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Okay, so starting the afternoon session it's my great pleasure to introduce Professor Hadi's a gala dingy who will be charting the first session this afternoon. Head is a is the founding director of a CPAP ah World Bank funded Africa Center for Excellence to Strengthen Interdisciplinary Evidence based policies in West and Central Africa had is a has experience off working and continuing to work with over 20 studies funded by various organizations like wh oh Bill and Melinda Gates Foundation, McArthur Foundation. Ah, Fiego. Um, I see the list goes on. She has trained and mentioned over 600 medical students are post graduate students, as the less researchers to date on has got numerous publications over 100. She is very experience in working with large bodies like W H O U S a. D. UNICEF, um FBA amongst others. She's really an inspiring role model for women being the first female obstetrician to qualify for her region and to see her do so much. It's being absolute motivation for young researchers she or in addition to being a fellow off the West African College of Surgeons and are see Woody. She also has a diploma from El Shtm on D um, Master's from University College, London. So please join us a visa and I shall give the family over to you Distinguished. Yes, distinguished. Ladies and gentlemen, very good afternoon on. But I want to thank you know, the Globe conference organizers for inviting me to this conference. I've seen so many friends and, you know, colleagues that were working invaders studies across the club. So thank you very much. I think you know, the morning session has actually introduced this afternoon session. Uh uh. It's very clear that we have a problem off, you know, either too many or too late cesarean sections on somehow we need to prevent unnecessary asses there in sections. And that is, you know, the the thing off this afternoon session on about this because I great speakers. So we're going to be here, and I think a lot of them are Here s so they're going to be a physical, like, physically here. But in case there's any one that is online, I think will be told along the way s Oh, it's my pleasure, actually, too, you know, start with the keynote address on the keynote address is going to be given by Professor. So don't from university off central, like ensure you okay on. She's going to be talking about promoting appropriate vaginal birth evidence based strategies for health systems on healthcare professionals. Uh, let me see. But it's a so you're very much welcome. Um, just a second, uh, to introduce you, you've been walking, you know, 15 years working as a clinical research midwife. Um Then in 2000 and one, you joined the investing college like ensure where you're now a professor. She's now professor off midwifery studies. How main research focused is the nature off and cultures around physiological, normal birth. And she has been a member of the Technical Walking group off the wh er until it'll intrapartum postpartum ultrasound on optimizing cesarean section get lights. She has published over 105 anti a reviewed papers on several balls she has under taking research using a wide range off qualitative Onda. On was a call after in three landsend, Siris, midwifery, stillbirth on optimizing cesarean section. How most recent completed study has examined the impact off pandemic on safety and personalization in maternity on, You know, it'll care in the UK. I'm the Netherlands. She is a core investigator on the current G. P s three. Trial on on the forthcoming See Safe. Steady. So we're going to be together in the CCB's. Yes. Yeah. It's great to have a professor. So with us. Thank you. So I have a lot of slight My okay to take my whole 30 minutes. Is that Yes. You have two minutes trying to be shorter, but I have got a couple of sand files I'd like to play if I've got time. I do speak very fast. I'll try to slow down. But if I'm speaking to fast for this this money Put your hands up, okay? And I'll try and slow down. So promoting appropriate for journal births on I think the first question is, Are we talking about the journal birth? Any cost on this particular post is a social media post from a woman in the US A. Basically as you can see, it says the enduring and unmedicated natural birth was one of the worst experiences of my life. Dramatic, excruciating, horrific. When you read the actual story, however, what happened before she had her vaginal birth was a range of interventions that would not be seen as physiological if we were to look at this is a physiological process. So one of the questions here is Are we just talking about any vaginal birth or are we talking about specific John A. Veress? This picture was taken in Bulgaria. This one has given her consent. She believes she had a good birth, but it the same possibility could be raised about alternative ways of actually doing both labor on birth. And that's this issue about being associated with positive birth experiences. And we've talked about this in terms of positive experiences already. And this is the kind of struck line for all the wh show until it'll intrapartum postnatal guidelines. As we know, this picture is also taken in Bulgaria. So this is taken by the same team that were originally working with that first woman or in that same hospital on they have nice set up for us alongside person to the first one in body area, where they're changing the way that the journal birth is is presented and organized, and I won't use we're trying not to use. We have managed, supported and I think It's also quite interesting about to think about how we link This was safely because very often, certainly in the UK and much of what I'm talking about is a European centric perspective, so because that's where a lot of the evidence is. So we need to make sure that that's translated, obviously, but the tens of a dark autumn And I did find it quite interesting that the figure well patient Safety Day last year or a Z, the issue of physiological labor and birth as being a safety concern bringing those through two things into into a synergy are supposed to opposition. And I also think this is an interesting study, too, which was looking at the outcomes Matilda mortality in It's a sub study. Secondly, analysis