 Okay. Okay. Now I present to you our next presenter, Helen Shalu. Our presenter Helen Shalu is an experienced midwife with three decades experience. She has practiced boot in the UK and in Botswana. She was a consultant midwife between 2000 and 2008. She led the development of Bath Centre with strong belief in social murder of careful women and the delivery of home-based midwifery. She had masters of medical science in 1999, PhD in 2016 and a supportive husband, two sons, two grandchildren and a lover. It seems like we lost Olofemi. I think that he will be back just in a second. But we also lost Helen. Just a second. She is the help lock back in. I am not quite sure what happened to Helen and Olofemi. But hopefully they will be back just in a minute. Okay. Great Linda. But we seem to have lost Olofemi as well. So I hope he will be here just in a minute. Okay. Olofemi, you are here. Can you please take over the mic? Hello. Hello Helen. What happened? I don't know what happened. Suddenly Olofemi, I couldn't hear him. It just went dead this end and we lost connection. I am so sorry but I am here. Yes. And actually what happened was that you both were shot out at the same time. Both you and Olofemi. But I think you are both here so we will continue where we left both of you. So please Olofemi go on and then we will give the microphone to Helen. Olofemi, can you say something so we can hear that your microphone works? I will type something to him. Yeah. But otherwise Helen maybe you can just carry on and start your presentation. I can't recall. Oh you are here. Okay. Can you hear me now? Oh sorry about that. You can hear you now. Okay. Let me present Helen Shalo again. Helen Shalo is an experienced midwife with three decades experience. She has participated both in the UK and Botswana. She was a consultant midwife between 2000 and 2008. She led the development of Bat Center with strong belief in social model of care for women and the delivery of home based midwifery. She had Masters of Medical Science in 1999. A PhD in 2016. A supportive wife, I mean husband and daughter, two sons, two grandchildren and a lovely dog. I have a present to you Helen Shalo and I hope you enjoy her presentation. Helen. Oh hello everybody, friends and colleagues around the world. I'm so excited to be here. I hope we don't get cut off again. I just wanted to say before I begin my presentation that I'm very mindful that my presentation is very focused on an English District General Hospital somewhere in the north of England. And you might think that has no relevant relevance to where you work but I have noticed over the years that many people have looked to Great Britain for inspiration with regard to midwifery. We don't always get it right and we have problems that we are dealing and grappling with here and that's why I did my PhD. So a mother says I'm in labour and the midwife says no you're not in labour yet. And the mother says but so the title of my presentation is are you listening to me and it's a feminist participatory action research study. And it's about the interactions between mothers and midwives when labour begins. I would like to thank Professors Ruth Deary and Mavis Kirk for making this study possible. So now I need to learn how to do this bit right. Just a picture from my kitchen window where I was showing some Scandinavians that we too can get snow in the UK. But with my introduction I'm going to give you a bit about the background to the study. The context of my study are my aims and overview and then very quickly I want to get to the findings. So many women came to my clinic that I held as a consultant midwife or in my role as a head of midwifery women would come having made complaints to our service. And they would say they being the midwives they didn't believe me or they didn't listen to me or us. And they said I wasn't in labour when I knew I was. And then they sent me home again. And one woman said and this for those midwives out there this is a sort of visual representation of the neck of the womb, the cervix. And one woman said when you're in labour it's fine. But when you're naught to four nobody gives a shit and you're just a pain in the bum. Why is that? Well I wanted to find out more about why women were being turned away in labour. But before I could do that I needed to set the context. And when you do a qualitative study you really need to be able to describe where you're coming from in your research. So I haven't got a pointer here but if you just follow me around from left to right. First of all I looked at my own biography of becoming a mother in the 70s. And I compared that with changing government policy. And here in the early 80s and late 17s we had two key government reports that talked about the safety of hospital birth and putting women off having their babies at home. And then we had changing childbirth in 1993 that commended continuity of care for mothers and choice and mothers being in control. And alongside that I looked at midwifery developments. How did midwifery respond to government policy? And then I could not ignore the political context because when Margaret Thatcher became prime minister in the 70s, was it the 70s or 80s? We began to see the rhetoric, the talk about the business model moving away from free healthcare at all which we still have but much more talking about money, finance and more about business, introducing business into the NHS. And alongside all of these contextual issues I wanted to see how mothers expect, thank you Celine, that was the word I was looking for, thank you so much, neoliberal policies. There were mothers' expectations and how they've changed over the decades. So a quick study overview. My feminists, my theoretical perspectives, the way I'm viewing or view the research that I undertook is from a feminist perspective and I saw Celine early on saying about midwifery being a feminist issue and Karen Gwilliland in New Zealand got up at the RCM conference last year and said to our audience that midwifery is a feminist issue and I would agree it most certainly is. I also took a post-modern perspective and