Ep 254: Maternal Disparities, How You Can Stay Safe, and How You Can Help

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This episode is being released during Black Maternal Health Week (April 11-17). Black Maternal Health Week was created by The Black Mamas Matter Alliance, a national coalition created to ensure all Black Mamas have the rights, respect, and resources to thrive before, during, and after pregnancy. 

In this episode you’re going to learn about pregnancy-related morbidity and mortality. Specifically, you’ll learn about the racial disparities in obstetric care as well as causes and solutions. You'll also learn how to keep yourself safe and how to help other pregnant people, too.

In this Episode, You’ll Learn About:

  • How maternal morbidity and mortality are defined
  • How many people die from pregnancy-related causes each year
  • How morbidity and mortality rates vary by race
  • Why focusing on Black Mamas is essential
  • How to interpret maternal data correctly
  • What the most common causes are of pregnancy-related death
  • What you can do to help

Links Mentioned in the Episode

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Dr. Nicole (00:00): It's Black Maternal Health Week, and in this episode you're going to learn about maternal and pregnancy related morbidity and mortality, maternal health disparities, and what you can do to keep yourself safe and help keep other pregnant women safe.

(00:19): Welcome to the All about Pregnancy and birth podcast. If you're having a baby in the hospital, you are giving birth in a system that too often takes away power from women over what happens in their own bodies. I'm Dr. Nicole Calloway Rankins, a practicing board certified OBGYN, who's had the privilege of helping well over a thousand babies into this world. I've been a doctor for over 20 years, and I'm here to help you take back your power, advocate for yourself, and have the beautiful pregnancy and birth that you deserve. This podcast is for educational purposes only, and it's not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it. Hello there. Welcome to another episode of the podcast. This is episode number 254. Whether this is your first time listening or you have been here before, I am so glad you're spending some time with me today.

(01:12): I want to apologize if I sound a little bit stuffy. I am dealing with terrible seasonal allergies here in Virginia. They are truly kicking my butt. These allergies are laughing at any of the medications that I have taken, so forgive me if I sound a little stuffy, but let's get back to the episode, which is about maternal and pregnancy related mortality, morbidity, health disparities, things you can do to stay safe and alive, things you can do to help other pregnant mamas. The release of this episode coincides with Black Maternal Health Week, which is every year from April 11th through the 17th. This is the seventh annual Black Maternal Health Week this week, and Black Maternal Health Week was founded by Black Mamas Matter Alliance and Black Mamas Matter Alliance is a national network of black women led organizations and multidisciplinary professionals who work to ensure that all black mamas have the rights, respect, and resources to thrive before, during, and after pregnancy.

(02:08): Black Mamas Matter Alliance honors the work and historical contributions of black women's leadership within their communities and values the need to amplify this work on a national scale. The Alliance is composed of existing organizations and individuals whose work is deeply rooted in reproductive justice, birth justice, and human rights frameworks that's taken from their website, as is this about Black Maternal Health Week, which is a week of awareness, activism and community building aimed at amplifying the voices of black mamas, bringing visibility to black led maternal health initiatives and centering the values and traditions of the reproductive and birth justice movements. This year's theme for Black Maternal Health Week is our bodies still belong to US Reproductive justice. Now, widespread restrictions on abortion care access coupled with rising cases, criminalization due to pregnancy loss continue to widen the gaps of adverse maternal and birth outcomes in the us.

(03:06): And many of the states that have the worst maternal and child health outcomes are the same states that have the least programs and initiatives in place to support children's support families, support mothers, especially black women and birthing people. So the call to action is at the time is now to demand comprehensive insurance for maternal, sexual and reproductive health, improve access to care guide healthcare entities on equitable quality care and fund research, prioritizing all black women, black mamas and black birthing people. And one of the things that comes up a lot that I see a lot of backlash about is talking about things that are specifically related to black folks like this whole anti DEI, anti diversity, equity and inclusion initiatives. It's like people are actively trying to suppress any of those things. And I want to say that that's actually ridiculous. Lemme tell you why.

