 It's my pleasure to introduce Dr. Saraswathi Vaidam. Saraswathi is the lead investigator for the Birthplace Lab at the University of British Columbia. She has been a clinician and a health professional educator for over 30 years. Professor Vaidam has successfully coordinated multi-stakeholder community-led research projects in provincial and national settings. Her research projects include the National Canadian Institutes of Health-Funded Canadian Birthplace Study that examines attitudes to place of birth among maternity care providers and Changing Childbirth in British Columbia, a provincial participatory study of women's preferences for maternity care. The Giving Voice to Mother Study explored experiences of respect, discrimination, and inequalities in access to quality care among communities of color and among those who plan home and birth-center births. Professor Vaidam is currently the principal investigator of the Canadian Institutes of Health Research-Funded National Research Project to evaluate respectful maternity care, research examining the stories of pregnancy and childbearing today, the Respect Study. In 2017, she was selected as one of the inaugural Michael Smith Health Research Institute Health Professional Investigators. Saras, I'm going to give the presentation over to you. Thank you. Good morning, everybody. It's morning where I am. I'm grateful to be sitting here on the beautiful, traditional, and unceded territories of the Coast Salish nations, the Indigenous nations, particularly the Musqueam, Squamish, and Swela nations. And I am a guest on their land, and grateful to be able to be with you today at this time when we are in an unprecedented global acknowledgement of the power of the uncertainty of nature. I'm going to spend a little bit of time with you today talking to you about what we do as midwives when we are faced with crisis and unexpected events and how we pivot and how we are well poised to bring some sucre and some common sense and some fellowship to this moment. Many of you are aware that in the global context, families and clinicians are questioning what happens when we have moved birth into facilities where there's a lot of exposure to each other. And so there is a spontaneous increased demand for home and freestanding maternity unit care all over the world. We've been hearing about it in the UK, in India, in South America, in the Northern Indigenous communities of British Columbia, and in Africa where people are not sure about they want care, they want skilled attendance, birth attendance, they've been exposed to the increases in wellness and well-being for themselves and their families when they have skilled attendance, but when the skilled attendants are all co-located, both skilled birth attendants and midwives and the populace are understandably concerned about exposure. Because of diverting care to people who are sick with COVID and really symptomatic and where people who have been normally looking after childbearing families are repurposed to look after those who are very sick, then there becomes a scarcity of care providers in other settings where the midwives have been providing the care in facilities, sometimes even getting to the places where they work is difficult. There's also in the context of there's an involving evidence basis for the care of the childbearing families should they come into the hospital, should they not, should they be wearing personal protective gear, do they need to do that in community-based settings? Is it only for hospitals? What is happening about the incubation period? How much do we have to be concerned? In fact, there's no local or global consensus on how to contain this as it's constantly shifting. And it's difficult to social distance in shared or un-stable housing when people are living in houses with many, many other people, particularly in low resource or in families that don't have the other options. There's challenges with social distancing every time you walk into an institution or the number of people you interact with. And what we're hearing all around the world, and this is what I'm really going to focus my remarks on today, is that there are increases in violations of human rights throughout the childbearing cycle right through the newborn period that people are experiencing. And that's in the context of specialists also recommending separation of wealth from sick people. So how do we respond to that? And what can we do to understand the context? I just want to point out that, you know, meant much of the discourse and the ability to rapidly put out guidance has come aside from the WHO. A lot of it has come from countries that have a lot of resources. They have communication systems. They have ways to use multiple systems to put out guidance and complex evidence and analysis. But much of the world is facing pregnancy and childbirth in these kinds of situations where they do not have the ability to isolate even when they're in labor, they don't have private rooms, and Nord of the midwives have access to things like personal protective equipment or the ability to stay distant. In some settings, you labor postpartum and give birth in in boards that really you're sharing even a bed. And these are these are images that have come from around the world that are quite current. So that's just to put it in the context. Now, when we know that the WHO as early as 2016 has shifted its focus from clean water and skilled births attendance, it has included the experience of care as a fundamental and essential component to quality safety, to reducing fetal neonatal and maternal mortality, that you need to have functioning referral systems, effective communication, that the respect and preservation of dignity are core to quality. And it's not just an also additional