 It's a little drop-down menu in the corner. I'm going to have your problem, I think. There we go. I can do it. There we go. Clear on. I have it. Thank you. OK. OK, everybody. I know lots of you have probably answered this one before, but please do let us know which country you're in. It's interesting to us to watch as the day goes by. I see a lot more in North America now, fewer in Europe, and very little now. We're left in Australia, or somewhere from Indonesia, so it must be late in the day for you. OK. Just to give it a little bit more for people to add. Any more submissions? Brilliant. Thank you very much. OK. My lot. And the next poll we'd like you to answer is... Oops. Excuse me while I do it. We're interested in what your main occupation or role is. So here you are. Please fill in. The last one, we had a lot of students. Actually, a lot more students this time as well. It's really interesting. Students are still dominating. Any more answers? OK. I shan't labour this, so thank you for that. The last of my three polls. We're interested in where you're joining today's conference from. Mostly people seem to have been joining from home, but we are starting to see people coming from various institutions. So we're interested to know where you're joining from. And if it is from somewhere other, we're interested to see what that might be. It looks like home is dominating today. OK. Thank you very much. I shall end the poll. And now I'll hand back to Lorraine to introduce the speaker for session 19. Thank you very much, Chris. It is my pleasure to introduce to you Hannah Lake-Homer. As I said, Lizzie Q2 cannot be with us because she's helping out with a baby as midwives do. Hannah and Lizzie are going to speak to us about a very interesting project that they were part of this past... this past couple of months with the Laos People's Democratic Republic. And working with them with their struggles for high maternal and infant mortality due to a lack of resources, as well as a lack of skilled and knowledgeable birth attendants. So the Yale School of Nursing partnered with CleanBirth.org for the goal of improving both the maternal and neonatal mortality rates in rural areas of southern Laos. CleanBirth.org is a nonprofit that educates and distributes CleanBirth kits to lay-on nurses. Midwifery faculty and students helped further the mission of CleanBirth.org by teaching the use of CleanBirth kits. They also adapted and taught the World Health Organization Essentials of Newborn Care Course. They taught that curriculum to the lay-on nurses. This presentation will describe how the birth kits were modified and how the World Health Organization curriculum was adapted to fit the training needs of nurses working in Salavan province in Laos. So without further ado, here's Hannah. Have we lost Hannah? Oh dear. Chris, we're going to have to sing and dance again. We've lost Hannah temporarily. This has happened occasionally. We had another speaker who dropped out twice in a session where I was facilitating. It does happen. That's what happens with technology and there's no reason to say it won't pick on you when you're supposed to be presenting. Does anyone here have any experience of working in Southeast Asia? Well, we're just waiting for Hannah to rejoin us. Perhaps she could tell us about it in chat. Does anyone have any experience working with CleanBirth.org or similar types of projects like the kits or projects that they've used before? There's Hannah. Hang on. I'm just going to bumper up. Welcome back, Hannah. I'm so sorry. Let me explain. So I'm at my school because I thought the internet would be more reliable and I guess it's not. So my apologies is reconnected and I hopefully won't have any more interruptions. Well, it's over to you now. Take it away. Why don't you tell us a little bit about yourself and then get started. Okay, so my name is Hannah Lake-Homer. My co-presenter Lizzie Kitouay is, we did this project together. We both, she is away helping, supporting her friend who is in labor. She wanted to be here so she apologizes for missing it, but I will take over for both of us. We both are registered nurses and are finishing up our studies to become certified nurse midwives at Yale School and Nursing in New Haven, Connecticut. And so this presentation is about our trip. So we took a trip to Laos and we adapted CleanBirth kits and taught WHO's Essentials of Newborn Care Curriculum. We taught that to nurses in Southern Laos. So this is a presentation about that project that we did. So we can go to the next slide. There we go. All right. So the goal of this trip was to teach the components of WHO's Essentials of Newborn Care to rural nurses in Laos and also other health care workers. We did this in conjunction with three other goals. It was a cultural assessment of birth and newborn services in Southern Laos and as well as a cultural assessment of the use of the CleanBirth kits and redesigning the CleanBirth kits. And lastly, we were there to assess and teach other birth skills as necessary. So this first slide is just a slide showing where Laos is. You can see its borders Thailand, Vietnam, and Cambodia. All right. We can go on to the next one. So just some general information about Laos. It's about 7 million people live there, roughly about the size of Utah for those of the people in the United States. The average life expectancy is 64 for males, 67 for females. They have a diverse ethnic group predominantly in the Southern region where we were focusing our attention. And there is some other languages spoken there but Laos is the main language. And