 Dean Huston again gives me great pleasure to welcome Dr. Susan Stone, and this is her shortened biography. Dr. Stone has a very impressive biography available at vidm.org. I'm doing the shortened biography and she has had a very extensive career in midwifery. Sue Stone, Doctor of Nursing Science, Certified Nurse Midwife, Fellow of the American College of Nurse Midwives and Fellow of the American Academy of Nursing, has been working in the field of reproductive healthcare for women for over 30 years. She is an early graduate of Frontier Nursing University's distance education midwifery program and practiced full-scope midwifery care for several years. Believing that having more nurse midwives would ultimately serve the goal of improved healthcare outcomes for women, she shifted her focus to the education of nurse midwives. She has served as president of FNU for the last 16 years. During this time, the university has grown from 200 students to the current enrollment of nearly 2,000 students. Dr. Stone continues in the role of FNU president with a goal of improving healthcare for families through increasing the number of well-prepared nurse midwives and nurse practitioners. She is also president-elect of the American College of Nurse Midwives. It gives me great honor to welcome Dr. Susan Stone for our presentation now. Good morning, everyone. Thank you so much for having me for this presentation this morning and thank you, Jane, for that very nice introduction. Welcome everybody from all over the world. It's really exciting to be talking with you today and I wish almost that we were sitting all around a table together so that I could meet you all in person. I'm going to talk to you a little bit about building our midwifery workforce in the United States and why we need to do that. So I'm going to dive right in. In the United States, we're experiencing increased maternal mortality rates over the last 25 years and this is a pretty dramatic increase. In 1987, we had a ratio of 7.2 numbers in 2013 or 17.3 and the estimated number for 2015 is 26.4. And there will be a lot of discussion about whether those numbers are accurate and whether the measurements are completely, as I said, accurate from birth certificate data. Whether they're totally accurate or not, what we do know is that this rate is increasing and has increased quite dramatically so we do have this problem. We know that about 700 women die each year in the United States of pregnancy-related causes and we also know that the rate of severe maternal morbidity more than doubled from 2000 to 2010. So these are women that land in the intensive care unit, very sick, and actually some people call these near misses for maternal mortality. So we've got this problem. What's going on here and why in this country where we spend so much money on health care, do we have this problem? This just is a graph that shows 1987 to 2013 and then this one shows our desperate 100,000 live births and in fact you can see how disproportionate this is when you look at other industrialized countries where other countries are going down in the U.S. we are going up. So it's a disturbing situation. So other issues and details about this are we know that African American women are three to four times more likely to die of pregnancy complications than white women. This is a very disturbing fact that we need to pay serious attention to. Also women who are aged 35 to 39 are almost twice as likely to die of pregnancy complications than when you compare them to women who are aged 20 to 24 and the risk becomes even higher for women aged 40 and older. So why is this happening? Well we know in the United States that excellent care is available for some but it's not available for all and we also know by having examined these deaths that at least half of them are preventable and probably even more if we really paid serious attention. We have shortages of providers and facilities and I'll talk about that a little bit more. We have financial, we have bureaucratic transport and language barriers and we have care that's not consistently culturally appropriate and it's not always respectful care. We know looking at these deaths the medical reasons are the top medical reasons are hemorrhage no surprise they are right. Pregnancy related hypertensive disorders, infection, pulmonary embolism, cardiomyopathy, and cardiovascular conditions. So these issues yes we're trying to deal with those with bundles and emergency protocols in hospitals and there's a lot of work going on around what to do when these things happen you know what is the step one, two, three, four that is standardized across the United States that would really help with these medical conditions and we are starting to see some progress in some hospitals but we do need more standardization. We need to see this really incorporated across all hospitals and that's our struggle. Maybe even more important is to look deeper on why these things are happening in the first place. Why are we in the situation where we have women who get into such bad trouble with their pregnancies as the pregnancy progresses? You know there's a lot of public health issues. I chose just a few of them to details. The obesity is a very big problem in the United States. Nearly half of women are obese prior to becoming pregnant and also nearly half gain more than the recommended weight during pregnancy and the obesity it's a we have issues around the types of foods, types of foods that are readily available and increased in carbs and not having a really well balanced diet available and not having maybe the care to help women and their families know what is the best thing to be eating and that kind of thing so more public health rather than emergency care may be an important thing. Smoking we still have trouble with smoking. About one in five women smoked in the three months prior to getting pregnant and one in ten smoked during the last three months of their pregnancies. This information comes from the Center for Disease Control. As you know you do it does make you wonder those are the ones who revealed that they smoked. What about the ones that don't tell us? We also have mental health disorders. About one in nine women had symptoms of major