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So we're moving on now. Two or a presentations. These were submitted and then selected by the organization committee. To whom Great, thanks, incidentally, Should should go. Ah, doing a fantastic job on and trying to get. I remember our hybrid conference from two years ago was so difficult to organize, and it's a credit that everything is going so smoothly, so well done to them. So let's get on with your presentations then. On day first up, we're going to have cake likely from the university Liverpool who's going to present on a cohort study off over 6000 births in India. The risk factors Indications Operative Robson classification and perinatal outcomes. Kate, what is it that much particular Thank you so much to my colleagues in India. Without all of them, this study wouldn't be possible. So I'm here today to present it just one aspect of some of my PhD research and really just to start off with saying whenever we're planning any kind of complex intervention, First of all, we need a really detailed understanding of actually what's going on on the ground on. The only way to get that is to get high quality data So if I could pass on my PhD lessons learned, get some really good data before you start any research studies we need to consider the maternal and fetal risk factors and outcomes on particularly were talking about cesarean section rates. We need to think about the granularity within the data. My PhD was all around and intrapartum fetal monitoring training program on whether that would improve cesarean section rates and whether it would affect her natal outcomes. But actually, when we're talking about getting intrapartum fetal monitoring, write for some ladies that will mean and increases area. And for some women, it will mean less is very in sections. So the crude rate the crude number of cesarean sections alone, is not enough data to understand many complex problems, such as intrapartum fetal monitoring. So this was part of a mixed methods evaluation of a fetal monitoring trading program on the study. I'm going to present here today is a prospectively Cobalts to be of 6.5 1000 births. But this was this part of a mixed method study looking at clinicians. Reactions to training, whether they gain knowledge, whether it created behaviour changed whether there was any increase well, any change in outcomes, which was also part of why the piece of work, which included quality of studies, including focus groups of interviews on also a development of the theory of change, about how this could improve outcomes. So for this particular study, we're looking at maternal para little risk factors, indications for operative birth, 10 group classifications, paradental outcomes and fetal monitoring practices in a tertiary referral hospital in central India. This was a post hoc analysis of a day set collected to evaluate the impact of the training program because reconnected prospective data on all burst of six months from the first of August 2019 until the first of February 2020 on discharge neck you dated for further six weeks we excluded still burst into 28 weeks still birth, where the fetus was confirmed to be dead on admission to hospital under 1000 g, or where the gestation age or the birth weight was unknown. So we screened 6989 cases is part of this study on. In total, 6511 babies were included on 6379 women basic maternal characteristics where the mean age was 25.7 and it was actually really small numbers off teenagers or any 980 of 17 on nine women over the age of 40. The mean parity was low. It not 400.6, with over half of the population being time, a gravity is on again, very small numbers of grandma to Paris, 99.5% of the population was booked, and by that we define that was one anti to clinic visit on 40% referred. So as you can see from the next couple of tables, it was a really high risk population. Around one in four women had maternal medical conditions, notably anemia, sickle cell and hypothyroidism. What about 1/5 had a previous Cesarean section on risk factors such as infertility? Previous injuries, drive, fetal death or recurrent losses or previous losses came up to 5% in total again antenatal. The high numbers of risk factors, the 22% were pre turn 15 had hypertensive disorders. Um, on a host term, not so common is you can see when we look at intrapartum complications 46.2 either induced or augmented during labor. Presence of meconium was around one in 10. And interestingly, I think the number of cases of prolonged labor was low. So that 1.3 classifies for includes First Day John second stage labor. So the total mode of birth was 42.5% had C sections. As you can see, there were very low rates of operative. A journal birth on 56.4% had a Catholic normal vaginal birth. When we look at the indications for operative birth actually presumed fetal compromise on other fetal conditions, including ultrasound diagnoses or meconium, actually with a primary indication for operative final birth. So if 2750 operative births a total of 4049 indications were recorded on 43.1 of those were actually for fetal concerns. Previous section was the second most common group. And then when we look at the 10 group classification, as you imagine, previous cesarean section is the number one, accounting for 13.7%. But actually group too. So the another Paris term inductions, or pre labor sections, accounted for 12% on higher than most cohorts, I think, is the preterm birth groups of 7.9% of sections. There is a limitation with the data on that Group two in the notes. It was very difficult to determine if it was an induction augmentation of labor. So there's definitely a date, a limitation on that Robson's group, too. When we look at indications for a special care admission, it's kind of a similar picture. So 13.7% of life births were admitted to nick you on. Actually, low birthweight prematurity were again the most common factors when we look at paranasal mortality. Actually, the Indian definition varies