 can impact maternal health in disaster and conflict situations. I myself am a midwife of a two decades experience who is currently working as a consultant in the humanitarian context. Claire reading is our presenter today who I actually have had the opportunity to find Gaudesh last year so it was quite amazing to see that she was then also matched with me with this. So we have Captain touch since and I know that you will enjoy her presentation which is timely. The estimates that are currently given that there are 807 women who die daily of presentable causes of maternal newborn health and that of the 807 that die that over 500 die in countries that are fragile because of natural conflicts or disaster. So this again gives us a scope of the problem. Claire we turn it over to you. Good morning everybody. Can you hear me? Pandora can you hear me? Okay fine I was I was obsessed that maybe I would start and then people be waving their hands saying they can't hear me. Tanya you can hear me this is great. Hi everybody. So this is my presentation. It's mainly based around the work I've done in South Sudan. I came back last week from a short two months stint there and previously I was there last year as well. I work for medicines on frontier doctors about borders and I've given this presentation before so that's why their logo is over it as well. Okay let's make a start and it works isn't it lovely when the technology works. Okay so basically the objectives of the presentation I wanted to highlight the neglected area of section reproductive health because I feel that it's often the thing that people add in at the end. It's oh yeah there's a malnutrition crisis or there's been a hurricane and now we have cholera and the team goes in and you have your doctors you have your nurses you have your water engineers you have your psychologists and it feels like the midwife can sometimes be the person that is added at the end because people then realize that you know what actually all these disasters natural man-made they all need somebody being the advocate and speaking up for the women and the babies. I'm going to talk to you a little bit about the health challenges faced by women who are caught up in conflict be that current conflict or post-conflict zones and I'm going to talk to you about the challenges faced by midwives that I've worked with and when we have time out from work and we talk about their lives and it's very hard to find a to really understand I cannot and I can you know say that's really going on in your life but I can't really understand it and I think then trying to relate that to a work context and makes you really understand the real challenges faced by by staff working in in lower middle-income countries where there is conflict. So I'm going to be sharing with you my experiences of working in the Democratic Republic of Congo I was there with MSF in 2015 and in South Sudan like I said last year in this year. I'm also going to talk a little bit about what MSF is doing for internally displaced people and refugees and what our focus is on which is very similar to many of the big international NGOs and going forward so how do we go forward and what are the solutions I'm not going to give you solutions if I had them I'd be out there implementing them now but it's very challenging and I've got some of my personal maybe their more opinions rather than statistically backed up ideas. Okay I know you can't click that link and we're not going to do it that is a short film it's around five minutes and that's of Malakal POC and the POC is a protection of civilians run by the United Nations and that's in Malakal in the northeast and that's where I was based in March and April and we have a hospital there but we don't provide maternity services but you get the idea of the quality of life that people are living and I'd urge you all to watch that film because it gives you a big perspective on what's going on and lots of people will say to me or how was Sudan and I have to keep saying I wasn't in Sudan I was in South Sudan it's quite a different context okay so I put a little map because people of South Sudan obviously very proud that they are the youngest country in the world even though that country is being ravaged at the moment and I know most of you probably know this but maybe some people don't and because some of my colleagues didn't know this so it's about what you can expect from MSF or from many of the NGOs who provide maternity care in middle and low-income countries because actually it's quite different to that of the UK so we encourage the women to come as early as possible obviously and we would still give folic acid if they come before 12 weeks and trying to encourage women to come for a minimum of four antenatal clinic contacts all right you might think my goodness that's hardly anything but actually if women live very far away from a health facility and remember that there isn't really a Ministry of Health in South Sudan there is in the Democratic Republic of Congo but it's very it's not consistent so sometimes drugs come occasionally people get paid it's not you know and it's not stable basically and there isn't a like I said Ministry of Health okay so most of the funding coming into the health is coming from the World Bank as well as international NGOs we're very hot on giving vaccinations and obviously we want to protect the women against tetanus and they have a little card and so people women are very good at this actually in my opinion but still meeting a lot of women here having baby number four baby number five who have never accessed antenatal care and due to displacement are then seeing MSF is there and coming to the clinic and we screen and treat and give management for malaria anemia STI so mainly syphilis and then we'll do flowcharts for other STIs if women have got some symptoms and equally we'll give them something called albendazole in the second and trimester as a one-off to treat for parasitic infections and the last one is quite a challenging one as giving a sterile delivery kit and that sterile delivery kit and is great so it has sterile gloves it has two small towels so one to dry the baby one to keep the baby warm it has a sterile blade