Professor Andrew Weeks & Ms Indie Kaur | Debate: Should Midwives be Routinely Trained in Assisted Vaginal Deliveries
Summary
In this on-demand teaching session relevant to medical professionals, Indy will present two talks on how midwives should routinely be trained in assisted vaginal deliveries. Indy will explain how they achieved astounding results in a hospital in Malaga by introducing the technique, as well as how task shifting can save lives in low-income settings. She will then debate the pros and cons of midwives taking on assisted deliveries in the UK. Participants can use their phones to submit their votes and have their say in the discussion after viewing Indy's presentations.
Learning objectives
Learning Objectives:
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Recognize the potential benefits of assisted vaginal deliveries led by midwives on reducing intrapartum stillbirths.
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Gain knowledge of Dr. Stephen Strong’s task-shifting approach to non-doctor cesarean sections in Mozambique in the 1990s.
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Learn how the training and use of midwives for assisted vaginal deliveries can potentially reduce the risk of fetal death in rural and low-income settings.
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Understand the correlation between medical doctors per population and stillbirths in various geographical areas.
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Analyze and interpret the data of Midwife Barbara Nolan’s delivery study in Malaga, which found vacuum extraction to be associated with fewer maternal and fetal issues.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
similar pathways off careful women with complex social needs. One, huh? The British Medical Journal Award. She's also the recipient off. 2019. Sheaf, Midwifery Officer Gold Award and HS UK for outstanding contribution to meet with three. Indy has several publications on presentations toe have credits up. Welcome, Indy. Let's have so we're going to have to presentations and then a discussion after that. So, um, we have 40 minutes for this. So, um, is it 10 minutes? How? How much do you want for the presentation? Yes, Dominus. Each and then we have 20 minutes to discuss. Okay. All right. Good. When is five minutes? I will just resolve my piece of paper. Okay, Professor, before we begin, can I just launch the mental can have? Ah, quick summary about what people think before the debate, and then we will repeat it after. So what people will need to do is using their phones. They need to go to mental dot com and use the code 95, 10, 4 to 6, and then they should be able to vote. And we're repeating this at the end of the bet. Yeah. When you say 65, 10, 4 to 6? Uh huh, Yeah. What? That's nice. Profit says minute. So I just give it another minute or so just for people. Finish roti. Let's try and reach 55 participants meeting and then Or class. That's 55. Okay, so we have 63% saying yes. 64% saying yes. 13. Say no And we have 24% of participants a undecided. So we'll paint this at the end of the debates and hopefully we'll see if there's any change. Thank you. Okay. Thank you so much. That's not what I expected. Actually, eso will be interesting, though. It's interesting today. Okay, So I've been asked to propose the motion that mid wife should be routinely trained in assisted vaginal deliveries. And I want to tell you a bit of a story, because I I worked in Uganda is a chemical lecturer from 2000, while in 2002 on Daft are left. I continued to keep contact with a fantastic department there, malago hospital and, um, call Barbara Nolan's came to chat over. She was planning to go to Malaga and said, I've got this idea. I want to introduce Bond Tuesday liveries wasn't well, it's not like it's not there like it's not like in the Deplin is, you know, way don't have on Tuesday liveries just because people have got epidurals and they're stuck on their back. And, you know, there is a two part of Push Brigade that these are sort of serious obstructed labors. Really? You know, really, you make it a few, but equally you could cause just a much harm and trauma on. Actually, the vast majority of they're going to come, they're going to come. I don't think you'll get very far on. Do I have to choose something else? And I have some other ideas of potential intervention. But she went ahead and she had spoken to a number of people and she went ahead and continue to do this study on introduced the key week up into malago, and they went from very low rates off vantas births up to very high rates on do, um, she wrote it all up on, but was fascinating because what she found is his theory. Oh, at the time when she introduced ah on Tuesday. This is just kiwi amongst amongst doctors. This was on she, uh low rates, historically low rates. In fact, when I did one of the very few forceps there and people crowded around cause I've never seen four sets used on D, but she introduced on twos, and actually, there you go up to about 3%. So it's a fire below what we had in, uh, in the UK on D. I thought, Okay, well, some babies do come out. But what was surprising then was that when she put it against, uh, neonatal death statistics the's a neonatal mortality, stillbirth statistics. There you can see the intrapartum still birthrate. Huge drug. Well, huge drop from 3.5% down to 2.5%. Maybe a third of the baby's born in in ah, third reduction