(04:03): One, we can specifically talk about black folks and acknowledge that there are other problems. It is not an either or. Sometimes specific groups need more attention because they're more affected by a problem. So for example, if you have two children that are sick, it's not like when you give attention to one, you're ignoring the problems of the other. Sometimes your attention shifts depending on the moment in time and in this moment in time for this week, we're talking about black maternal health. And then also when we take care of the most vulnerable in our population, when we discuss the issues that affect those in disparate ways, we actually uplift everyone. So when we address concerns and vulnerable populations, those foundational changes actually help to uplift us all so we can talk about issues with black maternal health and recognize that this fits into the larger issues within our maternal healthcare system.

(05:05): With that being said, in this episode, we are going to do an overview or you're going to get an overview of maternal mortality. What is pregnancy related death, the causes solutions, a little bit on the data about maternal disparities, things you can do to protect yourself and things you can do to help reduce maternal disparities. One of the things that I do and feel very passionately about in terms of my service and my slice of contributions and things that I can help with is education and empowering people with information. And along those lines, I want to give away spots in the birth preparation course. The birth preparation course is my childbirth education course that gets you calm, confident and empowered to have a beautiful birth. So for Black Maternal Health Week, I want to give away spots to black mamas in the birth preparation course.

(05:54): I of course will give away several spots, but I love to collect enough donations from my community to say that my community has come together and given enough to give away 10 spots. It's going to be about $2,500. So head to dr nicole rankins.com/help contribute anything that you can. Every little bit matters. Okay, so let's get into it. We're going to start off with maternal mortality versus pregnancy related death, and the difference between those two because we need to understand the definitions of the data when we talk about the data. So the first one is maternal mortality. That is the death of a woman while pregnant or within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management. Alright? So that's while pregnant or within 42 days of the end of pregnancy. Pregnancy related death, however, extends for a longer period that is the death of a woman during pregnancy childbirth or within the first year after birth.

(07:02): So within the year of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management. And when we look at the numbers, this is data from the CDC from 2023. That's the most recent data that I could find available in 2021. 1,205 women died of maternal causes in the United States compared with 861 in twenty twenty seven hundred and fifty four in 2019. So that made the maternal mortality rate in 20 21, 32 0.9 deaths per 100,000 live births. That's compared to 23.8 in 2020 and 20.1 in 2019. So that rate has been increasing in 2021. The mortality rate for non-Hispanic black women, the maternal mortality rate rather for non-Hispanic black women was 69.9 deaths per 100,000 live births. That's 2.6 times the rate for non-Hispanic white women. And that rate for black women was significantly higher than the rates for white and Hispanic women, although there was an increase across the board from 20 to 21, and that was thought to be due to covid.

(08:20): Now, I do want to point out the difference in absolute numbers versus rates. So when we look at a rate of 69.9 maternal deaths per 100,000 live births, that translates into 362 deaths for black women in 2021. When we look at 26.6 deaths per 100,000 live births, that translates into 503 deaths for white women based on the number of white women that gave birth. And for Hispanics, that is 28 per 100,000 libraries translates into 248 deaths. So overall, although there were more white women who died, the rate was a lot higher among black women quite a bit higher. Based on our numbers in the population, we make up about 10% of the population. Now, I will say that there is a new study that came out just in actually this month, April, 2024. It may have been March, 2024 where it calls this data into question and it finds that the rate is actually about a third of what has been previously reported.

(09:32): And I'm not going to get into the specifics, but the big reason behind it essentially is that on death certificates, there's a box that can be checked if someone is pregnant or if it was related to pregnancy. And apparently there have been a lot of mis classifications, a lot of errors with checking that box even in some rare instances that box being checked for men, for instance. So this new study went back and looked at the data and found that the rate is a lot lower than what the CDC has reported. And I want to be clear, the CTC is not misrepresenting data. They're not trying to drum up a problem that isn't there. As you can imagine, it can be quite challenging to collect data from the over 4 million people who get pregnant and give birth in the United States. So it's not that they were intentionally doing anything wrong, but there is some question about the data and that the rate is actually a lot lower, which is good.

(10:31): It's good that the rate is probably a lot lower, although I will say the disparities still exist. So even when we look at the reclassified rates, there's still a rate among black folks that is two to three times higher. So when we look at pregnancy related deaths, those are deaths that occur during pregnancy birth and up to a year postpartum. When we look at data on about 1000 pregnancy related deaths among residents of 36 states from 2017 to 2019, that's shared with the CDC through something called the Maternal Mortality Review Information Application. So only 36 states contribute to that. So keep that in mind when we look at the numbers of who died broken down by race and ethnicity, 144 of those were Hispanic. So 14%, 467 of those were white, so 46% and then 315 were black, so 31%. So those numbers are disproportionate to our representation in the population.

