Ep 117: Maternal Morbidity and Mortality and 10 Ways to Stay Safe

Ep 117: Maternal Morbidity and Mortality and 10 Ways to Stay Safe

Nicole: In this episode, I'm revisiting the important topic of maternal morbidity and mortality and how you can keep yourself safe.

Nicole: 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 it.

Nicole: Hello there. Welcome to another episode of the podcast. This is episode number 117. Thank you for being here with me today. So I want to start off with this story. One night, I received a call through the answering service at my last job. We used to take calls through the answering service and I'll call the patient Michelle. Michelle had an uncomplicated delivery a few days earlier, and she was at home. She was calling because she felt short of breath. She was having a hard time catching her breath. Now on the phone, Michelle didn't sound particularly short of breath to me. And I asked her several questions to try and get a sense for what might be going on. Nothing stood out as alarming in her responses. However, Michelle was pretty persistent that she just didn't feel right. So I advised her that the safest thing to do was to come to the emergency department to be evaluated.

Nicole: When Michelle got to the emergency department, she was diagnosed with a pulmonary embolism, which is a blood clot in the lungs that can be life-threatening. She got the treatment that she needed, and thankfully she ended up being fine. Now, of course, I'm glad I listened to Michelle's concerns that night, but I am not the hero of this story. Michelle is. She was persistent in voicing her concerns that something was wrong, both on the phone with me and in the emergency department. So why am I telling you this story? Because pregnancy related morbidity, which is health-related conditions that have a negative effect on a woman's wellbeing, and then pregnancy related mortality, death related to pregnancy. Those are actually on the rise in the U S this is a public health crisis. If you followed me or heard the podcast before, you know I've talked about this, this is a public health problem, especially for black women.

Nicole: So in this episode today, you're going to get an overview of maternal mortality and morbidity things like the numbers, what causes it, risk factors, how we can reduce the risk and then 10 things that you can do to help keep yourself safe. Many of which are things that Michelle did. All right. So let's go ahead and hop into the episode. We're going to start off with talking about maternal mortality. Okay. So pregnancy related deaths have nearly doubled since 1990. In 1990, there were 10 deaths per hundred thousand live births. And that's how we talk about maternal mortality in terms of the number of deaths per 100,000 live births. And it crept up to 18 deaths per 100 live bursts in 2014. And in the 2015 report, it was 26.4 per 100,000 live births. Now you may hear that number and think like well 20 per a hundred thousand, that doesn't sound like a whole lot.

Nicole: However, there are 4 million births in the United States each year. So that actually translates into between 700 and 800 women dying every year from pregnancy related causes. And it's significantly worse for black women. The rate for black women is 43 deaths per 100,000 live births compared to 12 deaths per 100,000 live births for white women. Now, when we look at when these deaths happen, in the study that looked at data from about 2011 to 2015, approximately 31% of those pregnancy-related deaths occurred during pregnancy. Whereas the remainder recurred occurred in the postpartum period. So 17% happened on the day of delivery, 19% on days one through six postpartum, 21% within the first seven days to 42 days after birth. And then 12% occurred 43 days up to one year after birth. So as you can see, the majority of maternal mortality actually happens after birth. That's why it's really important that you understand warning signs to look out for.

Nicole: I have a free guide that you can download drnicolerankins.com/warning-signs. And we'll link that in the show notes, of course, so you can learn those warning signs to be on the lookout for after birth. Now, when we break down causes of maternal mortality from a 2019 report, these are the top causes. Number one is cardiovascular conditions that accounts for about 15% of deaths and cardiovascular conditions or issues with the heart and circulatory system, then non-cardiovascular medical conditions, that's a big category, but that accounts for 14%, infection 12%, hemorrhage or bleeding, 11% cardiomyopathy, which is a little bit different, that's when the heart doesn't function well that's 10.8%, embolism, which is blood clots, 9%, hypertensive disorders of pregnancy 7%, cerebrovascular accidents, that's going to be strokes, another 7%. Some of them are unknown about 6% then amniotic fluid embolism, which is a very rare thing.

