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so thank you for coming back. We have another very interesting session here. We have a fine older presentations. Um, some of them are in person on DA. We have three intestine and two that are online presentations. So, um, we're going to now start this session. Each presenter has about seven minutes or so to present on, then three or so minutes for discussion, 3 to 4 minutes. So we're going to start with the first one, which is interventions targeting health care providers to optimize the use of cesarean section or qualitative comparative analysis to identify important intervention features. And this is by Ron A zero from the University of Melbourne, Australia. Um, are we okay being on line and available if you're ready. Okay. So welcome, Rana. You have about 7 to 8 minutes to make your presentations and then didn't have some time for discussion. All right. Thank you. Can you hear me? Well, now, So please go ahead and start. All right? Okay. How everyone? Um, my name, this runner. So today, on behalf off our team, I'm going to present about our study, which is a quality of comprehensive analyzes to identify important intervention features on it. The friendship in targeting health care providers gel few minutes to use the office period of the section. Um, I'm a little bit now and eso before I start electric normally to traditional honors off the lining which presented square. There were injury people off the combination. And I'm sorry to interrupt. You know, we can't hear you at the moment. Can hear your so compared to negative. Uh, no, actually. Hello? Can you hear me now? Two seconds on and we just sort this out for you. Okay. All right. Yes, Yes. Perfect. Yeah. Thanks. Going to go to the first live presentation, then we'll come back to you. Okay. So, course, could we have Zetia next? Thank you. Okay. Angel plan. We'll go back to Rana. Sorry. Okay. Can we Can you hear me? Not all way. Can't think so. I can start. All right. How everyone? Uh, my name is Rana. So today, on the health of our team, I'm going to present about our study, which is a quality of complicated analyzes. Still identify important in suppression of intervention. Features on intervention targeting hot kid providers jumped in like the use of cesarean section I'm in Melbourne now. So before I start electric knowledge in traditional owners off the land in which I present this work there were injury political in a shin and I like to pay my respect to the oldest passed presented images. Um, I'm sure all of you here are aware and this has been mentioned many times by the presenters and they come from this conference that there are rapid increase. This office is your own section use globally, which stopped that which, with some countries, have even reach over 50% of transection rates at publishing level. Arming laces are in section has been predicted to continue increasing over the next years as mentioned by, um, a nebulizer on the presence previous presentation and predicted to rich 29% worldwide. 2030. So they ran section has reached for women and Davies and impact health system in inefficiency, especially in law resource settings. The foot is a need to implement effective in defense in at country to help facility levels. The ensure that sister and section use can be up to my knees. In 2018, world as organization issued a glow guidance on on clinical intervention to reduce unnecessary cesarean section with intervention to find it hard to treat different stakeholders. That it's criminal healthcare providers and helps us the in this gut wines violation emphasize the complex challenges in read using a necessary cesarean section where single combo in a different defense men were perfect to be not ideal to reduce the unnecessary sister and section and is that complex Multi factorial are multi confident nature of interventions. I made it to potentially permanent reduction offices around section of Health facility. Try to the systematic refuse to be treated. It's Humana intervention. Trumpeting healthcare providers have been implemented. Talk to my sister and such, um used lovely This interventions are typically evening to improve a monitor clinical decision making off healthcare providers. However, this intervention are often complex and their effectiveness off area understanding is a friendship. True is that like they'll eat you up? Wrist is your instruction. Use is, uh, important to Optimus benefits. Therefore, on this study, with him tired into Phi important intervention confidence are he truce that, like just access, will not clinically in defense, in part getting healthcare providers to optimize the use off Cesarean section to achieve the MRI of the study we adopted. Qualitative operative analyzes are normally called excuse gave. Oh, what is juicy? Just a particularly African senses this method combining polyp it is, and whether the difference was drafted. Elegy to analyze cases which in our kids is intervention in complex situation. Explain why change cultures in some intervention and why it does not like you're in others. And that's that mentioned earlier existing intervention targeting healthcare providers. Stuffy, my sister and section use are multifaceted, complex and have mixed results. If well, we basically use Q t a pectus complex city and understand why some intervention work you have. The others do not work. So using Q c A V identify if combination of the French futures are associated with successful intervention, which in our case, this reduction of steroid section and what I tell the buckets of friends and futures he's a full price of like, for example, it's not going to find skin would, like, still characteristic and help the French was Delaford, until, I think you say, well, less evidence from existing spermatic refuse. Oh, included is the medical issues which were used to inform the Blue Ridge of that lens that is genital to toys and each and and also to refute. It was conducted afterwards. That is a few little frenzy. 