Ep 157: Disparities in OB/GYN – What They Are, The Causes, and What You Can Do

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This episode is about racial disparities in obstetrics and its release coincides with Black maternal health week. Founded and led by the Black Mamas Matter Alliance, BMHW is a week of awareness, activism, and community building intended to deepen the national conversation about Black maternal health in the US.

To be honest I’m actually a bit tired of talking about disparities. The problems and root causes are well documented yet things are getting worse. People don’t want to talk about racism or are actively trying to suppress efforts to talk about race. But not talking about it doesn’t make the underlying issues go away. Helping address this problem starts with LISTENING. So especially if you are not Black, take a moment and listen (I explain why I say this in the episode). I hope that by the end you have some empathy and the ability to understand and share the feelings of another.

Also - If you are a Black woman, it's ok to skip this episode. I understand that it can be traumatizing to repeatedly hear about disparities.

In this Episode, You’ll Learn About:

  • What does disparity mean
  • What are the statistics on racial disparities in healthcare
  • What are the causes of these disparities
  • How racism affects care and outcomes
  • What does the term weathering refer to
  • How I have been personally treated differently on the basis of race
  • Why it matters if you speak up about race in your own community
  • How you can help (donate to the groups linked below!)

Links Mentioned in the Episode

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I want this podcast to be more than a one sided conversation. Join me on Instagram where we can connect outside of the show! Through my posts, videos, and stories, you'll get even more helpful tips to ensure you have a beautiful pregnancy and birth. You can find me on Instagram @drnicolerankins. I'll see you there!

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Ep 157: Disparities in OB/GYN – What They Are, The Causes, and What You Can Do

Nicole: Hey there. This is an episode that I actually wish I didn't have to do. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Well, hello. Hello. Welcome to another episode of the podcast. This is episode number 157. Thank you for spending some of your time with me today. So in today's episode, I, I am talking about racial disparities in obstetrics and gynecology, and it's released the release of this episode coincides with Black Maternal Health week, which is every year from April 11th through the 17th and Black Maternal Health week is a week that was founded and is led by Black Mamas Matter Alliance. And it's a week of awareness, activism and community building intended to, and I'm just taking this directly from their website, deepen the national conversation about Black Maternal Health in the US, amplify community driven policy research and care solutions center of voices of Black Mamas women, families and stakeholders provide a national platform for Black led entities and efforts on maternal health, birth and reproductive justice and enhanced community organizing on Black maternal health.

Nicole: And I'm going to be honest here, I actually get a bit tired talking about racial disparities with Black maternal health. The problems are very well documented and have been documented for many, many, many years. And we also know what the root cause is. It really gets down to racism and I'm gonna get into that in just a moment yet, despite the fact that we know that these problems exist and we know what causes it, things are actually getting worse. Also, they're starting to be a bit of a backlash in society in general, for even talking about anything related to race or racism. After George Floyd was murdered a couple, two years ago, there was an explosion of interest and commitment to the topic. And in the last year, I would say, especially the pendulum has really swung the other way where people don't wanna talk about race.

Nicole: People are actively trying to suppress efforts to talk about race even so far as banning books and conversations and, and like that. But listen, talking about it does not make the underlying issues go away, the data and the facts and the statistics don't lie. And you're going to hear me share those numbers in this episode. And I wanna be clear, we can talk out these important and difficult issues and it doesn't have to be an either or, or it's not an exclusionary type of thing. So the national institutes of health defines disparity mean meaning that there's a significant disparity or difference in the overall rate of disease incidents, prevalence, morbidity, or mortality in a specified population as compared with the general population. And there are lots of different disparities that exist in the United States. There's disparities with Black folks, with Hispanic folks, with American Indians, Asian Americans, actually, there are disparities with socioeconomic lead disadvantaged folks with underserved rural populations, also sexual and gender minorities.

Nicole: And we can talk about all of these things and concentrate on specific groups of people and acknowledge that other things exist. All right, no, one's trying to exclude anybody or keep out anybody or ignore other people's problems. But when you see something that's there and you know, that it's a problem, then it has to be addressed. So we don't have to take a cowardly approach and ignore issues or suppress conversation. We can put our big girl panties on and we can talk about maternal health disparities and help, help fix this issue and helping address. The problem really starts with listening, listening, listening, listening, and learning, especially if you are not Black. I want you to take a moment and listen to the information in this episode. And the reason I say that I, especially if you're not Black, because honestly, as Black folks, we know this, we feel this, we live this as part of our lived experiences.