Nicole: That's 5.8% and then anesthesia complications account for 0.3%. The causes of maternal death have actually shifted throughout the years. When we look at maternal mortality data prior to 2006, there's actually been an increase in deaths since 2006 related to cardiovascular disease infection. And then other medical conditions like opioid use disorders. We know that the opioid epidemic has been a problem, and there's actually been a reduction in deaths from hemorrhage, hypertensive disorders of pregnancy, pulmonary embolism, and anesthesia complications. So in some places we or some ways we've gotten better. Whereas in other ways, things have gotten worse. There also racial and ethnic differences in the causes of maternal death from more recent data, uh, a study that looked at data between 2007 and 2016, compared to white women, black women had a higher proportion of deaths from pulmonary embolism, hypertension disorders and cardiomyopathy, um, American Indian and native Alaskan women have more deaths from hemorrhage and hypertension disorders. White women had higher rates of death from infection and strokes compared with black women.

Nicole: Also during that time period deaths related to sepsis, which is overwhelming infection in the blood, those also rose over 20%. Now, one thing that we don't take into account that is, um, included in most national maternal mortality rates, something that's under counted is actually trauma as a major contributor to maternal mortality. Nationwide, actually car accidents are the overall leading cause of trauma related maternal death followed by violence and homicide. And actually in some areas, homicide is the leading cause of trauma related maternal death. Like that's more than car accidents in some places, suicide is also a problem as well. Well now when we look at things or the circumstances that lead to maternal death, it is definitely complex and it's usually multifactorial, meaning that it's typically more than one thing that contributes to the maternal death. It's not like one thing you can always put your finger on.

Nicole: When they review cases of maternal mortality, typically they find that there are at least four contributing factors that come into play. There's also additional factors and they use something called a three delay model in order to categorize the factors that affect maternal death. And those three delays are facility delays, provider delays, and then patient or family delays, patient and family delays are delays in a decision to seek care. So maybe someone doesn't know warning signs to look out for, maybe they don't know, you know, symptoms that should require, um, going to see a physician. Um, sometimes people have a difficult family situations, maybe they're in abusive situations where they can't get to the care that they need. I think that this is actually a smaller piece of the puzzle. Um, I think the contributing factors of the medical provider and the medical system contribute more, but certainly there can be a delay or a misunderstanding of knowing some of those warning signs to look out for.

Nicole: Again, I highly encourage you to download that guide that I have at drnicolerankins.com/warning-signs. Now facility delays are delays in arriving to an appropriate medical facility. So maybe you don't have transportation, lots and lots of places unfortunately don't have labor and delivery, especially in rural areas. So this can be a definite problem in rural areas of the country where not being able to get to an appropriate facility is contributing to maternal deaths. You maybe live a long distance from the facility, or again, you don't have transportation to get to a place. And then the final one and the one that I believe contributes the most is delay in receiving adequate care. So once a woman arrives to a medical facility, she's not getting the care that she needs. There's a lack of prompt assessment, that results in misdiagnosis, there's a delay in treatment, there's ineffective treatment, um, not recognizing or under-treating what are considered life-threatening conditions.

Nicole: Um, just lack of coordination of care, and then poor communication. I think this is what ultimately contributes the most to maternal mortality and morbidity. When we look at risk factors for maternal mortality, we know, as I said, that race and ethnicity is one particularly for, for black women. And that is some, some consider it a complex problem. And to some degree it is because it is affected by the health status, your health status. When you enter pregnancy, uh, sometimes black women may have a poor health status when they enter pregnancy emotionally or physically, they may also be exposed to more chronic stress. But when you step back for a moment and you look at what is leading to that poor health status, what is leading them to have more stress, to have physical ailments, emotional difficulties. We know that that is related to racism. So there's racism in the background of society that black people are existing with.