20. So well at this to intervention. Uh, we look at the intervention, it click on the stool, refuse and just want to target healthcare providers, introduce our optimizes around section and have no high risk of bias to be infected or a QC We also looked for sibling studies on this included interventions. I just a four month free city are process process evaluation studies that that helps her off components off intervention, uh, included on his interference and study. We define successful intervention as intervention which were able to reduce the store and section while on census. What intervention is defined as in the French, in which you have one sister and section are increasing the story infection rates. So all the the corporate, if analyzes, is heavily of rely on fairies on yourself, like um, pathways on hot and difference in May work. So to develop varies on how into friends may work and understand of each, uh, potential intervention features overall in a different, um, success with different, uh, political framework based on problems with this effort, um, synthesis, as well as a conducted intervention component and license by looking at a trial list Reflection of discussion section. So based on our allergic a framework he's trying to five Power analyzes into sixties and models here. And so the Falling Artist. Six. They just off and allies. It's recommended by Thomas that'll that were run for each bottle. I did not have time to talk about this in more detail, but the process included. First, I didn't you find what I'm still a difference in truth, elliptical from work on a very different mint that I mentioned and calibrating the other, that this included the data into a more uniform language using hey the library or, you know, family and in the contracting threat tables toe to see as a treatment for figuration of different features and Oxfam's. Then we simplify the solution. Using valley and minimization and interpreting are the solution we conducted. This analyzes are from having some various injuries. It will pinch the floor like a tree and do so so they were total of 21 studies were included on our key See A and all of this study is implemented. Audit and feedback intervention. As you can see here, the majority of studies have between rates above 20%. And in terms of the upcoming, they're foreign studies which were able to reduce this transection while seven study says in first or no change into transection rates. The studies report back table car spitting countries probably. Where are 37.1% of studies conducted in heart come from trees? So now we're going to move into the results. So, in summary, respond off key, including integration features, which from successfully mentioned all through my sister and section use So successful intervention were characterized by the presence off this fives in the French and features and for us that the intervention provided training to a different provider. Snow, which and skills on label management and intervention itself. And then the intervention implemented active dissemination Off this transaction indication to a C materials are and remind your system on that beach out. It, um, keep back in an interference in part is a clear and actually actually the recommendation to be implemented. The intervention also encouraged, and from what that will do, disciplinary collaboration. A secondary off workers which inputted make lives up in obstetricians, doctors and nurses and there is help provide. It's related to change. Therefore, it is very important before any intervention, implementation help her for this perspective, willingness to change the references. So what's the Syrian section? Our address and are less and interest? Um, it is important to note that when one or more of this intervention features are outside of our studies, you're off intervention where her finest are interested in here to the intervention it's needed to prop. That's a school intervention. Uh, I'm sexually. I'm successful into French and you were characterized by absence of these indifference and teachers. So the things the highlights from this result is that, uh, he's quite important in the French, and features do not work in my lord, but instead they work jointly as part of configuration to enable successful in different versus will interventions. And secondly, what multiple pathways with a different configuration off this fight, indifference and features which may lead to success. So s you can see here on the slides that there are four different pathways resulting to a successful in intervention, different configurations off in the French in features. So based on our study results, we also definitely a checklist of that decided and important medication, audit and food Bank prevention too often misses reelection and real requirement of researchers help their providers and institutions the container including this, the present features that may promise off the intervention. So Total Konkola Sure, all right, It's just a really identifying five important, uh, interferon strictures that jointly work together to burn up permanent successor intervention and went the signing. The intervention targeting hockey providers the relevance holders can consider didn't push in office in his friends and teachers to promote benefits so that it's all family, too. Thank you so much for listening, and we just got to let me know if you're really crunching us things. Thank you very much. Run all the way from Australia. We don't know what time it is. Maybe it's late in the afternoon, late in the evening, but thank you for taking the same of the presentation always lived in. So let's, uh, have any reactions, questions, comments online, I think. And take a few minutes. Okay, So on a spoke about five interventions and measured mentioned that they do not work in silence and came out with a full pathway so interesting, you know, to look at a cesarean section reduction from from a qualitative aspect, you always look at it from the quantitative. Um, any time in Seattle? Yeah, it's tricky. Shake it out and bring in presentation. Granna, you mentioned the last two nights willingness to change. I was just interested to know that they actually use a specific tool, a whole one assistant in studies of the providers willingness to change. Um, thank you. So that shaky lot, uh, for a year, questions. So it is about, uh, willingness to change. So the reason why we actually include the willingness to change is because the in many and we actually conducted the intervention component and all. Isis looking at the trial list. Reflections on a discussion section where the trial is are actually given reflection on what works or not works in their intervention. And what we actually see, uh, most common appearing is that trial is mentioned that you know, providers, willingness to change or the providers, you know, motivation to actually to change and also adopt this intervention is very important. Uh, in their study Therefore, we actually included as one of the defense and features that we think is important even know it's really not about intervention feature, but, you know, about, like, more contextual factor. And so we're actually unclear how they actually assess this. Provide us willingness to change. But this is this This meant when they actually mentioned on their paper that you know how keppra fighters were actually actively involved. And they show, like, you know, positive reaction towards intervention. And they actually, you know, uh, wanted to change. Then we actually quoted that this contextual factors is actually presence in this study. And this is this happened to be actually a line with previous quality of evidence sentences. Um, that actually mentioned providers, you know, um, preferences And what they think about the transection actually important, Um, in the adoption of intervention and in changing their clinical practice. Okay, I hope. Actually, answer your question. Thank you. Yes, Yes. Circular grains