 And now it's my pleasure to introduce Dr. Eugene DeClerc. I can tell by the comments that many of you already know his work. Gene is a professor of community health sciences and is the assistant dean for the Doctorate in Public Health at Boston University School of Public Health. And he's a professor on the faculty of obstetrics and gynecology at the Boston University School of Medicine. He has served as lead author on numerous national reports on women's experiences in childbirth and in the postpartum period, particularly listening to mothers 1, 2 and 3, and New Mothers Speak Out. He's the founder of the website, www.birthbythenumbers.org. He was awarded the 2013 Martha May Elliott Award from the American Public Health Association for service to maternal and child health in the United States. Gene, we're happy to hear you. Well, hopefully you can hear me. That would be a plus, I guess. We'll see how this all goes. Let me get any other introductions or can I jump in? Jump in. Okay, I'm jumping. Then let's move in. Let me just see one thing here. So to advance the slide, so I hit this thing at the bottom. There we go. Yes! Cool. So this is the layout of the presentation. The premise of the talk is that, and I know this is going to be shocking to the audience we have, but the premise of the talk is midwives need to be made more central to women's health care at both the community and the facility level. That's going to be the premise. We're going to use the case of rising caesarean rates in part because I was asked to do that, and so I'm going to work through some of the issues around that, but then I want to come back to midwives' critical role in all of this. So this is a framework for quality maternal and newborn care. Mary Renfrew requires that I use this in every talk now, and so I'm presenting it as part of this because I think it actually works in this case. I think a lot of you may be familiar with this from the Lancet special series on midwifery, and I'm going to return to this, but I just wanted to note one thing at the outset, given that much of this discussion will be around caesareans, and that's this, that midwives can be involved in almost all aspects of care, perhaps except this final one where we thankfully have highly trained and skilled obstetrical specialists who can provide care to high-risk cases, but the other point of this was that high-risk cases are rare, so caesareans can be life-saving in those cases. The question for us is how often are they needed? So understanding that this is addressing only one small piece of that, we're going to look at the phenomenon of caesareans because it captures a lot of what people are concerned about regarding maternity care now. So how frequent caesarean sections be, and this has obviously been a question that folks have wrestled with for some time, and so this is a little bit of what the literature says, and people in our area often cite the WHO's recommendation of a 10 to 15% caesarean rate, but that was a consensus meeting. There wasn't actual formal studies that were associated with that, though people have relied on that for some time. Ferdinand Altebi and colleagues did a thoughtful study published back in 2006 looking at caesarean rates and neonatal and maternal mortality, and the references for all these are at the bottom of the slide, and I would encourage people to take a look at them because they're very interesting, well-done studies. And basically what Altebi and colleagues were, they were not trying to target a particular rate, but if you look at the figures from those research studies, what you'll see is two things. One, that very low rates are dangerous, right? Caesarean rates under 10% are often a reflection of a lack of infrastructure in a given country, and there's a need to have enough infrastructure to address what truly emergency cases, and of course in a lot of those countries, the variety of health conditions and social conditions is such that there's a greater need in many cases for dealing with things like obstructed labor. And so in those countries, the very, very low Caesarean rates were reflective of high, or related to very high neonatal and maternal mortality rates, and as the Caesarean rate went up, the neonatal and maternal mortality rates dropped substantially. But after about 15% or so, those benefits decreased, and in middle and high-income countries, when you look at this, those flatten out even more, and there's less and less clear a case for that, but they don't make a formal recommendation. Then more recently, a group that had worked at WHO around this, Yee and colleagues published a paper also in Berth, where they looked at data from 19 industrialized countries, and again, tried to wrestle with the question, at what point the life-saving benefits of a Caesarean section get offset by the unnecessary levels of medical intervention that might be associated with doing Caesareans on women who don't necessarily need them. And they found, interestingly enough, roughly that 10% to 15% range once again. And more recently, Molina and colleagues in the Journal of the American Medical Association analyzed data from 194 WHO countries, and they were looking at data from 2005 to 2012 and either used 2012 data or estimated data from 2012 to do an analysis that's very much parallel to the one that all the being colleagues have done about a decade earlier, looking at its relationship to neonatal and