 Good afternoon. My name is Shannon King, Associate Professor of History and Director of Black Studies. Thank you for coming to the Black Studies programs and the Black Lives Matters course event. This woman's work, a conversation about racial inequities and maternal child health and inclusive reproductive justice. Reproductive justice is such an important topic as we watch reproductive and women's rights be debated at this court's highest court. And of course, it is important to the movement for Black Lives as we witness the struggles of Black working class women, as well as world class athletes like Serena Williams address how reproductive inequities have impacted their lives. Since this is our final event for this spring, I wanted to thank all of our past sponsors and welcome a new one. Now to introduce you to Dean Meredith Kaser who will introduce the speakers. Great. Thank you, Shannon. And good afternoon, everyone. I'm Meredith Wallace Kaser, Dean of the Marion Peckam Eagan School of Nursing and Health Studies at Fairfield University. And on behalf of our entire faculty, staff and administration, it is my great pleasure to welcome you to this woman's work, a conversation about racial inequities and maternal child health and inclusive reproductive justice. An interdisciplinary program between the Black Studies program, the Eagan School of Nursing and Health Studies and women, gender and sexuality studies. Those of you who know me may know that I'm a little bit of a storyteller. And my years as a creative writer I've learned that stories have a beginning, a middle and an end. As I've immersed myself in a community of writers I've come to realize how strong the impact the beginning has on the end. What happens first bears greatly upon what happens last and everything in between. From a current contextual perspective, what happens during the first moments of life from conception to birth shapes everything that follows. From a historical perspective, the racial injustice that has been inflicted upon women throughout history impacts our current societal context. We've taken an interdisciplinary and important step in discussing and promoting a just equitable and inclusive start to life, so that what happens first has the best possible impact on what happens next and what happens last. The actions we take the words we say the hope we bring makes all the difference. It's no surprise to anyone here that our health system falls far short of the basic standards for equitable access and distribution of services. However care by knowledgeable and experienced providers like those gathered today can and will have a substantial impact on the experience of individuals and families who were privileged to serve. As you know an event like this takes a village and I'd like to acknowledge the hard work that went into coordinating today's program to our colleagues in the black studies program and winter women gender and sexuality studies we thank you for your hard work and coordinating and managing this event. We are deeply indebted to our colleague in care autumn cloud ingram a doula licensed clinical social worker certified and evidence based childbirth and parent educator and founder of parent technique LLC. Miss cloud ingram joins egan's own Dr. Teneke ease, an assistant professor and licensed clinical social worker who holds the Connecticut Association for infant mental health endorsement as an infant mental health specialist. We are grateful to you both for your work in developing and coordinating this program and for sharing your knowledge and expertise with us today. And thank you all for joining us in your commitment to this important work. It is only through collaborations like this that we have the power to correct course today, tomorrow, and in the years. And now just a little housekeeping tab technique here is that Shannon will be managing the Q&A so you can use the chat function and we'll we'll work it from there. So thank you and I wish you a great program. Thank you so much Dean kaser for that wonderful introduction. I'm so glad that you can all join us this afternoon for what I hope will be an informative and engaging. I think important conversation. I just want to extend my thanks again to Dr. King in the black studies department and Dean kaser at egan school of nursing and health studies, and Dr. Harvey and women gender and sexuality studies. I, you know, I think Dr. King and I maybe had a conversation early in the fall semester about coming together to do this and thinking about where are the intersex that you know in this conversation and thinking about the black lives matter course and how students are engaging in their studies of the black experience. And so I'm just really happy to be here and so happy to have autumn join us. And I thought maybe before we kind of get into our conversation, I just wanted on to have a few minutes to tell us a little bit about who she is and maybe what brought you to this work. Absolutely so hello everyone. I am so excited to be here I've been thinking about this for several weeks. And I'm just excited at any opportunity to talk about and be with other people who are interested in this topic. So I birth work has been something that I feel like really chose me and from the time I was really young. I just had an interest in when I was 18 I did my first training as a doula, and then I learned about full spectrum, doula care. And then I really got into childbirth education and the importance of that and then I got into postpartum doula work. All while working in the capacity as a clinician in different programs working for home base programs working for hospital programs, where I was also doing similar work and helping families in the transition from, you know, the early postpartum days throughout throughout parenthood and so I started about three years ago parent technique which provides a combination of like really comprehensive childbirth education perinatal therapy for parents that are needing some support in that transition to to parenthood because as a clinician what I was seeing and even in my work in various capacities as a as a birth worker was that there was such a tremendous lack of care and the service that did exist was really crisis oriented. There really wasn't a whole lot of work on the preventative side, and that, you know, I knew was was really my my calling and so that's what brings me here today. And I'm excited to just, yeah, have conversation and and answer questions. Perfect. Thank you. Yeah, so I so I think what we agreed to do is a little a little polling a little quiz. Yes, you will have the option in your zoom I'm going to launch a poll to get a sense of, you know, how much do people know about some of these topics and two so is going to be four questions. If we were in person I'd have candy and prizes for people who got things right, but we'll have to do that another