 Felly, mae'n gweithio'n gweithio i gynnig Dr Sally Pearman. Sally yn y llyfr yng ngyfaint yng ngyfaint Llyfrgellion Ysgrifennu. Mae'r gweithio'n gweithio'n gennyn nhw i 2017. Mae'n gweithio'n gweithio'n gweithio. Mae'r gweithio'n gweithio'n gweithio'n gweithio'n gweithio. If you haven't worked in midwifery practice and education and the regulation of the home country of New Zealand, your previous roles include Professor of Midwifery, Director of Learning and Teaching and Head of Midwifery at Otago Polytechnic. Before joining the ICM, Sally has also held several national and international midwifery leadership roles. five years as president of New Zealand College of Midwives, nine years as the first chairperson of the inaugural Midwifery Council of New Zealand, nine years as co-chair of ICM's Regulation Standing Committee and six years on ICM's Scientific Professional Program Committee. Sally has contributed to the Midwifery academic field with numerous publications and she's co-editor for the Australian Midwifery textbook, the Midwifery Preparation for Practice. Throughout her career, Sally has maintained her commitment to promoting Midwifery as a strong autonomous profession and to maintaining choices for women in childbirth services as evidence through her political and professional activities and through her research and publications. Her services to Midwifery were recognised in 2008 when she was made a member of the New Zealand Order of Merit. So welcome, Sally, and she's going to talk about the 100 years of ICM and exploring frameworks for the future. I'll just make you the presenter. OK. Thank you, Allie. Good morning everyone and Kia ora to my colleagues from New Zealand. I'm missing you, but happy International Day of the Midwife to everybody. It's really lovely to be with you today and I hope that you're all able to take some time in your very busy lives to celebrate yourselves and your colleagues today. I'd really like to thank the organisers of the Virtual International Day of the Midwife conference for inviting me to speak today and over the next half hour or so I'm going to talk through why this year is particularly exciting for us at ICM and give an overview of our new professional framework, which we hope will act as an informative and guiding tool for midwives around the world. I'm going to turn off my camera while I do this just because I'm trying to juggle too many things. So do that, then it's easier to do the slides. OK. So, Allie's already introduced me so I'm not going to say any more about that, but ICM is a membership organisation comprised of more than 140 midwives associations in over 120 countries across every continent. And while we're a global community unified by the shared issues confronting midwives around the world, there are of course significant differences in our experiences, distinguished by the cultural and political context where we practice. From my own experience, promoting midwifery is a strong autonomous profession across regional and global contexts. I know it can be quite daunting to come to terms with the barriers hindering full scope midwifery. However, it's important to understand how far we've come in each individual country in terms of midwifery as a profession and how our profession is working together globally to improve not just the status and competence of midwives, but also the health and well-being of mothers, babies and families under our care. In fact, we at ICM have been doing a lot of reflecting as this year marks 100 years since our inception. And asking ourselves, what does it mean to turn 100? And how do we best prepare ourselves for the next century of supporting midwives through our organisation? 100 years ago, in 1922, the International Midwives Union was created in Belgium. It was the full runner of the International Confederation of Midwives. And since then, ICM has transformed into what it is today. A global, non-governmental organisation representing, by way of our associations, over one million midwives worldwide. In marking ICM's centennial, our goal is to ensure our global community recognises that this anniversary is so much more than an organisational achievement. It's about exploring our collective and individual progress and acknowledging how far we've come. From the establishment of the first midwifery schools, to the increasing numbers of direct entry midwifery programmes, to the establishment of the first midwifery councils, to the appointment of the first chief midwives within health departments, to more and more women being able to access continuity of care from a known midwife. The past 100 years have seen the most consequential achievements of our age-old profession. Turning 100 allows us to reflect on our organisational history and its impact and influence on midwifery. Our organisation has not been exempt from the structures the world has lived by. And that's why it's so vital that we examine ICM's role in shaping issues related to identity, race, gender, ability and inclusion to ensure that we're representing our global midwife community and the diverse perspectives of those that we serve. It's a chance to self-reflect and listen to our community in order to grow and continue to push for progress in areas that represent different lived experiences. So, now that we've looked backwards, it's time to look forward and to look at the ways we can support midwives to have the enabling environment they deserve and require to do their jobs well. At ICM we believe that one way to do this is to have a strong professional framework in place and I'm excited to be exploring this with you today. ICM's revised professional framework for midwifery builds off the existing version that is supported in guiding associations to advance professions within the regions for the past decade. The updated framework encompasses the midwifery philosophy, essential competencies of midwifery practice, education and regulation of midwives, the vital role of associations, the importance of research to support evidence-informed approaches, the midwife-led continuity of care model of practice, leadership and an enabling environment as well as the significance of gender equality and