Nicole: And honestly, sometimes hearing it over and over again can be traumatizing. I remember when I was in medical school and I got so like exasperated with hearing that Black people were at risk for everything that I was like, jokingly hap you know, jokingly, not jokingly. I'm not gonna be Black anymore. I'm just gonna call myself something different because I'm tired of being told constantly that I'm at risk for all of these conditions. So if you are a Black woman, feel free to tune this out, cuz I, again, I understand that this information can be traumatizing and if you're not, then definitely please come on in, take a moment, listen and learn and what you're gonna learn. I'm gonna, um, tell you about some of the numbers with the disparities in OBGYN, we'll talk about the cause honestly it boils down to racism and I'll explain that.

Nicole: And then I'm gonna share a bit about my personal experiences as a Black woman in medicine, both as a physician and things that I've seen. And then I will end with things that you can do. And I hope that by the end of, of our conversation of this, this episode today, you have some empathy, which is the ability to understand and share the feelings of another. You have some empathy, some understanding about the importance of this issue, and you are ready to roll up your sleeves and tackle this hard topic because we can do hard things. All right, so let's get into the episode, but before we do, um, one quick thing for Black Maternal Health week, if you are listening to this during Black Maternal Health week, which again is April 11th through the 17th, I am doing a giveaway where I collect contributions to giveaway spots inside the Birth Preparation Course to black mamas.

Nicole: And last year I was able to collect enough people donated enough that I was able to give away 15 spots inside the Birth Preparation Course. I was completely blown away by people's generosity. And I would love to smash that record this year. Already, Lansinoh who I've worked with as, um, in, in multiple capacities with things they are giving away five spots in the course. So I would love for the community to come together and contribute enough to give away an additional 15 spots. So we can smash that 2021 record. If you want to, um, know the link to where you can contribute, you can head to my Instagram it'll be in the link in my bio. I can't think of it off the top of my head. And it's kind of a long link for me to say. So head to Instagram, I'm on Instagram @drnicolerankins, and you can find the link there to contribute, to give away spots for Black mamas inside the Birth Preparation Course. All right. So let's get into this conversation about racial and ethnic disparities. I wanna address something right off the bat, because this is something that I hear a lot that people wanna say. So let's go ahead and get this out the way I hear things like, well, if Black people would just eat better or exercise more and take better care of themselves, then they wouldn't have these problems happen to them. Now don't get me wrong. There is of course an element of personal responsibility that we all have for our own health and wellbeing. So I 100% recognize that those things are lifestyle choices. The things that we make decisions about contribute to that. But hear me out, you need to step back for a minute and think about what options do people have and what are things that influence someone's options.

Nicole: Personal response. Stability can be very difficult if you are in a system that is unsupportive and in some cases is actively hostile towards you. Not everyone has access to the same resources, like a safe and supportive environment to live in, a safe and supportive environment to learn in and get educated in. Not everyone has access to quality, healthcare, reasonably priced, healthy foods. Not everyone has access to examples of what being personally responsible looks like. Okay. And I'm not saying that that's an excuse, but you have to understand people's backgrounds. All right. And health is not just about personal responsibility. It comes from the interplay of lots of different things, your lifestyle, your genetics, but also factors like society, where people are born, where people grow up, where people live, the experiences that they have. And although, again, the factors like how you live your life, what you do, the choices you make, do influence your health.

Nicole: That does not account for the disparities in outcomes. Okay. I cannot say that strongly enough, that does not account for the disparities in outcomes as an example. And I'll get in some into, into some of the more data as I keep going in the episode. But as an example, non-Hispanic Black women have higher rates of preterm birth compared with white women. And that is even for adjustment after differences in come housing and education. That difference is still there. It is not explained by some of those things. So please, please, please, please let go of the, if you just ate better, if you just exercise more, if you just took better care of yourself, blah, blah, blah, that that would suddenly fix all of these disparities, that is not accurate. Okay. Now, now that that is out of the way. Let us talk about some of the disparities that exist in reproductive health and both, um, obstetrics and gynecology.

Nicole: They are quite well documented. I'm not gonna go into like intense detail. I'm just gonna kind of hit some highlights. So one of the biggest ones of course is maternal death. Maternal death in the United States is more common in non-Hispanic Black women. And unfortunately it has been rising. Uh, it rose through the pandemic. Actually Black women are two to three times more likely to die from pregnancy related causes than white women. And this is data from the Centers for Disease Control and prevention, the pregnancy mortality surveillance system. And when you look at these data, the mortality differences, persisted at all education levels. In fact, among women with a college education or higher the pregnancy related mortality ratio, that's one of the numbers that, that is measured. The pregnancy related mortality ratio for Black women was 5.2 times that of white women. This is one of the, the largest racial disparities in the United States.