time. So I'm going to launch the poll and then we'll see what we get so there's four questions. What year did the largest mass sterilization take place in America. Two is what is the current mortality maternal mortality rate for black women compared to white women. And three asks, who were the mothers of gynecology, and then the fourth one on and can you remind me the fourth question. Oh, um, what is the, I'm sorry that had to do with maternal, like rate of maternal complications for black women. It was a study about racial difference. That's right. That's right. I'm going to thank you so I'm going to, I'm going to launch the poll and hopefully I press launch now we'll see what happens. So it looks like a lot of people so I think we're done so it looks like about most of the audience picked night the 1930s. The answer so what year did the largest mass sterilization take place in the 1930s. What is the current maternal mortality rate for black women compared to white women. The question number three in a randomized control trial, what percent of medical students and residents endorsed false beliefs about biological difference for black patients such as their skin being thicker and their nerve ending being less sensitive compared to white patients. So, 67% picked 36% of medical students and 33% picked 50%. Who are the mothers of gynecology. Oh, so you guys are smart. A lot of people. So, 33% picked Jane Adams Molly pitcher and Elizabeth Blackwell, and then 67% shows Lucy Betsy and Anarka. Okay, so I guess auto would you like to enlighten us to the right answers. Absolutely so the first one and we'll, as we go through and to make a we talk and you'll see where the answers to those will come will come up. Oh great thank you for sharing that with me. So yeah, so for number one what year did the largest what was the largest mass sterilization that was actually in the 1970s between the 1970s to the 1980s. And I'll talk a little bit more about that but this was hysterectomies that were done really without consent by women predominantly black women and poor women that received Medicaid. So for number two, what is the current maternal mortality rate for black women compared to white women in America, and the answer is four times. So, a little more than half of you got that correct so four times. So number three and a randomized control trial will present medical students and residents endorse false beliefs about biological differences for black patients, such as having thicker skin and nerve endings being less sensitive compared to white patients. That answer is 50%. So 50% and an RCT or randomized control trial of medical students and residents endorse those false beliefs. And number four, who are the mothers of gynecology and we'll, I will, we'll talk more about that. The answer there is Lucy Betsy and then our. Okay, so I'm wondering how many people surprise themselves with how much they knew or how little they knew or that maybe when we get to Q amp a we can talk about that more. So I wonder as we begin our conversation. If you might give us some historical context that helps us situate black maternal infant health and how that has evolved over time in American US society. Yeah, absolutely so it's essential especially focus on maternal health, in particular black maternal health in America, that we have to look at the beginning right we have to look at the very beginning of the experience of black women and black pregnant women in America, which also tragically means that we have to talk about slavery, and that a lot of this started with slavery. And so, not only did you have enslaved people right that that were brought over to America, which is horrific. But those those women were also very much coerced and forced to child bear. What that means is that they were forced to also participate in the very thing that kept them enslaved, because that you know, as many of us know slaves for were property, and brought money right to to the people that own them. And so the more slaves that there were owned by white slave masters, the more money that they made. So child bearing was very much, very much. The biggest aspects of slavery that that continued at that perpetuated itself. And so that's a really heavy that's a really deep and as much as though I know that and think about that often. An aspect that is just it's all that's a lot to take it and that they were also forced to do the very thing that kept them enslaved, and that that brought, you know, the slaves money. And the other thing important aspect I think when we're talking about reproductive justice right and autonomy and like what are the, what are the fears when we when we fear that that's going to be violated, right. We think of things such as right coercion. We think of things such as the separate the sphere of the separation between like the mother's well being right and the baby's well being. And then the other thing is like really just viewing women in their bodies as a way to reproduce. Right. And those are all aspects that have come into play even recently right those thoughts that that can undermine reproductive justice. And black women at different all women right at different facets of time have experienced that black women and enslaved women experienced all three of those things, and have for endured for the longest period, since the beginning. When we look at things like the statistics now of black women, you know, facing complications and being four times more likely to die. We can't fully understand that and why that is without looking at that that very beginning. The other component of one of the questions the last questions talked about like who are the mothers of gynecology. We can't talk about them without also talking about this. OBGYN at the time whose name was James Marion Sims who is well known for inventing the speculum, which is a tool. You know if you're a person with a uterus at some point. All right, you might have had a well visit that included a speculum and so that is accredited to him. And also between like 1830s 1840s operated on enslaved black women so this was women that were, you know, did not we're not able to consent, and also weren't given any kind of pain medicine at all because the belief then was that they didn't need it. And again going back to that first quiz question right looking at the beginning thought belief. We still have a long way to go because clearly right 50% of residents and medical students still endorsed some kind of belief related to the fact that they feel black people experience less pain. And as I'm listening to you and so I actually, I was very intrigued by the story of Anarka Betsy and Lucy so I had gone back to do some reading about that and I think they are primary examples of sort of during that time and we think about how we think about pregnancy in modern day times in terms of you need to have proper prenatal