Transcript

SPEAKER_00
0:21

Yeah, thank goodness for modern medicine, right? Sometimes uh the weather is really turning here in Kansas City. I mean, it's like gonna be 90 degrees today with major storms tonight.

SPEAKER_01
0:35

That's not normal.

SPEAKER_00
0:38

Anyway, uh it's rock and roll spring weather for us. Is your snow all melted yet?

SPEAKER_01
0:44

Oh, yeah, we have no snow, but it's anticipated to return on Saturday. So it goes from 70 to 30 to 50. Yeah, it's it's like a roller coaster around here.

SPEAKER_00
0:55

Oh, geez.

SPEAKER_01
0:56

Kind of like the moods of some people I know.

SPEAKER_00
0:59

I would agree with that. Okay, so our new news, this uh podcast. And you know how I always like to try to find something current that might align a little bit with our guests, and I think I I think I found the golden ticket. Perfect. So this was with the news. Yeah, yeah, I'm gonna hit you with the news. And of course, you know, I don't post stuff anymore because I'm trying to, you know, shock you. You're trying to you are. This was posted about a week ago. Um, and it is about a lawsuit, and the headline reads, Alabama Midwives and Birth Centers, state Supreme Court review of a court order requiring unnecessary hospital licenses. And it's about birth centers in the state of Alabama. So let me give you just a little bit of history of sort of a timeline because whenever you know midwives are faced with like restraint of trade cases or even professional liability cases, they don't get resolved overnight. Right. You know, they take a lot of time. And so this entire kerfuffle began in 2023. Oh, wow. When there was an injunction by the Alabama Department of Health, which our guest might correct me if I'm wrong, is ran by physicians, which is a little bit unusual for State Departments of Health, uh requiring an injunction for these birth centers that had been open to follow sort of hospital guidelines or hospital rules. And of course, we know CABC accreditation that has been around for decades does not see them as a hospital. They see birth centers as an ambulatory care facility.

SPEAKER_01
2:57

Right.

SPEAKER_00
2:58

And the battle has been going on where the ACLU took it to court and they got an injunction against the Department of Health ruling that they would not have to follow those rules. And then it was appealed in July of 25 by the friendly physicians who got the higher level appeals court to reverse the lower court decision. And now the ACLU is taking it to the Alabama Supreme Court.

SPEAKER_01
3:34

Wow. Well, I have yeah, I have no words about that. Um I I don't even have I yeah, it's amazing how these things take forever and the back and forth. And who's serving, you know, who is it serving?

SPEAKER_00
3:48

Exactly. Exactly. I mean, and to and to get the ACLU involved, or in some of these cases, we have brought forward Denise, the Pacific Legal Foundation, which are pro bono entities because even physicians of which one owns one of these birth centers and midwives cannot afford legal representation to the degree that these battles with very well-funded um physicians and health departments can can take on. Sounds like power. Doesn't it? It's it's it's just it's befuddling to me. But here's the silver lining that I really appreciate is that these pro bono national organizations and even legal firms are stepping up to the plate. Yes. And it's almost like the reproductive justice movement post-DOBS has elevated rights on a spectrum, not just abortion issues, but on all kinds of choices and you know, good good for these people.

SPEAKER_01
4:55

I'm just well, I think what when do they anticipate having some type of answer, do you know?

SPEAKER_00
5:03

So they've just petitioned them. That doesn't mean they're going to hear it. Okay. They they must they may just say, nah, you might throw it out. Yeah, you gotta do what the appellate court says and and they'll just find another way to come back if they want to keep fighting, but it's time and money. And in the meantime, how these verse centers function, maybe our guests will know legally, compliantly, whether they can, you know, bill, hire staff. It can it can become very complicated. And then, oh, do we even care about what the public is asking and what their choices are? It's sort of like very complicated.

SPEAKER_01
5:41

Yeah, it will be it will be great to hear Liz's perspective on this.

SPEAKER_00
5:45

Yeah, I'm excited. Yeah, let me just move into introducing our guest today, which I am very excited to have Liz Munoz come on. Um, I've known Liz more closely, I would say, for the past four, three or four years uh in her work in Alabama, and know that she's been involved in some School of Nursing grants that have reflected elevating issues of midwifery in Alabama, as well as dabbling a little bit in the TMAH funds, which is part of what we're going to talk about today and how difficult it is. I've had three more midwives from three different states uh email me and say they've had no conversation at all. Liz share a little bit about her experience and you and I can sort of add ours in there as well. But Liz, we're thrilled you're here.

