 This presenter is Antonio, sorry about the pronunciation if I get it wrong. It's Antonio Ignacio Sierra-Garoccio and he's a consultant midwife for normal births at UK NHS Trust, as well as a professional midwifery advocate. He started his career in healthcare in 2002 and has worked across a variety of medical and maternity wards, across Wales, Backshear, Head for Shear and London, both as a registered nurse and midwife. He's passionate about a different aspect of healthcare. His clinical research interests lie in promotion of normality, women's advocacy and clinical education. He's specifically interested in the subject of women's experiences and perception of speech presentation at birth after a cesarean session. He supports the midwifery obstetric and linear terms in clinical practice using the four pillars of consultancy. Clinical and professional leadership, expert practice, service development, research and evaluation, and education and professional development. He's currently involved in a number of local and regional projects that will focus on the implementation of better births. He's clinically involved in the delivery of care, including the design of complex care plans and the running of birth options and birth after cesarean section clinics. He's also a student at the University of East England completing a pre-doctoral program as part of Health Education England's Integrated Clinical Academic Program. His current research focus is in LGBTQ plus health and childbirth. Thank you very much, Antonio. Please welcome him and over to you. Thank you so much. Can you hear me well, Elisa? Yes, I can hear you. Go ahead. Thank you. Thank you for the wonderful introduction as well. Good evening everyone in the United Kingdom and hi and absolutely everyone joining us from different parts of the world. It's such an absolute pleasure to be here today to talk to you about the subject of a bridge. So my name is Antonio Sierra. Introductions have been done already. So thank you for your time today. I'm happy International Day of the Mid-Web. We've got loads of reasons to be proud about who we are professionally and personally and the contributions that we make to society today. However, we're going to focus, we're going to narrow on this subject of women's experiences of bridge diagnosis. And I call this presentation What About Us because very often women tell us that they feel that their voices are unheard. I feel very strong and very passionate about the subject of advocacy and being that voice for the unheard. And I hope that I can take you through a journey. Hopefully you will enjoy this slide. So we'll be recorded and they can be accessed at a later date. So thank you for your time. Right. So we'll start talking to you about the aim and the research questions. So basically these forms the basics of a dissertation that I completed for my masters in midwifery science. I'll talk to you a bit about, you know, give you an introduction and also navigate through a literature review that I undertook. And then I'll explain what research methods I went for. And also we will talk about the results, the discussion and the limitations of the research. I will inform you of what the recommendations were at the time and what we've managed to achieve to date. And finally, we will be making a point about the subject of the International Day of the Midwife this year, which will be that of birth equity for all. And you will also have a number of references and time to ask any questions you may have. So this was the aim of my research. I was really interested and passionate in exploring women's experience of bridge presentation and also what the perception were with regards to what choices they had and also what support was there available from healthcare professionals in making decisions with regards to a bridge management. So I have three main questions that I wanted to answer with research, with this research. Firstly, I wanted to know what women's perception of choice was. Secondly, I wanted to know what women's perception of support from healthcare professionals was. And finally, what women's experience of being diagnosed with bridge presentation will be at the time of diagnosis as well. I just wanted to make a point when I mentioned the word women, I am talking about women and birthing people, but I may use the terminology women more often than not. But we are advocating the use of the positive language throughout the presentation. So to give you a bit of an introduction for those of you who may not be midwives or for those of you that may want to know a bit more about bridge presentation. So when it comes to the definition of what bridge presentation means, bridge is defined by basically the presentation of a buttocks or feet presenting first, as opposed to a head down presentation. But actually the term is defined in different ways depending on which author you go to. And in fact, there was a Canadian conference that focused on bridge a couple of years ago and they called the conference heads up what's a simple way of describing a bridge presentation. The incidence of bridge presentation at term is three to four percent. Now we have to remember that at around 28 weeks or so, the incidence is around 25 percent. And what happens is there are physiological changes taking place in the body that will allow for babies buttocks or head to come down. There is also relaxation of the lower segments of abdominal muscles that will hopefully allow for better