Ep 203: Maternal and Pregnancy-Related Morbidity and Mortality and What You Can Do About It

Dr. Nicole (00:00): 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 folks safe. Welcome to the All about Pregnancy and birth podcast. I'm Dr. Nicole Calloway, Rankins, a board certified OBGYN, 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 in 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.

(01:00): Hello there. Welcome to another episode of the podcast. This is episode number 203. As always, thank you so much for being here. Whether you are a new listener or a returning listener, I appreciate the time that you are allowing me in your ears today. Now, this episode is about maternal and pregnancy related mortality and morbidity. There's actually a difference between maternal and pregnancy related mortality. We're also going to learn about maternal health disparities, and then I'll share some things with you that you can do to stay safe during your pregnancy in the postpartum period, as well as things that you can do to help other pregnant mamas stay safe and well during pregnancy, birth, and the postpartum period, recent data has actually shown a really dramatic increase in maternal mortality for everyone with persistent and awful racial and ethnic disparities. So this is an important topic that we really need to talk about and all learn about.

(02:09): Now, the release of this episode coincides with Black Maternal Health Week, which is April 11th through the 17th. Black Maternal Health Week is founded and led by the Black Mamas Matter Alliance, and it is quote, 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. Now, I'm going to be honest that it is so frustrating that in 2023 we are still talking about black maternal health disparities and that they are actually getting worse. The problems are well documented. We know that the root cause is also well documented. It's racism in our maternal healthcare system. But again, things are getting worse. There seems to be a backlash even for not, there seems to be, there is a backlash even for talking about race, talking about racism these days, people don't want to talk about it or are actively trying to suppress efforts to talk about race, but data does not lie.

(03:19): And you're, you will hear me share that data in this episode and not talking about these issues doesn't make the problems go away. And I want to be clear that we can specifically talk about black maternal health disparities and acknowledge other problems. This is not in either or. Sometimes specific groups need more attention because they are more affected by a problem. You will find, for instance, kind of an analogy is when you have more than one child, sometimes you will have one child who needs your attention more than the other child. It doesn't mean that the other child doesn't deserve your attention or is being ignored. It just means that sometimes one child will need more attention than others because what's going on in that moment demands more attention. And that is the case for what is happening with black maternal health disparities. So in the context of an overview of maternal mortality and an overview of pregnancy related death, the causes of these solutions for these, we're also going to talk about maternal health disparities and then things that you can do to protect yourself and things that you can do to help reduce maternal disparities.

(04:39): Now of course, addressing maternal health disparities really starts with listening. So keep an open mind, listen to the episode, learn, take it in, and then when you're done, go forth and implement something that you have heard here today. Now, one of the things that I do during Black Maternal Health Week every year is collect donations to give away spots in my childbirth education class. The birth preparation course. The birth preparation course, of course, is my online childbirth education class that gets all mamas call calm, confident and empowered to have a beautiful hospital birth. And during Black Paternal Health Week, I collect donations to specifically give away spots in the course for black mamas who otherwise would not be able to afford or access quality childbirth education. So if you want to contribute to this, every little bit helps. You can head to dr nicole rankins.com/help and contribute today as little as a dollar or as much as whatever you'd like ask.

(05:38): So appreciate anything that you are able to contribute. All right, so let's get into today's episode. So the first thing I want to clarify are a couple of definitions. And these are important because this information can get confusing if you don't understand exactly what the definitions are. And I even realized that I was kind of confusing these two or cross mixing the data, for lack of a better way of saying it. But there's actually a difference between maternal mortality and then pregnancy related death. These are two separate things, and let me explain them to you and then you'll understand why you'll hear different numbers and why it's important really to be clear about the data. So maternal mortality is the death of a woman while pregnant or within 42 days of the end of pregnancy. So that's six weeks, right from any cause related to or aggravated by the pregnancy or its management.