SPEAKER_01
6:41

Hello, Liz. Welcome. Hi, thanks for having me.

SPEAKER_00
6:44

I'm thrilled you're here. Uh why don't you tell the listeners a little bit about where you're at? Like I think you're sitting in Illinois, but uh what your road to midwifery was and sort of what what's your focus right now?

SPEAKER_02
6:59

Sure, happy to. Um, and I know, Jinder, you've heard some of this before, but I might have a few surprises stuck in there. Um so my name is Liz Munoz. I'm a certified nurse midwife uh and have been since 2013. Um, but I was not always going to be a midwife. That um midwifery is a second career for me, and my first career is in theater and in musical theater, um, which I uh love to mention occasionally uh because I think it's it is interesting how many creative people find their way to midwifery. I think there's something about the process of being with someone and connecting that uh is a through line there. So um, so yeah, so I um my journey to midwifery really started in a theater. Um I played, I played a midwife in a play. I played a pregnant pregnant person in a play. Um and I loved it. And it didn't click then that I really loved it. I loved that part of my college experience. Um, and it wasn't until I moved to New York City um that I had the opportunity to attend film premieres and that sort of thing. And I ended up at one of the premiere dates of the business of being born. Ah so I uh a friend of mine who um was thinking about having kids at the time said, please go see this movie. I will um I will, you know, pay for your ticket. Go, you have to see this movie. I'm so jealous I can't go. And I thought, why do I ever want why would I ever want to see a movie about childbirth? But it's I'm not into that. Uh and I went and uh I was in awe of what midwives were doing in that film. Um and looking back, looking looking back, like it's not the most groundbreaking midwifery things happening, but at the time for me, it just opened a door to the work of midwifery and specifically the work around advocacy um for um people as they as they grew their families. Um, and so uh I apprenticed with a home birth midwife for a short season um and loved that. And um that midwife continues to be a mentor for me even today. Wow. And um but I ended up going to nurse midwifery school in Nashville at uh Vanderbilt School of Nursing and um stayed on to work at the faculty practice um as my first midwifery job, which was incredible to get to work with this historic practice that had been around a long time and to be sort of immersed in the power of midwives. Um being there taught me so much about what I can bring to the table, what value I add to a system, a health system. And it also taught me about navigating the health system and not losing my midwife self. Yeah. Um, and I think that is a lot of of what I continue to do today. I'm now in midwifery education. I am the interim director of a nurse midwifery program in the state of Alabama, and I uh practice and live in Illinois. So that is a little bit of a difference. Um post-pandemic, Zoom really makes things possible. So um I'm able to have my family all in one place and be here together, but still do the work that I'm passionate about in Alabama. And um I'm so passionate about that work in particular because I'm from Alabama. My whole family still lives there. Um, my mom and sister are and my brother are in Alabama and all of my extended family. Wow. And um, so the work I do now I see as um my advocacy work for my community that I grew up in, and my family members and friends and community members. So um it really is personal work and um you know it continues to be a wild ride some days, uh, but um never have I seen so much opportunity for the state of Alabama, and I'm really proud to be involved in that work.

SPEAKER_00
11:41

Yeah. What a journey.

SPEAKER_02
11:44

Yeah, that's it in a nutshell. Of course, there were like tears and laughter throughout all of that.

SPEAKER_00
11:50

Yeah, of course, we've we've all had those. I I I slightly remembered your theater work, but not the specific roles you played, and that's pretty cool. Yeah.

SPEAKER_02
12:00

Um I had a foam pregnant belly and everything, like a pillow. It was it was obviously very fake looking.

SPEAKER_00
12:08

Oh my gosh.

SPEAKER_02
12:09

Yeah.

SPEAKER_00
12:10

Uh Liz, how many licensed CNMs are in Alabama?

SPEAKER_02
12:16

Yeah, I check every week as part of my part of my job. Um, I checked last week and there were 60. 60. Um, this is when I first started um my work as a midwifery educator in the state, that we were in the low 40s.

SPEAKER_00
12:33

Okay.