engagement. And then gravitational forces as well will mean that babies head comes down. And this is why the majority of babies will turn to a head down position by four terms. So that is around 37 weeks. When it comes to bridge management, there have always been a variety of options available to women and birthing people, mostly elective disordering section and also bridge vaginal birth until the term bridge trial was published in year 2000. And I'll go a bit more into detail about that in a second. What we saw following the publication of the bridge term trial was a rise in cesarean section that was completely unprecedented. At this moment in time, I'll talk to you about the guidance in the United Kingdom. In theory, we're meant to be offering a full spectrum of choice to birthing people which include the use of complementary and alternative medicine, the use of ECB to try and turn bridge babies on to a head down position. So that would be external, catholic version. Also, bridge vaginal birth and elective disordering section or emergency disordering section if required. And these work aligns with national drivers such as the better birds dated 2016 and also the NHS long term plan 2019. We are encouraged to recommend and make sure that women and birthing people have got access to a personalized care plan and choice. But in practice, what we know and what women tell us is that they have limited choices and there are variations in what choices are available to them depending on which part of the country they are. And this is something that we have to tackle and we have to change. Up until now, the majority of the research that has been done on the subject has focused on offer and success of the different interventions that we're offering. But there has been very limited evidence regarding women's lived experiences. So let me take you on a journey. This is what I did. So I felt that in order to examine the, find an answer for the questions that I had, I had to have a good understanding of breach research. So what had been done up until now when it comes to systematic reviews and randomized control trials so that I knew why we were offering certain options or others. And then from that, I moved on to any research related to perception and knowledge. From there, I looked into the quality of information giving. This is reported from service users mostly. Finally, I tried to search for research on women's experiences. So let's start with the first one and that will be breach research. So the term breach trial for those of you that may not be familiar with this is also known as the HANA et al. Trial or the term breach trial collaborative. And what happened was that this is a multi-center international trial that took place mostly in Canada to say, but it included loads of different centers from different parts of the world. They included a total of 2088 women in their study and what they found and actually the researchers didn't even manage to complete the trial because halfway through they realized that there was actually a 97% reduction of neonatal mortality and morbidity in the elective cesarean section group. So what they did is they thought there was an ethical and moral responsibility to stop the trial and stop offering vaginal breach birth to the population at that time or at least genetically. A number of years after, there have been a number of publications from researchers highlighting some concerns and professional criticisms with regards to the term breach trial. So a number of things were identified that actually were concerning to these researchers to include limited internal and external validity. There was also a violation of the inclusion criteria in participating centers, which was only discovered years after. There was also a variation in the standards of care. So for example, when comparing a UK hospital with a hospital in Mexico, we just have different systems, different protocols, different ways of working. They also highlighted a lack of professional expertise to the point that actually there were centers where medical students were participating in the delivery and that violated the inclusion criteria itself. And finally, there was a criticism that we were trying to extrapolate short-term findings and outcomes towards long-term ones. And in fact, a couple of years after the publication of the HANA trial, there was a follow-up of all of those babies who were deemed to be severely disabled following a vaginal breach birth. And out of 18 babies where they massaged, 17 were found to be neurologically normal two years after. So what happened is that, you know, the HANA trial was published very rapidly. It changed practice. There was a complete decline in the offer of vaginal breach birth in many countries. And there are reported rates going down from 72% of obstetricians offering vaginal breach birth down to 27% in certain countries, which is quite a lot as you can imagine. The years have gone by and we have learned that there were loads of limitations to the HANA trial. But also, there have been further studies published highlighting that actually giving birth vaginally to a bridge-presenting baby can be as safe as having an electricity setting section for as long as we follow a strict criteria. So I'm giving you some examples here, including the promoter study, for example. There is now a publication quite recent, 2018, about a bridge vaginal birth at home, and also a very recent publication about upright vaginal breach birth as