Anti D -An interview with Dr Sara Wickham

[Music] On this episode we talk to Dr Sarah Wickham, a midwife, best-selling author, speaker and researcher. Sarah is the Director of the Birth Information Project. She divides her time between speaking, writing, facilitating online courses, creating resources and undertaking consultancy services for midwifery and health-related organisations around the world. Today we are discussing all things NTD. Who discovered it? How it's made? What monkeys have got to do with NTD? The limitations in the research and where we are at in current maternity practice. It's a jam-packed show. Plus Rachel and Sarah discuss their, let's say, unusual hobby of being guideline detectives and also why Rachel is scared of orangutans. Sarah's passion is getting good information out so women and families know what the evidence is and know what they want to do. This episode is both wonderfully informative and full of discoveries. You've probably never heard before and of course some laughter along the way. So go on then, get your lug holes ready, you're in for a treat. I'm Katie James and this is the midwives cauldron podcast. Each episode I'm joined by my incredible co-host, Dr Rachel Reed. Listen in as we Hubble, Bubble, Toil and Trouble are way through aspects of womanhood, midwifery, birth and lactation. So go on, subscribe now and hear us on your favourite podcast host. Hello! Hello, good morning! Good morning, good evening! How are you? I'm very excited about Rachel Reed's Instagram swipe up link. I know! I made a story about it! I saw your story from yesterday, Katie. I can't remember why, I don't know why I came up, but I saw your story and I was like, "Right, I'm going to see you're in my stories today, Rachel." Celebrating, obviously we are on the podcast to chat about Rachel Reed's, the birth, the Rachel Reed's Instagram swipe up link. That's exactly why you're here. I'm so excited, I still have a conversation about it. Love this Sarah, that's the best. My problem is Sarah, I was just saying like, it's all very exciting, but I actually haven't got time now to work out what I do with a swipe or how to use the swipe. So that's going to have to be next week, so I'm going to have to just like put my celebration on pause and let everyone else do it for them. Did you tell Katie the very first conversation we had about it and you were really sad? Yes, because I thought I was trying to work out to get a swipe up and you kindly informs me that I wasn't important enough to have a swipe up. I didn't say that, I didn't say you weren't important enough. You spoke to me, and you pleased that we had to do that cool swipe up thing that you do in your stories. I like it when you can find the message that I said, I'm really sorry but you can't do it because you need about 10,000 followers. She did tell me this story. I said I'm really sorry, but you just stopped trying because you can't. She's like, I can't find the button to do the swipe up thing. I haven't given it to you yet. I'm really sorry. I'm just so happy that you've got it now though. You watch, I'll be swiping up everything. I should be, honestly, I'll be cheering you on every step of the way. I'm beside myself with the excitement that you've got to swipe up, Blake. Yeah, it's not the fact that it's 10,000. It's the swipe up. Yes, exactly. You're the person I referred to in my little video when I said, and Rachel was angry because she was like, and I can't get this bloody swipe up and Sarah's then told me that I'm not important enough because I need 10,000, and I'm not important enough. And so when I said she was angry and there was someone quite famous who might be coming on our podcast, it was you. That's who I was talking about. Before the record, I absolutely didn't say she wasn't important enough. I'm having the followers. At least there's just been really clear. There is absolutely no correlation between number of followers and importance in the world. I mean, it's really important, important thing we need to know about. So cool. So we're going to do a whole podcast on your Instagram. Yep. Yep. In fact, that's it. Thanks, Sarah, for coming on the podcast. Oh, Sarah, it's just such a joy to speak to you and have you on the podcast with us, and it's so lovely to meet you as well. Well, it's lovely to be you too, and thank you for having me. I've been listening to the podcast, so I'm very excited to be here. So Sarah, welcome to the Midwives' Cauldron. I am so excited to get you on. We've talked about this for some time, and you know, used, let me first of all tell you so because you probably don't know how I first met you. So I had followed, I had followed you from a student midwife, and I'd followed you writings, and when I came to Australia, you were coming to Brisbane. So this must have been about 2004, five-ish, and you're coming to do a day workshop in Brisbane. And I drove all the way down to Brisbane, and I got there, and I was a bit radji because it was a bit early, and I couldn't get parked. And I came in, and there was you setting up, and I just thought to myself, right, how is she going to pull this off, and keep everybody interested for an entire day with just her. And you did, and it was amazing, and I went away, like, going, this woman is absolutely fantastic. So it's been really lovely to then get you to know you as a friend and a mentor many years later, and have you on my podcast, so welcome. Well, thank you. That's so lovely. I didn't, did you come to say hello to me on that day, because I wish I could remember the day. Oh, I probably wouldn't have. I'm a bit of a weirdo and introvert at events. Well, I'm really glad that we've got to know each other since, so that's fab, and thank you very much to you and Katie for inviting me on. So I'm, yeah, I'm excited to be here. Absolutely. And it's just a real treat for me, because obviously Sarah and Rachel have a relationship and have known each other. And for me, I'm like, Oh, I'm like the, I'm like Rachel back in 2004. Do you have been integral to so many midwives, to so many moms and families over the years, with your writings, with your work, and with 15 books previously. And we've brought you on to discuss anti-D explained, which is a new book that you are about to launch. And we really, like, this is one of those topics that we just, it's one of those topics that it's so difficult to find more than just a brochure or an information leaflet, or perhaps what the policy is in your hospital. And that's why it's so exciting and so important. The work that you do is to just give a wider, a broader look at this topic. And so it's just a pleasure to have you on and to be able to discuss a bit more about your book and why you've written it. And what's in it? Well, thank you. Which would you wish would you like me to answer first? Why did you write it? Start there. Well, I wrote it. So I have to start this story about 25 years ago, if that's all right. About 25 years ago, two women asked me the same question within a just a few weeks of each other. And the question of pregnant women and I was working as independent years of her life. And they both sent to me, do I really need anti-D? They were racist negative. Do I really need anti-D when I have my baby? And if I don't have anti-D, what's the chance that I'm going to become sensitized without it? And I didn't know the answer to that question. And so like many midwives do, I said, well, I'll go and see if I can find the answer to that question. But it was actually extraordinarily difficult to find the answer. And one reason was that, as Katie said, there really are just leaflets around. And there were books that also is going to be possibly hard for people who are younger today to imagine. But 25 years ago, you couldn't google things. And just put something in and find out a research paper. If you wanted to find out the answers to these questions, you had to go physically to the library. Yes. And I was working as a midwife in a relatively rural area at the time. And that was quite an undertaking. And no, one had to go to the library and dig around in all these dusty yellow old medical journals. And so I couldn't find the answers immediately for these women. And so about a year later, I ended up doing a master's degree. And when I needed a research topic, I remembered this conversation or these conversations. And when I'm going to go and look at that, I'm going to go to the library. I was by that time I was living in an area with a really good medical library. And I said, I'm going to go and see what I can find out. And so I mean, I'll try and shorten the 25 years in between. But I wrote about anti-D at the time. I did some research looking at what holistic midwives knew and thought about anti-D. Because when I went to the medical research, I found that I could get some of the answers. But there were some really big gaps in our knowledge in what we knew. So I did some research at the time, both in looking at what the medical research could tell us. And also what midwives knew and midwives theories about this. I wrote a couple of articles because again, 25 years ago, you couldn't just put something on Facebook, which didn't exist, and say, hey, who wants to come and talk to me about anti-D? I actually wrote a couple of articles in midwifery journals with