care and you should be getting follow up and the kinds of nutrition and rest versus activity that it's necessary. One of the things that struck me in reading the narrative was that they were 17 and 18 years old. So when we think of them, you know in the historical texts as mothers of gynecology or women. They were 17 and 18 years old and had already had at least one birth. I guess the infant mental health person and me wonders, were they able to be involved in their children's lives. Were they able to bother them what you know what what with those circumstances, and what, what they, they all had complicated pregnancies which is why Dr. Sims was operating on them without consent without pain medication. And it just, you know, I can only sort of, I mean I guess I can't imagine the conditions that they were pregnant under. And how that may contribute, you know, when you think about the intrauterine environment and epigenetics and how we're learning how environment interacts with genes and can be passed on across generations. And that's to me, you know why we're in the situation that we're in now. But I also wondered, how did this context intersect with this idea of sort of parental authority, or your child belonging to you and maternal infant health and mental health perspective. That is an excellent. Yeah, that's an excellent and also an excellent question and the fact is. Again, going back to the beginning. There was no print autonomy, they didn't own, they weren't people right so black women weren't people black men weren't people. Black women were completely ruled by, not them right by by by a family they did not have ability to educate them and they don't they want to be educated they didn't have naming rights right you were named after the master's I mean there was no, there was no I mean when we when we think about and maybe if everyone who's listening just take a moment and think about what when you think about parenthood. What is that like if someone asked you define like what is the core component of being a parent and parenthood. Just take a moment and think about what that is. For me, and you know I think, to an extent a lot of people the things that come up our care, right and autonomy to be able to make choices for your child and the bottom line is that that didn't happen you know, black women at that time were forced to literally feed master's children they didn't even get to feed their own children they didn't get to clothe their own children. All of that was was taken away from them. And, and that's that's heavy right and so thinking, almost if you think a little bit linearly to for a second, we have slavery which really started in 1600s. Right to about 1860. The ending, and then we had segregation right we had sundown towns we had Jim Crow laws we had there was right and so that went on. I don't know 80 years, right until about right till we had like Civil Rights Act. And so, all of that time was not time that you could care for right and make autonomous decisions for your child if you were a black person. And still today we see the impacts of those things still being in play. So even if we look at the question, how long have black folks in America been able to parent. That answer is like, maybe 120 years, right like maybe 120 years, if you count that time when we still had laws right like it segregation laws. So that's a really heavy thing to think about like, what does it mean to parent, and, and how much has that been impacted on families as opposed to white families and the truth is, if we were to draw that timeline, you know, of being enslaved of segregation laws. You know, that timeline looks like maybe 100 years. I think we talked about this a little life. I think we were saying 60 or 70 years because yeah, even pre so I mean I probably depending on what part of the country, you lived in, you know, the level of parental authority probably look very different. Before there was legislation to to protect the civil rights of all citizens right like so. Yeah, I maybe 60 to 100 years which is not. It's not a very long time and I also I know from from my perspective as a clinician. When you're in survival mode, it's very difficult to parent effectively, it's difficult to bond or attach with your child, it's difficult to hear or see your child as a separate individual with their own needs and desires and wishes that that's very difficult when you're just trying to survive. Or if, and if you're living in fear. So, so I think that makes sense that that this, the parental autonomy is probably a relatively new concept for African descendant people in this country. And really, it really is it really is and we still see where, if we ask the question which is a big one night like what is autonomy and choice, still how limited those options are even when we think about something like break it's we're a university so just keeping it to education, how impacted black families have been right and and how much choice has still been limited due to those hundreds and hundreds of years of enslavement of segregation, etc. So I want to shift that the conversation a little bit when we think about choice and sort of how Dr King began this introducing this conversation, we're having, there's a lot going on in terms of women and choice and and what's being argued and brought to the highest court and so when I think about going back maybe 50 years to to the reproductive rights movement. That was all about choice. Yes, but it was largely choice, not to have children. And so now what we're talking about is it in terms of parental autonomy and, and being denied the right to have and parent and raise your children, you know, under under the conditions that you set. In what ways does the reproductive rights movement sort of maybe miss miss some things in terms of how black and indigenous and women of color that, you know, can it be assumed that all women have the same concerns when it comes to reproductive rights and choice. Does it look the same for all of us. No. And, and this is great because something that I think, at least at the university level is happening a little bit more but still hasn't happened a lot is not recognizing that the women's rights movement was not originally built and designed for black women. It wasn't. It wasn't. And so, so when we look at the impacts of reproductive justice and black women in the time of the women's rights movement. We also have eugenics happening around that time. Okay, and so some of you might be familiar. I was too many of your familiar with Planned Parenthood, and Margaret Sanger was the founder of what later became Planned Parenthood and and had other names before that. And at first really was trying to advocate for birth control was a huge proponent of birth control within the women's right movement. And at that time, that movement was a very conservative movement so they kind of Margaret