back. You didn't answer her question. Very well. Thank you. I think you have anything on line. Just some comments from the online audience saying they really enjoy the presentation and found the findings very useful. Thank you. thank you. So I think we can more back to the next person. That was there Another one? No, we can move on to the next presentation which is in person. We've heard about the Robson classifications this morning, but now we're going to look at a presentation. But is there a in a gym alluding from the London school of a gene in tropical medicine using the drops and classifications for raising cesarean section great amongst Palestinian refugees. Results from over 290,000 Elektronik medical records across five settings issue here. Yes. Welcome. Oh one eso from qualitative are moving back to concentrated. Uh, but I think we all should like everyone saying talking to each other is always building more evidence. And so I'm be discussing on the drops and classification and really focusing on Palestinian refugees. So just a bit of contacts there Around 26 million refugees globally five millions off off them Are Palestinians refugees living in five settings in Syria, Jordan, West Bank and Lebanon on or what is that you? An agency that provides assistance to Palestinian refugees? It's really also provides three primary healthcare services for antenatal care. However, it does not directly provide child birth care. Rather, it uses a partial reimbursement system, so a copayment system where they credit non owner of our facilities where the child birth is happening. However, they do provide all the care needed until natively and later on postnatally. And so in the past 15 years they started noting very high increase in cesarean section among Palestinians that have doubled from 15% to 31%. And since we were already working with them, they asked us, What can we do? How can you understand what's happening? And as um said in the ER keynote speech, the first thing we told them is you have a neck tronic medical record you are collecting later on antenatal and postnatal care. How about using this data to really understand what is happening, where is the rate increasing and where we can really intervene? And so the study analyzes data from under one Elektronik medical records from 144 health facilities, and it really examines and context to advise is C section rains among past in in refugees in the five settings and really we need to compare them and using the drops and classifications, but also taking into account the context that those refugees are living in. And so I'm not going to give a detailed, um, plant into the Robson classifications. But just to say that since the electronic medical records were not done in order to do the drops and calcification, we had to do some adjustments. But actually this another stool, a Toronto underwear. Okay, we need to include some more, uh, indicator for the future in order to do the full 10 classifications. But since they don't include information on induction and on the type off my presentations, so we know it's, um, my presentation. However, we don't know if it was transfers or it was breach we had to come up with grouping some off the classifications and so at the group wanted to with include 90 Paris women who did not have a previous C section of business but also were a woman who had the liver. He's at camp, and we used the ups and gasification and between eating toe see what is the guidelines. And it was around 16%. The second group is the multiple Aris women with no previous C section and here we expect a lower rate off C section. Um, and the group five actually is the multiple cysts woman with a previous C section. And here the guidelines is around 50 toe 60%. Then we grouped some off the groups don't come up with a multiple risk woman with my presentation a 90 Paris woman with my presentation, study and multiple risk women with my presentation and then multiple pregnancy, meaning those will have twins, um and then find ended the preterm. I would be really focusing on the first three because we wanted to understand the unnecessary A C section. And what is happening there just to show overall prevalence is so I start with the Palestinian refugees in Jordan, then Lebanon, Syria, and then in the bottom West Bank and Gaza. And what we have in blue is the C section date on. What we can see is in some off those context of context, especially in Syria and Lebanon. The C section it is very, very high. It reaches 65% in Syria and 50% in Lebanon. Uh, influenza has the lowest percentage off C section around 22%. However, What is very scary is that this percentage is increasing. On top of that, I added the drops and calcification so that we can see how those see section are happening. And if you see in green, this is where the multiple areas women are. They are representing the highest proportion off those who have a C section. Now, if we move in specifically into the classic relapse and classifications, I also present in the past past in you nephew Geez, in Jordan, Lebanon, Syria, West Bank and Gaza. And we can see that compared to the guidelines and all of the five settings, the non the Paris woman at your, um have high C section dates and if you focus and never known around 46%. And when you saw that two doctors, they said, Oh, what what's happening here? So in fact, we can also suddenly see this rate increasing and those on another context when we look by year. But I don't show those results here. But this is very scary because in fact, in this setting, we have high fertility rates. So what's happening is that this is the 90 Paris Group. But when you go to the Monty Paris group without the previous C section. We expect a lower rate off C section and those groups. But what we see also is that there is quite high rates in those groups. And if you look at ah, Lebanon around 13% and West Bank out 10%. And so there is a Neutrogena, understand what is happening with in this group bed and the, uh, group to focus on is the multiple risk group with a previous C section. And here we clearly said that once the C section, always a C section, is very used in a lot of the settings. This is something that doctors have told us, especially in, uh in in Lebanon and West Bank. And it's moving one and more towards that. And there's a new to really talk and discuss with obstetrician what is happening and in order to encourage more, be back and learn from all the intervention that have been presented previously. And the other thing to talk about is that the Middle 57 is is are very, very, very low on those settings, which is also might be encouraging, um, C section happening and finally to talk about also that, uh, there's a need to off off certain intervention, like the second opinion policy, where in fact, in Lebanon, when you initially are so that the C section among Syrian refugees and number nine was increasing very dramatically, they asked the doctors in the hospital to have two opinions for the need