I'm happy for anybody to ask me any questions about that later on. My methodology was participatory action research and I chose participation and action research for its collaborative and its emancipatory potential. I wanted to include my participants in the research process. So I undertook a series of focus groups with mothers and focus groups with midwives and in-depth open interviews with mothers and with midwives. I then, sorry let me just click this button again, then before I got into any deeper analysis I held a one-day workshop where all my participants came together in collaboration in a one-day workshop where they looked at preliminary findings which I had put together through a series of coding exercises using an electronic EnVivo program and I wrote a story. It was called Jane's Story and Jane's Story basically was of a woman phoning in saying I think I'm in labour and she was put off and put off until such time that she actually gave birth unintentionally at home and the consequences of that for her and her family because those were the stories that I was hearing from mothers. But also Jane's Story also mirrored midwives accounts from their interviews so there was a mirroring of what mothers told me and the midwives, how they were involved in those scenarios, those situations. My deeper analysis I chose a voice-centered relational method called the listening guide which involves four readings of the transcripts and I actually did a fifth reading of myself and listening to what I had to say in the interview process which is a very reflexive and critically reflecting on my part in the research process. So the aims of this study were to examine the experience of childbirth with specific reference to the factors that enhance or inhibit mothers and midwives interactions when mothers report the onset of labour. I wanted to raise awareness of the implications of unsatisfactory interactions and with both mothers and midwives explore how that might be improved. So I'm coming straight now to my findings and I'm aware that was a very quick romp through the design of my study. When you're looking at your data it just seems overwhelming and there's so much of it and it's not neatly packaged but for the sake of a presentation that's how you'll end up seeing two tables here which look very neat but the actual process of it wasn't. So I identified three major themes. The first one was subjugating mothers' knowledge and in that I identified conflicted mothers. For example, one mother said whether I was dilating or not I was in labour and I was in pain. Frightened mothers. I don't think you feel safe when you're sent home again. I didn't. And stoical mothers. Mothers who said well thankfully he was born healthily in the end. So it's a success story but as the interview went on mothers reflected long and hard on their birth experience. For example when a mother would go on and have a caesarean section after being turned away and turned away after a very long lead into labour and the more she looked at it the more she began to question whether in fact it could have been different to the way it was. Very reflecting, deep reflective process during the interview. The second theme I identified was undermining confidence and generating fear. It was fear of uncertainty. For example one mother said I didn't have a clue what was happening as it was my first time. And another mother talked about her fear of midwives and she said you're in the hands of the midwives and you don't want to myth them off. Miffing them off was a colloquial local term for upsetting the midwife. So if the midwife said well you're not in labour you can go home a mother wouldn't dare contest that or argue with that because she didn't want to upset the busy midwife. And she likened this to going into a restaurant and if you didn't like the food you'd be scared to say so in case somebody would go into the kitchen and spit into your soup. And this is what she said. And then there was fear of the future or I called it foretelling the future. When mothers would be told so the midwives would say I wasn't in enough pain and I thought gosh what is enough pain then? And this particular mother nearly gave birth in the car trying to get back to the hospital after being sent home. My third theme was abandonment. Unsupported, unexpected birth out of hospital. It was like there were three groups of women those who have repeatedly turned away saying the neck of the womb is not four centimetres you need to go home and the trauma that that caused them. And then there were the group of women who arrived very late in labour and felt traumatised because although we would say that was great she came in she gave birth quickly this mother felt well no I didn't get any support I didn't get any of the help that you said I would get throughout my pregnancy. And then finally there were those women who were told to stay at home and then gave birth unexpectedly out of hospital and for one woman that was in the garden in sub-zero temperatures. So underlying this was abandoned babies. One mother said I think the experience of giving birth unexpectedly at home affected my bond with her when I thought she was going to die. And abandoned mothers. One mother said all of your deepest, darkest fears just go through your head and abandon to responsibility what about the partners? One mother's partner said what if something happens to the baby and there's no one there who can help and this particular woman said of her partner giving birth she said when she caught the baby in her bloodied hands she described the baby as being due luck's white and that really frightened her and she and her partner thought their baby was going to die I'm happy to say she didn't. So superimposed on these themes that I identified was becoming other mothers and embodied dissonance and bear with me because I'll come back to that. So I then turned to the midwives and asked them what they thought made for positive interactions with mothers and I won't go through all this but for example a personal greeting giving your name a sounding approachable being aware of