 Okay, so I would now like to introduce, I'm just going to give a brief summary of some of Sue's, the highlights of her career. She spent 15 years working as a clinical and research midwife, and in 2001 she joined the UK University of Central Lancashire, where she is now a professor of midwifery studies. Her main research focus is the nature of and cultures around normal birth. She's held leadership positions in several international maternal child health organizations. She's a lead author on the Lancet midwifery series. She's been involved in a range of projects with the Fernandez Foundation and the University of Hyderabad in India, and you will hear about several of those projects later in our conference. Her keynote presentation today will explore some of the issues arising from the apparent conflicts between professional and vocational approaches to midwifery and maternity care. So welcome, Sue. I'm going to go ahead and make you the presenter. I'm going to turn off my video and sit back and enjoy your presentation and monitor the chat. Thank you, Catherine, and thank you for the invitation very much. I was a co-author on the Lancet series, not the lead author, so I just need to clarify that. I'm a co-author on one of the Lancet series papers and part of the team that put the whole set of papers together, so just to make sure that's accurate. It's a great pleasure to be here. Despite, as we were discussing earlier on before we came online, the cold and the wind and the rain in the UK at the minute, which is very unseasonable. This evening in our house we lit a fire, a wood-burning fire, which is unheard of on the 5th or 4th or 5th of May. But anyway, it can only get better, as everybody says. So I want to kind of... Some of you may have heard some pieces of this presentation before. I did have a... Some of it was presented at the Royal College of Bidwis this year, but I wanted to run through it again, really, because I think there's some important questions to be asked. Perhaps as midwifery becomes more and more professionalised, and particularly, and this is a very valuable and very welcome move, as midwifery becomes seen as a solution, partly because of the midwifery series, but also because a range of countries are beginning to recognise that they actually need to invest in midwives going forward into the future. So I kind of wanted to come back to this notion of how vocation and profession might sit together, because there's always a risk with any group that rapidly professionalises that one can lose sight of what the roots of the activities that we're doing, or in this case, the vocation we're describing, where they come from. And I think it's also very important for us as researchers to recognise that the findings that we have from the research that show how useful and how important midwifery is are findings that are rooted in this vocation. And if we strip the vocation out and only focus on the profession, then we may actually not get the kinds of results that our current research is showing. We want to get the results on which this shift towards more midwifery and more midwifery training is based. So I want to just kind of put that question in the mix really, and hopefully we'll have enough time to have a debate about where we might sit on this continuum. And I've chosen this particular slide because the idea of the future perfect continuous tense is that it's always moving forward but never quite there. You know, it's a tense which describes the future that isn't quite arrived at. And so this idea is about becoming something rather than being something, becoming something which is maybe a blend of vocation and profession. And underneath that to use that to ensure that we really do have birth equity for all, which is the kind of overall framing of this event. So this is just picked off the net really, but I think it describes the situation very well that I want to talk about. And where is that sweet spot, that sweet spot of purpose in the centre of this graph here that actually combines something that you love, that the world needs, that you're paid for, always good, and that you're really good at. Where do those things come together, particularly around this notion of passion and compassion, so that being compassionate is about doing something with passion, and being a midwife has to be done with passion, otherwise it's just a job and that's not what midwifery is. So I think that this notion of where professionalism slides into managerialism and bureaucracy is really the space I'm wanting to kind of warn against I suppose. So I don't want to warn against professionalism as a notion, because there are some very valuable values that are associated with professionalism notion, values of ethics and morality and all those kinds of things. But this slide between profession and managerialism and bureaucracy that I think is the issue. This particular quote is from quite an interesting paper, which is actually focused on doctors' acceptance or resistance to knowledge management, so guidelines and rules and safety cultures and so on. And what the quote suggests is that, what happens is that professions tend to adapt to this kind of neoliberal bureaucracy in ways that sometimes mean that in this particular case doctors become managers. In order to resist managerialism, they create themselves into managers in this particular study, or they create themselves into bureaucracy. So adopt some of the bureaucracy so that they can control it, but in controlling it, they also become kind of beholden to it. And there's this concern about how that