thing, but it's actually has everything to do with whether people feel like they can access care and feel safe and that cultural safety and emotional safety has to do with how labor progresses and how what outcomes and whether or not people will trust recommendations that are offered to them. So that includes competent motivated personnel and the availability of physical resources, of course, but also the application of the best available evidence that we have around quality of care. So what we know is that if we look at previous pandemics and I'm going to talk a little bit about today about the situation that we're all in right now, but I want to remind all of us that this is just one in a number of crisis that we've developed that we've faced before and often the crises, whether they're floods or earthquakes or like the Ebola epidemic in West Africa and 2014 to 2016, those crises have have affected most sharply the people who live in the in circumstances where they have the least resources and the least ability to to access high quality care with all the bells and whistles there in in low resource or middle resource settings where people are unable to access antenatal care visit visit birth skill, birth attendants or equipment. During the Ebola epidemic, the use of reproductive and maternal health care services plummeted so much that maternal and neonatal deaths and stillbirths indirectly caused by the epidemic outnumbered the direct Ebola deaths and that's an important thing to remember at this moment women were unable to access family planning completed fewer antenatal care visits were more likely to give birth without skill birth attendants and some people stopped going to facilities because of fear of increased infections others because of financial barriers or transportation barriers others were denied care if they were suspected of having Ebola as many facilities were not equipped to provide care to people who were infected and didn't want to increase the contagion that's the same situation that we're in right now. In very recently some researchers the the Stein word and Katelmo used the save live saves tool to to model what it would look like over the next year in places like Indonesia, India, Nigeria and Pakistan if if we do not think about how we can reorganize and reallocate care these four countries are the most populism low and middle income countries in the world they account for almost a third of the world's population and as you can see from this slide they impact of the additional deaths from COVID-19 service use the decrease in their service use is is huge it's you know so so disturbing that this is just about access really it's about what we can do when all of the care has been centralized what happens when people don't access that care. On the ground we hear we're hearing in indigenous nations and people who are rural and remote that if they are in a remote and rural setting where they are they are COVID fee free and they don't have the pandemic if they have to be relocated to give birth they have both the the risk of contracting COVID themselves and bring it back bringing it back to their communities later also they cannot no longer bring the support systems and culturally safe ceremonies that that make their labors and births more smooth because of the because the system-wide concerns about too many people present in large cities where they were not prepared for social distancing and really aren't able to especially in in black and brown communities and in immigrant refugee communities and communities where they they are co-located at home and at work with lots of people we know that the impact has been very great and that is yet to come to to Mumbai and to see what's what's going to happen we know even in London where there's very different different birth threats are responding differently we have different types of prevalence rates impact in New York City they are now beginning in public hospitals to screen everybody who every material every pregnant person comes into the hospital and they're finding something like a 38% COVID positive rate not all of them are symptomatic but it's throughout the population in low and middle income countries we've heard from Uganda Malawi Colombia Pakistan many of these places and they're rapidly shifting their systems to try to cope with what might be coming down the pike so and we know that in high resource countries there's very very different responses depending on whether you're in the Netherlands or the UK or Canada or Spain or Italy and that in all of those situations marginalized communities are the ones who are most at risk for for receiving late or no prenatal care having more experience more likely to experience mistreatment loss of autonomy and decision making loss of lack of continuity of care that is consistent with what we've seen throughout time it's not something new but it's more sharp now and so we're more this challenge sort of increases the impact on our most marginalized communities and really requires rethinking re-engineering the system that drives disparities so that when when we focus on the needs of the most vulnerable that we can in fact get it right for everybody interestingly we can also learn from those communities and how they have have provided for themselves mechanisms and community-based solutions that have filled the gap that healthcare systems have not the national core quality forum produced a roadmap for promoting l-health equity and eliminating disparities and they talked about some of these interventions which I'm going to talk to you about so we've done research as Susan mentioned on what what care looks like both in in high resource countries like the North America where I have studied in collaboration with communities of color what their experience