 Fabulous! So then, without further ado, I think we'll hand over now to Julia, who will talk us through post-traumatic stress in Australian meatballs. Julia, are you live now? You might need to switch your microphone to live, actually, the button at the top of your screen. Good morning, everybody. Welcome to this session of the Virtual International Day of the Midwife. I am very happy to be able to present findings from my PhD work, which was conducted or finished last year. As you see, this was done in Australia, so I'm talking about post-traumatic stress. My research has done post-traumatic stress in Australian midwives. It says Germany on my name, so I moved to Germany meanwhile, so that's why there are the two countries. Why is it important to look at post-traumatic stress? Why have I decided to dedicate my time and energy to that? We see a lot of traumatic birth experience in women. It's like depending where you look between 15 and 40% roughly of women say they have experienced their birth as traumatic, as a traumatic event. And we also have now research that is showing us that midwives can experience post-traumatic stress. So that's been done in the UK and in America and my research in Australia. However, so these two things are just standing. We have a lot of traumatic birth, women experience this as traumatic, midwives experience as traumatic too. So what I felt was missing from this puzzle too was to work out, okay, what are risk factors? Because we do not have really a lot of information about which factors make it more or less likely for midwives to experience that sort of distress of experiencing themselves traumatic stress when being witness to a traumatic birth event in their role as midwives. Okay, so that's the background. That's why this topic was of interest to me. And in regards to our role as midwives where we are to promote normal labor and birth, I also see that post-traumatic stress does have the potential to affect the quality of midwives work. And that makes it even more important to find out about factors that make it more or less likely for midwives to suffer from post-traumatic stress. In particular, we've seen that post-traumatic stress can increase how midwives perceive risk during their practice, during their giving care to women in labor and birth. And this is of course very, very central to our, to midwifery practice because if we as midwives see more risk, then we may also, we are certainly acting differently and in the end this may result in an increase in obstetric interventions, which then increase the likelihood of causing trauma to women. So it's like a big circle. It's always, it's about midwives and women and how, what happens during birth actually really connects midwives and women and how, yeah, how we really also in this topic of traumatic stress, it's kind of mirror that midwives and women are connected. So we share all this lovely experience, transforming experience of birth, but we also share birth trauma and we are affected. And yeah, so this was something that very much fascinated me to how midwives and women are really both in that big, big topic of traumatic birth. So, okay, so if midwives are stressed, we know then, yeah, they can, they perceive things different. If they have had traumatic experiences that gave them traumatic stress, they are more likely. Traumatic stress does something like it makes you see the world more different, more negative. So like if you have experienced a trauma and you have not dealt with it and you have persistent symptoms of past traumatic stress, which is when, and these symptoms, they, they then give you a more sinister view of the world. And for midwives, that means a more sinister view of the normal birth process and a more an exaggerated estimate of risk in birth. So that has been observed, not only in midwives that has also that has been observed in other health professionals to this connection between symptoms of post-traumatic stress and increased perception of risk. Okay. So, to the methods for my research, I did an online survey and I invited midwives who were holding registration in Australia and the Australian College of Midwives agreed kindly to support my research and they distributed email invitations to, to members and invited them to participate in the survey. So when we talk about post-traumatic stress, it is, of course, important to be very precise what do we mean with it and how are we measuring it. I decided to use the post-traumatic stress, post-traumatic stress disorder symptom scale self-report version, the PSSSR. And I also had to decide on a cutoff point from where we say, okay, these people now have what we call probable PTSD. So just to explain the term probable PTSD, it sounds a bit funny, but it's just because we have self-report and with self-report by definition, you cannot ever set a diagnosis. So you always can only say it's like probable PTSD. To really give a diagnosis of PTSD, you would have to do a one-to-one interview. So when you do a survey or something, you use these self-report measures and as a result, you get the likelihood of probable PTSD. So the PTSD symptoms are intrusion, avoidance and arousal. So just to illustrate it with intrusion is that you have reoccurring thoughts. Also, we can also say