your tone of voice and sharing your name and sounding focused but I've put the clock in the middle here quite deliberately because time clearly became an issue for these midwives and lack of it. So here again is another neat little table with the themes that I identified the first was interactions with mothers as distractions. What makes for satisfactory interactions we've seen on that little chart before with the clock face however one many not one but many of the midwives said it's having the time to listen and the time to focus in and one I keep saying one but it wasn't one a theme running through the conversations and the focus groups was about the conveyor belt and a midwife said you don't get that luxury on labour ward and she was talking about the luxury of actually either being at home or being in a birth centre where you could offer a lavender bath to a mother and help her to relax and actually if labour progressed it progressed and if labour didn't the mother would work that out for herself and another midwife said they get bored of us before we get bored of them and this midwife here said she likened the labour ward to having a conveyor belt of mothers and a lot has already been written about that now we have a system called triage or maternity assessment unit where mothers cannot get to the labour ward without being seen and assessed in a triage unit and this is what one midwife said about it she said I hate it triage I hate it but best it's tolerable at worst it's deplorable and I didn't mention triage to the midwives they wanted to talk about it themselves but within this situation where they're working in an assessment unit where they're taking phone calls and seeing mothers at the same time and there's mothers queuing up outside the door midwives have developed a formulaic discourse as a form of self-protection and I identified something called conditioned conditional responses for example well you can come in but if you're not as far on as that's the magic four centimetres you'll have to go again many of the mothers talked about that saying well we didn't really want to go we wanted to go in but they didn't really want us to go in because when we went in they said you're not far on enough to go home again and this was very upsetting for them there was also an issue of non-reassuring reassurance many mothers talked about midwives saying well that's normal you're fine have a paracetamol and a bath and I can't tell you how many times the issue of paracetamol came up in my study and we're beginning to know more about the effects of paracetamol and the inhibiting effects on prostaglandin so it really is an issue that we need to look at in this country and of course there's changing expectations and one midwife said what happened 20-odd years ago and what happens now is completely different and in that context diagram I showed you earlier on mothers' expectations are often led by their aunts and their own mothers who are a generation ahead of them and their expectations were that I want you to understand that this study is not about advocating that all mothers should come into hospital and stay there for as long as it takes to give birth to their baby but these mothers were really not prepared and the midwives although they would say it was best for mothers to stay at home actually that's not how the mothers themselves viewed it were these mothers now the third theme was one to one or one to everyone one to no one in our nice guidance if you don't know what nice is I'm happy to explain that to you but it's an evidence base well it's supposed to be it's a body of so-called experts who put the evidence together and then come up with recommendations to standardise practice we have in our nice guidance for our labour care that mothers should have one to one care when they're in labour the trouble is when is active labour and who diagnoses that so midwives have developed a pragmatic approach as well as a form of self-protection for example one midwife said and this was a senior midwife I can dip in and out and do the care and do the obs you don't have to stay with a mother but actually I thought one to one care means you do stay with her and that's why care is continuity of care for women in labour is safe and reduces interventions but no this midwife on a labour thought you can dip in and out do the care do the observations you don't have to stay another midwife identified conflicting responsibilities it's my registration and if I let her in I have to be responsible and what she was talking about if she was in a situation where she was already looking after a woman in labour or maybe she had two women in labour and only two midwives if she took a phone call and a mother wanted to come in she found herself being reluctant to just say yes come on in because she would be worried that she couldn't do the observations that she's required to do and she thought that put herself at risk and the final thing that many midwives talked about was cumulative unreasonableness and what they were talking about was that after a woman's given birth it's three hours before the paperwork is done and I've experienced that myself in practice that the bureaucracy around paperwork in this country has just become totally unreasonable so the overarching theme that I fell upon or my aha moment was midwives becoming other and I want to talk about consonants and conforming or cognitive dissonance and disruption but before I just go on to that this is a visual representation of a first interaction it could be anywhere in the world the first time you meet a mother and she's in labour it's an opportunity to welcome her to smile and make her feel relaxed get her hormones going and make her feel welcome and respected and often that's an opportunity that's lost for example at the top line there oh she's not in labour she's not four centimetres so the mother will have to go home but the mother's thinking but I'm still in pain I don't want to trouble you but and then oh it'll be ages again you don't sound like you're in labour so you might as well go home or stay at home and see come for