works its way out. And I also think that there's this other piece about knowledge and wisdom. And again, I think this is important particularly for those who are working as researchers and lecturers. It seems like many educationalists as it seems like a number of people on this particular session are, because knowledge without wisdom or knowledge with wisdom is incredibly important. So having information but using it rightly, so the capacity to judge rightly is what wisdom is, is not the same as having a checklist of things that's based on population evidence and going yes, no, yes, no, yes, no, all the way down the checklist. That's not wisdom. It might be knowledge, but it's not wisdom. So this other quote again illustrates the point, and wisdom is profound understanding and a deep insight. And it's also a capacity to both at the same time see the whole picture and the detail. So look both in the focus of something and also in the wider picture at the same time. So to constantly shift between those perspectives. So whereas generally speaking, guideline based or rules based or protocol based evidence is about the whole picture, the population. So what works across the population. What we need to do as midwives and also as obstetricians as our colleagues is to keep the individual in focus at the same time as understanding that broader population evidence. And that's where wisdom comes in the right use of knowledge. And I've used this quote a lot and people may know it, but it's from Hilary Rose who's a feminist scientist writes about feminist science or wrote about it, it's quite an old quote but still. So this idea that the origin science story is about knowledge and power but feminist critique of it is about the danger of knowledge without love, in this case, caritas, that kind of love, the love of caring, caring for and caring with. And again, this is a notion I think we need to keep in the mix. It's a vocational notion balanced with a professional notion I would argue. So I want to just kind of roll back a little bit and say, okay, if our vocation is about women and about women and birthing people and newborns and the families, then we should be doing what matters to them the most. And of course, you know, you can look at that in terms of satisfaction, but satisfaction is a very poor measure of anything. Most people, if you ask them, if you ask people what they think about their local shoe shop, 80% are going to say they're satisfied. Generally, unless people are really unhappy, about 80% comes out, you know, in any satisfaction study about 80% tend to be satisfied. So it's a very kind of low level way of assessing how people feel about things. So this particular slide here shows the data that were generated by a series of studies that we did for the World Health Organization, looking at the qualitative evidence of what matters to women, both antinatal intrapartum postnatally, so a range of different studies. And this particular, the intrapartum metasynthesis was 35 studies in 19 countries, as you can see, and what mattered most was a positive experience, not just a satisfying experience or a satisfactory experience, I should say, but a positive experience that fulfills or exceeds their prior personal and sociocultural beliefs and expectations. And that was the kind of flavor of what we found across these particular reviews for each period of time that we looked at. So it's far more than just being safe and feeling satisfied. And this is an unpacking of that intrapartum one a bit more. So what that meant was to obviously give birth to a healthy baby in a safe environment, clinically and psychologically, that's kind of what we're given. Practical and emotional support from everybody around them. Most women around the world, we looked at every language, every country, every study that we could find around the world wanted a physiological labor and birth. But most of them also acknowledged that there was a need to go with the flow, that sometimes that isn't how it was, so they were happy to go with the flow. And if they did need an intervention, then again, this is what we're surprised to anybody on this call, what women wanted was to still maintain that sense of personal achievement and control by being involved in decision making or at least by trusting their caregivers to make the right decision and not to make a decision because the tick box says or because the professional organization says or because if the midwife doesn't or the doctor doesn't do it, they're going to get told off or hold over the coals at some kind of review session. They wanted it because they wanted interventions that were necessary and required by them done in a way that was compassionate and caring and took account of their cultural norms and beliefs. And I'm not sure you can see the Maslow's hierarchy here because the slider of it's small, but what we thought was that really this did relate to Maslow's hierarchy of needs and that the reason you've got the shadow triangle on there is that it seems to us that most maternity care systems and actually a lot of health systems at the moment concentrate on the bottom two lines of Maslow's hierarchy. So physiological needs in terms of food and water and so on and safety needs. And all the other needs, the esteem needs, the belongingness, the love, the self-affirmant that at the top of Maslow's hierarchy don't seem to be taken into account in many ways that we do maternity care, but they are part of the midwifery vocation. And one thing we might want to discuss is how you can operationalize this kind of approach that