 Our presenter is Dr Deborah Fox. She is a registered midwife in Australia and Singapore, and she lectures at the Centre for Midwifery, a child and family health in the University of Technology in Sydney. Her doctorate, which was attached to Birthplace Australia Project, was a qualitative study on the process of interpartum transfer from planned home birth to hospital. Dr Fox is the chair of the Australian College of Midwives Victoria branch and a member of the ACM Scientific Review Committee. An innovative clinician, she collaborated with et cetera colleagues in 2011 to establish Singapore's first midwifery group practice and has been instrumental in the implementation of group antenatal care in Victoria. She's passionate about the capacity for midwifery care to support positive pregnancy and birth experiences as a foundation of the transition to parenthood, sustained breastfeeding and healthy maternal infant attachment. Thank you, Dr Fox. I will hand over to you. Thank you, Megan. Thank you for your lovely welcome and welcome to everybody. It's wonderful to see so many people from around the world online. This is very exciting for me. Firstly, I'd like to acknowledge the Gadigal people of the Eora Nation upon whose ancestral lands our university stands. And I pay my respect to the elders, both past and present, acknowledging them as the traditional custodians of knowledge for this land. I would also like to acknowledge the traditional owners of all the lands and territories across the globe, in which we meet for this wonderful celebration of our international day of the midwife. Handover communication between health professionals from different disciplines is known to be problematic due to the different goals and priorities of those interacting. Handovers have the capacity to delay or expedite care and may act as a barrier or facilitator of the reduction of uncertainty. We know from multidisciplinary literature that rather than being guarded by policy, successful handovers often occur simply due to the presence of trusting interprofessional relationships. In the home birth transfer context, handover interactions have the capacity to provide the ground roots of collaboration between women and home birth and hospital caregivers by establishing the patterns of communication that follow. High-quality transfer processes are a crucial element of the provision of safe and woman-centered home birth services. I'd like to acknowledge my co-authors, Professor Caroline Homer from the University of Technology, Sydney, Associate Professor Athena Sheehan from Western Sydney University, and Associate Professor Sarah Swartie Vadam from the University of British Columbia in Canada, and thank the women, midwives and obstetricians who generously shared their views and experiences with me. As many of you will know, Australia is a large island nation in the Southern Hemisphere with a population of about 24 million people. On the left at the top of the screen, you can see a comparison of its size with the USA, and at the bottom a comparison with the UK. So it's about 32 times the size of the United Kingdom. The vast population and vast distances in rural and remote areas of Australia have obvious implications for women planning a home birth and for their midwives in the event that they may make the decision to transfer to hospital. Current recommendations are that women planning a home birth live within a 30-minute drive from a hospital with maternity services. I'm speaking to you today from the University of Technology, Sydney, in the beautiful city of Sydney, where I'm a lecturer in midwifery and a member of the Centre for Midwifery Child and Family Health. Relatively few women have access to planned home birth in Australia. In 2013, 0.3% of all births in Australia occurred at home. There are two ways in which women may access planned home birth. Firstly, publicly funded home births have emerged as a model of maternity care in Australia over the past decade. There are about 15 such services around the country. Women may also access home birth in Australia by engaging the services of a privately practising midwife who provides continuity of care throughout the childbearing year. Many are Medicare eligible, which means that women they care for may receive government rebates for the cost of their anti-natal and postnatal care. But women must pay for the cost of intrapartum care at home. Planned home birth is defined as when the planned place of birth at the start of labour is in the woman's home, with care from registered midwives who carry emergency equipment and who have established collaborative arrangements for medical consultation, referral and transfer. Evidence supports the safety of planned home birth for women with low risk pregnancies. It's important to note a number of studies which have demonstrated that low risk women giving both birth at home and in birth centres have lower rates of intervention than low risk women who plan hospital births, including lower rates of caesarean, lower rates of assisted vaginal births, fewer epidurals and lower rates of artificial oxytocin administration. Although one study from England reported a small increase in the absolute risk of outcomes for the babies of women having their first baby at home, a larger study from the Netherlands found no increased risk of adverse perinatal outcomes for planned home births. Qualifying their conclusion that our results may only apply to regions where home births are well integrated into the maternity care system. Handover is a crucial link in the creation of well integrated maternity systems. Here is just a small selection of quantitative data on home birth transfers. So as you can see, the majority of transfers from planned home births occur for non-urgent indications and they include, for example, delayed progress in labour or the woman's request for pharmacological pain management. Very small numbers of women are transferred due to emergencies. Women and newborns are also transferred soon after birth at home, of course, in smaller