 I am very honoured to introduce Fiona Marlowe to you today. Fiona came to midwifery about five years ago after almost 15 years as an occupational therapist. She now combines these two careers, working as a midwife and as an occupational therapist in Australia. In 2010, after discovering the horror of maternal and infant mortality in Timor, at least, she founded a non-governmental organisation, MotoAid, in 2015, working on improving access to healthcare transport in Timor. Her work in Timor is not as a midwife, but training people who use motorbikes to deliver health and community services in Timor. During her journey, she's discovered the complexities of traditional birth attendance rolled within the midwifery care in Timor-les as in many developing countries, respected and needed, yet often banned and denigrated. This has led to trying to discover the understanding of birth through the eyes of the traditional birth attendant. What do they do? What do they know? Are they dangerous or are they an asset? And what can we learn from them? Fiona will offer a space to discuss and explore the history, the current place and the potential place of the traditional birth attendant in approving our understanding of birth in women and potentially reducing maternal mortality for women where there are no roads and no healthcare. Welcome, Fiona. I'm very much looking forward to your presentation. Thank you, Megan. Okay, shall I just start? Yeah, that would be awesome. Yeah, okay. Since the 1970s, safe motherhood has been the focus of the international community in response to the high mortality rates predominantly in the developing world. But a safe birth isn't just an alive baby and a mother. A bad birth, a birth that's traumatic for the mother has a long-term impact on the health and wellbeing of the mother, the child, the family and the whole community. This pivotal moment should be a beautiful time as they make the transition to being a mother and a family. Pregnancy and pregnancy-related deaths have been all but eliminated in developed countries. In Australia, the chance of dying is one in 15,000. But birth has become a medical event that takes place in a hospital. Women don't die but many are traumatised. Women in Timor-Leste who live just a 45-minute flight from Australia have a one in 30 lifetime risk of dying. Women die and are traumatised. Their children, families and communities suffer. For every one woman who dies, another 30 suffer acute or chronic morbidity. I've been searching for a solution to this. Our Western developed loss of knowing and trusting in birth and the Timor problem of dying in birth. There's no one solution. Maternal deaths and trauma are multifaceted and a function of the personal, social, community and political worlds in which women live. But this search has led me to the traditional midwife or traditional birth attendant. And I believe they may be part of the solution. Today I'll discuss why I believe this. Have we thrown the baby out with the bathwater? Is an expression for an avoidable error in which something good's eliminated when trying to get rid of something bad? Or in other words, rejecting the favourable along with the unfavourable. I feel this is applicable to the traditional midwife and in this presentation, I hope to explain why. So from the 1970s until now, a series of policy directives from the World Health Organization has shaped the role of the traditional midwife, now traditional birth attendant. The power of these policy directives in developing countries where governments and health departments, NGOs depend on the World Health Organization support cannot be overstated. In the 1970s, the international response to maternal mortality recognised the value of the traditional midwife. During an international conference on primary healthcare, traditional midwives were recognised as a valuable, available resource within communities, delivering maternal and neonatal care. However, they needed training. For the following 20 years, many government and NGOs developed programs to train traditional midwives in biomedical knowledge. The focus of training was on hygienic practices, hand washing gloves, squad care, recognition of complications that required care in a facility with emergency obstetric care capacity. This was largely abandoned in the late 1990s and the traditional birth attendant and home birth strongly discouraged in favour of birth in a facility with emergency obstetric care and a skilled birth attendant. Uh-oh. Hang on. Amy Jumpern, are you good? How can I help? So it went from slide two to 15. Okay, let me grab it back for a sec and let me see where we can. Okay. Here it's important to understand the definition around the traditional birth attendant. The World Health Organization defines the traditional birth attendant as a person who assists the mother during childbirth and who's initially acquired her skills by delivering babies herself or through apprenticeship to others. A trained traditional birth attendant is one who's received a short course of training, not more than a month. A skilled attendant is someone who's been educated and trained to proficiency in the skills needed to manage normal uncomplicated pregnancies, childbirth and the immediate postnatal period. This labelling and defining of the traditional midwife to traditional birth attendant to trained traditional birth attendant was to distinguish the biomedical from the traditional. Much of the research into the trained traditional birth attendant includes other type of people who attend births, lay health workers, skilled attendants, trained health workers, community birth attendants. This presentation and my research has been into the traditional birth attendant as defined above. This is important because she and the vast majority are female is very different from a lay health worker or a community health worker. They're the women who throughout history have supported women through their life in all