of a larger study, maybe people here who involved in this study, I don't know. But the interesting finding was that they Theo only clusters in which they were lower levels of maternal mortality, where the ones that both did Imach well and is logical birth Well, so both on which again, I think it's where we've been going this morning. So I would like you to listen to this, though because it's also psych rays into the idea of assisted vaginal birth, which is a bit more complex area, as we know from some of our reviews that we did with with an appeal on others. So if you could play the cycles, it just is before you do it. Explain. This is a woman Nikola is her name on, but she had a very complicated first birth, Jonah Birth, which required extensive perineal repair. Um, she came in today with this time with a midwifery continent, carotene for women who had complex problems previously not necessarily complex, physical, that social and also some physical on she was she's having her baby in hospital on the story she's telling, is what happened when she got to the pushing stage of labor to the effects of second stage of labor. Um, and she finds you couldn't push because this history was in her in her head. So she's going to talk about Anita. It was the case holding mid wife who was her continuity midwife. We should do all the way through. And Liz, Mrs Martin Dale, who is the doctor involved. So just play the story of it. If we can 100. A very good job. Interesting channel. Too much today. Okay? Yeah. Contraction had trash after that. Just I tell you what you think you weigh way trying to, Charlie. Oh, she's having some pain and try it way they describe Wait time extraction. It's been resting excruciating. I just kind of snapped in contraction. Oh, sure. Uh huh. Respect just got shipped. I'm really whole that. I'm sure I'm I know what she has for sure. That was 12. So I'm back with these. You have to be a teacher way. I didn't check that instructions myself on My God, I'm Mr Time for food back. But that's what it was like that was going to do this. What's rational injection? Rest contract. You need any suture? Um, anything. You just are quickly, too. Great. Fabulous. Carrots just put you just let it just put it that way being. And when you sure it was because of the way? Sure. Sure. Something today That bash, I, um So that's what a positive instrumental birth could be on. This is just actually, this is a mock up. This is less Martin guitar. The obstetrician kneeling on the floor on the nature of the midwife holding the to keep in the middle of my guys being the woman. But this is the position she actually adopted. So sometimes it's a buy innovation in difficult circumstances. So I'll let you just read this. This quote this is another case, which is a woman, as you can see you had had previously. She I think she's being induced for the fifth time on had complex spirits with the other four on this particular one. She wanted to be in water. I'm going to show you the picture and you'll see it's quite a whole picture. It's an old NHS bath. It's all stuck up a sticky tape. You know, it's not a nice, beautiful pool in a lovely pool room. You know, it's I know that you know water birth isn't available or even water from washing is not available in many resource in many places. So it's obviously still something that isn't even to be dreamed up in many settings. But what happened in this case is that they all work together with this woman, and again she's given permission. This picture to be shown they all work together with her so they could. Actually, the induction could be carried out. Are they what they did with electrics? But they did talk. Electrician's reduction could be carried out as the woman wants it to be. And she ended up with a spontaneous vaginal birth, which is you saw from the previous quote. She reported us again. You know, in excellent experience. So sometimes it's difficult to do if you are the only midwife or doctor and there's 21 in labor and you're running around like a blue us, whatever on, you have to deal with emergencies, obviously. But sometimes the things that that we need to do a base impulse curtains to make to enable privacy or just getting people and to the bed and leaning on the bed, you know, the bed could be the the resource. Really, you don't need anything else. Sometimes I think what we found in our in our reviews of what matters to women about childbirth as well as much as two women women about pregnancy was that actually giving birth to a healthy baby did matter. This is in the systematic reviews. We did the wh show guideline in the right environment that they didn't want support, but they did. Most women do want if it's a physiological labor and birth, However, they also acknowledge that that doesn't always go the way they wanted to. And they're happy to go with the flow if they trust, Their caregivers are doing what they're doing for their own benefits, for their benefit. Not for the organization of benefit, well, for money or for whatever other reason that they might be doing it. Sure, this is an old study from Carol Kingdom is a PhD. I don't think that point on here so I can't show you. Yeah, anyway. But if you look at the top line, this is in the UK Women's preference for vaginal birth starting are booking on going until nearly term, and you can see how it changes so that by the time if women have had a successful pregnancy, they feel good about the pregnancy by the time it gets to term. At that point, when that when it was published, which was about 13 years ago, about 80% of women in the UK anyway wanted a physiological labor birth. Now that's quite a counter narrative to the current debate is going on in the UK at the moment, So maybe it needs updating that. Still, I think it's worth holding onto on at the recent CQ. See report. This is again a UK England publication basically looked at his experiences. They do this regularly on the even underlined unassisted. For John, A birth consistently reported better experiences. Obviously, that's confound us here in a women who need interventions often have other comorbidities, and that isn't gonna make their experiences as positive is maybe it could be, although of course we can make it was positive is it? Can be. But as I was