well. And I am really pleased to let you know that Dr. Walker is actually undertaking a research for NIHR called the Opti-Bridge Project. So we'll hear a lot more about this. But to summarise, we were too quick to change practice and actually I'm not sure that we did women any favour or babies in that respect. We're now going to move on to perceptions linked to knowledge. So quite surprising data here at SAAB at times. There are publications out there highlighting that 87% of women who actually eager for information regarding bridge-presentation have to turn to books or family and friends to find that information, which I find really sad, because we're meant to be here to be helping them in that way. ECB uptake dates. So this is an external, catholic version of only 39%. But actually 72% of women in some studies tell us that they want to be part of a shared decision-making with other healthcare professionals, but yet they are turning to leaflets and books to find information about bridge-presentation because they were unable to access professional advice in a timely manner. There are other studies as well highlighting that actually the uptake of ECB, which will be really helpful to turn the baby head down, it's actually increased when women feel that information is provided to them. So we also have a responsibility here to be a bit more responsive in that sense. Moving on to the third element, I'm just checking the clock, the quality of information. So there are publications out there telling us that one third of women are telling us that they were not aware of what options were available to them when they were found to have a bridge-presenting baby and also that very often obstetricians influence their decisions. Staple-tone telling us that midwives weren't always able to accommodate women's needs when they were having consultations with them, and this is how women felt actually. And finally, women telling us that they expect autonomy and support when making informed decisions. Finally, when it comes to women's and healthcare professionals' experiences, there are studies out there telling us that women rely on obstetricians and midwives to provide information, but yet we've heard that midwives are not always to accommodate that in their current practice. And it's very important that they've got access to us, so they can construct meaning of what bridge-presentation means to them. And finally, women's feelings as well. So the majority of women hope the baby will return, and for some it will happen, but for some others it won't. And they just feel disappointed when a virgin doesn't think that it's not successful and quite doubtful about which way they should be going ahead with the reverse mode of birth. They go through an emotional journey, this is what they tell us, and they also perceive that healthcare professionals have got a preference for elective sedentary section. So I'm now going to spend a bit of time without boring you too much about the research methods that we utilise, and I'll give you a rationale. If anyone's got any questions about this, we can go back to these slides in a minute, because can be quite complex if you're not used to qualitative research. But when it comes to the research approach, I went ahead with a qualitative research approach. I feel very passionate about qualitative research, and the way in which this is defined, I couldn't really find a holistic definition, so I have mixed two of them, and I hope that this makes sense. So it's an objective process used in examining subjective human experiences using non-statistical methods of analysis through the collection of narrative and subjective human experiences as well. So the main purpose of my research was that of exploring the substance, exploratory research, and by that I mean that by concluding the research, we're not aiming to generalise the findings, but instead the findings from this research may be utilised by you or other researchers or healthcare professionals in their practice if they feel that they apply to their population. In that sense, when it comes to research designs, we went ahead with phenomenology. I feel very passionate about these particular research designs. It's a non-experimental research design that aims to explore and search for understanding about people's lived experiences. And what's really interesting about it is that it takes into account the physical, social, psychological, spiritual and finally emotional needs of human beings, so basically who we are as a whole. The setting of the population was a UK District General Hospital just outside London, supporting give birth to 5,000 mothers or birthed people per annum. And the population that we care for is quite multicultural, which is one of the most beautiful things about this particular hospital, caring for low to middle social class population. And this is the inclusion criteria for anyone who may be interested, but pretty much low risk pregnancies up until the time when bridge diagnosis is made. So we went ahead with a purposeive sample and also it was a convenient sample. So obviously I needed to make sure that these women and pregnant people were presenting a bridge, which is really important and a purposeive sample is a non-probability type of sample. When it comes to this type of research and sampling, we aim for transferability more than external validity. So once again, though the findings of this research apply to the population where I am currently providing care, that's