10:00am 26th June 2016:: Think: Health

Midwives are vital to helping reduce child and maternal mortality in low and middle income countries (LMIC), so how are they tracking when it comes to education and regulation? And, the place of mindfulness in university. We also find out how you can reduce your risk of bowel cancer.

Caroline Homer – Professor of Midwifery at the University of Technology Sydney
Dr. Richard Chambers – Clinical Psychologist, Monash University
Claire Annear – National Community Engagement Manager, Bowel Cancer Australia

Presenter/Producer: Ellen Leabeater
Producers: Sam King, Ninah Kopel


Ellen Leabeater: Hi, Welcome to the show, I’m Ellen Leabeater. Today, we take a moment to consider mindfulness.

Richard Chambers: Think about times when you’re just in the moment. You know when you just… those moments when you’re watching the sun go down or you’re just walking down the street and for no apparent reason suddenly you’re just there and everything is really radiant and alive. That’s mindfulness.

Ellen Leabeater: And, how to reduce your risk of bowel cancer.

Ellen Leabeater: Midwives have long been recognised as vital to reducing maternal and infant death rates across the world. But who is helping the midwives to be midwives. The State of the World’s Midwifery Report in 2011 and 2014 has recognised three key pillars needed to establish and support the global midwifery workforce. These pillars are education, regulation and association. New research has looked at whether access to these pillars has changed since the original 2011 report, and the results are mostly positive. Caroline Homer, professor of midwifery at the University of Technology Sydney explains.

Caroline Homer: Well, the State of the World’s Midwifery Report in 2014 was really an interesting activity and an interesting research project. We looked at 73 of the lowest to middle income countries in the world and we examined a whole range of issues including how midwives were educated, how they were regulated, how they were professionally supported, the numbers of midwives in all those countries and the numbers of other maternity workers as well – obstetricians, nurses, community health workers. We had done a State of the World Midwifery Report in 2011 in about 50 countries, so many of those countries were the same, and then we had about 20 extra countries.

Ellen Leabeater: What countries are we talking about here?

Caroline Homer: So we’re talking about what we call the countdown countries, so countdown is a big global initiative looking at the lower to middle income countries, particularly the lowest income countries, so many countries in Africa; countries in our region – Papua New Guinea, Solomon Islands for example; countries in the Southern Americas and a lot of small island countries, so just as an example, in our region, Bangladesh, India, Indonesia, Myanmar, Nepal, Cambodia, China, Laos. So these are the countries that have the highest burden of maternal deaths and newborn deaths. So, we know that midwives save lives, so if we think about where the effort should be made globally, of course it should be made in all countries, but where 99% of women die is in these countries.

Ellen Leabeater: So let’s start with education. How has education changed from 2011 to 2014.

Caroline Homer: Around the countries there’s been huge improvements in education, so, I think from 2011 there was a diversity of education programs, length of training, the requirements within the programs and the international education standards had only really just started to be applied. What we saw in 2014 was a vast improvement in many countries. They’d really adopted the international confederation of midwife standards for education, and there was real evidence of trying to improve the quality of midwifery education. We know now from a lot of research that quantity isn’t enough. It’s not enough to just have more of the workforce – more midwives, more nurses, more doctors. You actually have to have quality. And the way to get quality is to ensure they’re educated properly. So there were some very encouraging parts of this study that showed that significant improvements had been made, but there are also some areas of concern, and huge discrepancies across the countries and across the regions – lots of inconsistency in how midwifery education plays out across the world.

Ellen Leabeater: The education standards that you mentioned for the International Confederation of Midwives (ICM). What are those standards?

Caroline Homer: ICM sets out some very extensive standards. They cover things like the length of the midwifery program. So the ICM standards say that if it’s a direct entry program, which means you’re not a nurse before you come in, it should be a minimum of three years, and if it is a program subsequent to nursing it should be a minimum of eighteen months. It also covers things like how the teacher should be educated and supported, how the faculty should be developed and built, what resources students should have access to, how assessments should occur… So, it’s very similar to many countries, which have accreditation standards for their education programs. These are the international ones for midwives.

The challenging part is resourcing countries and supporting countries to meet those standards, and not every country recognises midwives in the same way. So if you’re in a country that doesn’t actually recognise that midwives are a separate discipline, you’re going to find it very hard to even think that you need standards, let alone meet them.