and has two pieces of sterile cord to dry to tie the cord sorry so it's perfect but I had a kind of an internal emotional turmoil about it because if I give this kit am I kind of saying to the ladies it's okay you don't need to come back here for delivery you just have this kit and call your TVA and have your baby at home and it's very difficult because some women who live you know 40 50 kilometers away or if they go into labour in the dark actually it's not safe for them to come to to the clinic to the hospital to have their baby with us so I find this one a really a really difficult one so we used to team and I used to say here's the kits but actually can you bring the kit back to with us when you come in for labour only you have the baby at home if you're really that's what you want but we would encourage you all to come here with us and bring your TVA as well so we're all doing we're all here to support you together and I think that is it's a very much a collaborative you know that partnership as well okay so the health challenges for midwives and what are they so I think I touched on it briefly then the security for midwives and women working in maternity so you know we provided 24 7 service and I definitely felt that staff didn't want to travel in at night but as soon as it got dark so we had some staff in South Sudan who would sleep in the compound because they felt that they were safer there we've had staff in DRC when they were on call to be the first attendee at C section they physically couldn't get there because they they said it's just not safe for me to come it's dark it's the night I don't feel safe so you know not only is it not always safe for women to go out and get fired and leave compounds or leave the POC's that's like a camp that internally displays people to the protection of civilian camp so my only is it say not safe for women to leave it's not safe for health workers either just because you have an ID badge doesn't mean obviously it's safe for them either so there's a definite issue of looking after our staff so it also giving them somewhere to live which obviously isn't always the easiest thing either and working in a place like DRC or South Sudan after years and years decades of war has meant that we have a massive depleted pool of midwives and skilled birth attendants and not only to care for them but to identify complications and that for me is the big thing identify when we need to refer this women to a higher level and comprehensive unit and this is a really big issue and I know lots of people are working on this trying to provide midwifery schools and support and so our role working with MSF when it's a very acute situation is still a lot of capacity building and I don't understand how it's going to get better because the main situation in South Sudan remains very fragile it remains it remains very unstable which means that there are still there are no schools I've worked in three areas of South Sudan in the last six months and every time I ask where are the schools while the teachers don't get paid because the Ministry of Education doesn't pay them so they move and the displacement of people out of South Sudan is a lot of people have moved onto Kenya into Ethiopia into Sudan and into North Uganda so we have a massive depletion of skilled attendants to look after the women and the children who are going forward that's not going to get better in the next 10-15 years we need to educate the next generation there's a lack of comprehensive maternity care so even if we have these small clinics where we're doing ANC starting to think about family planning providing first contact for survivors of sexual and gender based violence actually the operating theatres that can also provide blood transfusion is extremely unifar between we're talking hundreds and hundreds of miles it's okay if you have MSF because we will always have an operating theatre or we will work in partnership with another NGO such as International Medical Corps that will have an operating theatre that will be able to refer women to safely and will have sports but actually people who live very rorally if you look on a map and say where's the nearest operating theatre for a woman who you know almost you can close your eyes and point anywhere on a map and it will be hundreds of miles mostly and that's pretty difficult to comprehend that if there's a complication what happens and so what happens is that South Sudan has the highest maternal mortality rate in the world and I don't even think that all of these stats are easy to gather together I'm not I'm not sure where I think a lot of them are estimated because I'm telling you now that I know that when we have deaths we report them and we do for investigations but I'm not sure about what happens when it's so rural and women are in the bush that how do these deaths get reported so the stats that we're working with at the moment are that around they think World Health Organization thinks around 789 women per hundred thousand will die of pregnancy or childbearing reasons if we link that to the UK the UK is nine and that's nine too many so that's nine per 100,000 and in South Sudan it's 789 it's a it's you can't really understand that number can you because I can't it's pretty terrifying and it must be pretty terrifying to be pregnant and I think that's often some of the things that women will say to us you know I'm frightened and is it all going to be okay and this leads on to the correlation between conflict and sexual and gender-based violence as GBV and this is what we see a lot of and we're seeing a lot and that worries me that they're the women who are coming I would probably triple it of what is actually happening in the community so we know that when there's conflict when there's a man-made disaster but there's a natural disaster that the rates of sexual and gender-based violence increase and I would definitely say that that is something that I agree with and that is something that MSF is seeing a lot of and I'm going to talk a bit more about this in the presentation trauma experienced by staff now what does that mean now I personally think that that that means about displacement about leaving all of your leaving your life