 I see the first hand here by the pole, and I see a hand in the centre in the back, another hand here in the front, so one, two, three, four, five. I have a question for Severine. My name is Tisha, I'm MSF and the National Health Service. I was very impressed that you documented what you documented. It's really important data. I'm just wondering how you are influencing or discussing guidance, because your last point about how do we have that discussion with a mother, a pregnant woman now. It's a dramatic change in what you've found. I was just wondering, not only at the very level of discussing with the mother, but also the pregnant woman, but also with wider networks who are writing guidelines. Thank you. Can I have a second question again, please? Yes, the gentleman in the back. Hi, Jacob again. This is a question for Bev. In Somali region with such a spread out population, I'm just wondering whether any of the kind of themes coming through regarding difficulty in accessing transport to get to services, which I know was something that was a challenge during the emergency response. Thank you. Can we take a third question? I think there was Elaine there who was before you and then you. Did we have somebody there? I've got a microphone now, do you want me to go? No, then we'll have a question here, please. Okay, thanks. I'm Kiran from DFID. Thank you for the presentation on the postnatal clubs. Again, it's the first time I've heard of that in this sort of setting. Can I just ask, when you were talking about the comprehensive care for the mother and the baby, was that including reproductive health? Hi, two questions. One for me as well on the postnatal clubs. I just wondered how the women were recruited and whether women were more likely, sorry, whether the group of women who joined the clubs were a select group or whether, you know, what happened to the other woman in Caelicia who went off it. And the other question was for Renault and was really just about what are the next steps. Now we know what we know. We think we know what we know. Thank you. We also have some questions online. So the questions from the online audience include a question to Bev Stringer, which is what is the MSF project in Dolozone doing to carry forward and act on the findings of the study. There are a couple of questions to Renault about whether congenital syphilis was considered and whether you tested for HIV in the study. And then finally for our colleague from South Africa, the question is essentially retention in the HIV early infant diagnostic. Early infant diagnosis, castaid, is crucially important and frequently neglected. You guys have great results. Is there broad implementation of the additional visits in the study feasible? Thank you. Would you like to go first? Yeah, I can go first. Thanks Jacob. So your question was about transport and difficulty associated with that. Yeah, I think what we found interesting that was more profound than the transport difficulties because certainly they are there. And I think you saw when I talked about decision making, when that collective decision was made, it would include trying to, excuse me, I'm losing my voice, trying to find someone with the transport and ability to go to the centre. But what was surprising for us was actually for this population who are used to moving around their pastoralists and they move for their livelihoods, it was more a social barrier rather than having the transportation to get them where they needed to go. Can I just add something to that because we face the same problem? Very often women who have postpartum problems are bleeding or even with a placenta preview, a woman is bleeding and public transport do not like to take a woman who is losing so much blood because it makes them lose other clients and it also damages or dirties the vehicle. So very often they say there is a car but they refuse to take us. Another problem that women also face in our part of the world is that a driver of a truck, a commercial truck wants to be paid in money. A rural woman or a nomadic woman or a family of that woman may only have a ship or a goat, that's the only currency they would have and a driver would say I don't have space for a goat and I will not take a goat for payment but I need to be paid for transporting this woman. So these are these added problems as well and obstacles, thank you. There was a second question online I think it was related to MSF. I mean I know Lindsay Bryson's also in the audience, she's the medical coordinator for the mission there. MSF has stopped all its routine programmes during the nutritional crisis in 2017 to respond to malnutrition and the different disease outbreaks that were ongoing. And they're now in a sort of post-emergency, they're doing surveillance and anti-natal care is included in that surveillance as is quite a strong community-based community health worker approach to the work. But because of that complete change of programming at the moment for MSF for the project there, the biggest concern is with catalyzing the interest because we involved regional health bureau were part of the research team, the Ethiopian public health institute from the outset was part of the process. It's just a matter of trying to work together to feed and catalyze that momentum that's very strong and the role MSF can play there would be more of an advocacy role at the moment. Thank you very much. For the question directed to me I interpreted as what to do with pregnancies with ongoing pregnancies while the mother is convalescent. Yes, well I want to say also first of all this is only a minority of