Nicole: And then there's also racism within the healthcare system as well, whether that is explicit, which I don't think as is as common or more implicit, where people don't realize that they're treating people differently based on race. There are many, many stories of black women to start research studies, um, encounters of black women describing where medical providers thought that they were poor, uneducated that there was no father around because they're black. Studies have shown that black people's pain is not taken as seriously as when white people have pain. So we know that racism is a factor that black women have to deal with on top of a system that doesn't always meet their needs. And often we believe that educational status and socio economic status and prenatal care can be protective against that, but that is not necessarily true. When you look at educational and associate economic levels at all levels, pregnancy related mortality for black women are three to four times higher than ratios for white women.

Nicole: So even me being a highly educated and someone of high socioeconomic status, my risk is still three to four times higher than someone um a white woman of my similar, similar status. Also prenatal care. Does it show the same reduction in maternal death as it does for white women? So we know that there's this underlying problem that all people have in regards to maternal mortality, but it's really a lot worse among black birthing people. Now, in addition to race and ethnicity, age, either young age, less than 20 in age greater than 35 are also risk factors for maternal mortality. So let's talk about reducing the risk. Here is the thing. And this number is always very startling to me every time I hear it, but it has been estimated that up to 60% of maternal deaths are considered preventable. Up to 60% are considered preventable.

Nicole: And one report suggesting the following interventions that could help reduce maternal mortality. And this is in order of significance, family planning with birth spacing and contraception could lead to a 30% reduction in maternal mortality. This is something that people really don't appreciate have the availability, rather, of reliable inexpensive contraception is so important to help moms stay safe so that they can plan their families and space pregnancies as they want. You know, it's unrealistic to tell people not to do an activity that's natural to us. Okay. Like sex is a natural part of being a human being. So just saying things like, oh, don't do it close your legs. You know, all of those kinds of things is pretty ridiculous. So we really want to provide low cost or free contraception. That family planning really makes a difference. Another thing that can reduce maternal mortality is safe abortion that can lead to a 13% reduction.

Nicole: And I keep saying that I'm going to do a podcast episode on abortion. And, um, I have it on my list of things to do. So I'm definitely going to get to that and why access to safe abortion is important. Also hemorrhage prevention and treatment that can lead to about a 10% reduction. Cesarean section only when indicated a 7% reduction and then prevention of eclampsia and treatment of preeclampsia another 7% deduction reduction. Eclampsia is preeclampsia with seizures. And again, especially in the United States, I'm not talking about maternal mortality and in the world in general, in under resourced areas, it's often a lack of resources. So it's a lack of a hospital. It's a lack of blood. It's a lack of trained personnel in under-resourced areas. That's what leads to maternal mortality, but in the United States, it's really deficient medical care, having complex medical problems and social circumstances are the things that contribute most to maternal mortality.

Nicole: Especially for black women. We actually have enough resources in the United States to help reduce maternal mortality significantly. We just have to better use the resources that we have now. I don't want to sound like all doom and gloom. We're definitely getting better in what we're doing. We have started focusing our efforts on things like team training, individual training, simulations, drills to deal with emergencies, protocols, guidelines, checklist, all of those activities help us diagnose and treat things earlier and more and more and more hospitals are getting better with this. We're also doing better with implementing a multidisciplinary approach where the nurse, the OB providers, the anesthesiologists, we talk to each other, talk about the patient's risk. And we identify those who are at high risk for complications so that we can be ready early. Okay. And then, so part of this process, when issues are identified, we need to communicate that with that birthing person, that shared decision making between the patient and the obstetric care team is going to help reduce biases that can affect those disparities in care.

Nicole: It's going to help everybody be on the same page and do that goal of keeping everyone safe, both physically and emotionally during the birth. There are lots of things we know that hospitals in the U S don't necessarily do well, especially when it comes to low risk birth, but one thing that we can do well, and we do have the ability to treat is emergencies. Like that is the benefit of being in a hospital is having those things to treat an emergency of bail, um, very quickly. So we just need to be sure, be sure that we're using our resources of being able to treat emergencies effectively. Other things that are also important are discharge planning and postpartum followup. For example, when people have preeclampsia, um, especially if they have severe preeclampsia, they really need to have close outpatient monitoring after they leave the hospital to check those blood pressures, um, depending on how severe they are.