the terrain is really mountainous in the Southern part and with lots of forests and they have very rainy seasons as well. All right. Next slide. So just some of the maternal and newborn statistics in Laos. So they have about 180,000 births a year. This is 2012 statistics. And the neonatal mortality rate is 27 per 1,000 live births. And they have a total maternal death was 400. And you can see their C-section rate is very low with a fertility rate also of three. And go on to the next slide. So here's just some other statistics about care, maternal and reproductive care. So you can see that there's a very minimal prenatal care. So in this study from the WHO, you can see that 37% of women, and this is in the Laos population in general, received only received some prenatal care. So and this was as four or more visits. Only 40% were having skilled births attendance at the delivery with only 40% receiving any postpartum care. And there's only in Laos, there's only a 26% exclusive breastfeeding rate. They're finding there's a big push right now to increase breastfeeding and improve the education about the importance of breastfeeding. All right. Next slide. So here's just a little bit more information about what are the challenges for improving these maternal and newborn statistics. So as you can see, a lot of these newborn and maternal deaths are from preventable causes. So you can see infection related, nutritional related, medication related. So that's why we tried to aim our focus for these trainings on some of the basic sanitation information and trying to focus on clean birth kits and getting skilled birth attendance with basic birth knowledge. So we can move on. So now moving on to just the region that we went to and are have focused on. So this is the Salavan province. It is a very mountainous area that's very minimal infrastructure as well with minimal roads and access to healthcare. As you can see, the life expectancy is less than the general population for Laos. So 56 years for males and 59 years for women. It's a very agriculture based area. So 80% of people are supporting their families through farming with lots of fishing and other fishing things to support their families. So just focusing on some of the maternal and newborn information. In general, it's very hard to get statistics about the general maternal newborn health in this area because of things like lack of infrastructure. The area also has a very high percentage of different ethnic groups with very different languages. So there's a language barrier a lot of times for people going in trying to do consensus and information data gathering. So just general information. So the average age of marriage is 15. Let me get down to... So in this area, women are at least likely to receive any form of prenatal care in the southern regions. And in the northern and central regions, they're more likely to receive some prenatal care. So in the southern provinces, if prenatal care was accessed, it most commonly occurred in the months of three to five months of pregnancy and was least likely to occur at the end of pregnancy, so in the eighth or ninth months of pregnancy. In one study that we looked at that was looking at this information, they revealed that the overall obstetric competencies of the skilled birth attendants was from 51% to 84% with the exception of management of third stage of labor. And the skilled birth attendants were only 22% competent. I'm not exactly sure what the study uses competency, but it just gives a general idea that there's minimal training for the skilled birth attendants that are attending births for these women in this region. So you can also see that most women are having home births. There's higher fertility rates in this area and that most women are very far away from clinics or hospitals and that they have to travel over an hour, maybe days, to even access a clinic or a hospital if they were to need medical attention or more interventions. All right. So that's the background about why there was a need for the project that we did, why there's a need in Laos specifically in that region. So Yale School of Nursing partnered with cleanbirth.org. And so this organization was founded in 2012 by Christine Zolota. So this organization provides clean birth kits and training to nurses and village volunteers in the Salavan province. They partnered with the Association for Community Development who has been providing community and health education and resources for the last 10 years. So the clean birth kits. So the clean birth kits provide materials for clean birthing surfaces, clean hands, clean cord clamping and cord cutting. Cleanbirth.org orders these kits from the company AZAIA as you can see on the label there. And they modify the contents based on the feedback that they got from nurses and the Association for Community Development. So they based it on what the needs were for the area. So in July when we went, these clean birth kits contained a bar of soap, one disposable underpad, chuck pad, a small sterile blade for cutting the umbilical cord, one plastic clamp for the umbilical cord and hand-drawn instructions on how to use the kits. And so based on the feedback from our trip, these birth kits were modified and I'll discuss those changes later. All right, so the partnership between Yale School of Nursing and clean birth started in 2014. We were the first trip to go in partnership with clean birth. So the goal, we went with the goal of reducing maternal and newborn mortality rates. So the Yale School of Nursing Midwifery Specialty Coordinator, Dr. Cecilia