 So, first of all, also from my side, thanks all for participating. My name is Michaela and I'm facilitating from Germany. So let me introduce you to Marquetta, Marquetta Pavlikova. She has graduated from Mathematical Statistics and she obtained a Master's of Science in Biostatistics in Belgium. She has worked as a data analyst and a researcher and I'm sure the rest she will tell you yourself. So, just two quick things, Marquetta will start presenting and in between she will already ask the participants for questions for discussion. So we will facilitate that and I'm sure it would be great if you could participate in this discussion. Thank you. So over to Marquetta. Hello everyone and welcome from the Czech Republic. As Michaela kindly introduced me, I'm a Biostatistician and I'm mother of four girls and I'm a birthright activist. I'm also a member of government counseling body which is a lot of work and hope for a little impact and I will speak about the role of the situations around birth and emergency services needs and what are the needs of all people around. I'm from the Czech Republic which is a little country in the middle of Europe and you may know it from the International Congress of Midwives that was held in Prague two years ago and I want to briefly introduce you into the situation of midwifery in the Czech Republic. You may have seen on the map that we are just on the border between the Western Europe and the older Soviet Empire so it's easily to be understood that the midwifery was quite suspended for 40 years here. Midwives were renamed gynecology or women nurses and they got really medically oriented in nursing education. By now there is quite few independent continuity of care oriented midwives. They really count in 10s and they face unsurmountable legal obstacles to assist childbirth outside hospital settings. Most of the midwives are now inside hospital and they are bound to accept hospital policies which is okay but also subordination to obstetric decision and this is required. They cannot act by themselves unless the OB decides. So most childbirths are now obstetrician led. There is also strong regional component. There is one region in the Czech Republic where the childbirths are more midwives led. They have a good tradition in allowing midwives leading childbirths and interesting things and quite logically this is the region with the least caesarean section. So it quite corresponds to finding that when midwives are in play the caesarean sections are much lower than in other regions. Because as I spoke most childbirths are held in the hospitals led by obstetricians and because of these obstacles you can see on this little map that home births face very difficult situation here in the red. We are also in red and these are the countries from Europe where midwives face fines for attending home births. It never happened by now but the law is there and where midwives have to be very careful if they assist it and assist it really in a clandestine way. So it's not really a good situation. And now for the emergency which is the question we are tackling here. We have quite wide network of emergency services. There are 14 regions, regional networks which are connected and it's mandated by law that the emergency service, emergency ambulance has to arrive in 20 minutes from the call. So and in the big cities it's really done like that. It's maybe even less, it's maybe even 10 minutes and they really try hard to make it 20 minutes in the country regions. Most of the cases are paramedic assisted and there is part of the cases of the calls which are medical doctor assisted. It's somewhere between 10 and 25% of calls. So now I want to speak about some cases which happened in the Czech Republic and were around childbirth and when there was an emergency call and it resulted in a situation that wasn't standard and how it was tackled. Our first case is a case that happened about six years ago. There was an unplanned, unassisted childbirth of a third child and a woman who had very bad experience from previous childbirth in hospital. She delayed transfer while she didn't tell her husband let's go to the hospital and she stayed until it was too late. So she gave birth to a healthy boy. In one hour after birth because the parents were not prepared to give birth unassisted they were quite confused about what to do with the court because the baby was still attached to the court and by that time there was really little information for normal women what to do with the lotus birth or with the baby who is still attached to the placenta. So they called for emergency service. This arrived, a medical doctor who arrived at the service because there was a newborn concerned, checked the baby, said the baby is okay and as usual he said okay let's go to the hospital and now the problem arrived because the woman decided well I don't want to go to the hospital, I'm here, my baby is okay, you said the baby is okay so we are staying at home and it was a very new situation for the doctor and for the whole emergency team because they are used to women who really say oh please take me to the hospital. So they really tried hard to find a reason why to transfer the baby and they were in so much stress that they called for police assistance and forced transfer on the woman and on the baby because this happened in February and there was a minus 15 degrees below freezing point, the baby who was not wrapped in the tin foil was arrived hypothermic to the hospital and had to stay for two days separated from his mother. So the mother asked emergency services for an apology and the original organization declined the apology and said it was all for the mother if she accepted the transfer on the first the baby would be okay. So mother sued in civil case emergency services for a harm that was done to her and to her baby and the court decision was okay, emergency services have to pay mother for the harms but the next court said no no no the doctors are always right