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Welcome back to Day two of the Glow Conference. Welcome to all those online joining from wherever you are in the world. Um The yesterday, we had a fantastic day. I found it a very, a wonderful day. There were talks to challenge, talking about some of the problems and the ongoing problems. For example, with antimicrobial resistance, there were others inspired, talk of work that people are doing in conflict zones and there were others to celebrate work is going on which tackled some of the most challenging crises in maternal health, for example, like the fistula work last night. So it was a wonderful day yesterday which has left us with lots of thoughts. And then of course, last night, we had the tribal dancing which we're very grateful to the team who took us through it. They took us through step by step. I'm sorry for those online who, who were there, but it was, it was very wonderful. The Kelly last night and some people been on a walk this morning, people, the walkers are back, the walkers are back. That's great. So we'll look forward to hearing about that later on. So thank you very much to all the organizers for yesterday. And we're looking forward to a great day today. So it's my happy duty to introduce the first speaker of the day who is Adora Banky Thomas. Now, he's a physician and public health and health policy researcher. He's associate professor of Maternal Newborn Health at LSHTM and he's also co director of the Center for Maternal Adolescent Reproductive and Child Health in London. Now, we heard him yesterday talk about an analysis of the gratuity user fee exemption fees policy in Burkina faso. And I'm hoping that today he's going to expand on that and talk far more about how we can improve access, geographical accessibility to in emergency maternal and newborn health, which is his subject of expertise. So, Adora, would you like to come and join us? We've got 30 minutes. Please put your questions into the app and so both online at home, type your questions in or those here. I think you're all on the app already and so type them in and then at the end, we've got of an hour for questions. So there should be some good time. So, aura welcome. We're looking forward to hearing what you. Thank you. Thank you. Thank you very much. Good morning, everyone. Yeah, that's what happens when you dance till 11 o'clock and nobody says good morning. Um So thanks a lot Andrew for the, for the introduction. Um Much, I appreciate it. Um I will be talking of talking to about a topic that's very dear to my heart, uh which are titled for this uh meeting We Thinking um geographical accessibility to emergency obstetric and newborn care in the global South. Uh But I thought it was important to start somewhere else. Uh And this is a big risk, I must say um at the risk of me not being invited to any other conference I've attended, I think the three major maternal newborn health conferences this past year. Um that was um the align M and H in Cape Town, there was um Figo in Paris and there was Glow in Edinburgh. So while we were dancing well before the dance, I couldn't do anything after the dance. I did a quick survey and don't ask me if I applied for ethics or got informed consent, but those who are part of this survey know who they are. So thank you so much for your participation. And so we, we did this quick survey of this works um where we try to look at um those three conferences based on a few characteristics. One was on outstanding nature of the venue and the other was on intimacy of the environment to allow for networking. OK. I'm I'm pleased. This is a secret survey. Please don't, don't share this. OK. Uh You know, so this was where Figo ended up. Alright. Is anyone here from? And then uh am and H at Cape Town? OK. And of course, we can all agree that Glow. So please a big round of applause for um about the venue. I was reliably informed that usually when uh presentations are going on on the stage, no one is looking at the stage, everyone is looking upwards. So I wanted to keep your attention. Please don't take this photo for her. Uh II, do want to keep your attention on, on the presentation. So that's the photo out of the way, make sure you're looking here. OK. And, and what a wonderful venue to really remind us of why we need to invest in women's health. So, thank you so much for all the organizers for having us here. Thank you. OK. So to my presentation, so as I said, I want to really argue on why we need to rethink geographical accessibility to emergency obstetric and newborn care in in the global South. I think we've shared these, these numbers. Uh But I just really want to put us in this situation of for every pregnant woman who goes through this journey of nine months. Really our expectation at the end of those those months is mother is happy, baby, is happy, mother is alive, baby is alive. That's really what you want. Unfortunately, in many parts of the global South, uh maternal mortality is a huge challenge and it remains a huge challenge to today. The numbers that were released by the um Wall organization last year February in the trends report um showed that we have over 287,000 maternal deaths still happening every year 287,000 A. And I know sometimes we call these numbers, but we don't realize that those are real people. 