numbers, but this is not the focus of today's presentation. The design of our study involved 36 semi-structured interviews with women who'd been transferred and with midwives and obstetricians who'd been involved in transfers across four states of Australia. A constructivist-granted theory approach enabled us to conceptualise the social interactions and processes that occurred. Ethics approval was granted by the Human Research Ethics Committees at the University and from two tertiary health services. The research I'm talking about today emerged from a larger qualitative study that I've just described. Four categories emerged from the findings of the larger study, which are displayed here, and the subcategories are listed within each category. I'm going to present a few salient pieces of the findings today in order to demonstrate how the larger qualitative study influenced the development of our principles for handover. Building the midwife-woman partnership explored the relationships that were developed between women and their home birth midwives during pregnancy. Reciprocal trust was a key element of the partnership. Women trusted their midwives to transfer them when necessary and to not suggest transferring them unless it was absolutely necessary. One woman said, having someone there who you know is on your side who shares your values, who you've chosen to be on your team, that you've spent time with leading up to the birth, and then who would continue to be with you afterwards, whose opinion you trust, I think that is the key to having a positive birth experience at a hospital. And a midwife agreed when she said, midwives need to be able to follow women through when those scary scenarios happen. The women need the person they know and trust. So it was clear that the midwife-woman partnership had a powerful capacity to support women through their changing expectations for birth and the uncertainty of transfer. When transferring women made the journey to hospital, they also made a psychological journey out of their comfort zone. One woman described it as, it's being removed from your little comfortable place into a place that's not your place. You'd had your nest where you were going to give birth and then suddenly it changed. Midwives were committed to supporting women to manage the transition to hospital. One challenge was that women needed time to process their psychological journey, whilst hospitals often wanted to expedite their labor. Women valued having time to think about their options and to manage their changing expectations for how their labor and birth might unfold. Even in urgent situations, it was usually still possible to enable women to have a few minutes to process what was occurring. One obstetrician we interviewed demonstrated a sensitive understanding of the time women need to process their psychological journey when she said, we know that for how people cope with things afterwards, half the time it's not what actually happens to them, it's how it was communicated to them and if they had time to think about their choices. Sometimes in obstetrics there is no time, but usually there is. Even five minutes can make a big difference. Sometimes women seem to be resisting monitoring an intervention after transfer. Not that they were trying to be difficult, but as a way to buy some time to adapt to what was happening for them. During a home birth transfer, it was not only women who transferred out of their comfort zone. Home birth midwives and hospital staff also had to shift into a different way of working and of interacting than that to which they were accustomed. Transfer events resulted in a convergence of women, midwives and obstetricians who may possess conflicting paradigms of childbearing derived from a range of educational, professional and life experiences. As one hospital midwife said, the transfer of women into the hospital is so interesting because of the different philosophies underlying the two different contexts of care which are so different. Hospital midwives in a tertiary setting, how they view the parameters and the risks of birth is very different to how home birth midwife does. This issue had the capacity to reconstruct women's labor and birth experiences into complex and unique clinical circumstances. In most settings in Australia currently, privately practicing midwives lose their rights to practice in the hospital after transfer. They are relegated to a support role but strive to maintain their partnership with the woman. This means continuing to provide her with emotional and physical support and advocacy as a part of the powerful partnership that's needed by women. Since data collection, there are a handful of hospitals around the country which have recently granted practicing rights to a select few privately practicing midwives and this will hopefully continue to spread in order to provide a more integrated system for women planning home birth. As one hospital midwife noted, you can't separate the birthing woman and her partner and her midwife, it's all one unit. Another midwife described knowing the intensity of the relationship between the woman and her midwife. Despite the obvious value of the partnership for women and their home birth midwives, its presence had the capacity to create barriers to collaboration for hospital midwives as they were left feeling unsure how to fit into the dynamic in the birthing space. The presence of the powerful midwife woman partnership and the different paradigms converging were among the social processes that contributed to the potential for us and them dynamics to emerge. This image about us and them is from one of our Australian national living treasures, cartoonist, poet and cultural commentator, Michael Leunig. Home birth midwives and hospital midwives often encountered us and them dynamics emerging in the birthing room of a transferred woman. For example, they said, it seems there is this you and us thing. And another, you do get that animosity sometimes between them and us. The category us and them showed that