 At this point, I'm going to turn it over to Cindy Farley from Georgetown University and I'll send you to do the presentation to introduce herself and her partner and the students. Thank you. Thank you, Lorraine. I'm Cindy Farley, Associate Professor at Georgetown University in the Midwifery and Women's Health Nurse Practitioner Programs. I teach labor, birth, postpartum and newborn care and I am involved in other professional activities such as leading advocacy activities with students and this is a shameless plug for session 20 on your VIDM program. I live in the United States in the village of Yellow Springs, Ohio. I am very happy to introduce the fifth annual Georgetown University Student Cafe along with Oxford Brooks University Midwifery students and faculty. Our students are going to discuss virtual and real time sharing and comparing of midwifery practices among United States and United Kingdom. The experiences that our students are going to share with you were discussed and structured with Dr. Ethel Burns of Oxford Brooks University, a senior lecturer and a midwife researcher focusing on water birth among her many talents. She will summarize our experiences at the end of this presentation and a shout out to Dr. Deb Dole who was also instrumental in facilitating our time together and I see her there in the audience. I do have a question to our live audience for the chat box. We are curious as to how many of you have engaged in an international exchange experience and what you learned from that. Please share in the chat box where you are from and where you had your exchange experience if this applies to you. The Fellowship of Midwives is a nod to J. R. R. Tolkien who famously wrote The Fellowship of the Rings. He was of Oxford, England and that is where this student to student exchange occurred. The Georgetown group also spent time in London connecting with midwives and students there. We want to acknowledge Jelana Lazar, Christine McCourt and all the London midwives who helped us in our learning journey. Fellowship is defined as a friendly association especially with people who share one's interests and that is exactly what we had with our colleagues at Oxford Brooks sharing both unique and universal aspects of midwifery care in our respective countries. We created this international travel opportunity through a Campion Hall residency in Oxford, England for fall of 2019. This Georgetown University program gave me the opportunity to live in residence at Campion Hall, the Jesuit Hall of the University of Oxford while conducting scholarly projects in the UK. I explored the structure and delivery of midwifery care in the United Kingdom for the lessons that can be gleaned for the United States. The United States unfortunately performs poorly on many maternal and infant outcomes compared to peer countries despite higher per capita spending on health care. Growing the midwifery workforce and better integrating midwifery care into the United States health care system such as the United Kingdom has done can contribute to improved maternal and infant health outcomes. I developed a short term study abroad experience to expose Georgetown midwifery students to other systems and models of midwifery and maternity care supporting a transformative approach to tackle some of the social, political and economic issues that can strain midwifery in the United States. Our short term study abroad experience was embedded in an existing course. The last course in a two year four month program. Our students from the fall are now graduates who have passed their boards and are launching into practice. Congratulations. Each student shows a particular area of midwifery practice to compare. You can see their choices listed on this slide. It was fortuitous that Dr. Burns second and third year midwifery students were studying global midwifery at the same time. Dr. Burns asked for Oxford Brooks volunteers to be connected via email to the Georgetown students prior to our visit. And so we created interpal pairs, international internet pen pals. Three interpal pairs will present their learning and insights to you today. There are many other ways we could make comparisons between the United States and the United Kingdom. However, for now, we will confine our remarks to our students experiences. I will now hand over our talk to Kate of Georgetown University and Eve of Oxford Brooks University and happy International Day of the Midwife. Thanks Cindy and hello everybody. My name is Kate Xu from Georgetown University. I'm a newly certified nurse midwife currently live in Baltimore City, State of Maryland in United States. I'm happy and very honored to be here today to share my short-term study aboard experience with everybody. There was some preparation originally assigned to all students before the trip, which I found to be most helpful. It included reading material provided by Professor Cindy that gave us some general knowledge of midwife practice in the UK. Additionally, every student would pick maternal health topic that they would like to focus on during the trip, as well as write down the learning goals and questions that we would like to ask from our interpal and midwife in UK. Eve from Oxford Brooks University and I were assigned as interpal pen