in intrapartum stillbirth. Of course. Compared today you've got a background, the macerated stillbirth. Right? And I was stunned. Actually, I did. I didn't think these babies were going to come out at all. And she went on to look at she did a parallel cohort study which was then published. This is 2017 comparing outcomes off second stage cesarean sections compared to one Tuesday, both on D. Remarkably, what she found was that? I look at that first sentence I haven't underlined. No maternal deaths occurred after vacuum. Five deaths from complications off second stage seat Caesareans live. That's A s S C D vacuum extraction associate with less severe maternal outcomes. Fetal death during the decision delivery interval was less common in the vacuum extraction group 0.9% versus 4.4%. So you make the decision to deliver a baby in the second stage. Bisys Aaron, Section 4.4 Nearly one in 20 babies have a stillbirth waiting for the attorney on the reality Waas that in Malago those particular problems with consumer balls and with starting etcetera on, people often had to wait for to six hours waiting for their for the for the birth. And it stunned me that I must admit and suddenly you start think Wow! What was really is a ah high quality intervention not only to reduce his air in births, which I thought would be its main effect, but actually to save babies, lives on to prevent intrapartum stillbirth. Now we know, of course, where still birth rates are concentrated. You'll know this map very well on. Do you conceive how the concentration of it in sub Saharan Africa is shocking. But the strange thing is, of course, that the negative of this image is medical doctors per population and you get almost exact negative off it on. You can see that the very place where we're wanting to reduce intrapartum stillbirth is exactly the place where there are no doctors. So how do we solve that now? Of course. You know what I'm gonna I'm gonna say. But the question is, how do we do that? Then? How do we get over this dilemma that we want to improve? Still, birth rates on. Yet there's no doctors there to do it. I want to introduce you to one of my heroes. Don't know who this is. Oh, dear. My that, um I think this gender a big effect on me when I was in training him when I was first coming into maternal global hope. This is Staffenberg strong. Who is professor at Carolyn SCA? Andi. He did a lot of work in Mozambique in the very early days and this is now a paper. This is 1996. I was looking back and thinking Wow, is really looking at in most and beak where he was working in the nineties, there were very few doctors. So saying is the diagram I just showed you on what he introduced Waas a non doctor cesarean section providers on. But this was part of the start of task shifting really on. Do we went on destocking publishing on this work and looking at outcomes, You go Well, yes, I'm sure that that they were non doctors, so they probably didn't let it be easy. One I expect the doctors magnanimously gave him just simple ones. But actually, when you looked at the data, there was enormous benefits to the non doctors during the Caesarean sections, and they found that not only were they well done, but in fact they're incredibly complicated. Once a swell they were, they were Caesarian. Hysterectomy's, a ruptured uterus is They were all sorts of horrors, but they outcomes were at least a good uh when they were done by the's surgical assistance. And in truth, that's know, greatly surprising because you'd think well, actually, if I wanted a piece of carpet treat, it might be very nice to have my carpentry cupboards built by somebody who had done a PhD into the the water content of during aging. But actually, I want to skilled craftsmen. That's what I want. I want to skilled crops person, not somebody who's got academic qualifications. And that's very much the case. This is Aaron section. You get very technically skilled people. So what should we do then? For what do we do that, um, on Tues on Tuesdays? Clearly right for Task 50. But then, who should do it? Is it also is it something that should be done by some surgical assistance? Well, actually, it's a bit more complicated than that, because actually, you need to know about the labor. You need to define where the head is. You need to be able to define position. You need to see the progress you need to be able to time it correctly, and actually, either doctors or mid wives are perfectly place to do that. Has it been done well, actually, in the UK, we're not unused to that. There's a number of situations in which it's been done, actually, very rarely written up. I couldn't find very much writing up off midwifery practitioners, and you could argue that actually, in the UK it's not a terribly good idea, but it's probably not going to save lives. It's probably more a financial benefit than anything else. But here we got. I don't know if married Black is actually in online today, but she wrote up this five year data from Aberdeen 13% of their assistant vacuum assisted vaginal birth. This is either forceps or on Tuesday, done by mid wives on. Actually, mid wives had very good outcomes. Uh, interestingly, had a preference on teach all the forceps that's either here or there. But they had significantly lower blood loss. No difference in paraneal tears or people out. So what should we do? I mean, is it that we should be encouraging midwives to do? Uh, on Tuesday? But it's on, I guess, the