kind of like got the boot. What really happened was, there was able to be an appealing to unfortunately the eugenics movement so the eugenics movement was really focused on the fact or the belief that that the challenges that black people say that, you know, faced poverty being less intelligent all of them were biological. So we know that those are those are social determinants right that that happened because of systemic social issues, but eugenics believe that like inherently black people had biological differences that made them more fertile less intelligent, to experience pain, etc. And so the birth control movement there ended up really becoming part of the eugenics movement and so that's where you get into a bit of the history of coerced sterilizations right or complete no consent at all. You know, sterilizations of women so so when that women's rights and reproductive justice movement started, that was really more about this. What the ideal of what it meant to be a mother at that point, which did not look like or encompassed black women and their strengths or their challenges. In fact, led to this other horrifying, you know, issue which was when became this, you know, forced sterilizations of black women and from the beginning and as we talk more about present. Notice that there's this constant what I and to make I know we've talked about this for this push and pull, right this push of like, you need to have children because that benefits me and makes me money, right to now. We are you have no rights you don't deserve at all to be able to have or be able to care for your children so now we're going to. It constantly goes back between this push and pull. But yeah, absolutely the women's rights movement and the birth control and reproductive rights movement at its start was not designed with black folks in it, which is a problem. And of course then did not have them in mind, and it was really thought of as a way to to to manage reproduction, as opposed to really give autonomy to black women and families. So you're taking me into sort of where my next question was going to go if we're thinking about the beginning we started at the beginning. And you've already mentioned the forced sterilization, I think it's sometimes I mean I've read cases of sterilization where women did not know they were being sterilized. They also didn't know that that was the surgery they were having. I know in modern current literature, I think black and Latino women are more likely to be recommended for hysterectomies, which is a removal of the ovaries and in many instances where maybe that isn't necessary there might be more, you know, less invasive alternative treatments for you know whatever is ailing them. So it's just interesting to see these connections but you mentioned at a certain point in history, African descendant women and their birthing was a commodity. It was a market profit commodity right, and they were forced to bear children for profit I think particularly after the transatlantic slave trade was was illegal, then it was what we need to reproduce what we have here right. And so, how I mean, how have those views and you mentioned you touched on a little bit like a fertility changed. So you mentioned the sterilizations in the 70s. And I know another thing that was happening in the 70s was a lot of controversy and vitriol around social welfare and public welfare so I wonder if you could talk about how those things are connected. Yes, so what happened there's there's a strong connection so so how did this like. How did this happen right how did these how what was the process for these sterilizations in so many of them hundreds of them hundreds of thousands of them to happen. It was oftentimes to be able to receive this assistance, which was needed because again, black people were shut out of education, out of jobs, right out of all the things that would help somebody housing, have enough money housing exactly redlining all these things right shut out of all of those policies legally right that was the law. So then of course right we need public assistance to live and then oftentimes those programs were the programs that would coerce so there's a lot of examples of women and even today, feeling really hassled and pressure I've worked in hospitals I've worked in programs, and there is they'll be like so and so came in or five doctors came in or pressuring me to give them an answer on birth control or pressuring me exactly right to like have have a hysterectomy. And so those were often used as as ways either to like you need to get this right like you need to. You know, take indoor plant which is like a longer lasting birth control pill in order to qualify for this form of public assistance, those measures or sometimes financial incentives right and so again we think about choice. This is impoverty and has been legally pushed out of all the things that they could do to better themselves. That's right that's a huge that's a huge ethical issue but it was done. It was done there would be my $500 $1000 if you, you know, get the North Plant implement, you know, taken today if you take the pill. So that's what happened and then there are plenty of women to that would go in for maybe more of a minor procedure or surgery and then they would have a hysterectomy and they wouldn't know like they wouldn't have been told or they would have tried to later have tried to get pregnant and couldn't. And, and so this guy reacted in between the 70s and 80s, I mean up to like 700 in the United States like 700,000 women without their consent that were all women or about 50% of the women. I'm sorry we're Medicaid, we're Medicaid patients. But I think about this from a clinical perspective with so many of the young women I've worked with as a clinician. You know 50 years ago would have been those women, or, and even today have have are strongly encouraged so now we have IUDs that I mean that those are not new but now they're they've developed an IUD so that's an intrauterine device that can used to be that you had at least one child before having that now they're designing it so that you don't ever have had to give birth. But for so many of the moms that I work with. When they get to that six week visit after having the baby, and these are young teenage moms who often don't have a lot of resources it's let's put this IUD in. You know there's not, there's the one and I was always conflicted about that because one part of me feels like, well, another baby would complicate the children are expensive children can complicate our lives. But who's, who's has the right, who's right is it to make those decisions, and then we're asking women to put things in their bodies that, you know, we don't know how they affect every individual woman there's been a lot of complications at the university with different methods of birth control particularly the longer acting