depression during their pregnancy but only about half received treatment for this condition and this is again we just don't have enough care providers to provide the type of care that's needed. What I didn't put on this slide but is our opioid addiction problem which is a huge problem in the United States. Let's look at cesarean section you know this is a this is a problem when we are having more than a third of our babies delivered through cesarean section this is a issue that we need to look at and deal with. The rate when a 2015 CDC study showed that rates of maternal morbidity were higher for cesarean delivery than for vaginal delivery. Not I'm sure none of us are very surprised by that. Studies examined this particular study looked at four morbidities maternal transfusion, ruptured uterus, unplanned hysterectomy and admission to intensive care unit. Maternal transfusion was the most common of the four morbidities followed by ICU admission, unplanned hysterectomy and ruptured uterus. Women have imbedual deliveries with no previous cesarean delivery had the lowest rate for all four morbidities. Again I know you're not surprised by that and women with v-back deliveries had lower rates of all four maternal morbidities compared with women with repeat cesarean deliveries and lower rates of transfusion and ICU admission compared with primary cesarean deliveries. Oftentimes you know we look at well I don't know it's not us but women are becoming coming to a point where they think it doesn't matter whether you have a cesarean delivery or a vaginal delivery and I think that some of the decisions oh I don't have to think that we know it and you know it some of the decisions we could be decreasing this rate and every time we pay attention to this rate and put midwives in the situation we do see a declining rate. I think this is a very important place where we could make a big difference very quickly. We also have shortages in providers from maternity care. The workforce because we don't have the workforce that we need this denies women and their families access to highly qualified providers. So we know in 2013 there were about 3.93 million births in the U.S. and we are projecting that to grow to 4.4 million by 2050 so we know we have an increasing demand but we also know that 40 percent of U.S. counties had no midwife or obstetrician in 2011 and that is climbing especially in the rural areas. The ACOG recently did a workforce study that was published in 2017 and they are projecting that they will have a shortage of OBGYNs of between 15,000 and about 22,000 by 2050. They know that less residents are choosing OBGYN for their specialty and so that we're having a decreasing supply and an increasing demand and what's going on in our rural areas we're having more and more hospitals the small rural hospitals that are closing and if they're not closing many of them discontinue maternity care due to legal liability issues and the complexity issues and the inability to recruit healthcare providers OBGYNs or midwives to work in these settings and also it's they have a greater difficulty with insurance coverage. So what are some of the solutions? We need increased access to primary and preventive care so you know it's the we put a lot of focus on the actual birth and the hospitalization but how much focus do we really put in helping women and their families to stay healthy? We also need data collection it's been shown that when we really are careful about well let me just talk about that in a minute I'm going to wait on that we need to diversify the health provider workforce we need to work collaboratively to address these issues we need team care and we definitely need more midwives in the US so access to care what does it really mean so it doesn't it when we look at access there's a few things that are really critical first of all to gain entry into our system the woman needs insurance coverage and we know that our Medicaid program which covers low income with women covers more than 50 percent of the births in the United States and then we have private insurance usually provided through employers that covers another large percentage but we still have around 15 percent that can slip through the cracks we've made some progress with our affordable care act but we know that we still can have women who slip through the cracks having insurance coverage we also it's important that there's geographic availability so if the clinic is 30 miles away and you don't have a car it's not available and also the personal relationship is very important when you're talking about care if you have a health care provider that you can't trust or you feel you can't communicate with there's not going to be excellent care so a personal relationship is a really important piece of access to care and so when we look at the social determinants again the service of availability and this can also include hours we often still have clinics that are open from eight in the morning till four in the afternoon just at the time when women are at work and can't get there so that's important locations hours and having a consistent care provider we think that care can just be provided by whosoever in the clinic that day without any real looking at is that person who is in that clinic able to have a relationship is there any consistency in that care those kinds of things can make a big difference in the care that we provide resources to make use of available services and this includes having the appropriate information but also having it in a way that's understandable to whoever's receiving that information so whether it's a language issue or a readability or the ability to just sit down and talk to give information and the appropriate absurd of services ideally women should be able to choose a provider that they want whether it's a gender issue when they want continuity of care they want confidentiality and they want quality care and they also want cultural sensitivity it's so important that that providers understand what are the cultural issues that attend with each particular woman these are issues that we often don't pay enough attention to and that we really need to do some serious work on so here's the data collection issue if this is a