 Here we go. And I'm going to introduce to you Caroline Homer. It is my absolute pleasure to do this. Let me go to my right page. Caroline is, so I've got to get up here. Good. Yes. So Caroline Homer is the Professor of Midwifery, the Associate Dean, International and Development, and the Director of the Center of Midwifery, Child and Family Health at UTS. She is the current President of the Australian College of Midwives. She has been involved in the development and evaluation of midwifery and maternity services in Australia and in a number of other countries in the Asia-Pacific region, including Papua New Guinea, Samoa, and Timor-Leste. This work has focused on the strengthening of midwifery capacity and skills and supporting the development of midwifery education and evidence-based practice. She was an author in the recent Lancet series of midwifery and the 2014 State of the World's Midwifery Report. She also wrote a commentary for the Stillbirth series in the Lancet, which is published in January 2016. With no further ado, I give you Caroline Homer. Thank you. Please keep your comments or your questions to the end. You can put them in chat and I will catch them and then Caroline will save time. Thank you, Lorraine. Good morning, everybody. Good evening and good night wherever you are in different parts of the world. I'm in beautiful Darwin in the very north of Australia and I'm sitting on Larrakea Country and I'd like to start by acknowledging the traditional owners of the country in which I sit. Unfortunately, I'm not outside admiring the beautiful country. I'm indoors but I'd like to pay respects to the traditional owners past, present, and for us as midwives pay respect to our future traditional owners of this beautiful country. Thank you for this wonderful opportunity to close the conference this year. I've been watching it over the last 24 hours on Twitter and Facebook and it's very exciting and I have heard a number of the presentations so it's just very exciting to be here. I'd like to thank a few people before I start because I'm going to use their material in my talk. The first is Vicki Flanady and the team from the Lancet series on Stillbirth which as Lorraine said was released early this year in January. I'm going to use a lot of the material from the series. I also acknowledge Mary Renfrew and Petra Tenbenhooper who led the big project that we undertook on the Lancet series on Midwifery released in 2014 and I'll draw on a lot of that work as well. And then finally the State of the Worlds Midwifery team led by ICM, WHO and UNFPA and again I'm going to draw on their work through this presentation. So let me do the next slide. So Stillbirth affects millions of families and essentially every woman who has a Stillbirth also has a midwife with her, an obstetrician, another skilled birth attendant or her family and her family usually. And so this is the tragedy for all of these people involved and this photo is a photo of my baby niece who's called Harper who died nearly 10 years ago now as a Stillbirth. And I think this photo encapsulates the grief of parents and all of you around the world listening to this will understand being alongside families who experience Stillbirth has enormous grief and has enormous loss, not only for those parents but for the whole family and for society as I'm going to show you. So this is a profoundly important experience that we do as well as we can as midwives, as obstetricians, as maternity care providers when it happens, but gosh, wouldn't it be good if it wasn't happening? So if there were no Stillbirths or if the Stillbirths were at a level that was incredibly low that would make an enormous difference to families all over the world. Sorry, something's happened, let me just, here we are. So the Lancet is the large international journal and that publishers who publish a lot of very important global work around health. And it's been many, they've published a number of series now over the last decade in relation to maternal and child health. This most recent Lancet series, Ending Preventable Stillbirths, was released in January 2016 and it reports on the present state of Stillbirths, highlights the missed opportunities and identifies the action to accelerate progress to end preventable Stillbirths. Globally, we're now looking forward to 2030 in many of the global indicators. As you know, the Millennium Development Goals ended last year. We're now in the Sustainable Development Goals and heading towards 2030. So many of the outcomes and the indicators and the investment in many countries is around leading towards 2030. And Stillbirths and preventable deaths of mothers and babies is a critical part of all of that work. The Lancet series are always available for free through the Lancet. You just go to their website. You have to put in your email address and make a password and that's only for tracking. You don't get charged. So lots of people get that far and get nervous but I promise you you won't be charged. You can download the whole series, both the Lancet series on Stillbirth and the Lancet series on Midwifery, which I'll get to soon. So as part of the Lancet series on Stillbirth, the authors undertook an analysis. They looked at the 500 most frequently used words in relevant reports from global agencies, partnerships and organizations, all who were engaged in maternal and newborn health. And they looked at these are these wordles that some of you will be familiar with. What are the bigger the word, the more it comes up, the more it's relevant. So word size is proportional to word frequency. And I guess it's good to see, well not I guess, it is good to see women and