SPEAKER_02
12:33

So in just a few years, yeah, increased by about 20. That's fantastic. And every year we'll continue to increase as we grow our pathway.

SPEAKER_00
12:44

Yeah.

SPEAKER_02
12:45

Yes.

SPEAKER_00
12:46

Great. Denise, do you have a question?

SPEAKER_01
12:50

Um, I, you know, I I really liked your comment about the power of midwives. Um, I wrote it down. Sometimes I feel like we don't have a lot of power. Um, but other times I do think, you know, in small circles we have more power. Um, how do you feel like, you know, in Alabama and or in Illinois where you're at, how do you feel like the, you know, the climate is and in like being able to use your power?

SPEAKER_02
13:20

Yeah, I think it it is different in the two spaces and it's different during different seasons. Um, you know, I really saw the power of midwifery during the pandemic as I worked here in Illinois. Um, I um worked for a community hospital that is the only hospital in well, at least an hour drive in each direction. Um, and it is the only place you can have a baby, even you know, it's even a longer drive to have a baby somewhere. So um during the pandemic, the midwives really rose to the occasion providing um care for beyond our census of patients, um, uh covering, you know, for vaginal births when they when the clinician couldn't get there. Was a time when uh you couldn't go, if you were in the clinic, you couldn't go to the hospital. And if you were in the hospital, you couldn't go to the clinic. There was no crossover. And so whoever was on the floor was on the floor for whatever happened that day. And I really saw um the organization begin to value midwifery in a in a different way. Um and and also personally, just watching that happen, um, knowing that I was if I was on, I was the sort of the um the barometer for normal. And yeah, it was up to me to hold that, even in the most abnormal of circumstances when people were alone. You know, there was a period of time we didn't allow support people. Yes, baby babies had to go immediately, especially if the the parent was um COVID positive, go immediately to a different space. And um, you know, to hold that compassion and care that midwives are sort of reared in in our profession as we grow, um, to hold that during chaos, um, that is its own type of power. It might not be power that anyone fully acknowledges or says out loud, but it is, you know, it's power in in sort of all the ways um that I think count. Um yeah. So, and then in in Alabama, you know, one thing I I've always tried to take into as I do work in my home state back into Alabama is that the power that I feel as a midwife is internal. And I get to declare it. Um a system may not know how to fully value me yet.

SPEAKER_03
15:54

Yeah.

SPEAKER_02
15:55

Um, and I like to use that word yet because um being a stubborn uh Scorpio, I uh I like to prove people wrong. So uh, you know, I I think, oh, you just don't, you're not used to me yet, but we'll get you there.

SPEAKER_03
16:11

Yeah.

SPEAKER_02
16:11

And um some people call it compromise, but I really think it's just being fluid and figuring out where you can impact whatever space you're in the most right now. Um, and and that that hasn't been something I've been able to say all the time because I didn't know what to call it. And I think the longer I do this work, um, it's not that I am changing who I am. I'm just asking how can I help today in this space? And I think that's where the power is in my current role.

SPEAKER_00
16:42

You know what, you know what we call it, Liz. We call it what's possible.

SPEAKER_02
16:47

Possible. Oh yes, I know I love the name of this uh of the podcast. And I was thinking about that. Um that it you have to remain in that in that mind frame.

SPEAKER_00
16:59

Yeah.

SPEAKER_02
16:59

Um, or you're gonna get really tired and leave. And so you have to keep in the realm of what's possible.

SPEAKER_00
17:07

So let's let's move over to maybe the preponderance of our conversation, which is all these federal, I'll just I'll just call out two. I know there are many that many that name midwives, but TMAH to the 10 states, um, 15 states.

SPEAKER_01
17:26

15, yeah.

SPEAKER_00
17:27

And yes, and the new uh rural health transformation grant, and Alabama has both of those, correct, Liz?

SPEAKER_02
17:35

Yes, correct.

SPEAKER_00
17:36

And how the power of midwives can and must be elevated in these state and federal conversations. Any thoughts? What's going on there?

SPEAKER_02
17:49

So many thoughts. Um, I I will say, you know, much of what I will say today is is mine, it is my opinion as as Liz watching this unfold. Um but I will mention some things specifically that I think are really important. Um, and I'll start with the first one that the the TMAH grant grant or TIMA, as I as I hear it called a lot, um is where I think midwifery has the most opportunity to shine.