matters to women. And I think there's also this notion of how we use wisdom in research translation. So this is the arrived trial. Most of you will know the arrived trial I imagine. So trial, well a very well-designed trial in a number of sites in America looking at labor induction at 39 weeks routinely for primigrabid women, actually Nilla Paris women, versus no routine induction. And they did, there was lots of women, 6,000 odd. And they were looking for neonatal adverse outcomes and found no difference. So there was no difference to the baby at all during the induction. But it did actually reduce serensection, secondary outcome. And of course, as we all know, that's now the aspect that's being compounded for routine early induction for women. There was also not much difference in measures of pain relief or women's sense of, I don't know what the use of it, some VAS score I think, I can't quite see the details here because the slide's too small for women's sense of wellbeing. But of course the important thing again as many will know is that 73% of eligible women did not agree to take part in this study indicating that most women do not want to be induced routinely. And the median BMI in both groups was over 30 and generally women in the study were younger than the norm and more likely to be African-American. So the question is what's the external validity of this particular study? Does it, although it was well designed, does it actually reflect what women want? It was only an illiterate woman. Can you actually apply it to those who are not illiterate and it was only a quarter of the population that were eligible. Possibly more women took part who wanted to be induced than the average in the population because otherwise they wouldn't have taken part. One study, one country. And I think the most intriguing thing about this is that induction is being propounded now as a way of reducing serensection. The reason we want to reduce serensection is because we realise there are long-term effects. We have no idea what long-term effects of induction are, you know, beyond the first few days. And yet we're using it as a technique to reduce the technique that we want to reduce because we now know there's long-term effects. It's illogical to me. Especially when we have alternatives. If we really want to reduce serensection, that's fine, you know, reduce it safely, that's fine. But actually if you look at the supporting labour trials, the Cochrane supporting labour trials, they reduce serensection by more. There's a greater reduction into serensection in those trials than there is in the arrived trial. And there are multiple trials from multiple countries, far more women involved. And there's very unlikely to be any long-term adverse outcomes. Equally for place of birth, the evidence seems to be, not randomized trials, but it seems to be that women who are healthy, healthy babies, who want to birth out of hospital, who have good support in countries with good infrastructure, do better out of hospital generally than in the hospital and so do their babies. Unless it's the first time they're having their own birth, which gives slightly more risk for the baby on the UK data. And also from other countries too, that's been found. But definitely fewer interpartum interventions and more normal births and less serensections. So if you want to reduce seren, then you should be looking at the gold standards for reducing seren and not comparing induction with no induction. And then concluding that induction is the only way you can reduce serensection. And of course the problem is, and this is where I come back to the midwifery vocation versus profession, because ununderstandably what's happening certainly in the UK is quite a lot of midwives are working to create home induction. So the line is, or women have to be induced, they don't have to be induced actually, but you know this is the line, women are going to be induced anyway. Let's make it as good as possible for them. So let's do the induction at home. Now the problem with that is we have no idea what the consequences are really. We don't yet know because we haven't done the research of home induction, firstly. Secondly, induction should only really be done if there's a risk, really. So if you're going to be doing an induction, why are you doing it at home? If there may be issues, then presumably that's not where the women should be. And it raises this question about too much medicine because if it becomes acceptable to do an induction at home, you can just imagine that what might happen as we get remote people monitoring, for example, is that there'll be a kind of like, well if we're going to do the induction at home, especially if we get any adverse events, this will happen. We should be doing monitoring, but we can monitor at home, so that's okay. And actually while we're monitoring at home for induction, we might as well monitor at home for home birth. Let's do continuous feature monitoring remotely at home for home births. And we can watch the monitors in the hospital and that's going to be safe for everybody. It will be the argument, which of course it's not going to be, that wouldn't be true. But you can see the risk of technology creep once you start to bring this, these kinds of feeling, this idea that this has to be done into a setting where it's an atomite really, in many ways, and then you start breaking down the boundaries and you lose the sight, again it comes back to what I was saying at the beginning, you lose the sight as to why the thing, in this case, home birth, works. Because actually you