re-experiencing that these memories of a traumatic event come back to you in situations where you don't really want them. We have no control really over that. Connected to this then is also that you can have avoidance symptoms. You try to avoid anything connected with a traumatic experience. So for midwives, this could be like they try to avoid to work in the birthing room where they missed the traumatic event or they try to avoid a colleague who was part of it or an obstetrician. And the extreme example of avoidance is of course you avoid being a midwife altogether. Before that, maybe you just move to postnatal care or to internatal care. So you just try to avoid the birth setting because birth itself can be of course a reminder if you have post-traumatic stress due to witnessing traumatic birth events. Okay, and then there's arousal. This just gives you like stress, increased heart rate. Yeah, just symptoms of stress and alertness where again you can't choose, you have no control to stop that. When these symptoms kick in you just kind of are a bit, you just have to deal with them. So that is the symptoms of what we call post-traumatic stress disorder. And yeah, it will be called in my research probable post-traumatic stress disorder. Okay, so what was good and interesting is that many midwives were really happy to participate in the survey. So I felt that many midwives really appreciated being asked about this part of their midwifery practice. And that's also I got received emails from midwives telling me that. And so there was a general kind of appreciation of being asked about the topic of witnessing traumatic birth. So lots of respondents in a short time, 601 got to fill out the whole survey, which was quite lengthy, was about 35 minutes. And in this group, I had 17% of midwives scoring positive for what we defined as probable PTSD. So that is nothing really new. We knew already we have this research. We now midwives get distressed. They experience when they witness trauma and they experience signs of traumatic symptoms of traumatic stress. The number I found the 70% if at all is less than what has been found in studies in the US and in the UK. And this is because I had my criteria quite tight and the PSS SR gives rather in the cutoff I chose. So it gave a rather conservative estimate. Of course, you can now look and say, okay, there's lots of people also who don't have the full who don't meet the criteria to have this probable PTSD diagnosis, but they still have symptoms of post-traumatic stress. So that would be another whole group of midwives. So but anyway, 70% it's still quite a high percentage of midwives, almost one-fifths have have these symptoms to the extent that they meet the criteria for probable PTSD. So, okay, we knew we knew this, but many midwives suffer from that. But then it was interesting. I tested a model to see what what is it that makes it more likely for midwives to get that distress. I approached it. So you see already on the slide, this is what I found. I'll just explain a bit how I how I got to investigate these specific these specific variables. So I chose like what you call a socio a ecological model to look at it. So I look, okay, there must be individual reasons within the individual midwives. There must be professional reasons in the professional environment that make it more less likely to get these post-traumatic stress symptoms. And there must be factors that have to do with birth culture and with the way we manage birth. So I investigated these these layers and also, of course, I looked what what do we know what does the literature tell us in other populations? What makes what are risk factors for PTSD in other populations? So and so so I collected these variables. And then, yeah, these three variables that you see here on my slide, the emotional reactions, the first two, the peritraumatic. As a peritraumatic, this means during the trauma that you had during or shortly after midwives showed a reaction of horror. And they also showed a reaction or they had strong feelings of guilt that were the strongest predictors. So it means these midwives who had those, they were much more likely than to be part of those 17% who had the diagnosis of proper PTSD. And the last predictor that was significant in my model was a personal traumatic experience when giving birth. So when when midwives rated their own birth experience when they gave birth to a own child as traumatic, then they also had double risk for probable PTSD. The other factor that also showed in the model, but it was not was just significant was workplace decision authority. Maybe somebody was there last year, I talked about that specific aspect last year. So that was about professional autonomy. So that did show in my model to you, but it just was not highly significant. This was like on the edge of just being significant, but it played to you. So the more professional autonomy midwives had, the less likely they were to develop PTSD symptoms or the other way around, the less they were able to have a say what happened at their workplace, work independently, the more likely they were to actually have symptoms of post-traumatic stress after witnessing trauma. And yeah, so these three factors you see there, they double the risk. That's where the