the question that you'll be asking yourself to see if you can extrapolate the information and take it with you. So in total, we identified 24 women presenting in bridge at full term over an eight month period. What we did is we obviously provided them with the patient information, leaflets or sheets and also a consent form and send them a prepaid envelope. So they would read all the information and if they wanted to participate, they had the freedom at no cost to return the envelopes to us with a signed consent form. So we had a total of nine respondents and six people consented to taking part in the study, which is appropriate for qualitative research. When it comes to data collection, I completed face-to-face interviews and these were semi-structured interviews. I went ahead with these type of interviews because I wanted to give people the freedom to talk about their birth experience, but I also had the responsibility to guide them through a script that was flexible enough to allow them to talk about whatever was relevant to them, but also find an answer to my research questions. I remain quite flexible with regards to the location of the interviews. Some of them took place in a hospital environment and some others took place in people's homes. I use an interview that had previously been validated at another study that was quite similar. Before I went ahead with it, I undertook a pilot study to test the tool and the feedback was actually quite positive. It worked quite well. So the mean length interview time was 20 minutes and research participants were always made aware of their rights as with any other research. So obviously we draw from the study if they wanted to and also to have their data removed, but obviously confidentiality was adhered to at all times. Data analysis. So I transcribed the interviews word by word, paying attention to the tone of voice as well and any size that they made at the time. It's really important to remember that if you're thinking of using this approach in the future, 10 minutes of tape recording will actually take you around 60 to 70 minutes of transcription, especially if the language in which you're interviewing is not your mother tongue, it may take a bit longer like it was the case for me, but I completed A4 transcripts which were validated by the individual. So basically once you transcribe everything that you've heard, you send it back to the person that you interview and they tell you if that's what they said or not and if they agree to what you're writing. And also my academic supervisor helped with this which adds reliability to this study. I made use of bracketing transparency, consistency and conformability at all times. And I also aim for prompt analysis of the data. This is quite important so that you don't forget about the size and anything else non-verbal wise. I may have happened at the interview and also for you to make sure that there are no queries. You can go back to the participants quite quickly. We adhere to national guidance with regards to application for ethics. So we went through items and also address and we basically adhere to confidentiality and data storage and security as well. Any sensitive issues that came up were escalated through supervision and also management and it's very important that you differentiate between your role as a clinician and that of you as a researcher so that women and bracketing people don't feel that their care will be compromised if one of a sudden they decide to come out of the study. So let's talk about the results. I'm going to be using Colise's framework and we won't really have the time to go into it because I'm trying to summarise four years of master's dissertation into 30 minutes but if anyone is interested you will have my Twitter account and email address. Feel free to get back to me and I'll follow any information that you may find helpful. But in essence what you do is you try to do a thematic analysis of the information and I came through 84 significant statements that were cluster into 15 thematic areas and finally for emerging themes. I'm going to talk to you about those four emerging themes starting with women's feelings so the impact of bridge diagnosis. This is what women told us. They felt shocked, uncertain, quite disappointed and frustrated following diagnosis and these feelings were actually exacerbated if bridge diagnosis had taken place quite late in their pregnancy or if we were already interfering with the process of birth so like induction of labour or anything like that. There were actually a significant amount of women, five out of six for whom bridge was diagnosed quite late and they had doubtful thoughts and answered questions as well. They felt that certain procedures could have been prevented such as induction of labour had they known the baby was presenting bridge. Women tend to report optimism if there is early diagnosis. So these are just some of the quotes and I like to read them. For example, a woman said I was in the midwifery unit and got rushed to the labour war so obviously this is someone who is in labour and just found to be bridge presenting. You can just imagine how shocked they must feel. They are aiming for a low risk. Birth and all of us have been there in theatre within five minutes having an emergency setting section. Let's move on to the second theme. Women's health care expectations with regards to bridge care. Once again, when it comes to accessibility and care provision these variables