287,000 in a and of course, we know that we still bet we are talking about almost 2 million still bets, you know, happening annually. Um 99% of those debts that I just quoted the 200 it's almost 200,000 debts occur in the global South. Uh and and 97% of those still be occur in the global South. So I guess it's ok to say maybe it's not an Edinburgh problem, but it is our problem to fix because we are really passionate about this work. Uh I'll show us the map of the world as we know it because I feel again, we talk about these numbers. It doesn't make sense. Let's think about this in a different way. This is the map of the world as you know it. And the United Kingdom is still somewhere there. It's visible. So that means Edin Edinburgh is still there also. But if we were to use those numbers I cited just now and flip it around, use them to equate as the areas that these countries would, would be, this is how the world would look like the United Kingdom will cease to be a country and countries like Nigeria where I come from. Um, we, we used to call ourselves the giant of Africa. I II still don't know how it came about, but let's for the purposes of this discussion, let's say it's because it's based on size, right? Will truly be the giants of Africa. And I think this, this, this was done predating the 2023 estimate. So it looks like India is slightly um uh larger than Nigeria. But now Nigeria is the, is the, is the top dog. I'll say a little bit about Nigeria while we're on this slide. And, and that's to say that Nigeria is, it's quite a very populous country. Uh We're talking about people of over 200 million and the, the flag of the country is green, white, green. I'll tell you why that's important. I in a minute now, for all these deaths, we actually know what works. We, we know that if we can get access to emergency obstetric care that we can get women quickly promptly um to emergency obstetric care, they'll be fine. Um There is actually solid evidence that shows that we can have the maternal mortality um if we can get women promptly to emergency obstetric care. And those steel beds, intrapartum steel beds specifically can be reduced by three quarters if we can get uh women with the babies to uh facilities that can provide emergency obstetric care. But however, the way EOC is D is delivered, means that she has to get there ok, before the care can be provided. So she has to make it to a facility to provide the care. And somehow over this last um several decades since the Safe Motherhood Initiative and the rest of that, a lot of emphasis has been placed on. You know, I'm sure we all know these three delays, you know, trying to make sure that people use care and so on. We've had incentives like the user fee exemption policy that I talked about yesterday uh to make sure that people can get out of their homes and use care. Um More recently, we've talked about quality of care. Everyone has talked about quality of care. So when she gets there, what sort of care does she get exposed to? But that bit in the middle of she getting there, it's almost like we just expect her to and then get there and I know you are thinking about there should be an ambulance somewhere. She should be able to call 111999. Yeah, those are not for emergency numbers in many of the many countries in the global South. So putting all of that in context, I just thought, look, we, we need to start thinking about this differently and maybe where we need to start from is even our definition of what the problem is. And so over the next couple of slides. Uh I want to argue for four new thinking to help us as we move this field forward. I've argued or I'm arguing that we need new thinking about our understanding of the nature of the problem. And I would explain that in a minute. Number two is that we need to have new thinking around the methods that we use for assessing the scale of the problem. OK. Tree is the solutions to address the problem and then for the targets and the benchmarks um that have been set to um address the problem. So I'm gonna walk us through these, these four things over this presentation, the nature of the problem, the methods to be used to assess the solutions and the targets that we set. So let's start with the nature of the problem. Um I don't know how many people know this video and it's interesting that we talked about Professor Mahmud Ftaa yesterday. Um But this, why did Miss, do, does anybody know, why did Mrs X? Yeah, this is like you, you get your permission to be a maternal health expert after you watch this video. Uh Why did Missus X die? Uh such a very poignant way to tell the story of the challenges of Missus X. And the video started out a week um saying that Missus X could be anyone in 2016. There was an attempt to redo remake this video and uh you would have thought that from 1980 in the eighties. When this video was done to 2016, there should