Jevitt who is pictured in this picture along with me and Lizzie. So Dr. Jevitt spearheaded the partnership with cleanbirth.org. All right, and the next slide is just another photo on our way from Thailand to Laos. We can skip ahead to the next one. So now we're just going to talk about what we did. So you can see the nurses, the main picture is of the nurses we trained in one of our trainings and then Lizzie and I doing some role-play. So we can go on to the next slide. So to prepare for this trip, before traveling to Laos, Lizzie and I became certified in the American Academy Neonatal Resuscitation Program. So this was an online course with a certification. In addition, we gathered all of the materials for the training including picture cards, clean birth kits, four infant resuscitation mannequins, and five bags and elators. And these were all donated by Dr. Jevitt and we left them in Laos for future training. Because of the language barrier, we wanted to make sure we had adequate picture materials and hands-on tools to use that we could demonstrate for these trainings. And so we also, in addition to that, did fundraisers to gather for the trainings so we could cover the cost for the nurses to get to the trainings and pay for the clean birth kits as well. Okay, so for the trainings, what we really focused on, we did special, one of the focuses was on going over how to use the clean birth contents. So going through what each piece of the clean birth kit was to be used for and how the order of use and how to use them. We really focused on hand-washing, sanitation, and hygienic birth settings and practices. And we really focused on making sure people understood that we want women to have a birth partner with them and have someone who is trained how to use these kits to be helping the birthing woman, the birthing mother. So to teach those, we, the Yale School of Nursing team had help with, from the Association of Community Development members. I'm going to start short, call the Association for Community Development, ACD. So the members of ACD, they provided translation for us for these trainings. So in total, we taught 67 nurses, health staff, and district health officials over three days of training. To teach, so for the teaching of the WHO essential newborn care course, we had to modify it to make it appropriate for Laos' setting because the WHO's essential newborn care was meant for a clinic setting. So we had to adjust it because we were using only the tools we had within the birth kit and were assuming that a lot of women would be getting birth at home or in clinics where there was minimal resources. So some of the things we had to adjust was not with taking out the resuscitation supplies, the thermometers, the clamps that the WHO's newborn course included. We omitted eye care, cesarean birth, instrumental delivery. And with the resuscitation, we really focused on basic stimulation and drying and making sure the baby was warm. And then we also focused on only bag and, focused on bag and mask resuscitation as well. So for teaching all of these things, we used role play to explain how to use the clean birth kits, how to cut and clean the umbilical cord. We also included positions for breastfeeding and how to provide skin-to-skin contact to ensure proper that the newborn was staying warm. And after we did demonstrations, the nurses would then practice their skills in groups and we would go around and help provide feedback for them. So in addition, and so as you can see, both male and female nurses took turns playing different roles and they got feedback. So in addition, we also based the training on things that the nurses told us they wanted to know. So we gave a lot of information about physiologic birth. We did a lot of role playing and a lot of instruction on breastfeeding and skin-to-skin care. The importance of having a birth partner again because often it is one of the traditions is women do give birth by themselves in Laos and so we really wanted to emphasize that role again. They also asked about management of nukal cord and breech birth, which we covered in brief. And then again, another thing we really tried to focus on in these trainings was data collection on the clean birth kit use to make sure that we are understanding if they're being utilized properly in the order that they should be and what the outcomes are. So this is an ongoing problem. We're having more and more, there have been more trainings on the data collection and data review for the actual clean birth kit use since we went last July. So in addition to the three days of training with the nurses and the health professionals, we also did three village visits. And as you can see, it was very rainy. It was muddy and we actually were supposed to go to another fourth village, but because the river was so high, we were not able to actually reach that village. So as you can understand from our own experience, we had difficulty accessing some of these more rural areas. So let alone any mother who needs to come in or use the roads, she would have trouble getting to and from. And then you can see these are pictures of moms or their babies that actually were born using the clean birth kits. So here is some pictures of a nurse doing a training for some skilled birth attendants from different villages. So this nurse is going through how to use clean birth kits and distributing clean birth kits to these birth attendants and where they will use it within their own villages. So from this trip, what we learned, we gathered a lot of information about birth practices. So we learned that