areas of women's health, through menstrual health, perinatal care, abortion, obstetric issues. They're often traditional healers, not just the person who attends the birth of the baby. It's to these women that the role of the traditional birth attendant that I'm referring to is directed today. So what changed? A series of policy directors over the 1990s till now has resulted in the traditional birth attendant's current position within maternal health care. They're largely excluded or banned. The impact of this has been tragic in many places and I believe it's based on poor research and limited evidence of the skills and roles of the traditional birth attendant. They were blamed for causing maternal and infant health problems because of the harmful practices they adopted during home births due to traditional and superstitious beliefs that they held onto. They're blamed as incapable of benefiting from training because they're illiterate and they're blamed to jeopardise women's health. Their advice resulted in delaying life-saving interventions and delaying referrals. The language changed from trained to skilled. The traditional birth attendant has become someone dangerous who's to be avoided and in many cases banned. Injust the position to the skilled birth attendant who would work from a Western biomedical understanding and deliver safe medical care in a facility. Over the past 20 years, the focus has been on increasing the number of skilled birth attendants. In the early 1990s, 50% of women had access to a skilled birth attendant. On an individual level and from a medical discourse, lives are saved when women birth in a facility with skilled care and access to emergency obstetric care. And in the ideal world, all women should have access to educated skilled care first. The policy of banning or not recognising the traditional midwife and the restricting of assistance for home deliveries is part of the World Health Organisation strategy to encourage facility birth and birth with a skilled birth attendant. But there's evidence that the training the TBA did improve outcomes where other necessary things were also put into place. This is access to a health facility, access to emergency obstetric care and access to ongoing training and support. Even where there has been an increase in skilled birth attendants, many women continue to choose to birth with additional birth attendants because they provide care from a chosen, trusted, accessible, safe provider. Not because they're too illiterate or uneducated, but it's where they receive the care they need, one-on-one continuity of care across the continuum. Care that we know and struggle to provide in developed countries where care is hospital-based. But due to the policies outlined, the traditional birth attendant isn't recognised by many governments, including in Teymor. The governments put restrictions on ministry employee advice attending assisting with delivering in the home. The trained traditional birth attendants do improve outcome, but due to the ban working with traditional birth attendants is difficult. It goes against health department policies, it goes against World Health Organization policies, and few people are prepared to stick their neck out and support the traditional birth attendant as it risks their relationships with the government and the World Health Organization. This same negative impact is seen in many countries. In order to understand the current, we need to understand the past. From the respected and revered carers of women in ancient societies, the midwife has had a troubled recent history. We're often seen as dangerous. Midwives were traditionally women from their local community, trusted but untrained, chosen by the community, who learned through apprenticeship. The same labels, illiterate, uneducated, untrainable, unhygienic and dangerous, were used to ban midwives in the early 1900s in Australia. But 50% of women today still deliver without a skilled birth attendant. Medical discourse focuses on individual causes of maternal mortality, hemorrhage, preecamcia, sepsis, and abortion are the four main causes worldwide. These do require skilled treatment in a facility with emergency obstetric care. Some of these are real emergencies that cannot be predicted, but with skilled antenatal care and access to diagnostics and medications that are not relevant in most places where women die, many risks can be recognised. There's a lot we still don't understand about labour and birth. In Australia, understanding of culture around birth is biomedical. We've lost our knowing, our inherent knowing, how to birth. Much is still not known or poorly understood or applied, the CTG being one example. And the Friedman curve that led to the pardogram with action lines is another of how bad science has impacted on birthing over the past 70 years or so. It's rubbish. Women don't dilate in a nice smooth curve, yet how we and women measure labour progress. In many developing countries, the traditional birth attendant is not just the only but the chosen care provider, but they practice from a spiritual or traditional understanding, and this has been dismissed as rubbish. Biomedical knowledge hasn't done safe women's lives. Midwifery knowledge and education protects women. When women have no limited access to biomedical care, they die. This is a fact. Women need access to these services. However, they're not and will not be available or accessible to many women, as one doctor in Timo recently said, for 100 years, if ever. But the traditional birth attendant is there. There's one within walking distance of every village in Timo. In places where the traditional birth attendant is included, health outcomes improve. I'm wondering if anyone has heard of or worked within some of the programs in Guatemala or Peru, where for indigenous populations, the traditional birth attendant has been re-included with amazing outcomes in access to antinatal care and safe deliveries. 