justice, equity, diversity and inclusion. We're confident that if every country adopted this professional framework and put it in place, we would see higher quality midwifery services, more fulfilling careers for midwives and enhanced reproductive health for women, their babies and their families. I'd like to start by showing you a short video that speaks to why midwifery needs a professional framework, the evolution of the professional framework as well as the team key components that the framework encompasses. Many of us work within a career or profession, but what makes up a profession and why is this important? Let's explore this a bit more. A profession has a professional framework or a defined set of integral components that work together to support and strengthen the development of a profession. As a predominantly female profession, midwifery has long struggled to obtain the respect and autonomy it deserves. This is part of the reason why ICM developed its first professional framework for midwifery in 2009. But first, let's pack up. What is midwifery? Really. Midwifery is the profession of midwives whom ICM defines as accountable professionals who work in partnership with women to give necessary care and support during pregnancy, labour, birth and the postpartum period. The profession has a unique body of knowledge, skills and professional attitudes that come from other disciplines like science and sociology. But make no mistake, midwifery may only be practiced by midwives working within a professional framework of autonomy, partnership, ethics and accountability. Just like teaching or nursing, midwifery has a framework that is entirely separate from other professions. The revised professional framework for midwifery has 10 comprehensive components and they are all inexplicably dependent on and connected to one another. The 10 components are as follows. 1. Midwifery philosophy Midwifery care promotes, protects and supports women's reproductive and sexual health and rights while respecting their cultural beliefs and practices. This philosophy underscores what makes midwives a distinct profession that is worthy of respect and autonomy. 2. Essential competencies of midwifery The essential competencies of midwifery are split into four categories. Pre-pregnancy and anti-natal, care during labour and birth, ongoing postnatal care of women and newborns and competencies that apply across the entire childbirth continuum. In every country, midwifery regulatory authorities can reference the essential competencies to set standards for midwifery practice and the midwifery profession. 3. Education Midwifery has its own distinct body of professional knowledge and ICM's global standards for midwifery education outline how to provide effective learning and teaching environments so that midwifery students develop the essential competencies. ICM also promotes the continuation of midwife's professional development to ensure midwives take current in their knowledge and practice. 4. Regulation Consistent global regulation ensures public safety, establishes accountability and enables autonomy of midwives to work in their scope of practice. Regulatory authorities for midwives vary across the world, from midwifery councils to those combined with other health professions or those run by ministries of health. Specific regulatory processes for midwifery should be in place. 5. Association Midwives associations play a vital role in connecting, uniting and supporting midwives by strengthening, unifying and amplifying their individual and collective demands. Our midwives associations are at the heart of everything we do at ICM to promote and strengthen midwives and midwifery. 6. Research Research and evidence are critical to the forward motion of the midwifery profession, which is informed on an ongoing basis by scientific evidence. ICM and its partners work to support midwife-led research and evidence-informed approaches to care. 7. Midwife-led continuity of care model of practice Midwife-led continuity of care is a unique model through which a midwife and a woman can get to know each other and build trust across the childbirth continuum. It is the type of respectful care that women want and it improves maternal and neonatal health outcomes. The approach is woman-centered and is based on the premise that pregnancy and childbirth are normal, natural life course events. 8. Leadership The midwifery profession relies on strong leadership at every level from individual midwives to midwives associations to formal leadership positions for midwives and ICM. Increasing the representation of midwives in health policy and decision making is critical. 9. Enabling environment To work effectively and produce positive outcomes for mothers and babies, midwives need to work in an environment that supports them to deliver quality care. An enabling environment is one where midwives have professional agency and autonomy and work in a functioning health system with the policies, structures, systems and resources they need. Building an enabling professional environment is critical to successfully scaling midwife-led continuity of care and improving the well-being of women and newborns worldwide. 10. Commitment to gender equality and justice Equity, diversity and inclusion Gender and racial inequalities drastically impact the professional of midwifery and a profound understanding of these issues and the way they manifest globally is vital to the healthy, successful growth of the profession. These 10 components interact with and support one another to move forward the midwifery profession. The areas of interplay and intersectionality between these components are crucial. Enabling the midwifery profession and practicing midwives all over the world to grow stronger. Some of you couldn't see that very easily. But as the video illustrated, the ICM professional framework for midwifery acts as an informative and guiding tool for ICM that's members, partners and stakeholders. Before we delve into each of the 10 components in more detail, I'd like to reflect on the journey of the midwifery professional framework and why it was necessary to update the original framework that was established in 2009. As many of