maternal health and health and child health all as the big picture items here. It's very hard to see Stillbirth but it's right up there in that tiny little box right in the corner, which I guess shows how invisible Stillbirth is in the discourse on maternal and newborn health. It is one of those things that doesn't actually get talked about that much and this is a really good example of how often it does get talked about and written about in the literature. Interestingly, where do you think Midwifery sits? We don't see Midwifery there either or midwives very clearly. And if I can make this work in my next slide, there is Midwifery. So Midwifery's a little bit bigger than Stillbirth but Midwifery is not actually big enough either given the very important work that we know midwives do in addressing maternal and newborn health and in addressing Stillbirths. So just some data on the global burden of Stillbirths. This is from the series, 2.6 million Stillbirths a year across the world. The vast majority are in low and middle income countries, 98% in low and middle income countries and of those 75% are in sub-Saharan Africa and South Asia. So for me in Australia, my neighbours in Asia have this enormous burden and for you in other parts of the world, particularly people who are currently in Africa or currently in South Asia, this is your enormity every day that you deal with. The tragedy is that half of all Stillbirths occur during labour and birth and many or most are preventable. And these are issues that I've written there, maternal infections particularly syphilis and malaria, non-communicable diseases. We see women with hypertension and with increasingly diabetes and obstetric complications. So there is a lot of work that we can do as midwives and as maternity care providers. A number are due to congenital factors but the rate of that is actually quite low and it's in the order of 5%. So they are the harder ones to prevent although there's probably some preventable factors that we can put in place but we can actually do an awful lot about Stillbirth. And I think what's happened over the years is that there's been this element of fatalism. It's the fatalism that oh we can't do anything, oh it's all too hard, oh it's a congenital abnormality, oh it was meant to be. And actually that's not correct, it wasn't meant to be. And for that family it's not what they want or what they need. So this is a slide just showing the global burden of Stillbirths. The circles are proportional to the number of Stillbirths. So as you remember in the previous slide, most of the deaths are happening in South Asia, this very large circle here in India and then again some very large circles in Africa. This one here is Nigeria. Again Pakistan number three and China number four. These are the big countries so you would expect in one way that they would have higher Stillbirth numbers. But equally these are phenomenal amounts of babies who are dying. If we go to this side of the slide, the left hand side of the slide, you can see proportionally the countries with the highest Stillbirth rates. So we see Pakistan, Nigeria, Chad, Guinea-Bissau and a number of other countries in Africa with very high Stillbirth rates. What's interesting about looking at slides bluntly like this that have countries and data is that within a country, there'll be very different rates of Stillbirth according to where women live and their socioeconomic status within that country. So I know in my own country in Australia when we're around the edge, particularly in the populated areas for non-indigenous women, the rates are very low. Once we look at the rates in indigenous women, the rates are two to three times higher and the more rural women go, both indigenous and non-indigenous, the more the rates go up. So even within one country, the rates are different according to geography and according to socioeconomics. I know that's the same in North America and across Europe. And increasingly with high rates of migration and refugee populations, again, we're going to see even larger disparities, I believe, in the richer countries in the world as disadvantaged people come into those countries and experience the disadvantages that we know contribute to Stillbirth. This slide is just to show you that half of the Stillbirths around the world do occur during labor. So just concentrating on this worldwide slide number at the beginning, as you can see, this is intrapartum Stillbirth, the darker green, and this is antipartum before the onset of labor, Stillbirth. So 50%. And as the countries, as the slides go along or the numbers go along, you'll see that the numbers change a little bit but essentially half of the deaths occur during labor. So who's with women in most countries during labor? Not every woman, sadly, but many women have a midwife with them or some version of a skilled birth attendant with them. So here's an enormous opportunity for us to make a contribution to reducing that enormous burden on families. This slide again is from the Lancet series on Stillbirth and it shows the incredible link between social disadvantage and Stillbirth. So along the top we have the countries, the social disadvantage that we see, so African Americans in my country and Canada and New Zealand, indigenous Aboriginal peoples, migrants, women who are from low income families, who have low education and early teenagers. These are the women who are at double the risk of Stillbirth. These are the women we should be targeting in our care. We have down here the kind of clinical issues that make a difference to Stillbirth risk. So particularly poverty and social status and economic status. Nutrition, poor