have been some changes. It was still two dimensional, OK? Out of the uh but it was still missus X. She looked very similar to the 1980 missus X. And for those of you who have not seen this, I have a few screenshots of that. So um there was this panel of experts. Uh it started by saying Mrs X died. Ok, let's get it out of the way. And then there were a few panel of experts who were reviewing after several years. Why did Missus X die? Ok. Um And when they opened up a case, they reviewed and realized Mrs X is from one rural part of somewhere ex community. Um She was very poor as you can see. Uh she was so poor even when she had an emergency, she was walking to the emergency, then she started bleeding and then I think some people saw her, she had fainted on the, on the road to care and then they picked up on the back of a truck and then she died. I don't understand that story. I've seen people who are not poor. We don't live in rural settings and they die because of complications of pregnancy and childhood. And this perception of the Missus X being some poor rural woman who lives around where goats and II think it's just sort of made us think that the pregnant women in the rural communities are the ones who suffer issues with access to care. And the, and the urban women are like, oh, I'm doing ok. No. And if you don't believe me, because I'm saying it or you've not seen them in the city that you live. I pulled up some excerpts from news articles where every other week or month there is some story of a pregnant woman in Lagos in Kano, in Port Aot and for me in, in a in Ghana, so Entreso um who died because of complications of pregnancy and childbirth. So pregnant women die also in cities. Um And so that leads me to the big challenge that we have right now and what a fantastic conference to be discussing this, which is the challenge of organization. We we know that um popu countries by population increase, that the sub Sah Africa is probably gonna fill the brunt the most in terms of urban populations, people moving towards the urban urban areas. And that by 2050 we expect 950 million more people in African cities, 950 million more people, right? Uh This is Lagos, OK. This is where I come from. OK. One of those cities in in a in Africa, in fact is the largest mega city in Africa. Um The numbers are a bit all over the place but the the the state government says that 26 million people living in Lagos. Lagos is so tiny. Lagos would look like this in the, in the night time. So like every normal city, but Lagos traffic is the eighth wonder of the world. If you've been in it, you will know what I'm talking about. Right. And I want you to think for a moment about a pregnant woman trying to navigate through this Malae to get to, to get to care. But, but that's not the only problem we also have even within the cities, we have slum populations and there are pregnant women from these areas who also want to access care. In fact, there was a study um done in, in Lagos in one of the slum areas in Lagos that showed maternal mortality ratio from the slums three times more than the statewide estimates. So even within the cities, there are challenges and you, you recall the photo I showed you a moment ago. That's the other side of this bridge. This is the to mainland bridge. Then you have areas like this. Uh Macoco and I have an over you know, an overview shot of, of Macoco. This is within the city and there are pregnant women who live here who are also trying to access care. And so just talking about the slum population is just to share this in this that this is the share of urban population that will be living in slums. So it's not just a problem that urbanization is gonna be increasing is that a lot of it is gonna be slum populations also. So at some point in time, we need to really start thinking about how we deal with accessibility in cities because it's not simply a rural problem. And so what we did was to go speak to women in cities to get an understanding of their experience of accessing care within cities. And II just pulled out some of the quotes here. Um This is a 29 year old uh middle socioeconomic status, uh woman, multi power, she was bleeding uh with abdominal pain and she says that I was at home and I was having severe pain from about 2 a.m. that morning. I woke my husband up uh but immediately, um I woke him up immediately but because of concerns of safety, um at that time, we decided to leave later in the day at 6 a.m. These are challenges that people face within cities. Um There's another one here. Um It was my husband and brother that brought me here. We passed through three hospitals before we got here. But everyone knows that the people here are very caring and, and for me, that's, that's a very good example of bypassing for, for different reasons. Yes, of course, there are many hospitals in the cities but who likes them. OK, even when you have the teaching hospital in the city, um there is the per because all the most advanced cases end up there, there is community perception that if you go there you will die. So don't go there, go past that one and go a few