very important issue that we collect accurate data so that we can identify the key problems and create programs to address those problems this is a big push that's going on the Center for Disease Control is has programs to help states develop maternal mortality review committees and the goal is that every single state would have one of these review committees and that they would be able to operate consistently across the state so that we could see comparative data and zero in on where the biggest problems are and this really works California is a very good example they started their mortality review committee 10 years ago they examined the maternal deaths over several years and most reviews identified some chance that the death could have been prevented they created toolkits to train providers and maternal deaths at hospitals that use the toolkits dropped by 21% while those that did not use the toolkits fell only 1.2% today California has the lowest maternal mortality rate in the United States and so there is leg legislation pending and that we are advocating for that would provide funding to assure that this maternal mortality review was available in every state there are in about 26 states right now but they're not consistent and if they're in in some states they're underfunded so that even though they're there they may not be operating at the level that they need to be to be effective we also need to diversify the health provider workforce we know that racial and ethnic minorities are very underrepresented in the U.S. healthcare professions and this includes midwifery diversity improves access to health care for underserved and and we know some facts that african-american hispanic and native american providers are much more likely than their white physicians now we're talking about positions to practice in underserved communities and african-american and hispanic physicians as well as women are more likely to provide care to the poor racial and ethnic minority patients who have a choice are more likely to select health care professionals of their own racial or ethnic background and racial and ethnic minority patients are more satisfied with their care and are more likely to report receiving higher quality care when they're treated by a health professional of their own racial or ethnic background this issue is not just a physician issue when we look at the american college of nurse midwives in our membership now this is the members of our college and we only have about six percent of midwives who identify themselves as midwives of color and so this is an area too where we are working very hard on that and i'll tell you a little bit of our strategy in a minute it's also important that we engage in team-based and collaborative care and ACOG did publish a great document collaboration and practice implementing team-based care it's a very helpful document if you're looking for some principles on how to do this but it's really important that we work with our colleagues whether they're physicians social workers whatever it is that that patient needs at the time and i'd like their guiding principles because in the first place it's the patients and the families that are central and engaged in the care so i always had remember one professor who told me the first thing you do is ask the patient what they think is wrong or what they think is going on and they'll usually tell you oftentimes they can tell you themselves so but it's just very important sometimes we don't include the patient in the decision making of course it's a central tenant of midwifery care to do that but this is not in our large hospital systems when things are going on or even in clinic systems sometimes patients are not included in the decision making and that has to be a central concept the team has to work together rural clarity is essential we are educated in silos here in the united states where the medical medical schools are here nursing schools are there midwifery programs are there and we don't always cross fertilize so oftentimes they won't even one provider won't even know what are the capabilities of another provider that's in the team so we're working on a lot of interprofessional education here and trying to get some strategies where we're working together even as students so that we're kind of growing that team from the ground up and there are some very successful practices going on here but we need to see that develop throughout the health care system more so we have to also be careful about hierarchies when you have hierarchies it gets in the way of communication and then that can cause problems you know we know in the united states I think the latest numbers are something like 180,000 people died from health care errors I mean it's a tremendous horrible statistic but root cause analysis of that shows oftentimes it goes back to communication and how did the people providers everybody on the team communicate each other with each other so think about that if we just could communicate better we could improve outcomes I like the idea in this document they talk about team leadership the situation on dynamics so it's not just like the physician as always the leader of the team it's whoever is the appropriate person so the midwife may often be the leader of the team especially when she's caring for a low-risk woman or even a woman with complex social problems she's going to lead that team to make sure that woman gets the best care if it's a critically ill woman in the hospital yes then the physician may be the leader of the team but it's just situational whatever that situation calls for is who that leader of the team should be okay so bottom line in the united states I think we need more midwives we know that we have about 14,000 midwives when we look at the certified nurse midwife certified midwives and certified professional midwives in the united states I have mentioned that we are having increased numbers of births we do have a slowly increasing number of midwives our progress is slow and I think we need to increase that it's essential that we increase the numbers that are graduating each year because we cannot be a solution to this big problem if there are not enough midwives and I do think when you