you will know, the 2009 framework was made up of three pillars education, regulation and association. Two further elements underpinned these pillars the essential competencies for midwifery practice and midwifery research. This original framework was in place for more than 10 years during which time it served as an important and successful advocacy tool. Throughout this period, our partners and donors acted on the need for strong pre-service midwifery education, for continuing education for practicing midwives, for midwifery regulation to be implemented and embedded everywhere, and for midwifery associations to speak up for midwives and ensure that midwives are at the table where decisions are being made about midwifery maternal and newborn health services and midwifery services. We tick to get these to click over. However, as the global health landscape shifted and evolved, it became increasingly obvious that certain elements were missing from our framework and we soon realised that it was time to take the next step. It wasn't enough to only educate and regulate a midwife or have a midwife association. Every midwife must also be able to work in an integrated and well resourced health system with tools to do her job. These tools include but are not limited to communications mechanisms, transport, supplies, access to obstetricians and pediatricians for consultations and referral. All midwives need to be played appropriately. They need a safe and respectful workplace and in some countries they need adequate housing. Midwives also need to be able to practice across the full scope of midwifery and have their autonomy recognised and their rights upheld. They need continuous education and to be part of a profession that is respected and valued. These are just some of the aspects that are often referred to as the enabling environment. We realised that Ministers of Health, Managers of Health Services and even our donors required support to understand all the aspects of an enabling environment and that evidence-based policies need to be in place for a midwife to practice effectively and successfully. We also began to see that our original professional framework didn't get right to the heart of what makes midwifery unique from other health professions, our philosophy and our model of care. Underpinning ICM's constitution, the philosophy and model of care captures the very essence of midwifery. We know that by championing women's choice and voice, prioritising value and respect and working alongside women to make their reproductive health experiences as positive as possible, midwives offer something that nurses and doctors cannot. We knew that this needed to be better articulated in the professional framework for midwifery. As our thinking evolved, so did the professional framework. Drawing on years of conversations and collaborations, we developed a new and improved professional framework for midwifery to reflect the evolution of our profession and better represent midwifery as it exists today. It's an illustration of why and how we exist as a profession in a representation of our core beliefs. The key pillars, as you've heard, of the new professional framework or the key elements are midwifery philosophy, essential competencies for midwifery practice, midwifery education, midwifery regulation, midwifery associations, research, continuity of care model of practice, leadership, enabling environment and a commitment to gender equality and justice, equity, diversity and inclusion. The elements of this professional framework are deeply interwoven and entirely interdependent. This means that by strengthening one, we can strengthen all others, just as destabilising one destabilises all. Understanding where we've come from allows us to appreciate where we're going, creating the professional framework created the opportunity for our profession to remain relevant, innovative and ahead of the curve. I'm going to talk about each of the elements in a little bit more depth. We all know that professions are guided by certain core values or philosophies that shaped the practice and conduct of all of those within it. In midwifery, our philosophy informs everything that midwives do. It is what sets us apart from other health professions and makes midwives and their work essential. ICM's midwifery philosophy provides a universal definition that is based on ethical principles of justice, equity and respect for human dignity. It encompasses the core beliefs at the heart of the profession, including that pregnancy and childbearing are usually normal physiological processes and profound experiences carrying significant meaning to women, families and communities. It explains that midwifery care promotes, protects and supports women's human, reproductive and sexual health and rights and respects ethnic and cultural diversity. That is such, midwives are the most appropriate caregivers to work with childbearing women. It captures the idea that midwifery care is holistic and continuous in nature, grounded in an understanding of the individual, economic, cultural, spiritual, psychological and physical experiences of the women that we care for. And also that midwifery care is emancipatory, enhancing the health, social status and self-confidence of women and of midwives. Above all, the midwifery philosophy emphasises that all midwifery care takes place in partnership with women and therefore meets the individual needs during the childbirth continuum, including how they identify themselves and their family. Midwifery recognises the right to self-determination and is respectful, personalised, continuous and non-authoritarian. These beliefs and values act as a guiding light for midwives around the world and influence every aspect of the midwifery profession. The second element focuses on the essential competencies for midwifery practice. All midwives require a set of essential competencies that provide them with the knowledge, skills and behaviours to work across their scope of practice. ICM reviewed and updated its essential competencies in 2019. These competencies are split into four categories, pre-pregnancy and antenatal care, care during labour and birth, ongoing care of women and