maternal mortality, and they did say, they did come up with a number, and their numbers was 19%. Now, the interesting question here is, of course, what does that relate to actual Caesarean rates? And here's a bunch of lines that are almost indecipherable, but you can see the overall pattern. These are trends in Caesarean rates in industrialized countries, and by industrialized countries, we're talking mostly the countries in what we term the OECD, Organization for Economic and Cooperative Development. And what you can see is there's two flat lines there, one at roughly 15% and one at the more recent 19%. And what you can see is by the early 2000s, most countries were above that, and certainly by 2007 all but a couple of countries were above that, those rates. But if we carry this forward, just to note one other thing, it's not just industrialized countries we're talking about. And another WHO study based on 2008 data, and you see the study there, and it's available online, if you Google that name, you can get the study. What we find is that they looked at the global number in costs of unnecessary Caesareans, and two things stand out from this. One is China and Brazil, both emerging economies but not usually considered among the industrialized countries in the world yet, and accounted for almost 50% of the total number of unnecessary Caesarean sections, both because they have high Caesarean rates and of course they have massive populations. They use 20% in one of their analyses if you use 20% as a threshold rate to say that over 20% means you overuse the Caesarean sections, there's about 4 million Caesareans that are excess in 46 countries that they looked at. And the conclusion is on the bottom pot. Worldwide Caesarean sections that are possibly medically unnecessary appear to command a disproportionate share of global economic resources. Caesarean sections arguably function as a barrier to universal coverage with necessary health services because excess Caesarean section can have important negative implications for health equity as a result of this, both within and across countries because they use up so many resources. And this is just one example of that. It can be deceptive to look at countries and think that they're not in bad shape because their overall Caesarean rate isn't that high. And this is just the case of India drawing on data from demographic and health surveys. And what you see over on the left is for the three periods of time, the early 90s, the late 90s, and the mid 2000s, the rate goes from 2.6 to 7.1 to 9%. And that would seem, you'd say 9%. Well, that's low, that's probably not a problem. But when you break it down by subgroups, you see differences. In the urban population, it actually is up to 17% now. In the high income quintiles, which presumably would be the people who least need Caesareans because they're healthier coming in, the rates were already up to 27%. And that's back a decade ago. And if you were to cross both urban and high quintiles, the highest income groups, what you would find is extraordinarily high rates. And so as much as the large proportion of the problem here is coming from industrialized countries, the challenge that we have is that it occurs, it's increasingly occurring in developing and emerging economies as well. Now, having said all that, I am going to come back to the United States because I have better data on the United States. So this is the United States Caesarean rate for the last 25 years, between 1989 and 2014, which is the most recent data we have available. And you can see the patent, and it's not a patent that's common actually. In most countries there was a clear, consistent increase across this time, but the United States tried to reduce the Caesarean rates in the early 90s, and it had an effect. But since 1996, a tremendous increase, over 50% increase in that time. And so the question is, why was there such a major increase at that point? Here are some of the reasons that I've put forth for it, that it's because mothers are getting older and older mothers are at greater risk, hence they have to have Caesareans. They're more likely to need Caesareans. That because of assisted reproductive technologies is more multiples being born, and because of that they need to have Caesareans. That maternal obesity is a problem, and those mothers are at higher risk, hence they need Caesareans. That babies are getting bigger, because it's a bit ironic, given we're also saying mothers are less healthy, but mothers are healthier than they were before. The babies must be bigger, hence they're bigger, there must be more difficulty, and so therefore Caesareans are necessary. This is in contrast to the next one, which says mothers are generally less healthy. And then there's the argument that this is a function of maternal request, that mothers are asking for Caesareans. Now, the question I pose at the bottom here is what do these explanations have in common, and I think the obvious point is what they have in common is it's not about systems, that it's about mothers themselves, about the babies themselves that's driving this. And in fact, that's a common theme, that it's not us, it's somebody else. So let's look at each of these points in order. This is a question of older mothers. And I would note, obviously this webinar will be available to people to download. Also the slides will be available. People want the specific slides for their own