 And now, into the session we are waiting for. I'd like to introduce the speaker for the day, Royzin Lenon. She's going to make a presentation entitled, Changing the Face of Mid-Be Free Care Through Advanced Practice in 21st Century Island. Royzin is a midwife and mother with friends and family all over the world. Currently, living and working in Ireland as a registered advanced midwife practitioner, but worked in Scotland as a midwife for many years. Privileged to be a midwife and part of so many families pregnancy journey. Special interest in aromatherapy and reflexology and post-dates, pregnancy treatments and she's also an IBCLC that's lactation consultant. She's been involved in many audits and research projects and have been, have had a few articles published. Currently learning Spanish to keep the brain active with the hope of being able to travel again and put the lessons to good use. Royzin, you're most welcome. Thank you, Carol, and thanks for that lovely introduction. And thank you, everybody. And thanks for the opportunity for speaking today. It's a great privilege to be part of this great international day of the midwife. So I'm starting off. I know the theme for this conference is birth equity for all. And starting on my first bit, I like to think that part of my role is to empower women on their journey to motherhood. And within that, I love this Michelle O'Don't phrase, to change the world. We must first change the way the babies are being born. And currently in Ireland we're on a big, big change into rolling out midwifery-led care and expanding the whole service because up to now it's kind of been an obstetric model with a small input to midwifery care. So it's exciting times in Ireland. And she's given us the title and that's just the hospital where I work. So I'd like to say that I have no conflicts of interest. I would also like to apologize if I am not totally gender inclusive and I talk about females and not the pregnant person. To be fair, at the moment all the ladies that have been through my service do identify as females, but I do know that that's not always a case around the word. So I hope I don't offend anybody. This study that I'm going to talk to you about is part of my yearly key performance indicator that I have to do within the hospital to show what the outcomes are of the ladies that come through my service. And I've drilled down it further just to benchmark it against the Cochrane Data Review of 2016, looking at continuity care for midwifery models. So just to benchmark it against something that's been out there before and to see where I'm going along in that pathway. For those that don't know Sligo or Ireland, Sligo is on the Northwest. If you're into English literature, it is WB8 has done a lot of his writings here in his poems and we have been in a lockdown no more than the rest of the world and limited to five kilometres since Christmas. It's just extended to county level and we've been very blessed in that within our 5K we have this wonderful walk that you walk through some woods up a little hill, well, decent enough hill and you're looking out over Balasadir Bay, Sligo Bay and out to the Atlantic Ocean. So it's been a walk that I've done with my husband and my poor fourth year student and daughter who has been home from Glasgow for the last year at the table. So we've been very lucky. So if you ever do get a chance to come and visit Sligo, it rains a lot, but it is some fantastic scenery and some beautiful beaches. So to put where I am in perspective, advanced practice around the world is very different. So I'm going to just give a little background so that you know where I'm coming from around regions and tales and like I said, because I know, it changes within countries. So my service is based on local service needs. Advanced practice in Ireland being nursing and midwifery has to take a complete episode of care from admission to discharge and the whole idea is that you're promoting wellness, healthcare choices and you work within a specific caseload that has agreed inclusion criteria. You have clinical guidelines or other policies to govern your practice And what you're doing is that you're working within the free philosophy of care, but at an advanced level, using advanced clinical knowledge, critical thinking and decision-making abilities. And that's all based within codes of conduct from the nursing and midwifery board of Ireland. And then that's just the flavor. It's two years minimum post-graduation, educated to a master's degree. You have to get 500 supervised clinical hours within your area that you're going to be working at the advanced level. You have a medication prescriptive authority. So within my practice, I've a big list of drugs that I can prescribe, which really covers all eventualities of the ladies coming to my caseload. And for advanced nurses, they have to have ionizing radiation prescribing as well. Now, when I went to register, I know it was questioned and they did ask what I, you know, why didn't I have that? But I have to say as a midwife, even as an advanced midwife practitioner, if any of my ladies are needing to get an X-ray or to go through a CT machine or an MRI, they're needing even more input than an obstetrician. So