methods. And so that's another, you know, where's the concern for potential health hazards and what does that look like and I think it's very very complex and I find myself struggling with that on a personal level but as well as the clinician to like, you know, who should be able to say, and should that be something that they should, should they be pressured to have to make those kinds of decisions if they're not really sure if they don't know enough about the side effects, or if they just don't want it, they just don't want it in their body. So, yeah, it's really complicated. You, you bring up an excellent point about informed consent, which is something that again in our country, for any, you know, you know, birthing or pregnant person is really poor. And it's, it's an especially for, for black women for Hispanic women, that there really is very, it is seldom seldom seldom that their options right or the benefits and risks of anything are explained. It's assumed. And that kind of, it's assumed that it needs to be managed right that like this person is not capable and so I need to tell them I know it's best so this is very like paternalistic view and and that is it happens even more so with with again with with women of color that it's that we still don't really based on those stats and see them as individual people that are capable of making their own decisions and that we really need to look at. And because what we're saying is again that they're not fit to make these decisions they're not fit right to parent, they're not fit to make a decision about you know what is to go into their body. And that's highly highly highly problematic. And again, is not far from the thinking, right that happens going back to the beginning. It's really the same thought is the same thought process. More technology. Yeah, so it's right so it isn't just a parental autonomy it's it's the bodily autonomy and agency, which, which has always been tenuous and fragile and in this context right yeah. Yes, majorly. There are different different iterations of it and maybe. Yeah, like that making me think maybe it's not so terribly different from 150 or 170 years ago. So I so so given this complex historical and socio political context that we're discussing in terms of how US society has has treated black birthing bodies and then childbearing bodies. And that connects to what we are currently seeing in terms of the state of affairs where in 2022 black women have their four times more likely to die and childbirth. I think black infants are two to three times more likely to die. What's the, what's the connection. Right as a connect. The connection is, is not part of it speaks to. We are not as far along as we think that we are in terms of the treatment in terms of how we view and don't view black people and their bodies and options of pain still being what they are right and not listening. You know, the CDC says that most of these deaths are preventable that black women and died four times the rate than white women done most of those are preventable and preventable. Often because there are signs and symptoms that are dismissed that is that that is like the number one reason. And so, why are they dismissed more than white folks because there are still these. There are so many great people right that providers that probably have people of color in their family know people call them but there is still often this this unconscious bias right, I think running. And when we talk about the history of medicine and specifically OBGYNs. Mary and Sims is the, you know, known as the father of gynecology that's the history. And so as much as there might be some other trainings and and we think that we move away from those thought processes, a lot of them have not changed. And a lot of, you know, one of the things I talk a lot about with families that I work with is what's called the, the evidence based practice gap. Okay, so this means from what is the, what is the gap between when we have current evidence based, you know, what the current evidence is saying on an intervention related to birth, compared to when it becomes routine practice. Okay, and that gap is 15 to 20 years. Wow, 15 to 20 years so so like for my age right what evidence shows now, or even has shown right but it's just being acknowledged now will not be routine practice until my daughter is old enough to have a child. That's what that means. Okay, and so, and so that's now let's imagine being a person of color, right, and, and what that experience is that that gap in care becoming routine for them is going to be even wider. That's remarkable. I don't think I know things. So I once had a supervisor early in my career who said to me and we were working in policy. People will be having the same conversations for 15 to 20 years before this is gets implemented. And this is that's what you're reminding me of that and I don't think I've realized how long it takes for an evidence based practice to become standard of care, which, which I do feel like I would be a little bit remiss if I didn't mention, in terms of from an intersectional perspective, birth in the United States in general is not great for any woman. So the United States is considered one of the most dangerous places to give birth I think we have either the highest or second highest maternal infant mortality rate, the highest, the highest of all number one, we're the best. So in the industrialized world. So it's bad for everybody. Right. And, and I you mentioned sort of, and this is not to denigrate OBGYNs but, but that there is a lot of over medicalization of the birthing process. And so, so you're talking about with many black women were maybe signs and symptoms were sort of disregarded, but then you also have this over intervention that goes on that that in some way suggests that women don't know their bodies that women without that women don't know how to give birth. Yes, which is which is really remarkable and and and very particular to our country and culture. This isn't happening in other parts of the world. Yes, and as most you probably have things to say about it. I do. It's very true. It's very true. And so this like why so. So in most of the world, midwives attend midwives are the standard America is like the only nation where we have surgeons which are amazing and we need them because there are also so many women and babies that are living so I need to say that, that that are living healthy lives because of interventions and science and medicine. And that's really really critical and really really important. What the issue becomes right and anyone on that's that you know a medical provider knows that every single thing that is done has some sort of benefit and has some sort of risk. Okay, and so what we see in America happening is that. And again disproportionately negatively impacting black women, they'll cross the board it's it's bad for a