main findings of my study. And of course, just going back one step, I asked all the midwives, have you ever witnessed traumatic birth and what sort of traumatic birth have you witnessed? And of course, all midwives who participated in my survey have witnessed traumatic birth events. So that was a, yeah, that was, that happened to all of them. Yeah. Okay. So yeah, that was the main findings. I, here you see another time the table and where you see down there you have the empathic concern and personal distress. So they were like empathy measures. They also were, they also were just, they also showed up in the model as significant and also what we call psychological demand. So, but yeah, these, the adjusted odd ratio were the strongest for horror guilt and a personal traumatic experience when giving birth. So, of course, there's this, these are interesting findings. And we need to, of course, think what, what does it mean now? What, how can these findings impact how we address post traumatic stress in midwives? What can we do? And I did put in the implications here as a first line that we still need recognition that post traumatic stress is something that happens to midwives. And I feel we're moving towards that. There's much more talk about birth trauma and that it also affect midwives. So I see, I see, and when I talk to colleagues, I perceive there is a change in perception in that. And the second step or my second big, big, big implication is that we need in general, like a culture of what is called trauma informed care and practice. And here this is the point that brings together again, what I said in the beginning that women and midwives are in this topic together. So midwives are affected, but women are affected. And if midwives don't deliver sensitive care, trauma affects women even worse. So we need, therefore, we need like a bigger approach, like a system approach that not just looks at how can we help the individual midwife to deal with her symptoms. But we need to look at how do we make our birth culture? How do we change our birth culture so that we have a lower incidence of traumatic birth? So we have less traumatic birth in the first place. Because if we have less traumatic birth, we have less midwives witnessing traumatic birth and then we will have less post traumatic stress. So that's very, very clear. And of course, then we also have less women experiencing traumatic birth, which is would be, you know, a really, really important outcome if we look at all the effects that experiencing birth trauma can have on women in the postpartum time and also beyond that time. So, yeah, I would like really to see also to place my research like as a part of the big puzzle of trauma, birth trauma, and to say, okay, we're midwives, we are part of this, but the solution needs to be a bigger approach. It needs to be a system approach. And when we change, when we address post-traumatic stress in midwives, we automatically address also birth trauma in women. And that is totally what we should do because, yeah, by the definition of our profession, we are women and midwives are connected. So, yeah, that's, I think that's my last slide, too. So that's good final words. Yeah, these are the references. So, that's my presentation. It's always funny. You talk and Julia, you did a marvelous job. Thank you very much on behalf of all the audience. Thank you. I'm sure we're all clapping for you. Thank you. So audience questions, please, for Julia, if you'd like to raise your hand either in the left hand sidebar or right to your questions in the right hand chat box. We can feed those to Julia and she can answer your questions. While people are thinking about that, Julia, a question that came to my mind was, how does this compare with other countries? You are specifically looking at Australia. Does the results compare to other countries? I hope it was all clear and please ask me questions if there are some. Australia, no, the numbers are lower than what has what Beck have found in the US and also watch compared to what she and Spivey found in the UK. But that has to do with the way of measuring it. So, you know, that's like this whole area of how do you measure post-traumatic stress. And so comparatively, you know, I asked the audience if you have questions. I'm not sure if I remember how to say it right, but she and I think they had 23% of post-traumatic stress. So if you compare all these results, so if you say what happens with Australian midwives, it looks first like it's not more than other countries. But also I used a very conservative measure. So that's, you know, if we would all use the same measure, I would suppose we probably had a similar ish results. But then again, you know, there is risk factors. And yeah, so that's what it was also about to find out. Is there things that could maybe change midwives risks? Yeah, I would like to develop an intervention for midwives to see how can you, like firstly, I would like to take that step back and look at general trauma awareness in our culture and our birthing culture. And this would be one thing I'd like to create trauma awareness. I think if midwives, before we go on and look at the specific, you know, how can we reduce stress in midwives? It's good to take this big step and say, how can we