the help of the editors and said, if anybody knows about this or has thought about this, or has done any research, please come and talk to me. Please get in touch. And so that was really how my research began. A publisher saw those letters and was interested in my research. And in 2001, they approached me. I published my very first book ever, which was called anti-D midwifery panacea or paradox. And it was about what I'd found because I knew that more people had those questions, but didn't know where to find the answers. So that was my very first book. And as you said, Katie, I'm in another sort of, depends how you count my books. I've written another 14, but actually I've written, if you count the fact that two or three of them have been updated several times, it's kind of even more than that, but it feels a bit like cheating to say it's more. But so I've written lots of other books. And over the years, people have kept saying, will you update the book on anti-D? And yes, yes, I will one day, but one day didn't come until 2020 and the pandemic came along. And at that point, the stars all aligned because the book that I was writing in 2020, I realised I had to put on hold for various reasons. And what also happened was it was the 2020 was roughly the, it was the 20th anniversary of my first book. And it was the 50th anniversary of anti-D being brought in as an intervention. So that's what I mean when I said, like the stars aligned and I was like, okay, so like lots of other people, I am hearing lockdown, I'm a lockdown extra, but I'm really bored. So I decided that I would rewrite, well actually it's not a rewrite, I shouldn't say that, I would write a new, but the first was very much about my research. This book, anti-explained, is much more, it's like one of my other books is quickly struck, explained, but like that in my juicy labour and vitamin K books, it's very much written for parents and professionals because I'm explaining everything for somebody who doesn't know anything about it. So we go right from the beginning and then we get into, you know, what are the complexities as well. So there we go, that was a very long story, but that's how the book came to be written. That's the story of the book, it's been 20 years in the writing and it's here. That's amazing. I love it. And the stars did line, 50 years anniversary of anti-D being brought in and 20 years since your first book, bloody awesome. Absolutely, it's perfect timing. And anniversary. So that leads us perfectly into what is anti-D, why was it brought in? Well, so, okay, anti-D, so there's two different kinds of anti-D. When we talk about anti-D, we are referring, we might be referring to a substance made in the bodies of recess, negador, blood of recess negative people. I'll come to that in a moment, but we also might be talking about a medicine made from blood, which has the same name. In my book, I'm talking about both, but I'm really referring to the medicine that we offer to recess negative women, who might have been exposed to recess positive blood, if they've got a recess positive baby during pregnancy, on birth. So, for instance, if, when one gives birth, or if she has an accident that wants her tummy, or there's some sort of invasive procedure in pregnancy, it's possible that some of her babies blood can enter her bloodstream. And those are the situations in which anti-D, the medicine is offered. But, I mean, I don't know. Would you like me to just explain about the recess factor? Because most people have it, so we can classify our blood according to blood groups. Most people know about, you know, the ABO system of blood group typing, but another way of classifying our blood is human blood, is whether somebody has the recess factor or not. And most people have this, the numbers of people, the percentages of people that have the recess factor, do vary a bit according to ancestry, you know, where, whereabouts in the world your ancestors came from. So, about 15% of people of European descent are recess negative and 85% are recess positive. But if you go, if you're going to actually go and look at people of African descent, it's more like 8%. That's an overall figure. That's looking at the entire continent. It does vary a bit in the country. In Asia and in, you'll probably know this, Rachel, because in some populations of, in the Mardi in New Zealand, in some Pacific populations, it's 1% really, really rare being, being recess negative. So, the people who are recess positive, we don't worry about them, because they're not going to have a problem in this situation. But if somebody who has recess negative blood encounters recess positive blood in their bloodstream, so for instance, I mean, this never happens nowadays, because now we know about it, but in the past before we understood this, occasionally somebody who was recess negative would accidentally be given a blood transfusion of recess positive blood. But also, as I said before, there are situations where if a pregnant woman is recess negative, her baby's recess positive blood can sometimes enter her bloodstream. Now, when that happens, she can make antibodies against it. And those antibodies are the first kind of anti-d that I mentioned. The antibodies, the anti-d, antibodies that are made in, in the woman's bloodstream. Now, I mean, the making of antibodies is, of course, generally a very fab thing to do. It's a very useful mechanism. We want to make antibodies against viruses, for instance, very topical that we don't want. We want antibodies against those things. And it's also really important for me to just mention that if a woman who's pregnant makes antibodies, or even if she makes them before pregnancy, as I said, but that is very, very unusual. If she makes antibodies against the recess factor, and then she later becomes pregnant with a recess positive baby, that's when we can get problems. Because those antibodies are now circulating in her blood, the anti-d antibodies, and they can enter her baby's bloodstream. And if the baby is recess positive, that can cause a range of problems, which can sometimes become serious. And that's why anti-d, the medicine, was came about, that's how it came about in the first place, because we were trying to solve those problems. So, I mean, there's lots of signs behind this, which I know we don't have time for today, but the upshot is that scientists realize that if recess negative women, is it risk of her babies blood, her recess positive babies blood mixing with hers, but if we give her an injection of a medicine made from blood that contains the anti-d antibodies from other people, she won't then make her own anti-d antibodies against it. And that means that she won't have those antibodies if she becomes pregnant in the future with a recess positive baby, that baby isn't going to be at risk. And I think that's a really important point, Sarah, a lot of people don't know, which is that anti-d is made from blood. Absolutely. And when I first started talking about this, which, as you know, no, 25 years ago, so few people knew that, it really, really shocked me. I mean, I can't remember whether I knew it at the time. I think I found it out very quickly when women were asking me this, one of the things that shocked me the most at the time is that I would talk to rooms full of midwives and often doctors, and they wouldn't have a sense of that. And one of the things that really struck me at the time, in particular, is that if you go, if you're working, for instance, as a hospital midwife, and you go up to women with a bag of blood and say, well, so, you know, we've discovered that your eye levels are quite low. And so we're going to recommend that you have a blood transfusion. Is that okay? Now, not everybody will question it, but actually, in my experience, tell me if you would agree or disagree, Rachel, quite a lot of women will say, well, do I really need that? There is a reluctance to have blood unless it's necessary, and that's a very understandable reluctance. But what I was seeing at the time as a midwife, and I talked to many midwives, and they said the same thing, is that when you go to women with, instead of a bag of blood, you go with a syringe, which contains yellow fluid, that's the anti-d, and you say, well, so your baby's research positive, you know, shall I give you the anti-d now? Women weren't saying the same thing, they were saying, okay. And so that really made me question, say, well, do women know that this is made from blood? And no, I think that is changing now. I think that I've seen that change over the past 25 years. So I think there is more awareness of that now, and I think women when they get told that now, but absolutely at the time, that was a huge issue. And it's not just one person's blood, is it? No, absolutely. So, anti-d is made from pulled blood, which means that the blood, I mean, to become a blood donor for anti-d, you have to be a pretty cool altruistic person, because you have to be racist negative, and then you have to let the people at the blood transfusion service, or wherever you go to donate the blood, you have to let them give you somebody else's racist positive blood in order that you become ishumanized, so that you make the antibodies, that your blood is then going to protect women from making. And just I'm having such a fun