of C section or else they will not reimburse this ah c section. So there was an incentive by the hospitals to do that on that lead to a plateau going off the C section, but not a decrease. But at least we saw a quick increase among Syrians and then a plateau, and I think it's very important to talk about all of this without talking about the context. Uh, the high rates are really not happening and vacuum and seeing enough embarrassed in the refugee answer in refugee and on, in fact, the fiddle. This is first in in refugee data, but if they overlay the national data, it's really following the same trend. It is also very important to note that what's happening in Syria is not happening in vacuum. We did previously do some studies in Syria and so that with colleagues and the gentleman who actually noted that a lot off obstetrician left the countries. So the country had a lot of surgeons who prefer to do C section. And that's really what that one off one after a reason, but also the fact that people wanted to schedule there. They're pregnant, their delivery because off the situation that was happening. So there is some evidence and all of that happening in Syria and now giving everything. There's very limited midwifes. And so there is a need to really try to plateau and stop this very high rise and C section. Um, finally, just a somebody is to say that C section is exceeding recommendation and most of the bowel preps and groups are when I'm talking about unnecessary ones, the high Rates and Nana Paris group will drive. The future dries future increase as they become multiple risk women. And so with a previous C section and then turned drive high cesarean section, this has been noted also, I think in Brazil and other context there is I need to talk about the national and refugee community and how to try to do policies together and to plan on. And when using electronic medical record, we can start noticing that there are some information not available. And so it's really, in fact, we can now have more valuable. So this is another encouragement to use medical records on and then finally need to talk about the clear recommendation to target 90 Paris woman toe. Encourage me back in those settings and to improve the quality of scare. And finally, I just want to say that when we try to do some off the quantification off, how much it's costing on a while for this high rise and C section, it's I don't cost around 78 million a purty, and that's actually is very detrimental for you and agency. That's fun. That hasn't a major funding cuts on that has have having to make decisions on how to use money for refugees that is decreasing every year. So it's also not it has, like there's a need to target. Ah, this high rise and C section toe also turn and this funding into being used other life saving, uh uh, thanks. Thank you so much. Thank you. Thank you very much then a very, very interesting data on refugees and in all those countries we just think of about ourselves. We don't even, you know, think outside to see what answer is happening around the world. So I think this is so interesting to see how you know lack off midwives is leading toe on increase like off OBGYN guys. Um, and of course, VBAC is decreasing all over. People are just not comfortable doing be back. Everybody wants to pull a cesarean reactions. Yes, please. I have two questions from online. We've been asked, Has this rising cesarean section weight lead to any improvement in outcomes? Not really, no. And I haven't assessed it. But it's not that I know. Then the evidence shows like, I'm I know and can talk about this much more, but, uh, they don't want to use an overall rate of 20% but above that overall, there is no benefit. Yeah, we also have a second question saying, Do different refugee groups into from Syria all use the same range of providers in place of birth or some some subgroups attending particular private hospitals. Could this explain some of the diversity and cesarean section rates with in refugee populations Okay, so under what contracts? Public hospitals. Rayna on order to do the city embarrassment system. So if they choose to use private hospital, it's not really shown in this data. However, refugees are really relying on on a while for those services. So that's important to know that if they use private, this is the image just talking about public. We're not even talking about what's happening in private something. So if you think this is bad yeah, my question is about Do you have any correlation with internal mortality, for example, here, too pleasant. I create our kitchen. I haven't done that. So it might be it happen. And I'm Is there any plan to do that may be actually, Actually, yes, I can. I have the date after that. So we can definitely talk about that because if you look at, I was talking to somebody from Egypt, which has a very high C sexually on this gentleman on land does hysterectomies for pleasant of previa. Poquito. He specializes in that, and that is directly reflective of the high C section, right? Yeah. So maybe with looking at the thinking, Thank you for bringing back to our attention, honey. I think globally. We used to say in Nairobi we don't even say placenta create an over the last one day of insulin. So many cases, I think it's all over. I think the bottom line is preventing that first cesarean section. Yeah, thank you very much. Uh, way have one more story. This girl. Yes, I think you, um, talked about the hyper right there in your screen was they were break down within your multi Paris previous section on that basis of hypergly the time. But yes, that makes a lot of sense. Also, if you would sing one or two or Okay, great. Thank you very much. Let's go around with. So we're going to move on to Catherine than lot who's been here? Very active. She's going to talk about the simultaneous over and under use of antibiotics at Cesarean section in Lawry's or settings. Findings from a mixed methods study. Well, come get three. So we've gone from call to quantum. How mixed So just a Zaveri Quick overview. Maternal sepsis is the third most common cause of maternal death globally. On the w h O. Commends that single dose antibiotic prophylaxis should be given prior to skin incision that cesarean section. This is to help prevent surgical site infections, the development of infection and sepsis. They also advised that prolonged antibiotic use is not encouraged is this contributes to growing antibiotic resistance globally. So I'm going to be talking to you about an aspect of my PhD, which is a feasibility study exploring the implementation of wh show guidance for the prevention of maternal infection. But just today I'm focusing on the specific guidance on antibiotic prophylaxis. This was a multi site feasibility study that was conducted in Malawi. We did this in to community hospitals and one district hospital. It was the next methods study quantitatively the use of antibiotics. That cesarean section was assessed by notes review at Baseline and