A Midwife a day keeps the doctor away!

Ciarabear

Very interesting findings from this piece of research: http://www.irishtimes.com/news/ireland/irish-news/pregnant-women-under-midwife-led-care-fare-better-according-to-study-1.1500216

Logically, I guess I've thought this myself for quite a while, given that birth is an entirely natural process that's run a successful operation of it's own since the dawn of time!

I'm also not a fan of unnecessary medical intervention and sometimes think that we've become too inclined to consider medicine superior to our own natural biological abilities.

Obviously there are exceptions to every rule and not all pregnancies are straight-forward. It is interesting though to find concrete evidence suggesting that private obstetrician-lead care may be little more than a profit-turner for the majority of us.

Sleepy

Ciarabear wrote: »

I'm also not a fan of unnecessary medical intervention and sometimes think that we've become too inclined to consider medicine superior to our own natural biological abilities.

I think the vastly lower levels of infant mortality compared to those experienced in this era of modern medicine proves quite conclusively that medical science is in fact superior to our natural biological abilities.

Ciarabear

Sleepy wrote: »

I think the vastly lower levels of infant mortality compared to those experienced in this era of modern medicine proves quite conclusively that medical science is in fact superior to our natural biological abilities.

Lower modern infant mortality rates aren't solely due to superior medical practices at all. It's a culmination of better nutrition, proper sanitation, women having smaller families and subsequently less losses at birth and myriad other factors.

Unfortunately all the modern emergency medical aid in the world can't save Third World children who's mothers experience harsh circumstantial conditions throughout their pregnancies.

If medical science is superior to our own natural abilities,why has this research concluded that of 16,000 women surveyed, the majority of them fared better with less medical intervention?

lazygal

Ciarabear wrote: »

It is interesting though to find concrete evidence suggesting that private obstetrician-lead care may be little more than a profit-turner for the majority of us.

How on earth can you draw that conclusion? I'm currently availing of private obstetrician led care. I wasn't conned into it, I wasn't lured in by the fear of the public system, it was a choice. Is there a reason you're so judgmental about private care?

And as for 'keeps a doctor away' pregnancy and birth may be a natural process, but that does not mean its risk free. Cancer, bacteria and other illnesses are natural, that doesn't mean they're safe.

There's myriad reasons why people who go private choose to do so. Among my circles, its things like a bad experience first time, wanting privacy after a planned c section, wanting to be under a particular consultant or wanting to guarantee an elective c section.

I am totally happy with the 'profit-turner' care I've received. I'd never look down my nose at the not for profit care others receive though, and imply they are too stupid to know the difference between the different types of maternity care available.

How Strange

It's an interesting report and perhaps now women on their first pregnancy or subsequent pregnancy who are considered low risk will be booked into midwives clinics instead of with a consultant. When you think how over stretched our maternity hospitals are it would seem logical to guide women towards midwife led care. I was with a midwives clinic in Lucan and I was in and out within 20 minutes and at least 10 minutes were spent talking with the midwife.

I don't think the findings are new or unexpected. We have the midwives available in the hospitals, satelite comics and domino schemes but you have to specifically request this care or you'll be given consultant led.

pwurple

I'd be reasonably sceptical of these reports. You never know how massaged the participant list is. Cherry picked etc.

I think it's slightly odd in that article that epidural pain relief is considered to be an 'intervention'. Episiotomies, forceps and c-sections I understand you would like to avoid because there are after-effects, but pain relief? geez guys, come on.

Anyway, I'm high risk now, and was on last birth too. I saw consultant once I think when was pregnant, at the start, to asses whether I was high risk or not. It was midwives all the way after that. I was reasonably happy with my birth, and have gone public again this time. Would have preferred private to be honest, but I'm not paid for maternity leave, so we need to save up to have something to live on for those 6 months off.

lazygal

How Strange wrote: »

We have the midwives available in the hospitals, satelite comics and domino schemes but you have to specifically request this care or you'll be given consultant led.

A lot of women simply aren't eligible for this care, let's not forget. Just because of where I live I'm not in the catchment area for any of the midwife led teams in the three main Dublin hospitals, likewise often those with other medical issues are excluded. I looked into all my options before I chose my care, and I would think many women do the same. Sure other more mums-led forums are full to the brim with questions about which type of care to go for.