Nicole: Because again, remember up to 60% of maternal deaths can occur in that postpartum period. So really discharge, planning and postpartum follow-up are important. This is also an area where I think we need to improve for sure. Like a six week checkup standard is, is not adequate for most people. Well, there's certainly evidence that this can be improved. California has done fantastic things. They cut maternal mortality in their state by 50% something called the California maternal quality care collaborative CMQCC. This was formed as a public private partnership to help lead maternal quality improvements. And what they did is they reviewed over 200 pregnancy-related deaths in California. And what they concluded was that there was a good chance that 41% of those deaths could have been prevented and, uh, specifically related to deaths with hemorrhage and preeclampsia 60 to 70% of deaths related to hemorrhage and preeclampsia could have been prevented.

Nicole: So what they did is they developed systems and, um, rapid response teams to respond very quickly to hemorrhage, to re respond very quickly to severe hypertension and to respond very quickly to infection, sepsis and many places have adopted what they did in California. I know the hospital where I work, we have na very easy to follow protocols that are triggered without having us having to do anything necessarily like a lot of input to treat things like hemorrhage and hypertension. We have like a hemorrhage cart that has all the medications available. You can just pick up the little cart and bring the hemorrhage medicines into birth for hypertension. You can put in a S a hypertension order set that's going to trigger treating those high blood pressures very, very quickly. Um, there's scores and systems in the computer. That'll say, Hey, this person is at risk for infection and that'll trigger things that can happen.

Nicole: So there are things that are being done. Um, we are definitely getting better. Those things aren't at every single hospital, but I think they're getting more, more and more every day. So let's move on and talk about maternal morbidity. So the world health organization defines near miss morbidities as conditions or events that would have resulted in a maternal death during pregnancy childbirth or within 42 days after delivery, if it wasn't for a significant medical intervention. Okay. And then the CDC, the centers for disease control and prevention and the American college of obstetricians and gynecologists ACOG, they use the term severe maternal morbidity, a little bit different. They use it to describe an unintended outcome specifically during the birth. So specifically during labor and delivery, that results in significant short or longterm consequences to a woman's health. Now, here's the thing that is frightening. There are actually 70 cases of severe maternal morbidity for each maternal death in the United States.

Nicole: Okay. I'm going to say that one more time, 70 cases of severe maternal morbidity for each maternal death in the United States. So that means that there are so many times when there was an unintended outcome that resulted in short or long-term consequences to that woman's health on labor and delivery, right. And actually potentially life-threatening near miss severe maternal morbidity events are 50 to 100 times more common than maternal mortality. Okay. And that number is actually going up in the United States. Between 2006 and 2015, it went up from a hundred events per 10,000 delivery hospitalizations to 146 per delivery hospitalization. Some of this has been related to the increased use of blood transfusion, but even if you remove blood transfusion from the equation, the numbers have still gone up about 40%. So what that tells us is that there are still a lot of chances or near misses where women could have almost died if it wasn't for intervening.

Nicole: So again, we have some work to do within our healthcare system. And then when we look at the causes of maternal morbidity events, they're very similar to those with maternal mortality. Okay. Very similar. The top three that often stand out are hemorrhage or bleeding, hypertension disorders, and sepsis also similar risk factors are, um, young, young age, just like maternal mortality. So less than 20 older age greater than 40. Also those who deliver at a hospital that serves more vulnerable, vulnerable populations, um, black women, Hispanic women, of course. And then also those who have multiple gestation have a higher risk of having, um, a maternal morbidity event and then reduced risk for maternal morbidity or the same as for maternal mortality. Really just that team training, simulation drills, getting to the point where we are diagnosing conditions early and appropriate medical care of pregnancy complications is happening quickly, that there's not a delay in diagnosis or treatment.

Nicole: When you look at stories of maternal deaths, some of the ones that have been more publicized it's usually because there was a delay in treatment like Kierra Johnson is one. She died in California, uh, BA basically she bled to death internally after cesarean birth. And in that particular case, even though her husband, you know, was, was mentioning this, something was wrong. It was a big delay before the doctor got there. And in that particular case, there was also a culture problem where there were, there were other doctors in the hospital, but because it wasn't their patient, they didn't feel comfortable intervening. So that was an issue there as well. Um, there was a nurse, a NICU nurse who died, and it was because her high blood pressure wasn't treated, she died from preeclampsia. She was actually a white woman. Um, so often it's because of not recognizing things promptly and not taking things seriously.