Nicole: And when we look at something called the maternal mortality ratio and look at some of the most common causes of death, the maternal mortality ratio for eclampsia and preeclampsia was five times higher for black women. It was 4.8 times as higher for Black women for postpartum cardiomyopathy, 2.5 times for obstetric embolism and 2.27 times for obstetric hemorrhage. And these numbers are particularly alarming, especially for obstetric hemorrhage and eclampsia, because these are things that can be treated very well and very easily, relatively easily. So when you see that these numbers are so different, it suggests that something underlying is going on in the way that people are being treated. And again, just to beat a dead horse about some of the things like economics, socioeconomic factors, even prenatal care, although in general, they are protective against maternal death. When you look at all education and so socioeconomic levels, the pregnancy related mortality ratio for Black women is three to five times higher than for white women. Okay? So that's across all education and socioeconomic levels. Furthermore, the reduction in maternal death that we see with prenatal care is much greater for white women who receive prenatal care than for Black women who receive prenatal care. So there's some underlying systems differences that reflect or are the reason for these differences that we see.

Nicole: It's very clear that there are social, social and structural determinants rather than biologic factors. And race is actually not a biologic. It's a made up construct. Um, we on a genetic level at a DNA level are like 99.9% similar. It's only a tiny bit of difference. Um, so it's really social and structural determinants and not biologic factors that contribute to these disparities between Black people and white people. Now, when we move on, let's talk about not mortality. Let's talk about severe maternal morbidity and what that is is a life threatening event during pregnancy, delivery or the postpartum period. And in one study that looked at, um, maternal morbidity, it found a increased rate up to 115% higher rate of severe maternal for Black women compared to white women, 115% higher. And that was after adjusting for things like age and socioeconomic status and all of those things. And in fact, one study found that the severe maternal morbidity rate or incidence of it was significantly higher for every racial and ethnic group compared to non-Hispanic white women. And this was also the case when they looked at women who had multiple medical problems or physical issues, women of all racial and ethnic groups were more likely to experience a severe maternal morbidity event compared with white women. Okay. So anyone who wasn't white had a much higher rate compared to white women.

Nicole: And we, when we look at some other things that occur and, uh, study that looked at over 11.3 million births when compared to white women, Black women were 80% more likely to be readmitted postpartum and 16% more likely to have a severe maternal morbidity event during that readmission.

Nicole: One of the big contributing factors to this is, um, postpartum hemorrhage. And one study that looked at over 360,000 women who had a postpartum hemorrhage, even after adjusting for things like comorbidity, things and comorbidity are things that could affect whether or not you have a severe postpartum hemorrhage or whether or not you have underlying health problems. So what studies try to do is adjust or take into account differences in people. And when they do the adjustment, they still see differences that exist. So in this particular study of over 360,000 folks, non-Hispanic Black women who experienced postpartum hemorrhage had a higher risk of severe morbidity and death compared with non-Hispanic white women. And again, postpartum hemorrhage is so, um, important because it's one of the things that is very easily preventable and treatable, as long as it's recognized. And there's some, um, evidence to suggest that people's symptoms and people aren't listened to and the symptoms aren't recognized and treated promptly enough. Okay. And just a, another couple of obstetric related issues. I talked about preterm birth earlier, but I'll say it here again, that preterm birth is higher among Black women compared to white women. And that doesn't matter even after you adjust for, um, known confounders like socioeconomic status education, um, even self-reported measures of stress, Black women have higher rates of preterm birth.

Nicole: One study, interestingly found that the rates of preterm birth increased like with increasing amounts of Black parentage. So, um, a white mother and white father had the lowest incidence of preterm birth. And then it was a little higher, if you had a white mother and Black father, a little higher, if you had than that, if you had a Black mother and white father and then highest, if it was a Black mother and Black father, There's also an increased prevalence of other conditions like preeclamsia, gestational diabetes, also infant mortality, which is death within the first year of life is about 2.5 times higher in Black women for their babies compared to white women in their babies. Now, I know this podcast is about pregnancy and birth, but I'm gonna quickly touch upon some of the gynecology outcomes that differ by race as well. So for individuals who are undergoing a hysterectomy for non-cancer indications, Black women are more likely than white women to have what's called open surgery.