my baby and if it's like this now what's it going to be like then and then often on a labour ward in the UK you'll hear a midwife say oh that was quick she came in and she gave birth that was great but it's not always so great for the mother as I found out in my study or you'll hear a midwife coming off the phone said oh we've just had another BBA which is a baby born before arrival I'm really not much thought about it but actually the mothers feel abandoned rejected and very frightened so another wee picture from my kitchen window to show you spring coming and we've had a sunny day here in Scotland but I want to just talk to you a little bit about cognitive dissonance theory because I went I had these themes that I've just talked to you about and I thought but there's more here there's something else and I talked to my supervisors and they said think about it more Helen think about it more and the more I thought about it one day I was having a conversation along the lines of well midwives don't come in to do a bad job so why is a bad job happening what's going on so what is cognitive dissonance cognition refers to the mental process by which external or internal input is transformed reduced elaborated stored recovered and used so cognitive dissonance results when there's a feeling of discomfort which leads to alienation in one of the previously held attitudes beliefs or behaviors in order to reduce the discomfort restore balance to give you an example of this midwives tell mothers it's better for you to stay at home whereas mothers actually some mothers don't feel that at this point in time now if the midwife sends the mother home and she sees that she's upset at going home then she has to reassure herself well it's actually better for you to go home despite the evidence midwives themselves say well it's better for it to be home because it reduces interventions but the research has actually shown that staying at home for longer does not reduce cesarean sections, forceps or vantus and medical interventions what it can do if we provide support and this is key support for women at home to stay at home it increases satisfaction and that's really important so to go back to the mothers and this notion of embodied dissonance and conflicted mothers this is how I understood it well they the midwives must be right because they know best so they're restoring balance an incognitive dissonance theory that's known as consonance hang on, I must be wrong because I can't know more than them and that's that itch that needs to be scratched, that's that rub it doesn't quite feel right because I'm still losing fluid, I've still got pains I'm still passing show and I'm feeling like this and so I'm feeling embodied dissonance I know they must be right many women talked about what they what was in my head but what was in their bodies was something quite different what their body was telling them so I then found a definition of embodied cognition which is the surprisingly radical hypothesis that the brain is not the sole cognitive resource we have available to us to solve problems our bodies and their perceptually guided motions through the world do much of the work required to achieve our goals replacing the need for complex internal mental representations now I would argue that in the UK now we have two midwifery models or paradigms, one is the social model based on concepts of relationship, continuity engagement, birth centers, planned home birth, caseloads and midwifery lead care and then there's the obstetrical rather I prefer to call it now the industrial model which is more technocratic, routinized, process driven throughput, clear the board electric lead care yet the findings implicated midwives in both models in my study and that was a surprise to me so what's going on oh I don't know seems to be there seems to be something missing with this little slide but it doesn't matter basically we're trying to provide midwife lead care wherever we're working on labor ward or in a birth center or at home in the communities but actually things afoot that put barriers in place of midwives being able to do the job that they were trained to do and this causes a high degree of dissonance or when midwives change their narrative to say well this is best for mothers I'm doing the right thing for them they restore balance and change their narrative in order to conform and comply to process driven practices so cognitive dissonance is caused by conflicting paradigms and that came through strongly in my study and one midwife in focus group 4 said I think as well it's going back but it's kind of well the conversation as well she's having a phone call and the midwife at the other end of the phone says have you veed her when we're talking about late and phased mothers well no I don't need to vee her just yet we're talking we're chatting and then you know we might have another phone call and what's that mother doing have you veed her yet no we're talking about what's happening to her body and another midwife in the same focus group said but the trouble is they don't value what they're doing what we're doing do they and I think as midwives we don't value what we do either and it's about time we did but all was not well for midwives wherever they work as a lead midwife on the labour ward she found herself in a senior midwife found herself in an impossible position I asked her how this felt and she replied it's frustrating it's frustrating and at times it's frightening there's been times when you're down to the last bed on labour and I mean this is absolutely horrendous down to the last bed on labour ward and going and waking mothers up at three in the morning asking if they'd like to go home because that's what you've been told to do by the managers further up process driven care clear the board does it feel to work against your values and beliefs this conversation occur between two midwives midwife one said it's crap I don't want to work like that I don't want to work like that on a regular basis you know there will be days where it happens what happens that happens on birth centres as well what