think about these root cause problems midwives really can make a difference in the public health issues the social issues decreasing the cesarean section we do in the united states have an increasing number of programs offering distance education options and these programs are increasing their number of midwifery students at frontier nursing university we have very much focused with a distance education model of really recruiting our students from rural and underserved areas primarily when we look at our graduates it's around 70% of them are working in rural and underserved areas we currently have about 900 midwifery students so we're working on the problem but we need to increase these efforts across the united states you can see this is the department of labor statistics in 2017 shows employment of nurse midwives by state these are very small numbers the latest green being of 30 to 40 in a state in my state of Kentucky there's I think 111 nurse midwives and then in some of the even the biggest states and biggest population states like New York and California you still might only find a thousand midwives so we really do need to increase this is just another map that shows the employment of nurse midwives by area and to see we're just scattered there's not really enough of us to provide to be an essential part of the workforce in every single maternity care system so we know that we have if we have increased number of midwives will increase primary care including maternity care especially for rural and underserved women we are the ones that can go into those rural areas educating women or men who live in those areas to be midwives may be a very good strategy because they'll stay and serve those areas and midwives do play an important role in filling the maternity care shortage we know that most women are able to have normal physiologic births and so midwives are experts at these at low risk normal births so we honestly should be attending more births than any other provider just when you look at situational what the needs of the woman are or we have the potential to do that let me say that but in 2013 cnm's and cm's attended only 8.2 percent of all us births and we know we could independently attend a larger portion of normal births and that would free obstetricians to use their specialized skills to assist women with significant complications many countries make much more significant use of midwives than we do as this group wouldn't definitely know that so in a in a Cochrane review published in 2013 we know midwifery lead care results in better outcomes less regional anesthesia fewer episiotomies fewer instrumental births fewer cesarean sections more continuity of care fewer preterm births less fetal loss before 24 weeks higher maternal satisfaction and a trend towards cost savings I know that this group knows that but these are these are tremendous outcomes so this could by increasing our percentage of midwives in the United States we can increase the diversity we can focus on different groups that need midwives and educate recruit and educate directly from those groups so we that would help with the diversity we can help women stay healthy and so I think we need to spend a lot more time around primary care and just health care and strategies to it's easy to say to a woman lose you need to lose weight and send her out the door but how do we really help her with the problems that she's having of course we can decrease the cesarean section rate we can provide more pre-conception care and we can develop relationships with our patients and this is a critical aspect in increasing access so in summary the united states has increasing rates of maternal mortality and morbidity associated factors include a lack of concerted effort and data collection and analysis maternal obesity and other health issues that could be affected through better primary and preventive health care and as well as early identification and treatment of problems we don't have enough health care providers especially in rural and underserved areas and we have too many cesarean deliveries and I believe an increased number of midwives has the potential to dramatically improve those outcomes so that's my presentation and I will take questions thank you very much Susan that was fabulous I know that those of us who are not in the states don't quite understand the the multitudes of different roles that people seem to have around the professor of birth so there was a little bit of clarification by Cecilia there about thank you Phil who is what you know so have we got any questions for Dr Stone what kind of training I've asked the question what kind of training do the labor and delivery nurses have about birth if they're caring for all these women during labor that is a very big problem you know we have nurses that are associate degree nurses so they have two years of training before they start their start working in in nursing and then we also have baccalaureate so they may have four years and then of course there's different levels with masters and different specialties but generally in the hospital you will see either associate degree trained nurses or baccalaureate trained nurses and their curriculum may or may not have don't get me wrong they all have maternity care the level of training in maternity care though may vary and it will in any nursing curriculum they're trying to cover a complete from birth to death all types of patients so there's only a very small portion of specific area in maternity care so that can you may have nurses that are very well trained and then you may have nurses that are not and when you look at the rural in the rural hospitals you're more likely to have the associate degree trained nurses which who may have a lower amount of maternity care what happens though in most hospitals is there's orientation where they the hospital themselves will spend a lot of time training the nurses after they get started for a young brand new nurse but that varies hospital to hospital too so there's no standardization so that yes that is a very big problem when these nurses are the primary of care providers in hospitals and if we had more midwives the midwives could supplement their care they could provide