make everybody trauma aware? How can we see that everybody realizes that birth has potential to traumatize? Most of that is like re-traumatized because many people just go into birth, like many women go into birth and have already, they have already had some traumatic experiences in their life before getting pregnant, before entering their birthing situation. And because of the nature of birth, like the intimate nature and the physical nature and all of that, birth is just a very, an event that is very, it's very likely that birth re-traumatizes people who have had traumatic experience, particularly like sexual trauma or trauma related to experiences of interpersonal violence. So that's something where I feel like we should just aim for a trauma-sensitiveness in our birthing culture. So that would be something I'd be working on like an intervention, yeah, to do, to increase that. Okay. Well, again, here my experience would be that it's important at the workplace, that at your workplace, that there is like room to talk about these experiences and to name them. I think what happens still a lot, also I said it's trauma awareness is increasing. There's still like this normalizing we're getting used that birth can really have this women experiences as traumatic and everybody is a bit horrified. And, you know, there's feelings of guilt. It's just has become something so normal. So I think the first step is really to realize what is happening here. Is this, why am I feeling so weird or so off after this birth experience or after a shift or in general. So just really to learn about this language of trauma to accept, okay, birth is a subject where trauma is closed. So there's this really healing potential of birth and that's the traumatic potential of birth. So that it's been acceptance of that, which will then create a platform to talk about these experiences. And then I think that will already, you know, be good that it was clearly able to identify this. This is I'm having symptoms of traumatic stress. I feel I want to avoid the situation. I feel stressed and aroused. I'm re experiencing re experiencing this situation. So then you can give it a name to give a name to your distress. And then I think it's important to do more research and find out what is so my research point. You know, there was a bit of a tiny bit of evidence, which as I said, did not quite turn out to make it in my model. But other, you know, other statistics, I did did show actually that there is a relationship between how much professional autonomy midwives have and how. So the more professional autonomy they had, I'm sure that decision authority and like the job content questionnaire. I'm just for you want to look it up. These midwives shared in general a bit better. And I think because they were able to manage birth in a way that in a way allowed less for traumatic experiences to occur. So that would be one one way at looking at to see maybe how is our professional autonomy at that workplace. Could that would that help us maybe to avoid traumatic birth situation or to deal with them better if we could have more professional autonomy. That's I find that very important. See that like a, I think there are in the I would have to I think that there is some colleagues. Looking at the same topic in the UK. But I'm not aware that they had a check room. But another question has come up here. Yeah. No, I'm not aware that like the trauma. Maybe that would be, you know, not sure if you would have to have a really good moderator because it can also be, you know, disturbing to read. A lot of dramatic accounts from other people and not to, you know, that it can also affect you, you know, like negatively affect you. So they could be an aspect of sharing. That's good. We exchange, but they could also be like a disturbing aspect to this. Everybody, you know, describing really, really, you know, we experienced very extreme situations as midwives and to get this unfiltered. So I think we have to be find a very mindful and good way of discussing these experiences. A constructive way. Yeah. Okay. So thanks, Alyssa. That question. I did actually saw my survey had some had some open ended questions too. And in one of these open ended questions, I did also ask midwives. What was the most traumatic thing? Or what was like you talk about hotspots for what was the hotspot of your traumatic experience? Because again, when we look at research with women during birth and Iris and Harris and Harris and I have done some research and that they say, okay, for women, for example, the relationship with their caregiver during birth, that's a hotspot. So that's something if this relationship with their is like, that doesn't go well, they very likely can perceive that as traumatic as being neglected and so on. So that's a hotspot for women. For midwives, I did ask this, I did ask it in an open ending question. And I have not, I have not gotten around to do this. I'm conscious of time. So there are a couple more questions. There are very, you know, there is a lot happening. I have not done a conclusive analysis. I just commented in the text. What I can say is that witnessing about the impact of work. You know, like short analysis and witnessing. Trauma that had to do with actions of other obstetric