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to, ah, panel discussion now, which you're going to take on some of these very specific issues that we're gonna talk specifically about postpartum hemorrhage at the time of cesarean section on about sepsis and about how we can improve a newborn outcome. So we now have a panel discussion Up until 11 o'clock, I'll ask those. I think David is here on any years here on any pick. So yeah, you're going to come and join us up the upper, the front here for the, uh, presentations and panel discussions. So we I think, also have two people online on, uh who are Fernando al far Be? Who's joining us? I hope. Somewhere, no. Sorry is I hate to think what time it is in our sorry's on also van and oh, What time have you got there? Six. Okay, I'm not so bad. Not so bad. It'll on then. Also, Linda and Yon don't. Pando, are you here? Are you here with us? My hope is joining us from blank tire in a way. Okay, well, we'll be joining us in in a minute. Okay? So what we're going to do with the format of of this session is that we can have three presentations on post partum hemorrhage, then on sepsis and then on newborn outcome. And then we'll have a chance to discuss all those various issues on have a bit of a panel discussion, and I hope very much that Fernando and Linda will also join us. In fact, I think Linda was originally going to give the presentation, but I was hoping to be with us here today, but I wasn't able to come, So David's going to give it on her behalf. But I hope you'll stay David on be part of the discussion as well. So first off I want to introduce Fernando. Health are be who many of you will know. He's a consultant of the maternal and perinatal health unit at HRP at sexual reproductive health. Wh Okay, Um, he originally trained as an obstetrician and work for 15 years as that, but his his particular expertise is in the design and conduct of multi center multinational randomized trials in implementation research. So he's done. Many of you will know his name from the Big Cluster and, um, I've trials that he's done trials to reduce unnecessary cesarean sections trials to increase active management of labor and reduce a PCR to me interventions for brief counseling for tobacco cessation increasing the amount of antenatal steroids on to improve syphilis screening and treatment during antenatal care. So he's currently leading the W H O technical consultation on P. PH within the emotive project based here in Birmingham on Do also the Red Trial, which is refractory hemorrhage devices trial, which is just about to start in Vietnam. So Fernando's going to talk to us. First of all, about BPH as a complication Financial. Can you can you hear us? Fantastic. The stage is all yours or the video screen anyway, that but yes, yes, yes. Uh huh. Okay. Okay. Yes, it's I'm sorry. It's working very nicely. Yep. Okay. In, uh, what you mentioned station. Uh, first of all. Yeah. Is, you know, yeah. Most nights. Crazy place over used. Is that how it is? Well, the studies say see, seen. Well, which still have the first response still for Oh, that is that way. Yeah. Yeah. The scene. Yes. BPH. He says they when This stage first five. I say all these so And what? Bph. Yeah, first. And he's a Z. You see my visitation? I have a smooth approach. First for way, but the and so what way, Way, Way? Yeah, The right is what way you see, who's say fine. Say they did a a base was Any case is here. Mangler. Waas eyes use. Uh What do you mean, This guy? Well, a year and say complicated. Is she? But these old no see, that's the That's who. Yeah, I know. Okay. What? I'm actually you? Yes, those combinational loss question, My sis cancers combined way. And he wants me. She is no way seen, um And the same time use she say is No. He said is all fast for each thanks. So and instead sees that guy's suppose one. Yes. And see. And you get you on one. Use a lost Just Wait. Yeah. Where? This way. Oh, yes, Fernando on. We've got two other speakers still to fit in before 11. Whatever time it is before seven. Your time. Would you just be able to wrap up? Yeah. Fantastic. Thank you. I bought one. So the main saying way from from this is she? Yes, she is. And you've lost weight. What? So Thank you so much fun. And that's fascinating. Interesting. Look at the different guidelines. I want to ask questions, but we ought to leave them for the for the panel. Are you able to stay on you able to stay connected? Fantastic. Thank you very much. Okay, So next we're gonna have David this hour. Who's going to go talk to us about sepsis? Eso is professor of global maternal fetal health at University Liverpool. He's really resident in Malawi, working at the Malawi Livable Welcome Trust. A research institute is a sub specialist in fetal maternal medicine, and practice is clinically it QE hospital in Blantyre. So his research seeks to improve the care of women during pregnancy and childbirth and low income countries, including clinical trials, evidence, synthesis, implantation research and policy making, were specific interest in prevention of management of maternal infection. Which is why he's so appropriate to come and talk to us today. That back in his home, I think, really is Birmingham where had done so much work. David, thank you so much for being with us. Hi. Thanks very much and so lovely to be here amongst, you know, friends and colleagues to be back in the UK and Birmingham is really lovely. I'm here representing the maternal health group, that Malaga Liverpool Research program, but in particular Lyndon, the on them A panda who was meant to be the one here. But her visa hasn't come