sometimes women do birth by themselves and that helped us emphasize the role of the birth partner. We also learned cultural taboos surrounding birth. One example of this was that touching someone else's blood in Laos is considered bad or can cause sickness. And so that is often a reason why someone is not wanting to help with a birth. So from this, we learned that we need to modify the birth kits because we can adjust the contents of the birth kit to make it so there is not contact with blood. So we added a pair of gloves to help with this taboo that we learned about. We also learned about the immense difficulty that women have in Southern Laos accessing healthcare when they need it. And then we learned about the challenges with data collection due to just access. The nurses having trouble getting to certain villages during different times of the year based on the rainy season and other issues just due to logistics. So after this training, we adjusted the clean birth kits to, like I said, include a pair of gloves. We also added, instead of having one under pad, we added a second under pad that could be used to dry the baby. Because one of the things we learned was that they oftentimes women don't have clean blankets to wrap around their baby. And so we figured this would be a way for them to dry their baby and then apply blankets that they can use. We also learned that the nurses gave us feedback that they wanted another clamp instead of just one because that would reduce the amount of blood drained from the placenta and again reduce the amount of contact or exposure to blood the birth attendant might have. And then we kept in a bar of soap, one blade, and we changed the instructions from being pictures, from being drawings to picture instructions. Because the nurses gave us feedback that that would be more helpful. Alright, so goals for the future. We want to develop a sustainable model for clean birth kits to be supplied to Luation women. So right now they are being provided by donations that cleanbirth.org receives. So we hope we can find a way that these clean birth kits can be supplied without them being relied on from donation money. Also, we're working on improving the monitoring and evaluation so we can understand if what we're doing is helping. We want to train more nurses. There is definitely a need for more education for these nurses surrounding birth and maternal and newborn care. And then we also want to continue to tailor the WHO's essential newborn care curriculum to the Luation culture to make sure that it is applied to them and that they can use it. Alright, and that is it. And you can see all the resources that we used. And then now I can take questions. Hannah, Layla has asked a couple of questions in the chat. The first one was about the training that you and Lizzie took. So it was about, she was asking about the training that you took before you went. Was it NRP, ANS, Stable Course? Is that the one that you took? No, it's the neonatal resuscitation program put on by the American Academy of Pediatrics, or I believe I have it in my presentation. It's not the Stable Course. And then Layla also asked about in the kits, did you consider any emergency medical or devices for PPH or complicated births? So no, because we don't. So these clean birth kits are supposed to be used by birth attendants. They're also stocked in the clinics with the nurses. And adding medication would then require someone who has, I'm not sure exactly the licensure and practice, but we, that would require us prescribing. And I'm not exactly sure how we would include that, because these are just very basic medical supplies to enable sanitary birthing conditions. Well, I don't remember anyone. If you would like to ask a question using the microphone, just raise your hand, and I will give you the microphone. Put your questions in chat. And I see Amarillo's just wrote in the link that is the link to cleanbirth.org where it has all the information about the clean birth kit. I'm interested in knowing how you got involved with a project like this. It's really fascinating. Yes. So Yale School of Nursing has an international program, and they have many different international trips. And so with Ciel and Kristin, Solota, the founder of cleanbirth.org, met and came up with this project. And so as a student, you get opportunities to apply to participate in these trips. And so both Lizzie and I applied and were selected to participate in this trip, and we both took advantage of this amazing opportunity to do something to start this wonderful project of improving education and birth conditions for this very high needs area. And for those of you that don't know, Cecilia Jevitt is a member of our board with the Virtual International Day of the Midwife as well. So we heard about the project from her side, so it's kind of nice to hear it from your side. Thank you very much. Yeah. Are you planning on going back or what? So each year now the plan is to have two new midwifery students go and continue to do trainings with nurses and also further these goals with cleanbirth.org of improving maternal and neonatal mortality and morbidity. So the project is going to continue. Liz, we joked on our way back that we would have a reunion, Laos reunion in five years, 10 years from now. But the plan is that this will continue to be a partnership between cleanbirth.org and Yale School of Nursing, and it will be an opportunity for student midwives to go and participate in this wonderful project. It seems to me, and maybe Chris will remember, we had a presentation a couple of years ago