it was certainly good to transfer the baby and so if there is a five years lasting court ping pong and now I was asked for a statement for the court how the situation is in other countries. So I asking a question how the situation would be handled in your country here really what was underlying the transfer was a fear of the doctor who arrived but he's not fully qualified as a neonatologist who is a normal person who examined the baby in the hospital and this is really a situation that is complicated for medivibes here also complicate the situation for medivibes here because there is a high specialization of the care the babies are delivered as they say by obstetricians and then there is a neonatologist every time present at the child there who checks the baby so they are not medivibes who are taking care of the newborn babies and so even the normal doctors who are not specialized in neonatology really have fear to decide whether the baby is all right so please is there any opinion from your side how this would be handled in your country would the would there be a forced transfer or would it happen more smoothly the baby was all right by the time the emergency service arrived and it was even declared by the medical doctor and he only tried to find for the for the excuse for the transfer so his first excuse was the baby was attached for one hour to the placenta so he can bled to the placenta but apparently it was just he was trying to find his answer in discussion with his peer in the hospital and the baby was apparently okay in the room and just after the transfer he was found hypothermic okay thank you I think the baby was put skin to skin with his mother in this one hour after child birth when they were at home so in the medical record it's written the baby is on his mother's chest and his is latched is is suckling okay thank you and would they require some some against this to sign something like against medical advice or something like that okay thank you it's really important because these are the situations that are quite new for people in emergency services here like there is the estimate there is about between 500 and 1000 home birth planned home birth every year but of course the emergency services are called to only a very small proportion of the cases and they are there's always a big conflict and were and big and security how to handle these situations thank you okay in America they would require the signature thank you yeah yeah thank you thank you thank you Robin I think this is really very intensely connected to the main situation that there is but it was not midwife but this was unassisted so maybe I understand that if the midwife is there but if if the if there is an assisted childbirth they would also respect mother's wishes if anyone else from other countries than New Zealand USA or Australia would like to put their opinion it's a question Michela it's a question for me or for the others no it's for you it was just I was the person I want to ask you well theoretically yes and this law but not by the time actually the law for defining midwives is here since 2012 and this happened in 2010 so so not by the time but but it was real really unassisted childbirth of course now there are a lot of childbirths which are assisted but midwives leave the scene before the emergency service arrives because of the fear of the fine situation it's really really bad in that in that respect now so and there are some midwives that stay with the woman even when the transfer happens but they really can be prosecuted they very never prosecuted so far but as the law is really set to instill fear into midwives this was really the purpose of the law so well a combination of different legal legal sets or different laws so so they're they can face fine but never did so far yes yes I think so that the thank you Yvonne I think the situations it's really that the way it's that they are really very they have fear that they've never saw actually childbirths and I know that when they are educated in emergency services that the birth is always considered a highly risky situation for the emergency team so they really always fear when they are called to childbirth yes thank you Crystal yeah I think so that we are quite similar in some respects the USA and the situation Czech Republic also the OB's in Czech Republic are very well they consider US OB's as the most closest peers so yeah thank you Linda yeah I think we shall move because there is much more to discuss so I'm going to to talk about but you can you can write still in the chat I will certainly read it so let's go to the next case which is clearly connected with this one because now I will speak about the situation of the midwife under this under these regulations and under and what are the fears of the government in the situation the childbirths at home would be would be accommodated into our system I was also an expert and I give my statement and Dubska and Krasova case in European Court of Human Rights you may have here heard about it it's a case of two women who were declined assistance at childbirth with the midwife when they wanted to give birth at home so they sued the Czech Republic that the system doesn't allow midwives legally to assist and they took the case to the European Court of Human Rights because it's a right for a part of the family family rights to decide on the place of the birth of the baby and the Czech Republic says okay you can give birth anywhere you want but you cannot ask medical or the professional assistance whenever wherever you want to give birth and the recurring argument among others there are plenty arguments the the government is spitting but we are now speaking about emergencies so the recurring argument is if we allowed childbirth home birth in our country we are we would need to modify the emergency system to include the possible transfer and it would be excessively costly and you may you may be really surprised at the situation because I presume and