50% of the figure bandied around, but this is highly country and within country bearable. The numbers as high as 80 to 90% in some areas, and the most vulnerable women are the poor who can't pay the indigenous who are discriminated against, the rural with limited or not access and the illiterate who are also discriminated against. In some places where the TBA is acknowledged, there are some places where they're included, but where they're banned and excluded, such as in Timo, that I'm saying things must change. Maternal deaths and trauma are multifaceted and a function of the personal social community and political worlds in which women live. The solution's multifaceted. The social determinants of health hugely impact on the health outcomes for all people, but particularly for women in both developed and developing countries. The social, political, structural interventions needed for safe birthing are not available for the majority of women in Timo, not just during pregnancy, but across the lifespan. Given this from a midwifery point of view, what constitutes a safe birth? I'd like us to think about how safe we are. Are we providing safe birth? Where I work, less than 50% of women have a normal vaginal birth. 27% suffer a PPH. 5% severe trauma. 30% have a caesarean, of which almost 20% are emergency caesareans. They're all alive, but did they have a good birth? What isn't happening to meet women's needs and support safe birth? Within Australia, birth is both culturally and physically a medical phenomenon. It's not normal anymore to just have a baby. It's fear. Fear and birth don't work well together. We know this. The traditional birth attendant provides one-on-one continuity of care from a trusted care provider. They provide culturally respectful care. They provide care that retains inherent belief in the normalcy of birth as part of a woman's life. The essence of normal birth practice. They may not be skilled and by a medical sense, but they're skilled in providing care that many women want and many choose. Due to the policies over the past 30 years, the traditional birth attendant doesn't have access to the benefit of the ongoing education, training and support they need to provide safer care. Have we thrown the baby out with the bathwater? We know untrained midwives can be dangerous no matter where they are and we all need ongoing training, education, as new knowledge is learned. We know 50% of women can't access skilled care. We know many have access to a traditional birth attendant. We know how to provide safer care through education. So why are we not working with traditional birth attendants and supporting them with training and education? We know that women choose to receive their care from the traditional birth attendant. Women here choose one-on-one care if it's available, but it's usually not. The traditional birth attendant provides care that has an inherent trust in the normalcy of birth. These are the things we know maybe women to birth safely and maybe we can relearn some of these things from them. The traditional birth attendant has been seen as a curse, a danger to women who rely on them. But what do we actually know about the practice of the traditional birth attendant? I couldn't find a lot in the literature. There's vague information in anthropological literature about the calling of spirits and rituals, but not when they do this. In the medical and midwifery literature, there's a few articles when the traditional birth attendant has been asked about her practice. But the majority of the literature is from women reporting what the traditional birth attendant does. But women don't necessarily understand what we as midwives do. This is another real weakness in the literature. A my midwifery educator had a case of umbilical cord prolex. She turned the woman over on her knees and shoved her hand up in her vagina, called a code, raced down to theater with a hand inside the woman's vagina. Later when being debriefed, the woman told her she thought her hand had got stuck inside her so they had to go to theater to get it out. Practices that are dangerous is the use of fundal pressure late in the second stage. I still understand this from their point of view. They're trying to push the baby out. We pull the baby out with vacuums and forceps. Both are dangerous, but if the labor is obstructed, is obstructed, what else do you do? Traditional birth attendants use massage to position the baby, but when and how isn't well explained? We don't know how the traditional birth attendants are positioning the baby or if it's safe. They use herbs that are unknown to us. They use herbs to control bleeding, to augment labor, induce labor, to induce abortion, some of which have been studied and found to be both effective and safe. And here there may be alternatives to the crude oxytocin that we have. They use herbs to help the perineum to stretch, which facilitates normal labor and birth. Are they here recognising when a pregnancy is gone post-dates, where we use balloons and prostin? In teamwork tradition, it's a tradition to keep mothers near a burning fire after labor. Throughout many rural parts of Southeast Asia, it's believed that heat expels bad blood and wards off disease. This is labelled dangerous and it can cause burns and dehydration, but could it have a biological explanation? We now know that our body creates heat to fight bacteria. We get a fever. Is this prophylaxis in a world where there's no antibiotics? One study in Kenya reported a dangerous practice of putting a cooking stick or beads down the woman's throat to manage to retain placenta. I thought about this and I wondered if this was to force the woman to wretch, so increase intra-idominal pressure to try to expel the placenta. Where you get women to cough. That's all I could find out about the practice of the traditional birth attendant in the literature. So how does the traditional birth attendant become a traditional birth attendant? How do