of the compared to the wh show definitions that's important to bring it to him into content. So there were 229 Still this there were 58 intrapartum stillbirth that was either confirmed or non confirmed as intrapartum and 213 year natal deaths. The vast majority of these again were low birth weight and preacher. When we look at the still burst, if you see here the difference. Of course. The main gestational age for the still breast was 33.3, as opposed to 37.6. And again, the low birth weight there neonatal death rate again confirmed this picture of low birthweight prematurity. And then, of course, respiratory cardiovascular that brings in respiratory distress syndrome and then infection coming in. His number three calls for the nature of death. So this was a large perspective cohort study and Israel and strength to the data set. It took four research associates working full time to collect this quality of data, and I think that's a really strength to this study on. Hopefully we've outlined some of the relationships between risk factors, outcomes and Cesarean section rates. But of course it was a single center study. We're missing some data on some key variables such a socioeconomic status and the gender of the baby Nick. Your admission data is collected rather than discharge data on. As with many studies, we have more missing data from the still worse than the life birth. So fetal concerns with the most common indication for operative birth. But this was a very high risk population. But I think this study highlights the investment in basic data is absolutely essential if we are to plan on implement interventions that are going to make a difference. We need to think about prematurity and hypertensive disease. And we really need to think about how do we provide high quality into part of fetal monitoring that correctly diagnosed is the hypoxic fetus, especially a low middle income countries? Thank you so much. Thanks so much. Okay, so we've got a couple of minutes to questions. Any questions? Are there any online? Is somebody checking online? Catherine, have you got an online? We talked earlier. Hate was question earlier about increasing assisted vaginal birth and as to whether that could serve on twos or forceps And we got a discussion coming up after lunch about who should do that. But his tiny rates isn't it. And when you compare it to the UK rates we're talking 10 12%. Was it 120.5%? Do you think it was a mistake opportunity? There are these babies, actually, which wouldn't be suitable for operative childbirth. I think managing labor. Actually, we talk about this high second stationary in sexual rate, but actually, if you manage the whole of your intrapartum care differently, I, as my closest study, says if there you'll see one of the posters don't take a risk. Do a cesarean on. It's a different way of practicing. It's a different way of training, so we conduced, feels and girls and teach. People have to journal birth. But actually, if the seniors aren't doing that and that's not coming through the generations of doctors coming through, we have really a big problem on. We underestimate the complexities. Training, training people think. Oh, just do training on. That's often the response we hear that does not reflect the realities of implementing training that provides enough education on also confidence for conditions to change their practice. So again, I think that's a farm or completed. Okay, Yeah, thank you very much. And me? Yes. Thanks, Kate. It's really interesting data. I have a question on your opinion. Having spent a little time thinking about this. Do you think we should be trying to implement CT monitoring and intrapartum care in the resource settings so that that is the question? So if you look at all international clinical practice guidelines apart from wh show one, it says do ctg for high risk patients. But actually, 90% of this women in this cohort or high risk patients. We had one seated your labor ward on. Actually, we know from systematic of evidence that CT increase his operative intervention and does not improve paranasal outcomes. So I want to say no, but I appreciate that That doesn't reflect the realities of what the clinical practice guidelines recommend. Okay. Thank you. Fine, thanks. Have we got one online question? We just contain that quickly. So did you find cesarean sections being done for meconium like a without evidence of abnormal fetal heart rates or patterns? Yes, we did. But that was one of the things on my very busy notebook, but I have not mentioned to you. So when we look at the diagnosis of presumed futile compromise in labor, 88.5% of those diagnoses that let her operative regional birth were intermittent. Auscultation interests relation intermittent auscultation alone in 45.9% and meconium on dab normal. Intermittent auscultation 37.1% but to 10% have a section for meconium with a normal intrapartum fetal heart rate. Don't take a rest of us is area have two more online questions and I think we'll have to move on to the next person. That's okay. I think we probably need to move on already under. Great. So these online. But that for those asking questions online, thanks very much. Okay, So next we have been elope. Williams, who I think is joining us online. I hope she's there. Is she on disease? Going to She's from and in school, a tropical medicine on. But she's going to talk about birth by cesarean. The effect of it on the life course of the child. Uh, it should not connected in, you know. Are you there? Come in. London. Come in. London, please. Go ahead. Hi. So, my insulin of the Williams, I'm 1/5 year medical student on Dyess. I'd like to talk to you about the effect of birth by Syrian section on the child in lower middle income countries. Um, so we all know that Cesarean section can be a life saving intervention for the child on for the pregnant person, but it does have long and short term implications on health for both. On currently, most of the evidence that we have comes from high income