time. Like my mind is blown. I had no idea about that. Did you not? All do you have done? Hold, pop me labia. That's the best comment everyone's had with then. Brilliant. That's in the podcast. So we're going to get we're going to get a cordon referencing now. So wait for this, I've only just thought of this. So we know these lovely people, and actually there was I saw a couple years ago, there was a guy in Australia who was being celebrated because he was, he had over probably most of the 50 years that anti-d has been available, donated so much blood that's gone to make anti-d. So I don't, there are loads of questions that we need to ask about anti-d. It's very complex. I absolutely think that women and families should get loads of information, and that's, you know, that's why I write about it. But I don't want to downplay at all how really quite amazing this is as well. So you, we have these altruistic donors that allow the nice people at blood transfusion service to inject them with somebody else's recess positive blood, so they can make the antibodies. And then their blood donation is taken. Now, I mean, what I'm about to say is not exactly what happens, and you may well get the blood transfusion people ringing in. But in simple terms, what then happens is that all the blood donations taken from these lovely recess negative people who've been given recess positive blood, so they make their own anti-d antibodies. They're all sort of into this a cauldron at the blood transfusion service. Do you like that? Love it. Nice. They're also putting this big cauldron. It's very clean. It's all, you know, it's all very sciencey and metallic and whatever. And then it's pulled together. That's the, that's what I'm trying to get across is this anti-d is made from pulled blood. The blood donations are mixed because it's a very complex process to make it. And they need to in the blood and do all sorts of clever things that I'm not going to begin to pretend to understand. But yes, so to answer Rachel's question, when you have a blood transfusion, you're generally receiving blood from one donor that has been cleaned in its own little mini cauldron and, you know, and made into one blood, one bag of blood for your blood products. With anti-d it's pulled together. That's the process of how it's made. So yes, it's, we call it pulled blood. I mean, what I will say is that I know that there is a concern and there's a very real concern about the fact that it is the A is blood and the is pulled blood. So people say, but I'm then taking on the risk of lots of people, you know, lots of other people and what might be in their blood. And yes, and it's a really tricky one this because it's really important to say that there is absolutely a risk of viral transmission from anti-d as with any other blood product. And it's important that we're honest about that. But it's also, I think, important to say that the people that work at blood transfusion centers around the world are doing their absolute best and they are testing for everything they can test for and they're putting blood through all sorts of procedures. So that that risk exists. I'm not going to deny that exists and I think it's important we know about it. It also think it's important to recognise that, you know, there's some fabulous science going on to protect people as much as possible. If we're talking about, you know, we've talked about the controversy of why we need to know more about anti-d. Can we weigh up the risks in terms of if a woman decides, you know, this feels like a risky thing for me to take. I've now found out this is pulled blood. I don't like the idea of that. But what is the risk of her having transmission from her baby into her blood and potentially making antibodies for that next pregnancy? So how do we weigh up those risk factors? Well, it's really hard to answer that, Katie, and one of the reasons it's really hard is that the mixing of blood can happen in different situations. So when the anti-d was first kind of discovered, I mean, it wasn't discovered, it was made, you know, when the anti-d program first started, the concern was about getting, the concern was about sensitization that was happening around and after birth. So the first time, the first point at which anti-d was offered was post-natal anti-d. So when a racist negative woman has given birth to a racist positive baby, and we know we check after baby's born so that we know that the baby is racist positive. Because of course, if a racist negative woman gives birth in the baby's racist negative, there's no problem. That's not an issue. So the kind of the baseline intervention was when a racist negative woman gives birth to a racist positive baby. And this was really the question that those women were asking me. And so in order to try and find the answer to that, I had to go back to the original clinical trials in this area. And look, not just that, I mean, to some extent, I wasn't interested in what happened in the women that got anti-d. I mean, I can tell you what happened is anti-d is extremely effective. We don't know exactly how it works, but we know that it does work. We know that if you give somebody anti-d in that situation, they're very, very unlikely to become sensitized. So it works. It's really effective. That isn't in question. But the question that you've asked and the question that women are asking is, well, what about if I don't, what about if I decline the anti-d? And what we know from those trials is that the women in the control groups who declined the anti-d, I mean, I had been, I'm going to say led to believe, as a student midwife, that if you didn't have anti-d and you were racist negative and you've had a racist positive baby, that you were almost certain to become sensitized. And then when I went to the studies, I found that actually that wasn't true at all. In the studies, in those original clinical trials, most of the women in the control group who didn't have anti-d, about at least 85% of them weren't becoming sensitized. So about one in seven, it depends on what date you look at. The reason I'm slowing down and hesitating is that actually the data that we've got, the research that we've got, isn't of brilliant quality. And this is a enormous problem, I actually saw a lot of time talking about in the book. So these clinical trials were done 50 years ago. So we have to be nice. It's like expecting a film that was made 50 years ago to have the sort of special effects that we can do today, you know. But we have to accept that 50 years ago, people didn't know then what they knew now. But when you look at the quality of the trials and the fact that they weren't effectively randomised, there was no blinding. So everybody knew, the women knew whether they were having anti-d or not, the clinicians knew, well, I'm not so worried about blinding in the trial of a drug, as I am in, you know, a trial of something where knowledge of what you're going to have might affect your outcome, because of, you know, what's going on in your head around that. There are some issues with those trials. So this is where it gets starts getting complex and uncertain, because we can say it from those trials that, you know, around between one in seven and one in ten women become sensitized after birth, who are recess negative, who've had a recess positive baby, without anti-d, within the context of the clinical trials that were done 50 years ago. That's what we can say, which doesn't completely answer the question. Tell me Katie, I'm really enjoying watching your face, and I'd love to know what you're going to say now. I think I'm just absorbing the fact that I love your analogy with the CG of films 50 years ago and thinking about research in that context is fascinating. I mean, I had no idea, obviously I moved into the breastfeeding world a long time ago, and so sort of anti-d hasn't really been on my radar. So just knowing these kind of statistics that it feels like it's an area that we've got a certain amount of evidence, we've got a certain amount of research and we've got positive results, but also it seems quite vague in the fact that we did a lot of this research such a long time ago, and then it's not really been picked up or looked at for another long time, and that for me is like, gosh, why is there not this interest in this? And I think surely there is, because women are now asking those questions, you know, there's massive debates about vaccinations, the more we find out about things, obviously the more questions there are. So why is this not really being looked at further or why are we not repeating those trials with better controls and using the more modern way of doing things? What's also interesting is that you were talking about those studies, those studies were done post-birth, so that was after the birth event, if you want to call it birth and event, but you know from when I first started practicing midwifery, we would not offer anti-D unless the woman had, you know, fell down the stairs or something, was in a car accident or had a bleed, and then we would test the baby after birth and then offer it if the baby was positive, and then when I came to Australia, it had moved, I don't know whether it had in the UK, but it had gone to, no, every woman in pregnancy who is recessed negative gets anti-D in pregnancy. Never