hospitals further down the road and a few other quotes that I would not read out uh in the interest of of time II II should definitely point to this, this one about um the fact that even within the city, there are areas where cars are not accessible uh to women. OK. So we put all these experiences together of, of women. Uh And we did a different a survey to even look at how the city, the health system within the C is organized. And we, we published this paper in nature's communications, medicine. And what you will see there, the red dots represent where the poorer people represent, the poorer, the poorest people, the blue dots represent the the the the wealthier population. And what you can see very quickly is that the the entity is the median travel time that it takes the richer people, shorter time to get to care. Um The average number of facilities that they can reach within one hour is more for the wealthier population than the poorer population. OK? And that is even when, even when you include the private facilities with this is this is across Nigeria, for example, different the cities across Nigeria, you can see that it's, it's we've almost set up health systems to make sure that the poor people within cities have the most difficult access to get to care. So anyway, we, we, we, we wanted to change this narrative. And so we, we did this um advocacy video where we said, remember Missus X, she also lives in the city. OK? And you can take that QR Code and watch that video at, at your time. It's an animation, like I said that we've titled Missus X also lives in the city and we're able to show in a, in a, in, in, in four minutes, all the different challenges that women experience within cities. So my new thinking here is we need to recognize that urban and rural areas in the global south have unique problems with IOP geographical accessibility and within urban areas, poorer people and those who live in slums are more affected. That's the first thought I want you to hold. Ok. So new thinking around the metals of assessment and I've been in this space since 2015 if I remember and back then believe it or not, the way we did accessibility assessment was. Here's the way the woman live leaves. Here's the facility. We drew a straight line. Voila travel time. I'm so glad we've gone past those times. Now. Uh things are a bit more sophisticated. Now, we have geographic geographic information systems that allows us to use uh different modeling such as uh cost fiction analysis to at least cost surface and the rest of them to really then map journeys to care. OK. What some of this does not capture? Oh Sorry. Before I move on to that, what some of this does not capture are some of those challenges I shared with you in urban areas. And I'll talk about that in a minute for now. Let me tell you share with you one paper that really got me thinking and that was this paper and a a lot of the guys who are folks who are on this paper um are colleagues that I work with. But, but I can literally say this was the, this this singular figure here, started my journey in my career in looking at geographical accessibility. So I don't know if you know where Nigeria is. But I did tell you a moment ago about the color of the flag of Nigeria, which is green, white green. So I remember looking at this map and this map uh was essentially trying to replicate the proportion of women who are able to get to care within less than two hours, right? And Nigeria is sorry, I can't get a pointer, but Nigeria is somewhere there just in West Africa and it was almost green. So my first thought was that had to be the flag, you know, the the just to point to Nigeria, they colored the country and they colored the flag. But no, they were actually suggesting that 92% plus women were able to get to care in in less than two hours they like. Huh I II is that in Nigeria where, where I lived? That, that cannot be accurate. 92%. No. Anyway, so what we then did was to then compare the different methods. Look at what people had done before this sort of models that people have used to assess um accessibility to care. Um Compare that to what we used every day to get here. I used it to get here yesterday. I think today I was a pro I knew my way to the conference but II used Google Maps yesterday. I have to own up to that. Um um And then of course, we then compared it with actual drivers replicating the journeys of women. So we, we went into um case patients, records of a woman who presented in an emergency. We extracted information on where they started their journey from where they went to in the middle. And when they got to care, um use those, those um metals like I said that people have used before, use Google Maps and then have two drivers independently replicate the journey. And what you can see in that, in that in those box and Whisker plots is that the, the models are nowhere close to reality of showcasing what women actually experience in reality. OK. You can see the, the actual, the two drivers are down there. So uh long and short to that, the models do not reflect the realities of, of travel. Uh There is a tool