then during a five months post intervention face. The qualitative findings were semi structured interviews, for which we did 33 then we had six member validation exercises. It was a complex implementation approach. We had a single day training for staff members and then multiple other interventions that were ongoing throughout Study phase Qualitative data collection was used to explore the quantitative findings and help explain the results and we analyze these inductive Lee member validation exercises with then used to help confirm or refute the findings that we found qualitatively on to add additional perspectives. This helped to make sure that the qualitative findings were accurate. It's possible with an integrated the qual on the quantity joint display. So overall there were 484 cesarean sections that were included in the analysis. In the baseline face, 75% did have antibiotic prophylaxis price skin incision. This improved to 94% in the post intervention phase and this was statistically significant. However, we also found that throughout the study, over 90% of the Caesarean sections were having prolonged courses off two or more days of antibiotics. So I'm going to talk briefly about the qualitative findings for why these prolonged courses continue to be given on. There was two themes that were inducted be developed. One was the study context, and the second was the characteristics of the intervention. So study context. These sites were working in settings where the national priority was to reduce maternal death, and that was their key. Amen. Their clinical practice. They were also hugely worried about the wash inadequacies in their facilities. So these were sites where, quite literally, antibiotics were more readily available than running water. They did not have a reliable source of running water on a day to day basis. They also were concerned about the sterility of the theater environments and the cleanliness of the wards. They were concerned about patient hygiene as well. This was briefly discussed yesterday, but ah, lot of the patients that were coming in to have cesarean sections had traveled for long distances on dusty roads on arrived, not freshly showered, which no fault of their own. But the staff members were very concerned that this would increase their risk of infection and that they would send something subsequently, go home again to dirt your environments and find it difficult to keep their wounds clean on. Finally, these were settings where they didn't have laboratory facilities. So although they knew about the problem of antibiotic resistance, it was not something that they could easily test. They didn't know the burden in their own community, so it was more theoretical concept, whereas conversely, maternal death was a lived reality more than they did see women dying from maternal sepsis, so they were very keen to prevent that from happening. Okay, then the characteristics of the end intervention. So these sites were very keen to use evidence based medicine, and they trusted that the evidence shows that a single dose of antibiotic prophylaxis with adequate. However, they did not trust that the evidence was taken from settings that were similar to there's. They didn't believe that the studies have been conducted insights that had the wash challenges that they were facing, so therefore they didn't feel able to apply it. There was also a lack of sight consensus about whether or not to adopt this practice. So some people we we did convince to give single dose of antibiotic prophylaxis. But then it might have happened that the following day, another healthcare practitioner who was less on board would decide that actually, the safest thing was to continue the antibiotics and would prescribe them again. So this is a quote. I'm just going to read to you what I feel, help some up the issues. It's an old building with no ceilings. Look at our theater the way it is here. It's not in good shape. It's not clean. enough. It's got a lot of openings to the outside environment, which gives room for infections to get in. We don't have the gowns, so sometimes we usually improvise, maybe even the things that are not sterilized. We didn't have electricity, even in our postnatal. We don't have clean well in in to cover these women. Those could be the issues to think that maybe it should be a routine thing to be giving antibiotics even after procedures. So I just wanted to raise this that and we might think that this is a rare problem. But actually in 2019 26% of global health care facilities were found to not have a basic water service, so this problem could be more widespread. So in conclusion on. And this feasibility study found that there was a simultaneous under use on D over use of antibiotics in the low result maternity setting on antibiotic use. It may not be able to be addressed without improvement in Washington structure in these settings on it's David presented yesterday. Some of this work is being used to inform a small part of the at sepsis study, which is a nasty T ongoing. Thank you. Thank you very much. Katharine. Yes, Against Andrew is already acting Andrew. Thanks, Cathy. And that was great. Andrew Weeks, the I I should know this, but they How do you answer the criticism that the studies which have been done showing one dose is adequate, have not come from these type of settings? I don't know where the studies have come from, but my guess is that they weren't from these settings. I I very much sympathize with the people in those settings. Do you know what the systematic review show? Yes. So the systematic reviewed were conducted in low middle income countries, but they were mainly conducted in tertiary referral centers. So the total referral centers are likely to share some of the same challenges. But the district community hospitals probably experiences on a greater level. On it was a one of the themes that came out of my PhD was that perhaps we need to be focusing more on research in these places that are probably harder to do research in. But they face different challenges. Yes. Let's go on to go online platform Wendy Grams coming online and asked our women paying for antibiotics in this setting. In other countries, overuse of antibiotics is a driver of health related debt for families. So I think sometimes women do pay for antibiotics in this setting. It wasn't something that I looked at, so I I'm not gonna be able to answer that conclusively, I'm afraid. But I know that it is a is a problem. That is experience for a lot of families. David. I thought it Malaba isn't maternity services taken care of by the state? Yes. Yes. So in these hospitals events bottoms are available in the hospital pharmacy. They would be in provide it for free. But if they're out of stock, then they haven't seen her. I go out today's PSA. Yeah, uh, thank you very much 0.3. Inform your presentation. Well, I think I'm a culprit here because I all also get five days, one week and two by tech poster. A cesarean section for all the