How Strange

That's true lazy gal, I don't dispute that consultant led care has its place but I was quite surprised on my first pregnancy that I wasn't even given the option of midwife led care. The problem with being a public patient is that the first appointment is after 20 weeks and I'm not even sure how you'd go about changing from consultant to midwife or vice versa at that stage.

I personally believe that if all the low risk pregnancies were managed by midwives then those who have complications or are considered high risk would have more time with the consultants. As it is you're lucky, in the public system at least, if you get 5 minutes with them. The whole system is bulging at the seams.
Studies have found that women labouring and birthing with the assistance of a midwife are more likely to try gas and air before asking for an epidural. Everything medical is considered an intervention if you birth in a hospital. Gas and air, as pain relief, is an intervention. The thing about an epidural is the cascade effect where it can slow labour therefore making you and the baby more tired, so episiotomies, forceps, stitches etc. It isn't always the case but it can be.

In Uk they have midwife birthing centres and the emphasis is on natural labouring as much as possible. They'd have labour and birth pools etc.

Rosy Posy

pwurple wrote: »

I think it's slightly odd in that article that epidural pain relief is considered to be an 'intervention'. Episiotomies, forceps and c-sections I understand you would like to avoid because there are after-effects, but pain relief? geez guys, come on.

I would consider an epidural a fairly big intervention tbh- it paralyses you from the waist down and totally changes the labour. I found that I needed to be upright and mobile in all of my labours in order for them to progress, if you're stuck in a bed you're working against gravity. Also I believe that you need a catheter if you're having an epidural? To me that feels quite invasive and unnatural. Prolonged epidural can effect how alert the baby is after birth which can inhibit the establishment of breastfeeding.

I'm not casting aspertions on anyone for choosing an epidural if that's how they want to go- I'm sure for lots of women the actual benefits outweigh the possible risks, but it's a long way from natural childbirth, and a certainly a medical intervention.

In NZ there is midwife led care across the board. You sign up with a midwife team (they work in pairs) and they provide all of your prenatal and postnatal care as well as delivering your baby at home or in hospital. You build up a relationship with them and make a birth plan together. It's great if you have the same one for several births. They work together with doctors so if you want an epidural they call in the anaesthetist, if you need a caeserian they hand over to the obstetrician. They work as lactation consultants as well and call to your house every day for the first week and then as often as you need. It's an amazing service and its totally free. I don't think I'd opt for consultant led care if I had the choice, but I'm lucky I'm low risk.

pwurple

How Strange wrote: »

The problem with being a public patient is that the first appointment is after 20 weeks

20 weeks? That's not the case here.

I'm a public patient. My first apointment was 6 weeks, second at 8 weeks and 3rd at 12 weeks. I have another at 16 weeks and another at 20 weeks. This is CUMH, and I'm classed as high risk.

it paralyses you from the waist down and totally changes the labour.

There are different types of epidural btw. I wasn't paralysed, could feel pressure and contractions, just not pain. I consider it pain relief.

January

How Strange wrote: »

That's true lazy gal, I don't dispute that consultant led care has its place but I was quite surprised on my first pregnancy that I wasn't even given the option of midwife led care. The problem with being a public patient is that the first appointment is after 20 weeks and I'm not even sure how you'd go about changing from consultant to midwife or vice versa at that stage.

Mostly 12 weeks for first appointment now depending on the hospital. (Coombe 12 weeks, Rotunda 12 weeks, Holles St. 12 weeks just knowing women who have recently had appts with those hospitals).

I personally believe that if all the low risk pregnancies were managed by midwives then those who have complications or are considered high risk would have more time with the consultants. As it is you're lucky, in the public system at least, if you get 5 minutes with them. The whole system is bulging at the seams.

I've only been consultant led once but I never ever felt rushed with the consultant. He always made sure I had every question answered and I even got a mini scan at each visit, this was public.

lazygal

In Dublin the first appointment is at 12, not 20 weeks, for anyone I know, public or private, midwife led or not.

Rosy Posy

pwurple wrote: »

There are different types of epidural btw. I wasn't paralysed, could feel pressure and contractions, just not pain. I consider it pain relief.

Are you still able to move around? Genuine question, I'm not trying to get at you at all.