countries. But we're missing from low middle income countries which are diverse, with different burdens, health on different access to healthcare. So we just can't assume that they're going to be the same. Uh, so the engine objectives was to review and summarize the literature on Also toe identify any gaps that there might be, um, and just some background for you. So it's his air in sections can be elective or emergency, and the indication can be medical. So for the woman, the fetus or both, or can be elective, usually meaning on request, we use a really broad definition of child health in order to really capture all the elements that could be impact on health that could be impacted on health and wellbeing. On. We used to live course perspective, thinking of Cesarean section as a possible exposure that could have a later impact on health and wellbeing. So life course epidemiology looks at a health throughout the life course, and it tends to use prospective studies, particularly cohort studies, in order to establish a temp whole relationship. So from high income countries, you know, the short term risk to the Children are laceration and spiritually mobility on. In the long term, there are meta-analysis is an individual studies linking childhood asthma, obesity type one diabetes orders in spectrum disorder on allergy. And it's paid, uh, so this is my conceptual framework. At the top, we have the life course. We then half the pregnant person, the different options, the potential mechanisms and then the short, long term impacts on health as well as external influences outside of the mechanisms. So in terms of hormone your physiological changes, that's referring to the sort of the can excite of, uh, vaginal birth on the different hormone, or exposures that can have an impact on respiratory function and also metabolism. We then have sub optimal breath reading, which is a link teo mortality and morbidity, as well as development on later childhood obesity. On then, the microbial changes, which is referring to the hygiene hypothesis so different exposures to microbe can cause are potentially later immunological conditions. So investigating cesarean section and child health is quite hard on. These are the reasons. I don't think I have time to explain them now, but I can go back at the end on explaining the people interested. Um, so this was done according to a systematic review protocol, but I would be only extractor. It's currently being adapted into a scoping review with a wider research group and to extractors on. This is just my search strategy. The databases I use on the Peko criteria people are interested. So it's, um, number. I looked at 2115 titles and abstracts. I extracted data from 64 studies and then did a quality assessment, including the highest quality 31 studies on This is just a big bread of my results. It's worth noting majority of my, uh, off the results came from middle income countries like China and Brazil, so firstly, impact on breast feeding. So the papers that we found looked up early initiation of breast feeding, exclusively breast leading duration of breast feeding and delayed onset off lactation on. That found that generally it was a medium, medium, high quality evidence from different Lomotil income context that consistently showed a association with, uh, a sub optimal breastfeeding. We then have new little health, so neonatal and panic mortality. So that's some studies, including stillbirth thing. Evidence was medium to high quality but had very mixed results. I'm suggesting that the association was dependent on the type and the indication of that cesarean a swell a setting. But there was some evidence for reduced risk of stillbirth in some settings. This is quite similar to the evidence from high income countries, which often mixed depending on indication on setting. Okay, and then you need to morbidity. So, looking at respiratory distress, we found two studies suggesting on a sentence in between electives. Is there infection under spiritually distress? In terms of the competent adverse outcomes, we found two studies. He's had quite mixed results. All studies on you nickel infection also with very mixed results on then four studies on Nicky admission or abuse showed some degree of association between Touch of Cesarean section on on admission to the neonatal intensive pricing it so later. Child health. Now, in terms of metabolic and nutritional changes, we found four thirties three of little based in Brazil, one was based in the China on. They all showed some degree of association between his own section and parts of metabolic syndrome. However, they were all at risk of our residual confounding, either not measuring breastfeeding or not. Measuring gestational diabetes to studies on aspirin or both from Brazil won found an association. One didn't again, Not very conclusive. Um, one study based in China finding association with anemia, some ages and no other. We didn't find this replicated else last So the strength was this is a typical you use a really broad definition of child health across a low middle income settings on all cups of cesarean section. Looking at health in the short on the long term on looked a large number of studies. However, because it was so broad, that meant that the amount of detail on specific conditions quite limited on it only included observational studies on a lot of those were cobalt, so that may have been accumulation of certain types of selection bias. Um, again, a lot of studies with China and Brazil so biased towards these populations on the exclusion of the local studies could have introduced some bias. So we only found 31 high quality papers, which is quite you on, mostly for middle income countries. They really are know, finding a lot from the lowest income setting. There was good evidence on breastfeeding color. Everything else was quite next on, we found almost no data on immunological or developmental conditions. s so we really need to understand the effect on the child off