(06:41): Okay? So maternal mortality is the death of a woman while pregnant or within 42 days of the end of pregnancy, all right? And that's at any point in pregnancy. And then pregnancy related death is the death of a woman during pregnancy childbirth or within one year of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management. So pregnancy related death is going to include maternal mortality, but it also includes a longer period of time. And this is really important in terms of understanding the reasons and how to address specific problems. So when we look at maternal mortality, okay, that's death within the first, during pregnancy or within the first 42 days after the pregnancy ends. All right? So from a report from the CDC in March of 2023, in 2021 that's dated that we have the most recent data available.

(07:52): 1,205 women died of maternal causes in the United States in 2021, 1,205 women. That's compared to 861 in 2020 and 754 in 2019. So that number has gone up. So the rate in 2021 was 32.9 deaths per 100,000 live births. That rate was 23.8 and 2020 and 20.1 in 2019. So again, it's going up now in 2021, the maternal mortality rate for black folks, black women with 69.9 deaths per 100,000 live births, 69.9 deaths per 100,000 live births. That is 2.6 times the rate for non-Hispanic white women. All right? 2.6 times the rate for non-Hispanic white women. The rate among non-Hispanic white women was 26.6 deaths per 100,000 lab births. Now, there was actually a increase in all racial and ethnic groups, black folks, white folks, Hispanic folks, all racial and ethnic groups from 2020 to 2021. And that's actually thought to be due to the covid in the pandemic.

(09:27): Now, I do want to point out the difference in absolute numbers versus rates because this comes up a lot. So the number of deaths of black women in 2021, maternal mortality again during pregnancy in those four first 42 days afterwards was 362 deaths for black women. And again, that rate is 69.9 per 100,000. For white women, it was 503 deaths, but that rate is 26.6 per 100,000. In Hispanic women, it was twenty two hundred and forty eight deaths, and that rate is 28 per 100,000. So although the overall number of deaths, it's more white women who are dying, the rate is worse among black women. It's kind of like, and this is a really crude example, if you have 10 women in a room and there's a chance that one of them is randomly going to be killed, and then in another room you have five women in the room and there's a chance that one of them is going to randomly be killed, clearly in the room with five, you have a higher chance of being killed because you're in that smaller group.

(10:44): And that's kind of how it is with black women, even though it's a smaller number, the chances of something bad happening are higher, are higher within that group. And again, it's one of those things that it's not an either or. We're paying attention to the overall numbers and concerns and problems, but putting our efforts where we know that there are specific problems, now that was maternal mortality, pregnancy related death is a little bit different. All right? So pregnancy related deaths again occur during pregnancy delivery and up to a year postpartum. And looking at data like a deep dive into data from 1018 pregnancy related deaths among residents in 36 states from 2017 to 2019, this was data that WA came from the Maternal Mortality Review Information Application through the C D D C. So this was a really deep comprehensive dive into people's charts, medical records problems, all of those kinds of things for about 1000 women.

(12:04): So not a huge, huge group, especially for a three year time period. But this is the best information and data that we have. And when we look at of those 1018 women who had pregnancy related deaths during that time period from 36 states, 144 of them, or 14% were Hispanic, 315 or 31.4% were black, 467 or 46.6% were white women. All right? So again, that proportion for black women is out of proportion to our representation in the population, and that's why that is a problem. Now, when we look at the timing of these pregnancy related deaths, 216 or 21% occurred during pregnancy. 13% were on the day of delivery, 12% were one to six days postpartum, 23% were seven to 42 days postpartum, and then the remainder were in 43 to six hundred, three hundred and sixty five days postpartum. That's 30%. So when we add those numbers up, pregnancy related deaths, 53% occurred within seven to 365 days postpartum.

(13:29): So when you hear pregnancy related deaths or you hear people, we often say maternal mortality, and most of it occurs after pregnancy. What we're actually talking about is pregnancy related deaths because maternal mortality is actually within those first 42 days. So when we say that 53% occur within that first year after birth, again, that really is the whole spectrum of pregnancy related death. And I say that because I think understanding terms and what we're talking about when you see information is important so we can address causes appropriately. Now, one of the things that I have that can help you is a guide to warning signs to look out for after birth. And you can download that guide, it's completely free a dr nicole rankins.com/warning signs. Now, interestingly, when we look at the most, and when they looked at the most common causes of pregnancy related death in this cohort of people, 22%, the top reason was mental health conditions, and that's deaths of suicide overdose poisoning related to substance use disorder.