pals. We began communicating with each other through email about a month before the trip. Since we were both in our last year of midwifery school at that time, we started our conversation around the general study and clinical practice of both countries. Then we continued our conversation on postnatal care through Facebook Messenger, which gave us a more casual way to communicate. I think this was an excellent way to start our relationship as an interpal, so when we actually sitting together in the same classroom at Oxford Brooks University, we were not total strangers to each other that allowed us to just dive into deeper conversation in the classroom setting through small group discussions. During my time, I mainly focus on learning the continued postpartum care in the UK. In the US, the maternal-maternity rate is rising while other developed countries like the UK are decreasing. The current US data has shown that approximately 700 women died annually in the United States from post-pregnancy-related complications, and improving the postpartum care is one of the strategies to address the preventable pregnancy-related deaths in the United States. Compared to just a single six-week postnatal visit in the office here, about half of the UK women see a midwifery or four more times after going home, so this is a huge difference. Even now, Eve and I still continue to keep in touch on Facebook and share ongoing practice change during COVID-19 pandemic, and I really cherish our friendship as we share interests in global health, and I'm hoping one day we can do an international mission trip together. This short-term study of our trip helped me have a deeper understanding of the importance of organizational structure in promoting a sustained midwifery practice in the United States. It took UK decades and a number of organizations worked together to have guidelines changed to promote better and cost-effective maternity care. With this short-term study aboard experience, I would like to continue to pay attention on national level of midwifery professional regulations and continue advocating for full scope practice of midwifery, finally promoting a midwifery unit model in the US as well as promoting continued postpartum care for all women. Next I will hand over to my interpaw Eve to share her experience with you. Thank you so much and happy international days of midwifery. Hi. Can everyone hear me? Yeah. Go ahead, Eve. Perfect. Thanks. So, hi. I'm Eve. I'm from Oxford. I'm Kate Interpaw, as she said. So during my midwifery program, I have worked in the John Radcliffe Hospital in Oxford in the antenatal, the intrapartum and the postnatal areas, and worked alongside midwives in the community as well. I have my final placement block to complete on the labour ward and the midwifery-led units at the minute, and following successful completion of all of my competencies, I will qualify hopefully this September. So I was connected with Kate. It was an email connection that was initially given by Cindy to us. Myself and Kate continued to chat through Facebook, and prior to meeting face to face we had given each other information about the differences in postnatal care in the UK and the US. As Kate had said, she was undertaking a project on the subject. We had also discussed the visit to Oxford and arranged a meet-up after our day in university, and as Kate said, we continue to keep in contact. I think having the initial connection made the first conversation easier when we were at university, but I find that as many of us are healthcare professionals, we can make conversation almost anywhere. The US is such a vast place that I was initially surprised at how different the role of the midwife was across different states, and then the areas that it's different to the UK as well, with different healthcare professionals having different roles in labour, a more significant role in family planning and contraception compared to the UK, and the idea of group anti-natal sessions where there's an element of privacy, but a more open forum for information to be shared. As Kate said, we chose to compare and contrast postnatal care in the US and UK as we had discussed this in detail prior and during the Oxford visit. So in the UK, whether the woman has given birth in a hospital or a midwifery-led unit or at home, the respective community midwifery team are informed, and a midwife from this team will visit the family home, either the day after discharge from hospital or the day after the birth, and there's kind of a physical and an emotional aspect of a midwife supporting a woman. So the physical aspect of the care provided to the woman and the baby is, for example an IP check which has done 72 hours or up to 72 hours of the baby being born to check the heart, hips and eyes. If there are no concerns regarding mother or baby's well-being and feeding, then the midwives will visit on day five when the newborn is given an offered a blood spot test and the baby's weighed. These postnatal checks are completed in unison with the mother, which aims to give her the opportunity to be more involved in the checks as well, and then on day ten the baby is weighed again, and if the midwife is happy with the mother and baby's well-being, both physically and absolutely, and the