Cesarean section. As I said, we just can't assume that it's going to be the same as in high income. Contacts need to particularly focus on the lowest income statins, which have rising cesarean section rates and if they are perhaps higher degrees of Intal itty and morbidity. When we're designing our research, we should be strangers in your nothing for confounder on Trying to Power are studies to look at the different types of cesarean section asarum possible, including using the drops and criteria so that we can better directly compare on. But we just don't know the ideal cesarean section rate, but it is going to be some sort of balance between maternal health, newborn health and ending. Preventable still, But, uh, cesarean section rates and sunlen is the income context off above six cent and rising. So family's health care workers and policy makers really need to understand the effect of Cesarean section and the child so that they could make the best decision. Thank you for listening and any questions elope. Thank you so much. That's fantastic. Questions from the room Can I ask then, Penelope, the studies you've done. I mean, it is no great surprise. I mean, it's the age old argument, isn't it that if you have a Caesarean section for a complication that you've developed in labor, then it's no great surprise that your outcomes are worse and maybe that even in the future, that downstream outcomes worse. But did you find didn't any studies within this, Which is that subgroup of really very interesting group? Which other? The no medical indication? Cesarean sections Where Actually, they could have had a plan for general birth. They could have had a cesarean section, but they had an elective cause those the ones which I guess the real interest to see Whether this is Aaron itself is isolated as a as a a soprano. Blood downstream. Yeah, there were particularly. I found a lot of studies on that from China on some of those found increased respectfully morbidity. These were These were mainly based, like looking at the short term context, rocking along the long term context, and that was one of the gaps that we saw. But in the short term, we did see some association with respiratory morbidity. Nick you admission on, then? Sometimes adverse complicit adverse outcomes as well. Brilliant. Thank you. Any questions? Online? We got online questions? No, none is yet. Okay, but elope. Thanks over so much. Thanks for joining us online. Um, we're very grateful you joining us very much for having me. Okay. So we can and move on now to marry and rabbit, who I hope is here. Marrion. So we were hoping to link with Kwaku ASAP. Okay, from Ghana. But we're getting, but we've not connected with her. We're trying to connect with us, so we may well comeback once we've connected with her. But thank you very much for coming. Marrion Marrion works at the Institute of Research on Sustainable Development in France and she's going to talk in variation in hospital cesarean section rate for low risk obstetric women in 31 hospitals. Thank you. Marry in with a study with conjected with the research group off the party deck of project. Just to give you a brief context off this study of us, we have Children this morning. There is an increasing rate off cesarean section. What? We're including low, um, middle income countries. And this's problematic because the risk off death complication following this is I in section is very high in this country. So we need to optimize the practice. Many factors can explain the use of civilian section in variation according to the context and you can see on this ecological framework we can see that this factors can be related to woman and communities for examples of fear, off of unity section or vaginal birth. You know, that could be related to us professional, but also to organization in system factor and the Roll offs Hospital. This is very important. Obviously the chemical and obstetrical factor really important represented here about the wraps on ah quantification, I wouldn't know present you with the quality project quite a deck meaning appropriate use off cesarean section through 20 t decision making by women and has professionals. This is, ah project funding by, uh, European Union and wh show and the objective is to improve the decision making or getting cesarean section and to reduce the necessary cesarean section among low risk woman to have a C section. This's a project implementing it for countries in Argentina, Burkina Faso, Thailand and yet Momma and we are implementing for non clinical intervention in 32 participating hospitals in this country. This folk clinic none Clinic and intervention. Our first, the possibility for women to have a labor companionship during the child birth, the viability off a decision. And Alice the stool, which is ah, booklet or a nap ligation that will allow the woman to benefit from a lot of information on both civilian section in vaginal deliveries. And this is also true that alot better communication between the woman and uh as professionals, uh, conduct off these are gonna did and fit back on the regular basis in the hospitals and the presence in his hospital. Often Opinion leader um the roll off this opinion leaders to encourage and support the changes in practice in the hospitals concerning the study are represent today. The objective is to observe the variation in civilian 16 rates between hospitals and country. Among emergency in your group off women with a low risk off having a C section and also to describe our the literature Nikki we can find between the hospitals in Cesarean section rates can be explained by some hospitals characteristics. We used a monthly routine data collected for the purpose of the project which allowed us to analyze all the deliveries and Cesarean section performed in 31 hospital over the year 2020 so correspond to the pre intervention period. And we used the Russian classifications to study this. It originated in, um, a genius group off woman and we concentrated, um, low