I suppose it's to do with your interpretation of the word intervention. To me if it has to be administered by a doctor, inhibits your movement and involves multiple tubes in your body it seems like it's intervening medically with a natural birth, but I don't know an awful lot about it. I know a lot of women think its one of the greatest gifts of medical science.

How Strange

In the coombe the 12 week is the initial one with the midwife where they do a history, take bloods etc but the first proper ante natal app is usually around 20 weeks give or take a couple of weeks. That was the first time I'd met the midwives team or consultant.

I was referred back to a consultant at 34 weeks. I saw one of the consultants team and to say it was a race was an understatement. He just didn't have the time to even speak to me. My consultant was lovely as was another I had at 39 weeks but in general I'd say they are too busy to give each woman more than 5 minutes. That's not a criticism of them but more of the system.

missis aggie

pwurple wrote: »

I'd be reasonably sceptical of these reports. You never know how massaged the participant list is. Cherry picked etc.

I think it's slightly odd in that article that epidural pain relief is considered to be an 'intervention'. Episiotomies, forceps and c-sections I understand you would like to avoid because there are after-effects, but pain relief? geez guys, come on.

Anyway, I'm high risk now, and was on last birth too. I saw consultant once I think when was pregnant, at the start, to asses whether I was high risk or not. It was midwives all the way after that. I was reasonably happy with my birth, and have gone public again this time. Would have preferred private to be honest, but I'm not paid for maternity leave, so we need to save up to have something to live on for those 6 months off.

Epidural is certainly an intervention. Its a spinal anaesthetic done by medical professional. It does intervene with natural birth.

On topic - I agree that if all normal pragnacies were cared for by midwaifes it would free the consultants to spent more time with those who need it.

January

How Strange wrote: »

In the coombe the 12 week is the initial one with the midwife where they do a history, take bloods etc but the first proper ante natal app is usually around 20 weeks give or take a couple of weeks. That was the first time I'd met the midwives team or consultant.

I was referred back to a consultant at 34 weeks. I saw one of the consultants team and to say it was a race was an understatement. He just didn't have the time to even speak to me. My consultant was lovely as was another I had at 39 weeks but in general I'd say they are too busy to give each woman more than 5 minutes. That's not a criticism of them but more of the system.

You also get a dating scan at your first appointment in the Coombe, so I'd consider that an ante-natal appointment, even though it's your first initial one.

Rosy Posy

missis aggie wrote: »

On topic - I agree that if all normal pragnacies were cared for by midwaifes it would free the consultants to spent more time with those who need it.

One disadvantage that I've seen with universal midwife led care is that doctors never get to experience normal birth unless they do part of their training elsewhere. I think that that gives them a skewed view of optimal labour and birth conditions.

It certainly seems beneficial to mothers and babies that consultants time and expertise be reserved for those who need it most rather than those who can afford it, and I believe that low risk mothers would be better off attended by an experienced midwife who has access to a doctor should that become necessary.

How Strange

Yes, you do with a sonographer not a midwife or consultant. My point is that the first time you meet the consultant/midwife is around 20 weeks.

pwurple

Rosy Posy wrote: »

Are you still able to move around? Genuine question, I'm not trying to get at you at all.

I suppose it's to do with your interpretation of the word intervention. To me if it has to be administered by a doctor, inhibits your movement and involves multiple tubes in your body it seems like it's intervening medically with a natural birth, but I don't know an awful lot about it. I know a lot of women think its one of the greatest gifts of medical science.

Well, I was on my 40th hour of getting to 5cm dilated.... I was physically exhausted from the contractions, and wouldn't have been able to push at all. I slept for 4 hours after I got it. Didn't even try to get out of the bed. I got into a few different positions on the bed alright, but that's about it.

If epidural pain relief is considered an intervention, then I don't see why that noxious gas or pethidene isn't as well. I react far worse to those yokes. Dizzy, confused, couldn't speak, puking every time I moved. Couldn't even roll over with them. Awful things, I found them horribly toxic. My epidural was much better, I had a badly needed rest which gave me the ability to push properly and have a very pleasant birth.

Each to their own I guess. I would have had a section without it I'd say, which I would consider an intervention, so to me it prevented that.

dulpit

I'm a guy, but my girlfriend is a trainee midwife (heading into her final year) which means I'm surrounded by a lot of midwifery stuff all the time (what with her friends all being in same course and so on).