I just feel that, no, that is definitely totally outside it. So I don't have that. So there's five domains that govern advanced practice. And these are the same five domains that are set down for the registered general nurse and registered midwife, but it's just at the extra level of care and autonomy that's the extent of scope of practice. So within the respect for the dignity, the person is you're looking at the self-determination of the individual, that your care is in partnership with the woman. Again, like your professional responsibility is like no other codes, it's same codes around the world that you're responsible for your actions, inactions and emissions. Your quality of practice is to be safe, quality, cost-effective service and demonstrating leadership within that practice. The trust and confidentiality rolls out, the service users, the maternity team and the advanced midwife practitioner working as the link and the patient advocate between all members of the team and the other specialties. And then collaboration with others, basically for the goal that we want is that we've got a good outcome for a moment, baby. Taking into that then within your job description which you develop to suit and reflect what your advanced practice is, there's six core concepts. And they're as detailed before and to put it into context with me, I work within the midwifery philosophy of care. Advanced practice means that I've been able to stay as a clinical hands-on midwife with a career pathway moving forward and extending my knowledge of my base and my services. The focus and the health and wellbeing, it's evidence-based practice, person-centered, individualized and tailored care to the woman, but like I said before, working at that higher level of thinking and decision-making. So the professional values and conducts no more than anything is that you're accountable and responsible within the boundaries of your job description, your inclusion criteria, that you've timely referrals to and from the service and discussions with the family, the women and the clinical team that other team members that are involved in our care. Clinical decision-making means that I have to be able to undertake a full physical examination as required. I can order tests, investigations and then by putting them all together and interpreting them and then care planning with the right therapeutic interventions, which could be looking at just health care changes. It could be prescribing medicines just depending on what the findings are. The knowledge and cognitive competencies look at leadership that you're the lead expert within your service that you're involved in research and audit, education and ongoing continued professional development and evolving the services needs be. Communication and personal competencies go within the health care professionals, the obstetric team, the women and the family, other specialties. And within Saiga we're very lucky in that we've got a range of specialties that most times as clinical nurse specialists that you can pick up the phone to and refer the ladies very, very quickly to. So we're spiritual nurse specialists. If I've got a lady that asthma is playing up, the diabetic nurses, it's just fantastic. It's so seamless and so flow through. It's brilliant all together. Our leadership and professional scholarship competencies then are evolving the service, identifying the gaps, implementing change and evaluating and that's done through collection of key performance indicators that are set into the job description and also undertaking audit and research into the service. So putting it all together then, care is as per the three C's that are set down with the nursing and midwifery board of Ireland and that's for all nurses and midwives and that's what you're practicing within compassion, care and commitment. And I think that reflects around the world wherever people are working. And the previous slides are just put together that basically this is what my care is all about. It's the safety and autonomy of the woman, respecting her choices, values and beliefs, responsible and accountable, safe, compassionate, respectful care, equal partnership with the women and communicating and collaborating with the woman and the multidisciplinary team. And that is basic standards of advanced practices set down with the nursing and midwifery board of Ireland. And put into context, I have clinical guidelines and just that's how strict and sort of governed that the practices that I have one that tells, supports how I will telephone a lady and give her information, how I will do my physical assessment. So it governs all bits of practice. So as long as you're working within the job description and your clinical guidelines and your conclusion criteria, your practices is safe and it's safe for the woman as well. It's all brilliant. And then the accountability areas are a little bit different than other branches in that you're professionally accountable to the director of midwifery, obviously to the nursing and midwifery board, the service use in public and the laws of the land. I forgot to put that one in. And you're clinically accountable to consultant obstetricians. So just a different little bit of