nutrition, malnutrition and having a short interpregnancy interval. This is why contraception and family planning makes such an enormous difference because women go into the next pregnancy in the best possible state that they can be. During pregnancy, this middle box, we know women who have lack of access to care, delays in access to care, poor or placental health. These are women who live with, who are not empowered in their own care, who are isolated, who don't have community involvement, who experience racism in their lives. These women avoid care, they keep away from care, sometimes because we as midwives scold them when they come to us. We don't treat them with respect and with care and so women choose, they vote with their feet and they don't come. Then we have this big bundle of risk factors over here. So smoking, being overweight and obese and contributing to fetal growth restriction are the three big main factors. And you can see here, diabetes, drug use, preeclampsia, hypertension, mental health infection and having had a previous Stillbirth. I think it's quite ironic that we're dealing with obesity and overweight in a world that is also dealing with poverty and malnutrition and it seems to be at both ends of the spectrum. We know that midwives have an enormous contribution to make to working with social disadvantage and I'll come back to that again in a little while. So the burden of Stillbirth affects women, families, caregivers and communities and regardless whether you live in a high income country or a low income country, women suffer loss when their babies die. Parents experience psychological symptoms that could be changed by respectful maternity services. We know that significant numbers of women around the world are living with depression associated with their previous Stillbirth and there's significant stigma and taboo associated with Stillbirth. And as I mentioned before, the fatalism. So the, it was meant to be kind of concept means that Stillbirth either doesn't get investigated or isn't seen as something worth putting effort into to prevent. And I think these burdens are in all countries. They're not just in the rich countries, they are in all countries around the world. And what I've certainly heard also from working in countries like Papua New Guinea, a very poor country with a very high Stillbirth rate is that it's not seen as something in some communities women can even bury their babies. So there is a lack of acknowledgement that the baby even existed. And so the sort of psychological loss burden continues on. These are three quotes from high income countries around economics. And I have some quotes later from lower income countries. These are around the economic burdens. And these do fill across the board. So women who can't bury their babies properly because they can't afford to, women who can't go back to work or their workplaces don't understand the pain. And I've certainly heard that from women. They couldn't face going back to work because nobody asked them about their baby. Nobody recognized or acknowledged that they had given birth to a baby and that the baby had a name. And women just avoid going back to work. And then women who do have the fortunate ability to have therapy or counseling, the costs of that need to be borne somehow in the system. So this slide just shows from the data how stillbirth affects mothers, families, health services, society and the government. And I've mentioned most of these already, but certainly there is data around increased risk of family breakdown and in countries where giving birth and growing a baby up is an incredibly important part in your society of being a mother and if you can't achieve that, your husband may find another wife who can. So again, that's the stigma and the abandonment. Because women can't go back to work and they have increased healthcare expenses that affects every country at a societal level and every country's healthcare costs are also affected by this. I think sometimes we are kind of blazoned by the numbers and when I often present data on what we can do to prevent stillbirths or maternal deaths, I think it's really important to remember that behind every number is a story. So this is a quote from a father in Uganda about the men still feel the pain of stillbirth. Maybe the wife has some demons, maybe she's a woman with bad luck, it can cause breakage of marriage and also anxiety. I think this quote says an awful lot about tragedy and loss, but then also about stigma and discrimination and what might happen to this woman next because she's not been able to give birth to a live healthy baby. So what can we do? And as this is the last presentation in the virtual International Day of the Midwife Conference, I think we have to believe that we can do something and we can make improvements and that we need to also be careful that we're not pathologizing everybody, that the great role of the midwife is promoting and facilitating normality, promoting and facilitating women to do the best that they can do, which they will mostly do normally. So I'm always conscious in having these discussions that we don't pathologize, we don't make everything wrong and completely terrify women and over investigate and over and overdo things because mostly that's not necessary, but we do need health system improvements in many countries, particularly in low income countries, the care that women receive is substandard, it is not enough and the care that women receive from midwives, sometimes who are inadequately educated or inadequately supported to do their job properly means that they can't provide the care. We also need health systems that