they acquire their knowledge and how are they trained? There are two major pathways to becoming a traditional birth attendant. For most, it's a family tradition. The practice handed down within the family through an apprenticeship model starting from young age. Girls learn with referee skills from childhood within their homes by quietly listening to stories of difficult birds running errands and helping their mothers or grandmothers in fetching supplies and assisting in birds. It's the duty of the practicing traditional midwife to ensure the successor gains the knowledge about the profession in order to sustain the reputation of the family. This is the same as was the case in European countries almost up until the 20th century. The learning pattern involves both observation and imitation. In contrast to the didactic, instructive style of education of professional midwives, which is more common in Western biomedical systems. Women are often selected as traditional birth attendants by the community because of the characteristics that members of the local community perceive to be required for assisting women. A record of good delivery outcomes, a strong personality, warmth and patience. Through experiential learning, traditional birth attendants acquire knowledge of traditional herbs and local materials that manage menstrual and conception problems, abortion ease the complications of pregnancy in the pains of childbirth and help the woman in recovering. Some traditional birth dependants don't inherit their craft, but they acquire it from the spirits. They're chosen by the spirit and gifted the knowledge of treating a range of conditions, including maternal complications. The traditional healer is thought to come a channel through which the spirit works, but because of the mode of acquisition of the knowledge, it cannot be shared or passed on to descendants. In Timo, there's only a couple of people who are helping the traditional birth attendants. This is how one Australian doctor describes the traditional birth attendants. They're the unsung heroes of Timo. They have simply amazing dedication. The traditional birth attendants in Timo integral to the lives of women in the maternity care they receive. The midwives and doctors who work with them, believe in them. The argument that they're dangerous and can't be trained is refuted by these people. There's evidence of safe practice when the traditional birth attendants have access to knowledge. They learn and change their practice, including prevention of infection, identifying deviations from normal. They're willing to refer women to hospital and they appropriately use both traditional and Western medicines. They're accessible and this is a huge problem in Timo as it is in many countries. There's at least one traditional birth attendant within walking distance of every village in the remote areas where there's no road or access to transport. I was in an NGO clinic a few years ago talking about motorbike training and one of the midwives came in. She'd had a call from the traditional birth attendant. The night before, she'd had to run six kilometers up the mountain because there was no transport. I couldn't work out if it was broken or had no fuel, the two most common problems. So the midwife ran, but the mother died before she got there. On a motorbike, six kilometers would take a few minutes and maybe that mother wouldn't have died. One of the major criticisms of the traditional birth attendant since the 1990s is failure to refer or late referral to hospitals. This is also true in Timo. However, in a small number of midwives who do receive training and doctors say they do, given the training and knowledge of identification of complications, they do refer. They said traditional midwives who have support and have received training do refer and transfer women to facilities. Ours do all the time. We teach them how to pick up risk and when to refer and transfer out. This is confirmed by the few studies I found in the literature. Other problems identified in Timo are similar to those that are found in the literature, difficultly managing third stage, but they don't have access to oxytocin. Myzoprostyl could be a huge benefit, but it isn't used. This is similar in other countries where due to religious beliefs, it's fear that we use for overabortion. And this overrides its benefit as an oxytocic that doesn't need cold chain storage or injectable delivery methods. They miss twins, but they don't have access to ultrasound, or often they don't have access to dopplers. They don't have any neonatal resus equipment, and they often don't know the estimated delivery date so women go very post-dates. We counter all these issues with training and education and monitoring. We all need monitoring, training and education. It's fundamental for all of us. In remote areas of Timo, there's no access or limited access to health facilities or skilled personnel to birth. Here, universal access is an unreasonable expectation. The priority here has to be stop women dying, but how? This is the information I have from an Australian midwife who's worked extensively in Timo training traditional birth attendants. Train the traditional birth attendants that have chosen by the community. Ideally train them in the community. It's very hard for them to leave for a few days or the few months they need to receive adequate training. Training them by understanding their way of knowing. You can't just dump biomedical knowledge on basically illiterate and enumerate traditional birth attendants and expect it to be taken on board. On my first trip to Timo, we were out in a village looking at the impact of weaving on women's health. There, the women had a front bottom and a back bottom. Knowledge of anatomy and physiology within the remote communities who barely get any education is non-existent. This can't be taught in a few days or even a few months. I've had seven years of university education and I don't