Nicole: And that is where we need to work and improve. And which is where we are working to improve. Now, I don't want to scare you. Um, obviously I know that that was a lot of challenging information, but you need to know it to be prepared just in case. And it also to some degree can feel like, you know, all of those things I said are kind of out of your control. You don't necessarily have the ability to make your doctor diagnose something quickly, but you do have some power and things that you can do in order to help improve that process. Even if you can't be the one who makes the diagnosis. So what I'm going to do is I'm going to go through 10 things that you can do in order to help prepare yourself and help, um, be ready and help reduce your own personal risk of having, uh, a maternal morbidity of it, or of course, maternal mortality.

Nicole: And these aren't in any particular order. Okay. So number one is, if you don't feel right about something during your pregnancy, always know that you can reach out and speak to a provider anytime of day or night. Okay? Most doctor's offices have a way for you to reach someone 24 seven. It may be a doctor. It may be a nurse. It may be a nurse practitioner. Typically you can reach that person just by calling the regular office number. Even if it's after hours, it'll connect you to an answering service. Now, there are some practices that don't have someone on call after hours, or they will tell you if it's an emergency that you just need to go to the emergency department, just check with your office and make sure you understand what the process is for when you have questions outside of hours. And if you ever don't feel right then call to check in, so you can get some answers.

Nicole: And then number two, when in doubt, okay, if you don't feel right, you call and you know, you don't feel like you're concerns are being addressed, or if you don't feel right, you call and it just gives you kind of a go, you know, go to the hospital. When in doubt, when you have some challenges, questions, or concerns, then go in to be seen. Don't let things linger. Okay? If it's during office hours, you can try and get into the office for an urgent appointment. Many offices have slots for urgent appointments, where you can just come in during the day. They actually prefer you to come in as opposed to going to the hospital. But if you can't go into the office and you want to go to the hospital and you want to go to a hospital that has the labor and delivery unit.

Nicole: So go to the hospital where you're supposed to deliver. A lot of times, I see folks in pregnancy and they'll go to like a freestanding ER center or a hospital that doesn't have a labor and delivery. Those are not the right places for you to go when you are pregnant. Okay? When you are pregnant, especially the second trimester or later, you want to go to a hospital that has a labor and delivery unit. Now, of course, if someplace isn't close to you, if you don't have anything, you go to the place that's closest, but I highly, highly, highly recommend that if you can get to a place with a labor and delivery, that's going to have the team. That's going to know how to best support you, that freestanding emergency center, um, the freestanding urgent care, that is not, especially as you get further along in your pregnancy.

Nicole: Okay? Number three, be persistent. You have to keep voicing your concerns until your concerns are addressed. Please do not worry about being perceived as annoying. Do not worry about hurting anyone's feelings. I'm not exaggerating when I say that this can really be life or death. Okay. And persistence is especially important. If you are a black woman, it's an unfortunate truth that black women are more likely to have their concerns dismissed or ignored by healthcare providers. So you really need to be persistent until you get your concerns addressed. Okay? Now this goes along with number four, which is have an advocate with you. There may be times when you don't feel well, and you're actually don't feel well enough to speak up for yourself. I think every birthing person should have an advocate with them in the hospital who feels comfortable and ready to speak up for you.

Nicole: If need be, to be persistent, to get those questions answered when needed. So be sure that you have an advocate with you, especially during labor and delivery. Someone who feels comfortable speaking up for you on your behalf, if you are not able to speak up for yourself, okay, number five is attend prenatal care regularly. I don't think this is something that I have to tell most folks who are, who are listening, but attend prenatal care regularly. Yes, those visits are five minutes or 10 minutes. Um, they're often not long enough, but that is the best contact that we have during your pregnancy to make sure that everything is going okay. So do attend that regular prenatal care. And there's evidence that prenatal care does reduce the risk of maternal morbidity and mortality, because we can catch things earlier sometimes. So do attend your prenatal care regularly.