Before she started course, I was always of the opinion that the likes of natural birth/home birth/etc were inherently riskier than a hospital birth with doctors nearby. However over the past 3 years I've come to learn that in most cases a natural birth is perfectly safe (with the obvious exceptions of high-risk cases).

What my GF and her friends always say is that midwife-led care is what they think is best, but if a mother wants to go down the route of using a doctor/etc, that's fine. Their main issue is that most people aren't informed on the matter, and assume that hospital/doctor-led care is the best. More education on the matter is needed I'd say.

I was utterly skeptical when herself started talking about the likes of natural births and home births, but the opinions, information and so on that I've heard has brought me around.

On the epidural issue - it is an intervention, at the very least it numbs you below your waist, and it fundamentally changes the nature of the birth. Although as a man and someone who will never have to go through childbirth - don't let me be someone to stop you getting one - just be aware of the facts is all.

Rosy Posy

pwurple wrote: »

Each to their own I guess. I would have had a section without it I'd say, which I would consider an intervention, so to me it prevented that.

The teacher of the positive birthing classes I went to mentioned this, as in sometimes you might need to sacrifice a minor aspect of your birth plan (eg not wanting pain relief) in order to achieve another aspect (eg vaginal delivery). I think it's so important to be flexible and not to have too many expectations. I came across a lot of women through the home birth group with very rigid ideas on optimal labour and birth and a few of them experienced pnd as a result of not having the births they had thought they would...anyway, getting totally off topic here, sorry!

pwurple

dulpit wrote: »

On the epidural issue - it is an intervention, at the very least it numbs you below your waist, and it fundamentally changes the nature of the birth. Although as a man and someone who will never have to go through childbirth - don't let me be someone to stop you getting one - just be aware of the facts is all.

Ah now, how does it fundamentally change the nature of birth?

She didn't come out my elbow unbeknowns to me did she?



It's just pain relief guys. My husband had an epidural for an injury years ago too. I don't get the epidural hangups.

Rosy Posy

pwurple wrote: »

Ah now, how does it fundamentally change the nature of birth?

She didn't come out my elbow unbeknowns to me did she?



It's just pain relief guys. My husband had an epidural for an injury years ago too. I don't get the epidural hangups.

I suppose in that you can't move about freely or feel contractions or when to push? IMO there's a difference between pain relief and totally removing sensation. I would consider an intervention to be invasive and requiring expert medical administration (ie an an anaesthetist).

But you're absolutely right, there is no reason to be hung up over an epidural- if it helped you have birthing experience you wanted then that's great, if it stopped you from having to have a section, bloody marvellous. I also think its great that women who are having a section can be awake to see their baby delivered.

pwurple

Rosy Posy wrote: »

I suppose in that you can't move about freely or feel contractions or when to push? IMO there's a difference between pain relief and totally removing sensation..

That wasn't my experience though, as I've said above. I COULD feel contractions and knew when to push. I could move about. I had sensations. Just no pain.

*shrug* Maybe I just got a good epi. I've just the one experience of it so far.

dharma200

I have to say that the epidural is a huge intervention in birthing... There are serious risks involved in epidural s... I'm not sure how it can't be seen as an intervention and it totally different from gas and pethidene in how it is administered, the side effects and risk etc.

I personal have had one hospital birth with a myriad of interventions including epidural... And went on to have my second and third on the bedroom floor, with no intervention atall. I know which I not only preferred personally... Our local maternity hospital is absolutely crammed full, understaffed, and quite frankly manky....

cyning

In Kerry unless your high risk (which I am) your first antenatal appt is between 20-22 weeks. That will be your one and only scan and its not an anomaly scan but a quick dating one. That's the effect of cutbacks here: it's far from ideal that a woman wouldn't find out she's having twins etc until more than half way through her pregnancy.

Like pwurple I still felt every contraction with my epidural. I could move my legs and knew when to push. I'd take it over pethedine or gas and air any day both of which made me feel totally drunk and out if it. Not a way I want to be in child birth!

I'm a fan of midwife led care, and home births for those who want them. But there should be a choice for consultant led care too. There is nothing wrong with either, but there should never be cases where a woman should HAVE to be in midwife led care if that isn't their choice. Some women are more comfortable with consultant led care (I'm certainly one high risk aside), and it's a choice like any other.