are affected by the timing of and the response to diagnosis. Some women have quite strong emotions actually and some women reported concerns with regards to accessing care. Women have felt neglected, stereotyped and discriminated. I found this really heartbreaking and I'm sure that many of you will do as well and I'll talk about this a bit more in detail in a second. So women perceive certain skills to be core skills in the wifery practice such as power patients of making a bridge diagnosis through power patients and women's experiences were different if they were accessing NHS services or if they were reaching out to a care operator or someone who was able to provide a complementary alternative medicine through private services. So here you have some of the answers. One of them that I, you know, every time that I read it, it just breaks my heart is that of I feel that I was, there was a bit of negligence. This mother in English was not her first language either. I felt like another pregnant woman being Asian. It is really heartbreaking. And I'm sure that you will agree. So when it comes to women's preferences and making bridge decisions with guidance so overall women reported good care. They were less satisfied with anti-native services and they care that they have interpartumely or postnatally. They felt that they had some information but that that information mostly came from obstetricians and that they obstetricians influence women's choices. So instead of consenting, sorry, instead of making a decision themselves they were consenting to a decision that was already being made. But generally speaking, they were offered either elective section or ECB but also a general bridge berth was mentioned. So once again, the fact they were mentioned in the general bridge berth doesn't mean that, you know, this will be offered as a viable option for all. So that concept of making a decision versus consenting to a decision that somebody else has made. So here are some examples. The doctor said women to an ECB and that was it. That's not, you know, consenting to a decision really. And then someone else said, I didn't feel very rewarded but they said this is an intersection. What's the best options? Obviously they, you know, they fully trust us in that sense. Finally, women's values of professionalism, trust and safe outcome. So this was really interesting and I find this quite moving in a positive sense. So there were certain personality traits that women identified and behaviors from the midwives and the obstetricians that helped. So being caring, being calm, being comforting, feeling safe and also, you know, seeing people, seeing that people were acting quite quickly was quite helpful to them. The professional behavior, friendly staff, efficient and naturally honest. I love that somebody said that. We would be naturally honest, not just doing our jobs, which is great. I think as well. So, you know, once again, to read one of the statements, I felt like people were generally there caring for you and that made a huge difference. So to summarise, you know, the main findings and actually what we're doing is we're answering the main research questions as well. When it comes to perception of choice, women basically tell us that choice is there, but only on demand. They have to ask for it. And yes, there are talk spots that in section ECB and bridge vaginal birth, but not everyone have access to complementary and alternative therapies. A late diagnosis was always seen as a negative feature, of course, and that difference between choosing and consenting to an obstetric let decision. When it comes to perception of support, women felt that there were access barriers and, you know, there is an expectation that they'll have access to care, but actually the care that they receive doesn't always correlate with their expectation. And what's really important, and this is one of the things that we made, is that we need to enhance anti-natal care and make sure that obviously we implement continuity of care, but also looking at those big themes of, you know, women feeling neglected and discriminated, particularly women from black and ethnic minorities. And apologies about the use of the terminology BME. I don't necessarily agree with it and I don't think that it is representative of absolutely everyone who we are trying to capture. I'm really looking forward to a better term in the future. When it comes to bridge experience, finally, maternal feelings, you know, we've already talked about those, but women felt that care was not always meeting their expectations and so women felt quite vulnerable, you know, with regards to the management of the benefit that they had dreamt of for nine months and all of a sudden things are changing, you know, in that sense. So a number of limitations here, so limitations to the research methods we use, so the use of convenience and per-persif sampling. The haythorn effect, I don't know if any of you have heard about the haythorn effect, but basically it's where participants behave in a different way just because they are being watched and they're being heard. And this is something that we have to bear in mind as well. The bracketing was attempted at all times. So this is where the researcher tries to blocks his or her own thoughts and answers to the questions or perceive answers to the questions so that we can analyze the data objectively and then any others related to qualitative research. And I'm just going to speed up because of