does that do to you said midwife too well the crap makes me feel like I'm a bad midwife and a bad person cognitive dissonance and I don't want to do it and then another midwife midwife to replied well it damages you as a person and I would agree I think it certainly does the midwife from labour ward said yeah there's no job sorry there's sorry I did not happen there there's no job satisfaction at all you don't feel like you're caring for anybody you're not doing your role for anyone and you just feel like you're walking around apologising and feeling guilty all the time and then you're not providing the care you want to give because you can't you're spread too thinly by maintaining balance consonance midwives become other and they disconnect I don't like how it changes how you are sometimes you know sometimes if you've got a lot of people on the corridor waiting you've got all your beds you don't want to make eye contact with anybody and meanwhile in the holding pen a mother described how then at about 4 o'clock my water's broke and I started to panic so I ended up going down the corridor can I have some help please my water's broke and I don't know what to do I'm really scared can somebody help me and then the nurses came rushing back in and they get me on back on the bed and they check right we need a birthing pack now and she hits the alarm button and all hell and shallow lost her connection again hopefully she will soon be back this is what sometimes happens and I hope she'll be back this happens sometimes too you hope what I hope that she will be back soon but she was it happened just before I think it's her own connection but I think she will soon be back but there is a discussion interesting good discussion going on in the chat about the support in labour her presentation has been very interesting and she has really opened up a lot of discussions about social model and that is indeed being presented as very very superior to other models I hope she joins us very soon here she is so you take over can you speak again can you hear me can you hear me yes okay sorry about that everybody technology is wonderful when it works so here's an illustration of where those two models that are I believe that we have in the UK at the moment they can work side by side when factors identify here dovetail and add excessive strain there is a risk of creating the perfect storm the impending signs are all identified in two UK reports very damning reports about maternity services in the UK at this time so if you look on the right hand side the social model of midwifery we have a situation here where in some hospitals we're taking staff away from birth centres or pulling staff from the community to work on short staff labour wards and this destabilises the teams midwifes find themselves faced with familiarity, insecurity their confidence is undermined there's a lack of trust, a loss of autonomy midwives are conflicted and suffer severe cognitive dissonance and safety I would argue is jeopardised but from an obstetric or an industrial midwifery perspective there aren't enough midwives throughput and clear the board are the priority no time to engage with mothers you just dip in and out they manage rather than care midwives talked about rationing and prioritising they cannot provide real one to one care to mothers and that leads to a lack of trust midwives disconnect in order to maintain a balance in their life so that they continue to work but again I would argue that as a result safety is jeopardised but I've argued that the obstetric model and the midwifery model can work side by side and should be able to and I have certainly experienced that but now we've got this neoliberal business model that's been superimposed on us and I have this mantra that we're talking about cost per case efficiency savings, time is money staffer to work, leaner, meaner smarter, keener and do more for less and at the same time improve quality inattention to real root cause analysis and the infrastructure in communities is inadequate and UK maternity services are then I would suggest outmoded so findings from this study indicate that in both the social and obstetric midwifery models there are barriers to affecting consistent satisfactory care in terms of emotional as well as physical wellbeing situated as midwives and mothers are then outmoded organisational structures and I do have to say before I do finally finish that we have two government documents now, better births or two maternity reviews one's called better births and the Scottish equivalent is called best births and they are looking to the future and how we can provide continuity models, caseload models and it's far reaching and really exciting and I hope that we'll be able to put care in place that changes and transforms maternity services here but we've yet to see it happen. So thank you for listening, it's just part of my study there's so much more to say but not enough time in this slot but any questions welcome thank you very much over to you Olofemi I think Yeah, thanks so much Helen you've really presented very interesting result of your research and I found out from your presentation that you have dealt exhaustively with Swiss you obstetric business model as has been practiced in the UK now and you highlighted highlighted a lot of discrepancies that are called among these two models you've really done a lot of work on this and from the chart a lot of comments are coming in and I will quickly pick one of them so that you can deal with it that's about Becky from Virginia I said can there be the training of midwife assistant so as to quickly provide care Helen will you quickly look at that question and please attend to it Yes, I think it's an interesting comment and from my heart I can say that ethically that is probably what we have to do but professionally it breaks my heart because I believe that is what the midwife trains to do and when women come into midwifery in my experience that's what they want to do I've just come from the student conference here and it seemed overwhelmingly that that's what they want to do so yeah I've