of care looks like and we've also done it in low and middle income countries quite a lot Megan Boran and her colleagues published just this past year and we published two studies that talked about one in six families who who experience sorry my slides are not advice advancing so one in six pregnant women people have experienced mistreatment in the United States overall now if you looked just at the communities of color and just if people who had lower resources had challenges in their life maybe they were homeless that that rate went to two and six and that is consistent with the one in three rate of mistreatment that has been found in low and middle income countries so it's really it's the same it doesn't matter if you're a high resource middle resource or low resource people who have less less ability they're marginalized they're not in the mainstream and they're not well resourced themselves in their families they're more at risk for this kind of mistreatment so what's linked to mistreatment we know if you're an immigrant if you're at low socioeconomic status if you have some sort of pregnancy risk or social risk maybe you come from a non-dominant identity of of any kind it might be that you have an LGTQ identity and it might be that you have a disability it might be that you are homeless or or live in a situation where the people around you are just not the same that's definitely a red list and we've been shown shown this that also the types of birth that you have and how much interventions you have that that they being shouted at being scolded being your your request for help being ignored physical and verbal abuse increases every time there are more unexpected events that happen and we know that in many of these situations the midwives and the physicians who are involved are themselves disenfranchised they don't have the equipment they don't have the resources to be able to provide the care they want to and everybody's anxiety is up so what can we do in in in this context you know what can how can we respond to to think outside the box and maybe this is a moment certainly at a moment right now where we want to respond to the increased demand for community-based care we want to have evidence-based strategies placed in in place to triage to hospitalization when we have people who are sick or who are not sick with COVID but who have some condition or situation either the mother or baby could benefit from the additional equipment or personnel that a hospital has to offer so this is about appropriate triage interestingly midwives also already are well set up to do that in most situations they know how to set up and run free-standing maternity units they know how to attend people in low-resourced settings they know how to do community-based birth and when they don't when they're midwives who are in countries where that hasn't been normative and where their role has been mostly facilitated but birth they know how to attend normal birth without a lot of elizabeth because most of undisturbed and birth that's physiologic happens without that now there may be some cost-shifting and upskilling that needs to happen i'm going to tell you about places that have learned how to do that and done it in a very rapid way we also know how to repackage our supplies and keep infection control within community settings and there are standards for equity access and respect and quality that are in our core to the values and the ways that midwives have worked from the beginning of time so we're poised to partner not just with the specials but also with the community health workers who've been doing this i'm going to just flip through these next few slides fairly quickly to show you that there is a lot of evidence behind the midwifery approach to respectful maternity care and what i'm calling talking about respectful maternity care now i'm talking about 12 domains which includes access to equipment access to PPE access to clean water access to the basic quality things that we think of when we attend people through pregnancy and childbirth and postpartum that include that that is a measure of respect also when people can access that that type of care but it's also how people are treated we know that there are many many there's a lot of guidance that's come out this this guidance which i'm showing you here that comes from all over the world has been put out very rapidly in the last month and it all supports the fact that inclusion of persons in decision making ensuring the presence of a companion through labor and birth not separating parents from their babies even in crisis situations those are all supported by best quality evidence by people who have looked very carefully at how to attend to the needs and the health and the disparities and outcomes that we're seeing for marginalized families we know that if we address those things the the the outcomes improve and then people also access care and are able to do so in a in a safe way safe medically safe culturally safe emotionally safe ongoing for their long-term health so prioritizing prioritizing community-based birth in places where they're supported by the health care system right now can be rapidly done for places there and haven't been traditionally supported by the health care system we need to think about how we can transform thinking about delivery of care in ways that they've always done when they've had war or earthquakes or floods or pandemics we know that prioritizing breastfeeding best practices helps long-term health and immediate health and well-being for babies and mothers we know that we're limiting the use of of unnecessary interventions using them certainly but using them when they're medically indicated thinking about the fact that every intervention whether it's an early induction or an