 Mae'r pethau i'r meithio, mae'n dweud o'r tyd i'r ffordd, ac mae'n dweud o'r bwrdd. Ond wedi gael ei gael eu hwn i, mae'n gweithio'n gweithio ar y sgol. Cecilia Javet yw'r Cysylltu Llyfr oedd yn y cyfrifio mewn cytuniau a gweithwyr o'r cyfrifio. Mae'r cyfrifio ar y cysylltu i'r cyfrifio am yr unrhyw o gyfrifio a'r cyfrifio a'r gyfrifio a'r cyfrifio. Mae'r drwyd yn dechrau meddwl ac yn neud hynny. 30 yma, gyda'r cyfnod i gylliannol y 2013, Celsiwlau'r ffeithio sgolwch yn y Tampabey yma. Felly, mae'r rhan o gylliannol, llyfriddol, ac yn ymgyrchau. Mae'r pwysig cyfrannu cyfrannu ac ymgyrchau'r rhysgrifennu ar y gyflodau 999 a 2011 gyda unig ymwysig y sgolwch yn ymgyrchau fel yn gyfynig yn ymgyrchau gyda'r gylliannol gyda'r cyflodau mewn dda erbyn yn gyfnodol. Ceilia, rydyn ni'n gofio. Yn fynd, yw'n gweithio'r gweithio'n gweithio eich bod ymgyrchai'n gweld. I wnaeth i chi'n fawr o'ch ffynig o'r gweithio'r newid yma ymgyrch. I think it's kind of fitting this morning that I'm talking about the health concerns of refugee women. Many of our speakers acknowledged the native people of their lands and I want to remind you all that here in the United States, even our native peoples were migrants who knows what sorts of conditions they were fleeing as they came across the land bridge from Asia. This is a topic that I've been interested in for a number of years. Several of my great-grandparents were famine refugees who came into the United States through Ellis Island and some of my grandparents were war refugees from Europe. So the United States is a nation that has a long history of welcoming refugees and welcoming is kind of a relative term. We're now experiencing across the world the largest refugee migration since World War II. And those of you who are already working with the women who are new to your countries know that those refugee women have special help needs. All countries have refugees. Some countries have more than others. People have migrated across the world since people started walking on two legs. Here's a photo that was taken of Africans walking into Israel. Refugee movements are often semi-organized. There are illegal migrants coming into Asian countries. Here is Calais, France and one of the things I want you to notice is how many of these refugees are men. Take a look at this slide. This one surprised me. I've been doing this presentation in various forms for about 10 years now. My husband is a professor of social work and I often talk to his classes about refugee health. In Europe and in other countries you might call people who move from country to country migrants here in the United States migrants, that term is often tied to seasonal farm work so we use the term refugee. Anybody have an idea where these refugees have landed? I see a couple people typing. Chris is saying migrant is a political statement. Chris can you come on Mike and explain that to me? Certainly. In the UK we seem to be very exercised about the position of refugees and migrants. There's a big political debate over whether we should accept more unaccompanied children from mainland Europe into the UK. The use of the word migrant I believe rather than refugee is to shift the narrative towards making the public believe that refugees are actually economic migrants, that all refugees are economic migrants. There are some economic migrants but there are plenty of refugees and in this country people, you seem to be able to test the politics of people's views about this crisis by whether they generally use refugee or migrants as their term for describing these people. Ah, good, I understand, thanks. So for those of you where the term is most often migrant, let's define for this presentation a refugee as someone who leaves a home company, a home country because of hardship and moves to another country most often without resources. I'm going to see if I can turn my volume up. Okay, I'm on high volume now. Thank you all for your answers. Greece is very close but Nastia, who has said Italy is correct. This photo is taken on one of the Italian islands in the Mediterranean where Africans have taken boats from North Africa onto that island. Men often travel alone with the women and children traveling later so that women are often in a vulnerable position of traveling alone to strange places where they may not know the language. Here are men coming across the Rio Grande from Mexico into the United States. You may know now that in large portions of the United States we've built walls to try to prevent this sort of migration. Here's a photo that was taken off of the state that I lived in for 30 years. We have many migrants, refugees who come into the United States by boating from Cuba. It's only 90 miles south of Florida and to escape political persecution and sometimes economic persecution. Cubans and Haitians put together a variety of rafts and boats and come across the sea. Yes Maureen, that definition of migrant or refugee really I think encapsulates the people who are coming into Europe now. They're also coming into the United States. Here's a photo from our state of Arizona where a law was passed making it a crime to assist refugees who are found in the desert. You can imagine that most citizens resist that law and want to help people who are struggling. When refugee women come to the United States their health stabilizes but the health outcomes of their children tend to deteriorate over time. We've watched this process happen following several world wars and other waves of refugee migration. We've wondered is it a culturation here in the United States and some other parts of the industrialized world. We're known for our poor nutrition and we've wondered whether people pick up our stressful way of life and our food styles and then their health starts deteriorating. Now we're starting to think that there's an epigenetic component to this so that when women experience a pregnancy as they're migrating or shortly after migrating, there are actually genetic switches that are flipped on that cause genetic