Nicole: Number six is childbirth education. I used to not be so insistent about childbirth education. It was kind of like, well, I guess if you want to do something, you know, do it, um, look for an option. But now the more stories that I hear about people's birthing experience childbirth education is essential. Childbirth education, good childbirth education will help you understand what's going on in labor and birth. It will help you understand your options. It will help you be a more informed participant in your birthing experience. And ideally the advocate that you have with you should also have done some childbirth education. So again, they can speak up about things if need be. Obviously we know the expression, that knowledge is power, and that is so, so true in the circumstance of childbirth education. It just helps empower you with that knowledge. Now, I don't want to give you the impression that childbirth education is going to fix everything, but you are so much better off having that baseline knowledge with you and understanding some of those baseline things about options, labor, birth, how things should go.

Nicole: Then if you don't have them, you don't know what you don't know. And childbirth education is going to help you fill in those gaps. So I cannot say strongly enough that you need to do childbirth education. Now I have an option for childbirth education called the Birth Preparation Course. My course is entirely online and it covers everything from mindset, all of the details of labor and birth, um, things you can expect in the hospital like, um, episiotomy, cesarean birth, assisted vaginal birth. So you're prepared for some of those possibilities, the postpartum period as well. Um, I'm very proud of the Birth Preparation Course, and I know that it will give you the information that you need. So you are an empowered and informed participant in your care. But at the same time, I also know that there are other childbirth education options out there.

Nicole: So you just have to find something that, that works for you. Um, the Birth Preparation Course, you can check it out at drnicolerankins.com/enroll. And, um, right now it is currently 40% off. If you want to look at that there. All right now, number seven, I believe I'm on seven is ask questions. Okay. Ask questions. If you have questions about things then ask those questions, you deserve absolute clarity on what is going on in your pregnancy and your birth. So ask questions until you have that clarity. Don't feel like you are being a pest. Don't feel like you're being a bother. Write those questions down during your prenatal visits. If you need to, you can keep it efficient. You can keep it short. You can also say we can get to questions at the next visit. If need be during the course of labor and birth, I don't feel free to ask your nurse questions, ask your doctor questions again. You deserve clarity. And going back to childbirth education, childbirth education will help you ask more focused questions. It will help you ask or know what questions to ask. It will help you understand the responses to the questions better. So as childbirth education goes along with that as well of asking questions so that you can ask the most informed and useful questions. Okay? Number eight is have a team who is on your side to support you. Okay? Switch doctors if you need to, if you find that who you are with is not supporting you and your needs for your pregnancy, then find another doctor. Okay. Be sure that you have a team that you feel like is going to support you understanding if that team is the team for you goes back to number seven, which is asking questions.

Nicole: Okay. Asking questions about, do they support the things that you want for your birth? One of the things that you don't want is you don't want a doctor who is tolerant. You want someone who is actually supportive. Okay. So tolerant is like, oh yeah, you know, that's okay. Yeah, sure. I guess, you know, that's fine. You don't want someone who's tolerant. You want someone who's actually going to be supportive of you and the things that you want and helping you get the things that you want for your birth. So if you need to switch doctors and the earlier you do that, the better and my free class on How To Make A Birth Plan, I include lots of questions that you can ask to understand how your doctor practices also understanding the important factor of how your hospital approaches birth. Those are the two biggest factors that are going to influence your birth experience.

Nicole: So you can check out that free class. It's about an hour it's online. It's offered multiple times a day, or you can take it on demand. That's drnicolerankins.com/register. Okay. Number nine, connect with your providers, connect with your doctors, nurses, midwives on a human level. They are human beings too. And I believe that most doctors want to do the right thing. That's why we go in to medicine. We want to do the right thing, but we exist in a culture that doesn't always make it easy for us to do the right thing. A lot of people are suffering from burnout and exhaustion and just being tired. And sometimes, honestly, people you lose contact with their humanity and they lose contact with the humanity of the people that we are privileged enough to serve. So sometimes you have to help that doctor help that nurse help that person reconnect with the humanity.