epidural every single time means more requirement for more scarcely available right now health care providers and more people involved more nurses and midwives who have to start IVs who have to counsel who have to monitor how that those interventions are being being delivered so that there are more people involved if on the other hand you bring in a companion and the companion can do that close continuous support then the health care provider is free to look after the people who really need them more more often and also be a little bit more distance not have to do provide that that care and that's been supported by the WHO and many situations of having a single supportive companion can benefit everybody including reducing exposure for providers as well as as well as the population so seamless access to receptive a hospital environment is when needed is key to that we know that expert consensus guidance also talks about trusting community responders so i'm not talking necessarily about there are of course amazing transport people and people who are actually taking taking people from the community to facilities and many of those in india there are community health workers who are being paid $50 a month and their job is to help do the home visits and take people to facility when they need to and identify when people need to be accessing care even postpartum they do postpartum care and they haven't stopped doing that work they're they're not being paid they're not they're not employees of the government but they have they're basically volunteers and they're still doing it in what we find in places like whether it's looking after low resource people in the united states or low resource people and immigrants and refugees and in refugee camps or all through europe in the uk in the nevelins or in africa or the philippines we find that these community members have rapidly pivoted they have started to bring food hampers they've used the elders and the way they need they have always been used to do ceremonies do blessings but they're they've figured out how to kept those elders on zoom and how to use telehealth in ways that have been very rapid and responsive in what that that haven't been able to be done in the large health health systems because they're they are they have to be nimble and they have to react and they have to figure it out they have not however left to the side the importance of ceremony respect fellowship food basic services that's where they're putting their energy and that's what we can learn from when we are in partnership with communities so we are safer together i want to draw you i know this is hard to hard to see this the slide but i want to draw your attention to the to the the bucket that's under ngos and media it says share evidence-based information with women and families integrate integrate learning from women's experiences of pregnancy childbirth and postpartum to continuously inform decision makers collect and share examples of best out of the box practices that can be implemented in other settings i just put to you that as mid-wise we can do that as well it's not just about ngos we know we work in partnership with with families all the time and one of the things that we have done is set up a transdisciplinary a transdisciplinary task force to look at quality maternal newborn care to look at what the precedents are for rapid review of human rights and also strengthening health systems there's models that exist for how do you strengthen health systems in times of crisis and so what we've done is put together a large group of people in fact they have self they volunteered themselves to to join us and we do have uh people from all over the sector all over the world and also people who are across obstetrics midwifery human rights infectious diseases pandemic and disaster planning community health global health organizations like the WHO several of us are working on implementing these strategies in our own jurisdictions and we believe there's a benefit to sharing our insights insights once we have figured out what these templates are how do you mobilize a hotel how do you take community-based providers and help them extend the health care system by doing postpartum visits or pre-medal visits or or triage how do you take doulas and have them go doulas or cultural match who are trusted members of the communities or maybe they are traditional birth workers or maybe they are traditional midwives and have them do this screening and uh COVID testing even or taking food or take or helping them mobilize transportation so they can access care when they need need to we know that this is happening all over the world and many of the people who come to this task force have brought their examples they've already set up protocols and standard operating they've figured out how to reallocate call schedules how to take uh people who midwives were working in hospital settings and give them the skills and the confidence to provide the same care in in communities for healthy well people and then how to limit the transfers to those who really need it they've also figured out how to work with policymakers and um health systems to make sure that the human rights are preserved we know that happened in New York where initially people were not being allowed to have a companion and that was taken to policy and that's happened in the UK it's happened in India and in in Kenya so our goal is to make a an accessible resource it will be accessible by many to many different uh many different levels and you will see um this is a slide that shows you a model that someone uh some group of researchers in 2017 put together where if you click on any one of those circles it will bring up uh all of the evidence or the strategies that you that are relevant to that sector