newborns after birth and competencies that apply across the entire childbirth continuum. The essential competencies for midwifery practice are interconnected with each of the other elements of the professional framework. They reflect the midwifery philosophy and continuity of care approach to practice. The essential competencies should be developed during pre-service midwifery education programmes and midwives should maintain competence through ongoing professional development and practice experiences. Continuing competence is an important concept to ensure high quality midwifery care. Midwifery regulatory authorities can use the competencies as a measure of competence as midwives are registered in inter-practice. Regulatory authorities can support quality care by ensuring midwives demonstrate their continuing competence. In this way, the competencies are intertwined with ICM's global standards for midwifery education and for midwifery regulation. Midwives' associations have an important leadership role in advocating for the integration of their central competencies within midwifery educators with midwifery educators and regulators in their countries. They can also provide continuing professional development for midwives. It can ensure continuing competence. Midwives do require an enabling environment to be able to apply their competencies effectively. The competencies need to be updated as new evidence emerges from research. Every profession has its own body of knowledge and midwives hold knowledge not held by any other professional group. There is, of course, a great deal of common knowledge amongst health professionals, but the context for applying and developing that knowledge differs between professions. For example, all health professionals share knowledge of the physiology of the body. While this knowledge doesn't change because you're a midwife, the way in which the knowledge is applied does, since midwives work with women's bodies to enable the unique lenses of pregnancy, childbirth, postnatal or sexual and reproductive health. To support its body of knowledge, the midwifery profession has its own education system, for which ICM sets global standards and within which the ICM essential competencies are also embedded. In fact, midwifery is the only health profession to have global standards for its education system. These standards are intended for use by midwife educators and all others working to strengthen midwifery education in the maternal and newborn health sector. At ICM, we have two programs of work around midwifery education. The midwifery education accreditation program, or MIAP, and the midwifery education development pathway, or MPATH. MIAP offers accreditation to midwifery educational programs that meet ICM's global standards for midwifery education. It's based on international best practices in the field of midwifery education and accreditation and serves as a benchmark and quality label for midwifery education programs worldwide. MPATH acts as a hub of resources to support midwife educators in strengthening the development and delivery of pre-service midwifery education programs. Examples of MPATH resources currently under development include guidelines for curriculum design, guidelines for competency assessment, the assessment evaluation tool, guidelines for clinical sites, and standards for midwife educators. While all the elements of the framework are interlinked, as you will see when we go over regulation in the next slide, education and regulation specifically can be difficult to tease apart. Education programs need to prepare midwives to work autonomously across the full scope of midwifery practice in their country, and regulatory authorities set that scope. One way to look at these two elements is that if midwifery educators are convening, it shouldn't be without regulators. And if regulators are making decisions about midwives, they should include midwife educators, and both of them should include and involve midwives associations. Understanding the intersection between education and regulation starts with the fact that every profession has its own system of regulation to hold the profession accountable while enabling their autonomy and ensuring public safety. Midwifery regulatory functions include setting the scope of midwifery practice, setting pre-service education standards, registering new midwives as they enter practice, relicensing and ensuring continuous competence throughout a midwife's career, managing complaints and disciplinary procedures within the profession to ensure professional accountability, and setting codes of conduct in ethical standards. The competence of the midwife and therefore public safety can be ensured through professional regulatory mechanisms. And it's certainly worth noting that regulation varies across jurisdictions in ranges from limited functionality through to the full range of regulatory authority that I've just mentioned, often undertaken by a midwifery specific regulatory authority such as a Midwifery Council. To support effective regulation, ICM has set global standards for midwifery regulation, established an international code of ethics for midwifery, and produced a regulation toolkit to guide the development of midwifery regulation. These are all in the process of being updated, but they continue to be essential tools to strengthen midwifery regulation globally. Other elements of the framework tie in to regulation. Effective regulation would not be possible without our midwifery philosophy that underpins everything we do. Additionally, the collaboration between midwives' associations and regulators and policy makers is crucial to ensure that regulation is led by midwives and protects the title of midwives, as well as the public. Another core element of the midwifery profession is the existence of professional associations. ICM supports, represents and works to strengthen professional associations of midwives throughout the world, and as I mentioned earlier, we currently have over 140 members representing over 120 countries in every continent and representing through them over a million midwives. ICM provides mechanisms for communication and decision making with and between