way of working than you'd normally be as a midwife. And this quote I just love, it's birth is not only about making babies, birth is about making mothers strong, competent, capable mothers who trust them, says and know their inner strength. And I think that at the end of the day, that's what's about that you're empowering the woman on her journey and you're doing this so that you've got a mom who's taken a baby home and hopefully having a very satisfied experience of her care and moving forward to take her family on through the next step. So the AMP service was introduced into Sligo in 2017. Like I said, it's a complete episode of care and I take a medium risk pregnancies, which in Ireland is set out as assisted care pathway. Usually within midwifery care, it's normal risk and that in Ireland is known as supported care. I first meet the ladies at about 18 to 22 weeks and I take them through to postnatal discharge. I have admission and discharge rights to the services. Like I said before, I can prescribe medication. I've referred pathways to all specialties within the service and close links with the multidisciplinary team. Now where the service does fall down at times is I work Monday to Friday just so if any of the service users come in at the weekend, then they fall under the remit of the oncologist et cetera team. And then just a flavor of what my caseload looks like, just a benchmark it against where people that are working as midwives are saying, well, what's different with advanced practice is that I take a slightly extremer edges of ages. So 16 to 45, I started off with stable medical conditions and if then they needed changing of medication, like say thyroid medicines, that then they would revert back to the consultant. But within the links with the other areas, some of the consultant physicians were like, well, why is this lady going back to the obstetrician? Sure, I'm winding her for a thyroid or diabetes. You know, I'm looking after that, you're looking after our pregnancy. So we brought her back and that did change. The station on diabetics and diet group B strip, you can see them there. So it just puts into a little bit of perspective. And the other little bit that I take is where is that there is a midwife led anti-natal clinic. They take the ladies up to 39 weeks. And before I started the service, they would have gone back to consultant care for post-states and planning what they come to me now. And then if they're needing an induction, they take all that. Or sometimes they fall out the support to care pathway and they move into medium risk. They sometimes transfer care to me. So it works nicely. That's great. I love it. So that's a long-winded bit of what advanced practices, but I felt it does just benchmarking and it was relevant. So what's my study about? That's what I'm here to talk basically not just about the other bits. So what, like I said, for parts of the key performance indicators is to look at the birth outcomes and other bits for the service users. And most years what I do is I benchmark it. I take what this sort of births different things and benchmark it against the rest of the maternity unit within the hospital. But like I said, this time I wanted to just drill it down against the carbon data review for primary and secondary outcomes to midwifery lead care. And I benchmark it against a similar case load of ladies that were tending for obstetric lead care as per my inclusion criteria. And for those that I'm sure you're all familiar but just to recap what those primary and secondary outcomes are, it looks at the birth outcomes as in usually there's higher vaginal birth rates, there's lower epidural rates, more intact perineums and less babies born preterm. And then the secondary outcomes that Cochrane review came out with there was less labor interventions, less use of analgesia in labor, perineal tears, postpartum hemorrhages, breastfeeding rates, abgar scores less than seven at five minutes, birth weights less than 2.5, resuscitation and then ICU admissions. So it's just putting against all of that. So the study was, apologies, I didn't go forward. The study was a retrospective study. It took place from the 1st of November, 2019 to the end of November, 2020. It was anonymized data and it was taken from the maternity information record. Now the record we have is very nice. You can do a stat generator, you can put in what criteria you want and you can pull it over onto spreadsheets so you don't actually link it back to PCNs or hospital numbers and then you can benchmark against the different bits. So we included everybody that had come to my service and that came to 324 women and they were ladies that had the full episode of care through me. So I discounted the ladies that came at 39 weeks and onwards from the midwifery led care or ladies that had been transferred to obstetric care someplace through the pregnancy. When we did the stat generator through the maternity information record, we pulled out 672 ladies that had similar caseload and data. So we decided that we would put them all in because if we tried to sit them down, we might lose some of that. And as we were using percentages comparing it, that we felt that was a truer reflection of what was