reasons you have permission. Uh, I mean from experience, if your bones, they come back with a POSTOP sepsis, even with the antibiotics, as you're you're still have to, you know, like a post operative word Subsys. I mean, as you said the patients might come a boring that even though, ah, you know, pain. I just septic at the beginning of really going to get the organisms out. And, you know, sure, off the, you know, step a sterility of the, you know, equipments that he has it on. I work in a teacher husband, but we still don't have a running what time? So the bird buckets first wish. It's so weight again, you know, play up on Tobi Tick as a single dose. I actually insist that, you know, to get me on antibiotic before I make a decision, but I still follow it up with the, you know, five, just one week antibiotic and then, in terms of, you know, the cost us will have from maternity care in some settings. But at the end of the day, the antibiotics might not be available, so the pressure's still have to pay a new teacher hospital. Why? I walk. It's not free. So it's on the patients, so it's a pain for the antibiotics. Okay, thank you very much. We have another online comment. Yes, we have a couple, actually. Katherine, house us do that any of the qualitative responses discuss concern about Zuno. You know, tick infection? No. Uh um also from Helen Alavert. How receptive with staff to doing the giant cleansing prior to surgery. This was actually another part of my PhD that we were feasibility in testing, so haven't presented that today, But it is a wh show commendation that vaginal planting should be done prior to XYZ air in section on D. And this wasn't being done initially in the sights, and it was quite challenging to implement for a number of different reasons, But by the end, we had to manage to improve up, take the last one. That's it. Okay. Um okay. I think just take those two and then we'll end. Okay. Thank you so much. Um, just putting the question, Don't you think made the coke here alone is no longer enough. Enough for, like in prevention off sepsis. Because I come from a Lhasa, a low income sitting as professor has said. So this is very prevalent. If you don't prescribe at biotics, they would go ahead and prescribe it to themselves, or they would want around at least of find. Take it. So don't you think interventions only as Medco. Uh, proficient is not only enough. We need to add more to patient education and invest it in most of that. Empower them into other ventures that they really understand. And also they can play on, have that confidence that I can really hell with other positive health living styles. Clinton's and 80 see nutrition and you to see 100%. Yeah, hopefully agree. Okay, the last one runny. So someone question is about about research, as was mentioned, pregnancy. Where has this research setting being? But we have people were doing international research. Global research over here on on my plate is to try and get local people to pay first orders on some off these purpose because very often, they they have the patients, they have the workload, the other research. But they don't get credit for it on, but they're not very good at writing so they can present abstracts on. They don't get the exposure that we are privileged to get. So can I make a play? But we encourage people to do research to write papers. I know someone that has been done investment thing, What we need to do it better on try and get them on to those papers so they understand the importance of research. That's part off your agenda is the r c e g president of thank You very much 0.3. We're going to now move. Want to an online presentation? Family Hawker from the Sun, Your Research unit Stroke University of Liverpool experiences off induction off neighbor methods in India. A qualitative study Is she on like Yes, I'm here. Great. Welcome. Hello. Can you see the slides there? Hello? Can you hear me? Yes. So today I'll be talking about the experiences of induction of labor methods in India And this is a quality of study alongside the misoprostol, or oxytocin for labor induction. RCT names to provide a platform for women and clinicians in the trial to share their experiences. Most of the current quality of data is based in high income countries. On there were no current studies looking at induction method preferences in low to middle income settings. Okay, so the aims of ass today were to explore patient's perceptions, expectations priorities understand in, and concerns around induction of labor prior to induction to explore the experiences, acceptability and satisfaction of patients. Post induction on any difference between the two are CT groups onto better understand the feasibility, usability and acceptability of the different induction regimes to healthcare professionals on potential barriers for implement in the research findings into clinical practice. So the money RCT clue did women undergoing induction for hypertensive disease in pregnancy, all of whom received oral misoprostol and then were randomized to receive oxytocin or further mice possible after ruptured membranes. So the quality of study Que Molly was based to government hospitals. Inequity India. I'm very sorry for the noise. A building fact, a moment at the hospital. So it's based in that could injure and included women recruited to and stuff involved in the delivery off the Molly our city 53 7 structured interviews were warned both before and after induction of labor, as sometimes both on it was done by a local research interested in morass. You're ending and then translate it into English. And eight focus groups of doctors, nurses and research assistant's involved in the trial delivery. We're done. We use an overarching grind, a theory approach on framework analysis, data interpretation, mostly because of the research teams diverse backgrounds on the large volume of data. From our data, we developed four themes. Induction of labor methods, induction and childbirth, one small part of the wider experiences in life. Key moments in the job experience on impact of the study. So, you know, talk about each of the themes in more detail, starting with induction of labor methods. So induction was commonly performed, but only oxytocin had been used. Following ruptured membranes previously on it lead to a lot of concerns over my PSA prostate will switch specifically regarding hyperstimulating in meconium and fetal. Disparate fetal distress, especially a proper monitoring, couldn't be done, and clinicians felt strongly that women would actually prefer the IV route of oxytocin. But it wasn't echoed by the women in the study, who often preferred the pill because they like the mobility in labor. The all wrote on avoided needles on those women who did prefer saline or oxytocin felt that by going into the veins it would work quicker. But it wasn't always possible for women to choose that preference, as they'd only experience. One method felt the doctor should Jews that both drugs worked or they