start to introduce things into that setting that mean it doesn't work and therefore you get adverse events and therefore people say, well home birth is dangerous and therefore you lose that home birth space. So I think from the vocational perspective, we need to be thinking through the consequences of some of the things that we do as workarounds. And then from a professional perspective, we should be saying, well actually we shouldn't be doing the workarounds because there are alternatives that don't require the workarounds and much more in line with the mid or free vocation. And there is a risk of overextending, risk of various diagnoses and again you may not be able to see this, this is a cover from a few years ago in the BMJ and I think it's great and it's nothing to do with maternity, it's general, and they say there's a risk at the moment of over-medicalization because we start by arming the health, that's what we intend to do with medicine and general healthcare. And then we move into alarming the healthy by over-testing and over-screening and then we move into harming the healthy because actually we over-screen, we over-diagnose, we over-treat and the conclusion is over-diagnosis is one of the most harmful and costly problems in modern healthcare and I would include some of the routine interventions that we're doing in that box. And I think again our response during COVID is quite illustrative of what our dominant mental model not ours necessarily in this group but the dominant mental models of healthcare in general and maternity care specifically are. We all know the tragic stories of people in general being separated from families dying alone, having no human comfort of babies being separated from mothers for days certainly at the beginning of the COVID pandemic hopefully not anymore because of a fear of infection and a complete lack of understanding the human dimension of what health in general and maternity care specifically is all about with untold potential consequences we're doing a big study at the moment across in the UK and the Netherlands looking at the effects of COVID on organisation how organisations are organised around maternity care, what the response was and some of the stories from some of the women who are denied companionship are absolutely heartbreaking actually particularly around ultrasound very incredibly heartbreaking stories of women who didn't have any companions with them when they were told by an ultrasound that they maybe had died for example or they had a blighted over them or whatever it was and they had no way, they weren't like one of our phones and they couldn't talk to anybody and they had no companionship very very sad and again certainly in the UK and I know elsewhere in the world there's been a lot of evidence on this notion of companionship specifically in labour we're finding it's really very strong in the antenatal period as well as being an issue I know again you can't read the text here but this is another paper which is actually multi-country looking at the effect of COVID on neonatal visiting and it found kind of unsurprisingly that there was less neonatal visiting meaning that parents weren't allowed to see in many cases see their newborn in the neonatal unit but where neonatal units were planned better so they were more open more freedom of movement then visiting was actually more possible and again this isn't necessarily a professional vocation discussion but it is about saying we have to get the system right before a pandemic hits there's no point in trying to resolve issues while the pandemic is there we have to get a health service set up so that it's resilient when we get this kind of thing happening and resilience in terms of humanisation as well as in terms of safety and infection control and then in terms of maternal mental health again I know you can't read this one either this is basically saying again unsurprisingly that women well actually maybe to an extent surprisingly actually some women did quite well have done quite well during COVID not least because they've been at home if you're in a country where there's been good support for people to not work when they've been locked down I know that's not true everywhere the way that people have had that support they've had their partner at home if they've not been working in the same way if they've been paid by the government for not working they've been able to breastfeed better very positive things for some women but of course the women for whom it's been worse are the poor, the marginalized the women who didn't have social support in the first place the same groups has always suffered the most during COVID and the point about this to an extent is to come to this question really so one of the consequences of the lack of companionship and the fear of hospitals that has been noted anecdotally around the world and there's now emerging evidence that this has been happening is that a number of women decided to free birth so if they weren't allowed they didn't want to go to the hospital they wanted their partner with them but their partner wasn't allowed to go with them to the hospital they wanted a home birth but they wasn't supplied because home births were reduced because the ambulance services were overwhelmed again in many countries where there are home births not in the Netherlands which is why we chose the Netherlands to make a comparison with the UK anyway because they felt there was no other way that they could actually have their partner with them and have the kind of birth they wanted and not be exposed to infection so