going on. And like I said, we excluded the supported care and all the rest. So the breakdown of the parity, the purple lines are the advanced practice service and the green is the obstetric led service. And the obstetric led service means that, like myself, they would see the ladies, the care is shared between the ladies general practitioner and at the clinics then, it could be a different obstetrician they see each time, it could be a junior, it could be senior, it could be the consultant just depending and they would have a midwife that checks in, does their ops and that's the midwifery input with us. So just to put it into perspective. So between the parities, they were very similar spread out. The age ranges, again, I had slightly more with me. So at 20% of ladies were over 40 and I know that for the obstetric led care, that sort of 30 to 35 group had a higher bit. But on the whole, they were fairly similar and evenly spread. And just within the cohort group, and for those that are very quick to calculate things, you'll realize that the numbers don't add up to 100. Excuse me. That's basically because some ladies had two things going on. So they might have had BMI and anxiety and depression. They might have had BMI and GDM. So it was just to give a flavor of what's looking. And between them fairly similar, except I know for my service, I had more ladies that had anxiety, depression. Some of them were on medication, some of them weren't and similar to the obstetric led care. But the rest of the ones were fairly similar between the underlying medical problems of previous postpartum hemorrhages, the group B streps, all that. The data analysis, like I said, we captured it from the data generation. We looked at them, we did numbers and percentages to do a statistical analysis. There was nobody in the hospital does it. So I was very lucky in that my daughter is finishing off her finance and business. And she helped it. And her friend, who is a credit risk analysis, he did also the data. And between the two of them, they numbered crunch. They came up with exactly the same statistics. And it was actually very interesting, the conversations, because they hadn't a clue of what I was looking for. I really didn't have a whole lot of a clue of all these great big logistic regressions that was getting bandied about. But at the end of the day, the numbers proved what it was and came out. And so it was interesting and a nice steep learning curve for me. And we took a p-file of less than 0.05. And again, obviously anything that was less than 0.001 was really, really statistically significant. So the results, and we looked at the primary results, as you can see breaking down, statistically there was similar vaginal birth rates. This was a bit that threw me, and that's where there was numbers, but I was told the numbers can't lie, so that if the stats are driving it and saying that the probability was less than 0.01, that was down to the numbers and that the obstetric lab care actually came out better than that. The MP service had higher instrumental birth rates and the emergency sedentary section rate was less with myself, regional analgesia use was less, intact perineums were very similar and preterm births were less for those coming through the AMP care service. For the secondary outcomes then, induction of labor was less for AMP care and induction of labor resulting as the sedentary section was fairly similar. And when we drilled down into that, the actual induction of labor is that ended up in sections for within my case load were more ladies that were post-states or there was probably 40 to 50% of them had had prolonged rupture of membranes that went on to have the sedentary section was within the obstetric lab group, most of the ladies were less than 40 weeks to station and had various reasons for induction like previous quick labors, maternal requests, different things. So it was just an interesting breakdown. There was less sort of amniotomies done within the AMP group. It wasn't statistically significant, less use of oxytocin, similar rates of no analgesia, more ladies used entinox only in the AMP group and the opioid use only was less within the AMP group than in the obstetric lab group. Also from that then, the perneal tears within the two groups were fairly similar, but the Pseotomy rate was slightly less in the AMP group, which that was even considering that the instrumental delivery rate was higher, was interesting, and the third degree tears were very similar as well, but the PPH loss or more than 1,000 was less within the AMP group. For the babies then, there was more ladies initiated breastfeeding at birth in the AMP group. The breastfeeding at discharge was higher in the AMP group, but again, wasn't statistically significant. Birth weights was, there was more babies born over 2.5 kilos in the AMP group. Apgars less than seven were fewer in the AMP group and the resuscitation rates were fewer as well, and the neonatal intensive care admission rates were fewer. The vaginal birth after society section doesn't come into the midwifery led care and cochlear review, but I put it in there because it is part of my case load. As I put in, I think there was 18 ladies in total attended my case