SPEAKER_00
18:21

I agree.

SPEAKER_02
18:22

Um, the rural health transformation grant gives other opportunities, but the fact that the TEMA grant builds in in each phase of its unfolding a new benchmark for moving toward value-based care. Yeah um, I think that that is the place where midwifery is going to be able to really shine. Um, not only in you know, cost savings things, of course, but also just the the value that I see in the care that even students I work with are providing. Um, you know, if we're moving toward reimbursing for the outcome for the specific um better outcomes, we'll take reducing C-section as the example. If we're moving toward that, there's nobody better than a midwife to do the homework. Um we're always trying to get to that goal, right? And so um, you know, that's that's where I think midwifery stands poised to really shine. And um, you know, the the task at hand now is scaffolding the supports for midwifery to grow within the system. Um, because Alabama is a state with many maternity care deserts. And we see, you know, this interstate I-65 goes straight on the state. And you can have babies along I-65. But if you get too far off of the interstate, there's nothing.

SPEAKER_03
19:54

Yeah.

SPEAKER_02
19:54

And so really scaffolding um midwifery practices throughout the state becomes really important to reach the rural communities, which then ties in the rural health transformation grant. Yes. You know, how to do that and connect everybody.

SPEAKER_00
20:09

So Liz, they're they're in year two of the pre-implementation phase, which is three years. And Denise and I will each talk about our own state knowledge, but like how far has your affiliate or midwives in particular gotten into the pre-implementation conversations?

SPEAKER_02
20:32

Yeah, so I know of a few things that are happening. Um, I I'll start with how I was tapped to help with this. Um, and this is still a project that is being coordinated, um, and so hopefully will occur toward the end of the summer, early fall. Um, but I was asked to bring in the education component to really bring together examples of models of care that can demonstrate collaborative care models between midwives and physicians of all kinds, midwives and other types of practitioners, um, to bring in example speakers, speakers that are working together or have worked together in the past with a successful practice model to show the different ways midwives can be utilized in a health system. So that is a mini-conference that I'm working on and planning um uh now. And so that just bringing that information into the state is is revolutionary in that um those models of care have not yet been explored or haven't been fully explored. Although I will shout out that we are highlighting a local model um in the Birmingham area that is is growing and continues to thrive um in the major health system in the state. So we do have an example, but we need more examples as we expand. So um, so that is one way um that um midwives are getting involved. Yep.

SPEAKER_00
21:59

How did you? Get invited. We're trying to help people figure out how do you knock on the door, scream on the phone, send an email.

SPEAKER_02
22:08

Like how do you get answers? So in my case, I am the interim program director for the only nurse midwifery pathway in the state. And the the people running the um Tima education wing reached out and said, Okay, hey, we want the midwifery voice. Can you help us?

SPEAKER_00
22:32

So they reached out to you.

SPEAKER_02
22:34

Yes. And that has been the trend in Alabama with Alabama's Tima, which is beautiful and ironic. Yeah. Because that is not the case in other areas. And I'll share a story about when I met the National Tima um project manager, a conversation that I had. But I wanted to first say another way that midwives are involved in the TEMA process is in advisory groups that are happening. So there's, I know there's um a group that meets in Montgomery, and there are nurse midwives that are invited to that group. I I'm not sure if there are CPMs uh invited to that group or not, but I know that um there's a nurse midwife from the mobile area that goes up to Montgomery and advises um as this project is worked on.

SPEAKER_00
23:25

Um is the affiliate involved?

SPEAKER_02
23:28

So the Alabama affiliate um is I think involved to the extent that they can be um or that they're able to be. They're a small affiliate. And it is uh as it is in a lot of spaces in Alabama, the people who are doing the work are the people who are doing the work. Same people. And so it's just divide dividing them further. Um, but um, I can't speak to um the exact ways that they're involved at the current moment, but yeah, um, they are the midwives in the systems, working full-time as midwives and uh you know in practices. So um they are very, very, very busy. Yeah, of course. Uh as with us all. So yes, midwifery is involved in Alabama in a bigger way than I've heard in other states.

SPEAKER_00
24:21

Yeah, you may be in the most um integrated way, Liz.

SPEAKER_02
24:26

Yeah, integrated, but somehow still just disjointed a little bit. And maybe that will shift as as the years go by. Yeah, we get in the same spaces.