illustrating with the two previous cases, we can make a birth as physiological. It's possible within about that woman wants and needs with quite minimal resources. So I was very intrigued with some of the conversations earlier on about What is it just about training? And obviously that was a rhetorical question because, no, it's not on. So I just want to run through quite quickly. Some of the things that might work from the evidence and some of them are lasting the evidence of more from common sense and to think first of all, about the socioeconomic, a model which basically says You need to operate at all levels of a system to be able to make a difference happen. And training is kind of quite low down, but still important that the rest also matters are going to come later to the behaviour changed model because this is assistance model. But the behaviour changed model is a psychological individual model and each left with the system. Individuals make the system operate. The system is no independent of people, so we actually have to apply both models. It seems to me this is just for you to know about. So this is an American California Inc. Which is a whole range of techniques and tool kits to support physiological labor and birth reduces their inspection on then this is the protocol that's been put together by W. H 04 sites that want to reduce optimizes there in section. And it's a very useful tool that people can use and work their way through if they want to operate a systems level to make a difference. And then, at the practitioner organizational level, I would say the first thing is we have to really understand physiology. So we were all doctors and midwives talked about the three piece on the 1st, 2nd and 3rd stage. But of course, that's actually not have is allergy works. In fact, is a dynamic interaction between the mother between the mother and the baby, which starts in pregnancy goes always through labor has consequences in the in the early postnatal period on longer turn on the stages and phases or fluid. They often don't operate in this in the way that we're taught. And we really have to get back to understanding some of this man. I think you probably can't read this like, but this is an example of some of the neuro neuro hormonal back puts that happen during labor and some of the physiological or the symptomatic signs and sit and symptoms that we may see that are expressing those newer hormonal and, uh, you know, uh, outputs on. Of course, this is highly simplified. It's much more complex than this, but we really have to get back to understanding what is it is going on in the woman's body that we are either enhancing or getting in the way off if we do. If you do interventions for the base of standardized guidelines, population based under guidelines. What to be doing to the individual ones physiology. And this is if you want to follow that link to so but please a report on the neuro physiology off pregnancy and birth. It's fascinating, very in depth, extremely in depth. One of the things I picked up from this is a something isn't the Physiologist. This's idea that oxytocin produced so exogenous. Endogenous oxytosis are exactly the same chemical compound, but endogenous oxytocin is produced in the maternal brain is what is in the tissues in the fetal tissues on exogenous. Oxytocin cannot cross the material brain barrier, so the you're under crying. Benefits that the woman gets from oxytocin produced by the brain are not as pronounced. If she's getting external, she's going exogenous oxytocin. There's a whole range of other consequences for fetal neuro protection as well that are worth reading about on. Obviously, science is only just beginning, really, so we have to get close to the woman perception. Touch, smell, sound, how she smells, how she feels the temperature of the skin, the kind of how much sweat there is, how dilated pupils are, which tells you a lot of oxytocin output or all critical, but we do not pay attention. We look at the upper the CTG, but we don't look at her. And these are things we really have to come back to if we really want operationalized physiological birth, how about the mechanisms where we get these kinds of drawings in textbooks? Very often or fine. It's just flat on her back. But actually she should really be in a forward leaning position, especially towards the end of labor. That's the physiological position on if you turn the turn, the diagrams right, and you get different, the mechanisms different. The baby acts differently in those positions, but we don't teach our students this on. We don't teach ourselves this either. We know that we know that evidence on mobility and positions and this is, ah, the latest Cochran review, which basically shows on advantage for, you know, a mobile, Um, during labor. Or at least, I mean it's not. You can't we can't say to you and you must be mobile, because that's just about it saying you must be flat on your back. The idea is to let women mobilizing the way that their body is telling them, because that will be dictated by the interaction between the mother and the baby on what's happening to their pelvis and everything else. A study published by her Doland that I was involved in looked at first in various different settings on in the home setting. They found them changed position, leg, usually always towards forward leaning one. If she wasn't directed on. There's various tools that could be used to help with this. This this book of the labor progress hum book is particularly useful for labors that look like they're becoming this dosage. It's very well with looking at that. It's got lots of hints and tips in it. We need to recognize him in variation. This was, Ah, uh, published by Barclay Obstruction on 30 ones. What's that? Nearly 100 years ago. We don't know how long labor is is basically what they said on the nature to textbooks. Middle three textbooks separated by 20 years or so, so less than generation in which it had gone from 15 to 20 hours a day. Average length of labor to 12 hours on the first for a prime up and then in 20 years later to 11 hours. So it is not possible in evolution in terms for the normal physiological length of labor. To have reduced that much within one or two generations, simply not possible on miles