Ellen Leabeater: You mentioned earlier that midwives need to be quality midwives, not just the quantity of the course. Is part of that being involved in a certain amount of supervised births?

Caroline Homer: That’s right. The tricky bit is, we don’t actually know what the magic number is. So, it’s very hard to do research to find out what’s the magic number of births that a midwife should attend so that he or she ends up being a quality skilled and safe midwife. So, in Australia, at the moment, we’ve got new standards that say a minimum of thirty normal births. We know across the world that varies. In some countries it’s forty. In this research that we did in the 73 lower to middle income countries it varied from zero to 100. So the median was in the 30s to 40s depending on the region. So, enormous differences around the world of the number of births you need to attend. So, what while we don’t know what the magic number is, most of us would believe it’s more than zero, and that you need to attend a certain number of births to experience the diversity of women’s birthing. So, when it all goes well, when there are some challenges, when there are some complexities, when there are some emergencies. So, students need to see enough births, to see enough of that diversity.

Ellen Leabeater: Caroline, you alluded to this earlier – the importance of regulation in midwifery. How many of the countries actually recognise midwifery as a profession.

Caroline Homer: So in this study of the 73 countries, fewer than half of the countries had legislation recognising midwifery as an autonomous regulated profession. So, 52% of countries had no regulation acknowledging that midwifery was a separate profession needing separate regulations, separate education standards. And that has huge implications for the safety of the public essentially, because that’s the purpose of regulation – to protect the public, to ensure that people receiving care from people who call themselves midwifes are receiving the best possible care. If you don’t regulate for that person, you don’t know what their providing essentially.

Ellen Leabeater: The third pillar is association. How is that different from regulation?

Caroline Homer: So association is the sort of professional support that goes alongside midwives, and in many countries, there are professional associations for midwives. So in our country, we have the Australian College of Midwives, and in other countries there is a college or an association. These are different to the regulators in most places. So in many countries, there’s a council or a regulatory board that does the regulatory part of ticking people off, putting them on a register, checking that they meet the requirements for re-registration each year. Associations provide broader level support to midwives. They’re involved in advocacy, they work with government to make sure that women get the best care, they provide ongoing education, continuing professional development opportunities, and they speak for midwives at local, national and international meetings. So, it’s an advocacy and support role rather than a regulatory role. And we do try to keep them separate in all countries because they’re different. And they’re providing a different service.

Ellen Leabeater: And how many of these countries have an association for midwifery?

Caroline Homer: Almost all of them have some sort of association or they have some sort of group of people or midwives who saw themselves as providing this level of professional support, and sometimes it’s as part of a nursing association. So, small countries in our region have very small numbers of midwives, so there’s no logic in having a separate midwifery association. So they’ll often have a special interest group that’s part of the nursing association. There are some countries around the world that have more than one midwifery association, particularly in these countries that we saw, there might be two or three different groups who were providing that sort of level of support.

Ellen Leabeater: What’s the impact of this variability across countries for midwives?

Caroline Homer: There are a number of impacts I guess. One is that it’s hard to know what a midwife is in a different country, so a midwife is not a midwife is not a midwife because they’re going to look different across different countries if they’re educated, regulated and supported differently. It also has implications for migration. We are a globalised world and people move, and so when you want to move from one country to another, your qualifications may or may not be recognised because the country that you came from may or may not have education and regulation that’s to a global standard. So, it puts real difficulties amongst people who migrate or people who move, and sometimes people migrate not of their own choice as we see around the world now. So, it makes it difficult for the regulator in the accepting country to understand who that person is and what they might have had in terms of their education and it makes it really hard for the person moving. It’s their livelihood which now can’t be practised because they can’t be recognised in their other country.

Ellen Leabeater: Midwives, as you said earlier, they do save lives – of mothers and babies. Is there a growing recognition in these countdown countries of the importance of midwives.

Caroline Homer: Yes, I think the importance of midwives is really now being recognised. It has been quite a long journey and the work that we’ve done around the State of the World’s Midwifery Report and The Lancet series on midwifery has really started to provide the evidence as to why midwives make a difference. And in lots of countries now there are incredibly impressive efforts to further professionalise midwives, to further ensure that they are safe, regulated and well-educated and that they can make a difference. So I do feel we’re on sort of a wave of improvements, particularly in these low to middle income countries.