function, that have transport access, that have the drugs and the commodities that the midwives and the health providers need and that they have access to the screening tools that are appropriate and relevant and then where necessary, the interventions that are necessary to prevent stillbirth. And one of the papers from the series on stillbirth showed that these inputs can result in a quadruple return on investments. So not only preventing maternal newborn deaths and stillbirths, but also preventing and improving child development and that's important for everyone. Oh my gosh, we have lost Caroline. So it's that Darwin connection. We'll just hang on for a minute. I'm sure she will be right back. Some very interesting comments coming along in the chat. Thank you so much. Really, really good. There she is. Caroline, welcome back. Why don't you try? I can't hear you. These are the joys of virtual conferences. All good Caroline, all good. Flash will load. And you'll be fine. But there's some very, very interesting, as I said, very interesting comments happening in here. Mm-hmm. Yes, Caroline, do. They're very good. People are sharing their experiences in their regions, what they've seen. No, we still can't hear you. How about that? How about that? Yes, there we go. There we go, that's perfect. Sorry, everybody. I don't know what happened there. OK, so it was probably a good moment, actually. So we're talking about what can we do to prevent stillbirth. So my next slide is, I was very fortunate to be part of the Lancet series on Midwifery, which was a three-year project. With the first four papers, we're released just after Prague ICM in 2014. We had an enormous group of authors from around the world looking at Midwifery and the work of midwives in a range of settings and trying to unpick what it is that midwives do and what is the contribution of midwives to reducing deaths and increasing health. And then what has happened in different countries. And there are four papers, as I said, initially released. And there are more papers to come. Again, this is freely available through the Lancet website. I encourage you to download the series and the executive summary. What we came up with was Midwifery is a vital solution to the challenges of providing high-quality maternal and newborn care for all women in all countries. And this is really important. For us, who are midwives, we think this is actually just so obvious. And why did we even need to spend three years of our life working on it? And I'd have to say, I thought that along the way many times. But we do actually need to make Midwifery visible and the work of midwives visible in order to address maternal and newborn health. In many countries, midwives are not recognized as key providers. In many countries, they are not educated or regulated or professionally supported by an association. In many countries, midwives are not valued as an important profession or even a provider of maternal and child health services. So this was actually an important milestone to say, this is what Midwifery is. This is what the work of midwives is. We came up with this framework that I'm going to talk very, very briefly about in relation to the work we've been talking about. This we call the quality maternal and newborn care framework. The whole principle of the Lancet series of Midwifery came for what do mothers and babies need? What do they need? And then who's the best person to provide what they need? We didn't want to say come from a premise of, well, what do midwives do? Because that sounded a little self-serving and felt a little self-serving. So really, it was, well, what do mothers and babies need? What is quality maternal and newborn care? And then who's the best person? Who are the best people to provide that? So in order to say what do mothers and babies need, we needed to work out this framework. And as you can see, this framework, I'll just quickly take you down the side here. Mothers and babies need care providers. They need good care providers who have good clinical skills, who've got competence, who can work in a team, and who have the resources. So that's the care providers bit. We also need, mothers and babies need, to have their philosophy of care. So this is about optimizing biology, strengthening women's capacities, not doing things unless they're needed. So using interventions only when indicated, which, as you know, in many countries, rich and poor, this often doesn't happen. The values of care are critical. So to give quality care, we have to respect women. We have to make sure that we communicate better, that we use community knowledge, and that we tailor care to women's circumstances and needs. And the care then needs to be organized. And we know that critically around the world, midwifery continuity of care, midwifery led continuity of care makes an enormous difference. And there's now good evidence around this. But care must be available. It must be accessible. It must be acceptable to women. And it must feel and be of good quality to women. So these are the sort of pillars, not pillars, they may be bed rocks of quality care. And then across the top are the other, the sort of more traditional things, I guess, when we think about what the midwives do. We provide education, information, health promotion. We do screening, assessment, and care planning, both during pregnancy, during labor and birth, and after the baby's born. We promote normality, we prevent complications, we address complications, and we refer and consult with medical obstetric and neonatal mental health, all the other services. So the blue line is the purview of what midwives can do. And as you