that the WH O had put together and there's a lot of um interest in access mode as it's called an access mode allows for um you know, for you to be able to map actual pathways to care using one of the models that I shared previously. What it does not do is it does not include an element of traffic. And I think this is something myself and colleagues who are working in this area clearly recognize, but it allows large scale accessibility uh mapping. So like uh let's let's do Google Maps in those places where we have complexity of accessibility. Let's use Google maps to help us. And we, and we did that and we did that in Lagos. Like I said, being one of the largest cities, um the largest city, the most populated city in, in Sub Sahn Africa. And, and when we did that extracted over 5000 women who presented in an emergency, we mapped their uh their journeys to care. And what you see up here is a chart that shows every dot represents where a woman started her journey from. And when it's red, it represents that the woman traveled over an hour or two hours to get to cake. And so with this, we are able to, wherever you see an aggregation of red dots, it it shows that accessibility is different, is difficult in those areas and we're able to show this to the government in, in Lagos, say, look, women in four clusters as we define them were areas that, you know, women were experiencing particular difficulty in getting access to care. And this led to a lot of change. Uh It really informed policy, it helped with government deciding on where to build new facilities, on areas that needed to be optimized. Uh because it wasn't just simply about building facilities, sometimes it was about road networks and, and, and, and, and the rest of them. OK. So anyway, th this led to II will skip this Google part. Um You know, it, it led to Google reaching out uh with partners, set up my group, uh my group which we call the on time Consortium on time being on tackling inr delays for mothers in emergency. And Yeah. Yeah, yeah, Google became my best friend doing this work. Um And I'm really treasured and we've, we've worked together using Google data now to develop a digital dashboard. And II also put a QR code for that which you know, moves and is linked to Google's API and allows you to be able to estimate, look at geographical coverage of accessibility to care. Um The first, in the first phase we worked in Nigeria, we're now scaling this up to other um uh large cities, Uganda, Ghana uh being prior to cities and surface here. He has worked on the Ghana, collecting the initial data uh for mapping facilities in, in, in Ghana. OK. Uh By the way, it doesn't work well on your mobile phone. So use your laptop for it. OK. And we've been able to then come up with some suggested geographical accessibility metrics. Uh looking at um travel time, the percentage of women of childbearing age that can um uh access care within 1530 60 minutes. Uh the number of facilities that they can reach and the number of facilities is really important because we, we think women should have a choice on where they go to, you know, so this a lot of these assessments tend to look at travel to the nearest facility. Why does she have to go to the nearest? Ok. And we've done this looking at public facilities, public or private. We've looked with the Google data, we're able to sort of mind travel time at different times of the day. Um look at it weekend, weekday and at different geographical uh layers, whether it's at um what level local government or across the entire city. We published this paper in the lancet Global Health. And um I won't bore you with the details of the result, but you can see the variation, ok. That, that's up there. You can see us looking at the nearest, second nearest or third nearest and of course, we can keep going on. But again, we have to be pragmatic. This is an in an emergency. She's probably not going to leave London to Southampton or maybe uh to Edinburgh um to get access in an emergency. Ok. So we're going to the third nearest and um we were able to do this on a very granular level. Um even to specific words, specific communities to show variation at different times of the day. And this is sort of evidence that we think can really drive policymakers to make informed choices on how they fix emergency obstetric care, geographical accessibility. So, so my new thinking here is that in terms of how we assess uh geographical accessibility to emo uh it needs to better reflect realities of on the ground. And even though Google is not the best for the rural areas, it certainly works for urban areas and where in the rural areas where we have some stability. Uh There's not a lot of variation in those certainly access mode which wh has used would be a good tool to use. The top bit of my presentation is on the solutions and you would know many of these solutions. Uh I'm sure some of us over the course of this presentation have been thinking about. OK. So what can we do? I hear you and I'll give you a few examples. Um These are community based first responders being trained in Edo State Nigeria. Uh they