minute that a lot of these interventions carry risks, and they're used when that birthing person is already low risk so what we are tending most of the time in America, right like about 50% of births are induced right, and there are absolutely times that you need to have an induction right if you have preeclampsia right or severe hypertension, the benefits of you being induced far out right, the risks of not and so. So there are those times that what happens here is that we often implement interventions that are not medically necessary and we do the end convenience out of the patients and not knowing, you know, and so that's where we have the over medicalization is interventions that all carry their own set of risks. Right, but we're using them with low risk folks birthing folks that don't need it. So what we're really doing is just adding risk and introducing risk to a situation into a pregnancy that doesn't need it. And that's where that's where, you know, enter the statistics right that light where we have like the poorest maternal mortality rates. Compared to all other developed nations. And so we have to really work on, you know, striking that balance and midwives for low risk birthing folks are it their huge I mean the statistics are huge that's really the best. So I got, I'll get into mentioning what are like three practical things right that you could leave here today or tell a friend, right, that's pregnant or talk with your friend that's a I don't know a nurse or a doctor about. And one of those things is midwives. Okay, so we know that for lowest birthing folks, the care received by midwives is is the outcomes are better. There's significantly increased chance of having a spontaneous vaginal birth, their birth satisfaction is higher with midwives you have any decrease in perennial trauma, decrease in neonatal death, decrease in epidural rates. And so if you are a low risk person midwifery care really needs to become the norm there. And if you are high risk, then absolutely, right, that's when we need OBG my hands right. My heart is doulas, right and so I'm a doula some of you there's a whole wide range of doulas, but here I'm specifically talking about birth doulas so birth doulas decreased C section rate by like 25 to 30%. That's huge. The sections are awesome to see sections save lives, but they're also tremendously overused and they also carry a lot of risks. And so we only need we need to make sure that we're doing them when they're medically necessary. And right now, we are doing them when they're not medically necessary meaning we're doing them when we're really just putting birthing folks at risk. And the other aspect of increasing, again, vaginal spontaneous vaginal births with doulas so midwives doulas. And the last thing is really truly comprehensive childbirth education. And so when I say comprehensive I'm referring to childbirth not like a one day three hour hospital class because those classes tend to just cover. What to expect right like apartment and so the hospital and maybe they talk about epidurals comprehensive childbirth ed covers a whole range of comfort measures and has you practice them and really talks about what it means to get and how to obtain evidence based care. And that form of childbirth education is huge because again, it decreases the need for newborn resuscitation. It decreases the second stage of labor right the pushing stage by about a half hour, which if you're listening. And you've given birth before no is a very large amount of time 30 minutes is like a huge amount of time. That's huge so decreases the second stage of labor. So those are the three really concrete things that I really like to share and spread the word on because they can, you know, again you can share them and talk about their benefits and how they can help right to get midwifery care do look care and comprehensive childbirth ed things that become a part of the defaults right and and default because we know that they're preventative. And that's not particularly for black women for all way up right every person person is going to only benefit from this. But again that that goes to thinking about when we like equity right and when we center marginalized folks right and in this aspect we're talking about black women. That's not dismissing all other women right it's still only right when we go and focus on the marginalized group everybody benefits. Right. So this is so I just want to quickly after anyone who's on this webinar who has given birth or have been in labor, or will be every second count. So those are great statistics. So now you're leading me to so in terms of this access to evidence based childbirth education, and where the equity is with that. I'm kind of wanting to talk with you a little bit about sort of what what has been the activism but what's been the response to the state of affairs so we touched on reproductive justice a little bit but I'm not sure that we underscored that the reproductive justice movement was sort of an answer to the reproductive rights movement to say this needs to be more inclusive and more comprehensive, and it isn't just about the right to access to birth control or abortion. It's also about the right to a healthy birth and to have and raise and parent, my own child. So I wonder if you could talk. Yes. Yes. And I think this is perfect because we're actually entering black maternal health week starting April 11. So this timing of the like April is like just the best month for a lot of reasons also I love spring. But, but black maternal health week so be on the lookout if you're on social media. And I will start with then talking about the black mama's matter alliance so I'm going to talk about different agencies predominantly run by black women, because they know their needs best. The black mama's matter alliance has been providing training on the state of maternal care for black women on supporting black women doing the work supporting black childbirth educators do las nurses getting grants to be able to support them. So, please check out the black mama's matter alliance there's going to be a handout to make it to that we give that will have this information for everyone. But so they have been around for, I don't remember the exception but but several years. And their role has really been in doing a lot of advocacy a lot a lot of advocacy. I also want to talk about the black maternal health caucus, right which recently passed what's known as the the mom to bus bill in Congress so this is super comprehensive this this just happened and I think it was October. This past October, which provides black maternal mortality review board, which is covering and giving grants and funding to black maternal health care providers this was really, really huge. And so this caucus has been and now was going to have a lot of work, which is a great thing to do. So if you type in, you