of the so you may be a midwife you may be a community health worker you may be a policymaker where can you get the template or the protocol or the call schedule or the PPE that you're looking for and this would this kind of tool would rapidly put that in the hands and we're working our goal is to work with a technology partner so that it's available through mobiles it's a mobile phones it's available to through um in places where we don't have zoom or connectivity but maybe there is a way for people to get it through telehealth or through systems that are now being put into place uh multi-level so maybe you're very remote you don't have that and you need it in a uh a hard copy form so we can produce that we'd have the technology we have if we can put our global minds and our expertise together and work in a transdisciplinary way I believe it can be done now to transform health systems and access for those who are most marginalized which will then improve access for all ongoing not just through during a pandemic pandemic and maybe it'll live on a website yes you asked me to give you a time when it's 25 to it's 25 to okay yes I'm I'm moving moving I'm I'm getting there so thank you for that okay so um we have organized our work into committees we have an operations and logistic committee a clinical workforce recruitment community health linkages we are have a a subcommittee that's working on legal advocacy and human rights training and support of course evaluating what we're doing and also how to make this strategic policy and acceptability uh really being realistic that that that in order to rapidly change we need to buy in at every level including community members and so there's a communications uh mandate there these people are not trying to reinvent the wheel they are looking at what's already out there what's working in indigenous communities what's working in black communities or in rural india or in columbia what has been working in in kenya or for in any of these sectors for reserve respecting and preserving human rights for giving access to clean water to food to transportation to seamless access to hospitalization when people need it what can be then shifted back out to the community with community health workers what can we do now to respond in a crisis time that then can inform the future uh so we have already i'm going to just flip through quickly and show you some of the things that we've gathered we have best practice guidelines for interprofessional collaboration both between community midwives and specialist providers and that is throughout the course of reproductive health but also uh how um how that can be done during the moment of transfer what everybody's roles are what their responsibilities are this sort of a template there we have training resources around how to do person-centered decision making and how to rapidly teach that online we have policy guidance from the icm from from the WHO from the birthright folks we have a tracking system so this is from elfin circle which is an organization that has set up a rapid response tracking system to report violation and you could be a midwife you could be a doula or a birthing person but then you can then uh log in from anywhere in the world and say you know describe what you witnessed did you witness something directly what did the mid-treatment include it's already set up according to the WHO guidelines for what mistreatment the buckets that it looks for you can describe it in as much detail as you want you can do it anonymously and you can talk about where it person can start to provide some accountability and understand the prevalence what we're talking about is really reaching that critical consciousness in your own practice to appreciate the context that you and then take this moment to illuminate those power struggles and move beyond the day-to-day procedural but in fact think about how social justice and understanding the the need you know we all understand the needs of our clients but what can we do at this moment to transform access respect care and quality for those people in our communities who are least likely to be able to access it so I've in my own practice have I have a website so I started to gather and put up the WHO guidance we have in vc a lot of wonderful guidance around coordination of care so I've just put that in a way that that is accessible to my community who wants to get it of course it needs to be more globally accessible there are five approaches that the white rhythm alliance has brought forward and they have talked about these very simple things that you yourself can do and that is promoting the right to respectful maternity care and mobilizing the communities to around respectful care and recognizing that respect includes access to care access to PPE access to companions access to care when they're depressed when they're alone when they're postpartum all the way through they've done this in Nigeria they've done it in Nepal and and in Kenya they've integrated this so if we can do it there we can certainly do it in more hybrid or so settings where we have much more many more tools also supporting healthcare providers we should not set up these false doctor dichotomies between client patients and providers everybody needs to be protected and needs to understand their emotional safety as well and you know healthcare providers have families and have to think about what they can do so values qualification and attitude transformation has to do with us respecting everybody in the system and then incorporating the respectful maternity care into policies we have we're going to give you with through this task force we're going to give you the the the letter the template follow letter that you can take to your local government state health department