members and is mandated by the ICM Council as the Global Voice for Midwifery. Associations play a vital role in connecting and supporting midwives by enabling individual midwives to come together and collect a voice with others working in their countries and elsewhere around the world. ICM represents its members at global level and works with them at regional and country level. ICM provides resources that associations can access to support capacity building and raise their profile. Associations need to be recognised by in-country decision makers as the voice for midwives that must be involved in decisions related to midwifery and sexual reproductive maternal and newborn health services and rights. The ICM Head Office has recently developed a plan to work alongside our midwives' associations on building their capacity as they seek our support, and this is using several different tools, including networking, e-learning resources, and communities of practice in twinning. Throughout the presentation so far, I've talked about how each element is crucial to the midwifery professional framework, and research is no different. This is due to the simple fact that research and evidence are critical to the forward motion of the profession. The body of literature surrounding midwifery in childbirth has grown significantly in recent years. Many of you will have seen the results of the state of the world's midwifery 2021, and that's the fact that investing in professionally educated and regulated midwives could save millions of lives each year. Particularly, research has demonstrated the vast difference in outcomes between midwife-led continuity of care and other approaches to maternal health care. The knowledge that midwife-led continuity of care is the ideal model of care in terms of lives saved and improved is integral to our ability to effectively advocate for our profession. In addition, today, the ICM and White Ribbon Alliance have released the results of a global survey called Midwives Voices' Midwives Demands, which asked over 56,000 midwives which key areas of midwifery need investment. This qualitative data of midwives voices strengthens the data released in SOMI and shows clearly the investment needed directly from midwives themselves. Finally, research will continue to play an integral part in advancing and promoting our profession. I've alluded to the midwife-led continuity of care model already, but it's essential that it's represented as a distinct component within the professional framework for midwifery. By midwife-led continuity of care, we're referring to a type of care where a known midwife or a small group of known midwives come throughout the antinatal, intrapartiment, postnatal continuum. Research has unequivocally shown that this is the best model of care for women to have a physiological birth and a satisfying experience. Specifically, MLCC models have been shown to lead to reductions in neonatal deaths, preterm births, stillbirths, epidural, episiotomy and instrumental births and to increase spontaneous vaginal birth and women's satisfaction with no increased risk of harm. Investment in midwives to achieve these outcomes is cost-effective. MLCC enables each woman and her midwife, or small team of midwives, to get to know each other and to build a relationship based on trust, equity, informed choice, shared decision-making and shared responsibility. Relationships are negotiated between the partners and are dynamic and empowering for both. And it's worth noting that current evidence for MLCC comes mainly from high-income countries. Implementing and scaling up midwife-led, cognitive care models sustainably in low and middle-income countries requires addressing the challenges to midwife's education, regulation and working environments identified in various reports, including CIME 2021. But this will lead to improved health outcomes not only for women and their newborns, but also for their families and societies. You've just got five minutes left, Sally. OK, I'm going to go very quickly. Thank you. Sorry, Sally. Leadership. So we are all leaders every day. Every time a midwife works with a woman, she influences that woman's views about childbirth, her body, her rights, what it means to be respected. And in turn, that woman goes on to influence the views of those around her, creating a ripple effect through families, friends, colleagues and communities. But as we know, midwives are very underrepresented and overlooked in terms of leadership. We often don't have the educational career opportunities and we often don't have a direct promotion pathway for career advancements. Many midwifery schools don't offer postgrad degrees. And many midwives have very few opportunities to take up decision-making positions in institutions, facilities or government departments. But often, we're excluded because of the pervasive and sometimes invisible stigma and discrimination from working in a highly-gendered profession. But we need leadership at every level. And this is something that ICM is really working on. We have our Young Midwife Leader program. We are advocating for the establishment of chief midwives at national level in governments, and we are developing a leadership plan for all our members. And the living environment, I've also talked a little bit about already. But what we mean by this is an environment that values and respects midwives as well as valuing and respecting women. It's the environment that we need if we're going to practice effectively and achieve the outcomes that research shows we can. And so it's really all of the system, the health and social systems that are in place, it's legislation, policies, resources, facilities, safe and respectful working environments, fair pay, workforce development and deployment, health service integration, education, everything really. And we've been talking about it for a very long time. We had the 2016 Midwives Voices, Midwives Reality report that first brought this to attention. And last year, in 2019, we started working up a definition. And then last year, in collaboration with Ariadne Labs, we produced the enabling environment policy brief that we hope is going to help guide governments in