were gonna be placed in local communities to support. Um Well, specifically in this case, emergencies across board, so not just pregnant women but they do see some pregnant women so we can place people within communities. Of course, you can expect that there are the ambulances and this is the Mmr scheme in, in Tanzania, which you have ambulances that going to rural areas. Again, the emphasis of mmr being very rural, rural focused, uh, you have the one way scheme in India. Um, um, here you can actually call an ambulance and get a response. Right. That's what I read. So which, which is really good. Uh But in, in Lagos where you have ambulance services, uh I think they really work more for inter facility transfer rather than coming home. Um uh for that, you can obviously build facilities in areas where there are, there are no facilities a a and so on but so on on and I put the elephant there, sorry, there, there was a lot of this sort of building hospitals in every single area. II you know, someone described that as a white elephant project. You know, of course, politicians like this, you know, it's the one thing you can do that. Everybody sees that you've done something even though the hospital breaks down in a couple of years after you leave office. But yeah, you know, you can do it. Uh But Chapo let all argued in the B MJ paper that that's certainly an example of a of a white elephant project. So certainly we need to be a bit more strategic in terms of where we invest. Um the, the UN FP has worked in terms of looking at this and they said, look, it may be a more cost effective option is looking at how we optimize the network of um EOC facilities. Ok. And they, they, they call a workshop together, people decide on which EOC facilities should be prioritized, prioritized in terms of services that they they can provide. So my new thinking here is that certainly it's not a case of one size fits all right. This approach that, yeah, we need to get ambulances. Oh, we need to be at the hospitals. That's not it. Areas, different areas, urban versus rural slum areas and non slum areas. We need to have bespoke um interventions um that, that cater for the needs of people there. And II put here that we need to probably consider a care delivery system that principally takes a month to pregnant women in rural areas and takes pregnant women to em in urban areas. And lastly, in terms of the targets, um I'll start from it has I have to start on this book. This is the Holy Grail for emo accessibility. Everybody knows that. Right. Right. This book, it's been updated right now, which is fantastic. But when it was first written uh and published in 2009, it, it talked about um most women needed to get care within 2 to 3 hours of travel. And I have asked everyone about the science that informed this benchmark. Uh, the best answer I've got it is that, uh, it took about two hours for pregnant women to die from postpartum hemorrhage. So that should not be the benchmark. That's the benchmark to death. So we need to be thinking about something a bit sooner than that before. Uh, and said that as the benchmark and, and this, this has fed through, it has fed through into the Emm Target. You see Target four over there. It is still talking about two hours and it is talking about most women. And my question has always been what happened to the leave, no one behind. If we're happy to leave 50% of women home, they don't need to get to care. Then why? What about this mantra? So anyway, um we've done work that has shown that it's not just not ethically right to do it is actually, we're actually, we're actually doing something very bad because the evidence we've shown from work, uh where we've looked at travel time and maternal uh debt as well as still has shown that potentially for still babies are a lot more physiologically fragile compared to women. Uh They need about 10 minutes, 15 minutes. Optimum trend. We showed clearly that the odds of dying was significantly higher with travel time of more than 10 minutes. So that two hours is too generous time. And even for pregnant women, inter facility transfer or greater than 30 minutes was significant, led to significant sig significantly higher odds of maternal debt. So clearly, we need to be thinking about this time better. So my new thinking here is that we need to have context specific clinically relevant and evidence based benchmarks for EOC ge geographical accessibility that reflect on ground realities of women in those settings. So as we look forward into the future and as I wrap up my presentation, um you, I've, I've talked about this 44 areas of new thinking that we need to look at. Um II, really think beyond it, helping us to take us closer to realizing universal health coverage for those who are thinking about the investment case. It definitely guarantees value for money because now we can be more strategic about where we invest and we are really thinking about this for those who it matters for the most, which are the women. I firmly believe that every woman, every pregnant woman in emergency needs to be able to safely and quickly reach