(14:39): So most of the largest share were attributed to mental health conditions, which has not been the case in the past. And then that was followed by hemorrhage, cardiovascular conditions, infection, and embolism. Now, interestingly, and again, this is important where we have to look at the information so that we're addressing the appropriate causes. This was not the case among black women. So among black women, the most common cause was cardiovascular conditions. That was 15.9%, followed by cardiomyopathy, 13.9%. Then embolism, hemorrhage, hypertensive disorders of pregnancy, infection, and mental health was the seventh most common cause of pregnancy related death for black women, okay? So all the way down at 7%. Whereas when you looked at the group, overall, mental health conditions was the most common, and mental health conditions was the most common for white women when you looked specifically at white women. Now, the other important thing that was made in the determination of or in the review of these 1018 pregnancy related deaths is that they were able to look at 996 of these deaths and see whether or not the death was preventable. And among those, it was determined that 84% or 839 of these deaths were preventable. That is crazy, okay? That 84% of these deaths were preventable. That shows that we have a lot of work to do within our system in order to help keep folks safe.

(16:44): Now, switching gears, I want to talk about morbidity. So morbidity is something different. So severe maternal morbidity as defined by the Centers for Disease Control and acog, the American College of Obstetricians and Gynecologists, as kind of our governing body for recommendations for practice in the us, they describe or define severe maternal morbidity is unintended outcomes of labor and delivery that result in significant short or long-term consequences to a woman's health. And here's the thing that is crazy and scary, actually, there are approximately 70 cases of severe maternal morbidity for each maternal death in the United States. So for every one time someone dies, which of course is tragic, there are 70 cases where someone came close to dying. All right? So life-threatening near miss events are actually 50 to 100 times more than maternal mortality, all right? 50 to a hundred times more common than maternal mortality.

(17:55): So yes, although obviously maternal mortality is a terrible problem that we need to address, we also need to address these near miss issues or instances that happen where people are getting close to having life-threatening events. This is very scary, obviously very scary, very dangerous. And the most common things that are associated with these severe maternal mortality or morbidity events rather, are the same things that are associated with maternal mortality like hemorrhage, hypertensive disorders in infect, and an infection. So these are things that we absolutely can address. Alright, now next up, let's talk about a deeper dive into the actual maternal health disparities. And let me give you, and I'm specifically talking about black maternal health disparities. So a health disparity population as defined by the National Institutes 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.

(19:09): So within the United States, designated disparity populations include African-Americans, Hispanics, American Indians, Asian-Americans, native Hawaiians, and other Pacific Islanders, as well as socioeconomically disadvantaged populations, underserved rural populations, and sexual and gender minorities. So that is the definition of a disparity. Now, when we look specifically at racial disparities, they're very well documented within obstetrics, I talked about how pregnancy related death is and maternal mortality are on the rise. When you look at pregnancy related death, it's two to three times more likely to black women are going to die from pregnancy related causes compared to two white women. And I want to be clear, because this is something that comes up a lot. These differences persisted at all education levels. So among women with a college education or higher, the pregnancy related mortality ratio. So death within that first year of life for black women was 5.2 times that a white woman. So my risk as a college educated black woman would be 5.2 times that of white women, all right? It is one of the largest disparities in reproductive health.

(20:41): And yes, although increasing education and socioeconomic levels as well as care are protective against maternal death, a across all racial and ethnic groups. So what I mean by that is that everyone who has more money or higher socioeconomic status and prenatal care, that does help you regardless of your race. However, the benefits are greatest for white women. They're a lot greater for white women than for black women who receive prenatal care, who have higher socioeconomic levels. All right? So what this really shows us is that it is more than just about education or having money. It's factors beyond that that are involved. It's really social and structural determinants that are contributing to these disparities. It is not any biological factors. These are social and structural determinants, determinants that are contributing to these disparities. And when we look at severe maternal morbidity, we see similar things into the disparities.