Nicole: So say things like how you feel say that I am scared because my sister almost died during childbirth, or I am scared because I'm a black woman. And I know about the statistics of childbirth. You can even say, like, I'm not trying to accuse you of anything, or I'm not saying that I'm doubting your abilities. I am just scared. And I need some reassurance that I'm going to be safe and that I'm going to be cared for. And you know, I think some doctors get upset, like when you ask questions and like question their ability and their trust, but please know that they don't deserve just your ability and trust just because it's something that they have to earn. Okay. So don't be afraid to connect on that human level and, and, and ask them to demonstrate that they are worthy of your trust. Okay.

Nicole: So just say that I'm scared or I'm concerned, or I'm worried, or I'm frightened. If you notice that someone is treating you poorly, you can even say things like, would you treat your wife this way? What would you do if, if I were your sister, what would you do if I were your daughter, those kinds of things. So try to connect with people on that human level, if you can. And then number 10 is to be in the best health that you can actually, before you get pregnant. This is one of the reasons why there's a lot of advocacy work and why I believe in advocating for insurance coverage in between pregnancies, because so much of your course during pregnancy is influenced by your health when you enter pregnancy. So if you can really get in the best health that you can, before you get pregnant, that is going to serve you well, or even between pregnancies.

Nicole: So the best health that you can before pregnancies in between pregnancies, that is going to reduce your risk of maternal morbidity and mortality. Okay? So just to recap, we know that maternal morbidity and mortality are problems in our country. They are unfortunately on the rise. We know that these a prob these problems disproportionately affect black women. We also know that there are things and systems that are being put in place to help improve the problems. Although we still have some ways to go from the medical system side. And then here are the 10 things that you can do in order to help yourself or improve your chances of not being affected by maternal morbidity and mortality. Okay. Number one, if you don't feel right call, no matter the time of day or night, make sure you know those after hour numbers to call. Number two, when in doubt, go into be seen, you're not being a bother or dramatic or anything like that.

Nicole: Number three, be persistent with getting your concerns addressed. Number four, have an advocate with you both during your pregnancy, and especially during your labor and birth. Number five, be sure to attend prenatal care regularly. Number six, do childbirth education. Number seven, ask questions. You deserve clarity on the questions that you have in relation to your pregnancy and birth. Number eight, find a team who is there to support you. So switch doctors, if you need to, you can do so up until the end of your pregnancy. Number nine, connect with your providers, with your doctors, with your nurses on a human level, start off with kindness. If that kindness isn't working, then of course you got to take it up a notch, but start off with kindness and connecting on that human level. And then number 10, be in the best health you can before you get pregnant.

Nicole: All right, so there you have it. I hope you found this episode helpful. This is something that I am particularly passionate about. So forgive me if I was talking faster than I normally talk, but I get pretty amped up and wanting to help folks around this particular issue. As I said, this is a truly a public health crisis, but one that we have the ability to do better on on. I think we're getting there, but we still have some room to go. All right. Be sure to subscribe to the podcast in Apple Podcast, wherever you're listening to me right now. And if you feel so inclined, leave that honest review in Apple Podcast in particular, it helps the show to grow. It helps other women to find the show. And I do shout outs from those reviews from time to time also be sure to check out all the resources that I have for you to help you stay safe during your pregnancy, help you to stay informed, help you to stay empowered, grab that free guide drnicolerankins.com/warning-signs that will tell you got symptoms that you can look out for in the postpartum period. Do take my free online class, How To Make A Birth Plan That Works. That's drnicolerankins.com/register. In that class you'll get questions to ask so you can know about the hospital and the doctor and making sure that they are on your side to support you and your wishes for your birth. And then of course, check out the Birth Preparation Course at drnicolerankins.com/enroll. That is my comprehensive online childbirth education class. That gets you calm, confident, and empowered for your birth. It is currently 40% off. So do check that out. That's drnicoleankins.com/enroll. So that is it for this episode, do come on back next week. And until then, I wish you a beautiful pregnancy and birth.

Nicole: Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast. Head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.