uses to show at parties, to share with friends. That website that's on the bottom of these slides, birth by the numbers, all of these slides will be posted there and people can use them for their own purposes in their own presentations. So this is the issue with older mothers. In the United States, percent of older mothers is tracked from 1990 to 2014. There's a couple of things to note. First, it's true. The average age of mothers was increasing. The proportion of mothers in the older age groups, over 30 and over 35, was increasing between 1990 and about 2004. Keep in mind though, that in the first part of that increase, the Caesarean rate was going down, that since about 2004 to 2010, it flattened and actually went down. And between 2003 and 2010, while the age of mothers wasn't changing, the Caesarean rate increased by 20%. And from 2000 to 2014, it started to go up again. This is partly a result for those not from the United States and not sucked into looking at birth-related data all their lives. This is partly a function of the fact that we've had in the United States a substantial decrease in the teen birth rate. With fewer numbers of teens, the proportion of mothers in the other age categories goes up. But what's intriguing is, while that started to go up, and go up fairly rapidly on mothers over 30, as you can see on the right-hand side of the figure over here, the Caesarean rate's been unchanged. And so it doesn't appear to be much of a relationship at all between the proportion of mothers that are getting older and the actual Caesarean rate. What has changed is this. When you look at the Caesarean rate by age group, what you see is that it's increasing between 45% and 55% in every age group. And if there's any group you might worry about is having such massive increases in women under 20 and under 24, because in a lot of the same societies in which in the United States would be one of them, that vaginal birth after Caesarean is rare, that's going to mean they're going to continue to have Caesareans through the rest of their child-bearing years. So let's look at the second argument. And that's the one about multiple births. And what you see here is proportion of all babies in multiple births in the United States over a 35-year period. And again, what you see is a long increase occurring during the early parts, and this is much of this is related to assisted reproductive technologies. But again, since roughly 2003, that line has flattened out completely. A function of improvements actually in assisted reproductive technologies. What about Caesarean rates? When we look at that, what you see is the change again is in the likelihood of having a Caesarean condition. In other words, the conditions aren't changing as much as the behavior related to those conditions are changing. Let's continue. A baby is getting bigger. This is a very powerful argument. It's a sort of inherently understandable argument, right? That if babies are getting bigger, and that sounds like a good thing because they'll be healthier, then it might lead to problems with the need for more Caesareans. A very powerful, a very effective argument for the slight problem that it's wrong. There is no evidence that babies are getting bigger. Babies are, in fact, if you look at it from the perspective of the babies who might be at greatest risk, between 3,500 and almost 4,000 grams and then more than 4,000 grams, those numbers aren't going up at all. And actually, if you just look at all babies, the numbers go down a little bit related to prematurity. So that's not actually the case. It's not a function of babies getting bigger, though when you see media coverage of rising Caesarean rates, they almost invariably cite this as one of the pieces. But again, what we have seen is this. Caesarean rates for singleton births by birth weight, a substantial change. I think it's noteworthy that you can see in these groups on the left from 91 to 96, either flat or going down through that period, you see the rise between 96 and 2006 and then roughly since then pretty much flat. So the babies on changing behaviors around the babies are changing around the size of the babies. What about mother's health? Again, this sort of lays it on mothers, right? This is rates of pre-pregnancy obesity. I'm going to come back to that issue later. Pre-pregnancy obesity in the United States. And what you see is there was a growth. We don't have as much data on this over time. But you can see there was somewhat of an increase between 2003, 2006, up to 2009, and then level since then. And in overall studies of American society while we continue to refer to an obesity epidemic and rates are higher than they should be, those rates are pretty much leveled off in all populations in the United States at the most part. But this is the trend in terms of cesarean rates for singleton births by pre-pregnancy weight range. And what you see is clear differences in behavior. Now one could argue that obese mothers are at greater risk for other things and this isn't a function of obesity. And I know what your question, your natural question is essentially well gene. Maybe it's a function of other things and have you ever controlled for all of those things? So let's go to the next slide. Oh, we have. This is controlling for a whole range of things. You can see down in the bottom, this is from a study that was in birth last year. And adjusting for age, race, education, prenatal