In module six, we delve more deeply into care philosophy. In particular, an approach to care that supports biological, social, and cultural processes limits intervention and strengthens the capacity of individuals and families. In other words, the philosophy of care that is salutogenic, focused on building health and well-being rather than pathogenic, focused on disease and disability. To start this off, we have the extreme honor of hearing from Dr. Soo Downe, professor of midwifery studies at the University of Central Lancashire. Contributor to The Lancet series on midwifery, as well as an author of numerous publications with global relevance that relate to promoting and protecting the physiologic and psychological needs of women. To quote Dr. Downe, if we get birthright, we get the world right. Starting life with a positive birth experience sets the scene for the best possible future well being for women, babies, families and societies welcome doctor down an I will hand it over to you now to walk us through some of your work on what women need in their maternity care experiences and what we mean by a philosophy of care that supports biological, social and cultural processes. >> So I want to talk here about what matters to women and specifically to raise this issue about both/and and not either/or and what I mean by that is that in many parts of the world, there's become that kind of polarization between either safety or personal experience, either mother or baby, either doctor or midwife or nurse or whatever. And it seems from the work that we've been doing, and it's actually also common sense that generally speaking, women don't think about growth in those polarized ways. And one of the studies that we did that brought that to the forefront for us really in terms of research was the World Health Organization asked us to look at all the quality of evidence that exists around what matters to women about pregnancy, and this wasn't what matters to him in about the care they got. It was a kind of phenomenological question. What is it about pregnancy that is important to women independent potentially from of care providers? So we looked at all the literature ever in the world in every language and we basically found and it's not really a surprise that women want need and value a positive experience and I put birth in brackets because you'll see it's similar of birth pregnancy in our next study. Basically that was maintaining physical and statistical maintaining a healthy pregnancy. Obviously, an effective transition to positive labor and birth and then effective transition to positive motherhood and what was interesting here and again not really a surprise to many midwives is that women don't think about pregnancy birth, postnatal period in chunks. They think about it as a whole journey and we're now currently in fact finishing some postnatal reviews for guidelines for WHO and then we're coming back to the motherhood question. At that point, closing the loop, if you like. But the reason I put Maslow's hierarchy here, which is this triangle that you can see, is that we generally focus on safety and political needs down here in most maternity care systems around the world. And in fact, what our data show is that women want far more than that. Of course, they want safety, that's like, duh. But these other parts are also critical humans, positive experience of childbirth, not just at the time, but going into the future. And in our study published in 2018, which was the review of what women want around what matters women around childbirth, as you can see, similar things came out healthy baby, obviously. Practical emotional support, a physiological, labor and birth. Most women want a normal birth, but they accept that things that don't always go the way they expect, and happy to go with the flow as long as they feel a sense of understanding what's happening. Believing that it's necessary, it's not being done for the well being or for the interests of the care providers that's been done for their interface and their baby's interests and that they have some decision making power in that process. So the guideline needs to add the two of the guidelines that now are titled first time ever WHO guidelines have the word positive in them. So positive pregnancy experience. List of childbirth experience. These are based on a whole range of evidence, but they include the quality of evidence and that's where this positive notion comes into play. And we have since done work on caesarean guidelines, another just several completing the postnatal guidelines and similar kinds of philosophies are emerging. Why does this matter to society? Now this is an interesting study that Lillian Peters lead on, which was a retrospective analysis of, well, a prospective analysis of a retrospective data set of about half a million Australian mothers and babies that we followed up up until, as you can see, 28 days and 5 years. In fact, we're now following them up to 15 years, but this paper was up to 5 years. And we were looking specifically at various metabolic disorders. Into the long-term, and their conclusion we reached, was that children born by spontaneous vaginal birth had fewer short and longer term health problems compared to those born after birth interventions. The point here being, it's not just about not caesarean, or not induction. This is about doing physiological birth as far as possible. Some women, obviously, can't have his optical birth for safety reasons and health reasons. Some don't want one, and that's fine. But the point here, is that where women want and can have a physiological birth or birth physiological as possible. The benefits are clear, it's something that's important. It's not just a luxury, it's something that's important to the well being of women in babies into the longer term, and in fact, transgenerational, in terms of epigenetics. This, I think, is quite an interesting study in this regard, because very often in many countries, we assume that. Okay, it's alright, doing physiology, or it's alright doing kind of compassionate care in high income countries are women, are generally being looked after in places where they have access to all kinds of medical support. But when it comes to low income countries or women that are very marginalized, actually, EmOC emergency care is much more important. This is a very