personnel. Obstetricians or other midwives. So witnessing obstetric violence. That that was something that got to midwives very, very much. And that they find very hard to deal with. Is that clear? Is that answering your question? Where, hang on. I'm just trying to find. Oh, yeah. Okay. Yeah. Yeah. I'm just seeing that. Yeah. Well, I would say, you know, to tell me that we know that social support can really be a protective factor for people experiencing post-traumatic stress or severe post-traumatic stress. So if you have bullying at a workplace, you have decreased social support. So I did not investigate that variable in my research. But that is well known in all other PTSD research that social support protects people from getting long-term symptoms. So again, it's important everybody might have symptoms of avoidance, arousal and re-experiencing after witnessing a traumatic birth. Important is do they come back? Sorry. Do they come back or do they remain over time after four weeks? Do you still have these symptoms? And for those people who have support, that's less likely. And that's very established in the PTSD research. So I'd say bullying, the combination of bullying with a workplace where there's lots of trauma is a very bad combination for midwives' mental health. Yeah. Very quickly. So you see in the poll, I'm just asking basically, I would like to ask the participants if they have ever, you know, these findings resonate or if they've ever thought about what they experience in these terms. So I'd like to maybe quickly put it up. It's just for questions. I see there's another question from Michaela. If I've, yeah. Okay. So did I find any links to the model of care? No. So I did it in Australia. And in Australia, you have public hospitals. And then you have private hospitals. And you have a just developing workforce of midwives who is providing like independent midwifery care and they have like continuous care models and so on. So I distinguish these groups. And I think that's just because it was not so many. The statistics did not give it that you say it's significant that those midwives who work in work as independent midwife that they have less traumatic stress. And what is interesting here too is because it's only a recent development in Australia, what you can also assume is that midwives, all midwives have previously worked in hospital because there was no independent midwifery. And maybe one reason that motivated them to change into independent practice was that they had traumatic stress and, you know, that they had re-experiencing. That's my theory, you know, that that's a big thing for midwives to move away from birthing. They just don't know it or don't name it, but they want to get out of there and they do something else then, which for some might be independent practice or working somewhere else at least temporarily and maybe come back or maybe not come back. So it has to do a lot with retention too. Does that make sense to you, Michaela? I think very much related to that is then the question of the Comet from Joy Theatre. Yeah, same thing. I would answer Lindsay that it's really important because I'm working a lot with students on that topic too. And I think first thing is to give them concepts to make them realize, OK, what is a traumatic birth to give them an idea how often we see that and that there's different types of trauma. The final really important concept to give them to say there is what we call interpersonal trauma that has to do with other humans doing something. And then there's non interpersonal trauma. So that's like a earthquake or something. So if you look at the birth situation, you have to say, OK, we have interpersonal trauma that has to do with what the relationship and what people do and how the interaction is. But then you also have these obstetric emergencies, but those are very few. The vast majority of traumatic events has to do with interaction and it's interpersonal. And that then has to do with women also, some women re-experiencing previous trauma. So they get re-traumatized because we have a lot of women who have suffered from sexual abuse and then go in that situation about maybe even ever having disclosed that. So for the students, I think first step two is just to give them information so that they're not laying in this confused state like, oh my God, this is a lot of intense feelings and I don't know really what's going on. So give them some language, some concepts, some statistics and then self care. They're mindful of how to be still empathetic with the women but not kind of lose yourself. So that's the skill of midwifery. I think that's what we need to teach in the whole course of a three year midwifery degree. Fabulous. Well, on behalf of everybody, thank you very much indeed for your presentation Julia. We're all clapping here in it silently. But thank you very much indeed. We're going to switch off the recording now and thank you very much to Sarah for running the poll and handling the background things. Much appreciated. We're very interested to our audience. If you have any photographs of yourselves or if you could take some photographs of yourselves sitting wherever you might be and however you might be attending this workshop we'd be interested to see how and where you are.