Ellen Leabeater: Caroline Homer, professor of midwifery at the University of Technology Sydney ending that story.

Ellen Leabeater: Let’s try something different. Stop thinking about the future. Stop thinking about the past. Just exist in this moment right now. Harder than it sounds, but that’s the premise behind mindfulness, the psychological craze that’s gaining traction around the world. Mindfulness is now working it’s way into higher education. In fact, Melbourne’s Monash University is looking to incorporate it into their entire curriculum. Imagine signing up for an IT degree and finding yourself in a meditation lecture. Here in Sydney, the University of Technology Sydney could be next in line. Producer Sam King spoke with Dr Richard Chambers, a clinical psychologist from Monash who’s leading the push for mindfulness in universities.

Richard Chambers: So mindfulness is about being in the present moment. So if we engage our attention in the centres and pay attention to what’s actually happening in the moment, that’s being mindful. And so mindfulness meditation is a series of attention training practices where we focus on let’s say the body, or what we can hear, or something that’s happening in the centres, and train our attention to be in the present moment. So, you know, broadly speaking you could include… you know if you repeat a word over and over again in your head and focus on that, that’s a mantra meditation, or you could include yoga – focusing your attention on the body and the breath.

Sam King: There is a lot of science behind what goes on in the mindfulness brain. How does it work neurologically speaking?

Richard Chambers: So, what we know is if we activate a brain region, it forms new synapses, new connections. That’s neuroplasticity 101. So, with mindfulness we start to activate regions like the prefrontal cortex, hippocampus insula as well, but I’ll focus on the prefrontal cortex. It’s just behind your forehead and, you know, that’s the part of the brain that’s responsible for the executive functioning: attention regulation, thinking, reasoning, planning, short term memory, inhibiting impulses, managing emotions, self-awareness. So we activate the prefrontal cortex and strengthen it. So it’s like doing a mindful muscle. So when we practice mindfulness in any way – if we’re just paying attention to something that’s happening in the present moment – but particularly if we sit and do periods of mindfulness meditation you get that massed practice effect. So you see significant growth.

Sam King: While it is in essence a psychological technique, drawn on as it is by religion, but it still is a psychological technique, it’s also a fairly organised movement. You’ve got international programs like the Mindfulness in Schools project, the Mindfulness Initiative, and in the UK there’s even a political body, the all party parliamentary group on mindfulness. So, why do you think there’s such an organised push going on around the world.

Richard Chambers: A few things have happened. First of all, there’s a huge body of evidence now showing that it’s very effective for improving mental health but also for improving performance, communication, making people act more ethically, so this body of research is getting harder and harder to ignore. Plus the neuroscience around it, you can just literally see the changes happening in the brain. So, the people that were once sceptical are now becoming at least interested, you know, if not quite enthusiastic about mindfulness. And at the same time of course, you’re seeing faster pace of life, increasing pressures, financial crises, impact of digital technologies making us more and more distracted and at the same time, this is a wisdom tradition. It’s actually being drawn from other wisdom traditions, so people I think intuitively recognise there’s something valuable in this above and beyond the benefits for mental health and productivity. I mean think about times you’re just in the moment, you know, when you’re just watching the sun go down, or you’re with you’re partner, or you’re just walking down the street and for no apparent reason suddenly you’re just there and everything is really radiant and alive. That’s mindfulness at its heart you know, and people just recognise intuitively that that’s a very valuable experience.

Sam King: I want to move now to the idea of bringing mindfulness into schools. I notice that this whole idea is of particular interest to the groups that I mentioned earlier, and there’s a good argument that it does work and it helps students concentrate. Mindfulness programs have been available at Monash for about thirty years, as I understand. What kind of results are you seeing?

Richard Chambers: So we’ve had mindfulness embedded in the Medical school for about twenty-seven years, and one of my colleagues Craig Hassed has been there really just pioneering mindfulness for about the last thirty years. And we’ve evaluated it formally twice, and it’s a great program in a way, because the medical students… they have to learn it. They have to learn the theory; they have to learn the research because they get examined on it. And what we’ve found is about 90.5% of them – this a 2009 study we did – 90.5% of them, once they’ve learnt about the research and the benefits for their mental health, for their wellbeing, for their academic performance, but also for being a good doctor, they start to personally apply it in some way. So there’s an openness that’s there. And now we’ve got about 14 different faculties or units that have some embedded mindfulness, and there’s the vision to roll it out university-wide.