behind and moving because because armed fortes have come to move you and sometimes moving your family to a refugee camp in a different country and then maybe you're the only person that is able to work and so you come back into your own country back into South Sudan and you send your money to your family in the refugee camp I worked with staff and been to you last year who hadn't seen their children for a year because they were in Kaguma which is a refugee camp in Northern Kenya it's just so difficult to to understand how they must feel and you know there's me trying to be like you know you really need to be listening in with the pinard every 15 minutes and documenting it on the part of ground and I'm sure they just must think really clever I've got other things to be thinking about even though they would they did do and they did do it well but I think that's another issue to bring into it that the trauma that people bring and their own experiences of of being in a conflict saying and really interestingly MSF sent a psychologist for staff in Malakal last month and I thought that was a really excellent thing for them to do so they could have one-on-one sessions and confidential sessions where they could just talk about how they're feeling not about work necessarily but something for them because they had experienced so much trauma that's difficult to comprehend tribal and political boundaries and their effects on health care provision okay so I'll tell you this is a presentation full of stories I'm sorry but as someone said to me this week the clan that was a different to doctors they do love to tell a story and they sometimes do that in their documentation too so boundaries and their effects on health care provision what do I mean okay so quickly because I think I've already been talking 20 minutes and on slide three and I had a lady back last year who delivered baby six actually she had a massive postpartum hemorrhage and I didn't have any tranexamic acid so maybe this is something that MSF will be bringing hopefully into their policies and she was stable which in my opinion I need to transfer her I wanted to give her a blood transfusion so she was stable but not that stable and trying to find a man to donate blood was difficult her husband was in an armed group so wasn't around but her brother-in-law was she was of the new air tribe and trying to find somebody who could give blood that could that could go to the comprehensive which was also in the United Nations another POC so protection of civilians camp so if you think of it as a refugee camp but for internally displaced people and the problem with these camps is a bit like how do I put it they have they're very political how do I that's how I put it to be diplomatic they're very political so if you are not of a tribe it's almost like gang warfare but it's tribal and then you can't go so it turned out that distance but her brother-in-law was not of the right political view of right tribe so he he couldn't come and so we had to try and find another man so he had to try and almost find a friend that would donate blood for his sister-in-law and these are very very difficult things and they take a long time and and all the time I'm inside of a Land Cruiser with the lady on a stretcher on the back with the newborn baby trying to find a blood donor and this is all because of the tribal warfare that is happening and the political views and that has a massive effect more than you would realize on actually health by provision water and sanitation unable to build latrines on rented land so what does that mean so that means that with the displacement that I keep talking about so let's try and put it in UK terms if there is this big warfare around Bristol all of the people from Bristol have moved to Birmingham all the people in Birmingham had already left Edinburgh okay so all the people in Bristol they're now in Birmingham and they're effectively squatting in the houses of people from Birmingham okay but they cannot go into the back garden and build a latrine that is completely against their culture yes they can go in and live in their houses but they could never build latrines this is what people told me that that was a complete no-no so obviously we had issues with sanitation and and yeah and the illnesses that come from that so these are all things related to conflict that you don't necessarily think about when you go in as the midwife okay and some photos for you so this is the maternity in Bintutown which is in the north of South Sudan and I was there last year and we had there was five of us all together that was including Jani who was our translator and they're two hours ahead and they will be at work right now but I'm hoping that they will see this later and so my role and our role as MSF is to support and educate and we provide basic maternity care in Bintutown and in Bintutown POC the protection of civilians big compound run by the UN that MSF has a comprehensive centre there so we have a scanner we have a anesthetist and anesthetist we have surgeons and we can do a cesarean section but actually here in Bintutown which was about a 40 minute drive away we slept here so we were here 24-7 but we were not able to transfer women basically in the dark okay and as you can see here there were this is our waiting area and this is where women came in so it's about trying to provide privacy and I think the way I described it to someone was basically it's the Spice Girls and one of my colleagues said not sure how professional that sounds clear and I said it's really professional because it's all about women and back in the 90s when all of this feminism was very it really felt like it was it was feeding into reality and I so that was my kind of hashtag but it was Spice Girls in reality and we had female gods and there were four staff South Sudanese staff and myself and if you were a man you were not allowed in and I really like that I really really like that it was quite difficult when we had women who it was clear that they had sexually transmitted infections and trying to find somewhere that we could speak to them in private with their husband that was more of a challenge trying to figure out what where was the most