implementing the enabling environment that we need. Gender, equity, justice, diversity, inclusion, we need to really understand all of these and how gender inequalities affect our profession. It's vital that we tackle these issues at local, national and global levels. And we have to work better as a profession ourselves to value diversity and examine our own institutional biases such as racism, sexism and ageism. This is a really important part of midwifery, but as we are a women's centre profession, we are also one that is deeply impacted by a pervasive gender inequality. And it's very important that we actually are able to start to look at these issues for ourselves. So, I'm going to jump over the next and into talking about, quickly, except that I can't make the slide move. I don't know if you can help me, Ellie. Thank you. 100 years. So today, we've got two more celebrations after this, one at 1 o'clock Central European Summertime and at 8 o'clock Central European Summertime. It's not too late to join our IDM parties. We are launching the report I mentioned before with White Ribbon Alliance, the launch of the Midwives Voices Midwives Demands, and you can see it on the White Ribbon Alliance website. We are launching our own charity with Women, which we really hope our global community will help us to amplify our message and our call for donations across our own networks. We will be running a listening and learning series across this year, bringing together experts to explore subjects related to identity and representation. And the challenges of adopting forward-thinking positions while still acknowledging varied perspectives of a diverse membership base that we have. And finally, our push campaign, our global midwifery campaign. We launched it this year. It's continuing to grow momentum. And we're really excited that we've got an interactive messaging board translated into over 10 languages, so that more midwives can interact with our advocacy asks and become partners with us on the push campaign. So happy International Day of the Midwife to you all, and I'm hoping there's just a couple of minutes left. Allie, for some questions. Thank you so much, Sally. I think we've all been really encouraged that we have the leadership that the ICM provides for us as midwives. And this framework will surely only help to improve the autonomy of our profession. And that's a question that Celine has brought up actually is, does the ICM have a strategy concerning the so frequent confusion between midwifery and nursing? Yeah, thanks for that, Celine. It's such an issue, isn't it, in so many countries. But we've been doing a lot of advocacy on this and trying at every opportunity to bring attention to the fact that midwifery and nursing are separate professions, even though we have things in common, as we do with medicine and other health professions, we are different. And for ICM, I mean, we try to work really hard with partners like WHO and UNFPA, et cetera, to make sure that they start talking about midwifery and nursing as two separate professions. It's going to be a bit of a long journey, I think. We still have quite a few countries where you can only become a midwife if you were, first of all, a nurse. We've really been trying to promote direct entry midwifery education and talk about how we're different. And it's not to put down nursing at all, it's actually much more cost-effective to produce a midwife through a midwifery, direct entry midwifery education programme who wants to practice midwifery. Then it is to require someone to become a nurse who's never going to be a nurse in order to become a midwife. And so we have to dismantle these old frameworks. And I think there's a lot of energy for this. Our associations are really, really keen about it and working hard in their countries to try to make these changes. And I think that's a big change to the country, apart from Thailand, have agreed to move towards direct entry midwifery education. You know, this big change is happening, which is fantastic. And another question by Celine was, is this framework available in other languages on your website? Yes, in French and Spanish are two official languages at this time. And we've recently been running workshops, regional workshops, with all our member associations. And we've just run a whole workshop on this framework in three languages across every region. So we're taking it out to everybody. Great, thank you. There's a question from Hilary. Have ICM done any work relating to the impact of climate change? Not a huge amount of work has yet. I think we are very aware of the issues. We've recently started working with a sustainability consultant to help us build a sustainability plan for ICM long-term. And of course environmental sustainability will be a component of that. Certainly one of the things that we're doing and I guess we've learned from COVID is we're certainly questioning our travel and how we use those kinds of resources, time, but also the damage to the planet. And of course really promoting the idea that midwifery is actually a very sustainable practice in and of itself. We talk about physiology. We're about promoting health. We're about primary health care. We're in communities. We promote breastfeeding. We are against unnecessary technology and intervention. We're about really being alongside women and their families and their communities. And midwifery can be very sustainable for midwives working in continuity of care models and small group practices. They have incredible ability to manage their working lives. So there's much that we do but we need to bring a lot more attention to it and I think hopefully this is going to come up in our next as we develop this plan going forward. Thank you. Lots of interesting ideas and plans for the future. I can just say another question popping up but we're just short of time now unfortunately. It has been a privilege to have you here Sally representing the ICM in your centenary celebrations. So thank you very much on this International Day of the Midwife and I hope that the rest of the ICM celebrations go well today and please take the love of the IDM with you to those celebrations. Thanks so much Ellie.