risk of woman corresponding to croup, 1 to 4 off the ropes and transfigured. And the metal we used it, the meta analysis approaching that we sure you directly. So it looks like so this also reasons for the group wanting to repair it's woman with a spontaneous labor. And as you can see, it looks like a similar classic, classic meta analysis. But instead of study on the left, you are the country and the different hospitals. And on the right, you have the effect size, which is the Caesarean section rates in the confidence interval. And it's very interesting to say that to observe visually the it originated in cesarean section rates in sub hospital. Okay, Um, what we can see is, um, that the over or cesarean section rates for all these hospitals in for a woman from one is 26%. But we can see that, um, there is a lot off. It originated between these hospitals and there's a lot of it originated between countries, not only between hospitals. And we can also observe that the even be in the same countries. The it originated between hospitals is also very important on So we performed the same analysis for group too. And we can also observe very high uh, pulled cesarean section rates are 75% of food and other sister action in this group and with their still high virginity between the hospitals and there. So within each country between the hospitals yeah, the same ways observe for group three with 11% of human with a C section in that group and still high. It's running in the region et les in Argentina than all those country. For example, in getting on, you can observe very high. It originated fish, really and finally the same for group For approximately I for women are the six section in that group on and still high. It originated between the hospitals and between countries. So what we try to do on it it's some preliminary result. I will show you is to identify what could be the determinant off. This originated this variation in civilian section rates. So we performed the meta regulation analysis to identify the hospital scarrative ballistics. That could be that determinant. So, for example, he for group one you can observe that country is, ah the button determinant off the CIA C section race variation, but also the present off the functional interest in in the hospitals in hospital with an infection and interest in you will have more science section that in houses hospitals. The first volume is also determinants and the number off the section they're operating room is also the dominance. And all this for a Spitaels characteristic can explain 35% off the between hospital variation. So we did the same for each group. And what is very interesting to observe is that the determinants out really different according to the group. So it means that we need to take that into account when we establish some recommendation, because it depends on the group of human you want to target. You have to adapt your intervention. I don't have a lot of time to develop more, but it will be more detail in the paper associative toe this study. And if you want to know more about the quality project you can, you can go on very well. What site thank you for your thigh project is what we've heard about many times seeing the data from it. Questions? Yes, he's really a microphone. No, that's right. For those online, they'll appreciate the microphone. I think I just want to ask him payments. It was it all free or had the good woman. Women are only uses Aryan section. Of course, that may make enormous difference. Yes, uh, it's a really good question. It really depends on the country. Um, but it's, um I think it's a determinant which should add in the analysis, because in some country it could be really important to take that into account. For example, it's a country cesarean section are reimbursed by some insurance, and you know the country. Not so obviously, it's a very it's a very important arrest the Ristic to take into a combative through the country dependent. Oh, for that study. Okay. Thank you. Uh, hi. I'm really interested by your finding about the ultrasound correlating with the increased in cesarean section weight. I just wondered, Do you think that's a marker of increased detection of things that breach presentation or is an associate if they've got higher resources in those settings so it may be more likely to have higher section rates If you've got any feeling from the data Uh, yeah, I think it's ah, really context dependent because, uh, for example, we have ah, I presented, um, the over study. So we have country like Thailand and working FSH. Obviously, the interpretation, it's very different according to the setting. So, for example, in booking FSL, we have only two hospitals with uninterested a function of treason. So the interpretation is really different. So yeah, it's But it's a very interesting results said now. Yeah. Okay. Thank you. Yeah. Gretchen, um, you know, is there Birmingham? Beautiful analysis. Congratulations. A comment, and then a question or comment is the larger the sample size you might notice that I squirt automatically would be going up so it might be worth looking at tall scratch to look at the hatred and I d. The question is, it's interesting to see the variations, particularly within Vietnam. Do you have data on the actual outcomes in terms off the mortality and morbidity and other any variations in these hospitals that reflects the variations that you've observed. No, we do not have this information for I mean, with the monthly routine data we collected know. But we are also collected. Some also data we perform. We convicted some postpartum survey among women that that just deliver the, um in that hospital. So we have a lot of information for this woman is like approximately between 500 and one says in woman per country. So we will have a lot of things information for this woman specifically. So we'll be able to study the mortality for this woman. But with the elliptical like that, routinely, it's so difficult to have the mortality. But