care, nativity and so on, there's still a very, very strong relationship for both first time mothers, that's the blue columns and multiparous mothers, that's the red column and it's almost the same thing in both cases between pre-pregnancy weight and likelihood of a cesarean with mothers in the highest group having more than a double the likelihood compared to mothers in the normal weight range. What about mothers health? Well, maybe coincidental with the cesarean, coincidental with the obesity trends that we saw, what you see is an increase in diabetes and hypertension. It's a little tricky on the most recent hypertension data because they changed the measure slightly in 2014, but in other studies, you see the same kind of pattern here. What's intriguing is when you look at this by cesarean rate. Because what you see is a decline in the early period, an increase, I think some of this change you see at the end is a result of the change in measure, but what you see is an increase in recent years in the likelihood of cesareans, but what I'd really like to point out is this period. If this is solely a function of rates of diabetes and hypertension, the curious part about this is when there was a national effort to reduce cesarean rates, cesarean rates for diabetes and hypertension both went down and the increase has been since then, and at least in the case of hypertension, you see the recent leveling that we've noted in so many of the other cases. So what this all suggests is that the changes we're seeing are a function of changes in systems and how they treat mothers with given conditions far less than mothers themselves and changes in mothers driving that. And then we get to one of the more controversial ones which is mothers asked for this, that mothers ask for cesareans and you see interviews with providers who say it was because of pressure that mothers wanted this. Now initially we have to make one distinction and that's between primary and repeat cesareans, at least in the U.S. context. The likelihood of a VVAC is fairly low in the United States. National rates probably measurement on this is a little tricky, but it's probably around 12 or 13%, which we put it at the lower range if you compare it to other industrialized countries right near the bottom. And in those cases, mothers can't even anticipate the likelihood of having a vaginal birth after a cesarean. So to really understand what we're talking about when we deal with the idea of maternal request, we're focusing primarily on primary cesareans here. And we're drawing data here from listening to mothers, which is a series of surveys I've done with a bunch of fantastic colleagues who sort of carried me through this process. And this is the most recent one, listening to mothers three, which came out now three years ago. And in it we had questions that we've used in the last couple of these surveys. We had two criteria from maternal request cesarean. The first criteria was simply the mother made request for clans cesarean before labor began. In other words, this isn't something that she's raising as an issue in the middle of transition. The second criteria is that the cesarean was for no medical reason. Obviously, if a mother has a particular comorbidity or amorbidity that might be related to a cesarean and that's the driving pattern, then that's not really what we're talking about maternal request. I think when people talk about maternal request, essentially what they're talking about is, again, maternal preference for this. So what happens when we combine these two? Let me just go back for a second. So we asked both these questions at separate parts of the survey and we crossed them to see what proportion of the mothers who had a primary cesarean both made the request for the cesarean before they went into labor and didn't have a medical reason for the cesarean. When you do that, we come out with about 1%. In an earlier listening to mothers back in 2006, it was 4 tenths of 1%. Now, this is not to say it never happens because clearly it does and if one goes online, you'll see references to this on a regular basis from mothers who have done that. And this is a quote from one of the mothers. I think the cesarean is the best way to give birth. It's planned, no hassle, no pain. The baby doesn't struggle to come out and so on. I think everybody should have a baby by cesarean section. But the fact of the matter is, she was far and away the exception to the rule rather than the rule in these cases. And we found almost no cases where we saw the criteria being met. This isn't unique to us. Studies from England, from Canada, some state studies in the United States all confirmed very low rates of maternal request primary cesareans. So let's go back and consider the other side of this. We also asked if mothers felt any pressure to accept interventions based on method of delivery. And so here's the response. The question was, did you feel pressure from a health professional to have a cesarean? This is proportion of mothers who said, yes, by method of delivery. In other words, they have a repeat cesarean, a primary cesarean, a feedback, or vaginal birth. And when you balance these all out, it comes out to be about 12 or 13%, but that's because most mothers still have a vaginal birth. But when you look at this, it's really striking that 22% of the mothers felt they were pressured to have a repeat cesarean. 