Nicole: And experience surgical complications, and one study of over 15,000 women. And they adjusted for the size of the uterus, whether or not people had prior surgery, BMI, um, Black women were twice as likely to undergo open surgery and they experienced more major and minor complications. And the reason that this is important is that open surgery is a bigger procedure. The recovery is longer, it can be more challenging. So you really want folks to have minimally invasive surgery if they can. And in this particular study, there, wasn't a clear reason why women or Black women weren't receiving the minimally invasive surgery at the same number as white women. And some of this may be due to things like access. So are they not able to get with the more experienced surgeon at the better hospital? Um, those are things that the study didn't look at, but they suspected are some of the reasons why ha not having the same access to care. And then once in care not being offered the same options. When we look at cervical cancer in the US cervical cancer incidents and mortality is higher in Black women than non-Hispanic white women,

Nicole: Black women, um, are nearly 10% more likely to die compared with white women in the, this is after adjustment for socioeconomic status and the stage at diagnosis. When we look at breast cancer, Black women do have a lower incidence of breast cancer compared with white women, but their mortality is higher. Black women also have consistently worse survival both by time interval, meaning how long they live and then the stage of disease when it's compared to white women. And that's despite having very similar distributions of cancer stages. So it's not that Black women have like worse stage disease. It's like Black women and white women are diagnosed with roughly the same stage of ovarian cancer, but Black women just do worse. And then finally with endometrial cancer or uterine cancer, the mortality risk is 55% higher for Black women compared with white women.

Nicole: Part of this is that women Black women are less likely to be diagnosed with early stage disease. And in this particular example, or in this particular instance, the basis for that later stage diagnosis, so Black women are diagnosed at a later stage, appears to be based on studies. The result of improper evaluation, at least two studies have shown that Black women were less likely to receive care that was in line with recommended guidelines. And then that in turn led to a higher odds of advanced stage uterine cancer at the time the disease was diagnosed. Okay.

Nicole: Okay. So let's talk about the causes of these disparities, just to get back to the personal responsibility issue. Again, it is not related to personal responsibility. Okay. Um, that plays a very minor role in the cause of disparities. And even when you have access to all of the best things, this is sort of like anecdotal in a bit, but I wanna give you the example of myself and my Black female OB GYN friends were, it's a group of us. We all trained together, did our residency together at Duke. And, um, five of us have had children. All of us arguably grew up in good circumstances. Supportive environments were obviously educated, economically well off and of the five of us. Three of us had preterm births. Um, two had severe preeclampsia and, um, were quite sick actually. And four had cesarean births. Okay. And none of us are like extremely overweight.

Nicole: We don't have bad habits. We exercise, try our best that we can to take care of ourselves. And again, that isn't a research study, but is, it is an example that those numbers are a bit high. Like you wouldn't expect if you pull together five random physicians that we would have those types of experiences in our own pregnancy and birth, but it happens. Um, part of that is I think something called weathering. And I'm gonna talk about that in just a second, but really when we, when it, it gets down to it, the causes of these disparities is racism. And basically that is, they're not basically that is people being treated differently based on race assumptions are made about people based on race. The medical literature has shown that racial and ethnic groups. And I don't like to use the word minorities, um, more marginalized communities.

Nicole: I would say they're subject to less accurate diagnoses. They don't get the same treatment options as other people. They don't get pain management offered to them in the same way. And as a result have worse clinical outcomes. So this is very well documented, some specific examples and some of the bigger ones. Um, there was a study of medical students that showed that something like 50, 60% felt that Black people experience didn't experience pain the same way as white people. Um, there was a study of 287 residents in emergency medicine and internal medicine. They reviewed a clinical vignette of a patient presenting to the emergency department with a heart problem. And they stereotyped the Black patients. It be as being less cooperative with medical procedures, less cooperative in general, and as their preference for white patients increased. So did the likelihood of treating them with some of the more advanced options that are available to help with, um, coronary artery syndrome and then their preference for white patients increased. So did the, um, preference for not treating Black patients. Okay. And another study of 269, um, uh, primary care physicians, I'm sorry, two 40 primary care physicians. And 269 patients showed that the physicians tended to, um, prefer white patients. And there was poor health communication. The, the health communication was not as good and the ratings of care were not as good among black patients.