guidance to the nurses or they could do their care themselves yes we find that very strange in the uk where the only people who can actually care for a woman during childbirth is either a midwife or a medical practitioner you couldn't the nurses are not allowed to do anything beyond first aid i suppose you could call it um it's uh fascinating really yes i remember visiting and scary scary i have to say to think that nurses you know birth are caring for people in in labor how can they identify a problem developing because it's that's right so that's that is why we have communication issues we have problems that get out of hand um you know i remember i remember being a very young nurse myself working labor and delivery and what i had to learn was not to call the doctor too soon because then i would be wasting that doctor's time and so i was trying to figure it out by myself um so it's it is a very big problem i also remember i visited scotland one day i was in a a maternity unit in a day room with about 15 of who i thought were the nurses and midwives from the unit and i said to them which of you are the midwives and which of you are the nurses and they said why would we have nurses who are not midwives taking on the treatment we are in uh we arrived but it was interesting yes there's actually um with the issue around um free birthing uh one of the things we often have discussions for in the uk is because we have these very strict rules about a midwife or doctor nobody else can care for women does that mean that the husband or partner who is there at the free birth is taking on the role as a midwife and can he therefore be um uh you know in trouble for for taking on the role of the midwife so it's a very yes that well not sued but certainly um uh yeah get in trouble for taking on that role that they're not allowed to take yeah that's interesting yeah uh huh so so is there any kind of moves anybody else got i'm trying to um wait for somebody to ask a question here would anybody like to take the the the mic to ask dr stoner question i can think of hundreds but that's not my role sorry this is linda wiley i've taken over for jane who's gone off to do to a graduation thank you linda yeah no that's okay i'm here anyway i i don't get much sleep during the idm because i don't like to miss anything does ana here has suggested that one to one care is not possible then well it is you know and we do have um lots of very high functioning midwifery practices in the united states there are examples in many places and very it's so you you can find hospitals where a woman is cared for by that midwife during her pregnancy and then comes into the hospital with her also in the freestanding birthing centers that's a very common model where the midwife stays with the woman throughout the earth and it's a really great model and that is another area where we're showing um the really good outcomes in the freestanding birthing centers you know we just i really do think that if we we have got to increase the role of the number of midwives the sheer number because there's many towns and places where there's just not midwives available at all yes thank you that home birth is also growing here in the in the united states um and uh and so of course that's another model where there is one-on-one care did you see that question about above um gosh i don't know how to go above on this thing um from jade what is the role of hospitals versus academic institutions i'll get it to stay there uh in terms of training up new midwives because of the difficulty with clinical placements and getting good receptors or mentors yes well you know that is our limiting factor and because there are not enough practices there to be to act as preceptors so we can't just have a large number of students without any midwives to train them if you see what i mean so it is important that um that that midwives all of our midwives do accept the responsibility to precept students whether they're in birthing centers home birth practices or in hospitals um or clinic situations um that would be really important so our 900 students so the way we do it is it at frontier nursing university is we front load their academic education so um they do coursework for online coursework for and depending how fast they move through the program but usually for around um 18 months they are doing academics and it's a very interactive academic we're actually working hard on developing online simulations which is when you think about this communication issue you can really teach some very good skills um around communication and and then they go into their clinical sites so we may have at any period of time around 200 to 250 in clinical sites across the country but because they're in all 50 states um we are able to find those sites for them but we work very hard we have a staff of about 40 regional clinical faculty whose job it is to find help the student find those sites assess those sites to see if they're a good learning environment and facilitate and provide some services to the preceptor too as um as we go along and we are really working hard on that and putting a whole team of people on that just to really focus because if we don't have good uh we without good preceptors and a good clinical education we don't have anything it's an interesting question earlier higher up um asking about policymakers i'm just trying to look at that is there any movement by policymakers the government to work on the problem or is it different areas institutions stepping into the gap there is a focus by the government when i talk about the center for disease control and there are actually two pieces of legislation that we are advocating for right now so we do have legislators who have signed on to help us sponsor the bills that will get the funding um to assist with um this data collection project um to make sure that every state has the funding in order to make that happen um so we also recently in the last five years and I saw that Linda Cole is on here but we did have funding to examine outcomes in birth centers and um to see it to show that as a valuable model to be able to demonstrate that that is a valuable model so there are um projects going on but I think there could be much