Xdancer

pwurple wrote: »

That wasn't my experience though, as I've said above. I COULD feel contractions and knew when to push. I could move about. I had sensations. Just no pain.

*shrug* Maybe I just got a good epi. I've just the one experience of it so far.

This was my experience too, although I still had some pain (apparently they give a weaker dose here, so I'm told).

SanFran07

How Strange wrote: »

It's an interesting report and perhaps now women on their first pregnancy or subsequent pregnancy who are considered low risk will be booked into midwives clinics instead of with a consultant. When you think how over stretched our maternity hospitals are it would seem logical to guide women towards midwife led care. I was with a midwives clinic in Lucan and I was in and out within 20 minutes and at least 10 minutes were spent talking with the midwife.

I don't think the findings are new or unexpected. We have the midwives available in the hospitals, satelite comics and domino schemes but you have to specifically request this care or you'll be given consultant led.

In other countries midwives are the gatekeepers to maternity services rather than Doctors so you're starting with the mindset of pregnancy/birth being normal until proven otherwise. If complications arise during pregnancy mums are referred to an obstetrician for further investigation.

lazygal

SanFran07 wrote: »

In other countries midwives are the gatekeepers to maternity services rather than Doctors so you're starting with the mindset of pregnancy/birth being normal until proven otherwise. If complications arise during pregnancy mums are referred to an obstetrician for further investigation.

I'm under consultant led care and I'm perfectly aware pregnancy is 'normal'. Some very judgmental attitudes towards OB GYN care around the place, and correspondingly patronising views on those who avail of it. Women aren't stupid, they are able to recognise pregnancy as 'normal'.

Ciarabear

lazygal wrote: »

I'm under consultant led care and I'm perfectly aware pregnancy is 'normal'. Some very judgmental attitudes towards OB GYN care around the place, and correspondingly patronising views on those who avail of it. Women aren't stupid, they are able to recognise pregnancy as 'normal'.

I don't think anyone's been remotely patronising or condescending at all. People are expressing their opinions on something in the same way that you are. Just because their thoughts differ to yours doesn't mean there's offence to be taken.

Everyone just wants the birth that works best for them

SanFran07

Ciarabear wrote: »

I don't think anyone's been remotely patronising or condescending at all. People are expressing their opinions on something in the same way that you are. Just because their thoughts differ to yours doesn't mean there's offence to be taken.

Everyone just wants the birth that works best for them

Despite the evidence the public/private debate will continue. The issue is that women can choose private care - they can't choose midwife led (especially if they are outside a specific catchment area).

This is changing thankfully with teams of midwives around the country who now offer private midwife led care at home antenatally and postnatally for mums having hospital births. There's no exclusion criteria for mums not having the 'perfect' pregnancy as the midwives work in collaboration with high risk clinics. Unfortunately getting continuity of care in Irish maternity services is only available to those who can afford to pay for it.

Ciarabear

SanFran07 wrote: »

Unfortunately getting continuity of care in Irish maternity services is only available to those who can afford to pay for it.

Which is a financial fallacy really considering it would be much more prudent for the public purse to pay for midwife-led care as opposed to an unnecessary emphasis on obstetricians

Ms2011

I was with midwife led care & I can't praise it enough, I absolutely loved it.
I found the whole experience friendly & relaxing. Even the midwives clinic was just a normal terraced house with the 'office' in the living room, baby massage & yoga upstairs in the bedrooms & the waiting room was the kitchen where you boiled the kettle for a cuppa & chatted with other women waiting to go in (usually never more than 2) while you waited.
I always saw the same 2 midwives who were lovely & so supportive, I never felt rushed but was usually in & out in 10-15 mins.
After I went 7 days over my midwife made an appointment for me to see a consultant in the maternity hospital which is routine.
That experience was like night & day from the relaxed appointments I was used to. I queued for 4 hours in a noisey, hot waiting area to be seen for 5mins. The consultant was nice enough but v.rushed. She recommended an induction & really it all went downhill from there as I ended up with a section.
This was just my experience of course, others may have different.
I can now never avail of midwife led care due to me having a section & I'm absolutely dreading the thoughts of consultant led care on subsequent pregnancies

SanFran07

Ms2011 wrote: »