problem that will have because I suspect me. We agree on quite a lot of this, that the difficulty is this question of routine on should it be routine on. That's probably the problem with it. On that My get my suggestion, actually, is that its location specific on, I think in many parts of the world I don't think it should be a routine function off midwifery here in the UK. Actually, you need to have a significant number of births that you do every year. You know, what would you choose? At least 20 a year to keep your skills up was actually, if every obstetrician and midwife was trained in the UK, maybe do one every two years. In which case, actually, that's no way to So you do need skills concentrated on people who are going to do it regularly. But so in the UK, probably not. But I think if I was training South Sudanese midwives, then I think it should be routine. And I don't see any reason why this'll didn't be a major intervention to improve fetal outcomes on certainly whether you're in Sierra Leone or, well, indeed, if you went to Rule Australia or two rural Canada anywhere where there's difficulty in in getting rapid access to doctors, those places where you should have, um, access to midwifery done on Tuesday liveries so in low income setting clearly want to. Still, every's will save lives. A lack of doctors is a major problem on ditz ideal. Then, for task shifting midwives air ideally placed to take on this roll on. So I think they should be routinely taught as an advanced skills. Sorry, Perfect. Thank you very much. Um, Andrew the and it's it's really interesting because, um, it's a very good question. Should mid wives be routine? The trained and I I I hear what you say in in certain countries and maybe not so good in other countries. Uh, I do not agree with it. And, um, and my reasons why I was soon follow. Um, I'm a midwife for 30 years, and, uh, in my midriff free practice, I've learned a lot. And for the past four years, I've actually spent by time in India and bedding professional midriff free on. I feel that in a country where you know, um, bedding a skill that is so crucial. Um, if we have midwives trained to do instrumental burbs, it will cause the confusion off boundaries and scopes off practice, especially in India when we're trying to embed the profession. Um, instrumental burbs, C seven burbs. Midwives do not have the same years of training like obstetricians do on the training is totally different. Uh, midwifes can reduce the need off instrumental births. because what we are trained and how were trained, they still look at birth. That's a normal physiological event. And, uh, let let us do what we're good at. And that is being with women supporting women on give for the care that she needs. And we know that that also reduces instrumental both and unnecessary, says interventions. So it's a clear purpose. I feel that when you have a midwife, um, starting to do instrumental burbs, the boundaries are going to be blood. Um, England's just having oxidant review and it stays multi collaborative, uh, training. It's so important. And doctors and midwives must work together and let us understand each other's rules. If I need us. If I'm concerned with a woman, I need to work with my doctor in my team and have timely, um, escalation. But my role isn't to do an instrumental birth. How does that feel for a woman? I'm there for her. I'm an advocate. Professor sues just showing a lovely video. The midwife is there supporting the mother and timely A doctor comes and the doctors one the dust, the instrumental birth and the team works cohesively together for the outcomes. You know for the mother and the baby, and the mother had a positive birth experience. Let's not forget at the end of it, it's yes, healthy baby, a good outcome and a positive birth experiences because women do don't have positive with experiences and then due to fear. Then we'd want to have a cesarean section. So let's come back to the little They're the important points and to protect the profession, uh, end. We know that the world is short off midwives. There's a global shortages. We know that the lens, it's a it's having professional midwife strain to international standard will ever 80%. So why do we want midwifes to come away for the rules that they trained for to do training that should be done by obstetric college? This is important demarcation, um, midwifery care. We know that continues support during labor reduces the need for instrumental birth. So let us midwifes concentrate on reducing the needs for instrumental. But rather than performing an instrumental birth, we know that this is one of the most effective non clinical indication interventions. We know that position's upright positions in comparative to supine lithotomy positions reduces instrumental births and let us with drives, be with women to support the women To do this. We know that when you offer women hydrotherapy and water burbs and that reduces her need to have an epidural energy XeA. So let us support our women as she may not need to have an epidural energies, and that may decrease in a foreign instrumental birth. Uh, so let us midwifes concentrate on what our training has told us to do. Let us support women in the non pharmacological hydrotherapy energy, easier water, birth letters and power women. And that's what Midwifes are for. You know, we do that. We empower women. We bring women to us. We are there advocated how confusing it is for a