baby's above birth weight, then the woman can be discharged to health visitors in the UK. A postnatal check of mother and baby, if there are any concerns, extra appointments are made with the midwife to support the woman. In order to support the women on an emotional and psychological level, the midwife aims to work in a partnership with the woman, giving her a safe space to open up and talk about her feelings and emotions, and this is where continuity of care is so important as small changes in the behaviour are much easier for the midwife to recognise then. So that's kind of a short summary of the UK postnatal care and how we try to have a holistic approach to the care that we give, and a little summary on me and Kate's connection. So thank you for listening and happy international day to the midwife. Thank you Eve. Is NIPI a neonatal initial physical exam? Yes, sorry. Okay, it's just acronyms can mean so many things. So thank you for clarifying. And now we're going to hear from Brandy. Well, I'm Brandy Fields. I'm a newly certified nurse midwife and women's health nurse practitioner. I'm in Sunbury, Ohio in the US. My interpell that you're here next room is Heidi Webb. When Dr. Cindy Farley announced the opportunity of traveling to the UK to learn about midwifery overseas, I knew this was an opportunity I did not want to pass up, travelling and learning about different cultures and ways of life are a true passion of mine. I was told we would be meeting Dr. Ethel Burns, whose research focused on water birth. And as a previous labor and delivery nurse and moving into my role as a student nurse midwife in clinical, I had never experienced a water birth or even a patient laboring in the water. So this really fascinated me and piqued my interest and it became a central focus of my international comparison project. In my pre-trip research, I determined that all governing bodies related to midwifery and obstetrics had different guidelines that surrounded the practice of water immersion for labor and for birth. The Royal College of Midwives and the Royal College of Obstetricians and Gynecologists had a joint statement that supported the informed decision of a woman deciding to birth in the water. However, in the United States, the American College of Nurse Midwives and the American College of Obstetricians and Gynecologists, they have separate guidelines that did not agree. The ACNM statement is similar to the RCM and RCOG guidelines, whereas ACOG states a land birth as a recommendation for birth overall. Integrating the short-term study experience into my research surrounding water birth in the UK was very eye-opening. We had several opportunities to tour several facilities, both hospitals and birthing centers in the United Kingdom while we were there. Each of these facilities had birthing tubs available for water immersion and for birth. Not only were they vastly available, but as you can see in my photo, the center of attention when you entered each of the birthing rooms. It was during our time spent with the Oxford Brook students and asking the question of how many students had experienced a water birth, with most of them raising a hand, but I realized how important this choice was for a woman to get birth. Personally, the project I completed for the experience and the entire study or broad trip have made a lasting impression on the type of midwife I want to be and how I want to practice. I believe learning opportunities such as this can help shape changes to improve our maternal, fetal and neonatal health outcomes, not only in the United States, but all over the entire world. Now I will pass it over to my interpal Heidi Webb. Happy International Day of the Midlife. Good afternoon, everybody. My name is Heidi and I'm a third year student midwife studying at Oxford Brooks University. So this means I'm set to qualify in July this year. Throughout this international exchange program, I've had the pleasure of corresponding with Brandy, whom, as she's just told you, is now practicing certified nurse midwife. So during our exchanges, it became evident that despite sharing the title of midwife, the path to the qualification was significantly different in each country, and many of these differences stemmed from the roles between the countries. In the United States, midwives remit begins at reproductive age and continues right through to the menopause and as a result of which advice on sexual health and contraception are included. This also includes the prescription and administration of contraceptive devices. Although midwives rights vary between states in America, a common thread is that they interface with obstetricians. This relationship is different to that of the UK, particularly in the pregnancy birth and peripure. For midwives in the United Kingdom, the role of the midwife may in some circumstances begin with preconceptual advice. However, in contrast to the USA, traditionally it begins with the antenatal period. Midwives are the lead health professionals for healthy women experiencing a straightforward pregnancy and hold a key public health role. It is expected that referrals will be made as required to ensure the well-being of the mother and baby throughout the period, using up to date research to inform dialogue with