load that had a previous design section and were aiming to have a vaginal birth. Out of the ones that didn't attempt it, three ladies were breached and obviously that was a repeat elective section and one lady at 38 weeks was all for having a vaginal birth, but at 38 weeks, just something just said no, so she asked for an elective section. Out of them, the ladies that did go on to labor, there was an 85% rate that did achieve it and the ones that didn't have a vaginal birth, there was various things between meconium, maybe scar pain, maybe bleeding, was in the obstetric lead group, there was only 58% of the ladies that actually achieved a vaginal birth. So, experiences have clearly shown that an approach which demedicalizes birth restores dignity and humanity to the process of childbirth and returns control to the mother and that has shown to be the safest approach and that again is Michelle O'Donnell. And like that, I think that's sort of what I'm trying to do to give that back to women. Yes, obviously, if more people have a vaginal birth, yes, that's probably the goal in a lot of studies, but I have to say for my philosophy, if a lady has a satisfying experience, even the ladies that opt to have an elective section after the vaginal birth, but they leave the hospital feeling that they've been listened to, that they've had choice, that they've had good care and that they're going home to move forward, minding a baby and look after a family, I think that's really what it's all about. But again, it's just trying to get everybody safe. So, what do all these mean? So, benchmarking it against the Cochrane Review, there were similar findings in that there was lower preterm births and lower epidural rates and the intact herniate rate was similar. But what was different was the spontaneous vaginal birth rate was similar. The instrumental rates were higher within the AAP group, but the emergency scenario injection rates were less within the group. Secondly, outcomes similar was that there was less artificial rupture of membranes, less episiotomies and pernial tears were similar, but I think the third degree tears overall, there was less that required suturing and similar opioid rates. The difference was that there was actually lower induction of labor rates. And again, that might be different to the Cochrane Review because traditionally are the midwives in that care then going on to induce ladies and that was something that I just didn't really drill down thoroughly with, but probably did look for the birth outcomes first. There was lower oxytocin rate. And again, like as I always say, once you add in oxytocin to the equation and something goes wrong, that's where everything seems to just tie back onto that. So less oxytocin is obviously better. Lower postpartum hemorrhage rates. And again, that's going to affect going home, breastfeeding, all the rest. And then, like I said, similar in the one of GZ rates. So they were different to the Cochrane Reviews. For the babies, it was very different in that there was less babies that occurs less than seven, less babies requiring resuscitation. And interestingly, the babies that needed resuscitation weren't always the ones in the emergency zone section group, sorry, the less NSU admission rates and then the higher breastfeeding rates. What does that mean then? Well, expect to me at the end of it, it means that it does show that it does work, that you can roll out a similar continuity of care model against an upper level of risk ladies, just using advanced medical practice. So it's something that could be looked at and developed, but it's certainly, it's made a difference with our unit. I'm certainly going back to the theme of this year's conference, equity for all. It's not equity for all, but it's offering choice and a little bit of difference and expanding midwifery model of care and philosophy to more women than one it did before. The AMP care is less interventions. So expect if you're looking at cost effective and keeping things normal, that certainly comes into it. And then the baby outcomes exceed the findings from the others. Again, less separations of mommies and babies, less stress at the moment, the initial point of delivery because you all know, even with the baby's lying on mom's chest and it's crying, she's always still gonna say, is it okay, is it okay? But obviously if you have to take it away to the results of tearing two extra bits, that's a whole different ball game and extra stress levels from everybody. The strengths that we kind of pulled from it was that, and this is where we could have had even better rates or maybe worse, I don't know, but all the ladies come in through our obstetric led delivery suite unit. So it's core label ward staff and midwives that look after them. If there's things that need reviewed, it is on the oncologist team that usually make the decisions. So again, both groups were subjected to similar care and the lottery of that core label ward staff. So that was kind of doing that a little bit. The demographics of women were very similar and the cohort of women were similar. Yes, it was just about the double of amount in the obstetric led care. But like I said, we didn't set them down just so that we could