understand all the physiology. This is the second serious issue with the research and the literature into the traditional birth attendant, the so-called training that fails. As Sarah Moulton who's the midwife who's done a lot of work over there explained, the method of training health workers, trained health workers in Timo, the teachings by road, it's didactic and there's limited practical education even within the current university trained midwives. They don't understand the reasons behind the practice. They can recite what they taught back but can't necessarily apply the knowledge in practice. So let's not repeat the mistakes of the past. When you're working with two different ways of understanding the world, it's crucial you recognise this and work with it, not against it. The trained traditional birth attendant is ideally placed to be the link between the Western medical and local knowledge, both of which are equally important in a good birth. In a limited number of places where indigenous health inequities are being tackled, traditional birthing practices have been included with very good outcomes. In Australia for Aboriginal women and in Peru and Guatemala, the traditional birth attendant has been incorporated into the health service, cares provided in the local language. They can practice their traditional remedies, food, drinks, birthing positions and both they and the family of the women are accepted as an integral to the care. The facility staff accept the presence of knowledge and important role of traditional midwives and they work alongside them. Spiritual religious cultural beliefs are important to maintaining a safe birth culture. These beliefs are many and varied but strongly influenced ways of understanding the world and reacting to it. We accept some of these and dismiss others, particularly those based on animism. Animism is an ancient religion, very prominent in this part of the world. It's the belief that spiritual forces often the souls of one's own dead kin intervene for better or worse in the land of the living. Spirits are in all natural objects, rivers, trees, animals. Ancestors can be the link between the spirits and the living and these spirits can be maligned or benevolent. Timore's traditions are thousands of years old and relations to the land are the substance of life but they're not static. Traditions in Timor involve continual adaptation and reinterpretation, which allows the Timore's to both resist and assimilate new ways of being and knowing. Having an understanding and respect for what's valuable in local traditions and a willingness to acknowledge their value is fundamental when creating new understandings and ways of acting. This is where our understanding of the traditional birth attendant is missing. We only understand her from a medical discourse which I don't feel tells us everything we need to know to be able to work with her. When a traditional midwife recognises a complication in the birthing woman's pregnancy and labour, she typically calls on the spirits, ritual blessings and herbal medicines to remedy the adversity. These responses inherent in traditional midwifery are dismissed as dangerous superstitious, irrational or irrelevant and the product of no education. However, ritual or spiritual processes are clearly connected to the midwife's understanding of what constitutes normal birthing processes and what deviates from the norm. Current maternity care is organised in developed countries around identifying normal. So risks or complications are recognised early. For the majority of women, maternity care requires little or no intervention. However, assessments required throughout the entirety of the maternity period to determine everything is progressing normally. The necessity of maternity care is in the recognition of something being not normal. So intervention and care can be provided to ensure the health of the mother and the baby. The traditional birth attendant acts when she recognises abnormal. What the TBA does, she calls on the spirits or uses hermal remedies. We know but dismiss because we don't understand it. In doing this, I believe we fail to recognise the full extent of their knowing. What is going on when the traditional birth attendant calls on the spirits? Are the points of intervention in maternity care the same for traditional birth attendants as us as midwives? Where are the points of intervention different? What assessment skills do traditional birth attendants use to determine what they do? In traditional birth attendants, understanding of maternity care and the biomedical framework be reconciled, can these two systems of knowledge and practice co-exist and be productively interwoven rather than biomedical model dismissing the other? Is there knowledge that the traditional birth attendant have that could inform research into maternity care that would advance understanding and practice globally? Only by working together with the traditional birth attendant can we know this and I mean closely. What I feel we need to do is to go with the traditional birth attendants to their antenatal care, to their births and when they're providing postpartum care. When the traditional birth attendant performs a ritual or provides a herbal drink, what's happening for the woman? As a midwife, would we recognize points of care where we would also act? We'd explain it in biomedical frame of knowing. The traditional birth attendant understands it from a spiritual way of knowing. I feel these two things will likely intersect and hear the shared understanding will take place. Why is this so important? Because you can't know what you don't know and you can't learn if you don't have a context to put it in. Here the context will be created and the learning can occur. On this slide, I've just put a whole lot of things about the things that we need to know and that we feel are important in the antenatal care, interpartum care and postpartum care that we know are important