through. So uh, yes, I'll try to do her just this. Um And I think there's a team of people back in in Malawi watching So hello to one of you in the office is so we're, you know, all absolutely committed to making birth a positive and safe experience. And, you know, it's great to be able to be talking about the problem of infection after Cesarean section. As you know, it really is so critical and something we see on the ground with such a n'importe challenge. So if we can just think first about the mother and her family, what we see is on label ward on the HD you a Queen Elizabeth, that other similar hospitals every day mothers' suffering the consequences of infection after their cesarean, you know there's mother's there. They wish that they could have somehow avoided that. All the problems with increased pain, prolonged hospital stay, extra expense a deep, aping, slow to heal wound infection challenges with feeding with bonding on Balto often unfortunately, see this progressing to need for hysterectomy and death. And this is a picture we really sick and the health care workers, you know, we wish we could have done more to protect this Mother got her into theater so that she wasn't waiting so long, so the head wasn't impacted deeply. So the port, in turn, didn't face a difficult delivery with extensions leading to using. They didn't have the kitchen theater to deal with it. Hematoma and mommy, triceps, hysterectomy and death. And, you know, the manages to they're the ones responsible for for the facilities and they wish that they could provide, you know, safe on be appropriate theaters, ward environments so we could deliver safe and clean care and that they had those management structures in place. That meant we could monitor on respond to hospital acquired infections. But you know, that's just within the facility. Beyond that, you know, there's a complex sort of web of problems in constraint within which we were so just the high life in a few, you know, commodities. A massive challenge not only for cesarean but for us providing, you know, prevention and treatment For women with infections, access a local level to the right antibiotics for prophylaxis and for treatment is an increasing challenge. Seeing that the drugs we have available on no longer suitable for the organisms in the wrist distance profiles that we're facing in that you know, both prophylaxis 1st and 2nd line treatments becoming increasingly ineffective. And then for the for the mothers and wider society, as we've heard already mentioned, how do we, um, prioritize these health needs of these women within society and bring the BRECCA mission required so that we can change And then just to think of us is research is you know, are we asking the right questions here? Are we doing the right thing to tackle this problem? How we working with policymakers in government, providing the right data and tools and sustainable solution so that we can really improve care for the women with this problem? So I guess this in data and the problem itself with fortunately wh oh, not so long ago completed the cross study and more than 52 countries trying to get a handle on this under researched area off maternal infections. And if you look carefully, you find that in fact, around half of all maternal deaths are in fact infection related, even though that may be not be the prime reports. And if you see the top cause of infection, endometrial tissue know tract infections wound infections. It's not surprising that Cesarean section is an enormous risk factor. And of women in glass who developed an infection, you know twice the number who developed an infection or had a really severe outcome. I can near miss or a maternal death around twice a twice a smelly had had a cesarean section 60% as it had a vaginal birth. So, you know, it says they're in section just incredibly important risk factor. What about our experience in Malawi? You know, just a toe highlight some of the team busy working on this, Yeah, me, Jenny and Condi. Um, over the last two years, we've been developing a national surveillance platform to try to collect information from all maternal deaths and near miss events at government hospitals throughout the country. And it's it's starting to now give us useful insights into what's happening nationwide. in Malawi on what we see is that around 20% of maternal deaths in the last two years were due to infection. That's directly due to infections and probably is a significant under counting. But I think really relevant is around. Third of all of those deaths were proceeded by cesarean section and involve a cesarean section deaths. In fact, that latest numbers that Jenny Kind gave me yesterday 17% would directly due to a infection on Greeley are death classification means we can't understand in greater complex Keelan that how many then they're not directly due to infection were, of course, due to pee pee. A short or ruptured uterus is the primary cause infection. Played it a really important part. And, um is also, you know, doing work alongside this to try to understand that complexity on what the journey's of these women who have serious infections really looked like in that there experiences. So what to do, uh, wh show of increasing identified maternal sepsis is such a critical problem and tell us that we need to be practicing clean care, preventing infections, diagnosing it early and treating it properly. And that's of course, that management cross the pathway of infections is the right way to go. The highlight, I think, some important work and useful tools that we can all used to do this here. A lot of work by Catherine