can see, it's an enormous amount of the work that mothers and babies need midwives can do. And we actually showed in state of the world, in midwifery, that 87% of the essential interventions that mothers and babies need midwives can provide. So we have an enormous opportunity here to make a difference. So the first paper of the Lancet series developed that quality newborn, maternal and newborn framework. The second paper, which was the one I was involved in, I'm just going to give you a couple of slides on this. It's quite a complicated paper and has many slides, but I'm not going to do that all today. This was to look at the effect of midwifery care. So actually, did it make any difference? If we added up midwifery care in the way that we did in the framework and said this is what midwifery is, looking at the evidence, looking at the essential interventions would re-retuce mothers and babies' deaths. And that's essentially we were asking, does midwifery save lives? And we showed that universal coverage saved an enormous number of lives. So if every woman in the world had access to midwifery care, there would be considerable reductions in maternal deaths, stillbirth and newborn deaths. We were only looking in 78 countries, the 78 lowest income countries in the world from the countdown analysis. And even in those countries, there were significant reductions in deaths. Even if you only increased the amount of midwifery that your country provided by 10%, you reduced mortality by 27%. If you managed to increase your coverage of midwifery by 25%, you reduced mortality by 50%. And if you increased to universal, and we call that 95%, 82% of maternal deaths would be reduced. And this was exactly the same numbers essentially in stillbirths and neonatal deaths. So midwifery care saves lives. And for those of you who like a table, a figure, this is what it looks like in the different groups. We broke countries into groups based on their Human Development Index, which is a index of wealth and GDP. And you can see that the deaths goes down for all of them, depending on whether you increase by 10%, whether you increase your coverage by 25%, or whether you get your coverage of midwifery up to 95%. This one here, which is attrition, which is what will happen in your country if you do nothing. So essentially, the numbers of deaths will go up. They will not go down. If you increase your proportion of midwifery coverage in countries, the deaths will go down. So that's essentially what that table shows. So this was particularly prevalent in low to middle income countries. Increasing coverage of midwifery care to women can reduce stillbirths. We also showed that women need access to family planning because family planning or modern contraception will make a difference and will reduce the pregnancies that are of potential risk for mothers, fetus, and the newborn. When women have family planning, they have longer gaps between their pregnancies. They go into their pregnancies healthier and weller and more able to maintain a healthy pregnancy. So family planning will save lives. Family planning also saves women's lives. You can't die of a maternal death if you're not pregnant. So if you're not pregnant 20 times or 10 times, you're only pregnant three times, your risk of maternal death goes down considerably. We also showed that access to specialist care, and this is particularly obstetric or medical specialist care, also makes a difference. But actually, interestingly, not as much as family planning. So family planning, in terms of what we can do as midwives, is also a critical component of our role. So in high income countries, it's very similar, although we didn't have the modeling and we didn't model those countries. But we know from research like the Cochrane review that Jane Sandel has just recently revised. So there's a 2016 version of the midwife-led Cochrane review on midwifery-led continuity of care. Reduces preterm births and fetal death less than 24 weeks. So there is something going on with midwifery care. There is something about the relationship between the midwife and the woman. There's that involves engaging women in preventative care, in supportive care, and ensuring that women have the best care to reduce their deaths. So I'm just going to look at this table very briefly. This is, again, back to the Lancet series on stillbirth. And if you look at all these pillars here, the things in them, this is what's going to prevent and respond to stillbirth. So we already talked about family planning and general health. Having educated girls makes an enormous difference to preventing stillbirths because educated girls get all the other things that they need to do. Pregnancy, this is all in the purview of the role of the midwife. Anti-natal care packages prevent managing women with hypertension and diabetes, growth restriction, and this very big important one down here, respectful care. Respectful care means women will come to care. If we treat women nicely, kindly, with a big smile, with a welcoming attitude, that will make a difference. And then all the care that we do during labor, this is critical. And again, respectful care is an enormous element. And then if a death does occur, women need to be cared for in the best possible way. And we also need to ensure that there is audit and response so that we measure stillbirth. What can't be measured doesn't count in a sense. So we need to count stillbirths. We need to try and work out what the causes were. And we need to collect national and global data. So State of the World, Midwifery, and I've already told you about this slide. This is a very important number to remember. Midwives who are educated and regulated to international standards can provide 87% of the essential care needed for women and newborns. And I use this statistic all the time when I'm talking to people in many different countries. 