we will have other information after about this. Fantastic. Thank you. A quick question. Yeah, Just again. From the colorectal perspective, this looks very much like a resource variation. So it's about the resources Are you going to analyze it in that way? Because I think that that that will be very informative. Thank you. Was that a yes or no? Are you going to analyze it? related to resources. Yes. Yes. Sorry. Yeah, yeah, it's It's only preliminary result that just shows just to have a discussion and to see if we can at some. Yes, Thank you. Okay. You We are short of questions. A desperate question. Yes. And online question one online question whether any evidence of varying rates by week, day versus weekend. So we can you repeat any variety and rates between week day and we can No, we do not have this information. Sorry. Yes, it would be very interesting because I think the result will be three different. But no, we do not. We just try to, um, to see there is different between, um, day and night shift, but we do not have the information for with a and weekend Marrion. Thank you so much for Okay, so now we can go to Ghana. We have quacko Asa Poku, who's joining us from Ghana. I hope on Diz going to present on shared decision making on whether that has an effect on Cesarean section. They're teaching hospital in Ghana. Uh, quacko you there? Fantastic. Yeah, we could We can hear you really clearly. You're very welcome to Birmingham. Um Yeah. Please, go ahead. We've lost you Just a second. Is your signal gone? We can see your slide, but we're just not getting any sound of the moment. I can't see what's happening. Yep. No, we're still We're still not hearing you crack. Ooh, is Elizabeth Online the final presenter? Because if so, we could we could move across to Elizabeth and then come back to crack. Oh, okay. Sorry. Quick. Were having difficulties connecting. I don't know if your signal if it's a signal problem at your end or are end, but we're going to move on to the final presentation. Then we'll come back to you in about 10 or 15 minutes, if that's okay. So, I mean, vital is a birth mark. Ah. Ah, Who is? It's from the Burnett instruct you in Australia. And she's going to talk about the effectiveness of part a graph education and training for monitoring and managing women in labor. A systematic review. Elizabeth, you there? Yes. Looking human. Hello. You're very welcome. And what time of injury in, uh, in Melbourne? I'm actually involve beans. Land. So it's, um it's about 10 past nine here. So? So Children are a bit at in bed, and I'm ready to percent. So thank you for having me. Fantastic. Okay, The, uh, zoom call is all yours. Take a right on. Ugly. Thank you. So, thank you for having me today. I'm a GP obstetric registrar, PhD candidate. And it gives me great pleasure to present the preliminary findings of my PhD basis. Um, on the effectiveness of autograph education and training for monitoring women is up. So, um, everyone in the room is probably familiar with the potty. We've been using it now, folks, into the 19 fifties and since the 19 nineties. It's really being recommended for use across all clinical context after a huge landmark trial showed that the part about plus intensive training significantly reduced the number of women experiencing prolong labors. Augmentation still. But so essentially, the premise of the paragraph is that the findings would be recorded by the school findings of being reported on their four girly intervention and prevention of complications could ensure. So over time, it's kind of being sold as the simple labor monitoring tool that can be implemented in any clinical context, regardless of the skill set the provider. But in order for it to be used effectively. Well, first, the paragraph actually has to be used on. It has to be perspectively completed by the bedside. And also it's not really true that the provider can just turn up music. There has to be some underlying foundation knowledge, and then can we can meet, expect to provide it to be able to interpret the findings, Understand? Importantly, I don't give a pre intervention because what was saying now is that is that this is five gallons between too little and too much intervention, as in an unnecessary cesarean section that might be a result from getting this balance in correct. So, actually, when we think about it, the pot a graph, even though it's old, is a simple tool is actually a really complex intervention requiring appropriate implementation. And I think the speakers before we have really hit the nail on the head because there's no point in implementing a tool unless we teach people how to use it correctly. So we know that provided training across all aspects of the step tricks is is important annoying that particularly in low income sittings, that is, particular challenges such a limited support of supervision on access to training that we need to consider. We also know, and it has been documented for the last three decades of It was deeply that part of education and training is known to be a sub optimal and does not meet the needs of providers, particularly in the low income six. But despite this and despite the fact that we use the paragraph so widely, the effectiveness of kind training and which component to work best in what settings have actually not being explored. So this takes me to the Lady Care Guide. So the W h o in 2018 least in the instead of recommendations on intrapartum care, which I'm sure you're familiar with. And from that came the creation of the later care God Next Generation pot, a graph which include mints, Supportive Care practices. Now this is actually a gold image opportunity for us to take a new novel tool and re evaluate how it implementing it into settings and safe. We can do a better job way. Have so many people on the ground passionate about intrapartum can monitoring that we really need to take a step back and think about well, actually, how people using is tool, and how can we optimize it in settings where