timing. So things that we do to try to mitigate limitations to the qualitative research aiming for rigor, transferability, credibility, conformability and dependability which we've already mentioned. So a number of recommendations you won't be surprised to hear that I will be talking to you about continuity of current today because this will hopefully address some of the issues that women reported they had with regards to accessing information. We as meatwares have a responsibility as per our regulator to make sure that we are able to offer effective care and that we are able to communicate with women and birthing people at all times. But of course I don't want to underestimate the pressures that we are under in certain parts of the world. As NHS providers we need to look into defining and developing specialist bridge services and this is something that happened as a result of this research. So the trust where the research was undertaken now have a dedicated meatwafer-led bridge clinic and if anyone is interested please contact me and I'll direct you to the right people because I left that unit. Fully implementing guidance that advocates for promotion of choices were really important and finally the big subject of black and Asian women and how you know some difficult to reach groups struggle to access care as well. So I will be ending the chat saying that further research with this particular population is required to explore their experiences of care. So nearly done now talking about birth quality for which is the overall overarching theme for today. We need to maximise access services that are free of charge particularly in countries that offer NHS services. We must improve anti-natal care as well and make sure that everyone has got access to care that we deliver and that there is good provision of services. And finally being aware of women's feelings and vulnerabilities. So I have told you quite a lot about the way in which certain women found their understanding and I am so pleased to let you know that there has been loads of research undertaking on women from a black and ethnic minority population that are highlighting that we have to tackle this problem. There is so much more that we have to do to make sure that outcomes are safe for women who belong to this group as well. So a couple of references there for you, we won't go into detail about that. But there are maternity drivers now the focus on black and ethnic minorities which is amazing from maternity transformation programme, also public health England and the Butterbirds are aiming to provide continuity of care to 75% of people from a BME background by 2024. So another reference is here for you and I just wanted to end with a quote that I absolutely love and this is for anyone who may actually be thinking of wanting to make significant changes while you work and wanting to change the world. I know how you feel and this is what I wanted to do as well when I first started looking at this subject of bridge. I just thought that this was going to be mission impossible but actually if you feel passionate about a particular subject you will go all the way and I'm not just telling you because I've gone through that myself but also because I've got inspirational friends and people that I work with do this day in and day out so of course I had to quote the one and only Barack Obama today and this is what I want you to remember as well as change will not come if you wait for some other person or some other time. We are the ones we've been waiting for and we are the change that we seek so always remember that it is in your hands and you've got the power to make things possible. So don't underestimate what you can do as healthcare professionals. Thank you so much to absolutely everyone attending this conference from once again different parts of the world and I am here to help answer any questions that you may have for me. Please tweet about today at Meet Wife Sierra as well so that we can celebrate the subject of bridge and if you've got any questions feel free to ask them now please. I'm going to have a look at the public chat. Elisa I don't know if you've picked any questions yourself. Yeah I have a lot of comments. Yeah I've seen Loredana is asking about moxibosion. Absolutely this is something that we implemented thank you Loredana this is something that we implemented in the clinic moxibosion which is an alternative therapy that has been used in China for many years was actually implemented in the bridge clinic. So women have access to moxibosion from 34 weeks and they continue to have access to that as well. Loads of studies I can remember Italian studies highlighting the effectiveness of moxibosion in terms of bridge presentation and actually for those of you that don't know much about it when it comes to moxibosion even if moxie doesn't turn the bridge presenting baby it makes the success rate of ECB higher and greater. So you know there are no complications to it if you meet the criteria and I will strongly advise women look into it absolutely. I can see the urinary acupuncturist as well which is absolutely amazing. Yeah I agree with you I believe the moxibosion works as well. So Mary Cronk yes yes I obviously have spoken to Mary Cronk in the past and I happen to give her a call. I came across her telephone number and I just I was very brave I'm not very shy and I happen to call her and she just pick up the phone and we started talking about bridge birth and I felt the luckiest