(11:36): So if we track it along black folks being about 10% of the population, we would expect a much lower number than 31%. So that's where these disparities come into place. And when we look at the timing of those deaths, 216 or 1% occurred during pregnancy, another 132 or 13% occurred on the day of birth, and then one to six days postpartum was 12% or 127 to 42 days. Postpartum was 233 or 23%. And then after 42 days postpartum was a full 30%. So when we look at pregnancy related deaths, 53%, so over half occurred between seven and 365 days postpartum. So you're not out of the woods just because you have the baby. We have to continue to monitor your health. I want you to go ahead and grab my warning signs guide, things to look out for after you have a baby, things that are concerning.

(12:35): It's dr nicole rankins.com/warning signs, and it's a nice handy one page sheet you can print out, stick on your refrigerator so you have it available for anything that comes up, especially in those immediate first six weeks. Postpartum item. When we look at the common causes of pregnancy related deaths, actual the number one cause overall was mental health conditions. So deaths by suicide overdose poisoning related to substance abuse. That was 22%. And then after that, that's followed by hemorrhage. Cardiovascular conditions and infection, hypertension disorders. The data is a bit different among black women. Actually the highest problem among black women for pregnancy related deaths, so within that first year afterwards is cardiovascular conditions. That's 15.9%. Then cardiomyopathy, which is heart failure, 13.9%, and then embolism hemorrhage, actually mental health conditions falls a lot lower on the list as towards the bottom. Now an important point to make among pregnancy related deaths, a preventable determination was made for 996 deaths. So 84% were determined to be preventable, 84%. That is a huge, huge number. That's why it's so important for you to know those warning signs to look out for and also speak up, advocate for yourself. I'm going to talk about how you do that coming up in just a moment.

(14:04): Now, although mortality is important, morbidity is actually a much bigger problem. So the World Health Organization defines near Miss Morbidities as conditions or events that would've resulted in a maternal death during pregnancy childbirth or within 42 days after birth, if not for significant medical intervention.

(14:29): And then the Centers for Disease Control and Prevention, that's CDC and acog, the American College of Obstetricians and Gynecologists, use the term severe maternal morbidity to describe unintended outcomes of labor and delivery that result in significant short or long-term consequences to a women's health. Now hear me. This is a really important number that I want you to hear. There are approximately 70 cases of severe maternal morbidity for each maternal death in the us, okay? 70 cases of near miss events. So near miss events, the severe maternal morbidity events are 50 to a hundred times more common than maternal mortality, and they are rising in the us. As a matter of fact, there was a 45% increase in severe maternal morbidity from 2006 to 2015. And when we break that down a little bit further, the overall rate of severe maternal morbidity increased from 49.5 per 10,000 delivery hospitalizations in 1993 to 144 per 10,000 delivery hospitalizations in 2014.

(15:53): And when we look at the causes for the most common disorders associated with severe maternal morbidity, those are the same that are associated with mortality. So hemorrhage, hypertensive disorders, infection, or sepsis. So let's talk about disparities. So a health disparity population as defined by the National Institute of Health is one in which there is a significant disparity in the overall rate of disease incidents, prevalence, morbidity, or mortality in the specified population as compared with the general population. So that's what I was saying, that black folks are affected by conditions more compared to our representation in the population. We are not the only ones. Other disparate populations are Hispanics, American Indians, Asian Americans, other Pacific Islanders, some socioeconomically disadvantaged populations, rural areas as well as sexual and gender minorities. We know that racial disparities and reproductive health are well-documented in OB GYNI talked about maternal health and maternal death and why that is an issue and something that's really important to point out is that mortality differences persist at all education levels that suggest that factors beyond education are involved among women with the college education or higher.

(17:20): The pregnancy related mortality ratio for black women was 5.2 times set of white women. This is one of the largest perinatal health disparities in the United States. So that means me as an educated woman, very highly educated woman, as a matter of fact, my risk is higher. So although increasing educational and socioeconomic status as well as prenatal care are protective against maternal death at all, educational and socioeconomic levels, rates are higher for black women than for white women. And the reduction in maternal death associated with prenatal care is greater for white women than for black women. So we don't get the same benefits. It's really believed that social and structural determinants rather than biologic factors contribute to these racial inequities and that disparity gap between black and white mothers. When we look at severe maternal morbidity, a study in the US looking at birth between 2006 and 2015 reported that the severe maternal morbidity rate was up to 115% higher for black compared with white women. And that's even after adjusting for things like age and other possible contributing factors.