mind what the baby is, the baby could be negative. That's the only change for me when I moved to Australia as well. But it is now, I mean it came in, I'm not going to see if I can flip through, but I think it was, or I don't want to say without double checking, I'm going to tell you the year it came in in the UK. There was several questions in there, and I'm going to try and remember all of them, but you're welcome to like remind me if I have, but 50 years ago, the first intervention was about offering anti-D post-naturally. And as I said, anti-D was very effective and that did cover, it prevented most cases of sensitization, but some women still got sensitized because birth isn't the only situation in which the baby's blood can cross into the mother's bloodstream. The second situation, I mean chronologically, what then happened, as you both sort of talked about, is that when if women had an invasive procedure in pregnancy, or a car accident, where there might have been some sort of small injury to the pleantra bit of blood may have transferred, then they were offered anti-D. And we talk about these sorts of situations as potentially sensitizing events. So anything that happens and birth is also a potentially sensitizing event, we're only talking about a tiny amount of the baby's blood. In, you know, the scientists refer to this as fetemoternal hemorrhage and part of me wishes they wouldn't because when we hear the word hemorrhage, we tend to think of like postpartum hemorrhage or the sort of hemorrhage that you need on a, you know, at the end of a police TV drama, you know, death and paradise sort of hemorrhage. And we're talking about like one or two milliliters, you know, a really tiny amount. So I think that's, you ever see the words fetemoternal hemorrhage, that's what you need to remember, potentially sensitizing event is any point at which that could have happened. And so it was sensible to offer anti-D because medical procedures like amniocentesis, they do carry a risk a chance of the baby's blood entering the maternal bloodstream. So we should be offering anti-D at that time. Now whether or not the woman wants it or not, that's up to her. But we should be offering it because that the risk of fetemoternal hemorrhage trans percental transmission, whatever you want to call it, that that chance is there. But what then happened, as you said, is that still a few women were becoming sensitized. And this is where it gets really controversial because depending on what kind of how you look at it, you either believe that route offering routine anti-natal anti-D impregnancy is justified, or you look at the same data which I do and go, "Oh, I'm really a bit concerned about this." And I mean, I'm concerned, I was concerned when the conversations about routine anti-natal anti-D began. And the reason was that we had good evidence that the current program where we offer anti-natal anti-D to racist negative women and experienced a potentially sensitizing event. We had good evidence that that wasn't being followed. There were several studies that looked at what. Well, actually, there were different studies, but one study, for instance, looked at women who had become sensitized. And then they looked back through their notes about, "Well, why had this happened?" And in many cases, actually, there was a potentially sensitizing event that anti-D hadn't been offered. So what that means is that we're talking about a system of failure, or a human error failure. And I'm not going to sit here and berate health professionals on an individual basis, because often this is about the systems not working. The giving anti-D offering anti-D is a very complex system. There are so many things that have to happen in order for a dose of anti-D to get into an individual woman. It's an awful thing to think about, but occasionally systems fail. And so what I would have done at the time when they were looking at bringing in routine anti-natal anti-D, as I at the time was calling for more work to be done on whether improving the program generally would reduce this problem rather than giving every woman, or offering every woman, anti-D, at a certain point in pregnancy, simply to compensate for what might have been failures in the current program. That makes perfect sense. Absolutely. I mean, it's a common sense approach. I mean, if I can also go back to your other question, though, about, you know, what happened, because you asked Katie about, you know, why haven't we got better information? And the reason is, well, I'm going to try really hard not to say anything, but the reason is that 50 years ago we had a problem and the problem was this disease that was awful that we were trying to prevent. And some fabulous people did some fabulous work, discovering and testing the answer to this problem. And we discovered that anti-D was very effective. And I mean, you know, it won awards. It was truly, you know, it was hailed as a medical miracle, you know, at the time. And so, so that's what I'm saying is it really was fabulous. And I don't want to remain it. Anybody think that I don't think it's amazing because it is. But the trials that I've already mentioned, the trials that were carried out in originally, they were carried out between about 1968 and 1971. Those trials showed two things, which I've already said. First, they showed anti-D is very effective when it's given to a racist negative woman who's given birth to a racist positive baby within 72 hours of the birth. It's very effective. But they also showed when you looked at the data of the control groups, as I mentioned, that not everyone's going to need it, that we knew from those studies. It looked, I mean, the numbers varied. And what was interesting was that some of the studies showed that it was lower, that it was around 7% of women became my swimming eyes without anti-D. And there were, and there still are some really tantalising clues because people have theorized and suggested that it might be that intervention means that sensitisation is more likely or just the transfer of blood. And we have no idea if that's true or not because it's not been researched. So it's there as a theory. So at the time, when we had the results of these trials and the control groups were appended on which study you looked at, but it was pretty clear that the majority of women don't become sensitized after the birth of a racist positive baby, even if they don't have anti-D. Well, the people that make the decisions, they had two options really, they could either say, well, this is really interesting. Let's go and do some more studies and try and find out what makes slung women susceptible to sensitisation? And not, can we look and see if there are any factors in the women who became sensitized? Can we do some more crunching of the data to see what's going on? That was one option that they had. The other option that they had was to say, well, anti-D is clearly effective, so let's give it to everybody. And that's what they did. And that's what's continued ever since. And this happens not just with anti-D, but as you know, with so many things, it's the same with vitamin K, which as you know, I've also written about quite a lot, the actual patterns of one healthy baby experiencing what is called vitamin K deficiency bleeding, which is, you know, sometimes think it's like, you know, calling something a parasitimal deficiency headache. Anyway, that's another podcast. I really come back another day in June. Please come back. It's so great, fascinating. So the chance of a baby having a healthy baby having a problem if it doesn't have vitamin K is really, really low, like one in 11,000. But we also know that if you give, if you give, I mean, there's more nuance in that. What I will say is actually, if people want to look at that, there's loads on my website about it. So go and have a look because there's some, there's some caveat. There's different types of problems there. So what we know is that if you give vitamin K to every baby, then hardly any babies have that problem. And so this is the approach that Western medicine takes. It says, oh, well, this works. So we'll give it to everybody. And as you know, that's what's been going on in many different areas for years. But what then happens is when women come along, like the first two women I met me five years ago who asked me that question, and frankly, hundreds and thousands of women and families that I've met sit and say, well, I'm not entirely sure that I want to just sign up for this routine kind of medicine made from blood that I'm being offered. Given that, you know, there's clearly it's a bit complex and there's other things to know what can help me make my decision. And then you have to say, well, it's really, it's really difficult because we have to kind of try and gather bits and pieces of the evidence because the time the trials were done, it was decided by a group of, you know, white middle-class doctors. That we're going to go male doctors, I should say as well. You know, that we're going to go down this route and give this to everybody, rather than looking for more nuanced information that can help people make individual decisions about what's right for them. And does, I've got a question, does anti-D past, now that we're giving it in pregnancy, does it get through to the baby