women when negotiating their care. Intrapartum care is also overseen by a midwife. This begins from the moment a woman feels she is requiring more support until the birth of her baby. However, some scenarios may mean that we work in partnership with medics to secure agency for women. Within the UK, there is currently a national drive to increase the number of women being attended during birth by a midwife she has previously met. As Eva's already pointed out, during the postnatal period, mothers and babies are cared for by their named midwife, which extends to the 10 to 14 days postpartum. Following this, the midwife will have no further contact with the women. For some women, it's possible that they do not see a doctor for the entirety of their pregnancy and birth. In the United States, there are three options to practice in midwifery certified nurse midwife, certified midwife and certified professional midwife. Within the UK, registered nurses can undertake a shortened 18-month course to gain a midwifery registration. However, in order for dual registration to be maintained, they must work a minimum amount of hours in each discipline as set out by the nurse and midwifery council. As previously mentioned, the variations of the roles of midwife lead to educational standards different. In the UK, the nurse and midwifery council is the government body and outlines the requirements to each registration. Students must demonstrate competence in a variety of different areas, ranging from using evidence-based practice clinical skills, obstetric and neonatal emergencies, interpersonal skills and medicine management. Competencies are completely collated yearly with gradual autonomy throughout the years. In addition to this, over three years, EU requirements linked to the International Confederation of Midwifery Competencies must be met. This includes the completion of 100 antenatal checks, 100 postnatal checks, including mum and baby, to personally care for 40 women in labour, conduct the birth and deliver the placenta. This also includes water birth. Care for 40 women in pregnancy, sorry, complete 2,300 hours of clinical practice. Care for 40 women in pregnancy, labour or postnatal period with complexities. And the completion of 2,300 hours of relevant academic study, including assignments, stimulation-based exams and exams. We are also required to have each service user feedback twice yearly. The largest scope of practice for midwives in the USA is a reflection in their requirements, the minimum of which, as Brandi has said, are 10 preconception care visits, 15 new antenatal visits, 18 return antenatal visits, 20 labour management experiences, 20 births, 20 newborn assessments, 10 breastfeeding visits, 35 postnatal visits, 40 common health problems, 20 family planning visits, 40 gynecological visits and 20 perimenopausal or menopausal visits. In addition, exams and written academic work is also required throughout. One thing I must say, though, that during our sessions together in Oxford, it was evident that despite the variations in the education and the role of the midwife across the countries, we held a common goal to advocate for and provide women-centered care whilst improving experiences and outcomes for women and their families. Thank you all for listening. Happy International Day for Midwife. Hello, I am Danae Elston, a former student of Cindy's and am a recently certified nurse midwife and women's health nurse practitioner. I live and work in the Twin Cities of Minneapolis in St. Paul, Minnesota, USA, which is in the Upper Midwest. Midwifery is popular and well supported in the metropolitan area of the Twin Cities and is growing in the rural areas of the state. Though midwife attend and births still count for less than a quarter of births in Minnesota. In the time since returning home from our UK visit in October of 2019, I have graduated from Georgetown and passed national credentialing exams to be a certified nurse midwife and women's health nurse practitioner. Due to the SARS-CoV-2 epidemic, my state licensure has been paused and my new start date for my new role has been put on hold indefinitely. So I'm looking forward to starting my new role as a midwife once that is safe for me to do so. I can easily say that the UK visit is one of my favorite memories of graduate school and one of the most influential experiences on my view of midwifery. Initially, I perceived the assignment of an intrapal as silly busy work, but the opportunity to connect with Laura before traveling to Oxford created a bond that truly enriched the in-person experience in a way I hadn't anticipated. Through email, Laura and I shared about our personal lives and explained to each other what the midwifery structure and scope of practice is like where we work. Once my classmates and I arrived at Oxford Brooks, I was amazed at how quickly we all became comfortable learning from each other. It was evident that the intrapal relationship created strong connections and allowed for all forms of conversation to flow easily. My learning focus for this international midwifery experience was to examine the differences between group beta strep, known as GBS, screening procedures in the US and the UK. In the US, every pregnant person gets tested for GBS colonization