about a similar project that happened in Haiti after multiple disasters in Haiti. And I know in the last presentation there was a lot of talk about what's going on in Nepal. So it would be a great need for many of these cleanbirth kits around the world, I should imagine. I do remember something about Haiti, but I can't remember the detail unfortunately, but yes, I do remember that Lorraine. Yeah. I think our next facilitator was, I think it was Catherine Salomon who was part of that project. Oh right, okay. Yeah. Okay, sorry Hannah, go ahead. Oh, so the cleanbirth kits have been, it is a company that makes them for different countries and they are distributed and modified for different areas. So I know there's some use of them in Cambodia and other places around the world. And what's really nice about this project that I think is helpful for distributing the cleanbirth kits is doing it with this education part of it and adapting and making the WHO Essentials in Newborn Care culturally adapted to the area. And it's a nice partnership to give supplies with the education. I see Catherine's typing. Nicaragua. Okay. Yeah. There was one in Haiti. I remember which one that was. Really interesting. Are there any other questions for Hannah? Go ahead. Ask your questions. Catherine says they did theirs through the olive tree. They did training for Nicaragua. More typing coming through. Yeah. So what advice would you give someone who is planning a project like this? It is helpful to, at least for us, this was our first year going and doing this. And we went with less of an agenda because we really needed to gather information and hear what was needed from the nurses and the women in the villages. And I think that really helped us get a sense of where the direction of this project could go. I think that was helpful for something like if you're starting and wanting to do something in a high needs area, making sure that you listen to what that specific population needs and then start working and adjusting your goals to what they say their needs are. Because now the future trainings have a much better focus and structure, I think, to them. Because we went in and decided before we just come teaching all of this information, let's find out what is really needed to be taught and where we're starting from. I think that's a really valuable lesson. I see Sukhas a good question there. Can you see that? Yeah. The question is, I said that these women have little or no access to pre-needle care. And do these women wish they had access? Is there a demand for it? And in general, I think that they would like to receive pre-needle care, but I'm not exactly sure how to answer that in that I think they do prefer to berth at home, because that is where they have been berthing and they feel comfortable there. But I think that there is a desire for them to have access to these basic clean berth kits. And so I don't know. There isn't much motivation right now for them to go to the clinics to receive pre-needle care. But with education about why they need pre-needle care, a lot of women did express a desire to have checks when we were in the villages. But they also were very clear to us that it is very hard for them to access it. So it's not even on their, it's not something that they even think about wanting or demanding it, because it is so challenging for them to get there because if they did need to get there, they're having to find someone to give them a ride because most people don't have cars. People get around on motorbikes or trucks that they pay someone else to get them to. So I think it's a little bit, what they really want is access to clean supplies, which is what we were providing with the clean berth kits. But I don't know with more access how that would change. So it's a very good question and something that we should definitely look into when we're going there and asking. Question to that. And Amarilse has also let us know about, it was midwives from Haiti. I knew there was something and it was different, but along the idea of providing the supports, women in challenging situations. Thank you. So follow-up question was, Silkberg is working on a project. I have not heard of the safe pregnancy kits. That is something that I will definitely, we will definitely look into, but no, we have not seen it. And I would need to look at it to see if it would be, if it would work. There's a lot of challenges in working in this region in Laos. They have many obstacles to receiving care and basic necessities. So I don't know, I don't know how it would apply or if it could be adjusted should be used. So I would need to look into that. And that's very interesting. It is really interesting. We're now in the under five minutes left in the time allotted for this presentation. So last questions, please. Oh, look, you've just got a colleague in Norway. Perfect. I'm going to give you my email. That would be great. Kind of the email in the chat. If you have questions that occur to you later or you want to make connections, it would be great. Yes. And thank you so much for this opportunity. This was wonderful. I'm very glad to share this. Thank you very much, Hannah. And best of luck to Lizzie and her friend, please. Pass that along from all of us. A good day to be born. Same day as a princess. That's pretty neat. As I was telling you before, I had to leave early last year because my granddaughter was born. Kind of exciting times. So thank you very much. Always is. There's no further questions. We're going to be moving on. And thank you again, Hannah. I'm going to turn off the recording.