from what I heard from other countries that the transfers from home births are really not different from transfers just in case of of stroke or some heart problems etc and even now as I remind you the Czech system ensures 20 minute arrival time and even by now 10% of the birthing women call EMS because well this is true a lot of people here really take advantage of this wide net of emergency services and they just call the women just call they want to transfer to the hospital they don't taxis are not really used and people well take their own cars but usually but they're like 19% but 10% of women which get usually in panic because the labor starts and they were instructed by the OB's oh yeah and when the labor starts you should get immediately to the hospital so the culture is the the birth is something very dangerous and it has to be done in a really confined or hospital environment so a lot of people really just call out of fear and so only so by now for 10% of women which like like 10,000 cases a year are attended by emergency services and about one percent of birthing women which means a thousand a year are attended by MD's in this kind of a system so so it's very funny to say that it would be excessively costly because as we estimated when the if the child of the home bird was included in the system it would be like from 50 to 100 cases a year of an urgent home bird transfers and so would we would I make out of it that the probability reasons they think that there should be a special treatment of transfers from home birds is that strong disbelief that may device at home birds are able to handle the situation before the woman or the baby is taking care of in the hospital so as someone pointed out in the discussion this is really strongly related to the to the globe to the to the perceiving to to perceiving of midwives and midwives role as usually the midwives are perceived as being subordinated to to OD's and they are educated in that way they are not educated to be autonomous people with autonomous decision so the idea that midwives would be taking care of the woman and the or the baby during transport seems really unacceptable to to the people who are making health policies here and this is also also enforced by something we call Netherlands ambulance with it appeared in the print some 10 years ago and it's recurring in the discussions around home birds and it is said that okay but in the countries when home birds is allowed there is always a full equipped ambulance with an OB or a neonatologist waiting outside the house where the home bird takes place so you may say this is very funny because like if the if the transfer is needed like in five to ten percent of cases it would be a really waste of money and a waste of time of specialized people but this this myth is perpetuated in the press and among people and what really surprised me I found it once in an article from I think Malaysia about home birds so it's not only chick specified myth but probably some OB is just perpetuated on their conferences or I don't know so point for the discussion how is the urgent transfer of care organized in your country is there some special amendment to transfer from home bird or is just the normal part of the of the transfer system and also there is was as far as I know one time I think in in Germany there were independent in autonomous midwives that were usually doing their own business but they were on call to assist unplanned home birds which I found very very interesting and very very good thing that even women who are not planning home birds but they are found in professional assistance if it surprises them at home there would be a midwife and not just the regular medical doctor restraining other types of emergencies so does this service exist somewhere else yes Linda thank you we are trying to educate the women really and the movement is getting quite a momentum now but it's getting momentum for for last 20 50 years but I think that the spread of social media the information is spreading quite fast so there is a lot of women really now wanting to even in the hospitals to wanting lots of births which is really disputed but at least they they discuss delayed cutting of cords and things and this is also part of the policy they are trying to to introduce really understand the meaning of informed consent which is not really easy because like okay informed consent and those things about rights in biomedicine really stemmed out out of from the western culture and it was quite let's say forced on check medical doctors but really doesn't stem from their from their education and from their traditions and from what they did during the times the communist regime was here yes yes I know and that's what yes I know about the the transfers from home birds are not usually emergency transfers that that's not what we made we may discuss this but I I think in germany it's about 1.5 percent of urgent transfers before birth about three percent after birth okay thank you Yvonne thank you yes thank you Robin this is this is from UK I cannot see I cannot see in New Zealand thank you so at the Specialized Neonotolar Retriever team is specialized the is it from hospital or is it from the emergency services Sheila this is which country please thank you Robin yes okay so this is the hospital team that just gets alerted yeah I think it's a good it's a good organization yeah so so just the basic services but there is there is a possibility for the for the hospital team to be ready for transfer actually I as far as I know there is a specialized Neonotology ambulance for the but I I'm not sure this is the part of the emergency service of the hospital service but certainly there is a quite a lot of of preemies for example we transfer from small hospitals to bigger hospitals so there are specialized ambulances and I think that they can be easily incorporated even to the situation of home birds thank you thank you Karen yes and that's what I think that it can be easily