compare it more accurately than you might just lose certain different cohorts and different bits. The limitations with it was that, it was retrospective as opposed to prospective. The other bit is the input of what goes into the maternity information record. You're relying on that being accurate because we certainly didn't pull the thousand charts to go trailing through. So some of that input might have been not accurate. I know from my own stats, certainly from what I would do from keeping a record was similar to what I pulled from the stats generator. So I know from that that was fairly accurate. And the other bit is in the obstetric led care. Like I said before, there's different levels of experience and expertise of the obstetricians looking after the women that are coming through that. Once the ladies that were coming to me, it was the same person that they were seeing each visit. I am not anti-obstetric team because we all have a great big place to play. But I do have to say I like this quote. So the midwife considers the miracle of childbirth as normal and leaves it alone unless there's trouble. The obstetrician normally sees childbirth as trouble. If he leaves it alone, it's a miracle. I have to thank all these people. And at the top, I certainly have to thank the women who have opted for AMP care in Sligo. Because when we started off, people were like, I'm not sure I have to see the doctor. I have to see the obstetrician. You know, oh, midwife can't mind it. But as women have come through the pathway, the best bit now I have to say is women are actively seeking, looking to seek and they come to the service. So that's great in itself. And I have to thank the consultant obstetricians because without their support and the director of midwife free and Miss McDermott who's now retired because she started the ball rolling. Without them, I wouldn't be where I am here today. So, you know, it's all part of a team. They're the kind of key core members. And then like I said, the rest of the midwives within the unit, the healthcare workers, everybody that's in the team is just part of it. So I'd like to say thank you very much for listening to me. I'd love to take any questions or comments. And what I would really, really love to ask and find out from people if they wanted to put it into the chat box is, you know, are you guys working as autonomous midwives? Are you working within an obstetric led care model? Is there a advanced practice within your areas? And what else? And they're just little bits I'd love to know and I'm happy to take any questions. There's loads of comments. I haven't had time to look at them there but it looks like it's interesting reading. So thank you very much. So thank you. Thank you very much, Rezin. That was a great presentation. We have a few minutes for questions. And I'm sure you're looking at the chat box. There's a question from Loreadana Zodan. I want to believe that you can be able to see it but I can also read it. What is opinion if all midwife in Ireland would study and become advanced midwife practitioner? Do you think the service to women will improve? I think it would be great. And like I said, we're just trying to at the moment expand the midwifery led model of care. So the midwives working as autonomous practitioners. So some units around the country, so there's 19 maternity units in Ireland, are working at that and some are just developing it. And currently there are 12 candidate advanced midwife practitioners going through the program to set up and expand the midwifery led models to care within their units. So that's exciting and it would just make such a difference, you know, just that kind of working at that level, offering the choice and then linking in with the obstetric team because absolutely we do need them and just sort of flowing it more. But what the women traditionally kind of have lacked here is not that midwifery model, not that input, not that health promotion bit. And that's the bit that I think that we can change to make a difference. The other one that I see there, I see Sheila there is just acting about interpartum. I forgot to say that. No, I don't do interpartum care. We looked at it and we looked to see if we'd do that, but that would mean probably 30 to 40 ladies a year and the actual service needs analysis looked to just kind of trying to change bits. So if I do have ladies that are coming to me that need induced, I will come in, I'll do their induction, but hand it over and liaison with the core labour ward staff who provide the interpartum care. At the moment, the service has been a bit disjointed because our anti-natal clinics have been away from the main hospital. So before that, I was certainly more of a presence on labour ward, but now I'm lucky if I'm up there once a day. But it's getting that bit. And before I was maybe downstairs in the clinic, if somebody needed sutured and none of the midwives in the labour ward sutured, I'd do the suturing. I'd quite often be the second midwife in at the birth of those any of my ladies in birthing, but that isn't as fluid and joined up in the last year just because of COVID and the restrictions. Hopefully that answers your question, Sheila. There's another question here. Was