Nicole: And the thing about it is I don't think people like intend or wake up in the morning and set out to be racist. Okay. I, I don't wanna, you know, say that because I, I don't think that that is true, but the reality is that people treat people differently. Like studies show that the role of the individual clinician and how they treat people can be different. And the problem is that a lot of physicians don't want to see that. And it's actually a greater threat when people don't want to recognize that they have done things or could do things that are racist. It's actually a greater threat when people don't want to acknowledge it because they have these sort of rapid judgements, attitudes that arise subconsciously. And when they don't recognize it, it comes out in the way that people are cared for. And people don't want to acknowledge that these disparities exist or their role in perpetuating them. And I get it, no one wants to look like a bad person, but it really is honestly, and truly harming people lives. And then in addition, like there's also instances on the individual patient level at the clinical encounter where communication may be suboptimal. It may also not be, um, very culturally sensitive.

Nicole: Again, this is anecdotal, but recently when I was dealing with some health challenges for my dad, and actually this has happened multiple times, both for myself and for family members, the communication and the information that I get pre saying that I'm a physician and after saying that I'm a physician drastically different, like drastically different. And sometimes the communication beforehand is, is quite frankly awful. A absolutely awful.

Nicole: All right. Now the final couple things I wanted to talk about are something called weathering. And then I'll just share a few of my experiences and what you can do. So weathering is a hypothesis where it's believed that experiencing racism or disadvantage across the span of your life can contribute to early aging, potentially even changes in your body at a cellular level. So what that does is by the time Black folks get to the point where they are in pregnancy, they're physiologically older than they are. They've accumulated all of this toxic, toxic stress in their bodies because of experiences of racism. And it can lead them to have wear and tear on their bodies that puts them at a disadvantage with respect to their health.

Nicole: And that's not the only explanation, it's an important explanation and an important piece. We still have to think about the healthcare encounter with the individual doctor. We still have to think about the institutional environment. So the environment of the hospital, of course, access to care, it is a complex issue, but weathering is certainly something that plays a role that chronic sort of stress that you experience as you go through your life. It's something that I have personally experienced myself. And for me, it's often challenging to know, like I experience these things and is this because I'm Black? Is it because I'm a woman or is it because the person is just like a, a? So it can be, you know, I'm at the point in my life at 47 where I don't like do the mental gymnastics over this so much anymore. I kind of live my life, show up, do my thing, keep it moving, but it can be stressful.

Nicole: It can definitely be stressful. Like some instances that stand out, um, that happened to me throughout my life. When I was in medical school, I was once told that I was just flat out lazy and needed to do better because I was so lazy. Now, keep in mind that before that point, I had degrees in mathematics, mechanical engineering, like Summa cum laude law, top 10 in the school of engineering, I at my school, um, I was part of, um, the alpha omega alpha honor medical society. So like to be told that I was lazy, was like, where is this coming from? You know, is it racism? Is it sexism? Is it both? Is it something else? I had a professor who was visibly in medical school when I was inducted into the honor medical society, like visibly, visibly, like wait, you're being inducted kind of thing.

Nicole: Um, once when I was making rounds and I went into a patient's room and I was rounding with the, the fellow at the time, this was when I was a, in residency, we were dressed the same. Um, he had scrubs on, I had scrubs on like the exact same scrubs, exact white coat, and the patient who happened to be Black, looked at me and said, was I there to take her food tray? And that's to say that like Black people, aren't immune from doing racist things as well. Um, I can not tell you the number of times that I've had a white male physician walk up and interrupt a conversation while I was talking to a nurse. Um, I have worn my badge where very clearly says like physician and had someone ask me, when is the doctor coming? I have had family members, um, look over my shoulder while I was doing a repair. This was actually a physician, uh, uh, male physician looking over my shoulder. Um, just, just lots of little things that make you question, you know, is this because I'm Black? Is this because I'm a woman? Like why are these things happening? And these constant sort of things can add up, add up, add up.

Nicole: And also when I see instances of the way people are treated, who look like me compared to white women, that can be stressful, painful, um, um, infuriating, really a couple of examples. I have found patients. I, I remember just very distinctly finding a patient. She was having a miscarriage. She, she was left, I'm completely sitting in blood pool of blood, like blood, all on the sheets, blood on top of the sheets. Uh, and I literally got the, the things to help get her cleaned up and called her nurse out. Like, are you really leaving your patient like this? Uh, I remember a patient who had a 17 week baby, she was 17 weeks pregnant, came into the emergency room with pain. I remember the, the physician, it was actually a physician assistant, uh, male calling me white male calling me being very dismissive of her symptoms, saying that, you know, she's saying she's having all this pain, but on the ultrasound things look fine.