Sam King: Yeah absolutely. I’m wondering about students that aren’t interested at all in mindfulness. Like, is it an opt-out or is it just choose a different university.

Richard Chambers: That’s a really good question actually. So what we have is – we have elective programs available to students, but as we pioneer this curriculum based model – and of course some students land in first-year IT and they’re getting taught mindfulness. Now, we present the evidence. We present it in an evidence-based way, a practical way; we make it relevant for them. Of course, you can’t force anyone to mediate or practice it, but they at least are expected to understand what it is. And so, we do get a little bit of pushback from some of the students who don’t quite get it, but the vast majority by the end of a six-week training in their tutorials and a couple of lectures on it, will at least be open to the idea.

Sam King: OK. So the seminar today was all about embedding mindfulness in the curriculum at UTS as it is at Monash. How would that affect students in a practical way?

Richard Chambers: To embed it in the curriculum… Well, if you look at the evidence, it would mean that students would be able to manage stress better, they’d be more productive – because like I said, you rewire the brain, key learning areas, prefrontal cortex, hippocampus insula, key learning areas so that we know that they become better students. And there’s a lot of research that little bits of meditation or sustained mindfulness training improving academic outcomes. So you’ll see students who perform better and who are less stressed. Less stressed, better grades. It really makes a lot of sense in an academic context.

Sam King: You’re obviously very passionate about the whole idea of mindfulness. Do you get much professional kickback in psychology circles?

Richard Chambers: I’ve been working with mindfulness for about seventeen years and I’ve noticed that a few older-school medical practitioners, psychiatrists etcetera have been a bit slow to sort of recognise the value of mindfulness. In the last two years or so there’s been this sort of – it’s sometimes called “the dark night of the soul” phenomenon. You know, obviously sometimes people practice mindfulness and they have what are called adverse effects, or what are called adverse events – they get in touch with some anxiety that they’re not equipped to deal with yet, or people who are already at risk of psychosis perhaps might precipitate a psychotic episode.

Sam King: And how common is that?

Richard Chambers: It’s very rare. If you look at the literature, it’s very rare. It often happens on long retreats where people are spending ten days on a silent retreat, meditating all day long, often against the recommendation of their doctor or the retreat organisers. Every now and then you hear this story about someone who does five minutes of meditation and just runs into something that just freaks them out and it takes them ages to recover from. That’s extremely rare. And you know, there getting in touch with something that they’ve been avoiding anyway, so you’d have to… in my mind it’s unclear whether that’s a good thing or a bad thing. But, like I said, you look at some of the evidence and a lot of these adverse effects are happening before retreats start, that kind of thing. So, what I like about that is that it’s kind of nuancing the literature a little bit, because people have been just “Yay mindfulness” for quite a long time, so it’s nice to see people saying, “Hang on, we know mindfulness is good, it just makes sense intuitively and the evidence backs it up, but who does it work with and when and it what situation might you want to be a little bit careful,” so we’re just starting to get a bit more nuanced and intelligent I’d guess you’d say about our approach. And that’s a good thing.

Ellen Leabeater: Dr Richard Chambers speaking to Sam King about plans to introduce mindfulness to higher education.

Ellen Leabeater: Bowel cancer is Australia’s second biggest cancer killer after lung cancer, yet 90% of bowel cancer cases can be treated successfully if found early. The problem is, nobody really wants to talk about what happens when things go wrong in the bathroom. June is Bowel Cancer Awareness month, and Bowel Cancer Australia is encouraging Aussies to know the symptoms and risk factors of bowel cancer. Claire Annear is the national community engagement manager at Bowel Cancer Australia. She spoke to Ninah Kopel.

Claire Annear: Bowel cancer is otherwise known as colorectal cancer. So that’s cancer of the colon or the large intestine and the rectum. Bowel cancer is a malignant growth that grows most commonly in the lining of the large bowel, and most bowel cancers develop from tiny benign growths called polyps. So one of the reasons bowel cancer is called one of the most preventable cancers is because if you can catch those polyps and remove them before they have a chance to turn into a bowel cancer, you are able to prevent bowel cancer.