know, black maternal health caucus you can check them out for any person that's listening or if you know right person of color that's that's pregnant are going to be, you know, giving birth soon. I also want to highlight Kimberly seals, so she founded what's called the earth IRTH app, which is the first and only app of this kind that is specific for black and brown birthing folks and care providers to rate the care in a hospital. So if you are a black or brown birthing person or provider you can go to this app and literally it asks different questions about what was the care you received how responsive were care providers to you. I have gone in myself and entered the like the hospitals that I've been in as a doula for other people and then I went in and talked about where I delivered in the birthing center that I delivered that you know, and and went in and rated that so right now. And this is another huge thing. Hospitals do not are not obligated to report their statistics on on breastfeeding on you know cesarean rates they can voluntarily. You can go to, if you go to leapfrog.com, you can check out the hospitals that that post their statistics but they're not required to and often right like you're going to want to post your statistics if they're good and you're not going to want to post them. They're not so good. And so this app is really huge because again looking at that disproportionate black women being four times more likely to, to have a complication or die as a result of travel. Let's them go in and look at wow what is the actual care that other people that look like me right and have my background or receiving. Because we can't rely on hospital statistics unfortunately and I hope at some point that that kind of lock and we change and that it is mandated that we post but in the meantime they're not so this app is really really huge earth app. Very easy to use. You just gave a whole bunch of awesome resources. I'm just curious if hospitals do not have to report out statistics. I mean, do you have a sense of what sort of accountability measures are in place. In terms of how are they recording how well births go so I worked for a community, a federally qualified community health center where we had there was a midwifery practice who birthed all of our young mothers and they had, I mean I don't know if they reported them out but they knew that their attended births mothers were less likely to have C sections, they labored for shorter periods of time they were more likely to breastfeed, they were less likely to have tearing. And they, you know, they really documented and charted and paid attention to what are these outcomes look like. And this was a community that was mostly you know black and brown women. So, I mean, what is the accountability ability. It's not good to be to be frank. It's, it's not good. I will also want to talk about. Oh my goodness, birth monopoly. And I apologize for getting her name. Oh, Kristen. I think I'm pronouncing her last name wrong, but birth monopoly is her is her website and she does a lot of work talking about and fighting for policies that need to change and transparency. Right now, honestly, there isn't a lot of accountability like if you have like a poor experience that you want to report you can bring it to the hospital but typically there's a review board, and they kind of handle internally and there isn't necessarily a lot of recourse. I get a lawyer, but we ate we know again access to that is is tough and still are very hard cases to win a lot of the times when it comes to birth because it's it there isn't necessarily a measure right or there isn't evidence if you said well so and so said this to me or treated me this way or did this thing is really it's a lot easier to hide behind while we needed to do this thing, and that is a person person or partner that's in the room. Right and so but but she has a lot of great information on like what are some ways you can try to get through that process but honestly right now, there isn't a whole lot of accountability that's built in to be able to choose right and you should be able to So a pick right we should have options available for different kinds of hospitals different kinds of birthing said there's more support for home births, but you're also we know evidence base for low risk people. Right, still happen very seldom but very safe if you're a lowest person have a home birth. So options in and hospitals and birthing centers and providers being able to share more readily those statistics should be made me really two families and it's unfortunate that at this point in time. So those are really, those are hard to get but you can check out. Yeah, leapfrog and if you type in m pink so we're in Connecticut you MP inc Connecticut that tells you some, you know information about like rooming in and breastfeeding rates and rates of skin to skin to skin for the state. And if you go to leapfrog.com you can type in any hospital. And if they report their statistics, then you can get statistics and apesia to me rates. And if you type in serian rates. Let's see skit to skin, and I'm forgetting the other two, but, but so you can go and even that can be really interesting like what hospitals do you see do and don't report, because that in itself can give you a lot of information. I wonder if now will be a good time so so you're reminding me. And I don't know if she's on this webinar but a colleague of mine who you know because I think you guessed lecture for her class. Dr Jenna and I hope I'm going to say her last name wrong but. I don't know if I'm saying that wrong, but she's a colleague here in the nursing and even school and as a midwife, and she very graciously invited me to participate a few months back in a perinatal quality improvement. 28 day anti racism challenge and it was released through the Institute for perinatal quality improvement. And it was really, it was really incredible. I think those kinds of efforts are at play in order to get providers to really be thinking about their implicit bias to be thinking about issues of access and equity. But I wonder if now will be a good time to share. One of the things I forgot what day was, but I received this really interesting graphic called the maze of life that kind of depicted. Women in society with like where do they start so it was comparing black women to white women in terms of, what's the historical context where do you start and how that impacts birth and pregnancy. So I'm going to try to share my screen and hope that everyone will be able to see it. Yeah, sure. And while you're pulling that up I want to say if you are someone interested right and becoming a medical provider, you know, you're just, you know, somebody that's going to be giving birth or you're maybe thinking about, right having child soon I highly highly recommend specifically taking to an evidence based birth child birth