Dunlop on Leo in LA We trying to think how we combat to prevent infections in the maternity setting, working with the WH show to develop materials around hand hygiene specific for maternity settings. I think great improvement on what was there before and to highlight the W H O open free for all course that's available that could be used at sites on also some of the super other materials, like wash it. That really great for facilities to use. That's his area in sections. Specifically, there's a range of evidence based guidance. We know, you know, keep actions. We should be doing it cesarean section such as vaginal cleansing preoperatively such a correct use of antibiotic prophylaxis that there have been new updated guidance recently from the WH shape a big gap in between this guidance and implementation on the ground, particularly some of those those practices that, whenever we have audited and look carefully, are rarely performed. A rift performed not done optimally and then beyond the prevention, moving onto sepsis management from, you know, studies and systematic reviews in high resource settings. We know that early treatment or women who have deteriorated, or anyone with infection that deteriorated to suspected sepsis reduces mortality. And we've been really pushing hard to develop and then implement a maternal sepsis bundle. So a bundle of care developed for women in particular in law, resource settings and Lower and James Cheshire, who mug shot should also be there alongside lowers have done a lot of work in Malawi on that developing the bundle, implementing it and seeing that at least across multiple sites, this improves the process of care on women who need them. Get the antibiotics on other parts of the bundle sooner. So where to go from here and the future, working alongside Mercedes Bone and others from the wh. So we're really trying to bring all of this together to see that if we can develop an implement a complex intervention that tries to tackle a lot of different levels of the problem, improving hand hygiene, better preventing infections, uh, treating those infections appropriately, detecting women who deteriorate on baking sure they get right care with a sepsis bonbon. That's the active prevention of treatment of maternal sepsis. So that out sepsis trial so just very briefly, This is a multi country class cluster randomized trial in Malawi and Uganda, across 60 sites which were all district hospital size sites able to deliver. See Monk And this is a pair of cluster designed with baseline phase on. But as I've mentioned the intervention, the exception program really trying to combat these key goals of improved hand hiding practices, adherence to guidance around infection, prevention of management and then better sepsis management and this takes a behavioral change perspectives working with healthcare providers with carefully design a program of work to try to help improve our behaviors towards these three key goals and the outcomes were hoping to see our reduction in maternal mortality into their morbidity due to infection on alongside that a really detail process of violation, to understand how this implement in practice and to see if it's cost effective. So yeah, that's just what I wanted to mention it into. So thanks again to the team in Malawi on also say thanks to the mothers and healthcare workers who consented to having their image is used in the presentation. Thanks very much thought Thanks for overstated. That's great. And I'm not going to call on any picks. A cruise. She's a circle memory welcome fellow at the infectious Disease Epidemiology at London School of Hygiene and Tropical Medicine. Their research focuses on the use of electronic health data in middle income countries, especially an infectious disease and maternal child health. So she works, particularly in collaboration with partners and see Dax Feel Cruise. And she uses big data approaches to investigate the effect of obstetrics and prenatal conditions, congenital infections and social policy on the outcomes, especially using a big Brazilian birth cohort. Is that right? So any Thank you so much for coming to talk to us. And we're going to talk to us in fact, about neonatal outcomes related to this. So thank you. Thank you very much for having year. So it's my first time since covitz. Oh, it's a pleasure to be here. You person, um, any end my research focus on the use of a little cabin data that you see upstairs to care and also a pronated condition in continual infection all my hair. Knowing you need a box comes on. Today we are going to get a little big of a urinate. Out comes associate. It gets very in section. But first, I think it's really important to discuss about Cesarean Section rates and these papers permission to have 21 showed another oral cesarean section rates off to 1 to 1%. But there is a huge discourage and, uh, the lowest rate are seen subsidiary in Africa, and they hired 21 in Latin America, and national rates converted from 58% to 1.4. And there is another paper work, she 2018. That's a hunt from 160 90 countries. They found that 63% head as a serum rates higher than 15% whereas trying to 8% head size are in section rates lower than 10%. And even with being the same country, we can see a lot of disparity. In Brazil, for example, women leave in Sipowicz with higher rates. Offices are such up with high human development index. They were more likely to have a cesarean section rate than women leaving in response with low human development index, and it's really a common for us to see when discussed. Those are a section to see, like the terms you a little too late