in utero? Some of it does, yes, my understanding is that some of it can pass through to the baby in utero. And I mean, I've actually written quite a lot in the book about the issue with side effects with the baby because it hasn't been adequately researched. Now, again, I'm not going to sit here and say, oh, I think it's horrendous. I'm not, I'm not going to say, I think there are massive problems, but we don't have enough research on this. That, you know, there have been concerns have been raised in literature and they haven't been adequately addressed. Good point to mention, one of the massive paradoxes about anti-D because I mean, for some people, the main, the controversial bit about anti-D is the fact that it's made from blood. So for other people, as you've just mentioned, Rachel, it's about the fact that we do know that some of the anti-D given in pregnancy will cross the placenta. We don't know about the side effects. We particularly don't know about the side effects when, depending on whether the baby's recess negative or recess positive. Now, at the moment, we're seeing in many countries the advent of antinatal recess testing so that women can know from usually for about 15 weeks onwards, a test can be done, which will tell you whether the baby is recess positive or recess negative. That will help about, I mean, if we're looking at you, I've got the data from you, but if we're looking at people of European descent, that will help about 42% of women, because about 42% of recess negative women will be carrying a recess negative baby, and as soon as they know that, they don't even have to think about this again. Some people are saying, well, that's fabulous, isn't it? That's great. My answer is yes. That's great for the 42%, but I'm also concerned about the other 58% who still need to make these decisions. So for some people, it's about the fact that we don't know what effect it has on the baby. And we do have studies showing, we have a study that was carried out in Yorkshire in the UK that shows that there are no short-term detrimental effects on things like app bar scores or mortality. And it's great that we know that, but to be honest, those aren't the things that people were concerned about. People were more concerned about long-term effects. But the controversial bit, one of the controversial bits about anti-D for me is I have to watch Betty's face when I say this. It's the only bug that I know of. That first of all, is given to a person who doesn't physically benefit from it. Because the woman herself doesn't benefit from it. When is given in pregnancy? It's given to the possible detriment of another person, the unborn baby, who doesn't physically benefit from it. And anti-D is given for the benefit of a person who doesn't yet exist and who might never exist. And because even if the woman has more babies, I'm sorry, I'm laughing because I'm watching baby's face here, even if the woman has more babies, they might be racist negative. And that wasn't a risk at all. And these days, we're having small families. So for me, that's why I use the word paradox and you know, when I'm talking about this. Oh my god. I mean, obviously I knew that, but I just the way you phrase that is like, oh my god, I'm like, what? Yeah. Wow. Very, I mean, absolutely. It is the only thing. Wow. I know. I can't think of any other drug. No. Absolutely. And the fact that it comes with this controversy and it comes with all those things that you've just beautifully explained. And it's for this kind of what if that doesn't yet exist and could exist. Yep. But it also could exist with the baby's also racist negative. Yeah. Wow. Oh, you might not have any future babies. And I mean, going back to the question about how can women and families make individual decisions that are right for them? Well, actually, that's one part of it is that, you know, if somebody knows for certain that this is going to be their last baby, then actually, it's really worth bearing in mind that the anti-D doesn't benefit the current baby. And if you're absolutely certain that this is your last baby, then that may make the anti-D decision easier. I mean, it would be remiss of me not to mention as a midwife that that then means you need to think really carefully about about contraception, you know, and everything that goes along with making that decision. But in the absence of really good data about what the what the risks are and, you know, who doesn't doesn't need it, these are some of the things that that people can take into account that we do have the ability now to test a baby's racist group in utero. And things like, you know, it doesn't, it's not going to benefit the current baby. It's only going to benefit Reese's positive future babies if they exist. And so for that reason, some people are also getting, you know, they want to know what the father's blood group is because that can make a difference and give you knowledge ahead of time as well. That was just going to be my next question, whether we could be testing the father. Well, I don't know of any country where the maternity services offer blood group testing of the father just so that women can decide whether or not to have anti-D. But what I do know is that it's actually really easy in most high-income countries to find out your blood type and racist group by going off and donating blood because you get a nice little card that says, you know, you are a racist negative or whatever you are. And so, you know, that can that can help because if you are, the gene for the racist factor is recessive. So don't worry, I'm not going to do later science, but what that means is that if you have two parents who are both Reese's negative, they cannot have a Reese's positive baby. So if you are Reese's negative and the father of the baby is Reese's negative, then the babies are going to be Reese's negative and you don't have to worry about any of this stuff. You know what I was told about that? No, I don't know what you were told about that. Tell me. Because I can remember raising this. Oh, I do know what you're going to say. Go on anyway. With a couple of mother who knew what the father's blood group was and it was negative and I was told that no, she still has to have anti-D because, you know, women lie and you might not actually be the father. It's crazy. I mean, this was a really, I mean, it still is, it still is a thought in some areas and I, I'd really like to pick up on one aspect of that because it really frustrates me as I can hear that it does you that women are kind of not believed and that's absolutely something that we need to get around. What commonly happens is if a woman declines anti-D and says, no, it's because my, I don't know, the father of the baby, you know, whatever, whoever is, is Reese's negative. Sometimes, you know, they're told, well, you need to have it anyway and of course, nobody needs to have anything. You just say no. So that's obviously the first thing is you never have to say yes to any of these things. So the, you know, my passion is about getting good information out so that women and families know what the evidence says and know what they want to do and know that they can say no, I don't want this. But yeah, I mean, there is a concern in the maternity services that, well, what about if the baby, the woman's partner, the man that, you know, that she's there with whatever, isn't the father of the baby. And so what happens often is that midwives and obstetricians try and get the woman on her own just to ask that question. And I hear now and again from women who have really crossed about that, they say, I really didn't like that. But I think we also need to acknowledge that the reality is that some women are living in situations where they're not safe and they can't be honest in front of their partner. And so I think we just got to bear that in mind that it's all about looking at the individual context, isn't it? So absolutely, absolutely need to believe women and I'm not suggesting that for a moment. I do understand why in some situations, healthcare practitioners feel they just want to talk to women on her own. So what I commonly say, you know, to women is, yes, if you're recess negative and you know, your partner's recess negative and it's his baby, you know, you can be really confident that your baby's going to be recess negative and you don't need to think about anti-dead and you don't need to answer this question, but I just need to say to if there is any chance that this isn't the father of your baby, then you know, you need to just let me know and we'll find a way of really kind of saying that you want that anyway, if that's what you want. Because we just have this situation where not everybody lives in safety and that's a big concern. Absolutely. I think it's a really good point and I think it's a really valid point because that is the situation that is the scenario of the world that we live in and the women that we see and it is always looking at that as an individual. But it is about giving that choice, but I think you've just phrased that really nicely in a way that helps us as midwives or healthcare providers to phrase something to the women that we are working with that doesn't come across as judgmental or scary or that or any of those negative qualities it's about this is information. I'm