SPEAKER_00
24:36

The the key here in my mind, and Denise, I'm gonna come to you next, is the pre-implementation phase of three years is to get stakeholders together, is to find consensus on these value-based driven experimental models, I will say. Um and there's a lot of money that's coming out in years one through three. And my question is, where's the money going? And and who's being invited to the table? So, Denise for Wisconsin, what I mean, all three of us represent a state with TIMA money. What's happening?

SPEAKER_01
25:16

Well, I actually had no idea what Tima was until a very short time ago because um despite the fact that ACM created some toolkits to prepare people to go to, you know, for their affiliates to be involved with TIMA, I we weren't involved at all. I mean, I'm part of the affiliate, but I again I had no idea. The only way that I really found out is that I was doing some research and work for the MCTA grant in the state of Wisconsin, the shortage um maternity um care target area. And and I, you know, I started to research what grants and what entities are working on very similar projects and also very disjointed. And I came across the TEMA and the Rural Health Transformation Grant, um, which Wisconsin received both. And then I tried to find information, you know, really about the pillars and the work being done. And all I can really find is, you know, words that refer to midwifery and do us as far as the healthcare providers, there is not, you know, any reference to nurse midwives or CPMs, just really general terms of midwifery. The work that I was working on was to really, you know, figure out what the workforce of CNMs are in the state of Wisconsin. That is not an easy project to do because as you may experience in your state, we have maybe 70 of the 292 midwives are affiliate members. And so, other than trying to delve through licensing data, um, it's really hard to figure out where the midwives are and who they are. So, my idea was since TMA, Tima's grant says that they're going to assess the midwifery workforce in the state, why aren't we working together to figure out what that is? And then workforce, the CPMs, the CNMs, and you know, all of that. So I really, it's all very new news to me, and I'm learning a lot about it, but not via our affiliate, unfortunately. And yeah, I don't know of any midwives that are at the table, unlike you, Liz. So I think that's amazing. But we should be at the table.

SPEAKER_00
27:35

Yeah, it's long overdue.

SPEAKER_01
27:37

Yeah.

SPEAKER_00
27:38

The story of Kansas is um I'll I'll shorten it, but for those who know me, I'm when I get on to something, I'm pretty persistent. When I knew the TIMA uh opportunity was coming out, and and there was a lot of discussion with the affiliate of who's gonna reach out and ask the Medicaid, State Medicaid Association if they're writing it, you know, somebody did, but they were basically told they weren't gonna do it. And then in less than a week or so, at the very last minute, Kansas submitted. Now I'm gonna just say it again, which I've said somewhere before, how we got this money for 34,000 births a year, I have no idea. But we did. And in the meantime, there has been some interesting commentary about defining what a midwife is in Kansas, so that most of the stakeholders at the State Department of Health and Medicaid office think they're talking about CPMs, not CNMs. And in Kansas, we have no regulation for CPMs, which is another topic for another day. But I continued to ask our affiliate, like, what do you know? We're now in year two. Has anybody reached out to the Kansas affiliate? And these this is an affiliate with 109 member, 109 licensed in Kansas, maybe 20 members. Just like you said, Liz, the people doing everything are doing everything, and oh, they're working full-time.

SPEAKER_01
29:13

Right.

SPEAKER_00
29:14

And for them to take on one more thing, I decided to offer my personality at an affiliate meeting about a month ago. And I said, look, I will spearhead a quite directive letter to the state Medicaid office demanding a meeting in person or on Zoom and explain why. Who would like to join me? So a couple other people said, I'll join you because you never do this without another set of ears. And we ended up maybe three weeks ago now having a one-hour meeting with the project director who was hired by default, who had just hired two months prior the person over pillar one, which is midwifery workforce assessment, birth centers, who didn't really neither one of them knew anything about midwifery in the state of Kansas. They didn't know the difference in midwife types. And at the end of the hour, we were able to to level set and get clarity on operational terms and how going forward how important the affiliate was in the conversation. Because even though there aren't that many midwives who are paid news members, they are the official voice of midwifery in the state. Which I'm gonna come back to one more time in saying there is so much going on about our profession in our states that if we're not part of it, they're talking about us in most commonly incorrect sort of descriptors, which was clearly what we discovered after that hour meeting. So it concluded with names being shared, meetings being designed, ongoing conversation as they begin to upstaff what was slow money coming out, slow technical assistance coming from the team a team at CMS, and an intent and a promise, really, to to bring midwives in the fold. But sort of the the moral of the story is they are not, most typically, Liz, going to come knocking on your door. Right. They're not.