functional health facilities. And that has to be the thinking, not most women, every woman. Thank you very much. Fantastic. Thank you so much. That's, that's really insightful and a real challenge to our, our senses. Thank you. So we're getting questions through on the app. Thank you to all those who submitting them. So a question here about the model that you're using with the Google app. You said there's all sorts of things incorporated in it. But Wendy Graham rightly points out that other obstacles like finance, which can that somehow be incorporated into the model? Have you thought of other ways of looking beyond just those purely physical processes? Fantastic question. Thanks a lot, Wendy for that. Um So I, I'll, I'll tell you what the utopia of this is. Um And I think when you spot on, first of all, is, is that there are, there are many other things. It's not just about how far or how close. Um It's how expensive, it's how it's how, how much of um the, the, the the quality of care, the expected quality of the perception of the quality of care. So there are a few other things. The utopia for me is us using leveraging technology where we can actually incorporate all of these things together and build for the want of a better word. Um The Expedia of EOC accessibility to care or if you use booking.com, if that's your preference, whichever one works for you. Uh Because when I see those platforms, what they offer, they tell you the distance from the airport to the hotel, they tell you the perception of the quality of care in the review scores, they tell you the cost of sleeping there per night. All right. So they give all this rich information and then you can make an informed choice on where you need to go to part time. I also think specifically in the context of accessibility to care for pregnant women. Um It also needs to be a platform for connectivity between women and the health facilities. So that even in the middle of the emergency, they can you know, make a connection with the health facility, health facility says yes, we have bed space because that's another consideration. Yes, you there's a facility, yes, you can pay for it. Yes, you've heard that the quality of care is generally good. But do they have a bed at the time is needed? So I think there are a lot of things that we can incorporate and that's the utopia of this to develop that one stop platform that can inform not just policy makers on actions they need to take but for women themselves in an emergency on where they need to go to part time. Ok. Fantastic. Thank you. Can I take chair's action and ask you a question? I suspect that what you've been addressing. Had we asked women in the slums of Nigeria 20 years ago, they would have told us all these problems, but they've been excluded from decision making and traditionally been this big mismatch between the decision makers who are often white male, 58 year olds like myself and those who are actually suffering the problem, the most vulnerable who by their nature are disempowered. Voiceless. How can we try and incorporate their voices into decision making? So we don't end up having to wait for many years until we really understand the nature of these problems. Brilliant question. And so that paper that I showed on the reaching emergency care and LATS was us engaging with women. We engaged with 56 women then who actually presented in an emergency and actually got their stories. I've always sort of described that journey to care as a black box in um in the way we sort of engaged or understood as a health system, um how women get access to care. So we spoke to women, we asked them, we wanted to understand their journeys to care. Um The sort of things that they needed to support them in care. We've done that. I think there was one missed group in that conversation and that was disabled women because I think somehow they are lost in the conversation. No one really knows how disabled women who are in an emergency gets to care. No one. but it's something that we're hoping to address in our next engagement uh with women or all, all true um adolescent, how they engage care. Um you know, um refugees, asylum, all these sort of they, they are women, but they are particularly vulnerable women. Even in these communities, we need to sort of engage with them to understand the access to care. And hopefully we can then elevate their voices to inform policy choices going forward. Ok. Thank you. It's exciting that you talked about the process being expanded beyond Nigeria. There's a question also about you're talking about expanding to other areas in Africa. What about Asia? Have you had engagement from India? From Pakistan? Yeah. No, not yet. But I, I'm sure this is essentially what Nigeria was and I, and I've heard this before and this is not in trying to minimize the, the challenges, the global challenge of maternal mortality. Someone said non Nigerian said, if we can fix maternal mortality in Nigeria would have fixed the world's global mortality problem. You know, I've heard that before and it was not in Nigeria, II think certainly um the the plan for this is that