the pregnancies, thank God because it's complicated discussions. In most cases, the vast majority, 90%, the patient already reported that fetal movements had stopped for days or was bleeding or was spontaneously miscarrying or delivering. But in the few cases that we had where the pregnancy was ongoing, we had patients who chose different options. We had three patients who chose a termination of pregnancy but we also had two patients who chose to continue their pregnancy. One of those two patients I already mentioned between the lines, she was the patient where the PCR on amniotic fluid still was highly positive 32 days after convalescence of the mother. So what happened, this patient chose to continue her pregnancy. The team on place did something really marvelous in a Ebola outbreak. They built a small wooden hut for her next to the Ebola treatment centre but outside she was convalescent. She was not any more infectious so that her family could come and visit her because they wanted to keep her close to the Ebola treatment centre in case she would go into labour. She did go into labour one month after her own convalescence and discharge. She delivered a macerated stillbirth in the Ebola treatment centre and the stillbirth and the amniotic fluid was still highly positive. The three patients that chose termination of pregnancy, well I think it was a complicated discussion and also a complicated discussion with many question marks. The only thing what we could do was say what we know now is and at that stage not a single baby has survived transpasental acquired Ebola. We do know that PCRs remain for a long time highly positive and what also plays a role is in an ideal world all pregnancies are wanted and planned. We work and even also in our countries in a far from ideal world I can perfectly understand if I'm pregnant I just survived a life-threatening condition. I probably saw family members die because everybody who has worked in Ebola knows it causes the white part of families. One week after admission to children the father and the grandmother are dead so I have suffered a lot. Now they inform me about the insecurity about my pregnancy and even a possibility that it might be infectious. I can perfectly understand if your pregnancy was already not really wanted in the first place not planned that you say this is too much for me to take please help me and this is also what we did in those cases. But I was also happy to hear that two patients chose to continue their pregnancy because you also feel a bit uncomfortable as healthcare provider like are we not putting pressure on the patient to terminate with only very limited data. And I also have to say Nubia is a game changer because up till Nubia we could say in like very often a baby has never survived congenital Ebola while with Nubia this changed. Thank you very much. Thank you for the questions concerning HIV and syphilis testing it was offered and prevalence was low, 0.3% in this population. So then you write we have to think about the next steps. This court is still ongoing so there is a lot of additional results to come to complete also the full picture on the mortality with late mortality and infant mortality at one years of age to be able to address that also with the nutritional supplement that was provided systematically to all kids. So we are already thinking about these next steps. The one possible option would be an intervention introducing the complication score and with full referral system in place so that women with a complicated score can be helped to deliver within the health facility. But it's more complicated than that because it's not only the matter of what healthcare provider can do and give us advices and there are more complex things to understand on the decision when a woman decides to deliver within a health facility or not. And so we are also doing some research on the other side of Lake Chad in Chad and Great Region and we just completed some mixed method studies qualitative quantitative and this time more focused on the perception of women and trying to understand why they want to deliver at home. And also whether the messages were given by the healthcare providers on the dangers of not delivering in a health facility and how it is perceived by these women. So I think we have to take all of that into consideration to plan for future intervention. And of course it will include a reproductive health component so our idea is to be able to continue following up the women including in this cohort beyond this first pregnancy and to test new intervention aimed at dealing with for instance with birth spacing. We were thinking about self injectable contraceptive methods maybe it may be appropriate in this context. Yes, of course. I mean I was taught and this was a long time ago that you know even got it. But antenatal care doesn't predict almost 50% of the things that go wrong actually at the time of delivery. So is it that part of it is a basic problem with predictive risk factors or are there is there also a possibility that there are risk factors that you haven't identified. So in your model you're actually not looking at some other potential risk factors. Sorry and the third thing was I can talk to you afterwards. Is it difficult to hear because of the reason? Can you hear? Could you just say it again and a bit slower and a bit louder please? So my question was is it possible that there were risk factors that you didn't identify and therefore aren't in the model. Because what I understand is that even with the best antenatal care up to 50% of things that go wrong at delivery have