(18:41): Another study looking at over 11.3 million births between 2012 and 2014 when compared with non-Hispanic white women, non-Hispanic black women were approximately 80% more likely to be readmitted postpartum, 16% more likely to have a severe maternal morbidity event during remission. When we look at things like postpartum hemorrhage and the study looking at over 360,000 women with postpartum hemorrhage, non-Hispanic black women experienced it at higher rates compared to non-Hispanic white women. When we look at preterm birth, this is really a longstanding disparity that black women have a higher rate of preterm birth. Our rate is about 14% compared to 9% among nine Hispanic white women. And that's even adjusting after so many factors, including measures of stress. Also, infant mortality is higher for black women. Infant mortality is death of the infant within the first year of life. That's about 2.5 times higher in black women compared to white women.

(19:52): Now let's talk about the causes of disparities. One thing that I hear constantly see constantly in comments is this notion of personal responsibility. So why don't people just eat better and exercise more? Black folks are out there just being huge and fat and eating all the things they're not supposed to be eating and they just need to take better care of themselves selves. I want to say that there, yes, there is an element of personal responsibility. I don't disagree that there is some element of personal responsibility for all of our health, but you have to think about people's ability to be responsible. And what I mean by that is that you have to think about what options people have. You have to think about the things that influence a person's options. Personal responsibility can be hard in a system that is unsupportive and in some cases is actively hostile against you.

(20:51): For instance, not everyone has access to the same resources like a safe and supportive environment to live in, to learn in. Not everybody has access to quality healthcare. Not everybody has access to quality, healthy, reasonably priced foods, okay? Health actually results from a complex interplay of not just individual factors, which may be genetics, which may be lifestyle, but also population factors, all right? As well as social determinants like where you're born, where you grew up in, where you live, where you work, what you were taught and exposed to in your life. And while these other things like personal responsibility or disease risk factors, all of these things, intermix, they don't account for all of the gaps in healthcare outcomes between different populations. For example, a common thing that comes up is obesity. Actually most of the United States is obese. And when we look at obesity broken down by Reese, about 41% of reproductive aged women are white women are obese compared to 49% of black women.

(22:09): So yes, there's a difference, but it's not that significant and it's not enough that explains the disparate outcomes. So can we please stop putting Our hats are hanging all of the answers on personal responsibility because that is not it. So then how do we reduce the risk of maternal mortality? So one study, as I mentioned earlier, is called pregnancy related deaths. Data from Maternal Mortality Review committee in 36 states show that 80% of deaths are preventable. It didn't provide a lot of details in that report about how they were preventable, but 80% of deaths are preventable. And another report suggested the following interventions to reduce maternal mortality. And this was an order of significance. This came from a paper called Saving Mother's Lives, transforming Strategy Into Action, global Health Policy Summit Report of the Maternal Healthcare Working Group. One of the things, and I know a lot of people may be surprised about this, but family planning with birth spacing and contraception would lead to a 30% reduction in maternal mortality. So being able to plan your family and when you want to have children can reduce maternal mortality by 30%. Next up with safe abortion, that would be a 13% reduction. So the ability to end pregnancy if you sow desire or for medical reasons if need be. The next was hemorrhage prevention and treatment. That would be another eight to 9% reduction followed by cesarean section when indicated, 7% reduction. And then prevention of eclampsia and treatment of preeclampsia, another 7% reduction

(24:02): From that report. It was felt in the United States that a lot of the issues were related to deficient medical care and then medical comorbidities or health problems as well as social circumstances. Those all appear to be strong contributors to maternal mortality, especially for black women. Now, another thing that's important for healthcare providers to do is to acknowledge and address implicit bias. Medical literature very clearly demonstrates that racial and ethnic minorities and women are actually subject to less accurate diagnoses. They don't get the same treatment options, less pain management, and then worse clinical outcomes. Some examples of implicit bias at work in medicine, a study of 287 internal and emergency medicine residents who reviewed a clinical vignette of a patient coming to the emergency department with an acute heart problem reported implicit preference favoring white patients and implicit bias, stereotyping black patients as less cooperative with medical procedures and less cooperative generally. And as physician preference for white patients increased the likelihood of treating white patients with a therapy that would help increased. And then also not treating black patients with that same therapy increased.