like the system already existing we have also helicopter service in for emergency cases and it can be easily accommodated to the needs of home birds actually there was one case two years ago when the woman was bleeding heavily after home birth and so she was transferred by helicopters and everything went well and finished well thank you Robin so actually it's quite easy to incorporate it in the existing system just by the education not by financial extra finance in equipment or in staffing okay so yeah Makata I just wanted to remind you on the okay so we have 15 minutes to the end okay I'm closing discussion now on this or you can still type and I will read it later and you can okay and I continue just to show you some data because as I'm by statistician I need to show some data and certainly this presentation will be available on my pages and I posted also on the Facebook of the conference so you can check the if you are interested in the data you can check the links later and these are just to get an idea how many urgent transfers happen during during the during home births and it's about as you can see about one to two five percent of the of the home birth and this later one is not from this systematic review but it comes from a new study by Hutton in Ontario and they had about eight percent of transfers by EMS and so these are also some interesting studies and which give details about about transfers and now for the role of the midwife because always I'm sorry I clicked this is the this is the correct one midwife can be in the case of the of the transfer she can be usually is on the delivering side because she's transferring her client with or without continuing her care or she can be even on the receiving side if it is a hospital midwife so I think every midwife should think should think about how to handle the transfer I on on each side she can she can happen to be and it could be expected that if you are practicing autonomous midwife and you have clients and you give your services outside hospital setting you can expect that five to ten percent you'll need really urgent emergency contact and maybe an extra ten to twenty percent will need to be transferred to the hospital so I think it's very important to think about the about the situation and to be prepared for the situation because the the transfer is always stressful there is a really good text by Cheney which considered different narratives of the risk and fear and of how to handle the transfer and it was from the United States and there are also other studies from Netherlands and Sweden and other countries that discuss the the situation of the transfer and the to see the cause it's stressful because the cause is stressful with the baby is in need or the woman is in need and it's really concert urgent so everyone is stressed out and the transfer itself is stressful because there were some plans to give birth to the home and now the plans are changing so everyone is stressed and even just because of the transfer and of the discontinuing of care and trying to continue the other type of care in the hospital and the outcome is often stressful it's well known that if already the urgent situation arrives that the outcomes are not as good as it is in average from the home birth so it's very very important to take all these things and considerations and think about what can help in the situation and I think the most important thing is a good communication between all the all the people involved in the transfer it's it's you have the midwife has to has to really communicate with the woman before and after the transfer happened and there is a need of good communication between the midwife and the emergency services to really make the emergency services understood well what happened or allow them to accompany to let the midwife accompany her client to the hospital and there is a big need to come good communication between midwife or emergency services and the hospital to understand what was an underlying situation and what is also very important to really transfer the information and make the environment the most hospitable possible and I think the good thing is there are some guidelines for transfer and I really thank Saraswati Vedam and her presentation in our ICIM conference about the home birth summit and the practice transfer guidelines they laid up so my question is do you have guidelines for transfer is it included in your professional organization of the care and also which I find really really important is an evaluation to do after the transfer both for the situation what could be avoided also how the transfer could be handled or handled better and also do the evaluation for you as a professional and also the discussion with the client so please this is my final slide and please I want to continue a bit the discussion about the about the organization of transfers and the well-being of women and well-being of the midwives which are included in the situation read what you have written your time oh this is great Yvonne a lot of really good words to include in the in the situation yes I also think so that we need really to enhance continuity of care it is really much much but better for the woman who knows her midwife to handle the situation easier and with more with more calmness and this is all I really feel this is very important for the midwife to accompany the woman to the hospital and to to be included in the in the care even in the hospital which is quite complicated here some some the most famous home birth midwives are literally forbidden to enter the door in the house in some hospitals yelling that I think I think UK UK situation is very very good and otherwise I know even about the an ICE guidelines which included home birth as a best option for multi-paras and so so if the situation is such Linda there also all the time are there are these issues in communication between between midwives and the home birth transfers and the hospitals are the are the women told