(21:49): One study of people who delivered between 2006 and 2015 reported that severe maternal morbidity was up to 115% higher for black compared to white women. And that was after adjusting for factors that may contribute to things like age or insurance status or socioeconomic status, all of those kinds of things. So again, this suggests that it is more than just race. These are not biologic determinants, determinants that are causing this. When we also look at things like postpartum hemorrhage, we see that non-Hispanic black women, this was in a study of over 360,000 women, even after adjusting for having other medical conditions, black women were experienced postpartum hemorrhage at a higher risk of severe morbidity and death compared with white women. When we look at preterm birth, a study of over 9401st time moms showed that again, even after taking into account other factors, black women had continued higher risk at all age groups, at all categories of preterm birth compared to white women.

(23:12): All right? And again, these differences are not explained by differences in income housing or education. And then finally, infant mortality, which is death of a child within the first year of life. It's about two and a half times higher in black women compared to white women. This was all, there was also a recent study back in the fall of 2022 that looked at data from California that showed very clearly that income did not protect black women, that they still had higher rates of infant mortality as well as maternal issues as well. So these disparities are well documented and persistent. Now, when we look at the causes of these disparities, again, I talked about how it's related to racism. It's not when we take into account education income, those things do not account for, it's related to racism. But I want to say a specific note on personal responsibility.

(24:11): I see this constantly, constantly that people say, why don't people just eat better? They just exercise more. They just have terrible diets and take terrible care of themselves, and that's why they have so many health problems. Does anybody ever look at those things? Okay, well, first off, the America in general has a horrible diet. They're horrible problems with obesity, hypertension, cholesterol across all racial and ethnic groups. When you look at data, for example, on obesity, 41% of white folks are obese compared to 49% of black people. So that's not a huge, huge difference. So nobody actually, I shouldn't say nobody because that's not true, but a lot of people have persistent health issues or not eating healthy or not exercising or are not able to take the best care of themselves, yet they don't have the same outcome. So don't blame it on that, all right?

(25:09): Because it's not like black people are the only ones who are running around and not necessarily taking the best care of themselves that they can. Okay? So that's number one. And then number two, yes, there is of course an element of we all have personal responsibility for the things and choices that we make, but you have to think about what options and when things, things influence a person, person's options and choices. Personal responsibility can be hard, and a system that is unsupportive, and in some cases it's actively hostile against you, has preconceived notions about what you are can do. And not everyone has access to the same resources like safe and supportive environments to live in, to learn in. Not everybody has access to quality healthcare, reasonably priced foods or examples of what personal responsibilities look like. Health really comes from a lot of not just individual factors like your genetics and your lifestyle, but it also comes from population factors, all right?

(26:20): And social determinants, where you were born, how you grow up, where you live, where you work, all of those things, intermix. All right? And so we can't just say like, oh, you just eat better and exercise more. And if you take better care of yourself, then suddenly these things are going to go away. That just is not the reality of how we live. We have to look at, yes, personal responsibility is a factor, but you still have people who are taking the best care of themselves, being incredibly personally responsible people who you think would have the most access to resources in terms of high socioeconomic status, education, and still having bad outcomes. So stop it with the personal responsibility of just eating better, exercising more, and take better care of yourselves. And that's why these disparities exist. That is not it. That is not it.

(27:09): That is not it. So if you don't take anything away from this, I need you to take that away from this as well. And honestly, that factors into lots of people who have issues or concerns with their health. Sometimes it may be people who live in rural areas. Sometimes it may be people who are of lower socioeconomic status, whether regardless of race, that you have to take into account peaceful's circumstances. And I'm not saying this to absolve people of personal responsibility and say, oh, you can't take that in an account. You absolutely do. But you have to look at a bigger picture beyond just people making choices for themselves and think about the environment in which they are making those choices. Okay, so let's talk about reducing the risk of maternal mortality and morbidity. As I said earlier in that data review pregnancy related deaths, they concluded that 80% of deaths were preventable.