appropriate place so we took them into outpatients into a special more of a private room and why this really matters okay so for me not only is it all about maternity and women being together it's also about having private spaces to to provide good quality confidential care for women especially who have been raped or had sexual assaults and that is what we're seeing a lot of themselves to turn at women who have been abducted by gunpoint I'm saying it but I can't really just find it so difficult so this is what's happening this is what is happening and they have no one to tell because they feel their community will shun them and their husband will divorce them and that means that they will die and that is what women believe and that is how communities perceive people and so there's a lot of work for us to do regarding engaging the community working with both men and women and and providing a service that women can really access and that's why I'm really happy with what happened in men to you and the logistics that it meant basically it gave the logisticians a big headache to create this female-only space but the women liked it and the women queued up every day I mean 40 women a day would come that learn women coming in with their small babies with chest infections let's learn women coming in needing post-abortion care as well as women in labor so it was a very busy clinic and yes I know you can see the delivery table delivery bed but we did have a mattress and we did try and support women to use the mattress it could be a bit more upright but you know people always say as soon as the midwife arrives oh you've got a bed and I think oh god if you just bought us a couple of mattresses that's actually what we really need. Okay so challenges for women and babies on the move and there is a lot of movement sadly and they'll sit down there is a lot a lot of movement of women pregnant women women with new babies being pushed out of their homes by armed groups so the challenges finding safe free accessible maternity care very very difficult for women to access this without international and non-governmental organizations okay because as I said the Ministry of Health doesn't really exist in South Sudan. Nutrition and food insecurity yes I know you've heard probably a lot about the famine that is happening it is happening in South Sudan I want you to be aware that that is happening in the world through the world food program is doing an absolutely wonderful job with airdrops and trying to make sure that when everybody is fed why is there insecurity okay so I'm going back to the movement if you plant your crops and then you're pushed out of your community and you're forced to be on the move you can't go back and water those crops you can't go back and cultivate those crops they've gone they've been burned people burn these these armed groups are burning everything okay so people don't have food security that they would normally have so this time it's not about climate it's not it's not there isn't rain it's the fact that people are on the move and they cannot and they don't have any crops they don't have any food to cultivate nutrition is a big issue I've never seen more nutritional issues than both times I've worked in South Sudan women as you can see here this is a MUAC so mid to upper arms a conference that we use and the the parameters are obviously low for pregnant and lactating women and so this meant that a lot of women were on food supplements that we could provide for them and obviously that that has a knock-on effect to the pregnancy and to the baby as well so seeing a lot of low birth weight babies other challenges for women and babies on the move regarding documentation and follow-up and a lot of people will say to me when you go overseas you don't go do as much writing now you do have to do just as much writing and it's just as vitally important and the follow-up as well and it may not just be reams of it but the documentation is still there and that's important to reinforce and if a pateogram isn't filled in then that is that's just as serious as it is here in the UK and so women who who don't have their documentation because they've had to flee their home women who don't know when their babies immunizations were last given because actually they don't have the piece of paper because actually when they left their home that wasn't really on the priority list general postnatal care and I mean that regarding small babies so knowing if babies have put on a good amount of weight and following that up so that for me was always a really really big hurdle knowing that I'm sending him a small baby am I going to see you again is it possible that we can follow you up in one of our mobile clinics and the amount of work that is as well to try and chase is enough because there is no phone signal and I think a lot of people think oh but you know Claire you know Africa people have got phones they may have phones but they also might not have any charge on it because there's no electricity okay they may not have any credit on it so it's not something in in a post and current conflict that we can rely on caring for women with fistulas again I remember in PRC when I said right let's get a fistula surgeon here we can really make a big difference to all these women's lives trying to take their village and their name and then trying to follow them up three months later so that we can make sure that we have the right numbers for our surgeon was so difficult because actually people are on the move people are people aren't where they said they were they don't have phones they don't have addresses so how to caring for these women with fistulas is also a really big challenge contraception and so giving depot and it's it's great but it's a short-term contraception isn't it it's three months so actually how do I follow you up women who are interested in having a contraceptive implant they get concerned that if actually the side effects are too much for them who's going to take it out if something happens and who's going to take it out in five years because who does that for me Clare so these questions are pertinent and we do need to think about this and how do we provide contraception and training