I was with midwife led care & I can't praise it enough, I absolutely loved it.
I found the whole experience friendly & relaxing. Even the midwives clinic was just a normal terraced house with the 'office' in the living room, baby massage & yoga upstairs in the bedrooms & the waiting room was the kitchen where you boiled the kettle for a cuppa & chatted with other women waiting to go in (usually never more than 2) while you waited.
I always saw the same 2 midwives who were lovely & so supportive, I never felt rushed but was usually in & out in 10-15 mins.
After I went 7 days over my midwife made an appointment for me to see a consultant in the maternity hospital which is routine.
That experience was like night & day from the relaxed appointments I was used to. I queued for 4 hours in a noisey, hot waiting area to be seen for 5mins. The consultant was nice enough but v.rushed. She recommended an induction & really it all went downhill from there as I ended up with a section.
This was just my experience of course, others may have different.
I can now never avail of midwife led care due to me having a section & I'm absolutely dreading the thoughts of consultant led care on subsequent pregnancies

That's how every mum's antenatal care should be.

Although you've had a previous section your antenatal care is no different whether you attend the obstetric team or midwifery team. Some mums in the Coombe have been able to go to the midwives clinic (with some discussion with the obs team) and negotiated going with the midwives. Is that an option in the hospital you're attending? Or connect with a midwife in your community who will do your antenatal care in collaboration with your hospital. So you'll still book in to the hospital and have your bloods/scans done but your care will be with your midwife.

Merrilady

Some fantastic points raised and great opinions, especially for me.
I am 20 weeks on a v high risk pregnancy, 6 IVF attempts to get this far.

Personally, I don't have enough experience to have an opinion either way as I believe there are valid points in both arguments.
In my own case I will be doing a Hypno and Active Birthing course and will do my best on the day, am adamant I don't have an episiotomy or induction, but will probably have to have a section.

Ms2011

SanFran07 wrote: »

That's how every mum's antenatal care should be.

Although you've had a previous section your antenatal care is no different whether you attend the obstetric team or midwifery team. Some mums in the Coombe have been able to go to the midwives clinic (with some discussion with the obs team) and negotiated going with the midwives. Is that an option in the hospital you're attending? Or connect with a midwife in your community who will do your antenatal care in collaboration with your hospital. So you'll still book in to the hospital and have your bloods/scans done but your care will be with your midwife.

I would be attending the Coombe as that's where I had my son.
I will definately be pushing for midwife led care if I can get it but their policies are so strict I don't know if I'd qualify next time round.
Guess I'm just psyching myself up to be told no so that if by some miricle they say yes I'll be pleasantly suprised ;-)

January

SanFran07 wrote: »

That's how every mum's antenatal care should be.

Although you've had a previous section your antenatal care is no different whether you attend the obstetric team or midwifery team. Some mums in the Coombe have been able to go to the midwives clinic (with some discussion with the obs team) and negotiated going with the midwives. Is that an option in the hospital you're attending? Or connect with a midwife in your community who will do your antenatal care in collaboration with your hospital. So you'll still book in to the hospital and have your bloods/scans done but your care will be with your midwife.

How much of an option is this for someone who has successfully had two VBAC's after the first being a c section? How hard would I have to fight? I'm not in a catchment area so an aerial clinic is not an option for me but even attending the midwives clinic in the hospital would be great. I'm not adverse to consultant led care, loved my consultant on my second pregnancy and hoping to have him again for this one if I can't go midwife led.

SanFran07

Having had 2 VBACs you'd have a great argument for going to the midwives clinic. A few mums I know who've had a previous csection and planning VBAC were able to successfully negotiate this option. You can just agree that if there are any problems at all during your pregnancy you will of course move back to consultant led care. It's a very reasonable discussion to have.

Ms2011

I've joined a VBAC group on Facebook & it seems there is an increasing number of women allowed to choose midwife led care after having a section once they are signed off by a consultant.
Gives me hope for any future pregnancies ;-)

csm

Just saw this on the front page. My wife just had a baby in Australia and had midwife-led care. It was fantastic but in no way was it 'natural' or somehow not backed by medical science. In fact it was extremely scientific with excellent literature that made scientific studies accessible to the public, see this website:
http://www.havingababy.org.au/

As a first time parent I have no way of comparing to obstetrician led care but I certainly would not change our approach next time.

EDIT: oh and she had an emergency caesar in the end. Midwives confirmed we can go VBAC next time no problem