SPEAKER_02
31:40

Yes. And I I think that that um is is what I meant when I said it's a it's a little ironic that that's how it happened in Alabama, because that historically has not been how things have gone down. So uh, you know, I it's um it's a something I'm very grateful to be involved in and hope to continue to to grow my involvement in um because the level of collaboration that is happening um right now in the state of Alabama is unheard of as far as midwifery of of all kinds goes. Yeah. It's a new day. It's a new day. And um it's a moment to seize in in whatever way midwives can in the spaces they're in.

SPEAKER_03
32:31

Right, right.

SPEAKER_02
32:32

Um, and you know, going back to the comment about everyone who's doing the work that they're doing more work, you know, um uh trying to inspire that message um across a group of overworked and incredible, but um overworked and split in so many different ways, um, midwives um is hard. And and um and then to inspire a new group of midwives, a new generation of midwives that are coming out of school to stay in the state, yeah, and and be ready for those opportunities that are coming.

SPEAKER_00
33:12

Yeah.

SPEAKER_02
33:13

Um, and you know, it's like everyone needs to go back and watch Field of Dreams. Um, you know, we have to we have to do the if we build it, yeah it will come. It will come.

SPEAKER_03
33:24

Yeah.

SPEAKER_02
33:24

My husband will be so proud of me for mentioning a baseball movie. I just need to say I just scored points there.

SPEAKER_00
33:32

Oh, that's great. So that's great. It it is it is about, I think, a post I had this week about joining AC and M and why people, you know, our membership is extremely, I don't know that it's ever been this low in the history of me being a member. Uh it it's it's slightly terrifying. And I value the shared, heartfelt reasons many posted that they have left. But what is missing in our polarizing viewpoints is what commonly must happen for our profession to be stable. And right now, as you said, Liz, this is the window of opportunity. And for us to be so fractionated, you don't have to be an affiliate and say you're going to do 15 volunteer jobs. You know, you may not be able to do any, but you can supply money and you can have your name on a list that shows higher representation of people in the state. Um we we are jeopardizing a lot by our apathy and our anger. And I think how to how to push towards what's possible here. And a couple of people, Denise, said they're actually going to buy the book, um, who are quite angry. Is it's so important because we get stuck in these line in the sand positions and can't see see our ways through it because we are an oppressed profession. So you keep oppressing us with things that I don't agree with, and I'm just gonna say no. I don't want anything to do with you. I'm getting a paycheck. Who cares what's going on with the professional organization? Yeah. And and I think oh, go ahead. They the professional organization organization sets the core competencies. The professional organization writes the standards of care that you will be held to in a court of law. The professional organization is written in every state regulatory licensure rules. We take them away, and we think we're in trouble now. It's gonna be big.

SPEAKER_02
35:46

It begins to unravel.

SPEAKER_00
35:48

It begins to unravel.

SPEAKER_02
35:49

Yeah, and it it is uh uh, you know, a knitted, uh a knitted sweater that isn't sort of knitted loosely already because of the the history of the profession. And um, and uh, you know, I I have this timeline that I created for a course that I uh teach in, and it's a history of midwifery foundations course, and um the timeline lists all the points of modern sort of changes in midwifery from um a little bit before the founding of the ACNM. Yeah, and then everything since. And uh what is uh it also goes back the other direction too, but for the modern mid-wife, I focus on just uh mid-century um uh mid-20th century forward. So um, so one of the things that I noticed when I was making this timeline is there is this period of time where I don't have enough room to write everything that is happening for midwifery on the timeline. It's like this thing is happening and this thing is happening, and and here's an you know, an ACOG statement, and this is how we responded, and and this is where we stand on out of hospital birth now, and all of these things happened in a short window of time. And I feel like we're in that type of pace again from midwifery, where the timeline when we write it out for future history of midwifery classes, it's going to be the build of all these little moments, and they seem insignificant to people looking in. But when you look back, yeah, and you think about how few people uh came together to knit the current, especially uh under the AC and M, right? And the current state of our professional organization, the few people who came to together to do that. Um

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