when she talks about it says, is to do with the use of oxytocin so that actually we rare fight the normal length of labor. Because of our overuse of oxytocin, she said, you've heard about the Neighbor Care guide. That's an extremely useful tool, which is about what has been called slow but normal labor. So labors a wrestler than usual, but they're not just, oh sick. And this is what the idea of the care guide, along with companionship on be other elements of that you've heard about. So that's a very useful tool. We need to know more about research. More about Logan birth guidelines. Hopefully, you won't know about these, and there's lots of those about supporting a logical apron birth environment. Now this is probably more relevant. A lot of studies that from high income countries, but I know there's interest actually been thinking about this in low income countries to that, actually, women in their own environment. So these are comparisons between different birth settings from UK data are much more likely, are equally like you have a good outcome for the baby, more likely to have a better outcome for the mother unless it's the first baby at home, in which case is a slightly increased risk of permanent mortality. But what can we do to make the hospital environment as home like a possible? So those benefits could be transferred into hospital if that's where women are, there is data to show that induction of labor reduces is there in section from randomized trials. This is the latest review. It doesn't include date on spontaneous vaginal birth. So it's Caesareans there, looking at reducing Syrians, not the same as increasing spontaneous birth. But remember these numbers things, I'm telling you. It's similar to that epidemiological studies and hope. Operation studies don't seem to show the same reduction in Cesarean, so it's a It's an interesting area that needs more research. I think we don't know the long term consequences either of induction. So if we're using induction to reduce his area, because a word about the long term, every genetic and microbiome of bio me or consequences. What happens if induction houses long term effects as well? We don't know because he looked at it. So we're using one intervention to replace another one without knowing exactly what's going on. We come into the end. Okay, Okay. So continue slavers supports. I've been afflicted with these because, you know, most of these Medrol is doing good A free or useful continuity. But if we care, we know about that intermittent fetal monitoring we've heard about these all associated with that understanding. The difference between physiological and pathological pain is critical. Knowing when to sports went to act when to refer. Also critical Addressing fear, particularly fear of litigation is absolutely critical with unfair violence in some countries as well. Some countries where where partitions have been beaten up because of because of adverse outcomes. We have to address this. I haven't got time to show you this video, but I could give you a link if you're interested. So we have to make my mind closing remarks. Now we have to move from fight flights to attend and befriend. If we want to support physiological labor and birth, we have to understand the physiological impact of social support. So what happens if we have good social support? This is not from a maternity study, because from a general study you increase a whole new decrease. You increase the recovery from illness on infection. You increased opioids and you increased not circular cell activity. All important for women who are in the postnasal period. Have had that working with staff of women. You've heard about this already? This is probably quite a deck work on, then finally, we have to change the conversation. We had to change the conversation to make what should be done. Easy to do. So this this is the behavior change model, which I was summarize very simplistically as Make it easy, normal. And it gives me a benefit on whatever you do to make it easy. Normal, and it gives me benefit. People will do it. People weigh have to work about every love with that socioeconomic ecological system. It's a couple of final, So final quote Thank you very much. Uh, prophecy. It's too. Um, I'll not attempt to summarize what she has presented, but I think I have like, three key message is as an obstetrician when I got from your study, I mean, from your presentation, um, one is that really Very few people will have the experience right now off the you know, Nicholas. I mean, it was a great experience, and she was very, you know, thankful for the experience just had. But unfortunately, they're many women outside that I don't have that sort of experience. But what is important, as you have said, is safety on the well being. So I think that is something we should keep in our mind. Safety is number one. If normal birth is safe. Safer than we should go for a normal breath. And it's both for the mother on the baby. You shouldn't forget about physiology off breath as well as neurophysiology. I think it's very important you reminded us. You know, on that on. Then we need to look at the woman, not just look at C. T. J. I think that's also an important message that I got from your presentation on. Then I think since morning would be talking about, you know, let the woman doing what she wants. Let us not insist. She has to be on, you know, some time position and a lot of our women, even in Nigeria, run away from, you know, hospital because they don't want to light up. They used to swat, see, and then we tell them in the hospital You can't spot you can't even, you know, put your legs on the floor. You've just got to lie down flat on the back. So we need to allow women to do what they want in terms of mobility in terms of position on. Then we should always remember that you know, there's a lot of variation for women in terms of labor that one hour one centimeter is no more the rule on but we've proved it with, you know, the LCG. You don't have to say the woman doesn't progress once intimate a power, then we've got two inducer and then at the end of the acidity in section, so make it easy, make it normal, and then we'll review the benefits. I think that's so Thank you so much for your presentation. We need