Greetings. I'm Professor Suellen Miller. I'm part of the University of California San Francisco's Safe Motherhood program. I've been a midwife since 1977 and have practiced all over the world. I work now in many countries on projects that have to do with maternal survival and maternal health. In 2016, I was part of the Lancet's maternal health series, where there were six papers with data telling powerful stories about the past, what's been happening, and forecasts where things might be going globally around maternal health. We talk about maternal health in using the phrase too little too late, and too much too soon, which we have used to describe the variance in care from the very, very low-income countries to higher income countries and that balance that can be achieved. It can be achieved by appropriate, timely, evidence-based, respectful midwifery care. This conclusion that we reached, that this was a solution, is backed up by a lot of data of [inaudible] reviews of care, that this being respectful midwifery care is really a key and the evidence backs that up. What do we mean by too little too late? Well, first, the lack of evidence-based guidelines governing care. Women could be delivering completely by themselves. There's a lot of disrespect and abuse and access is lacking. So a woman may need to travel for days to get to care with a postpartum hemorrhage and then when she gets there, there's nobody there to take care of her. There's too much too soon and I think those of us who are living in the United States really know what that is. The routinized medical interventions or over medicalisation of birth with inductions, augmentations, episiotomies. We tend to use C-sections, especially those that are not medically indicated, as a rate that which we can cling onto to tell us what's going on in countries. We look at Caesarian section rates. The two little countries are poor countries with low access. Their rates are about somewhere less than 10 percent, which the WHO has identified as a target area, anything under that being too little. Then we have too much too soon and these surprisingly are not high-income countries, but are actually the low and middle-income countries. Egypt, Brazil, Dominican Republic have rates approaching 60 percent. Now these rates don't tell the whole picture. We can't just divide the world into those that are giving too little too late and those that are giving too much too soon based on countrywide statistics. So we should question our assumptions. Maternal mortality rates are highest where C-section rates are lowest. So what's this due to? Well, what we think is women needed C-sections and they didn't get them. But what the data shows is that women who do get them are more likely to die a peripartum complication such as anesthesia complications, sepsis or operative errors because of what's going on in these countries. Those women who do get C-sections experience major morbidities such as iatrogenic fistula because of access to C-sections and the inexperience of the operate. The rising epidemic of accretas. Yes, we can take care of them in the US, but imagine if there's no access to ultrasound, there's no access to antenatal care at all. So many accretas are not diagnosed and we see these increasing in places where there's little capacity to care for them. Another thing that can happen is that providers, once they're trained in a skill like C-section, will turn to over medicalisation and they'll have much more rapid decision to go. We find out these very low resource settings. We finding too much too soon, too early. This picture, as I said, is complex. Wealth and socioeconomic status and where you live can have a lot to do with whether you get a C-section or not and this is true everywhere. In Haiti, for example, with very poor country in our hemisphere. Wealthy women are 11.3 times as likely to have a cesarian birth. In rural China, it's 13.5 percent. You can see that being poor and being marginalized will often deny a woman the potential for having a C-section, while being wealthy may actually put her at more risk because of the more likely instance of them doing too much too soon and rushing to a C-section. What are we looking for? We're looking for equity in maternal care. Maternal care that's neither too little too late nor too much too soon. Data has demonstrated that the best outcomes with the fewest interventions and lowest costs are evidence-based, respectful, midwifery-led care. This data has become available. There are many publications including a few Cochrane Database Systematic Reviews that demonstrate that this is where we can find the best care, and we need to just be sure that this is equitable care. I say to midwives, talking to you and myself, that this isn't a reason for complacency. What we found in our review in the 2016 maternal health series, was that any place that there was a discrepancy between the race, the ethnicity, the wealth, immigration status of the birthing woman, and her healthcare provider, whatever these intersections might be, there's evidence of decreased maternal well-being compared to those whose indicators are more similar. I believe in the United States this is very clear. In 2010, African American women in Manhattan, we're more likely to die than women in North Korea or Vietnam. A well-known stat, that's very much in the press, is that maternal mortality rates for African American women are 3-4 times greater than that of white women. This is despite or because of, having higher rates of interventions than white women. These findings come from the US where rates of midwifery led care are around eight percent. But other high-income countries where there are 75 percent midwifery lead care, these findings remain very similar. In Norway, refugee women had worse outcomes than their national-born cohort. In the UK, where there is a confidential inquiry into maternal deaths, black women are five times more likely to die during birth, and Asian women two times more likely compared to white women. Again, midwifery care is attending 75 percent of births. I think in this time of rising immigration due to economic, social, religious, or ethnic oppression, we need to be more aware of how each of us engages with others. We need to place intersectionality at the heart of midwifery care. An inter-sectional approach will acknowledge systemic discrimination due to all of the many factors that differ between people. I'm focusing on race, ethnicity, and immigration status, but there's certainly others. It allows one to identify that there is, and how it limits and impacts access to quality care. What can we as midwives do to continue to lead the way for equity and quality evidence-based care, care that's not too little too late nor too much too soon? The first, yes, we need to recognize access to the best care, with continuity for care and emotional support comes from midwives. But also we need to start practicing cultural safety. The process of overturning systemic personal biases and privileges in our interactions with women and with other members of our team. First step acknowledge potential power imbalances. Something that we need to think about in every interaction with every woman. We need to undertake ongoing self-reflection and reflexivity regarding our own assumptions, biases, and values, and as midwives leading the way, provide role models for our students, for other professionals and their students and community members on self-reflections and identifying one's own biases. Every time I'm asked, well, how can we do this? The best way, as I said, is role modeling. Once we've come to grips with the ongoing process of reflection about our own biases, we can demonstrate this to others. Too little too late, too much too soon, we want to find a balance between those with equity and access to evidence-based respectful care. This means increasing the rates of respectful, high-quality interventions where they're lacking, and decreasing over-use and over medicalization. We want every woman, every newborn, everywhere, to have respectful quality of care with midwives taking the lead. Thank you.