there a comparison of ramp and other midwives? Because that service is so limited, so traditionally through the midwifery anti-natal clinic, there's about 10% of the whole case load come through. They only provide the anti-natal care. They don't flow back into the wards and everything. So what I would do is I would gather the stats from them and do birth outcomes in that. And for within them, the vaginal birth rate tends to be similar to the MP birth rate and emergency sections. And then obviously the inductions in that don't kind of come into it because they would fall into my stats. And just we're hoping that we have got now same and two waiting to go into post to roll out sort of midwifery led care and early transfer home. So she's going to be rolling out that midwifery led service within the unit. And hopefully in the next few years then we'll see an extra change with that. So that will be following ladies on the clinic interpartum postnatal and going home. So that'll be interesting and really exciting. Looking forward to all that happening. Okay, thank you very much. There's a couple of more questions but I think we have some lifetimes to take one or two. There's one from Iska who's saying considering the importance of advanced midwifery model of care, why are many hospitals still keen on OLC especially private hospitals? I think a lot of it is that it is recruitment. It's the training and it's also then just getting the local service need. Because I have to say when I started the journey I thought my vision was about supervising consultative obstetrician shared that vision but we hit many walls on the way and even down to there was one stage I was just going to leave and the lady that's practice development that coordinates all that I remember phoning her and said, look, that's it and I remember her saying to me, Roting, you signed a contract as a candidate at AMP your job description is to get registered as an AMP so suck it up and get on with it. So I sucked it up, I got on with it and that's where I am now but I think that's you really need to be committed. It's a steep pathway, it's a steep learning curve and it's just trying to get everything into place and just get the agreement locally to put it into place and to practice at that level. So I think that's why it's kind of slow to take off and I know last week I think it was I tapped into a conference from the UK and they were talking about fans practice and they're similar, they're small but I'd say beginning to start going to grow and leaps and bounds as well. Okay, thank you, lots of comments, great presentation you've done a good job, it's lots of accolades. There's one more here that I'm seeing, does Ramp have more autonomy than other midwives? I don't know if there's more autonomy than other midwives and you would like if you're working as a midwife you've got that full, you know, package of care and decision making for your ladies and I know the midwife rules in the UK have changed but when I was training there I think it was rules 30 and anything out with the norm you have to escalate care up to and similar to me, so out with my inclusion criteria and my guidelines, so if I come across something that I haven't got that skill set or I'm not quite sure so for example, a lady coming for clinic her blood pressure's up, we've done her blood she's now showing that maybe her urea is 3.84 she's 36 weeks, she might have come back to my clinic and we've done those, I'll link in with the consultant, consultant obstetrician at the clinic and say look what are we going to do? Now sometimes it'll be a case of the blood pressure's fine we'll should keep an eye on this lady twice a week if there's anything untoward come back to me or it could be right, okay, let's decide we're going to induce her so you've got that kind of flow way through and that immediate access to the consultant so for that, yes, I've got extra clinical decision making around the ladies that I'm caring for but there is a limit within that and then I report back to the consultant from that so hopefully that answers what the question that the person is asking. Okay, I don't think there's any more questions and I want to believe we're all comfortable now and thank you once again, Rosine, that was a great presentation, the accolades like I've mentioned are awesome, yeah, good job. And I think the other bit that I didn't say is I think from this study and looking at it what the next step that's looking forward to is to try see then as the community model and the midwifery care model comes into play and we have that kind of home from home room that there will be more people taking within that and not automatically doing the artificial rupture of membranes and I mean, so many ladies sit at my clinics and say, oh yeah, but once they break my waters I'll labor so once I'm in there I'll get them to break my waters and I'll have the baby then in no time. So it's changing the women's mindset, changing the midwifery mindset and it'll just be interesting to see if that changes a lot of things moving forward as well. Okay, thank you very much, Rosine. Thank you once again, thank you all for being around and just a few more slides and then we can get to the end of the session.