87% is the number to remember. This is a very important contribution that midwives will make to maternal and newborn care. So we know that many women around the world don't have access to a skilled birth attendant or a midwife. And this varies hugely across the world. And this also includes lack of access to modern contraceptives. So a lack of access to midwifery means increased stillbirths. So the world needs more midwives. And that's a very important message on International Day of the Midwife. My other message always is that access to midwives is key and that we have the most to give for the most disadvantaged and the most vulnerable. So midwifery care will make the most difference to the most vulnerable people in every country. And I think this is a really important message for us when we're thinking of how we set up midwifery services, how we set up maternal and child health services, that we should go looking for the most vulnerable. They are the hardest women, obviously, to care for, but this is really important. So essential elements of quality care, and I believe this is in every country, that we need educated, regulated, and supported midwives and doctors. We need to support the three pillars from the ICM, education, regulation, and association. We need to make sure that midwives have the best education, are appropriately regulated, and are supported in their day-to-day work. We need to keep women at the center of care. It is so easy to keep the institutions at the center of care and provide care according to what's convenient to the institution or what's convenient to us as the providers. We have to flick that around and make sure that women at the center of care. And in many countries, the easiest way to do that is to have midwife-led continuity of care. I've already said about caring for the most vulnerable and the most disadvantaged. We need to work in teams with mutual respect, and that means that midwives need to be recognized for the profession that they are and the professional that they are, but we also need to work with other people in the team. Many women won't need to have anybody else care for them, but some women will, and we need to make sure we've got good consultation and referral networks that we've got to transport networks, that we can get women to the next place that they need if that's required. My last few slides are particularly around the support providers and about supportive bereavement. So I think in the last few decades, we've done good work around helping women and families deal with their loss. We've done research on whether women should see their babies and what they should do. We've done work around the kind of counseling that works and the kind of support. I don't know that we've done such good work around healthcare providers, particularly midwives, and I know that being with women who experience stillbirth is emotionally challenging and that we have our own feelings of distress and sadness, and I think this is particularly evident when stillbirths happen during labor. When women start labor with a live baby and they end labor with a stillbirth, I think that adds a whole layer of complexity for midwives and for healthcare providers. So we need to look after each other. We need to make sure that the care that we provide is the best care we can provide, but then we need to support each other when things don't go as well as we would have liked. So this is an infographic that you can download from the International Society of Stillbirths and from the Lancet series on stillbirths. I think it's a really useful slide. At least it gives the data. So 260 million babies are born each year, half of them before labor and half during labor, gives some numbers about how many women suffer this experience, the fact that it occurs mostly in low and middle income countries, but that we can make a difference. This triple return on investment is another very useful phrase. So we need to count stillbirths around the world, break the taboo around stillbirths, ask policymakers to act and invest on the issue, and that's at every level in our health system and in our governments. I'm just putting up this slide. This is from State of the Worlds Midwifery, and I think it's just useful to remember about the work of midwives because this is the full continuum of care. And the data that we looked at for State of the Worlds Midwifery report and the work that we do around the interventions is where we got the 87%. So that comes from State of the Worlds Midwifery report and also from the Lancet series on midwifery. And then we looked at, so what do you need to get this to happen? And we wanted to make sure that it wasn't just around labor and birth. Labor and birth obviously is critical, but there's a whole lot of work that needs to happen with women beforehand, making sure that women have a healthy start even before they're pregnant, that they plan and are prepared for their pregnancy. And this is particularly important around adolescent women. We know that they have twice the risk of stillbirth, particularly young adolescents. So adolescents are an incredibly important part of care in all of our countries. Making sure we've got good pregnancy care, making sure women are supported to have the best labor and birth they can and that complications are alerted to and managed and then creating the foundation for the future is in the postnatal aspects. And obviously in some countries, the work