when limited access, but also that there are two miniature soon when we see no medical indicated cesarean section. So we are going to discuss a little bit today about the burning outcomes associated with these two contacts. And we can see these, uh, graph here on we can see that cesarean section Lee that rates below the 10% it's associated with, Ah, high new NATO mortality. And I'm not going to discuss optimal rates. But we it's really clear that, uh, went this is our section great, sir. Really low. We can see. Like how I knew me a new needle deaths. And I'm not approve of evidence. It's that this's a facility based. It's 30. And they saw that stillbirth a break that cetera section way to work higher amongst your birth. Uh, then, um um, the life births. And when they arrested gated the, uh, the calls off stillbirths, they observed that not only delayed on management, but also unnecessary ass is our sexual performance. Who, when the baby did. The Beatles didn't have, like, heart to beat anymore. And there is another study published in 2009 that find evidence that tornado outcomes and that's were associated with later fullness off cesarean section rings off for the infection. And then we go to studies performance in low in high income countries, and we can see these ones that I waas done in Scotland. And they investigate a virus on, you know, not only knew later, actually, offspring outcomes, and they saw that for mortality up to one year, there was no difference between those that head are planets is our insection and those that had a vaginal delivery. And they also had similar results when they they analyzed those with a repeat it says are in section and like comparing with those that head of that, not the But then we have some evidence from what's in America, and these is that it's building interesting because they start fired babies with a cephalic presentation and those with a breach presentation and the stable. They didn't include the babies that have, like the mom mom's that had a cesarean section because off of distress and even, uh, remain sample. They saw that babies that had, like an elect, elective cesarean section and even interparty cesarean section they were. They say it's longer you. And also they saw higher rates off new NATO. More Dalit among those that had a cesarean on the electricity is our instruction compared with vaginal delivery. Although the the association between interparty says or a section in vaginal believer that you didn't see, um uh that she's got significant difference anymore. And they're not the interesting find for these studies that among breach presentation, baby, they saw a lower mortality rate. But it was not See if that satisfies significant and then thinking about this, we decided to perform. I start in Brazil. Brazil is they come with this 2nd, 2nd highest rates off. So there are a section would while and we had data from 2011 to 2018 and we used it The robin, some constipation. So, uh, as a proxy off indication for us is our in section and then we analyze that the mortality and we analyze it phone like birth up to five years, and we also group it the Robertson Classification two. We want you for like those that we expect. A low says our sexual right, uh, 6 to 10 and left the group number five by itself. Okay, And we come up with this nice girl on working rob some group another 1 to 4 that it's the group with a low expected. So they're in section right after we control it for confounding. We saw that cesarean section weight was associated with a higher mortality, even up to five years. And when we saw, like, we leave it the group number $5 with the Prevacid very scarred by itself. And we didn't see a difference between those like born vaginally. All those medicines are in section and the group 6 to 10. We observe it a lower rate off offspring that I thought those that head like a cesarean section comparing with a you know, and we continue to investigate some figures from Brazil, and he's a study. We also start if I'd buy Robinson Group and we try to see if Cesar a second says on a sectional waas associated with increased risk off early terms. So those babies with more than 37 weeks, but like in four weeks, and we found on association in an increased risk of a little some of babies that were born by a cesarean section and these nice. The magical big deal showed some off the outcomes associated with early. And they found an association with money coordination with respirator distress with later that on also sepsis. So showing the the negative effect off only big compared with those with more than 40 weeks off. And then I know that it's such a hard time. So and there are a lot of things that we need to consider when thinking about the weight about comes associated with Cesarean section. I would like to highlight these ones like we need to take into account if it was a planet on emergency section. We also have to think it's a repeated or the first of the section of women. Uh, if it was performance in the high income countries or low, we can come contribute like, uh, limited resource it and also sometimes training uh, just as an eight at birth, the medical medication, and also think about what all the maternal conditions and I didn't talk in my presentation, but we also need to consider the long term outcomes off the offspring. Because there are some papers. Associates is our section with asthma, um, visiting in other morbidities. So, uh, I know that they have this regarding outcomes off cesarean section is complex and carries a lot of uncertainty, but I think that taking wrong message here is that either the overuse or underuse