(25:31): And there are multiple other studies showing implicit bias, showing not treating people's pain all the way down to black children even. And when people hear things like this, they automatically think we're jumping to people being racist. So I think of racism as intentionally treating someone different. You're treating someone differently just because they're black, but this is not that. This is more implicit. It's more you don't realize that you're doing it because you're conditioned by all of the things around you that you see. And people are just unaware and sometimes, quite frankly, not open to understanding that we may be treating people differently even if we're not doing it intentionally. And the key is not just recognizing that you have those biases. That's important to recognize that you have those biases, but then acting on it. But so level setting, resetting, changing your behavior, changing what you do when you realize, oh my goodness, I assume that this person had A, B, C, and D, and I shouldn't have done that, right?

(26:44): It's about recognizing that you have your bias and then changing your behavior. Having a bias doesn't necessarily mean you are racist, and we all have the opportunity to change. Another thing that's also incredibly important is policy. Policy matters so much. Policy is what drives a lot of changes in healthcare, whether we want to believe it or not. That's why voting is so important. We can see that policy and politics has made a tremendous impact in abortion access, correct? I mean, it's being stripped away right from underneath us with policy and politics. And that's been a longstanding effort of people using politics in order to do that. So I cannot stress how important it is for you to vote and pay attention to policy, not only at your federal level, but also your state level. That's really, really important also in your local level. And we really do have enough resources in this country.

(27:44): We're the richest country in the world. We just need to focus on better using the resources that we have. Okay, now, real quickly, I want to run through 10 things you can do if you have a problem during your pregnancy and birth in order to advocate for yourself and make sure you get the best care possible. So number one is if you don't feel right, call, no matter the time of day or night, most practices have a doctor who's on call or a nurse who's on call, someone who you can reach 24 7, especially for OB issues. Sometimes practices don't have anybody on call, and they may direct you to go to the emergency department if you have concerns, but do know what your practice's policy is for when you have concerns outside of your regular appointments. This is really important. Number two is when in doubt, go in.

(28:33): If you are not feeling well, you're concerned, go into be seen. Don't let things linger during office hours. Do try and get into the office for an appointment because that's generally going to be a little bit easier. It's ideal for you to see a regular doctor if you can, but if you can't go into the office than go to labor and delivery, go to the emergency department, get checked out, alright? And you must, must please go to a hospital that has a labor and delivery, especially if you're over 20 weeks pregnant. They're going to be way more familiar with treating problems related to pregnancy. Number three is be persistent. And this is a big one, a big one, a big one. You have to keep voicing your concerns until your concerns are addressed. Don't worry about being perceived as annoying. Don't worry about hurting anyone's feelings.

(29:20): I'm not exaggerating when I say that persistence could be the difference between life and death. It's especially important if you're a black woman when your concerns are more likely to be dismissed. So if you know something is wrong, ask to see another doctor. Okay? Please, please be persistent. Number four is have an advocate. You may not feel well enough to speak up for yourselves, so identify an advocate for you. Again, this can be really important if you're a black woman, identify an advocate who can speak up. This isn't the person who's not as comfortable with speaking up. This needs to be somebody who's like, well, get in there. Ask for demand for someone to be coming and who can really push to get you the care that you need? And it doesn't necessarily, I say push, but it doesn't have to start out with that sort of adversarial aspect to it.

(30:12): It can start out as, Hey, I'm concerned. Hey, we're really concerned that this is going on. We're worried that her blood pressure is high. We're worried about the swelling. We're worried that she's not feeling well. Okay? Start off with that connection on a human level. That's actually one of the things I'm going to say in just a minute, is connecting on a human level to tell your doctor that you're scared, that you're worried. Yeah, lemme just go ahead and get into it now. Yes, tell your doctor you're scared. Tell your doctor you're worried. Connect on that human level in order to get across your concerns. Now, of course, if you don't get a response when you connect on that human level, then take it up a notch and be demanding and do all the things you have to do in order to get seen and get your answers.