off for trying for home birth or they really try to be polite and helpful thank you Sheila yeah this is good thing that you have referral guidelines I think this is very important okay thank you Robin yes I think it's really important okay but I think it's really depends on the on the team who is who is at service by the time I think that you have always count have to count on people for for for getting for getting the different types of care but important thing is whether there is a there is a kind of standard and of course some people can differ because of the personal feelings or or unprofessional behavior and so this can be tackled even by the and you can say okay Mr after the situation is finished okay you you behave that way but you should have behaved this way and there is other other situations when there are no guidelines and they just can behave any way they want and be not really facing discussions about it well of course yeah the the discussion about guidelines is another thing and I have a plenty plenty of examples from here when the when the guidelines are just set without even any scientific link to any scientific study it's just the guideline which is made up from from a historical point of view and still keeping their ideas written down and practiced I hear a lot of typing in my speakers I think it's Linda maybe Linda you can yes yes there is a lot of scare even among women here the tradition is the birth is very very hard and bloody and a lot of pain and you have to the message which is given from mothers to daughters is you have just to suffer and you have to stand everything what is done to you because the it's because of the baby but I think it's plus minus same everywhere there is a discontinuation of the childbirth and family life yes Karen I let a lot I've read a lot about the situation in New Zealand and also in Australia where women decide to go against against the guidelines yes and so so you are not as a as a medivive prosecuted to go outside the guidelines you have to be really well backed legally as I presume actually is this now applies also to women who decide to do homebirth and I think this is very this is not a really good thing for women who want to get a good care to be strong and resilient because women as we saw really nicely in the in the opening lecture need to be relaxed and not not thinking they have to be really just birthing so it's it's counter it's going against the the good the good childbirth experience to be strong and resilient and I it's very very important that the supporting people around the women are strong and resilient in a system that is hostile yeah thank you Karen yes it's it's a good good thing that you have the process set up but yeah the the scare is there and the scare is the scare of the of the professional is everywhere it's among the the medical doctors it's among the midwives as it's not really a good good setup for for a good home for good birth anywhere and the situation of the of the informed consent is also a big issue here we have we have a law saying that the medical doctors can overcome the decision of parents concerning a baby I think the medical doctors cannot overcome the decision of a person itself even if she decides to to make harm to herself but of course sometimes done but it can be legally done in case of a child up to 18 years and but the but the child has to be really in immediate need of life-saving procedure and it's but it's quite often misused by doctors out of fear that they don't recognize very well the situation so they extend this to the situation which are not immediately harmful for the baby and around the birth they are there is also an extra insecurity because they they are not sure whether the child is already a person and the law applies and they have to force the mother to to submit succumb to their decision or whether this is really just a mother's decision and so a lot of things and procedures in the hospitals are done unnecessarily just because of the well-being of the baby and either they do it without consent or they really force the women to consent and I'm really happy that at least in some countries as you have written here that there is a good support for midwives and good support for for even all other healthcare workers that they really can communicate in a good way so so I'll be analyzing your chat afterwards and thank you very much for your for all your input okay I think I think any more questions or shall we how many minutes do we have like one minute because we need to finish okay so I hope you you all got some interesting things from the discussion and from the presentation and I'll be posting the the presentation and maybe some other links onto the conference Facebook so you can you can get and find for yourself the interesting things we are discussing thank you Marquette I think that was a really really nice session thank you for being so interactive with all of us I think Marquette deserves okay thank you very much thank you very much it was pleasure talking with you all you and I hope I'll meet you some other day or on some conference or or or Facebook or anywhere where people who are wishing for good care for mothers and their babies meet yeah thanks I mean the key I learned today from this session is basically the woman should be in the driving seat of the decision-making and and yes there could be guidelines for this actually the woman she has to be supported and very well informed yes yeah thank you so much so let continue Kiran you want to um yes Marquette thank you overall it was a wonderful session and I could observe that many participants participated in this and we came to know that what are the situation of emergency system system for women in different parts of the world so thank you for generating this discussion and bringing this this thing to the international conference Marquette congratulations for your presentation and here we end this presentation we can now stop the recording of the session