changes, expressive changes in the offspring. So we want to think about what this means for the immigrants who are coming to our countries now. Yes Maureen, we think there's a huge stress component. Imagine the lives that women have experienced as they're coming across countries. Their basic needs aren't being met. They're living without good shelter. There's no refrigeration and very little cooking in route so it's difficult for women and their families to maintain a safe and healthy diet. That generates its own type of stress. I also want us to think about the tremendous violence that refugee women experience before their migration, during their migration. Assault, rape and torture are the tools of war. And it's those crimes or the threat of those crimes that pushes many families into migration. Violence against women has lifelong repercussions. Women don't find themselves in a safe place and get over their past assaults. So post migration, women may have difficulty with intimacy. They may avoid health care, particularly prenatal care. They may fear physical touch. Some women who've been physically assaulted can't bear to breastfeed and may choose bottle feeding. Women may seem detached from their newborn, partly because they're having difficulty making relationships because of fear of loss. These women are at high risk for postpartum depression. When refugees come to a host country, if they can make it to a host country, they generally earn less than the prevailing wage. They start with low wage jobs. They may have no benefits, no safety social net, no social safety net, and they have little occupational protection. So for refugee families, there's a greater chance that they will have work related incidents, kitchen burns, factory incidents, agricultural related accidents. Those accidents may further reduce their ability to work and support themselves. Refugee families have less buying power for nutritious food and they have reduced access to safe housing. Maureen so well keyed in to stress. You can imagine that these families, even when we view them as being landed and being in a safer place, still have tremendous amounts of day to day stress. Child care is always an issue. The families generally have low language skills. So as they're trying to find work, it's more difficult to find childcare for the children who may not also have learned the new language either. And when women are trying to seek healthcare, if there's no childcare for them, they will avoid care. I want everyone to think about the varying social safety nets for refugee women as they come to other countries. Some countries have very generous support from the state or other charitable organizations. Here in the United States, refugees have to work pretty hard to enter our social safety net outside of what family and church support they may have. Oh, Salines brought up the concept of isolation. Even if a woman has a family around her, that's a smaller social unit than she is likely to have been accustomed to. Isolation is a perfect word and a terrifying word. Years ago, I cared for a Jordanian family who were political refugees. And there were six cousins. They were each other's language and translating safety net, and they were each other's social net. And when one of them became pregnant, they all came for prenatal visits, and when one had a problem, they all were stressed and had a problem. Few refugee women even have that small of a social safety net. As women cross countries and come into new countries, they will be exposed to new viruses, new bacteria, and as part of their health care, we need to assure that they've had appropriate vaccines and tuberculosis screening. That's part of our primary care here in the United States, and it's an educational component for midwives in most countries. Once women escape the violence that they may be fleeing in war zones or countries with political instability, there still may be a legacy of intimate partner violence. There tends to be alcohol and drug use in families that are very stressed. We believe that violence is a learned process and that it can be unlearned. Midwives need to be watchful and mindful of the signs of family violence for women who've come for care. Signs of violence such as bruising, a history of broken bones, women who don't seem to be able to converse with you, women who are avoiding contact, or women who are missing components, missing visits during prenatal care. There are such varied cultural and religious laws, country to country. Here in the United States, our overall cultural belief is that women have a right to their own bodily integrity and they have a right to refuse sexual advances even within a marriage. And that they have a right to control their own fertility. These may not be the same cultural norms and laws that the women we're providing care for live under. So we need to think ahead of our usual selves and think about the background of the women we're caring for. I've just taken a minute to read Maureen's comment about family translators, and I'm going to come back to that just a little bit later, Maureen. So I want us to remember the best of midwifery care, having a welcoming attitude if we're delivering prenatal care in a woman's home, trying to show that we're at ease there, or if the woman is coming to us in the clinic area, making sure that we have our sunniest face on and that we are ambassadors for health care. It always serves us well to learn what we can about the cultures and the norms of the women we're providing midwifery care with. I've seen some interesting projects lately. One was in Switzerland where the midwives are being deployed in pairs with social workers. These practices understand that many women have social needs and mental health service needs that are as important to their health as their basic physical health. So the social workers go with the midwives and they're providing service in pairs. I think that's a wonderful situation. Yeselene, culturally competent care. There's a new