a lack of clarity around roles and responsibilities, especially for midwives, had the potential to cause stress and conflict. Hospital midwives often perceived the need to take over whilst home birth midwives were often striving to continue to support and advocate for the woman. The behaviors that engendered us and them dynamics included stereotyping, resisting, blaming and taking over. Stereotyping is known to be a fundamental way in which humans reduce uncertainty about complex social interactions. Mainly because it helps them to simplify their own worldview. Stereotyping was a way of strengthening identification with those who held similar beliefs about childbearing, whilst distancing themselves further from those they perceived as other. Here are just a few of the examples of stereotyping that emerged from the data. Home birth midwives were described by some as hippie midwives who were seen with dreadlocks and a rainbow scarf. Hospitals were regarded as big intervention machines that were full of doctors and midwives who just wanted to intervene. One hospital midwife even said, they think we've all got two heads and we want to do caesareans on everybody. Hospital midwives were sometimes observed to blame the home birth midwife. One quote was, something's gone wrong and the midwife should have figured it out five hours ago and not now. There's a feeling and a judgment by the midwives at the hospital that this decision could have been made sooner and therefore the outcome could have been less harrowing for the woman. For privately practicing midwives who lost their rights to practice in the hospital, negotiating their role in the birth space was especially complex when hospital staff expected to take over the woman's care clinically and emotionally. One hospital midwife reported, I was given the talk that we were responsible for her care once she came and so the care with her midwife at home dissolved, disappeared. Other hospital midwives were adamant that their role was to take over the woman's care in every sense, perceiving that taking over was similar to their routine experience of receiving the care of a woman at a change of shift. That is taking over from another hospital midwife who would then go home and leave her to it. Another hospital midwife had observed the perils of taking over. She said, if you start getting someone who comes in and dictates, the woman feels that she's a failure because she hasn't had her birth at home and now she's got this whole medicalised model taking over. And in some instances, the medicalised model needs to be involved but they don't have to take over. They could work alongside. So I began to wonder what is going on here? What is the social process driving problematic interactions between midwives in the home birth transfer context? Well, the contrasting fundamental beliefs about childbirth and the presence of the midwife-woman partnership in the birthing room adds to the sense of what Melissa Cheney and colleagues called a contested space. Our findings build upon the concept of the contested space by addressing the social dynamics that occur between groups of individuals as another layer upon the psychological and cultural influences that may drive their individual behaviours. Hence, we argue that the issues extend beyond personality and culture to the influences of intergroup conflict, or in other words, us and them dynamics. The theory of intergroup conflict is derived from social psychology and seeks to analyse human interaction by situating individuals within the social processes they partake in, making distinctions between personal identity and group identity. To increase confidence and self-esteem, humans align themselves with groups of like-minded individuals and tend to boost the perceived status of their own in-group and discriminate against the other out-group. Seeking a group identity is known to be an effective way to reduce feelings of uncertainty because it enables individuals to predict the behaviours of others and plan their actions accordingly. Common examples include the way in which we may identify ourselves with groups of a particular race, religion or sporting team. The need to seek a group identity often motivates individuals to adopt negative behaviours such as stereotyping, blaming and trying to control others. What follows is an us and them situation. In settings where high levels of collaboration or negotiation are required, the presence of intergroup conflict can prove to be a major barrier. And the home birth transfer context is one such setting. The argument for applying intergroup conflict theory to the understanding of interactions in the birthing space during home birth transfer is strengthened by the evidence that the release of oxytocin increases in-group trust and cooperation and elevates defensive behaviour toward an out-group. The effects of oxytocin have been widely studied since seminal research published in 2005 in Nature Journal by Cosfeld et al., which demonstrated that exogenous oxytocin increased levels of trust felt by humans. More recently, a number of studies have shown this effect to be dependent upon the social context and the level of connection with people involved in the interaction. It's been found that oxytocin facilitates empathy with familiar others and appears to increase in-group trust and cooperation. Oxytocin is also known, however, to elevate defensive behaviour toward an out-group and decrease out-group cooperation. So how might we ameliorate us and them dynamics in the home birth transfer context? Midwives who enabled safe and respectful care during transfers showed that there are some key social behaviours and actions we can implement in order to create a woman-centred collaborative approach. These include sharing goals, making time for women to manage their changing expectations and communicating and behaving in a way that demonstrates mutual respect. Universally, women and clinicians in maternity care share the goal of a healthy mother and a healthy baby. Healthy is commonly defined as