Hi, I'm Holly Kennedy and I'm the Helen Varney Professor of Midwifery here at Yale University School of Nursing. I'd like to welcome you to module two, on quality maternal and newborn care in the midwifery model of care. A few years ago, I was invited to join a group of researchers, clinicians, and service users to examine the evidence and the role of midwifery on quality care of women in newborns, globally. It was funded by the Bill and Melinda Gates Foundation, and was published as a special series in The Lancet in 2014. In that process, we conducted several studies, and we also developed a definition of midwifery. We looked at over 400 Cochrane reviews, 7 systematic reviews of workforce studies, and meta-syntheses of women's experiences. We conducted three case studies of middle income countries, and we also mapped our findings in our exploration of the evidence on the ICM Competencies for the midwife. In our definition of midwifery we took our definition, we expanded the definition based on the evidence that we found. And it included what I've highlighted here in blue of caring for families across the continuum, not just the mother and baby, of optimizing normal biological, psychosocial and cultural processes. And really work to strengthen women's own capabilities. And by doing that, that would improve not only short term outcomes for the mother and baby, but really of the entire family in the future. These are some of the outcomes, we found 56 outcomes that are improved by midwifery care. And these are some of the highlighted ones have decreasing mortality, decreasing pre term birth, reducing interventions, increasing birth spacing because of the use of family planning, increasing breast feeding and shorter hospital stays. And these were improved particularly when the midwife was known to the woman. In our workforce studies, we found that midwifery led continuity models resulted in a range of possible positive outcomes, including cost effectiveness. An we found few benefits from relying solely on less skilled health workers, but rather that midwifery led care working within a team, was really what made the difference. So when in summary the framework that we developed can be used in tested in a range of contexts. Midwifery has a particular contribution in preventive and supportive care in promoting positive outcomes, and that is most effective when midwives are educated, trained, and regulated, and integrated within a healthcare system, and with effective teamwork. So that was the first major paper in the series. The second paper examined what would happen if we scaled up midwifery, particularly in the 78 countries that bear the highest burden for mortality. And using a sort of a complicated lives saved tool modeling, they found that if we universally scaled up midwifery with family planning, we would reduce maternal mortality by 82%. And we saw similar reductions on still birth, and neonatal deaths. The third paper, did an in depth case analysis of four countries that had had sustained decreases in their maternal mortality over the past two decades. And we, that case study examined the political systems, the regulatory systems, educational systems, and social systems within those countries to see where was the political will? What were the things that happened that really contributed to that decrease in mortality? And these are the four major areas that we found. So if you look at the blue line, that is really an expansion of the service network that services were made available to women and their children. The pink line is the investment in midwives, so all of them had an increase in investment in midwifery. The green line is a removal of financial barriers, and the turquoise line or that teal line, is action to improve quality care. So out of that, these three papers and the work that we did, we developed what we called an evidence informed framework for quality maternal and newborn care. You're going to learn a lot about this framework as you go through this module. But just to briefly describe it for you, that very first row which starts out as green and then goes into pink, is practice. It's what we do in caring for mothers and babies, so its conducting assessments, care plans, education information, promoting normal processes. The first pink box is what we do if there's a first line management for complications. So let's say a woman develops anemia, so the midwife would, how she would assess and care for for anemia. And that small pink box over there to the right is referral, it's what we do when we refer someone who has major complications. Now, our ability to practice in the evidence supports that our ability to do effective practice is built on those next four rows. The purple one is how care is organized. So is care accessible? Is it acceptable to women? Is it organized and integrated within the women's community. The blue line are the values upon which care is built. So is it respectful care? Is it tailored to women's individual needs rather than be one size fits all? Is there an understanding of the community in which the woman lives? That is also founded and built on a philosophy of care, so in that philosophy really is grounded in that a belief that women have a capability to become pregnant, give birth, and nurture a child. And that is best done by optimizing her capacity do to that. But sort of supporting her biological, sociological, social processes, and using expectant management. So intervening when you need to, but not intervening if you don't. And then finally, the last row is who provides the care? Are the care providers competent? Are they deployed appropriately? So that you have, in most countries, midwives taking care of most women and using your more specialized providers for women who have more complications. So that is the framework for care, and when when you examine the care in your own setting, this is a very helpful framework to think about the evidence that supports what we do, and it's important its relationship to outcomes. So in order to implement that framework of care requires a bit of a change in a paradigms. So from a medical care that's focused on high risk, or in other words, that little pink box, to really all the aspects of care that before you get to that need to refer for services, and a real focus on quality care for all mothers, and all babies. So I just want to finish with some take home messages for you. From the series, is that 82% of maternal deaths could be avoided if midwifery with family planning were scaled up. And those countries that have lowered their mortality rates over the past 20 years, are more likely to have increased and have to have increased in accessible services. And finally, that the evidence supports that over 50 outcomes are improved by midwifery. So as we think about providing the best care to women, we need to situate that in human rights. That all women and all babies have a right to the highest quality care possible, and investing in midwifery is an effective solution, to deliver on women's rights to sexual and reproductive health.