ago probably before uh they became memory 20 years ago before water birth became quite so uh accepted i can also add that in um in iran um the physiological the gynecologists um are telling everybody that water birth is unsafe as they are saying that physiological birth is unsafe um and i was trying to encourage the midwives to think about evidence and provide the evidence and having the evidence at their fingertips about the whether or not any of these things are safe or not they need to know the evidence and when i was talking about the risks of caesarean section they were quite surprised that there were risks of caesarean section because it's obviously being marketed very well as a supposedly um safe option what about the idea that water birth opens the discussion for physiological birth not too sure what you mean there becky yes joy was saying that um and that's the same in most of the birth centers i know as well that uh most of the women use water and most often stay in the water to give birth seems the most natural thing to do yes you're right kathryn um they do say that first water births were in russia in the sea i think um and then there was michello don was was uh promoting it in his um french clinics um yes and i think that's the point i made when i was over in ron uh joy that confidential inquiries that we do in the uk that look at the statistics show that women are three times more likely to die from caesarean section than they are from a normal birth and that's that's uh what's not been mentioned in this country let alone elsewhere it's it's a huge big discussion area isn't it the whole um issue of physiological birth and stopping the medicalization how do you reverse that trend having said that i would say that we've done that pretty well in the uk because we got to that kind of low area um a few years ago and we had to um fight really to get back the um autonomy of midwives and uh the empowerment of our women and now we are still got a lot of medicalization but we've also got a lot of that um midwife led unix which encourage physiological birth so yes um i think the problem is that when people in a country find um start hearing about something like water birth that seems to epitomize um physiological birth that that it seems to be like that's that seems to them to be a a wondrous thing a very normal natural thing and it does of course help with pain relief as becky has just mentioned water is for drinking in my country water is for drinking well i always say that actually water birth to me water birth is not natural because if you look at the animal kingdom um not many land mammals choose to give birth underwater i think the hippopotamus or something like that is the only other one that does this um so i've always said that when we when we were trying to change um childbirth to becoming more less medicalized and more physiological in the uk people were a bit like teenagers they kind of rebelled and went further than they needed to in order to do that rebellion against medicalization and chose to have water birth i think one of the other problems about iran is that they don't the midwives do not have their own regulation they're regulated by the medical council um and they don't have protocols and uh they do not have seem to have any um method of um proof of education before practicing something so i think there's a big huge political change needed there as well before they can take charge of their own education and their own practice batima seems to have disappeared as she come down did she log out and come back in again nope she seems to not be here maybe that storm has thrown her out altogether question i posed from earlier talked to the husband of the mum is this a cultural component i know in some cultures you have to get them a husband and mother-in-law or the mother on board yeah i think that there is definitely that issue also in iran okay so any more questions because um batima has left and i really can't give you an awful lot more about um what she was going to speak about um and we could perhaps does anybody have any general questions about water birth or physiological birth i think you're absolutely right ginger that um once you get some women um experiencing something like water birth or physiological birth um they will then spread the word won't they yes the issue of physiological birth can be addressed by asking people what their traditional practices sometimes women know they're all right of course i hadn't thought of that i know that some in some areas where that it's not they don't have an awful lot of medical support that there are tribal practices and home births and such like this there are no home births at all in the cities that's not an option yes i totally agree becky that we should thank batima for trying to challenge the system um she's asked if i will keep in contact with her after the conference and um hopefully i keep sending her blinks to various papers etc to enable her to be educated and hopefully um educate uh her colleagues and the women that she's caring for it is a huge topic it is a huge feminist topic yes i agree and i'll pass that on to her so i'm still reading all the comments that are coming up in the chat books this is a really useful and interesting chat going on here interesting that you're talking about um those links that are growing um i had a midwife colleague stay at the weekend and she said that i'm a web weaver because i keep bringing people in from different places and weaving them into things that i'm involved with and then throwing them out and they're going out together to work together and i think that's what the social media is all about is is weaving people together and taking on opportunities thank you for that compliment in gaiana you do not have this practice is that this practice of water birth yes is it very medicalized in your country childbirth so you'll have some of the problems to um fatima then i'm not too sure tracy what you're saying no it's not too do we have any tips for student midwives you might be struggling with demands of working within the nhs all that's another big huge subject isn't it rose you know we've got a student cafe later on this evening i think it's at um six o'clock no seven o'clock no eight o'clock i'll get it right a minute it's at eight o'clock and although it's going to be talking about student electives we expect to be talking about other things as well so um you'd be very welcome to come to that uh at eight o'clock this evening you really enjoyed this presentation well that's a great thing to hear okay so maybe we should have a break and um move on to the next person who happens to actually be in the same room as i'm in right now so you talk about web weaving oh sorry yes there was a comment about napal wish they were midwives from napal in this chat well do you know i sent um lots of uh social media information in their direction to invite them to the vidm so um joy i will work with you anytime to encourage people from these countries to come to the vidm and discuss what they've been doing yeah we will sort that one out we actually have already referred to the rcm some information about electives joy so we know about that i'm i'm doing that session as well i'm kind of overseeing it thank you chat and girl we kind of anticipated it was a possibility we might need to do this okay so i'm definitely i'm going to sign off now um and finish off this presentation in the usual fashion and it's recorded joy so um you you once we've got it on the website maybe you could direct your colleagues in napal to um listen to it and it might help with what they are seeking to do and my thanks to fatima as well so i'm just going to start to stop