phrase in the United States that's being used, culturally humble care, acknowledging that there's no culture that's more right or wrong than another. As midwives, we may be able to reach out to women's groups or their church groups to help deliver health care and advice to women. For example, in many cities in the United States, the mosques and the churches have women's support groups and the midwives and other health care providers visit those groups and give general talks about health care. For example, they may go to a women's group and give a general talk about how women can support each other in labor and tell them what American hospitals are like. I'm seeing a note from Makayla saying that the social workers are going every other week to the refugee camps. Wonderful work. When it comes to using translators, it's almost as if there's the two sides to the coin. Some families may feel most safe if a family member is translating for them. It's generally not appropriate to put family members in a position where they have to be responsible for the translating. It's better if they're freed up to provide emotional support for the woman, and there may be issues such as family violence that we don't want the family involved in. Our hospitals in the United States are now required to provide certified translators, translating phones or software. We have computers, for example, that have programs on them very much like Skype conferencing, where you can see the face of the translator and hear the voice, so that the midwife and the woman and the translator have a three-way conversation going on. These certified translators know the health care language and provide more accurate translation. I have vivid memories of my father and his brothers and sisters talking about being the translators for my grandmother and what that process was like as she learned English. As midwives, we're the prenatal navigators. We are the face of health care in our countries, welcoming families into that. We're actually like tour guides. We often assume that if women are coming from urban areas that they understand what our own health care systems are like, and they're all quite individual, every little thing we can do to reduce stress in women improves their pregnancy outcomes and their general health. We need to think for the refugee women how hard are they working during pregnancy. I think I'm preaching to the choir when I say that hard physical labor and stress increases the risk for preterm labor. In many countries, we need to think not only about women's nutrition while they're working, but their hydration. My years in Florida, which is a very hot state for the most part, we often had women come in with dehydration and symptoms of preterm labor that was easily cured by getting them hydrated. We know from years of experience in postwar populations that protein deficiency causes first asymmetrical and then symmetrical growth restriction. Maternal starvation stays with a child for a lifetime. Those are those epigenetic switches that have been flipped. This is Barker's work from the United Kingdom, the Barker hypothesis, that nutrition in utero makes our metabolism and our future health care so that when mothers starve, children are at very high risk for future hypertension. Heart disease and type 2 diabetes. So we need to think extra cautiously about nutrition for our refugee mothers. Oh, here's a question from Carrie. I've seen cases of family members trafficking women. As I put this presentation together the other day, I stepped away from trafficking because that is another group of refugee women and boy, that could be a topic all on its own. Human trafficking is heartbreaking and the women who have been caught in human trafficking have all of these same health risks and many more than we need to be thinking twice as seriously about the effects of violence on them and then sexually transmitted infection treatment. In our refugee population, girls as young as 14 may be mothers. In many urban areas and post industrial countries, it's illegal for women under the age of 18 to be mothers and to be married. It is not the same in other countries and we need to be mindful of the special needs of very young mothers and to be careful that we don't treat them through the filter of our own bias against teenage pregnancies. As we're helping women plan for birth, we need to figure out what their expectations for birth are like. What did they learn about birth in their own countries? Who are they thinking might provide the best support for us? And their usual cultural routines, how can they be adapted to make the women most comfortable during birth? I listened to Marilyn's presentation last night about birth spaces. Applying that, we would want to figure out, does the woman need a very small intimate space or does she need space to roam? And then we want to know, what are the postpartum care routines for those mothers? Years ago, we discouraged families from bringing their own food into the hospitals. We thought of it as unsanitary or less than nutritious. Now, I encourage the families if they have the ability to bring in their particular foods because many cultures have ritual postpartum foods that will help the families be comfortable. Christine has just written that epigenetics is a terrifying concept. And that word terrifying is so striking, but yes, it's terrifying in its magnitude. But I would say to that, that there is a hope behind it. Gene switches are being flipped on and off, but it shows the plasticity of the human genome. We have been adapting to different climates and different environments and different social circumstances for millions of years, and I believe that we will continue to adapt. Oh, so maybe Maureen, you're thinking that the epigenetic research would lead to our manipulating our adaptation, our evolution. That's kind of a terrifying concept. What other ideas do you all have to help refugee women? I'm seeing from the chat box that it looks like many of our listeners have experience. I'm