person on earth if I'm completely honest Linda that was really inspirational and I have read loads from Mary Cronk as well just quickly going down to Jane Evans is another person that obviously works with Mary Cronk as well and absolutely inspirational as well going out to home births to support women have a bridge for general births and we've been to a couple of studies and we've collaborated in the past in organizing and arranging study days locally. I'm just reading through the comments. Yes so people are sharing their experiences this is brilliant. I have been very fortunate to be present at the number of bridge for general births and thankfully the majority of them have actually gone ahead they've been quite straightforward I am quite proud to call many of them physiological bridge births. Some others have been assisted bridge births and some others have been bridge extractions but yes it's really important and I was quoting one of the studies before you know the position of the mother when moms are in war for when they are upright how beautifully bridge babies come through and that's been my experience as well thank you so much for sharing that. People are interested in implementing a bridge service that's absolutely fine not a problem just to let you know we were also trained as midwives to do the external catholic versions ourselves so watch this phase and if you want we can follow you any protocols I will contact the right people and you'll have the protocols with you within 72 hours I pledge to that. So yes midwives and obstetricians in the United Kingdom receive yearly training to support a physiological bridge birth but obviously I think that it will be a further statement to say that we have become the skill because of the Hannah Trial you know we haven't proactively advised women to give birth vaginally to the bridge presenting babies of the skills that we currently have and not the skills that we used to have once for the time but we're working very hard in searching for and designing resources to support training in that sense correct. So someone is asking is my research being published so I have had an approval from the British Journal of Midwifery the research was going to be published this month but I think that they've been inundated with COVID studies and I am being told that the research will be published in August, September so watch out for it and you will be able to reference the study as well if you're undertaking a future research but very happy to share anything that I may have. Yeah that's right the Curtini Italian study that is the one thank you Loretana, beautiful study as well reported conversion rates of as high as 87% if my memory doesn't fail me in that sense. You're absolutely right Rihanna sorry you're telling us that doctors get the most of their experience from midwives and that's right I've been in bridge births where the obstetricians have kindly asked if they can just wait by the corner and that's absolutely right yes of course but always making sure that there are good communication systems in place so that if they're not experienced that there is another person you can escalate your concerns to so that they can be readily available in that sense and you know we've had beautiful experiences recently of mums there is a particular service user who I care for who was presenting with a diagnosed patient you know we always started panicking I wasn't panicking really but you know we were interested at the time and actually this was her fourth pregnancy and she had given birth to her three previous babies in bridge and vagina at least so to her she just couldn't really understand the panic mode because that bridge was normal to her if that makes any sense which was beautiful as well so I've got somewhere Loretas I'm asking if there are any plans to undertake another research once we have implemented the recommendations this is a really valid point Loretas I will definitely look into doing this in the future it may need to be with a different population because I've moved on from the place where I was but it's a very valid question and this will be the only way to test if we've implemented really worked thank you so much for that yeah I've got people telling me that it'll be great to implement a clinic like this please get in touch and I'll be very happy to share everything with you Elisa you're thanking everyone I don't know if anyone had any other questions that you wanted us to talk about I think that we will soon be running out of time yeah unfortunately we have to unfortunately could I kindly take this opportunity to thank you all for sparing an hour of your time in this beautiful evening to you know pay a bit of attention to bridge presenting mums and birthing people who also deserve you know our dedication and care I wish you a good day please celebrate widely and for those of you who are from a weekly background or anyone else who supports midwives thank you for your contribution to society thank you for supporting mums and birthing people giving birth safely whatever you are we learn so much from your practice as well in different parts of the world we are really inspired by the amazing work that takes place in under source under resource countries as well as developed countries yeah thank you thank you for your care to women and birthing people you're actually the reason why women, birthing people, babies and their families exist thank you for your time today and enjoy the rest of your evening