didn't plan on having another induction, so it wasn't relevant for them on for over hers. It wasn't possible to choose it for every woman, because every person is different. So induction and childbirth of one small part of the wider experiences in life family were really important to women in all aspects of life. But especially in pregnancy, where the whole family is involved in the experience on the baby remains the main priority for women essential to their feelings and worries. With some women feeling it didn't matter what happened to them as long as their baby was safe on the baby underpins the women source of round induction. And although natural work would've being preferred by most women before the induction, it wasn't understanding that it would be done for there. And the baby's safety on what ever happened in labor. What matters is there, baby. It's a chemo mints in the child that's experience. Vaginal examinations were discussed unprompted by many women as causing fear, pain and embarrassment with many describe them is the worst thing in the whole induction experience. Some woman did feel that it was made more bearable if the vaginal examination has been explained properly before hand an induction involved agonizing pain and lots of waiting. So women expected to Beth in and leave Earth. But the experience playing with much worse on there, waiting throughout their experience, is well for the pain to start. For the pain to be over on, most importantly, to meet their baby relationships of conditions was also very important and could be positive for women and creating a sense of importance by being careful well, on valued, my clinicians give them the respect to try for a normal delivery and high with for some women. Actually, they had very negative experience, and this would take my experience so much that they couldn't recall their experiences without becoming upset. So impact of this study women felt it was important to be interviewed, and they felt good sharing their experience is for the benefit of others. There was also a notable difference in the language use by clinicians of counseling from not being a expecting women to be able to understand, even with good counseling prior to the trial, to accepting that woman could understand if we gave property tax Lindholm with care and there was a reluctance to implement the trial protocol due to concerns over misoprostol when giving more than three doses on multiple conditions. Quest Maximum number of my spots A which could actually be given oxytocin, remains throughout throughout the more comfortable will conditions who accepted it would always be reluctance to change to another familiar regime. I did feel that with more supportive evidence in the future, it could change so conclusions from our data. There is a disparity between the importance placed on method between four induction in between clinicians and women on conditions felt that would be a dissatisfaction with All right, so But it was no. I could buy the women in the study who were more concerned whether the route would be safe and effective with their babies well being being the most important concern. Some clinicians were reluctant to implement the trial protocol over concerns about misoprostol on the label. Induction has failed early on there for growth of cesarean section. Key moments could negatively or positively affect the birth experience for women, but could be within the control of conditions such as good explanations to reduce the around for journal examinations adequate analgesia for one inning. But I have great in positive interactions with stuff. A woman can understand what we need to know about induction if they're given the proper counseling and they'd want to share their experiences when asked. Women should be given this opportunity and involved in the research which is going to affect them as they finally, some take home messages for us all on implications on our practice. Induction counseling should be given the time, effort and care to ensure women are informed about the process. Vaginal examinations were particularly negative for women so should not be used unless necessary. On effort should be made to reduce anxiety through good explanations so women know what to expect. Even with pragmatic trap protocols, conditions can be reluctant about implementing new raise use, which I have ingrained concerns associated with them. But by having quality of alongside studies, we can not only explore these concerns and understand the study implementation, but also provide insight into the experiences and priorities of the participants in the study and how we can improve these experiences for them alongside quality of studies should become the norm as they have a significant role in explaining the nuances in our CT results on different our city outcomes. Thank you so much for listening. I'm happy. Take any questions. There is a bit of a whistle stop tour, and I'm sorry if there was some background noise as well. Thank you very much. I think in spite of your little background noise, be hard, you doing well. And that's the reality of life. The construction going on. So you have some comments on line, please? Was the dose of my the pasta for induction of labor. So it's 25 micrograms every so every two hours, which was different to what would normally be used. So that was also brought up by clinicians as being uncomfortable for them because they've normally used it more spaced out than what we were asking them to. So every four hours, every two hours, as opposed to every four hours, can I just add are ask, Was the solution or was it the 25 microgram tablet tablet size? And where there is Andrew's in the audience can correct me if I'm wrong, but it was a tablet tablets, the misoprostol pill. Okay, don't you Thank you. Um, comments here. I think what we've seen so clearly is that it's that interaction with our patient. Me. When we talk to them, things are so much better. We just, you know, imposing upon them what we want to do. Get a Q out. We want to invite us, but we don't have time to explain. We do a vaginal exam, but we don't think the time to explain. You know what is around it? So I think bottom line is we need to be talking. But then they say we don't have time. We have to feel. But providers, too many patients. Any reactions from here? Okay, fine. So thank you very much for that very interesting presentation around the clothes now going to the last presentation for this session, which is the It's an online Sorry. It's It's here. It's in person The association between the density of obstetrics and gynecology ical doctors and Cesarean section rates a country level data analysis in Sichuan Province, China. And we have a man you know, you from the London School of Hygiene and Tropical Medicine presenting to us here. Welcome. Hello one Today I will be sharing a recent study thing association between the density off doctors and C section writing China It's a county level data analysis in Sichuan Province