people enough so that they feel confident in in removing implants as well as putting them in and going back to the challenges of women and babies on the move and the correlation that they they experience with section gender-based violence this isn't just happening by by by armed actors I met many women last month who were experiencing intimate partner violence and trying to provide them with some form of protection and speak to humanitarian workers that may be able to do some mediation in their community to to try and help them have a less violent life and it's so much more than than being a midwife and I think that's I did so much more section gender-based violence and family planning counselling and education than I did of actually delivering babies this time and I think that's really showing us the need of of midwives in the current conflict zone and as you're probably aware the challenges regarding access and transport so access talking about security traveling at nights not not possible not safe transport you know there are no there's no buses there are no cars and and if people if women are traveling with other women you know they are targets they are more vulnerable and in certain cultures in South Sudan cattle are seen as as a higher status than women that's only in some cultures but I think that's important to to bring into the context okay and going back to barriers again about accessing comprehensive care if it's in compound is that then safer people to access or not and I want to share Nagai's story and because she was very special and she is very special she she gave birth in September and she was 15 years old and I was called around 3 30 in the morning I think on the radio and I remember we had a we have a solar lamp and there were flies everywhere it was a hot night and Rhoda one of the midwives had called me and she said Claire this is what we've got and she pointed to her vagina and there were just two testicles hanging out of this vagina of Nagai's and I just think I took a deep breath and then probably rubbed my face was okay this is going to be fine and we found the fetal heart rate and we did all the observations and she was actually she was doing fantastic and she did acrobatics for us and and really was you know remained upright and was pushing and yeah she she was a real inspiration she's just she's just was fantastic and I remember saying she really doesn't look very old Rhoda said no it's the first baby the first baby she's 15 and I think that's the other issue to bring into this so within this context in the South Sudan you know women do get married very young and that can also bring a lot of potential challenges regarding birth as we all know so I won't go too much into this as I've been talking a lot basically she has a beautiful delivery while I'm still thinking about every manoeuvre to to overcome every problem that could possibly go wrong with this vaginal breach birth and obviously the baby comes out delivers itself and it's really quite emotional and it's a very hot day so she delivers around 6 6 30 in the morning and she still has some team bread and the clinic's very very busy so by the time it gets around 4 4 30 I said the guy you're going home he says hey I'm just I'm just packing up and because of all the flies and the insects and the heat she she put a little piece of cloth over her baby space to protect the baby from being bitten by mosquitoes and flies and all that which is quite normal and so I said oh can I just have a little bit look at the baby and look at the baby boy and this baby was sweating profusely and was very tachypneic and had a had a fever of 38.8 and I said I'm gonna go your baby's not well and then so we cannulated the baby gave the baby antibiotics and I said I want to transfer your baby to the comprehensive maternity unit again 40-minute drive within the boundaries of the United Nations in the protection of civilian site for the IDPs so there's a lot of abbreviations and and she said okay but if you say that's the best thing for my baby she was you know very she was articulate and she understood the importance so I didn't take her my colleague took her down in the in the Jeep and we handed over on the radio and I was quite happy that you know this baby had a good weight it was 3.2 kilos and we picked it up so you know it's good that she didn't go home anyway so she told her sister but her sister refused to go to the comprehensive centre and around 730 I was at my computer in the in the compound and and rode and knocked on the door and she said Claire and the guy's father's here I said oh right well I'm not sure it's pretty late night I think we were able to get getting down to the hospital now he loved to go in the morning and he and she just said no Claire he's come to collect her body and that's what he said so when and I couldn't quite understand I thought maybe I miss her and the guy's father had come to request the body and he didn't believe me when I said that the baby was unwell and he just said it's okay I would like the body of my daughter please because I know she came to the clinic and she hasn't come home so that to me must mean she died so please can I have the body of my daughter and that isn't a story from 25 years ago that is a story from September 2016 this is not normal that people should be believing that that is okay and that that is what you didn't come home so she must have died I was and this doesn't happen once this happened three times where people got transferred there was no communication or maybe her sister didn't get home in time to meet the father and and people coming to to collect the bodies of pregnant women and I hate that that's very telling in South Sudan and that shows us how much we have to still do okay so going forward and I'm quite passionate about how how do strategies that are being made in boardrooms with people dressed in wonderful clothes eating great food how is that realised on the front line how are we going to realise and actually make these sustainable development goals how do we achieve those more than 225 million women have unmet needs of contraception in the world right now you know there's a lot to do I don't necessarily have the answers for you but