28% of the mothers were the primary cesarean and 28% of the mothers who ended up with a V-back actually talked about their sense that they were being pressured by their provider to have the cesarean. So this turns the whole argument on its head. This basically says, just when you thought that it was women who were driving it, mothers are saying, essentially, the opposite, that they're feeling pressure from their providers to have it. Some of this is perceptual. If you talk to providers, they do think, they're not making this up. They do think they're being pressured by mothers. And mothers in reverse will feel it from their providers. All right, let's revisit the arguments. So we had six factors here. Age of mothers, more multiples, bigger babies, maternal health, five factors. Obesity, diabetes, hypertension, and maternal requests. So to what extent are these right? Well, first one, older. Mothers getting nup, bigger babies? Definitely not. You can tell because I put some exclamation points after it, so that makes it really important. Maternal health is worse. Yeah, to some extent. There are higher rates of obesity in the past, and obesity is related to caesareans, and there are higher rates of diabetes and hypertension, so that can't be completely dismissed. Mothers are asking for it a handful, but that's hardly indicative of the larger population. So that leads to the question of whether or not a rising caesarean rate is inevitable. And there were certainly studies around this, or at least commentaries around this that suggested, this is a train, we can't stop. A caesarean rate's just going to keep rising and rising as we go forward, and there'll be no way to prevent that continued increase. Well, the answer is no. Some colleagues and I did a study about that. I was also published in birth several years ago, where we saw back then, and this was over five years ago, that caesarean rates, the increase in caesarean rates, it started to slow dramatically, and that's continued to be the case. And in fact, now, let's look at this. This was a slide we saw before of caesarean rates in industrialized countries from 1990 to 2007, and I focus on the fact that most of the countries were above what we either the recommended or targeted rates for caesareans, above 15% or above 19%. If we take this forward to 2013, what you can see is most all of these countries have leveled off. Really, are they continuing to increase through this period? And I think that's sort of good news and bad news, right? The good news is they're not going up anymore. The bad news is they're leveling off at rates far above even the most generous, most pro-caesarean people would generally say are appropriate rates. So it's a bit of a conundrum. We should feel good about the fact that we're no longer on that inevitable rising tide of caesareans. On the other hand, we have to actually reverse this trend and not settle for simply plateauing at unacceptably high rates. One other finding here is that some of this depends on where you started, right? So countries like the Scandinavian countries who generally started with lower rates went up as well, but when they're flattening out now, they're flattening out at 16% and 17% and 18%. And in some of the countries that started out much higher, like the United States, where they flattened out at 32%. All right, so you're saying this isn't the virtual day of caesareans, this is the virtual day of midwives. So where do midwives come in in all of this? Back to this. And where midwives come in is all of this area within the blue frame. The ability of midwives to present all of this is really important at preventing a focus just on medical obstetrics of neonatal services. So let's break these pieces down a little bit. Well, first, some context. This is just a look from the United States of where things stand if you were to look at both proportion... This is by states, in U.S. states. So each of these dots represents a U.S. state. And those of you who are on this from the United States can try to figure out just where your dot is and which state it represents. But if you look at this, you see this general downward pattern, a general negative pattern. In other words, states that rely more heavily on nurse midwives to attend birth, and this would be true if we used all midwives. States that rely more heavily on them have lowest caesarean rates and states that rely less on midwives have much higher caesarean rates. Some of that's inevitable because midwives aren't doing caesareans, so states committed to it are going to have more of a problem with that. But it's important to note this sort of core fact. Okay, so now we look at the components of the framework. For all child-bearing women and infants, they all need this, right? And this isn't happening in hospitals. This isn't happening in facilities, for the most part. But overwhelmingly this is going to happen at the community level. And ideally, especially in this first period, education, information, health promotion, it is going to happen in women's health, not necessarily in prenatal care. In terms of organization of care, the need for competent workforce, the need for midwives. I know in international health that the movement to skilled birth attendance is an important movement, but the movement needs to really have as a foundation an emphasis on midwives for reasons that will become hopefully clearer as I go through this. Continuity services integrated across