(28:07): Now, that report didn't provide details about what the deaths were, why they thought they were pre preventable, that wasn't there. But there is one report that has suggested the following things that are important to reduce maternal mortality and in order of significance, and this is based on this was, it's a little bit older data, so it's from 2012, but it was a global policy summit looking at things to help reduce maternal mor mortality. And these are things that are more so from a systems issue. And then I will talk about things that you can do from an individual issue. So from a systems issue, things that can reduce maternal mortality, morbidity, our family planning with birth spacing and contraception that is estimated to reduce maternal mortality by 30%. Safe abortion reduces maternal mortality by 13%. Hemorrhage prevention, another about 10% only doing cesarean when in cesarean when indicated 7% reduction.

(29:12): And then prevention of eclampsia and treatment of pre-eclampsia, also a 7% reduction. In the us, it really appears that deficient medical care, medical comorbidities, so having medical problems and then social circumstances all strongly contribute to maternal mortality, especially for black women. So it's really deficient me medical care, having additional medical problems that aren't being appropriately. And then social circumstances all contribute. All right? And we really have the resources within our country. America is the richest country in the world, yet has the poorest maternal outcomes across all racial and ethnic groups, not just for black women. And it, it's really embarrassing actually, that we are in this situation where we have this amount of money as the richest country in the world, yet people are still actively dying. So we have the resources that we need. The money is here, we just need to make sure that we are using it in the most appropriate ways.

(30:17): Another thing that we have to address as implicit bias, okay, implicit bias. All right? We know that racial and ethnic minorities, and I hate the word minorities because it implies less than, but I will say racial and ethnic groups that are not as represented in numbers, I should say. And women are subject to less accurate diagnoses. They don't get the same treatment options. Their pain isn't taken as seriously. Some examples, one study of 287 internal emergency medi medicine residents, they reviewed a clinical vignette of a patient presenting to the emergency department with heart problems, and they stereotyped black patients as less cooperative with medical procedures. They tended to favor the white patients. And then as preference for the white patients increased, the likelihood of treating white patients with their appropriate things increased and the likelihood of not treating black patients also increased. Another study of primary 40 primary care physicians in 269 patients showed that there was poor healthcare communication and ratings of care for black patients.

(31:41): And data actually shows I can go, there are lots and lots of studies that have shown this. There have been studies in pediatric populations that shown the pain is taken less seriously. And much of this bias is really not explicit. People don't realize that they are exhibiting these biases. They're called implicit biases, and we have to recognize that we have a bias and then are actually perpetuating them in some cases. So especially in this day and age, it can be invite lots of commentary, lots of backlash potentially to admit that you have a bias to be discovered that you have a bias, but it's not. Yes, having biases can be problematic, but what is most problematic is what you do with that information and how you address it. So if you have this bias and that affects how you approach care and it does so in a negative way, then that is a problem.

(32:48): But if you have this bias and you say, Hey, let me stop for a minute. I'm seeing that I'm treating this person differently. Why is that? Or I'm looking at this person this particular way, why is that? And you stop for a second and you adjust incorrect course, then over time, those biases will fade. So we have to acknowledge that these biases exist, and then also course correct were necessary. All right? So acknowledge and change. We all have biases when we encounter people. It's really how you interact with the person and what you do with that information. And when you acknowledge it, that makes the difference. And then I will also say that some of these things in terms of a systems issue like family planning, contraception, all of these things are related to policy and politics. This is where being active in at voting matters.

(33:44): All right? So many of these things and changes happen at a policy level. For example, expansion of Medicaid, Medicaid covers, 40% of births in this country is for low income people, very low income people, and it covers a lot of births because of a lot of people in this country are low income. And finally, that coverage is to, is being expanded to up to a year postpartum. Recognizing that care in between pregnancies greatly affects how people come into pregnancy. Really having baseline good quality healthcare throughout the duration of your life, not just during pregnancy, is really important to improve pregnancy outcomes. So this is where your vote matters. This is where advocating for things that are important to you matter. Because these policy and politics things really do make a difference. All right. Okay, so let me get off of that soap box and go to some things.