for many professionals this is actually completely unacceptable it's an immoral choice because the woman is putting herself and her baby at risk but from a vocational perspective from the point of view of wisdom we should really be able to understand why women have made this decision and to work with those women how can we make this better for you so that we don't have to feel abandoned at this point in your maternity journey and again the Covid example is a micro-example of what is happening across the piece really this whole rhetoric certainly again in many countries there's a whole rhetoric about choice, maternal choice but really your choice in many cases as a woman is any colour as long as black which is a quote from the original Ford cars as long as you chose any colour as long as you chose black and this definitely was a case in Covid yeah of course you can have any kind of birth you want you know as long as you go to the hospital or your free birth that's your choices and generally speaking that is the kind of situation that women find themselves in in maternity care as a whole so the question arises about what kind of information do women make their decisions based on and again you know as a professional the professional standard is to actually provide information about things that we think are important women to know about the reasonable person standard is well we'll tell you things that a reasonable person in general might think is acceptable but actually the individual standard they feel like the vocational standard the you as a midwife from Trump to the woman that particular woman at that particular time that particular case is the one which is now supposed to be the standard in the UK legally which is what matters to that individual is the thing that you should be discussing with them in terms of their consent or their non-consent you know they can equally as well refuse they want nothing on with that that's a legitimate choice to say no I would not I would decline that option thank you very much so I think this reflects in the literature around informed choice and the legal obligations that we may have although I know the laws are different in different countries and again I think there is this we tend to talk about obtaining consent or obtaining informed consent really it's about women giving us that not us obtaining and not drawing it out of them and usually you know sign here here's the informed consent here's the informed consent thing so informed consent and consent in general is a kind of continuous ebb and flow it's not a one-off thing that happens all the time and that dance between the midwife and the woman which is going to split second and change an order in the split second it's not something it's just a piece of paper signed at once and for all as it may be some of our professional standards may cause us to go down the line as well as long as we've got them to sign that bit of paper then we're covered professionally but we're not covered vocationally under those circumstances and this is again an example of the menu I suppose you know the choice menu so this is quite again quite an old study actually 2016 or so old but I thought it was quite interesting because there's this whole rhetoric about how in Brazil women really want caesarean this caesarean rates high because of maternal choice but in this case there was a two public and three private hospitals not huge numbers of women but a fair number of them and you can see their demographics here and 8% and only 8% and 6% in the public and private sectors respectively preferred section right preferred section interestingly higher in the public but actually 34 and 40% of those who wanted a vagina birth had a caesarean so not much room for their choice there really some obviously would have needed them and some would have wanted them but not that many and again you know what kind of vagina birth is available to most women and babies if this is the kind of vagina birth that most women is available to them it's probably not surprising that a number of women will actually choose caesareans because you know this isn't the kind of generally speaking I mean sometimes these kinds of births are required and sometimes they're wanted by women but most women as it's all they're on don't want these kinds of birth and as the military vocation is when it rolls out we should be really trying to support women as much as we can and sometimes we work in very toxic systems so that's not always easy but to achieve a birth which is quite different from the ones that are displayed here and this is illustrated in these two this particular piece I saw this online and the heading is normal natural birth traumatise me and underneath it says you know something like it was traumatic, horrible horrendous torture I hated it and as you read down you realise this one was induced so it wasn't natural in the sense of physiological because she was induced but she didn't because presumably so many women this is an American woman so many women she knew have been induced that she couldn't differentiate that from what is physiological whereas the other picture here which is also a normal birth shows something very different just got a drip in her arm that's because it's in Belgium but in Bulgaria but you know it's still a very different kind of experience and I think as researchers when we look at the data on the outcomes for vaginal birth we should always say what kind of vaginal birth are we talking about here is it a forceps, is it a bontus, has she had an apesiotomy, was she up right and mobile the