communities and facilities. And one of the dilemmas we have internationally is the fragmentation of care that people either work in communities or in facilities. And one of the great values of midwives is their ability to work in both and provide a transition point for mothers between both of those. In terms of values, health status isn't a function just of health. It's a function of social context as well. And people who can work in the community and understand women's lives in that community and can empathize and relate to and communicate with mothers around that are going to have a greater impact on that. In terms of philosophy, here's where the prevention comes in. Expectant management, using interventions only when indicated. And the key part to this is that it's not an argument against intervention per se. It should never be. It's an argument against using interventions when they're not necessary. The difficulty is for systems is as they develop and they start building structures to provide these kinds of services, there's going to be increasing pressure to provide these services. Once you staff up a facility, then the economic benefits of keeping that facility running will accrue only if you start going into interventions. And then in terms of care providers, practitioners who combine clinical knowledge and skills with interpersonal and cultural competence is absolutely critical. There's a need for people who are in the community, understand that, can work with mothers, but then provide that transition. You know, one of the great challenges in global health to try to reduce maternal mortality is to get mothers to come to facilities. They don't trust facilities. They're not treated well. They're disrespected and abused oftentimes in facilities. And once that word spreads, there's a distrust in actually using them. What we need is people who can work at the community level and be the transition point to get mothers to facilities when necessary to get services only as they're necessary. Okay. So this is my... I was one of the 97 people who worked on that Lansing series on midwifery. And it wasn't my term. Somebody else came up with the term linchpin, but I'm going to steal it because I really liked it a lot. I thought midwives were really suited to apply these principles in the community where prevention has to begin. Again, waiting until a mother is pregnant is just too late. With respectful care, midwifery and the community bills trust it's necessary to do both these things. I've touched on them already, so I won't belabor it. Convince women of the value and the safety of facility births when necessary in developing countries and provide women in industrialized countries with the support and care that can minimize unnecessary caesareans. Now, why this big push on the community part of it? Well, I'm going to cite another study that I was luckily involved in. You can't wait until pregnancy. Case for community level women's health care. There's not enough time to go into it in great detail, but let me just note this. This is another study we just published. This looks at neonatal mortality by pre-pregnancy body mass index category. What you see there is underweight, overweight, obese one, obese two, and obese three. What it shows is deaths in the first 28 days that's what neonatal mortality is children buy mothers pre-pregnancy obesity controlling for everything we could control for. What you find is strikingly higher rates of neonatal mortality this is in the United States but neonatal mortality based on pre-pregnancy obesity or pre-pregnancy body mass index so waiting until pregnancy is too late. One of the other findings of the study and I won't drill down too far into the study but one of the other findings in the study was even if women followed recommendations concerning weight gain during pregnancy based on their body mass index pre-pregnancy it didn't really actually impact this relationship all that much and so it's getting to women beforehand and midwives are so ideally suited to be able to do that by their nature. Now the other implication for this is going to be around training. The problem itself is in caesareans it's the need for systems of care with midwives in a central role in women's health care in both communities and facilities and the need to recruit and train midwives who can work in both settings who can build a trust in those. It doesn't mean everybody has to do everything but you certainly have to identify train, support, retain midwives who are comfortable in both settings and provide the transition point between those and the results of that will be both better prevention to deal with issues like body mass index as I mentioned better transition in terms of getting women into hospitals when they need to and keeping them out of that when they don't need to be in there and ultimately improving mothers and infants health. All right, I can only talk about this for 17 or 18 more hours but I think there are other speakers. If you want more of this information this is the website I have students who work with this website they're great. We post the data these slides will be posted there you can download them there's considerable other data available as reports there and we basically just try to give everything away so that people can use them in their own context and we're also developing there's some videos up there if you want to present it to groups and we're