during their pregnancy, usually between 35 and 37 weeks gestation. People who screen positive for GBS colonization are treated prophylactically with antibiotics during labor at least two hours before delivery, with the goal of reducing bacterial load in the birth canal and limiting the exposure of the newborn to group beta strep to caca. I recently became aware of a push in the US to limit antibiotic use during labor due to the potential impacts on the fetal gut and of the widespread use of antibiotics. I wanted to see if the UK way of limited screening and therefore more limited antibiotic use was equally safe. My understanding from research I could do on my own was that GBS testing in the UK was not universal and depended on risk factors, but was still a fairly common practice. Through conversations with Laura and her classmates, it was evident that while there's a push for more universal GBS testing guidelines in the UK, most districts continue to follow current guidelines, which screens pregnant people for GBS disease risk factors and only offers tests to those with an elevated risk for GBS disease of the newborn. Of note, GBS sepsis rates in the US are lower than in the UK, but with less than one out of a thousand live births difference between the rates for both early and late GBS sepsis of the newborn. The UK National Screening Committee has recently acknowledged a 31% rise in the prevalence of GBS infections of the newborn since 2000 and have approved a trial to evaluate the effectiveness of testing protocols to identify maternal GBS infections to prevent transmission to the newborn during birth. The trial will evaluate screening at the end of pregnancy between 35 and 37 weeks, so similar to what the US does, and then also a bedside test to be administered at the start of labor. While Laura and I both have busy lives and are starting new careers and missed wives, our interpal connection took a break between last November and this spring. It's been exciting to rekindle our international friendship while working on preparing this presentation, and I hope to continue to share life's achievements and struggles before as we move forward into our midwifery careers. The greatest benefit I have experienced from this international midwifery experience is a broader understanding of global midwifery and even of midwifery within America. The scope of practice and practice structures of midwifery very wildly between continents, countries, states, and even neighborhoods, and despite these differences, it's humbling and exhilarating to know that at the root of it all, we're all midwives here to serve working people and their families and support the growth of new life. The ties that bind us are stronger than our differences, and that's the main lesson that I'm taking with me into my midwifery career. Thank you and happy International Day of the Midwife. Hello, I'm Laura. I am also a final year student over in Oxford in the UK and again, dependent on those competencies that Heidi spoke about should be hoping to qualify sometime between June and July of this year, so not long left to go. I would like to echo what Dene said in that I think the biggest learning point for all of us at the exchange was that we could see many, many differences between education between the way that practice was undertaken in the UK and the US and also the way that midwives standing in the community was viewed. But I think that overall we all had that same underlying want and desire to be there for the women and you know that was something that was really strong in that room. So I will speak to you a little bit about the screening practice for group B steps in the United Kingdom and the reason that we do things very differently from the US. So within the UK, the rate of early on set GBS infection in babies is one in 1,750 babies every year will be affected by sepsis linked to this bacteria. One in 19 of those babies will die and one in 14 of those babies will suffer a long term disability. However, the UK does not have a routine screening program in play. Parents are able to opt to undertake screening privately, but this does come at a cost to them and it takes place outside of the routine midwifery care. So their NHS midwife would not have any input in that and the swabs are done by the couples themselves. The cost of that is around £30, which I think works out roughly $43. And the major reason that the UK do not routinely carry out this test is that the UK National Screening Committee don't believe that it is accurate enough to effectively predict the risk to those babies at risk of early on set GBS infection. And the decision not to test is endorsed by national bodies in the UK, such as the Royal College of Obstetricians and Gynecologists, along with the National Institute of Health and Care Excellence. So as Dene said, we understand that the ideal time to screen for GBS in pregnancy is between 35 and 37 weeks of gestation. But one study in the UK found that actually 60% of deaths from early on set GBS infections in the UK occur in preterm infants born before 34 weeks, and therefore the test wouldn't be effective or preventative or offer any opportunity to provide those prophylaxis and antibiotics in labour. The UK National Screening Committee