we know that there's already challenges we have to take into consideration? So the thing off my existing make review is to evaluate the impacts of current paragraph education and training programs on paragraph on providing knowledge skills and the actually use of paragraph in clinical settings. I also like, and had hoped teo identify which components of these paragraph interventions are more central than others and to determine the effects of the education and training programs on women's health outcomes, clinical care practices and organizational practices. So in terms of the inclusion criteria, so we we kept the types of interventions that we included quite broad. So any complex will simple interventions related to paragraph use aimed midwives, nurses, doctors and undergraduate student equivalence anymore door combination of delivery methods on any facility level from any country or language. I'm looking specifically at evaluating, providing knowledge, paragraph use, paragraph completion and birth that comes. But of course, within that way we also have to make some had choices that ensuring the highest possible quality data could be included in a systematic review So we live in to the types of studies to the criteria, which was awesome eighties. I have known randomized control calls control before, after interrupted time Siris. So if you could imagine, even though the paragraph has Bean used for such a long time, they actually is not that many studies, um Valley waiting training interventions. So we actually identified 408 ABS titles and abstracts on following full text. Reading actually only included seven studies, most of which were excluded because of the eligible study design. Um, factors you're overall study characteristics showed that only a total of 484 providers were actually included in the results. And in contrast to previous because all of our results showed that the studies were conducted in low income countries and the majority of those studies have looked at provided knowledge as the primary outcome. Now, this is a very busy slide. But just to demonstrate you will, how different the training interventions were in terms of the components and this sample sizes so very small sample sizes and very, um, next bag of different types of loads of delivery and interventions. Overall, the majority off into paragraph interventions were multimodal, so they included multiple training sessions. Small group Victoria was some type of any short and intensive workshop as well. A supportive supervision for my feet. The majority will need wife only eight. And even though they did include providers from community care settings, they were actually conducted within totally cast sittings, which may be quite far to travel some providers. Now, again, this is just a bit of an overview to give you an idea about the quality of the studies. And unfortunately, even those that were included still had quite high risk of bias using rubs and one toe would number. And my studies involved too close to our CT's do two on most often do two missing missing data and level of certainty is very low, too. Lord, a cause of the hydrogen 80 between studies, the interventions, the outcomes used as well, a small sample sizes and missing an incomplete. So with all of that, essentially, a med analysis is pretty difficult to conduct. So I just wanted to present to you some of the suggestive findings that that we can kind of use it as a baseline for future studies. So in terms of providing knowledge and skills. It makes sense that training should increase provided knowledge and skills in some shape or form. And all of these studies demonstrated some significant increase in providing knowledge, so they use different ways to evaluate what was less certain. However, up is how these training programs actually increased the use off the paragraph and importantly, the correct use of the photograph a swell. So he's summary despite the oil, so use off the paragraph many decades now they were mine is a generalized lack of robust evidence evaluating effects of current autographed training programs and the available studies that we have been able to have it at identify. I have to be kind of a red would caution because they have a higher risk of bias lower to very low certainty of evidence with small sample sizes. And it really hasn't shown us anything that we don't know really, that training equals increased knowledge. So so really, with the advent of the implementation of the new double high chair paragraph is really gives us the basis Teo push forward and not only think about the implementation of the LCG, but also happen. We of implement and develop a evidence based training program that goes with it on day. That is really the basis of my paged ain't going forward and hopefully, after present, some of those findings with you in light of conferences. Um, thank you for your time and looking forward to questions that you have any Elizabeth. Any questions? He probably just got time for time, for one. Is that one online? Yeah, online from somebody on the room. Okay, from what you want to read stout So that why do you think the clinical education and medical education researches so understudy? What can we do about this? It's astonishing that they're only seven studies on such an important and widely widely used intervention. Good question. That's a great That's a great question. And I guess that's the golden question of the day. Really, I think, you know, whenever we have a new tool and have a lot of evidence in research settings in perfect research settings, that suggests that it's going to improve outcome. So women, everyone gets really excited about wanting to start using it and which is not which is not a bad thing. But I think it it really come to a point now where we can just have a stick back and start to think more about implementation, which I think again has come out in so many other talks today as well. About Well, we know that this might work, but how are we going to make it