woman when I'm there looking after her. And the next thing is, I'm going to put an instrument on, too. What role in my playing, I think it's important for women. Lets us are women in the audience. What do they think? That's also my drives. A swell midwives. Ah, so been told in this country, my colleagues are telling me, Don't come back. It's terrible. But like, you know, mid rifs are leaving the profession. Qualified midwives when they should be the ones that they're around to train our junior mid wives. Because that's fear. That's not enough of experience, midwife. So why are we considering taking them away from what they are good at? So let us support women, be women. And my conclusion my landed opponent, is what happens when midlife sertraine and the and the instrumental births failed, you know? Then, you know, would it not be more appropriate that we've escalated it to an obstetrician? You know, we've seen failed attempts resulting in the second stage to serve inception. Instrumental vaginal birth retains an important role in current obstetric, not midwifery practice. So I'm against emotion. Thank you very much. This is really interesting. Uh huh. Well, we had from Professor on gave us fax that really? There is a place for routine, you know, training off midwifes to do a cyst it for general delivery on then. We've had from Ms Indy, who says no. She thinks that you know, midwifes should be trained to do what they are. I mean, they should do what they're trained to do, which means they should give supportive, uh, care during labor in such a way that we reduce the mood for even the assisted vaginal delivery. So we have the four and we have against. Now we are open for discussion. Saw Do we have people that will go for days and then we can have a response from the debate? Is anybody okay? Brilliant Debating going on the question for Andrew how would you respond to in these querian war happens when the want to fails on. There's a midwife that given of the concerns with midwifery And she said the UK example of a condemned review on even the word normal birth has bean um sometimes frowned upon. So I just want to know your thoughts on Okay. What happens in mid wife puts it on Tuesday. Does it work? Can answer. Yes. Well, I think it depends on the situation, doesn't it? On I I think if if you were say in a village in south Sudan, then clearly you shouldn't delay transfer because of that. But I think if you're a waiting a long transfer, then you have to take your chances. Because actually, the alternative is is a high risk off silver Now. Yeah, if you're, uh, damaging the baby so much during of on twos or forceps delivery that if it fails, then the baby dies. Then you probably shouldn't. Your training has been wrong, and you shouldn't have done it. If, however, you can put it on Tuesday up on on, see whether the baby comes, comes down on if it doesn't come, you take the vantas Cup off on leave, leave things to continue. My suggestion would be that that's a safer situation than waiting 45 hours for transfer and for a cesarean section. So I think it would depend on the situation. Yet, of course, we'd ideally want toe have a mid wives playing their their best role on obstetricians or medical staff playing their best role that, like, isn't that easy on? I think sometimes you've got to take pragmatic decisions on that would include sometimes doing of on twos when you don't have that back up. Okay. Do you want to comment on that? Um, I I suppose. And you you've worked in South Sudan. So you've had an experience on Uganda, not Uganda? Yeah. Uh, my my concerns still remains that it bless with boundaries and that hugely concerns me because even setting an embedding professional midwifery in India. We're not even talking about instrumental births. And we have a huge challenge without obstetric colleagues understanding when the rule of the midwife is, um And as you've said so eloquently in your debate earlier, that it's not for every country. But I feel that lettuce first concentrate on getting enough off professional midwives across the world. I think once we've got enough of professional midwifes and the subsequent rolls can be thought off, But currently we're not in a good situation. Okay, Yes. Um, online. Please remind. Let me know if there's any comment on, like, yes place. Yeah. Okay. Teo. Indy. Um, just at a cure. Curiosity. If you were a community mid life in a village with no easy access to a hospital, Um, and you're in a situation, and but so it was fully and baby was not coming down. Would you like, Would you like to have the option off being able still on teas? Um, So there's two things to the questions like, I've actually done the RC of J cause to understand what I want to use is what, four sepsis. And it's coming handy. not for me to do that, but I know in my health care when my obstetricians is not doing it right, I'm actually say Well, actually, baby, could you try something else? However, in the situation that you have highlighted the signs for, You know, when things start deviating the scientist normally show up much earlier I would have probably think of transferring her in a much earlier face that rather than to keep her in the community so timely escalation So she goes in the right place, gets the right support from the right evening. This know, as I'm saying, like, you know, we be betraying ah midwives in the community with when things deviate. They don't happen straight away. The science