also found that there is a degree of inaccuracy within these tests and that it could lead to ineffective or overtreatment with antibiotics. So at 37 weeks of pregnancy, there were women who tested negative for the bacteria who actually then were positive at delivery and vice versa. Thousands of pregnant women carry this bacteria asymptomatically and it is difficult to understand exactly which babies of these mothers would go on to develop an early on set infection. The number of women who would require treatment to prevent just one case is high and the rates of the rates of infection in the UK are very similar to some countries where screening is recommended and routine and the current tests are unable to distinguish which women are at high risk of transmitting the GBS to their babies and which babies then would be susceptible to infection. Whether or not the fact that our health services have run very differently would come into this. I don't know. It's very interesting to see that within the US care appeal is quite fragmented and obviously for people from state to state a midwife may or may not be the lead professional in pregnancy. The UK is a very very similar across the UK. We have national guidelines in place from the NHS and most of our local services will choose to follow those. It's really interesting to hear about the new study that has been undertaken or is due to be undertaken by the National Screening Committee and it's something that I'll be watching out with very appreciative. I'm pleased to patient. Thank you for listening. I hope you've had a little insight into the differences and happy International Day of the midwife. Hello everybody. I'm delighted to be here with you all for this session and thank you Cindy for inviting us at Oxford Brookes to be involved in it. So I'm Ethel. As Cindy mentioned, I'm a midwifery lecturer and I do a search. I'm based in Oxford Brookes University. I teach across a range of modules within the midwifery education programs, particularly those linked directly to developing critical thinking and research skills. Which may sound a little boring, but it isn't. I'm subject coordinator for the direct entry. That means no previous healthcare education students who do the master's program. Most importantly, I retain for me alone, I retain a clinical role as a bank midwife working mostly in a freestanding midwifery unit. For me, this link to real world midwifery is an essential stimulant for ideas and it remains a privilege to care for women and their families. I feel it also enhances my connection with students. Lastly, and in the context of this wonderful global event, I would like to share that I've worked on midwifery projects in a range of countries which have included Vietnam, Russia, Nigeria, Uganda and Nagorno-Karabakh. Which for those of you who may not know, the latter is a flank of beautiful but scarred mountainous terrain that lies between Armenia and Azerbaijan. It is a self-declared republic and in an official state of ceasefire from a bitter war during the 1990s following the Soviet breakup. It is not UN recognized and so it receives very limited aid. These experiences humbled me and taught me so much that I cannot articulate it in words except to highlight the strength, flexibility and sheer courage displayed by many people who managed to preserve their innate humanity and grace amid harrowing experiences. Well, enough about me. I'm sure you will agree it has been an interesting sharing experience that offers us food for thought with our colleagues and will hopefully stimulate some questions in a few minutes' time. As you can see here, the interpile exchange went down a storm and indeed the whole cohort of students who met their American peers. For those of you who cannot see this in clear detail, here is a random sample of their feedback. So we have heard UK-US Comparative vignettes on postnatal care, Kate and Eve, Waterburth, a shared passion with Brandy, GBS Screening with Diney. I hope I've got your pronunciation right now, Diney. And Laura and core skills and competencies with Heidi. Thank you all. I'm keen to optimise our time for questions and further sharing. So we'll move on quickly to expand into thoughts and plans that Cindy and I are exploring to develop our collaboration. Pre the coronavirus pandemic, I was invited to visit Georgetown University to attend your graduation ceremony, Kate, Brandy, Diney and cohort and present some of my research around water immersion during labor and waterbirth. However, despite this being scuppered, I have recruited Cindy to be a member of an international group I'm leading on creating a systematic review on this topic. It's one of a suite of three systematic reviews, a scoping review on caregivers, views and experiences and a systematic review on evidence relating to women's experiences and views. So the goal is to apply for funding to develop an online clinical guideline based on the best available evidence. And this will be an online woman and health professional facing resource. There's a picture here of the opening of the first custom made birth pool used in the NHS in 1990 in Oxford. So we were the first to offer a service to women. So thank you for this gift to Sheila Kitzinger, a friend and mentor who I still miss. So