(30:55): Questions answered rather. But try connecting on that human level first. Alright, next one is a 10. Prenatal care. Studies have shown that prenatal care really does improve outcomes. So a 10 prenatal care on a regular basis. And then number six, educate yourself because your doctor won't. I mean, the reality is in those five minute visits, 10 minute visits, you're not going to get a lot of education. Prenatal care is not designed for a lot of education, so you are going to have to take it upon yourself to educate yourself. That is going to be through things like listen to this podcast. That's going to be through childbirth education. Of course, I have an option. The birth preparation course, you can check it out at drnicolerankins.com / enroll. But there are lots of options out there for education, childbirth, education, and you just really, really, really need to educate yourself.

(31:39): It's so important to help you advocate for yourself, and then be sure to ask questions. You deserve clarity on your health and your wellbeing. So ask those questions. You deserve that clarity. At the end of the day, if you don't ask those questions, your doctor's still going to go home and go on about their last. Okay? You're going to be the one sitting there with questions and concerns. So get that clarity, you deserve it. And then finally, switch doctors if you need to. You don't want someone who's tolerant of you. You want someone who is supportive of you, someone who's listening to you, someone who's respecting you, someone who is taking into account the things that are important to you and what you need and what you want for your pregnancy and birth experience. And then the last thing I'll say is being the best health you can before you get pregnant.

(32:29): So much of what happens during pregnancy is related to health prior to pregnancy. So be in the best health that you can before you get pregnant. All right? So what can you do if you want to help about addressing disparities and maternal health disparities? So one thing you can do is just listen, right? Listen and keep an open mind to the things that you hear. If you've made it to this long in the episode, then thank you. Thank you for listening, for keeping an open mind and willingness to learn new things. The next thing I'll say is acknowledge that these problems exist. Acknowledge that racism and disparities exist. It is just a lie. When people say, I don't see color. Yes, we see color. You can see color and see people's differences and treat people well. Like this whole, I treat everybody the same. That's not a good approach to life because sometimes people need to be treated differently based on the circumstances, and one of those circumstances may be race.

(33:31): It's like if you have two children and they need attention in different ways, there's nothing wrong with that. You can see color, you can see people's differences. You just can't use those differences as a way to base negative assumptions about that person. See each person for who they are. Also, speak up. When you see racist things happen in your environment, so much of change happens from the ground up. So speak up when you see things happen that you know are wrong, whether it's your family, whether it's your friends, whether it's coworkers, speak up, please, that's really, really important. And then donate. There are lots of organizations you can donate to. Black Mamas Matter Alliance, common Sense Childbirth is another one that helps promote a certain type of prenatal care for marginalized communities. Of course, I would love it if you donate to help give away the birth preparation course to Black Mamas.

(34:28): You can go to drnicolerankins.com/help to do that. And then the final thing is vote. Vote advocate for policy change. We have seen the implications of what has happened when people set out voting or when people don't pay attention to policy. Abortion rights are being restricted. They're coming after IVF. There may come after IUDs and contraception. Next. Trust me, these things are not like theoreticals. These are things that are happening. So you have to vote and use your voice. It matters. Okay, so just to recap, maternal morbidity, mortality, pregnancy related deaths, they're rising rather with worsening disparities for black women. We know the disparities are really caused by racism. And structural changes are not caused by any biological factors, and they're not caused by personal responsibility. The things you can do to advocate for yourself. If you don't feel right, call talk to somebody.

(35:29): When in doubt, go in. Be persistent, have an advocate. Attend prenatal care. For the love of God, please get childbirth education. Ask questions, switch doctors if you need to. Connect with folks on a human level and be in the best health that you can before you're pregnant. And then also acknowledge that these issues exist. Acknowledge that racism and disparities exist. Please don't say you don't see color. That's not a way to go through the world and be helpful. Speak up when you see problems, whether it's among your family, friends, or coworkers. Donate and vote. Okay, so that is it for this episode. There you have it. I know when I get to talking and I get excited about things, I talk pretty fast. So forgive me if I was like speeding through the episode, but I get amped up about these topics. Do again, please consider donating to giveaway spots as a member of my community to Black Mamas. Go to drnicolerankins.com/help. I would love to collect about $2,500 to give away 10 spots to Black Mamas in the birth preparation course. So thats it for this episode to come on back next week and remember that you deserve a beautiful pregnancy and birth.