are normally emerging and an early transfer would be ideal. I wouldn't want to do in Vantas because that's not in my rule in my damn it. Can I Can I come on to that? I think that's very true on it's about being pragmatic, I think, and I think that we do in an ideal situation, would have enough midwives enough obstetrician throughout the world to do so. Everyone's got their specialist role, but I think you're exactly onto. It is what do we do in desperate situations on? I think there are many desperate situations around the world where you don't have the luxury of saying. Actually, I don't do this or this is not my role. I'm not sure about the difficulty With with crossing professional boundaries, I I get that there's maybe potentially legal issues, but equally I wouldn't want to say Well, as an orchestration. My role is not to advocate for the woman. My role is not to be alongside the woman that that's a midwife job. Well, actually with with want to both playing the best of all Alrosa. So long as we've got good training so long as with safe on, so long as we've got legal support, I guess I think that's a totally different argument. Andrew, you know, I use everything I can to try and get Uh uh, yeah, that's exactly the same. Okay, this is definitely my most chickie point today, So I gained from the colorectal specialist perspective. This is an incredibly good debate on It is so valuable. The task shifting question goes way beyond the world of obstetrics and in colorectal surgeon general surgery. There is a huge need for it. And so we've got so much to learn from you say thank you. And actually, I believe it's about teams, and I'm trying to work on teams of players that can run together to provide care on. I'm looking from the outside, actually world. And I see teams of people, uh, perhaps know Kolok ated all the time, but teams of people working to deliver care. So in my world, I think I would be advocating the vendor I a gram. I'm a great believer in ven diagrams, and I don't think we should be fined of overlapping areas, off expertise and care. Willow challenging. They may indeed be best for the patient, but I don't really see the boundaries that you're talking about. I can understand the fears as well as the hopes. So really thank you. We've got quite a lot of comments from the chats. I just wanted to bring some of these injury. And so somebody said, should mid wives be trained may be selectively for like in remote areas? Um, some people have said that in their experiences in the middle income countries, it would help with midwives could do back in extraction because they're the ones that are more often with the women, but so far, then allowed to, um But other people say yes, but then is to be a backup in case that onto scales. Somebody said that mid wives often eager to bring the birth to a good end. Where is the alternative is often waiting for space and clear to sometimes the hours somebody's commented that mid wives and Uganda often feel afraid to do such practices is they don't feel covered or licensed to practice. Um, yes, lots of great engagement with the debate. Thank you. Okay. All right. Um, we have, um Let's go ahead. Are we ones? I'm a doctor. Told Frank I am currently based on a limb. Um, Universitatea. I'm come from Vietnam. Um, it's not a question with it. I'm just want to share my idea. And as for your advice in debt, I haven't. But I happen to work, not a non prescription. And the female hospital in the sounds of Vietnam is consider it the the Pickets Hospital in the South Vietnam. We have a rousing sick, his house and birth a year Yeah, 40% off. Um, smoking is siete and, um way also think about that to train the midwife to do the assisted delivery Because we want to reuse the race off CS. And you know that instrumental deliveries can contribute to the really use off the CF. Great. Um oh, yeah. But, um, we have when you quit, it does that we have some problem with that, Uh, some of them in day or so. Also mentioned, uh um I must say that I vote for under, but our eyes they're here support in days in the comment about any mention that Mr I have lows up where I have to care. Patient. And then a lot of that, um I've been instructed Task Another thing is that they're not the same quantification because that the doctor and need more time to be crane been. And we also have that the retraction by the National Medical Medical like lettuce straight. And let's do the social refugees because when the patient come to the hospital, they just like to believe in the doctor rather dying from it. Why? And Onley Doctor Onley Doctor can get the medical indication into the into the beige in It could be that the reason we cannot offer ms right to do an assisted delivery. And in the last one, I think it still assist Now that the conflicts between the obstetrician and the midwife uh, to be honest, the obstetrician doesn't lie someone some any minute. So I can do the assisted liver E. But hey, or she can't do that. Thank you dot my idea. And I just stick your advise about us. Yeah, Thank you to 20. It's It's fantastic having toe trying in our department cause the Vietnamese perspective really is very different. And I think right, the end that you bring up, uh, a challenging point with task shifting is that, um, uh, doctors see it is their domain and they don't want to lose it on. That has been very much the case with Cesarean section on D in Uganda. I know people who have tried to bring in a non