interesting study published recently, so last August, few months ago, and it looked it was a secondary analysis of two cluster randomized trials in Garner. They looked at 64 childbirth facilities, and you can see that actually what they found out, was that if you had more births in a cluster, in a facility, that did not necessarily lead to reductions in mortality outcomes, what made a difference was having both EmOC and safe-guarding uncomplicated birth. That was when you got them the most value in terms of outcome for mothers and babies, of positive safe outcome, which is actually very surprising, I think, but, very encouraging. So FIGO, the Federation of Gynaecology and Obstetutions, the International Federation, and the LANCET in the series that were done on reducing caesarean section, or optimizing cesarean section of different kinds of phrases used for this. Basically, what FIGO says, in this paper, the LANCET, is the rise in caesarean section has to be stopped. I mean, that's my emphasis, but it's their words, their very strong words. And WHO says, and FIGO repeated this, is there in section rates of more than 15%, something 19%. But unlikely to improve outcomes, and we know many of our countries, the rates are really much higher than that, and the LANCET series on interventions to reduce unnecessary caesarean, concluded that, actually, what we need to do is more labour companionship, midwife-led care, physiological birth. That will actually result in safer outcomes and lower health care costs, so again, the kinds of things are done in the kinds of things that are supported by the are the kinds of things that generate positive outcomes. Let me look at relationship based care in the Cochrane Reviews, we find that in the Cochrane Reviews, having continuous support in labour leads to is associated with more higher likelihood of giving birth spontaneously. Lower rates are cesarean sections, less pain medications for women, and when it comes to military continuity of care, midwife-led continuity of care, it doesn't actually reduces caesarean, and it does increase the chances spontaneous for vaginal birth, and no differences in caesarean birth in that particular review. But there is in the continuous support labour review. I think it's quite interesting to look at the arrived trial, which, I think, many people will know about. So this was the trial that was undertaken in the US, very well designed trial in a number of sites in the US. The primary outcome originally was near natal while being composite well being. For first time women being induced routinely at 39 weeks gestation. Some of you who are listening to this may never been some controversy about this study, largely, because, most women about 70% of women who were asked to take part, did not agree to take part, and the woman who did take part were quite different from the main American population of women. But that aside, as soon as a reason, of our design study. But what's interesting about it, is the choice of intervention. So this is the data from the arrived trial, and basically, they did reduce caesarean. Although, bearing in mind, this was a healthy, low risk population, the baseline rate was still 22% down to 19%, so still higher than the rate that was recommended by the World Health Organization. But when you look at continue supporting labour, and you look at the relative risk, the RR, so the lower the RR, the better, the less caesareans, and you can see here, that actually the relative risk for continuous support in labour was lower than the relative risk for inducing routinely at 39 weeks gestation. And if one of the reasons for inducing women routinely, Is to reduce cesarean section which was a secondary outcome in the ARRIVE Trial. By the way not the primary outcome. But if it does that, the reason we want to do that is because we're beginning to realize that cesarean section has long term potential, negative hex for mother and baby. So to use a technology like induction for which we don't know the long term effects on mother and baby. To reduce something which were worried about the effects long-term to a mother and baby outcomes seems paradoxical when we have an intervention that works as well or better. Continue supporting labor, for which we know there are no adverse long-term effects, likely the opposite. So really, towards end of a segment, one of the things I would want to say is we need to re start with the basics here. We need to be reading the woman in the baby and not just the machine. Getting close to the mother to say, how does she feel? How does her skin, what's the skin feel like? Where is it smell like? How does she sound? What she doing? How she behaving, rather than divorcing ourselves from the woman's body behind machines that's happening Increasingly. That is remaking relationship with the woman. And this, one of the reasons why this might work is because it's completely aligned with evidence based medicine. This is a quote from David Sackett, who is one of the architects of evidence based medicine. And you can see what he said is the integration of best evidence, qualitative, quantitive, with clinical expertise and patient values. And when these are integrated there's an alliance which optimizes clinical quality of life. That is the relationship as well as the evidence need to come together both and. And we know that good quality relationships based on social support are powerful. So this is a study not in maternity care, looking at people who had good quality social support. And they found differences in various neural hormones, biochemical measures in the individuals who had the social support. So lower plasma and urinary catecholamine levels, so that was stress levels. Reduction in inflammatory processes. Impact on natural killer cell activity. This picture is of natural killer cells attacking a virus so improved healing. Increase in circulating opioids and an increase in oxytocin production in the brain and in the circulation. All things that we know are very helpful for women in pregnancy in labor and postnatally. So I think at the end of this kind of section of the module, the point really is relationships. Positive relationships are not just nice to have. They are nice to have, but they're actually fundamentally important for the biochemistry and the well being of mothers and babies now and into the future.