not been pre-identified. And the other question is actually what was the causes of the maternal mortality and do they give us any clue as well about the perinatal mortality? The causes of which mortality? Maternal. Because you have deaths as well. And that relates to the bleeding issue a bit. Is there a high rate of anti-postpartum hemorrhage which would contribute that your respecters don't actually... I'm afraid we don't have that information. It was already difficult to track all pregnancy until the term. The term you saw that we had 50 unknown pregnancy outcomes. So we did our best to reduce. Initially the number was much higher so we tracked two women and we ended up with this 50. I'm afraid we don't have any more information on the causes of maternal deaths. Of course there are some other potential factors associated with mortality that wasn't captured here. Did you think about some factors in particular? Could I maybe give you the example of my hospital? In 16 years we've delivered 22,000 women and we've lost 63. 27 of those women died of eclamsia. That's the biggest killer in a hospital. But I believe that there is a much bigger number of women who die of postpartum hemorrhage. But they don't reach us. They die on the way so we never get them. Eight of the women died of post infection. Pupyr infection. So conditions that kill fast do not reach us. Conditions that take longer to kill the women are the ones that reach us. Raptured uterus. They can be alive for two or three days. Time for them to be brought here. So as far as prenatal care is concerned I know and I'm confident that many of the women who died of eclamsia could and would have been saved had someone checked their blood pressure. And even if they don't have a sphigmol they would have seen a woman with a puffy face. The ring was getting tighter. Somebody would have guessed that she had a rising blood pressure. Can I add as well to that point, Edna, because I didn't mention that this momentum in Ethiopia at the moment, the London School of Hygiene and Tropical Medicine, but also King's College are trying to tackle the problem in different ways, the London School through community based work. But Kings have come up with a device. It's a blood pressure like a traffic light and it's about 12 pounds and you can charge it through a USB like a mobile phone. And it says it will reduce maternal mortality by 25%. And this is the very device that when I talked about the population in Dolo, they want to see visibly what's happening to them. And my sense is like the MUAC and the way that that could screen and change how we manage malnutrition. We could do the same for maternal mortality. We also have women being delivered by their own children. We've had a woman with a shoulder presentation and her nine-year-old daughter was the only person in the house. And all that the child could do was pull on this prolapsed arm. And the mother would say, no, no, it's almost out. Keep pulling. No, no, pull harder until the arm was updated. The mother reached us alive, luckily, somehow. Of course, we have to do a cesarean section for a dead baby. Thank you. We have a last question. Thank you. Thank you. I had three questions to answer. How do you recruit women in Caericia? The postnatal clubs, precisely, we are looking into HIV positive women. Then what we are doing in this specific clinic that is down to clinic, we talk about the postnatal clubs alternately whilst they are still pregnant. Then when they deliver, they are not delivering in that setting, they go to an obstetric unit. When they come back, they come back fully knowing that there is a postnatal club which they can benefit. Then when they come back, they start to show up in the clinic at six weeks. Then again at six weeks, we recruit them. All the ones that are HIV positive, we recruit them at six weeks, encouraging them to be part of the postnatal clubs because of the benefit that are in the postnatal clubs. But we have been challenged by the nursing in charge of that clinic. What about the other women in the clinic? We have adopted or we have drafted a stationary that was used now, it's used by the whole clinic. Even the HIV negative mothers have benefited in the program because we've got this beautiful stationary that is using a checklist. So when you see a mother and the baby, you know exactly what to look for into the baby. The second one is do we include reproductive health? Yes. When I was presenting, I said the next that will be doing the session, it's a one stop station. You offer women's health in the session. If the mother have never done a pepsmeer, you offer and do the pepsmeer. We do family planning, all types of family planning in there. It's a whole woman's package that is entailed in the program. Then retention and care. Yes, retention and care. That's the reason why we've come up with this program because retention and care was very poor. But at 18 months, remember, we recruit them for six months. Then we are managing and supporting them for 18 months. At 18 months, they graduate to an adult club. That's what they are doing at 18 months. Thank you. Then we have this program. It's the first of its kind in South Africa. It was approved by the government in the western Cape where we are coming from. We'll be rolling out into two sites starting in June. We'll be rolling out into two sites, one for the city and one for the province. So, really, it is something that needs to be looked into. How can we manage the mother and the baby in a one-stop station? Thank you. Thank you very much. Most interesting. Thank you all panellists. Thank you.