(34:42): These are 10 things that you can do to help keep yourself safe during pregnancy in the postpartum period. And I do want to reiterate that it's actually unlikely that you're going to have problems during your pregnancy or after birth. Most people are just fine. I know that the numbers sound startling. A thousand people died in a year, and that's awful. However, 4 million people give birth in the US every year. So it's not likely that you're going to have any significant problems, but you do want to be prepared just in case. So here are 10 simple things that you can do to help keep yourself safe. So number one, if you don't feel right, you have questions, you have concerns, pick up the phone and call your doctor's office. A lot of people don't realize that typically there's someone who's on call 24 7. Now, some answering services may say, okay, if call back during regular office hours, if it's an emergency, go to the hospital, but pick up the phone call no matter the time of day or night, pick up the phone and call.

(35:41): See what the process is for reaching someone after hours so that you can get those things addressed. Don't wait if you don't feel right. Number two, when in doubt, go in to be seen. If you're not feeling well and you're concerned, then go in to be seen. Don't let things linger during office hours. Try and get that appointment in the office. Most offices keep like emergency slots available for appointments, and it's nice if your regular doctor can see you, someone who knows you and has a sense for your care. But if you can't get into the office, then go to the hospital. And if you go, especially if you're more than 20 weeks pregnant, please, please go to someplace that has a labor and delivery. Those freestanding emergency departments, they are great for if you need stitches for something or if you have a cold or a respiratory something or another or anything else, not that is not related to pregnancy, but do not go to those places.

(36:35): Do not go places where they do not have a labor and delivery if you are especially more than 20 weeks pregnant because they are not familiar with treating pregnancy problems at all. It freaks them out, even they don't like it either. And it really delays care because what has to happen is an ambulance has to come and transport you to a place where you can actually get the care you need. So drive the extra 15 or 20 minutes, assuming it's not like life threatening baby's not falling out kind of thing, but drive the extra 15 or 20 minutes to get to a hospital with a labor and delivery because it'll serve you so much better. As a matter of fact, I posted on Instagram about this recently and someone sent me a DM and said that their emergency center gets so freaked out when pregnancy pregnant people come in that they call an ambulance immediately.

(37:26): When the person checks into the place, they don't even wait to see what's going on. They immediately call an ambulance because that's just how uncomfortable they are with treating pregnancy problems. So if you have a problem, go to a hospital with a labor and delivery. This is really, really important because that's where you're going to get the best care. All right, number three is be persistent. You have to keep voicing your concerns until your concerns are addressed. Do not worry about being perceived as annoying. Don't worry about hurting nobody's feelings. I'm not exaggerating when I can say this could sadly be life or death. And persistence is especially important if you are a black woman. The truth based on data is that black women are more likely to have their concerns dismissed or ignored, all right? They are more likely to have their concerns dismissed or ignored.

(38:18): Now, when you are persistent, this leads to another piece of advice is connect on a human level. So say, listen, I am scared. I am worried because I hear that black women are dying more frequently. I'm concerned because I have heard about pre-eclampsia and my blood pressure is high. I am concerned because I have heard about blood clots in my legs. So use, try to connect on that human level first, doctors are human, and most often we will respond to that human connection. So make them see you as a human being in front of you and keep being persistent until your concerns are addressed. And if the person in front of you is not addressing your concerns to your satisfaction, then find someone who is addressing your concerns. So that number four thing is connect on that human level, and along with number three, which is be persistent.

(39:16): Now, sometimes people think getting your concerns addressed mean that, I will say that doesn't always mean that you will have a resolution to your problem. Sometimes we can't always find a reason for something, but what we can find is that it's not this, okay? It's not the laundry list. It's not anything that's dangerous. We know that it's not that it's not preterm labor. We know that your baby is not in danger in terms of how the health baby looks on an ultrasound or on the monitor. So sometimes we can't always give a specific answer as to what thing something is. But we should do a thorough evaluation, ask lots of questions, do the appropriate test, and make sure we have evaluated for anything that is serious. I think sometimes folks get frustrated, and understandably so. This can come around the in instance of pain, for instance, that we can't say what it is, but we should also be able to say what it's not and that it's not anything life-threatening or dangerous.