of midwives goes for much longer than six weeks. In my country, it's six weeks postnatal period, but I was in Indonesia last week and it's to five years in their country. So every country is a little bit different in terms of the scope of practice of the midwife and we need to make sure that all women have access to that care in their context. So this is my final slide and I haven't presented the data on the numbers of midwives in the world, but in the State of the Worlds midwifery report, we looked at 73 of the lowest and middle income countries. Only four of those 73 countries had the midwifery workforce that they needed. So that's an enormous amount of countries who do not have the amount of providers, the amount of midwives, the amount of maternity care providers that they need. The world needs more midwives and I think days like today, the international day of the midwife, I'm waking up to the next day after the international day of the midwife, but days like these are critical to show the world that the work that we do, the work that we could do, the work of the deaths that we could save, the lives that we could make better and essentially we need to work really hard every day around trying to get more midwives. More midwives that are supported, that are educated, that are regulated and that have satisfaction in the work that they do. Every midwife is important and it's been great to talk with you this morning and that's my last slide. Thank you so much Caroline. What a phenomenal way to end our conference. I think we need to give her a huge round of applause everyone. Well done. And our participants have been so amazing. They've actually been answering each other's questions as they go along. So I really only have one question that I've... I was just seeing that, it's so great. Aren't they terrific? So the only one I had was early on and it was about the early teens. So the question was from Rachel Ripley and it was, early teens is news to me. This is due to not accessing care or smoking. Whoops. Have I lost sound? No, oh we lost Caroline. Oh dear. I think that those planets that are aligning have told us something. She's in the participants. All right, there she is back. Thank you very much whoever did that. Caroline, do you have sound? Okay, you can hear me. So we had one question and it was from Rachel Ripley and it was about the risk factors for early teens and stillbirth and she was wondering if it was due to them not accessing care or smoking or what could that be? All right, so we'll wait for Caroline to come back. While we're waiting, I will probably just bump you through to remember I'm going to turn off the recording in a few minutes. Do you have any photos? We've already got the slideshows ready. We're gonna show it to you in just a few minutes, sorry. But if you have any photos and you haven't been able to share them, go ahead and you can pop them in, send them to us at admin at VidM and we can add them to our Facebook page. Our recordings of this session and others we posted on our website, YouTube and the Facebook page as we get time, so we're getting there. Please don't, please remember to download your Certificate of Attendance for your portfolio and don't forget to fill in our online survey all found at the website and the link that Linda is sharing. Caroline, do you have sound yet? Yes, can you hear me now? Yes, yes. So I think we have time for one or two questions, yeah. Okay, so that's a really good question about adolescent girls and women and I think the three issues that you said are all probably true. I think there's a great shame in some young women being pregnant and so they don't access care and they hide. I think the sadness in many countries is that there is early marriage and marriage before an age that we would, well I would think in my Western view of the world is reasonable, so I was in Indonesia last week hearing of young girls being married at 14 and I know that happens in many countries. Those young women are not developed enough to often grow a baby and give birth and so early marriage I think contributes enormously to stillbirth rates and to fistula and to other morbidities that these women suffer. I think in some countries in my country I think smoking is an issue with young people. Young people are still smoking as something that looks cool and so those women are at higher risk obviously and I think just issues of malnutrition and disadvantage. So in some countries having a baby in your teenage years is seen as really normal and I guess there's sort of differences about what the right age is. In many countries 18 is not an unreasonable age and I guess we have to balance it with women who are having babies at an older age and the problems that that or the challenges that that also arises. So it's always a balance I think but I think particularly the young ones so less than 16, less than 15, those women are at significant risk. Thank you so much. And I do want to get to our closing information for people. So let's just give Caroline another round of applause and thank her for being our closing speaker here at the Virtual International Day of the Midwife. Thank you so much and congratulations to the whole team of Virtual International Day of the Midwife. It's been such a pleasure to be involved and I think an enormous resource for midwives around the country and so a very, very big congratulations and thank you for doing this because I know it's not an easy job. Yes, but it's challenging and wonderful. We love it and I don't want to get too far ahead of myself but I have a slide here to finish off the show. I'll leave it on. Could someone turn off the recording please?