in China, the C seven C seven section writing China is very high on days, a large perfect variation. The national rate was 35% in 2014 and ranging from 4% in T button area to 60% in northeastern China. The healthiest um in China encourages more C sections are intentionally. China has very few meter wives, almost over's take sure, um, China has very few midwives on almost over's on but take take place in public hospitals and our thumb by obstetricians. Hospitals received marginal financial support from the government on they're allowed to make money from the services they provide it based on people service payment mechanism. A same time. The price for C section is about tries the price off Madonna delivery, so C section is available for most off the person China on. But there is a financial incentive. Well, the providers to do mostly sections are positive if that's the provider factors my country use to overuse off the sections in China. So this study it's to examine the strengths off association between the density off tiny doctors on do the C section Rates off Draws into the time in 2014. Already starting a surgeon province, it's in western China. It has 181 counties in 21 prefectures. We got a tough for 2040 on. We have variables in house system factors like the density off Johnny doctors person flavors. Um, education off a journey. Doctors County average travel time to the nearest hospital, um, on social demographic characteristics, including the rope percentage Judy people Capita average year off Schooling. The population average year of schooling. The person rate under the outcome Variables dissection rate. Um, that's is that, uh, they are about 700,000 libraries in the Trump Province in 2014 on the overall C section raises. A certain 39% also is large geographic variation from 3% to 74%. The C section rate is higher with her. It is higher in eastern time, then westerns, the time in 80%. Off the counties, the C section rates is above 20% but also in shelf counties, the C section rate was below 10% On all these countries, that's in Russians. The trial I'm such are has a best huh has high density off of genital doctors, but they have low level of education course amount of amount of counties. There was a median off 12.3 up Johnny Doctors percent Leiber's on with also with large very variation across counties. Um, only a median off 17% off this object. Doctors has a bachelor degree. I'm I'm not going to go into the details are models. One thing to mention is that we separate because counties are affiliated to perfection. On also one seeking care woman can, um, woman may travel to the neighboring counties or the prefecture centers to for delivery. So way we accept the association might be 50 for between countries and wheezing countries. Though we get, we got separate estimates off the fact for who? Teaching fact in between Prefect er on the wheezing prefect er oh association. We found that we found that incision province where the C sexually is is already very high from where they're more doctors, they almost there Ah, higher cesarean section. Right, Um after just for comfort commanders including thie education off any doctors, access to care and the social economic characteristic cancerous ticks Ah, doubling off a density off object doctors in the pre factions. It's associated with 11% point, uh, highest. It's actually getting all the countries weeding the pre factors, given the larger operation off density off object doctors into trying a tablet off density off China doctors is not that much. So. It's a strong than a strong positive effect. So in summary, we found a substantial overuse off this section in most of counties in September Means and also a matinee. It persisted in several roll counties. We also find ah, hide and steep of low educational level off object doctors, Um and also ah high, a positive association between the density off attorney doctors in pre factors on the C section race in the counties, which is independence off the education, off up Johnny doctors and the social economic that characteristics. So our study suggests that in because that's ah heart health system, where obstetrician predominantly provided delivery okay, may fuse. Use off on C sections on a financial insensitive for C section could be crucial factors driving the use off C sections. Um, in this in a setting like the increase in the number of objective off surgery care providers, even if with a low level of training can lead to Hi. Hi, Leslie. Section. Right. Thank you. That's all. Thank you for everything. Thank you very much. We have seen that there are several things contributing to this increase in cesarean section rates, comments, questions. Yes, from online platform on. Thank you very much. Futile. I just wanted to clarify when you were talking about the obs and gynie doctors, you mentioned that the level of their training varied on that some of them had only a bachelor's degree. So are they will qualify doctors Or some of them? Sort of, um just with health care in China, not only doctors with a battery degree can become a doctor. Become off obstetrician doctors with a lower level, lower level off education can also get a license for off Johnny on, obstetrician, with more years off, walking or training in the hospitals. But, um, what about my my exposure here, intestine off Geodon does do include some doctors that do not provide delivery care, including those abstract on off situations that did not do delivery. And the guy on, uh gi Oh, gee, white. And they do not to deliver care, so Yeah. Um, say they Sorry. They are off trying the OB situations with very low level off education who do delivery care so they can only know Caesareans, but they don't have normal deliveries. They do. It does. Okay, we have an online question. Have you fed back your results to the province? Health managers and providers. What is their reaction? And is there an appetite for change? Um, I haven't. Is a going study. I have. Um Yeah. Well, I will do. I will share my results on the population pain. Um, Chinese comments are aware off the off the situation actually on, but they are some implementations and talking at provider side trying to reduce the overuse of C sections. Um, yeah, recent. Yes. And there is a job in hospitals and regions with very high level of C section. Right, uh, in China. Thank you. Okay. Thank you. Anything. Okay, So I think let's give her a round of applause, So thank you very much for being very attentive and interred. Active participants, the presenters We went all over the world. We went from China, toe India too. My lobby Palestine run, uh, presented global. And then we had the international field here. We had our see a GI. We had wh you And then we had the patient provider. Very interesting presentation from on alli and, uh, yes, mean Onda. Did you notice that this was all female group? Yeah, except the overall chairman. So we've taken up a bit up all the time or the lunch break, but I think we're still doing quite well.