whole way through was she induced, was she augmented because all of those things, all of that labour is going to influence the way the woman feels about the birth and also the outcomes of that birth so in fact the nice guidelines have separated the comparison between spontaneous vaginal birth which is interesting and this I think is quite interesting this is some information that is sometimes given to women this is showing a thousand dots showing the difference if you are induced at term plus whatever it is now 41 plus the difference in stillbirth rates so there's two little red dots there are women who continue their pregnancies and the one little red dot there is women who are induced so it's doubling so you could say the risk has doubled but of course if you look at it like that it looks very different in terms of the meaning of that doubling of the risk so I'm going to just finish off the last few slides now so we've got a bit of time for a conversation this is from these quotes from Jill Thompson's PhD she was looking at women who had a first traumatic birth and that included normal birth as well as caesarean and then a following positive birth, again some of those were caesareans most of the were vaginal births spontaneous vaginal births and in the first when she asked the women to describe their labour and birth after traumatic birth they used words like trauma horror, agony rape, abuse those are the words they used and when she asked them after they used these words jaw, euphoria, fantastic, positive, amazing in love, incredible after their positive births now that is not satisfaction that is something much more than satisfaction that is where the medical vocation sits in that space accepting that sometimes we're not going to have we have to accept that sometimes births aren't going to go well for women but even when they don't some of the women using these words had caesareans but they had caesareans where they believed they were done for good reasons and they were done compassionately and they were cared for properly and this is where we should arguably be so there's also evidence that actually if we both do EMOC, so emergency care when we safeguard physiology we have the best outcomes this paper is from Ghana and it's looking at the use of facilities and what it found is that women who use facilities were not necessarily didn't do better but when they use facilities that combine both safeguarding of physiology and judicious use of the emergency obstetrics then they did better it wasn't either war, it was both those things that had to be in play so watchful attendance is a term that Anke Jong and Hannah Darlan and myself have been writing about both requires watchful attendance not disaster preparedness and my fear is that in our push towards being labelled as professionals we sometimes veer into this disaster preparedness space so we need to be educating for wisdom and uncertainty management and capability to manage uncertainty, again the space where vocation sits is in the uncertainty to an extent and being able to manage that with wisdom to take into account the evidence that we know about things like continuity of care but to remember that you have to replicate that evidence in the same way that the evidence was done and not take it piecemeal, so you know continuity of care throughout antinatal interpartum postnatal not one or the other bit of that building that relationship so again this has come out very strongly in Covid and this is a disaster but any of these disasters you look at it ends up saying actually you have to get your community strengthened because if you strengthen your community then if your hospitals collapse you've always got the community that's going to be supportive and there's a very moving paper from Italy in the early stages of the pandemic when Italy was completely overwhelmed and a lot of Italy saying exactly the same thing and I find looking back at SARS the same thing was said so community strengthening community strengthening those relationships strengthening the mid-free contact with women in the early stages of the you know during pregnancy and all the way through is incredibly powerful and of course we have to build out inequity so again we know from the pandemic it's been we've known it before but the pandemic has brought it into sharp focus how much worse women do in more marginalised groups and we have to stop that happening so the advantage of getting it right this is a quote from a midwife the pictures here of somebody called Geraldine he's actually not didn't say the quote the quote from a Dennis Walsh's birth centre ethnography but you've given me power in my life I could never have dreamed of I've achieved something wonderful for the very first time and no one can take that from me thank you so final slide vocation and profession could we combine the two in a way to move towards something that's future perfect both for research and for practice and for reducing inequities and for improving outcomes for mothers and babies and for making sure that we provide the thing that mothers and babies are birthing people want and need so which I would argue is joy and human flourishing as well as safety and wellbeing so over to you all for questions chats and conversations I guess at this point oh thank you so much there's a lot to think about in your presentation and we have some interesting comments going back to towards the beginning of your talk Bupe Wamba has commented on Africa where she's saying the issue of vocation or the calling aspect has really cost us in Africa we need to move to a