over the next couple of years, we started with Nigeria. First of all, we scale up across multiple countries in Africa. And then afterwards, we look at uh uh uh Southeast Asia as well as um the car, um Latin America. So those are areas that we, we strategically ex you know, exploit linkages. Uh that is a fantastic group in, in, in Colombia uh who has also been working in similar things, not specifically for EOC and we are planning something in future to, to work with them. And certainly also in the Southeast Asia where we have some connections also. OK. There's a cluster of questions around if you're going to expand, moving care into areas where it's most needed rather than trying to improve sort out the traffic or get a helicopter or something to get people out to try and improve care. Are you going to use this as an advocacy to try and improve community based care? Um And if you do, how's that going to fit in with trying to get supplies and try to get equipment to all these really quite small isolated clinics, well, not isolated but smaller clinics. How have you had thinking around how that might work? So, um II, think I talk very briefly about that. Um I showed the first slide of this community based first responders uh which has now been trialed now um on a spinoff project that we have called the Evidence for on time in those states. And these are community based um trained community based health personnel who are placed in local communities to provide care to pregnant women in those communities. Um And I think they're setting that model, which was the new thing I was arguing that I think for rural areas, there was a time when we had things like maternity waiting homes, uh which was always a stop gap before you get to, you know, the big hospital in the in the city. II think that model cannot go away. Uh Because frankly, we know that governments have lots of uh priorities that they have to deal with. There's a lot of um um building a hospital, like I said, is a huge investment and some will call this a. Um um I argue that this is it's sometimes a white elephant project. So I think trying to build and equip every single facility might not be the way to go is about strategically deciding on where is the optimum location for the one or two facilities, big hospitals you want to build, where do they need to be such that geographical accessibility to them is sufficiently optimized to allow the majority of women to get there on their own. And then those who are away from there have um the support of community based first responders to get them to those places. Um To the point you made about helicopters. II think it would be fantastic by the way in the at some point in time. But I think there are simple solutions. Um I look at a place like Lagos that has bus rapid transit lanes, they call them that, that dedicated lanes to to buses where actually there was a there was no legal right for anyone in an emergency to go on them. But if you went on them, you literally skip past traffic if you are legally bound to and the police was not stopping you, you know. So we think those are those small things that don't they, they are there, there is committee advocacy. If I and I'm sorry, please Lagos accepting when I come back, I'm not bashing on Lagos. But if you go to, if you're driving Lagos and you were driving in an emergency, trying to wade through traffic. I said please, please, please II need to drive to somebody will wave back to you and say, look even I am in an emergency, I'm trying to get to work. Ok? We all have emergencies. So even community awareness of the right to give way that can drastically even change there. So II don't think we are talking about big high cost um interventions. We are talking about some small ones almost like a, a basket of interventions that can potentially make a significant difference. Ok. Fantastic. The final question, we just got 45 seconds for is that somebody's asked a very pertinent question, which is your graphs are fantastic about how distance and poverty affects access. But I wonder if that's also been done for outcomes because you could do a very nice if you had a big enough dataset about mortality or more related to both distance shown by a straightforward Google or by your application, you could expand it quite well if you had a big enough dataset. So I maternal mortality is huge but still rare. The work I presented where we linked outcomes to travel time. Um We had about 100 and 82 debts and we geographically represented this to show where the debts were, were were highest. So I think that's in the B MJ Global Health uh paper. So we've done that. But hopefully, what we, what we plan to do is beyond now is those debts I you build on them. So it's not just a static representation. You have something more dynamic to show where a woman would, who died. Unfortunately, due to complications of preg where did they come from? So hopefully, we can build a dynamic platform that can showcase that way forward. Brilliant. Thank you very much. Thank you so much. Round of applause, please. Thank you. Thank you very much. Thank you, Doctor.