here to support whatever your decision is, but I want to make sure that you know risk benefits alternatives and not doing anything and I will support that, but I want to make sure that it's safe for you as much as possible in terms of the information I've given you. Absolutely. And I mean, it's all about balance and I mean, this is, you know, this is really at the core of what I'm trying to do just with everything I do really because none of these interventions are really, really terrible. Nobody's going, nobody's getting up in the morning going, do you know what, I'm going to go and disempower a few women today, you know. But we live in a culture that is all about systems and, you know, offering things on a routine basis and it's based on bureaucracy, you know. So we have all these things and so absolutely it's about questioning those things and saying, well, what is useful? Is this what I want? Does this work for me? But it's about balance because nobody's saying that these things aren't useful ever. Some of them are, most of them are incredibly useful when they're used appropriately. It's the appropriate use, you know. And we live in a world, of course, that's become so polarized, you know. And on the one hand, you've got some people who are being really paternalistic about this and going, everybody should have this in every situation. And on the other hand, you've got people that are going, well, I'm never going to engage or have any of this. And so for me, it's about getting information so that you can see that there's a balance to be kind of had there. Sarah, you have just really unpacked this and put it in such a beautiful way for the podcast. Like my brain is just whizzing around, putting knowledge that I was told, knowledge that I used and new knowledge for me and really put it together in I think a fantastic way for us here on the podcast. And I can imagine in the book, it explores it in much more detail, which I'm definitely doing a book plug right here. And right now it needs it. By the book. I'm on by the book. It's bloody marvellous. Right. We've got the north of England. Well, I'm not sure where I go to, but apologies folks out there for Katie's love of the northeast of England. But I just wanted to like, I want to just get in and talk a little bit about both you and Rachel do a huge amount of research and writing and my god, and my grateful for it. And I know so many of us are. But you have this kind of shared hobby of how you unpack research. And I'd love you to tell me a little bit more about that. I start Rachel and then you can jump in. Absolutely. Okay, so yes, so Rachel and I discovered a few years ago at I think at a conference in Australia that we have a shared hobby of tracking backwards through obstetric guidelines to see what evidence they're based on. Because I mean, so many evidence make these sweeping statements, you know, like X is safe or Y is recommended, whatever it is. And they have a reference beside them. But I mean, if people only remember one thing I say from this podcast, please let it be the following sentence. Just because something has a reference beside it does not mean it's based on sound robust data. And that's why we need to be careful when we throw around phrases like evidence-based. Because firstly, we need much more knowledge than just research evidence and make decisions about our lives and to purchase as midwives or doctors or whatever it is that we're doing. And secondly, not all evidence is good evidence. You can find a piece of research that will show all sorts of things that it might not be good research. And as an aside, I mean, one of my passions, as you might know, is to teach people to really understand the research, to dig into it. You know, when I'm not writing books, that's what I'm doing. I'm teaching courses so that people can better understand research and not feel kind of scared by all the numbers. So, you know, when you go and look at the reference in the guidelines that says X is safe or Y is recommended, you will sometimes find good evidence. But what you sometimes find is that the reference simply points you to the last edition of the guideline. So, off you go. So, well, I mean, also people like Rachel and I go, I don't know that this is a popular pastime. It's kind of a niche thing. And there are policy detectives on the scope. Oh my god, there needs to be a theme tune for this totally. Can you put it on the top? Yeah, I'm going to just make it up and then I'll edit it in. Okay, so off we go. So, we follow the reference back and you go to the previous guideline. And there's the same statement saying X is safe or whatever. And there's a nice reference, but then it's the guideline before. And so you go, you've, and basically the short version of this story is that you keep going backwards in time. You go and find all these old guidelines. And it doesn't just happen in guidelines. It happens in papers. I mean, I found one in a little bit like this in the Kotkun review in Acty. Tell you about that in a moment. One of two things happened. You either get back to the first version of the guideline. And you discover that it was written in 1987 and there are no references at all. But that hasn't stopped anyone from stuffing every subsequent edition of the guideline up like a house of cards. Or you can't find the first guideline because actually it was an information leaflet that some doctor wrote or that some company put out and they kind of sort of found the estimated the number. But now you've spent hours looking this stuff up. And you can see that if the evidence for this statement existed, you would absolutely have fallen over it by now because you've now spent hours trawling through this, you know, on the internet these days or in the library. So, I mean, yes, it's an extraordinarily weird hobby. I will admit that. But it's incredibly useful as a hobby. And if you make a living by helping people to understand why guidelines aren't always as evidence-based as people make out. I mean, there was a really little study which I talked about, talk about in the book, but I talk about on our website as well, where a group of obstetricians and medical students in London actually, friends of mine went to look at the green top guidelines, the Royal College of Obstetricians and Gynecologists, green top guidelines to see how many of them were based on, how many of the recommendations were based on the highest level evidence. And it was 9 to 12%. I know. But I want to stop because I really want someone Rachel to share what she does with the guideline as well. And what can you talk about that because Well, I do the same thing. And I think I kind of got hooked on that when I was doing my PhD and you were trying to find every bit of literature about everything. But I still do it. And I've actually been extremely mean to the midwifery students and they've had an assessment where they have to pick midwifery practice and do exactly that, find a guideline and then track back to find the evidence for that recommendation and then assess the evidence. And as you say, often, you know, sometimes you find, oh, there's a cock and review and it actually does support the thing that's just been written. But more often than not, you kind of head into this, you know, you go from Queen's and Health, for example, um, guideline. And then that will reference nice and then nice will reference itself from years ago. And then that will reference the World Health Organization and the World Health Organization, which is right statement with no reference. So you don't actually get to a reference or, so that's what happens, um, I think with a giant examination, well, that's where I ended up. Oh, no, with a giant examination, we ended up on research that was actually not about whether or not it was, it was a, it was a good assessment, but rather research that said that doing it more times didn't interfere with labor progress and doing it less times, which doesn't support doing it. And the same with people heart rates monitoring when I try to work out, you know, what is the underpinning evidence here for listening to the people heart in labor with a, you know, consultation. It ends up being this bizarre study from many, many years ago, you might know this, but compared the outcomes of an Amish community in America, with like a population, a big population of Americans and said, oh, they have, you know, more IUGR babies and more negative outcomes. So what's the difference here? Oh, they don't listen to the baby's heartbeat in labor. That was the, that was what supported listening to the baby's heartbeat in labor. Absolutely, we'll make any sense. Then another great one is the due date, when you look at what this was, you know, my PhD talk, when you go back and track back the research on the due date, you find that what we're doing today is based on a study involving 100 French women about a century ago. And I mean, I'm sure they were very nice French women, but I'm not sure that their experience 100 years ago is really a valid thesis to inform what we're doing for tens of hundreds of thousands of women today. We're having a proper nude on now. This is like a full week. I just feel like the gooseberry that's sort of watching you to having a nerd on. And I'm like, oh, I'm liking it. That sounds a bit wrong, doesn't