work? And how are we going to make it work in how specific context this? Well, so So I think it's just a bit of a back step after we've after. We realize now that actually contest at have one size fits all of courage to these new tools. Okay. Thank you so much, Elizabeth. And you'll be very welcome back. A bit of a spoiler here to Edinburgh in a year or so is time about the results of this and how you've implemented the program. Okay, so we've got I think wacko is now with us. Quackwatch. Apologies. We had a bad connection earlier, so we're hoping to hear about your work on shared decision making. Are you able to hear us clearly? Yes. We got a really good signal. Thank you. Please go ahead. Yeah. Morning. These I Yes, All right. Resources sections. We sent off common be won't help the house and weight way. We have people with the special ones. That was my best one house. No, no, For custom, these rashes, the they don't want section is single Case. How is also the off? So So I I want to use it sufficient and all the necessary five. You're saying most procedures exchange section got an exception for a section on that section was sitting by the way. Now this says we're not stuck before the shade or the she uses it. And I mean, well, flushing. But in its pleases month, as much people all. It's a shame. Now way you don't tell me what I was saying. Okay, we got about fusion process. Husband's around now on the market. But they help get your house, they lose off steam. Rather one of the plants Or now, were your DVT stay in the gration way. Way more. What way for fashion moves thing? Yeah, I mean and then help solve that. That wasn't We shouldn't expiation. I agree. That's one. See a baby. Thank you so much quacko it and very nice to have you join us from from Ghana. It came out really clearly. Thank you On questions. Are there any questions online? Yes. Oh, hi. Days ago, I didn't change from African Center of Excellence for Population Health policy by investigators in Nigeria. Figured it to corporate for your presentation is just a comment. I have, um one of the message I can get from your study is that we need to improve. You know, communication between health care workers and our patients on This is something that we have already dictated on reading a lot. When we're training residents in the West African, a rigid canceling on for any reason for any intervention where there's going to be a family planning or it's going to be a cesarean section is something you know, the skills is really lacking. I mean something that we're going to train our healthcare workers to do well to communicate to our patients. You can imagine, you know, most of the patients saying that they they got that information from friends and got rooms, the sort of information, but they got. But if we have a healthcare workers I trained to run, they have good communication than a lot of this shared decision. Will be improved. Thank you. Thanks so much. A diesel? Yes. There. Enough. Well, we've got now loads of questions coming. Yeah, Yes. Thank you so much, Doctor. Cocoa for representation. I'm cross the middle from Uganda. Yes, I'm saying that you are saying there is high in your age? Yes, this high in radiance. In which group is it? The health workers or the patients themselves? Because in actual since they're say, actually that someone was asking about abrupt your present. Yes, the marriage is there, but which emerge, I will give them to their patients. Surely there is a god. Between that, we will call me Nick. Eight store patients. They're just very for the intervention because they know to possibly from the pain by their rules. Don't understand what exactly going to be done on the right is the exact indication, because some of those see indications with a different section, they may put a put faces. The incident or bill down in the midst of breath and others may learn placed on indicate that essential. Since I should've elevated in the nets to, uh, chart back, Uh, when it happens. So there is the lack of communication that I'm really saying that it's really happening, the patient said. The doses is, but they don't understanding those owners to write, similar to improve the communication. Which is, should the statue rate from the training because in most cases, yes, we're trained. But there was no growth spirt version of hard with a quarter to a disciple sense that didn't But I was supposed to all of us. That's great. And quickly. Do you have a comment on that? Well, yeah, And what I think. Thank you, Cracker. And just just to be clear, the comment on abruptio percentage that was amongst what a mother was it rather than a health professional. Yes. Yeah. Okay. Thank you. And I think final question, because we're we're we're eating and tweet Lunchtime A little bit. My name. Telephone, please. I'm training at the women's, but I've worked previously inside C done and in North Sea, done years ago. I was just wondering, Is there any W h o health promotion material that's aimed at mother's antenatal? He just explaining potential interventions in labor, um, to give women a sort of pre consent information. I think that's something that will be made here small globally, but I don't know whether anything like that exists. Does anyone know of such a thing in this general educational tools? But I don't know. There's a specific cesarean section one. Do you have one cracker in your hospital to try and improve knowledge? Yes, I use sessions. Three. Yeah, brilliant. Thank you so much. I think we should finish the lunch, I'm afraid. I know there's lots of I'd love to continue this debate, but I'm aware that people are online on that. Also, we've got to keep the time after lunch. So I think we should finish here, I'm afraid. Thank you so much for everybody who's participated for all the present a shins, and especially for those who have joined online, it's fantastic to be able to get live it alive. Presentations from a gardener and from Australia, a zoo. We as we continue the conference so