doctor cesarean section and it's completely opposed by by a lot the professional bodies. Why is it a Is it opposed because they're be bats is Aaron sections? Is it supposed because all the doctors want to go to the rural areas to do cesarean sections? Well, no, actually, it isn't it supposed because this is part of the mystic domain of being a doctor. And if you allow non doctors to do these, actually, they're just technical jobs there. You know, if if you if you start to release that that those mystical jobs, those powers outside, then actually who will pay for private practice you could just get a midwife for half the price to go into your PSAs are in section and do about a job, so on day. So because it there's a clinging to these roles by medical professionals, And to me, that's very sad, because I think that actually, our whole existence should be about improving outcomes both for mothers and babies. On that, I think, to not improve outcomes because of professional pride. I think ah isn't healthy. Shall we say it's not a it's not something we should be proud off. So toe my mind if we're looking purely from the woman's perspective. I think if I was in a place where I couldn't get intervention, I would take whoever was well trained and who was there and could help me. I wouldn't really care whether they were a doctor. The last comment. I think we're good. Thank you. Um, Burn Georgina from Uganda. A midwife like to give an experience. Um, I work. I walked once with, um a lady a midwife on had a meeting with relayed model in a community, and she worked best color with midwives. So huh, thing waas insured up. The midway's I were trained on sustained the skills and your confidence among them. So they would easily I didn't fight any abnormality as the mothers labored or so it allows. It is very, very deep. They're around, uh, 500 kilometers from the city. So it was timely. Referrer and Carol Big event property. The example off. Malago malago. We assure me it's a well equipped, but because it's a center that receives mother's in ledge situations. So the assistant delivered is a book to be given, so I'm I'm continuing with with a his Westchester. What do we do in the spirit situations? I think we can still perform our best as midwives. As long as this continuous, sustainable training we have the knowledge that computers I didn't fight the risk areas provide Referrer as much as on. I believe most of your gun than now. Areas are easily not everybody accessible in any suspicion. Thank you. Thank you very much. One minute to say one money to So yes, to some one minute Whether you still have with what you're you're still you know, you still agree with your job too? Yeah. So I'll ask you to vote for this. I think this is a progressive action. I think this is the new way. We're trying to break down professional barriers on I think the right person in the right place with the right skills is the best person to do that job. I don't think we should be defined. Whether Where? That what? Uh um uh, letters we've got after our name. It's far more about how we got the skills. And if a doctor is there but doesn't have the skills, let them not do it. How dare they do it if you don't have the skills to do it? If, however, you've got a midwife there who's got the skills and has been well trained, then that's a perfect way. So I would suggest that it's not. It's not for every not for every country, but I think there's many parts around the world where they would hugely benefit from a good training process in in Vantas. Ah, I'm for the mid wives. I still I still am against it. I'm a professional. Mid one. I feel that our midriff freak Aries under deep scrutiny at the moment, Midwifes are being vilified even to talk about normal labor and birth. And to now think about instrumental births. Maybe Andrew the later stage. Let us have moment twice. Let let the world have moment, wife's and then making ring have this depends again and I'll probably will agree with you then, um, for me, I'm a bit confused. In the beginning, I was like mid wives should be trained for men choose, But now 100. I'm a bit confused, I'm not sure, but I think I just live this debate with, you know, from the color rectal surgeon on that is the team approach. Um, I have three boys in my house for hoist. Plus that dad on. We watch. We watch football all the time on, you know, in a football t The striker is the one that's supposed to put the ball in the goalpost, But at times, even the A good keeper can still put the ball in the goalpost. Even a defender can do that. So what is important is that even though the support the strikers, one put the ball, but any one of them can actually put the ball. So what we're supposed to do, a probably is, you know, an overlap off, you know, responsibility. There's no doctor than a midwife. Is this a midwife, then? I mean, if there's no doctor than a midwife, there's a doctor, then it is a doctor's responsibility. I think that's my take home message, So thank you very much. Okay, So let's see if that you have an increase with the same boat. Same same code. So if you have a weapon on your phone, it should just go to the next slide. Just to remind everyone before the debates, Yes, was 64% you know, was 13% and undecided was 23%. Thank you. Yeah. Okay, So you've got 54 votes on, so, yes, we have 52% know we have 31% and we have 17 undecided. Yeah, So I think in Do you have succeeded in drawing some people to your sites?