it? But this is like, oh, this is fabulous, but just, I mean, I've done it not as anywhere near as much as you, but recently with a, with a research paper and then went to find the reference that they were quoting. And then I read that paper was like that paper's quoting another paper because it doesn't actually say anything at all. And then went back. And then I was back to 87, 1987. And I was like, this, but this is using really old technology to look at sucking with the baby at the breast. And this doesn't make any sense whatsoever. And it's the multi-mic fly, midwifery. Oh, back to the future. Yeah. What would you like me to tell you the anti-d example? Yeah, I mean, it fits perfectly. So when I was when I was writing the big, and this was about going back to the possible risks of anti-natal anti-d on the unborn baby. And my understanding had always been that we didn't have much data. But, I mean, I'm not going to pretend that I read anti-new research every day or every month or everything. So when I came to start the new big, I went back to a literature search, you know, and I went and looked at what, what was new. And I noticed this really interesting line in the Cochran review, which I hadn't previously noticed. And what it said was that while we do know that small amounts of anti-d can cross the placenta, numerous studies, and I'm quoting this line, numerous studies have shown that anti-natal anti-d doesn't have adverse consequences for the fetus. And then it gave a reference for paper that I'd never heard of. So I thought, oh, this is, this is really interesting because, you know, I do not have a vested interest in people saying no to anti-d. I don't mind what people. I just want everyone to have the information that's right for them. There is data showing that we now know that anti-natal anti-natal anti-natal is safe for the baby brilliant. I'm going to be shouting all over about that. It will be great to be able to tell people, yes, look, we've now looked at this really carefully and we've got evidence that they've got no harm. I'll give you the spoiler alert now and tell you that's not the conclusion I'm going to just, I don't want you to get overexcited because when I look to that paper, I found that the numerous studies, well, so there were a couple that were like about 40 years old that didn't even mention safety and just reference each other, which, you know, I Rachel's already said that sort of happened. I know it sounds crazy, but I hope we're sharing that, you know, it's more common than you think. Now, one of them was a really interesting paper in which the author was raising concerns about the safety. The author was really concerned and like me was arguing that we should be looking at the safety, probably not hardly proved the safety because this is a doctor who was saying, you know, actually, if we need to look into this before we recommend it, the pregnant women, he was concerned, as am I, about the longer term implications of giving immunoglobulin. So there was a small retrospective study which confirmed that anti-nate-lantid didn't increase pregnancy loss. That's great to know, but not really what we were concerned about. And then one of the British research studies, which I already mentioned earlier in the podcast, where the research is confirmed that anti-nate-lantid didn't have an effect on app-rascals or mortality. But as I said before, no one was ever really suggesting that anti-nate-lantid might affect mortality or app-rascals or these short-term outcomes. It's great that we've got that data to know it doesn't, but people are more concerned about whether it affects the medium or long-term outcomes. You know, does it affect the immune system? Does it make a difference if the baby is Reese's positive or Reese's negative? What would happen if we did a prospective study and followed babies to see what happened? Of course, we don't know because none of that has been done. And yet here we are in the cock and review, quoting a paper which says numerous studies demonstrate the safety of anti-nate-lantid. And I'm not, again, I'm not here to say that I think that anti-nate-lantid is a terrible or dangerous thing. I'm simply saying that we don't know. We don't know that because we haven't done the studies to find out. And I think it's really important to be truthful about that. And I'm hoping that that illustrates why, you know, just because it's in the cock review or just because it's anywhere and it's got a reference, doesn't mean you shouldn't just look into that for yourself. Mm-hmm. Wonderful. Thank you. I think that's such a great point that we need to be thinking about more. And often we don't because because it's so time-consuming and it's not everyone's favourite hobby, it's not Sarah and Rachel on the case. Hobby. So thank you for doing that hobby for us. And as you said, if I come back, I want that, I'm not coming back until you've got that jingle made just, you know, what you want it more professional than that, that was pretty professional. We can do it like that. It's just you need to be able to press a button like in radio shows and like we just plays your voice singing that jingle. I want that on an Instagram story so that we can share it with Rachel's swipe up link. And then you can have it as like your ring tune on your phone. Oh my god. Who wouldn't want that? That's for sure. It's like podcast merch. Brilliant. Bringing you on as our marketing director. Thank you. Then I want a theme tune for all three of us. That's another podcast. Right. Thank you, Sarah. Well, I want to ask you about how you've got Michelle Donne to write your forward for the book because I also have a habit. I wouldn't say it's a hobby because it's not a hobby. I also have a habit of being socially awkward around important people. My Michelle Donne story is, well, this wasn't social awkward. It was when I met him. So when I was a student midwife, I wrote an honest dissertation on male midwives. And as part of my research for that, I emails Michelle Donne because that's like really cheeky thing to do and said to him. So you say that father's probably shouldn't be in the birth room. Well, how can all the photographs of women given birth? You're in the birth room with them. And blessed is cotton socks. He actually wrote back to me and said, you know, explained and said, you know, you're right. And, you know, I often spend a lot of time in the kitchen, but then women asked me to come in at the end and blah, blah, blah. So anyway, years and years later, I saw me at a conference and I went over to get a book signed and was being awkward and things and went, oh, you probably don't remember. I sent you an email when I was a student midwife and told him the story. And I think he just looked at me like, what? I don't remember. You are, yeah. And then my anime moment was, I got in the lift with the anime at a conference. And I'm going, say something, say something, say something as we're going up in this list. Say something. Say something as doors open to anime got out. Door shut again. Anyway, tell us about Michelle Don. So, okay. So, well, when I first published my research on anti-D, this was even before just like a year before the first big, was so completely out of left field. And nobody had, nobody had questioned it before. It was a really kind of sacred thing that I was challenging. And it was a bit shocking in the, in the world of midriffry. And so a lovely editor who was involved in, you know, getting my first article ready for publication. She's, well, you know, this, this is going to be, you know, kind of a bit, a bit out of left field. So maybe it's a good idea if we get some commentaries on this, which you may know is a common thing to do in medical and midriffry journals. You know, if you're, you're getting people to talk about research, putting it into context. So, you know, she said, maybe we should get some commentaries on this and publish those at the same time to give it a bit of context. I mean, Michelle and I and anime were often, I mean, we often would speak together at conferences at the time and since, I mean, not anyone's doing any conferences at the moment. But so I, so I, I phoned him up and said, okay, so, you know, because he had been really interested in my research when, you know, he'd sat in, you know, waiting for his turn to speak and there I was whittling on about anti-D and he'd been really interested and said, wow, nobody's asked these questions before and they were similar to the questions that he likes to ask, you know, he likes to kind of dig back and say, you know, I mean, one of the questions he asks a lot is what are the optimum conditions for birth and what would go on if we didn't interfere? And that's, you know, that's not entirely dissimilar to some of the questions I was asking about anti-D, you know, is this is sensitization and an inevitable thing or is it to some extent brought about by intervention? And I will say, I don't think it's wholly brought about my intervention, but those are the questions that I was asking. And so, so I phoned him up and I said, look, I'm publishing this research and the editor said, you know, that she feels that probably this would be useful to have a commentary and would you be open to writing that and he said yes and he wrote this lovely piece to go