in recognizing possible complications so that we can deliver the women and provide the care they need, somewhere where it's safe to do so. But we have access to blood tests, to Dopplers, to ultrasounds and CTGs. If we didn't have any of this equipment, how would we know? I can't do this. I stumbled across an amazing book that I'd highly recommend to everyone. It's called Maternal Death and Pregnancy-Related Morbidity among Indigenous women of Mexico and Central America. One chapter is on the importance of communication. Understanding is not just in knowing the words. Words have multiple meanings in contexts that take years for a learner of language to understand and the language is integral to understanding the culture and beliefs. I don't speak much Tetum nor will I ever live there for long enough to know it. One thing I've also definitely learnt from my work in Teymol is the last thing women need is white women coming and doing it for them. They need and really appreciate us sharing our knowledge. But the knowledge I'm seeking here is a deep understanding of culture and language is fundamental. Australian women are predominantly supported by a Western biomedical model of childbirth that's scientific and evidence-based. While this has led to considerable improvement in maternal mortality, we've lost the culture of belief in the normalcy of birth. Birth takes place under medical supervision in a hospital. Birth is often traumatic and difficult. Women's perception of their birth impacts on their belief in themselves and how they become parents. Birth position is just one thing that's strongly held by many cultures. Women in Australia expect birth to birth in a bed in the thought of me position. But the lobothotomy position is not the safest or best position to birth in. The main reason is cultural conditioning. Nearly every image of birth in the media involves laying down or semi-sitting positions. So we need to recognise the contribution culture makes in shaping women's behaviour and choices through the perinatal continuum. I propose all women deserve a better cultural understanding of birth and that we may learn this from the traditional birth attendant. But how do we do this? This is where I need your help from why I submitted to speak here. As an international community of midwives, I hope we can work together to better understand the traditional birth ascendant and ourselves. I want real research into the practice and knowing of the traditional birth attendant. I'm not an academic, but I'll find someone to lead this if I can engage your support. I'm calling out today to midwives in countries where the traditional birth attendant is an integral part of women's health care, where midwives know the culture and the local language. I'm asking, can we collaborate and find a way to work with and alongside the traditional birth attendant to learn from them and share knowledge with them. To walk in their shoes and listen and learn and share. There's many challenges to this. First, I need you to agree to help me with this and to see and believe in its importance. Also though, where the traditional birth attendant is banned or discouraged by the World Health Organization, Government Health Departments, it can be very difficult for midwives to engage with them. This is the case in Timor, but a few dedicated people who want to save women's lives are doing it, so so can we. Another problem is overcoming the power differential. For this to work, we must have trusting equal relationships, which can be difficult when you are known to be educated, but without these practices might be disclosed. And there's often secrecy around disclosure of traditional practices and disclosing can harm the spirits. But if we're not asking them to tell us their chant or their ritual, but just observing when it happens, then this can be overcome. If we do this, I believe we can make a real difference. So, the traditional birth attendant like the midwife has had a troubled past and present, which shapes our role in society and the culture within which birth now takes place. This is true for both the midwife and the traditional birth attendant. For many women, the traditional birth attendant is the only resource they have to keep them safe. With the right support and right sharing of knowledge, the traditional birth attendant can be a resource, but the 50% of women who did not have access to a skilled birth attendant. For this to work, we need to better understand the practice of the traditional birth attendant from her understanding and recognize her skills within her practice. From this, we can both learn a shared understanding where two ways of knowing work together to bring about real change in the maternity care of women all over the world. If as a community of international midwives, we can work together, I think we can do this. Thank you for your time today. Megan and Connie have my contact details to share with anyone who wants to get involved with this. Thank you. Fiona, thank you so much. That was an amazing presentation. I think that was excellent. No, there's been lots of communication in the chat box about, as you were going through making comments, we do have time for a couple of quick questions. I wanted to highlight something that stood out for me. You talked about it at the very beginning, the similarities between midwives in Australia and some of the things that were said originally, so I think around the turn of the century, about midwives and how similar that was about what's being said now in traditional birth attendance. And then when you were talking about the fact that with traditional birth attendance, one of the critics that's happening is the failure to refer or transfer care and that resonated with me in the experience in America right now where that's often a critique that's happening with midwives. So I loved hearing that and those things are kind of some of the things that just stood out for me, but was wondering