presenting a whole bunch more on different issues around maternity care. I will thank you so much Gene I can tell you from the chat box people have not been mapping yours I think has been the most popular presentation of the day and I want to thank you for the generosity in this presentation but also the generosity in your birth by the numbers for sharing those data so freely with us that magnifies your voice. There was one recurrent question as you went through the slides. What was the country with the green line that had the highest cesarean section rate? I think I'm going to scroll back. I don't know if people all see this but Brazil Brazil they're asking the lowest green line I believe that is Portugal the lowest green line and let me just amend that again the upper green line is Italy the heavy green line is Italy which has had the highest rate among industrialized countries and also leveled off the lowest is I want to say let's see what is that 12-13% I'm stalling now as I try to pull this up hang on he's almost there it is there was a question about whether you had any data on the diagnosis of cephalopelvic is proportion as a reason for cesarean sections the trends on that have been pretty flat at least in the United States I can't speak to other countries data but at least in the context of the United States that has not been increasing it's a mushy designation by its nature but it has it's up there with fetal distress in a way to convince someone to have a cesarean right away because A if a mother is told either of those babies not fitting through so it's sort of game over at that point but you don't know if that's a diagnosis that's made prospectively or in retrospect as a justification likewise the other one is fetal distress and there's not many mothers who are going to be told that babies in in peril don't worry about it though we're just going to hang out for a while and it's a great way to move mothers I do have the answer that's the Netherlands by the way as the country with that lower with the lowest rate and that's probably a function of the fact that they have a significant proportion albeit a declining proportion of the births happening out of hospital if you were to just look at among the births in hospital in the Netherlands the caesarean rate of about 20% but when you take about 20% of them out of the hospital to be home births then obviously the overall proportion goes down and so part of the reason the Netherlands maintains a low caesarean rate is their commitment to home birth but again that's under fire in the United States I mean in the Netherlands I did see a question about giving voice to mothers there's another survey that's just starting where efforts are being made to try to reach out to mothers who are not part of listening to mothers as much mothers we explicitly excluded home birth mothers in listening to mothers because there simply wouldn't have been enough of them nationally to do much analysis with given our sample size we would only have maybe 10 surveys to deal with and that's not enough to analyze and so there is a survey out now that's giving voice to mothers that's tying it explicitly at mothers from underrepresented minorities and mothers who give birth at home which is also pretty much an underrepresented minority and so I would encourage people if you have one I think we have time for one more question and it looks like Catherine Salam has posted a great one can you elaborate on the intersection between caesarean birth and neonatal morbidity and or mortality yeah so it's again nothing simple when you really start drilling into this it's problematic but the study, the all to be study that I noted before and more recently the Molina study and again there are slides that have references to those both looked at it at a global an ecological level at a national level of the relationship between those and what they found interestingly was that at a certain point and again it was roughly between depending on which study you want to look at 15 to 19% that the rates would start to go up that the neonatal mortality rates would start to go up or flatten that there would be no additional benefit associated with it the reason I say it's a tricky matter is because when you're only looking at infant health oftentimes caesareans aren't bad for the first time, for the first birth they become more problematic in subsequent births because if you have repeat caesareans the likelihood of placental difficulties obviously increases and that can be a threat to mothers and infants in subsequent births but just off of a first birth generally it's not so bad it's not nearly as much of an interest or a threat as it might be but this is very much a problem of decision making so for the clinician who's doing the first birth they have not a great incentive to avoid that caesarean because it might feel well for the baby and the difficulties for the mother wouldn't be experienced until recovery later and that same clinician might not be dealing with that mother in a subsequent birth Thank you so much Jean for setting up for our next presenter I'd like to hear a round of virtual applause for this fantastic presentation I'm going to remember that next time I look at my evaluations My students too, so that works out really well I have a few closing slides to go through Thanks everybody we'll try to share as much I'm going to turn off the recorder first thanks again Jean