off cesarean section is associated with, uh, negative outcomes. So we need to try to find the balance between this, and I know that it's not, um, using desk, uh, so over Gadda and thank you. Probably got indeed. Okay. Thank you so much, thanks to all those speakers. Okay, so we've got a bit of time for a panel discussion on for questions that people might have from the audience. I'm hoping that Fernando is still online on Maybe Linda's online as well. I did is then to remind so Linda and you know, me, panda should, as David said, should have been speaking here today. She's in Blantyre, Malawi, on she's a next pertinent health systems and implementation research science research with a particular focus on quality improvement. So, Linda, thank you so much for being with us. Yeah. Maybe I can start with it with a question for the panel. But often the focus is put on on training. People say, Well, if only we could train better then then this would solve a lot of our problems. But it seems to me write a note that training is gonna have fairly limited impact on a lot of this on. Maybe we're We've been over over pushing it for years. I'd be interested to hear what they're there is people on the panel Think about that. Is there a big skills gap in your particular area? Whether it's in improving the natal outcome or in sepsis or in people can ask you, David, first of all, what? What do What's your thoughts? Yes, I'm happy. Good. Can I defer to Linda for the police, please? Yes. Uh, Linda. Linda, what do you get? Did you catch that? Yeah. Me. Still be once a day for for me to teach, but this'll meeting you. Okay? Thank you very much. Uh, any. I think at difference on the contacts because I can receive versus and delivery something that doesn't happen at all. So if we don't have, like, a proper 10 be as assistant delivery. You weren't going to be like a vaginal delivery without any complications to us. The science section. So I think in some countries Chinese, it's a stool problem and should be like trying to Okay. Thank you, Finance. So, you that okay is I see who's doing? Uh huh. It is okay. Thank you. David. Was there anything you wanted to come on? Yeah, If I could just comment. I think that point is well taken. That training in isolation. I think you know, there's then a gap where people have the knowledge, but they don't have the resource is or systems around them. Teo do the work. And so I I see that there are trading gaps, but it's off the more complicated toe. Have the impact been just training alone? Okay, we've got a couple of specific questions, which of which have come in on line one relates to, um three care bundle for sepsis on talking about how whether it includes improving environmental cleaning, there's a lot of focus. They're on personal hand washing onto biotics. But what about the environment, Linda, I don't know if if that's, uh uh If that's something you could address, it could be worse than it was low less the vision that smoking and that that position for that? Yeah, No indeed. And David, did you want to talk on? Yes, sir, anything in terms of the specifics app, sepsis is really focused on individual behavioral change, and we recognize that there are really critical facility and white health systems changes like improved hospital cleaning that are outside of that complex intervention. But we sort of felt we had to draw the line somewhere. It doesn't mean that all important, but it was already a huge intervention and complex. So, yeah, I think it's no a specific component within acceptance. But there is a flexibility, and we have quite often seen it that once a team or infused about reducing infections, that's a sort of thing that a hospital, you know, starts mortifying. For example, you know, changing where they put patients in the ward system or midwives initiating you trading with the clean. It's but it's not a strict part. I was always interested me that in Liverpool, whenever we have anyone with MRSA, we give very strict guidance, and that includes having a really good wash before you come in for your cesarean section if you if that's what you're coming for on. But I was when I used to run the clinic that we had for overweight women, we often found that there was a sort of, um, over the Panis that was a new area which was often unclean skin pouch there, exactly where we're going to cut on so people raise their eyebrows. But I would at me. But I would often say You need to make sure that area is really clean before you come into the attorney and just reducing the bacterial load seems to be something which is, well, it'd be simple to do and yet on yet often ignored. Yes, I don't know if Linda wants to comment, but many of our women have been on long by the time they get to a facility can get back to Sierra Sierra section. They had long journeys, and it's you know as well as a long labor, and it's been on the smaller facilities will normally not have had running water, will not have Washington cities, and I think it's in interesting question how, before and off the birth. We can improve the facilities so that these women could look off themselves. And there babies, you know better us with a little swap. Doing a bit of swapping before the operation is probably not reducing the bacterial load is it would have a woman that cleans getting to stop. Okay. Uh, yeah, right. Just wait for the microphone so we can. The people online can hear. So thank you for the great presentations. I have a concern, and the concern is about vertical I station. So David is doing great work addressing sepsis. You are developing tools, instruments on solutions for add dressing, sepsis