physically alive and well. However, for women giving birth, healthy may encompass deeper meanings that emerge from psychological, emotional, social, cultural and spiritual domains. Woman-centred goals can become the focus of collaboration when the definition of healthy mother and healthy baby is based upon respect for what this means to each individual woman. Supporting the midwife-woman partnership is key to providing woman-centred care in the context of home birth transfer. Demonstrating mutual respect towards interprofessional colleagues encompasses stepping back from normal routines and ways of working and sharing the goal towards safe and respectful care. One hospital midwife said, if there's mutual respect, I think then you would certainly help out more. Handover is a key way in which collaboration can get off to a respectful start. I've summarised here some of the barriers and enablers for privately practicing midwives in the context of transfer to hospital. I'm focusing on privately practicing midwives in the Australian context because they work in a much less integrated maternity care system than do publicly funded home birth midwives. So enablers included being familiar with the hospital and the staff, the relationship with the woman, having relationships with hospital midwives and obstetricians and fostering and maintaining them, and a very important enabler was for the woman to be booked into the hospital as back up during pregnancy. And we know that this is not universally available in Australia. The barriers included the loss of right to practice when privately practicing midwives entered the hospital in a home birth transfer setting, having to hand over at the time of losing her rights or his rights to practice. Different documentation, both paperwork and style of documenting and the us and them culture. All the privately practicing midwives who participated in the study were required to provide a professional handover at the time they simultaneously lost their clinical rights to practice. Due to a lack of guidelines and the diminished professional status of the privately practicing midwife, hospital staff could ostensibly make an individual choice, whether to take any notice of the handover or not. When privately practicing midwives felt that their handover was disregarded, they were concerned about the potential impact on the woman's care. Usually handovers from privately practicing midwives were verbal. Sometimes written documentation was also provided. Often this was driven by the preferences of the individual midwives and individual hospital staff on duty, rather than by policy. Most privately practicing midwives were happy for the hospital to have copies of their documentation. One midwife said they could photocopy any of our notes and they would often photocopy the partogram. Another midwife felt that offering copies of documentation was part of a transparent and collaborative approach to reducing uncertainty for the hospital staff. And said, the more information people have to work with, the better the story is going to be. So I'm really willing to share my documentation. Hospital staff often perceived documentation to be problematic when receiving a transfer from a privately practicing midwife, saying, for example, they can't write in the case notes because they're not employees of the hospital. This resulted in feelings of uncertainty around the validity of the documentation. How that transfer of information stays accurate throughout the course of that woman's journey is very concerning, said another midwife. Hospital midwives valued written handover information, saying, if I missed something when someone's telling me, then it's written down and I can read it as well, and it would probably be a bit clearer. Written information not only provided them with a clearer clinical picture, but also a better opportunity to assist women in their decision making. As another midwife said, so you can make good informed decisions with the woman, something written down that shows what's happened, what the fetal heart rate has been like up to the point that she's come into hospital. A clear midwifery handover and anti-natal booking in of the woman seem to reduce uncertainty for everybody, both clinically and administratively, thereby ensuring a more successful transfer. Clarity of the handover communication was paramount for obstetricians because it reduced their uncertainty about the woman's clinical situation. Some obstetricians were keen to interact with the home birth midwife for a direct formal handover in the presence of the woman, saying, even if somebody isn't going to continue care, a handover in front of the woman about, this is who it is, this is what's going on, this is where we at are really important. Several obstetricians believed that a clear handover directly from the home birth midwife to the obstetrician was integral to safety in a home birth transfer situation rather than the information going via another midwife. One obstetrician explained her strong feelings about the process of the transfer handover communication. When she said, from my perspective as a doctor who receives transfers, it's really important to recognise that communication is not just with the unit, but it's actually a practitioner handover. The woman's not going to be cared for by a unit, the woman is cared for by individual practitioners. These women are all getting transferred for medical care. They don't need to be transferred for midwifery care, they already have midwifery care. That clarity of communication between the midwife who has recognised the complication and made the decision to transfer, that person needs to be directly talking to the medical officer. There's lots of opportunities for miscommunication or misunderstanding if that doesn't happen. The final part of the findings I will share today explores home birth transfer as something to be celebrated as a success of the system, providing woman-centred care that is safe and respectful. This notion was elucidated by an obstetrician