more we also I should say um we have funding uh that is available for many um universities our university is just one of um that receive funding from the federal government to provide scholarships and services especially to students of color so that we can help to increase the diversity of the workforce so there are either definitely are things coming funding coming from you know from the government um hospitals themselves need to always step up to the plate and most of them do some of them um you know I deal with this every day talking to hospitals about why it is important that they allow students to come in um and be educated in their institutions uh so that's an ongoing conversation most of them do though I want to make that a point um but there are still that say why should I allow a student in here it's just increases my liability there's a lot of talk around the liability um and especially that's interesting in the United States is we don't have universal health care um I wish we did I think that life would be much better for many families if we did but we don't so I know that the well I gather that um across the states there seem to be different kind of rules in different states is there any move to have a kind of a professional regulatory body of midwifery that can bring all these different types of midwives and labor and delivery nurses to a common standard well there is and it you know but there's two things that go on one is licensure which is driven by state by state and then there's certification which is a national initiative so most midwives in the United States are certified by the American Midwifery Certification Board if they graduate from a certified midwife or a certified nurse midwife program and then we also have our certified professional midwives and they take a national certification exam um by um that is presented by NARM so so we do have standardization all of our programs are based on the ICM standards as the underlying basis and then they grow from their whatever specialty that program may want to add in as they're like at frontier we do much around rural rural and underserved care since that's one of our focuses um so we do have standardization of midwifery there's still some lay midwives or practice but in terms of really working on this we I think we've come a very long way in state by state it's a licensure issue so you have to be licensed to look to practice in the state in which you you are practicing so you may need to meet those requirements as well as the national requirements okay someone's asked there if there's any scope for partnering with other bodies of midwifery she's actually said the Royal College of Midwives which is in the UK one here to facilitate opportunities for nurses or midwives I guess to complete training with midwives in other countries I think that would be great I think that is a great idea I'd love to talk to somebody more about that idea I think we have so in in the United States don't we really right in the UK do midwives provide um primary care in gynecology no it's I'm looking at Seales comment um no we don't do gynecology if we're midwifery we're just obstetric well not obstetric we're midwifery trained we don't do gynecology at all so it would be different it would be different there may be some though some part of the education that would be helpful to cross-train um and look at different models see then that's why when I was talking about primary care I think it's important that we have enough midwives that are in these clinics providing primary care not just maternity care because I do think we have the expertise to help women be healthier and help women have healthy families I think that's part of our role a huge part of our role is just teaching yes we agree there and the midwifery is definitely involved in primary care as well um because women are that right are in the right place at that time aren't they to listen to health education messages yes that's definitely I'm smiling at Cecilia's comment about standards and guidelines and measurements being all different because you can find it by working even within one small area like here in the in the west of Scotland if you work in one hospital they have slightly different or quite sometimes big differences in measurement type things um so we all have to learn the ways of the local trust etc yeah yeah yes I know I do I do and I'll see um that yeah it is difficult it is difficult but I do think we've um that I still think we could learn from each other and I know Ceil knows that because she's done a lot of that too I totally agree with you there um with social media and everything you definitely you do get more um comparison I mean there's been a lot of discussion about the use of in the states which in the UK we've used since um oh the year dot um and we have no protocols and procedures and I remember Cecilia asking me you know what are the protocols for use in the well we've used it all the time we have no protocols for that because it's been in use forever so there's always going to be huge differences but there are the one thing that brings us all together is that childbirth is a normal event and we all experience it in the same way midwives should be the custodians of normality and should be identifying deviations and then bringing in the appropriate people there but anyway we've only got a minute left well said we've only got a minute left so if we've got any more burning questions before we conclude thank you everybody I can only say thank you as well um Susan that was a fabulous um summary I'm sure it's a very big subject altogether but that's it so I so thank you very much and I'm sorry that um to see uh that Jane had to disappear like that well that was a good reason let's face it so that's right go on about that and and thank you very much for taking place I see we've gotten applause in the audience from SLW thank you okay so I'll just conclude the session then um there is still discussion going on in the in the chat because I mentioned it's not um okay so I will just move on oh right there's your final seen this one before yeah wish to see in the world yes that is a fabulous saying quote okay so I thank you very much Dr Stone and um I'll just turn