we move on to the next slide. Here's a wee slip into pre-COVID restrictions. I'm not completely insane here now we're doing the social distancing. Celebration of women, their families and students at our annual fundraising event this February for a community service. I introduced this in 2013. It's called Zumba for Bump. So it's a weekly hour of dance followed by Club Bump Chat with the women and their babies. Heidi Mande, she's down in that bottom picture by the balloons, the registration table. We thought we I thought we would be pausing this class with the lockdown, but no women wanted to carry on with it. So we're now doing Zoom Zumba, which is helping me to keep vaguely fit. Next slide. So just before we go into interactivity, a huge thank you to Cindy, her colleague Deborah, students and interpals for making this happen. And at global level, remember the best available evidence is unequivocal. It tells us that midwives matter. With courage, kindness, a keen knowledge base that is continually reflected upon and added to and advocacy, we can and do make a seminal difference to society. This journey is really easy, but it's transformational. Happy International Day of the Midwife. On this special year of the midwife and special best wishes to colleagues caring for women during this pandemic, go safely. Thank you. Open to questions now. Thank you. This is Cindy and I just want to acknowledge our all our students. Ethel and I are so proud of you all and just enjoyed our connection both in the UK, prior to the UK and then after in creating this presentation for you all. If anyone would like to unmute and ask a question or type it in the chat box, we can respond. Hello, it's Louisa here. Hello, Louisa. Thank you for that presentation because really interesting. I've enjoyed hearing the perspectives of the students from both the USA and from the UK. I just wondered, and I thought it'd be great to do something like that at Bournemouth University, but I just wondered, did the students from America self fund themselves to come here or did they get funding from the university itself? So this is Cindy. And yes, the students self funded to come. We were able to support a few meals and let's see. Oh, we visited the call the midwife set. So we were able to fund that as well, but the bulk of the expenses were borne by the students. And we did get some tea and biscuits from all the UK midwives we visited and launched on occasion. So that was lovely. Thank you very much. I see some questions in chat. We only have time for a few more. I see one from Juliana and she asks would UK midwives be able to revalidate their credentials in the US and vice versa? I can start that conversation. I know in the US that we have very limited programs that work with what we call foreign trained midwives and they have to be evaluated by an international education company that looks at credit load and topic and equivalents. So in most, in fact, all foreign educated midwives would have to take something we call a refresher program and they'll very likely get a lot of credit toward the childbearing aspects of midwifery because that is a universal part of our role. But in the US, we include well woman care, primary care and a fair amount of GYN practice that is not typical and so would need to be added and then they would have to sit the national board exam. I'm a bit unsure. I'm going to fess up and be honest and say I'm unsure exactly what goes on now but there was a trans, I can't even remember the name of it but I know I did some workshops with midwives for example coming to the UK from Iran and Iraq. I'm unsure of what currently happens. I'm going to ask Jelana Lazar in the audience to unmute because she's investigated getting her, she's a US midwife who's investigated getting credentialed in the UK. Are you there Jelana? Well, according to when I've chatted with Jelana the US midwives would have to take the UK exam and so it, oh, she's on listen only tap. So there's a fee involved and I believe both a simulation exam and a didactic exam. The test of competence. Yes. And while Jelana is typing we can take this last question from Malena who has asked us a couple of times. Did the students experience postpartum repairs very differently US versus UK? Interesting, I do know there are some differences in repair, the standardly taught repair of the perineum but that specific topic was not investigated to the extent that these other topics were. So, and we did visit for a systems look not individual clinical care. So we were definitely not with patients or midwives in practice during the practice. We toured facilities, we listened to emerging research and we talked to midwives about their practice. So didn't really get to observe repair work. Well, all good things must come to an end. Thank you. Thank you so much. Let's have some applause in the chat. I see Jelana has responded. She said that essentially you have to submit an application and yes, two tests and also pay a fee and an English test all laid out on the Nursing Midwifery Council guideline or guidance online for anyone interested. So thank you very much, Cindy Ethel and the fabulous students who've been participating in this. Thank you Lorraine and I'll see you next year about this time. You bet.