who said, you do hear this is a home birth failure. I always pull people up and go, well, actually, let's look at what's happened. Somebody's had a care plan, things have gone different to expectations, that's been recognised and appropriate transfer has been arranged, that's the system working, that's a success, that's not a failure. The only time I would think of it as a failure would be if the problem isn't recognised or the decision to transfer when the problem is recognised isn't made. Those sorts of things, that's a failure in the system. Overall, successful transfers tended to occur in more integrated settings where there was solid relationships between the health professionals who worked in home birth and hospital, where hospitals enabled pregnant women who were planning a home birth to make a back-up hospital booking and where continuity of midwifery care was prioritised. These factors enabled the woman and her baby to remain at the centre of care. Home birth transfer is very complex and unlike any other clinical situation. I will explore why on the next slide in a moment. Our study demonstrates how the attitudes and behaviours of health professionals may influence the processes that ensue. In other words, home birth transfer is a social process that disrupts and challenges the status quo for everyone involved, not only for the woman and the home birth midwife. Home birth transfer is a unique clinical situation because of a number of factors. Most women who choose to give birth outside the hospital system are well-informed, but paradoxically, they're often stereotyped as naive and alternative. Although uncommon, when home birth transfer does occur, it can bring high levels of uncertainty. There is clinical uncertainty for everyone involved, changing expectations for women about their labour and birth outcome and the people who will be there and the place they find themselves in, differing paradigms around safety and childbearing, different styles of handover and documentation, and sometimes conflicting views of accountability, whether it be to the woman or to the institution. Women need time to adjust to their changing expectations and process what is occurring. However, hospitals may be more accustomed to expediting the progress of labour and birth. The parameters of risk and safety in a hospital are biomedically driven, but in a home birth setting, they stem from physiological expectations and have clinical, emotional, psychological and social dimensions. The midwife-woman partnership is based on reciprocal trust and shared understanding. Some hospital staff we interviewed had different notions of their relationship with women in their care, expecting more recognition of caregiver expertise and hence, sometimes more immediate compliance from women. The strength of the home birth midwife-woman partnership may make it difficult for hospital midwives to develop their normal rapport with women. Women will naturally look to their home birth midwife for support and advocacy. Often hospital midwives are left wondering how and where they fit and how they might manage the social dynamics in the room. The woman's home birth midwife is her primary caregiver throughout pregnancy up until the time of transfer, however, may not be employed or ensured by the hospital. The home birth midwife may therefore lose clinical rights to practice upon transfer. And paradoxically, the privately practicing midwife is required to give a professional handover after losing such clinical rights and responsibilities. Just before we talk about the proposed principles for handover, I'd like to let you know about the Australian College of Midwives transfer from planned birth at home guidelines, which I was very proud to be part of the working group that compiled these guidelines and they are freely available online. There's a number of useful guidelines and included in the appendices is a template that may be used by midwives to provide a written summary of the woman and or baby's details. You can see the link at the bottom of the screen. Before I go on to the handover principles, I just want to summarize by saying that timely referral, consultation and transfer and smooth collaboration between caregivers is so important for the safety and well-being of women and their babies, especially when place of birth and caregivers change. The quality of the handover communication has the capacity to influence the level of collaborative interactions and processes that ensue after. Our principles have been synthesized from our findings and from a model for handover between anaesthetists and other health professionals in the perioperative setting, derived from a wonderful book by Alan Cena and colleagues that you can see on the left of the screen. The principles are also informed by findings of the home birth summit in the United States of which Saraswati Vedam is a key driver and author. And my final slide is as yet unpublished. It's expected to be published later this year. So I would ask you please not to share this last slide on social media. Handover occurs in the presence of the woman, partner, support team, her transferring home birth midwife, receiving hospital midwife and obstetric staff and includes the following. In the event of a clinical emergency, a clear verbal summary of clinical details is given immediately to address physical safety concerns for the woman and baby. In the absence of an emergency, this information is given as a summary of what is important to the woman. This may include a handover of a written transfer summary and the woman's emotional, psychological, cultural, spiritual and environmental needs are acknowledged. Written and verbal clinical information is provided, such as the woman's handheld pregnancy record and or a written anti-natal and interpartum history or transfer summary. The summary of the decision-making process leading up to the transfer and a discussion with the woman about her emotional and or psychological readiness to accept medical intervention. A discussion of the roles of the