I think it's really important about how that strategy gets realised on the front line how that money how does that get there yesterday I was with friends who said oh I donated some money to the family in South Sudan was that the right thing to do Claire is that really happening yes it's really happening yes if you give your money to the World Food Program they are doing a great job that's my opinion that's from from what my eyes have seen and and following on from really what Joy Kemp was saying about collaboration with with your your host and and I think the MSF catchphrase as it were is that normally we like to say we are your guests and we work in collaboration with the Ministry of Health and that's definitely what we did clearly in the DRC and how we work still in the DRC and that's how we work in Haiti as well it just there is a Ministry of Health as I've said um to to work with in South Sudan and the communication is the key and that good collaboration will mean that we actually achieve more in partnership I'm very passionate about involving men and educating men and actually when you start the dialogue involving men they just they want to help their women they just you know these are things that that people don't know about I was doing a session two weeks ago in South Sudan in in Yambio in the South talking about contraception and we covered everything so we started talking about female condoms and a man turned around to me and said so if she's supposed to leave the female condom in for a couple of hours she'll have to take it out when she needs to go um and pass urine and so we did a small session on female genitalia and drew some drew some um we did some drawings of vaginas and that really amused them um I'm sure they would have been blushing if they hadn't had such black skin um so involving men is is definitely a big thing that we need to do more on education around contraception and FGC so sometimes people will write FGM female genital mutilation I don't particularly like using um that word mutilation I like that's just a personal thing in my practice I prefer to use the word cutting um and like I say using every opportunity to start a dialogue and whether that's with women or men young or older I think that's um that's the key and as is making the strategy that is being made in boardrooms how do we realize this on the front line it needs to be down to grassroots and that's how we're really going to have um all of these wonderful ideas that we have about realizing them um and also having the the cash behind it because actually we all know that these these are long these aren't just a short-term intervention we want to be there for the long term for for women and babies um I've talked a lot sorry thank you if you're still listening um I I think there's lots of questions I haven't read them Pandora yes clear thank you for that presentation there was one question from Lindsay saying asking you did you have UK contraception abortion rape and survivor support before you went out with MSF we have about five minutes left if you could just speak to that and the issue of support for the healthcare clinicians who are working okay so um did I have I can see it now yet the contraception abortion rape survivor support before you went out with MSF okay so MSF sent me on a course after three months and so full week of um basically understanding sgbv and how to uh implement a service and also how to train the trainer as it was so it would mean that I could then leave um my team of midwives in a Democratic Republic of Congo at that point this was 2015 um with the skills uh to be the focal points um which is what we really wanted but no and I think it's a very it's a very good question because actually my skills and knowledge around abortion post-abortion care termination of pregnancy uh being able to put in implants and intrauterine devices was very limited and so MSF has trained me um in that I'm very lucky that I have those skills now but in those first uh couple of months no definitely are they the the Congolese midwives for holding my hand and uh and teaching me a lot yeah um the second question was Pandora speaking quickly very quickly to systems of support for the healthcare workers such as yourself on exit and re-entry as you're now re-entering I think when you work with a big organization like medicines on frontier you're very lucky on the front of the fridge in South Sudan where I've just been was the psychosocial support which is a 24-hour free line that we can call back to Europe where we have a psychologist at the end of the phone 24-7 um often for for me that's knowing that it's there that's enough um and that's in all the projects that I've been in uh everyone is very much if you need a phone you call you just go and speak to your manager you don't need to ask what it's for because people will probably be like she just wants to to give someone a call uh when you come back uh yesterday I spoke to the psychologist in Barcelona uh maybe an hour and a half on the phone of just decompressing I think that's the word that people use um and that is always I I always say I don't need it and then after 90 minutes I feel a lot better thanks for that so that's great for me but I think we can do more for for our staff um in-country and that's why I said I think it was really great that MSF Spain sent out their psychologist um she was out there for two weeks just doing one-on-ones group sessions with different groups uh yeah I think that was I was I was really impressed MSF for doing that I was really happy and I think they were aware that that was needed through to all of the displacement and trauma that's going on at the moment we thank you all for joining us time has rapidly run and that wraps up this particular session I know that there are some questions pending the following session that is next up will also deal with midwifery um in disaster settings so I encourage some of you to stay logged on with that and we can begin the dialogue to carry forward with some of this and Dora could I just um I could maybe type the answer to some of the questions while um while you're preparing the next session would that be okay that would be lovely thank you very much clear