if anybody had any questions. If you'd like to unmute, please put your hand up and I will hopefully catch you and unmute or you can just type it in the chat box. Oh, and I wanted to apologize for my incorrect pronunciation of T more earlier. Please accept my apologies for that. Not many people know about T more. It's a tiny, tiny country. I've never heard of it. It's T more. So I wasn't aware of it. It's less say, is that right? T more less say. Less say, T more less say, awesome. Thank you. Less say, yeah. Yeah. Wonderful, so any questions from anybody? There's one there from Sarah. How does one get involved with work like this? Well, as far as I know, no one's doing it. So if you want to come and help with me, I would love. This is why I'm presenting this because I haven't seen anywhere where anyone has actually worked alongside traditional midwives to see what they do. They've asked them questions sometimes and they've asked women who get their care from traditional midwives. But if you ask a question of a traditional midwife about a biological happening, then you're not gonna, something's missing. So this is why I feel this needs to be done. Thank you. So Lynn's asked a few times, is there any research that's been done yet on this? Anything published as of now? I haven't been able to find anything. Okay, Connie, do you want to unmute? Yes, thanks very much, Rihanna, great presentation. And you mentioned three countries, Australia, Peru and Guatemala, that have already integrated TBAs in the healthcare system. Can you say maybe what was sort of the key sort of reason why they went against the recommendation of the World Health Organization and did sort of go back and well, for lack of a better word, used TBAs? So the in central, Mexico and Central America, there's not been Peru as well. There's a huge disparity between the care that indigenous women receive and the care that everyone else receives and the outcomes are very, very different for indigenous women. Now, the same is here in Australia, the care that Aboriginal women receive. So they're using the traditional birth attendance because they've recognized for indigenous women that this is really important to their life and to how they understand birth and to how they birth. But they're saying that's only for indigenous women. But this is why I feel this is the same for all women and especially women in all developed countries. You know, the traditional birth attendant is sort of integral to their lives but I've only seen their practice sort of included where it's been in relation to a specific indigenous population. Yeah. Did that answer the question? Yes, it does. And because there was also in the chat a question on research, I would be, or I'm curious, have there any research available? Have they done any research that, you know, you or we can build on? Yeah, well, I contacted the program in Guatemala. I meant to have it in front of me. The program in Guatemala was supported by, I think it's an organisation now, let me just pull it up. I think it was supported by, was in, I know this is the one in Peru. The one in Peru is supported by an international non-governmental organisation called Health Unlimited. And they've got research from 1999 till now. And I did email them and I got a message back but it's in Spanish and someone translated for me saying that they got my email and they'd get back to me but they haven't gotten back to me. So, because I wanted to get in touch with them and say, well, you know, how did you make this work? Well, you know, I think that there'd be a fantastic resource to work out, you know, what did they do and how did they get this to work? And I know there's a program in Guatemala and there's a program in like Southern New South Wales in Australia where they're with the Aboriginal women. But they're the only three that I've really been able to find out about, at least there's a star. Yeah, there's a star. Yeah, maybe you can, or Megan, maybe we can make that information available. Yes, and Lorraine is also saying that there was a presentation on the topic a few years ago in the archives and I'm sure we can throw something up on the, on the VIDM webpage as well, if we can get that information from you Fiona, we can throw that up there as well. I am sorry to say we have come to the end of the time that we have for this slot right now. Just wanted to throw up Fiona's thank you slide that's there, Fiona, I don't know if you wanted to say anything about it really quickly. Yeah, thank you to the people in Timor. Now a big problem, and I didn't really mention this, the people in Timor, I can't really say a lot about who they are, because it really, it's dangerous to, well it's not dangerous, it can impact on their work if I share their names, especially the Timor is with wives, they really get into trouble when they do this sort of thing. But they know who they are and I thank them. And my lovely children, especially Hannah, the art in, I thought a lot of the art in this was from one of my daughters who does beautiful art. And so I've used her art and I thank you for that. But I thank all of them for putting up with me and supporting me while I'm doing this. Thank you. We enjoyed it so much, so we thank them as well. Fiona, are you still okay with people downloading your slides? Your slides? Absolutely, and- Okay, so at the bottom of the screen on the left-hand side of the bottom of the slides thing, you see a little arrow that's kind of pointing to a flat line. If you click on that, you can download the slides. So if you're interested in downloading them, you can grab them from there right now. And I don't know why these slides here are blank, but I wanted to thank you all for- Oh, these are all of the references that Fiona used. And I had a look at them prior to the presentation. So much research was done in this presentation. So Fiona, thank you for all your work for this. And I wanted to thank everybody for attending today.