Ninah Kopel: Who is most likely to be diagnosed?

Claire Annear: Bowel cancer affects men and women almost equally. Around 15000 Australians each year are diagnosed with bowel cancer and it is more common in people aged over 50 years of age, however bowel cancer is increasing in younger people, and around a thousand Australians in their 20s, 30s, and 40s are diagnosed with bowel cancer each year, so bowel cancer is definitely something that men and women of all ages need to be aware of, and younger people shouldn’t be told that they’re too young to have bowel cancer because it can affect younger people as well.

Ninah Kopel: Do we know why there’s that increase in younger people?

Claire Annear: They don’t know exactly why it is increasing in younger people. There are a few different reasons that they’re surmising could be the case, particularly in relation to diet and lifestyle factors. And they do also know that there can be some genetic difference with the bowel cancer tumours in younger people that can cause them to be more aggressive, but there isn’t any solid evidence either way at the moment, so they’re doing more research to find out why that can be the case, and how they can help to reverse that increase.

Ninah Kopel: You’ve recently mapped out the geography of bowel cancer. So where is it and what are the areas that are most affected?

Claire Annear: So, a couple of years ago Bowel Cancer Australia developed a resource called the Bowel Cancer atlas of Australia, and each year we update that information with the latest statistics and information. And it includes information on things like bowel cancer deaths and risk factors in local communities. And this year we’ve also added information about colonoscopy rates and national bowel cancer screening program participation rates and lots of other things. The aim of the atlas is to provide local communities with areas they can focus attention on when it comes to health behaviours that could be improved to help reduce the bowel cancer risk in their local communities. And if we have a look at the information in the atlas that relates to New South Wales, you can see that over the five-year period of 2009 to 2013, bowel cancer claimed the lives of 3065 men and women across New South Wales. And the highest death rate was in a place called Lachlan. Metropolitan Sydney had a slightly lower mortality rate than regional NSW, and there are a few areas that the atlas looked at when it came to risk factors for bowel cancer as well, so, the local government areas in Sydney’s North performed really well. Kuring-Gai had the lowest rates of smoking and alcohol consumption. Across NSW, the Sydney Lower North Shore and Blue Mountains had the lowest rates of Type 2 diabetes, which is a risk factor for bowel cancer, and then it also had a look at Central and Darling region and Broken Hill, and they had the highest rates of smoking and alcohol consumption and they’re all risk factors for bowel cancer. So what the atlas is looking to do is highlight the areas in all the local communities so that each local community can focus on how they can improve those risk factors in their area and hopefully reduce the rates of bowel cancer.

Ninah Kopel: What are some of the things that people can do to kind of prevent getting bowel cancer during their life?

Claire Annear: So, it’s estimated that changes in diet and physical activity can reduce the incidence of bowel cancer by up to 75%, which is actually quite a large amount. And some of the things that people can do – the simple things they can do everyday to help to reduce their bowel cancer risk – can be things like aiming to be physical active. So that doesn’t mean you have to be running a marathon or pumping it out at the gym everyday, it just means thirty to sixty minutes of physical activity each day can help to reduce your bowel cancer risk. What you eat can help as well. So, foods containing dietary fibre, yummy fruits and vegetables with a lot of plant-based fibre can help to reduce your risk, red meat and processed meat can actually increase your bowel cancer risk, so limiting the amount of red meat that you eat, and avoiding processed meat can help. Limiting the amount of alcoholic beverages that you drink, watching what you weigh and quitting smoking can all help to reduce your bowel cancer risk as well.

Ellen Leabeater: Claire Annear from Bowel Cancer Australia speaking to Ninah Kopel.

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Ellen Leabeater: Don’t forget, if you’d like to find out more about anything you’ve heard today, you can visit us at 2ser.com/thinkhealth. We’re also available on demand. Just search for Think:Health in your favourite podcast app.

Please remember that journalists are not doctors. If we’ve made you ask questions, go and see your GP. This show is produced with the support of the University of Technology, Sydney, Faculty of Health. I’m Ellen Leabeater, see you next week for more in health research and news.

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