got two conflicting thoughts in my head about that it seems to be that we get services ever cheaper ever more on the cheap if you like because if you train birth attendants doolers and I don't have an issue with doolers per se because they do a really great job and that sounds really patronising however I'm concerned about the loss of the midwifery profession and if we don't address these issues now then what is the future for midwifery? Thanks again coming from the chart again selling ads midwebs can be considered as an oppressed group from the two models three models we have explained do you think so? Sorry Olufemi can you repeat that question selling said midwives can be considered as an oppressed group so from the models you have presented do you think it is correct to say so? I definitely believe that midwives I think midwives are an oppressed group but I think that perhaps we particularly in the UK have brought that on ourselves to a great extent we have signed up to the medical model and to extricate ourselves from that is going to take a great deal of work so I think we have been an oppressed group I think we are trying to fight back if you like but yes Celine how do you power midwives? and I I always had this thought that ok labour awards seem to be process driven conveyor belt factory type places so Marsden Wagner said get mothers the hell out of labour award and hence my support for a social model birth centres and more home births however I can see that as long as we are employed by organisations who are driven by the business model those pressures are still on midwives to do those quick community visits to do those quick post natal visits to not promote home births because there's not enough of you to do the on call so it's very very difficult um yes I'll rambling I'll shut up ok thank you Helen I think I was just saying I mean Chatham girl said our role has been reduced and reduced and we have nurses looking after women who have had surgery we have had care assistants looking after normal deliveries our role has not been fought for absolutely I'm totally with you on that one totally with you I think if we don't do something now then midwifery is little more than and I'm not denigrating the nursing profession myself I'm not denigrating but it's different and um how to empower midwives well they need to we need to be talking to midwives they need to learn how to speak up as you speak up Selina and as I speak up we just need to keep banging on and to equip midwives I think in their training I think we need to equip midwives to be active and to believe in themselves okay you talk about deep in and out I think that can be dangerous what do you think we may feel safe and usually no but what can you what can anyone do about that I profoundly believe that women do not feel safe a midwife comes into her room she does some observations a blood pressure or listens to the baby's heart then leaves her again this is profoundly unsafe and the whole the whole preface of a social model of midwifery and continuity of care models is that midwifery led care is safe because we are with the woman but if we start to translate labour ward practices into community settings and labour ward practices I think we are endangering mothers and endangering midwives because we will get into serious trouble I don't think it's safe so dipping in and out is not good enough okay this that came up in my mind and on a lighter mode I think I would like you to respond to it midwifery is a feminist issue can you explain better when men are sometimes there with their wives sharing the debates when they are delivering how is it a feminist issue alone put quite simply I think Olufemi women's voices are not heard women's or mothers opinions about their birth experiences are not generally heard for example the midwives the mothers I interviewed in my study were all women who had on paper they had a normal birth so their voices were not being heard and it's a feminist objective to raise consciousness and to raise women's voices to make those voices visible and listen to because what the women in my study had to say was very important but because they had a statistically they just had a normal birth nobody was listening to them so birth is a feminist issue because we're talking about empowerment we're talking about enabling women to be in control of their own destiny with our support and our help I don't know if that answers your question it is a political position to take coming from the chat finally Selin said it is a epistemic injustice do you think so where does it epistemic injustice yes absolutely definitely epistemic injustice in so far is whose knowledge counts and whose knowledge matters and at the moment it seems to be even now despite our moves in this country to have continuity of caseload models it's only now that we're openly talking about that but in the last 40-50 years the only knowledge that's been heard and counted for anything was medical knowledge can you still hear me yes oh you can sorry is that everything went black here for a second but it's coming back up again so yes epistemic injustice and I don't know if we're ever going to get justice for women why are so many women around the world dying every day every second due to childbirth issues what's that about that's epistemic injustice so thank you so much Selin okay thank you so much that is all we can take for now oh okay okay sorry I can't answer any more questions we need to sum up the the session yeah will you thank Helen all of MAO yeah we appreciate you which has appreciate your presentation and you've dealt so exhaustively with all the models and the situation that women face when they deliver and I really appreciate and I think the entire conference participants have really been informed and they've been encouraged by your presentation I really appreciate you for this and thank you so much yeah thank you very much Selin for very interesting presentation you can see that the comments in the chat has been very appreciative for your presentation so thank you very much we would like you all to I'll just turn off