Nicole: You know, I'm just gonna send her home just really like a dismissive of, of and annoyed, really, uh, a Black woman. And she ended up going to the bathroom and unfortunately her, her baby passed like baby fell out in, in the bathroom, in the emergency department, he hadn't done any sort of pelvic exam. Hadn't really done anything to really figure out what was going on. She was in pain because she was in labor. She was in pain because she was in labor. Um, and, and that woman later came back a couple years later, maybe a year later, pregnant, um, a year and a half or so pregnant and ready to, to deliver. And I saw her, I had seen her. And during that time I saw her when she came back and she said to me, she was so glad that she didn't have to go through the emergency room because she had been so traumatized by the experience and the way that she had been treated.

Nicole: And I've had, um, white colleagues. Tell me about the differences that they've seen, people being treated. Um, I've seen, uh, another case. I remember a patient. Um, she was kind of written off as being dramatic and she wouldn't listen and she wouldn't cooperate because she was in pain, turns out she had a placenta abruption and her baby subsequently died. So again, these aren't research studies, but these are examples. These are things that happen that it's very hard not to think that some of it is related to race, because I know you wouldn't treat someone. You certainly wouldn't treat a family member. Some of the ways that I've seen people being treated. And when you have these sort of chronic instances and things that happen, whether they're big or small, then it adds up and it impacts your health. It impacts your, um, it impacts you physically, it impacts you mentally.

Nicole: Okay. The final thing that I want to do is just mention three things that you can do to help with addressing maternal disparities and health. Okay. Three things you can do. All right. Number one, acknowledge that racism exists. I hear people sometimes say, oh, I don't see color. I try to, you know, I understand where you're coming from with that, but it's actually really dismissive of, people's lived experiences to say you don't see color. And it's kind of a cop out to not acknowledging the experiences that people have, you know? Well, I don't see it. So therefore, maybe it doesn't exist sort of thing. It's kind of like saying like, would you ever say like, oh, I don't see women or I don't see men. I don't think anybody would ever say that. It's okay to acknowledge that you see that people have differences based on the color of their skin and race, and that sometimes bad experiences happen as a result of that.

Nicole: It can be a balance. You certainly don't wanna dwell on it. Like for my own children, we've been able to afford them experiences where they haven't experienced a lot of racism. Um, if any, honestly, or they know that racism exists because it's something that we talk about openly within our family and in our environment. And speaking of family and environment, number two, speak up when you see racist things happened around you. When you see your family, when you see your friends, when you see your coworkers, say things that are racist, call it out, changes happen. Um, first in community, right around you, you can be a big agent of change. You don't have to be marching down the street if you don't want to, like, that's not something that I do that I feel comfortable with, but it really makes a difference to make changes and suggestions in your own community.

Nicole: And then the third thing is donate, donate, donate. You can contribute financially to organizations that are helping address Black maternal health disparities, like Black Mamas Matter Alliance, the National Birth Equity Collaborative and Common Sense Inc. Black Mamas Matter Alliance is a big organization that does a lot to address maternal health disparities. In fact that they originated Black Maternal Health week. National Birth Equity Collective, uh, Collaborative rather was started by a Black female OB GYN, Dr. Perry, and then Common Sense, Inc was started by a midwife, Jenny Joseph she's down in Florida. And I will link all of those in the show notes. Okay. So just to recap, disparities exist, they're getting worse. Racism is at the root cause of it. And then there are things that you can do in your own environment, acknowledge that racism exists, speak up and donate financially where you can.

Nicole: Okay. So there you have it. That was a challenging episode for me all. Um, do share the podcast with a friend, also subscribe to the podcast, wherever you're listening to me right now and leave an honest review in Apple Podcast helps a show to grow, helps other women find the show. And I would love to this continue this conversation, um, you know, outside of the podcast, if you have questions, if you have thoughts, DM me on Instagram, I'm on Instagram @drnicolerankins. So DM me there, any thoughts or comments you have about the episode, or you can comment on the post, uh, in my feed about the episode. And also if you're listening to this during Black Maternal Health week, I would so, so appreciate you contributing to the funds to help get Black Mamas enrolled in the Birth Preparation Course. All right. So that for this episode to come on back next week, and remember you deserve a beautiful pregnancy and birth.