going to make some of my own notes here as you talk about what you've learned from helping refugee women. You can turn your microphones on, the little microphone at the top of the screen, right under conference. I see a couple of people typing. I think I might need to enable microphones, so let me do that. OK. OK, everybody, you have microphone rights now. If you would like to use the microphone, then you'll need to switch the white microphone to green on your toolbar, but please remember to mute it as soon as you finish speaking or to disconnect it. Cary's written that we may need specialized services for these women, and then we wouldn't see inequalities in mortality rates, and that would go for any of the related pregnancy risks. It's interesting that we call these specialized services. They are really the services that the best of healthcare provides to all people, and somehow when we need to deploy them, we think of them as special services. If we had a mother from an attorney's family here in the United States who had family violence within that family and the family was momentarily unemployed, and this happened in our last economic recession, and we deployed special social services for that woman, we wouldn't think about them as special. Somehow we have a bias that refugee women or migrant women need special services, it's the best of our services. So Nastia is saying there were refugees who came into Slovenia, but they didn't want food or clothing. Cary's asking, are the best of our services appropriate for their cultural needs? Ah, yeah, it's a good question, Cary. So not only do our basic healthcare services need to meet cultural needs, but the social services need some cultural competency so that they're also appropriate. I think also a portion of that question is, do we have the resources within the social services to provide for those special needs? And certainly that's a question that many governments are facing, and many governments are being protective as the representatives of their citizens and saying, no, we don't have the resources to help just anybody who would come here. Ah, Celine is tying this together with her presentation from last night, prenatal care as surveillance behavior and screening, instead of providing care that's soulful and really meeting the needs of the mother. It's hard to provide services for refugee or migrant women within a system that's really not designed for them. Here in the United States, I would say that our dominant healthcare system isn't even designed for our own citizens. It's designed for surveillance and screening the way Celine is talking about it. Yes, cultural competence is part of our core competencies in midwifery education here in the United States. It's easier said than done in some areas. In many areas of the United States, there are few refugees and migrant women so that it's difficult for people to step out of their own cultures and see the needs of others. I grew up in a household where on holidays there might be two or three different languages being spoken in different rooms of the house. So it's pretty easy for me to feel comfortable outside of English. I had an idea, Nastia, that the women you were describing were on their way to Germany. I saw we had somebody here from Germany. I want to thank the Germans and all of the Europeans from what we've seen in our news here in the United States for the work that they have done in helping particularly the Middle Eastern refugees. Wow, Kerry, a powerful statement. The screening for something like partner abuse in English anti-natal care is really a poor screening tool in itself. It doesn't meet anyone's needs but those of the service. Nastia is just talking about worrying about refugees not being vaccinated and bringing disease into a country. So many things to keep in our minds as we're working with refugee women. Chris, and you can imagine the United States following the attacks in the year 2000 on our city of New York and our city of Washington. Our American citizens are very hesitant to help others. I can say that my state of Connecticut is actually a state that is resettling refugees. We could take at least triple the amount of refugees that we are currently accepting. I think one of the strengths of midwifery is that we learn to be at ease with women quickly and use the non-verbal behaviors in communication to help women feel comfortable. I'm going to interject now and say we've got a few minutes left because we need to close by ten to the hour so we can change over for the next room. So probably just one or two more quick comments or questions and then we'll move on to closing and taking the polls that we forgot to take at the beginning. Great. Thanks so much, Chris. Paula Aurelia from Burn, Switzerland is a midwife that I have been working with for three years now and the research that she's developing looks to the needs of migrant and refugee women. Paula has put a poster on the VIDM website. You might see that. It talks about her literature review and the findings that low income women and many of them were migrant and refugee women. Felt that they weren't paid attention to in clinic and that they were kind of given second standing. Yeah, Celine, Chris is putting up the website for you. We've got several posters posted there. If you have one, we'd be happy to have you post it. Send it to us and we'll get it up. OK. I'm going to draw to a close now. That's really, really interesting presentation to Celia. Thank you very much for that. There's a lot of news about refugees in the UK and other parts of Europe because of what's happening in the Middle East and I'm sure around the world. So this aspect of it and tying it into our conference is really brilliant and obviously really struck a chord with the audience because that's been a really busy chat box. So thank you very much everybody and just thanks again to Celia for that. I'm going to... Thank you all for your attention. OK. That's my reminder to switch off record now, which I will do.