and financial and team are doing great work during same sort of stuff, but for postpartum hemorrhage. And you would be doing something similar for noon eight. But are you all talking? Oh, are you vertical eyes ing it To the extent that you are developing instruments that are going to be imposed on the same patients at the same setting that are going to be multiple pieces of papers flying around on, how do you bring it all together into a coherent, meaningful whole that actually works seamlessly a challenge? Thank you? Uh, very, um, finance. So, uh, could you take that? Any comments on that, I think. Use way? Uh huh. You know, just be here. I see all these complications. Cool. Thank you, Linda. Any comments on that for me? The citrusy to be busy for excitation and see every day over. Thank you. Been any any comments on David? Yeah, thanks. I have shared it concerned, and I It's not easy, but I think we are in a good position in that at least, for example, in PPH and infection. The large studies using similar methodologies well, vertical have a lot of tentacles that cross. And so I think that's our responsibility of researchers working with wh show and others who also cross both trials To think how we can integrate so that for a user on the ground, they're not worried about the research base with this or for that, but just have clarity about what they should be doing on, but it I think it is. Aaron sections another great place where we could integrate where, you know, you have a single procedure on us as a community. Need to figure out how to fit it together. So it's not that individual practitioner who's thinking or what bundle, Um, I using today. Which training was that around a great challenge. I guess it's one of those things where it's holding on us. Researchers weaken largely only look at one area, but not to be too arrogant. Ourselves and believe are areas the only area but hand it over to face like wh show in the Ministry of Health? Because they're the ones who will integrate it all together and involved them at a nearly stage so that we're not trying to just drive our own agenda. And that is this Malaria week. That way, we've got the intervention in malaria, or is this PPH week? We're not quite sure. It just clicks from one thing to another. There was a question that the back there thank you. I have to declare a conflict of interest, a colorectal surgeon. But it's a great place to be here and some fascinating work, so vertical is a shin area. We need to avoid fertilization between disciplines, and there are many areas that crop there. There are things we can learn from you, and I hope that we can work together and harmonize our practice. Um, so I said I didn't see it, and I'm doing more and I'm from burning. So I actually really like the question from the chair. And that is how how how should we prioritize training? And I think in our work, our global work, we are prioritizing implementation, and it is about it's about, you know, getting the job done, but to implement. I think we also have to have evidence based practice, and it's actually introducing evidence based practice on implementation. True that as a vehicle. And I think that is, I believe that is our current thinking and what I was going to kind of push on David and others. I really loved the trial you were describing. David. Sorry, I can't remember the name. But how you reaching out to the smallest hospitals to the smallest unit on how you making sure that they have the opportunities to implement, because that may be your greatest benefit. We see that as our greatest challenge. Thank you. Don't respond directly to that or yes. I mean, if that's possible. Yeah, thanks. And really, I think really great that you're here cause I think there's so much that we can learn. You know, many of the study who were quoting a sauce and others you know are not specifics. Is Aaron section studies? But Cesarean section such a common operation, you know, and and yet we somehow it treated Moses different toe. Other general surgical procedures. But it's the same practitioner. So I think it's much to learn from an abscess, this point of view have for the trial itself. We are limiting two facilities that can deliver comprehensive emergency obstetric, Really, because of the needs of the study and the number of you know women we need in the rates of adverse outcomes. Other work done around sepsis panel included very small facilities, and it definitely was implemented in those small facilities. But the issues around sustainability, when they're so resource limited beyond the project, I think the come along the greater If there's only one mid wife working in a small outpost that's just a little toe walk she has capacity to do. Yeah, okay, I'm gonna have take cares, profited and have one final question myself before we finish. And it's only one word answers I want from a large team that is, if you had if you had the opportunity to introduce one intervention which could make cesarean section say, for what would you all go for? Uh, Fernando, it's your your your your choice festival. If you have the power to implement one single intervention to make cesarean section say, for what would it be? Uh huh. No easy question. Oh, okay. Now that's okay, Linda. Yes? Any ideas? What you choose? Okay, Fantastic. Any B complex Brazilian contacts? A specific. So reduce the normal night. It really necessary Cesarean section Reduce the unnecessary nonmedical cesarean sections. Thank you. And finally, David Host is Aaron section monitoring? Fantastic. I bet you've got your own ideas of what it would be, but that's exactly what coffee is for.