midwives who will provide ongoing care of the woman. Hospital staff respect and support the partnership between the woman and her home birth midwife. Home birth midwives respect and support the clinical responsibilities and duties of the hospital staff. When clinical rights to practice are not available, home birth midwives continue to care for the woman in the hospital setting in a support and advocacy role. When the home birth midwife is not available due to fatigue, her backup midwife known to the woman is provided. And this is not possible. The home birth midwife spends 30 minutes in the hospital with the woman to complete handover and assist her to make the transition to hospital care. And as I said, these are due to be published later in the year. Thank you for your attention, everybody. Does anyone have any questions? Awesome, Dr. Fox. Thank you so much for your presentation. I've really enjoyed it. I learned a lot about it and I really enjoyed the slide about oxytocin. It was something that I hadn't realised before how it had that kind of dual effect of feeling like really connected to some group but possibly then alienating from the other group. I thought that was fantastic information. There's already a couple of questions in the chat box. We don't have too much time, but if you have a question, add it to the chat box while Dr. Fox is answering these ones. The first one here is from Selina May and she asked the recommendations of 30 minutes away from the hospital for a home birthing woman. Who did that originate from? Was it from obstetricians or midwives or both? It's not evidence-based. There is a study just in its very infancy looking at these issues, but it was just a... 30 minutes was just arrived at by consensus as a recommended guideline in Australia. Awesome, thank you. And we had another... I'm just trying to find it now. Now I've lost my chat box here, but we had another question from Jean who asked, when women are transferred into the system, do they still have to pay for the intrapartum care that they received from the midwife before the transfer? I think she was talking about you had to pay out of pocket for some midwifery care. Yes, women have to pay for their intrapartum care with a privately practicing midwife. In a publicly funded home birth setting, the women don't pay. It's fully covered by Medicare. Awesome, thank you. And I can see a follow-up question to the location question, which is, what happens to the woman who are living more than 30 minutes away from the hospital? What if they live an hour away? Is there some kind of home birth option for them? And how does informed choice play into that? I can see Celine's put a follow-up question in the chat box as well. This is a very contentious issue in Australia. So we do know from... We know anecdotally and we know from some research that's been done by Melanie Jackson and colleagues that there are many women opting to free birth, so that is to birth at home without any professional caregivers present. And anecdotally, we know that this is occurring in increasing numbers for women who cannot access home birth. And women's distance from a hospital is one of the problems around access, as is the cost of a privately practicing midwife. So only having 15 publicly funded home birth programs around the country, around such a vast country, means there are many, many women, even in big cities, who cannot access publicly funded home birth because they're more than 30 minutes away. And they may not have the financial resources to pay for a privately practicing midwife. So it's really problematic and a big reason why we need to expand publicly funded home birth services. We need to integrate the system for women and privately practicing midwives. And we need desperately to find indemnity insurance for privately practicing midwives who care for women during the interpartum period at home because currently that's lacking. Awesome. It sounds like a very complicated situation with a lot of factors that kind of come together into play. Yes. Absolutely. Yes. It's interesting how different places in the world sort of deal with things differently like that. Thank you for that. I'm trying to see if there's any other questions. There's lots of chat about the 30 minute distance from the hospital and about how that works in different places or doesn't work in different places as well. But I'm going to... Sorry. Oh, I just noticed an interesting point from Sarah Langford that restrictive guidelines is a huge factor in rising free birth in Australia too. And this is true and this is another study that we're about to embark on. We want to look at what happens to women who develop complications and are unable to retain their home birth midwife because of that. So, yes, I acknowledge that that is a big factor. Yeah, really interesting because that's coming into play in some places in America as well. I know where there's like 42-week guidelines and stuff around birth too. So, this is coming into play more and more, I think, as we in America head down this road. So, fantastic. And I'm aware that we're coming to the end of our time, but I don't want to interrupt you, Dr Fox. So, please add... Oh, thanks, Megan. I'm just also seeing another comment from Midwives Geelong who support women birthing at home who live further away than 30 minutes from their backup hospital. And, yes, I'm well aware that there are privately practicing midwives and providing that service for women who are in more remote areas. And that's fantastic. But the current guidelines are for 30 minutes. So, these kinds of issues are things that we need to really sort out in the private and public sphere to enable greater access to choice for women, about place of birth. Wonderful. And there's that great research that's just come out of America here talking about distance where they found no difference in terms of outcomes for up to two hours away from the hospital. So, that was interesting too. So, I'm being told that it's time to move on. So, I'm going to turn off the recording.