(40:24): So number five would be have an advocate, especially during birth. All right? When you're in birth, you are focused on having the baby, or you may not feel well enough to speak up for yourself if you're sick. So have an advocate, someone who can speak up for you on your behalf. Again, super important to have, if you're a black woman, have an advocate with you. That can be your partner, that can be a doula. Now, keep in mind, not all doulas feel comfortable doing advocacy, which is fine. Some doulas to focus on providing that physical, emotional support for the person who's giving birth, and that's perfectly within their reason. And so do be clear that if you are asking a doula or have a doula that they feel comfortable in an advocacy role if need be, because not all of them do, but have an advocate.

(41:10): It's really, really important. And they can use the same sort of language, like I said before, about connecting on a human level. And I should say that if connecting on that human level doesn't work, then you take it up a notch notch after that if you need to in order to get answers for what you need. But start with connecting on that human level, both you and your advocate, and see where that gets you. Okay? Number six, attend prenatal care. Prenatal care has been shown to improve outcomes. So make sure you get regular prenatal care starting as early in pregnancy as you can. And then number seven, sorry, I'm looking at, I got my numbers mixed up, I feel like. So number seven is educate yourself because you, y y'all know this is the reality. Your doctor won't your doctor, they are busy. They are unfortunately in systems where they don't have a lot of control over the number of patients that they see.

(42:07): Fewer and fewer doctors are in private practice. More and more doctors are in big groups. They're owned by hospitals. They don't have control over their schedule like you think they do, but they don't. And that leads to having lots of patients scheduled and just really, you may have five minutes for a tummy check, maybe 10 minutes on a good day. That is not enough time to provide significant education. So you really need to educate yourself. You must educate yourself and educating yourself. Doesn't have to be overwhelming. You don't have to read every book, you don't have to listen to every podcast, every kind of thing, but find some good resources that resonate with you that make sense to you, and then stick with those. All right. Maybe it's one or two books. Obviously listening to this podcast is an educational resource. There are other pregnancy podcasts out there.

(42:56): Follow a couple of accounts on social media. It doesn't have to be overwhelming, and you can get great information in a short period of time. Childbirth education, of course, goes along with that. I would love to have you in the birth preparation course. That's dr nicole rankins.com/enroll. Comprehensive childbirth education is great. This podcast is fantastic, but it's not in a structured, organized way. The episodes are stand independently of each other, whereas Childr education puts things together or an organized fashion that you can easily follow. So that's the difference between the podcast and childbirth education. So definitely check out childbirth education for sure. All right, number eight, ask questions if you have concerns. Ask questions. You deserve clarity about what is going on in your pregnancy and in your health. Ask questions and expect answers, ask questions and expect answers. And a tip for asking questions is don't ask questions that can be answered with yes or no.

(44:02): Ask questions that require some more thought. All right, so instead of, is this pain serious, I want you to say, what are some things that can be causing this pain? Or How am I going to manage this pain during my pregnancy? If you ask how questions and what questions as opposed to questions that can be answered with yes, or you're going to get a lot more feedback and response just because of the type of the question. So ask questions because you deserve clarity. All right. Number nine, switch doctors if you need to switch care providers if you need to. You don't have to stay with anybody who is not serving you during your pregnancy and birth. Some people are like, oh, I've been with this person. They were my GYN for the last number of years, and blah, blah, blah, blah, blah. For real. Forget that.

(44:59): F that to use more adult language, this person is going to go on about their day living their lives, okay? They'll be fine, all right? Whereas you are still going to be pregnant and still have your concerns, don't stay with them in order to appease their feelings. They will be fine, I promise you. All right? You need to go to find a doctor who is supportive of you and your care, and not just tolerant of you, but supportive of you. There is a difference, and I can honestly say I have yet to meet anyone who has regretted switching to another doctor when they felt like the one that they had was not serving them well. So definitely, definitely. If you feel like you are not having the or receiving the care that you need, then 100% find another doctor. And then the last thing is being the best health that you can before you get pregnant or in between your pregnancies.

(45:58): I know it is a challenge to do the things that we need to do to take care of ourselves. I am currently in a monumental battle with my weight. I weigh more now than I ever have, and I really am trying hard to lose. I would ideally like to lose about 20 pounds, 25 even. And it can be, it is so hard. It is so hard to prioritize yourself and your health and make the choices that are best for you. But in the end, it really, really is worth it, especially in when it comes to pregnancy, because once you're pregnant, yes, that is an opportunity to make changes and improve your health, but it's really ideal to be in the best health that you can before you get pregnant. So think of it as you know, are your number one priority. You need to be as healthy as you can in order to show up for others healthy.