with my research that got published with that research and this was, or I mean, I, this was 20 years ago and I don't and that was great and it did help it put into context and the editor to herself wrote a piece as well. So, so that was brilliant. I mean, normally have forwards in these kind of books, you know, I've got the series of books that I have about different interventions and I don't normally get people to write forwards, but he's he's been such a part of that journey with me and and Sharon and I have continued to speak together for 20 years and I mean, he actually does the same thing to me that we just did with Rachel and I talking about hobbies. There are things I say that he really thinks people should hear so he will ask questions from the audience, very pointed questions because he wants me to say a particular thing, you know, so we've been on the journey together and so I when I decided to write this book and I was halfway through and I remember to the commentary so I framed him up again and because obviously we've not seen each other, we've also both been we're not very far away, but we're both locked down and I said, okay, so this is what I'm doing, would you be open to writing a forward for this book and he said, yes, which is great? And then when I profited, he emailed me and he said, he said, what do you know what? He said, I read, I reread what I wrote for you 20 years ago and I want to say the same thing again because it's all still true and, you know, and I want to, you know, and I want to say that it is all still true, which for both of us, you know, as this really interesting and quite coinion element to the conversation, you know, because some things have changed and some really haven't at all and so it does feel really pointed because we've published his original forward in the book and he just added one sentence, which says, it wrote, this is an introduction to Sarah's work, research on NTD 20 years ago, my words are still just as relevant today. And that was the thing because there are some more things that we know. We do offer NTD more in more situations now than we did 20 years ago. We do have some more information to share with women. We, you know, one of the biggest positive things, as I said, has been the recess testing in pregnancy, which means that a proportion of women will know their baby's recess negative and they don't have to think about NTD at all. But in so many ways we haven't moved on and that's what is really frustrating that we have more and more women in families with all of these questions, you know, and I can, you know, and I can write a whole book and say, well, this is the evidence, this is the evidence, but it's so many points, it's really frustrating because I have to say, I'm really sorry, but I can't actually tell you the exact answer to this, you know, and that's really, really frustrating. You were probably at this conference, Sarah. In fact, you were at this conference. When he was presenting about Water Booth, and I was asked to present with him, which would then sent me in a real nervous kind of spin. And while I was sitting in the audience, he actually called me up, and I thought, oh, it's because, you know, I don't know, because you're awesome. Michelle, don't go, I don't really make anything with me. So he called me out of the audience, and he kind of said, can you just stand here and he said, turn to the side, and I turned to the side, and he said, as you can see here, I pointed at my nose, the large nose, like the bobbuscus monkey, to demonstrate how similar humans are, the bobbuscus monkeys, because of my large nose. I feel so bad for laughing at that, and I know the story, and I'm sorry, it always makes me laugh, but I love you, and I love your nose. You notice your nose, but now I want you to turn around so I can see it. I don't think it looks like a bobbuscus monkey at all. We could do a monkey's thing though, because of course the racist factor was named after a racist monkeys. So this could be the monkey podcast. Absolutely. There's your photos, Katie, go find them. Hey, Salas, and I can do this. That's very impressive. Actually, I mean, should I put it in Rachel's swipe up story? Definitely should have. Do not send me any photos of orangutans, because they scare me and freak me out, right? This is something you don't necessarily have to put this on the podcast, Katie. Because otherwise, they'll be inundated with pictures of orangutans. I have, I can't stand them. They really freak me out. So anyone who knows that sends me photographs of bloody orangutans. Do you want for ages? Oh, God, I'm going to be doing this. It's raining. I'm going to be a grown-up and not send you photos of orangutans. Thank you. It doesn't mean I won't cross stitch you one for Christmas, but I won't send it. Oh, please do. I can make you one. I can make you a sculptor one. You can sit on your door. Rachel, I'm going in the oven. Exactly. I mean, she's got sculpture, Johnny. She's got the birthing head one. I do not need an orangutan. Thank you. I think that's a good place to end, isn't it? It's great. It's going to have to go to the podcast now, because I can't edit that out. Sorry. So thank you, Sarah, for giving us a whirlwind tour of monkey theory. And thank you, Sarah, for being on this podcast and just giving us an absolute marvellous insight into NTD, the world of NTD and research and delving into research and being with us has just been a pleasure for me. And I know for Rachel, it's been fun, informative, and my goodness, I want to bring you back. And I cannot wait to put this episode out. And if you want to learn more from Sarah, Sarah, just online courses, check them out on her website because they are amazing. I've heard fantastic feedback. So if you want to know how to do tracking back of research and research. Research detective. Research detective. It comes with a theme tune. It does now. And go and check it out. Well, that's been fab. I've had a lovely time. Thank you very much. By the book. Hey, man, by the book. It's coming out. When is it coming out? That's how we need to end. Good thing. We forget that. Well, I don't have an exact date, but my hope is, and I don't know when the podcast is going out, of course, but the book we're planning for it to come out in June. And I don't have an exact date, but I do have a mailing list. So if anyone would like to know or keep in touch, they can just pop to my website and there's a blue box on my website that you can put your email address in and then you'll get all my emails and also our free monthly birth information update newsletter. So that's, you know, that's when people can know when it's ready. And also, like Rachel, I'm on Instagram. And so I will, there will be pictures of it all over Instagram. I'm at Dr Sarah, we can with no age on the Sarah. So thank you very much for having me. It's definitely the most fun morning I've had all week. Thanks for being in the cauldron, Sarah. It's been a pleasure. We hope you enjoyed this episode. What a fabulously full cauldron of info. And the good news is Sarah's book. Anti-D explained is out now. You can pop over to her website, Sarah, without an H, Wickham.com to get your copy. And of course, follow her on Instagram for all her daily insights. As always, details are in our links and on Instagram. I'm also starting a new slot here at the end where I'm going to take the opportunity to say thank you for those utterly wonderful comments you are putting over on Apple podcasts. And I want to read out the occasional one or two. The first one that really caught my eye is from Eerie Midwife. And Eerie writes, "I had almost given up on midwifery and birth podcasts. Finally, a woman centered no disclaimer's podcast, centering the power and magic of female biology with joy and humour and without pretence. Thank you. Thank you for your wonderful review. And this one comes from my silver QT and they say, "Love your nuggets." Great, we love a golden nugget here. Or is it a nugget of poo? Well, only you and me and Rachel can decide. KTN Rachel from a student midwife, thank you for helping to nurture my own woman-centered philosophy. For the way I want to provide midwifery care to my patients. Your wit, passion, singing and golden nuggets make me a thousand percent sure I'm heading in the right direction. I had always wanted and planned. Thank you, my silver QT and thank you to all of you. There are some amazing comments on there and it really, it really does. More my hearts and it's so fantastic because not only is it really lush, but it helps get the message out there. And it helps the podcast get recognised and picked up by other people who may not have had someone down the street telling them, "Hey, listen to this." And lastly, before you go, I also need to tell you that soon we will have our very own Patreon page. Yes, we figured it out. It's not a paraben or a parafin page. And that will be where you can head over and have a look at what's going on for you there. As this gets up and going, I'll post about it on Instagram too. So thanks for being with us. And of course, as always, I'll leave you with something. But this is actually for Sarah. Rachel and Sarah are on the hunt for guidelines because they're the research detectives. Rachel and Sarah aren't the hunt, they're the research detectives.