profession because when people hear that I am a midwife because I was called to service they start looking at us as nuns and priests and expect us to give our freely acquired gift freely and expect nothing in return I completely agree Bupe this is the kind of paradox because again we were in that state I'm not saying that the UK is the best example of anything but just because the midwifery profession has been moving towards being a profession since 1904 or whatever in the UK and so definitely that point we were in that space where it was seeing that it was just something that you did because you were good hearted and you did it for free I want to understand that notion and of course ICM and all the other organisations pushed for us to be a profession and this is why I say that I think we should move towards being both because I think if you are just a vocation I think we should pay properly for our services obviously but if you're just a vocation you shouldn't be marginalised but if you're just a profession then you can end up being divorced from the women you serve so we are still a service we still serve the women and I think the issue really is at the same time as insisting that we have a knowledge base and that what we do makes a difference to the lives and the wellbeing of women and babies and I think that's irrefutable the great thing about the good evidence we have is that we can say look at their job properly which is a vocation job but if you let them do their job properly as a profession by vocation I mean it's a job that's about relationships it's a job about forming relationships as well as a job about having hand skills so it's head, hands and heart it's hand skills, it's coming from your heart but it's also knowledge and applying knowledge in a way so if we can make that case which we can now because we have got really good research and in many countries that's the strong case that has to be made but I think what I'm saying is please don't lose sight of the vocation while you make that case because if all we end up is just being in a job which gives us a salary where we just follow the rules and we won't achieve the outcomes that we want to achieve for women and babies so keeping those two things in focus at the same time really I don't know if that answers your question I kind of in a way what you were just saying that we appreciate the theories and philosophies but we need to bring them together to formulate our own personal philosophy I agree and I think this is across the board I mean I'm going to give you a little anecdote here so a friend of mine has just been a hospital for a couple of weeks, she's a midwife and she's been, none of you know this person and she's been working on respectful care and compassion for years and years and when she went into the hospital she was clearly septic but the nurse just did a checklist, oh this this this no you're not septic, well she was and in fact a few hours later she was extremely ill now you know the nurse only had to look at her and to engage with her you know at the kind of level of person to person to see this but she was doing the kind of professional thing of going down the checklist and all that kind of stuff and that's the risk I think we have to walk away from not going to get tied up in this space of you know checklists and managerialism we're not going to slide towards that as a profession we're going to keep our profession focused on our vocation maybe I'm not saying it very well but that's what I'm trying to say and also to reinforce your discussion of issues of power with informed choice and consent you know Celine from Canada commented on that power differential and how important it is to acknowledge it and frame the information so that the woman really is has the she just says how do you frame that information I don't want to put words in your mouth Celine she's proud of being midwife and yes Sajfa is a midwife in French wise woman wise woman right yes and Celine would love to have a congress with it all around the theme of wisdom and midwifery and Tammy from New Zealand is commenting as an indigenous home birth midwife she's just reinforcing it's so true it's not the woman that predominantly determines the outcome of her safety in birth satisfaction incidence of birth trauma it's the birth attendant and birth management her transfer rate is far below 5% and c-section rate less than 2% congratulations Tammy that's a that is amazing indeed and actually and I'm reading down as well as a book that's what you've described there I'm very passionate about midwifery and neonatal care I care with love that is absolutely the point caring with love and keeping that caring with love at the same time as making ensuring that the profession is recognised having the space it needs to I think that's right and then coming back to the power thing because again I think that's another thing we have to be very careful of you know if you've anybody who's read the literature on professions will know that one of the cardinal the cardinal factors of a profession is it gains power so the more it professionalises so we're talking about originally it was the church wasn't it and medicine and law they were three cardinal professions and the more they became professional the more power they got and the more distance they got from those that they served so I think that what you've written down there is about keeping the connection at the same time as having that credibility and that kind of sway with governments that you have if you have a professional professional and with that we will wrap up