(46:52): So I know it's hard. I know it's challenging. I know from personal experience how difficult it can be, but be in the best health you can before you get pregnant. All right. And then the final thing that I want to wrap up with is what can you do to help address maternal health disparities? Number one is to acknowledge that racism exists and that racism is a problem. All right? Please don't say anything. I don't see color. That's a lie. First of all, because you do see color. We all see color. So, and it's fine to see color. People think that when they're saying that, they're saying that they're treating everybody the same, that is actually harmful because everyone isn't treated the same in our society. Everyone doesn't have the same experiences. So when you say like, oh, I don't see color, it's really kind of putting blinders on to the things and the realities of things that are around us.

(47:43): So acknowledge that racism exist, acknowledge that it is a problem. Number two is speak up. When you see racist things happen. I know it can be challenging, and I know this has led to some horrible, terrible conversations around dinner tables and whatnot. But speak up when you see racist things that are wrong. Speak up on your family or friends. Your coworkers say things that are racist. It is these small conversations that help lead to bigger change. All right? It is starting in more intimate environments and closer things. And it doesn't have to be a angry kind of calling out. It doesn't have to be shaming or anything like that. Just be like, that's not really appropriate because that's not true about black people. So just speak up when you see racist things happen. Have that courage and strength and resolve to do so among your family, friends, and coworkers.

(48:36): Because again, it's those small conversations that make a difference. And then if you have the means, you can donate, donate to Black Mamas Matter Alliance, donate to the National Birth Equity Collaborative. That's another organization that does a lot for black maternal health disparities donate to common sense childbirth. That was started by a midwife named Jenny Joseph, who helps promote midwifery care. So donate to organizations. If you have the means to do so. You can also, of course, donate to help black mamas get inside the birth preparation course. That's dr nicole rankins.com/help. And then the final thing I'll say is advocate for policy change. Pay attention to the politics. It doesn't have to be, again, an overwhelming activity, but just pay attention to what your elected representatives are doing for you, what they stand for. Because we were, we're going to look away, or we're going to look and see a period of time if we don't pay attention.

(49:34): Whereas, how did we end up in this place where the government is controlling what's happening in our bodies more and more, all right, and making our choices for us. So you have to pay attention to these politicians to policy and advocate for policy change with your vote. All right? With your voice. Your voice and your vote matters. All right. So just to recap, unfortunately, maternal mortality, morbidity, and pregnancy related deaths are rising. There are worsening disparities for black women. We know the disparities are caused by racism. That's period. Some things that you can do in order to help keep yourself safe are if you don't feel right, call, no matter what time of day or night. When in doubt, go in to be checked. Go to a place that has a labor of delivery. Be persistent. Have an advocate. Attend a prenatal care. Educate yourself specifically with something like childbirth.

(50:30): Education is great. Ask questions because you deserve clarity. Switch doctors if you need to. Connect with folks on a human level, and then be in the best health that you can before you're pregnant. Also for disparities, acknowledge that racism exists. Speak up when you see racist things happen. If you have the means, donate to causes that are working on this, and then advocate for policy change. All right, so there you have it. Do mi a sola share this podcast with a friend. Sharing is caring. And be sure to subscribe to the podcast and Apple Podcast or wherever you're listening to me right now. I would love it if you let me know what you feel about the podcast. Shoot me a DM on Instagram. As a matter of fact, follow me on Instagram. I'm on Instagram at Dr. Nicole Rankins. I share lots of pregnancy and birth information there, and I would love to hear your thoughts on any of the shows. Good or bad, I shouldn't say bad. People don't give me bad feedback. People give me constructive, reasonable things. I'm grateful that I have a community that I don't have problems with, like nasty comments or trolls or anything like that. So I'm grateful for that. But definitely reach out to me on Instagram at Dr. Nicole Rankins. All right, so that's it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy in birth.