or your your through your own systems and adapt them as you want we've done it in the past it's been done in Nepal it's been done all over the world so if you want to learn more about that and keep in touch you can go to the birthplace.lob.org if you want to just be informed about what the global task force is bringing forth at this moment and what you can do at your level you can go to birthplace.lob.org global-task-force we can put that for you and we look forward to your input and to our fellowship this is one moment where in fact we're all we're all in the same boat and we need to mobilize the expertise that we already have thank you thank you so much Saraswathi we have about seven minutes for questions there was an initial quick question the photos in your early slides wherever those from they look like they might be Africa yes one was from the first one is from an African country I believe it was Kenya it might have been Malawi and it was some years ago when I when I was given that by a photographer and the other one is from the Philippines thank you Saras tell us a little bit more there was a grid about a project that you're working on that would also become available on cell phones where you hit the button and it gives information yeah so that we are that's what we're building now with the global task force is a matrix that allows you just locate yourself maybe you're a community health worker maybe you're community a midwife maybe you're a hospital-based midwife maybe you are a health policymaker or a lawyer and you can locate yourself you can say I'm in a rural or a large urban setting I am interested in rights or I'm interested in access to PP or the evidence and then you can find the area in this grid where you want to go and find the documents that will help you move the needle forward in your own context in your own role now what we will probably ultimately produce will not that that grid was produced by researchers to pull together the research around community health interventions that grid is a complex grid and not really accessible to the average person so we are going to we are our goal is to partner with technology with a technical technology experts to turn something like that into a web-based tool or a mobile-based tool that could be clickable or searchable very easily to bring you right to your cell phone or to your contacts the documents that you need or the template for the letter or the step-by-step protocol how to change your call schedule or how to repackage your birth supplies you can find it how you want to and that's what we're trying to produce in a rapid way over the next few months thank you there's a question from Jenny Hall what is being done in your education practice to help improve respectful care thank you yes so we have content if so in i'm a midwifery educator and in the university where i am we have content all the way through the curriculum that addresses what equity looks like and that equity is not the same as equality and that in fact we have some resources we have online courses and content that has been developed by indigenous partners that help all of us not just our students but our faculty members also to understand about communication i put up a slide a few slides ago around a person-centered decision making i can bring it back up for you it's the wheel that has person-centered decision making that is part of a course an online course that is delivered to physicians midwives nurses anybody who wants to do this and it can be done non-synchronous in these small groups where they they're interprofessional groups and they learn how to communicate with each other as well as how to communicate around the family and keep the families goals and values and priorities at the center as opposed to our own agenda and how to attend to those power imbalances and of course document it and revise the plan it's necessary but it's a step-by-step process that we teach our our students it's a respect is a large word and it may be about communication it may be about how you ask permission before touching it may be about attending to their cultural context and doing anti-racism training all that needs to be done i would say we're on a journey we're certainly not perfect at it ourselves one more quick question and then we'll need to start closing off the session several people are asking all these activities by government and non-governmental organizations there's still a lack of supplies and personal protective equipment saris what would you say your one target for action there would be yes so we will have as part of our resources how you can work with your government and system systems to to change that but since that it is not a rapid thing we also will provide guidance around personal pp that can be made in simple ways some of that is on my website already on if you go to the last slide the web birthplace lab dot org and you go to the cove it so you'll see there's some guidance around making personal protective it and with very very simple materials that are available globally we don't have testing about what you know what is perfect pp but we know that there are some guidance around negative ion materials that can be used at the plastics and things that that are available all over the world in the world that where people can and in india they're making those ppes themselves communities are making it and community health workers are making it for themselves so i think we don't know everything about that but we know that just simple masks and eye covers are what's necessary and i think that it's possible to do it to do in collaboration with our communities who can core not health workers but can make those things and are doing it saras thank you so much this has been a very informative presentation i am going