class so I have said that I'm an evidence based birth instructor, and the, the core of ebb was founded by a nurse, Dr Rebecca Decker with her PhD, who, you know, was a nurse went through had her first baby and afterwards questioned a lot of the experiences that she had right and a lot of the treatment that she got and began to do research on, huh, what is the evidence for eating and drinking and labor and what is the evidence for being able to have a lot of birth and found in fact that a lot of the routine or regular care in a hospital was in fact not evidence based and could even be detrimental to burning folks and so she started evidence based birth. So that is on that will be on the sheet of resources but I highly recommend going to evidence based birth calm. There is a ton of like one page handouts to that Rebecca has on just the evidence on, you know, different things that come up in pregnancy and different routine care and the evidence on them. And again if you're interested highly highly recommend taking the evidence based birth child birth class. Thank you. Yes, I can see this to me. I can I hope everyone else can see it. Um, so I was able to audit one of autumn's evidence based child birth classes and it really is incredibly enlightening I mean even, you know for me I'm past giving birth, but I just for for people who I know in my life who are still child bearing and expecting. It's really helpful to get a sense of you know what what's happening. New information and and again, minimizing the medical interventions as much as possible. So I hope everyone can see this if you cannot maybe put a little note in q amp a section. This is this was one of the visuals that the perinatal quality improvement Institute had shared during their challenge. And so I think it's a little bit simplistic I do not know that it's fair to say that every white person starts with privilege and freedom and you know that that could be debatable, but it's just trying to offer a context of if we're starting with this sort of collective intergenerational post traumatic stress of 246 years of slavery, and then having to translate Jim Crow racist policies, this idea of the weathering effect which has to do with how, and this is I don't want to get too biological but sort of how to stress impact gene expression, and then how does that interface with people's health, and that people who are living in compromised circumstances experience a weathering, which which diminishes their health and well being. So this is just a really sort of powerful graphic in terms of like, where do you start when you're pregnant and and and what you know what's already sort of working in your favor perhaps was working against you. So you see, I mean, you know, in the United States, white women are more likely to have better education better health care, more opportunity, not all, but they are more likely to have that access than black women. So that's just one graphic visual, but I also wanted to touch on a little bit autumn. Before we get to our wrap up in question and answer session. But you'll hear a lot. I think, in the sort of public pop culture, you know, is that this is just about class. And I know we've talked a lot about poverty and equity and access. And I know there've been a couple of news coverage where this is idea that it used to be that race itself was a risk factor for birth outcomes. And now that narrative is shifting to it's not the race of the patient, it's the racism that they encounter. Yes. And so why is this not just about class because we've seen very high profile wealthy powerful black women share some of their challenges and birth experiences. Well, and I think right that's, I think the narrative for so long was this deficit model right and, and, and only thinking of black people as a whole people of color as a whole as it's still right in this this thought process that not always conscious but inherently just having and struggle. And so what began to happen was we were saying well that's not the case we have there are, you know, black people that have master's degrees and doctorate degrees and our fluid right and have money and our athletes right and entertainers, and and all of that and so the conversation was forced to begin to move away from well this is about race to racism, because what we were seeing is being able to account for wait a minute we have, you know, black folks that are pregnant, that have access to all of these things, and the disparity is still the same, the disparity is still the same. So this cannot be right like when we talk about other factors you know, you know, dental health right and, you know, living longer people living longer in certain areas compared to other areas, but this is, we have been able to rule out for right if you had to, you know, black women, one that had a very high income had higher degree had access to a lot more resources, one that maybe just had a high school diploma didn't have their rates of complications and dying in birth are the same are the same. And I think we got there because there was a slow move out of wait a minute. Actually right there are black black all black people are not living in poverty. And I think for a while I think still culturally that is not when we think of right black and brown people that is if we're being honest with the image that we are told from the time we are very little kids. That is not the image that comes into our mind. And so I think it has taken a while to see, well wait a minute, no this is there are black people that have all these access and the same access that some white people have, and these disparities still persist. I know in a lot of the research where they started controlling for things like race and education. Yes, and black mother still fared worse. You have, and I think there's a data point that a high school educated white woman has better chance of having a positive birth outcome than a college educated. Yes. Yes. And I've seen that, like Tanika I have seen that in the last eight years I have been in rooms with white pregnant folks and black pregnant folks and the difference is palpable. That's happening right now. How the patients are listened to, there's things like even who is allowed and not allowed in the room. I'm going to tell you right off the bat right now in our hospitals several of our hospitals in Connecticut. What they see are once Medicaid or Husky is seen in the patient's chart. It is a very different level of care. There is, oh well you can come in and see this and monitor this, where if there is a patient right that is not Medicaid and that is at least maybe light or white presenting right even not white. That is, you do not have eight people walking into the room with a woman that's in labor, never, never. And I would love to collect more statistics on this, right, but every single other doula and lactation console anyone else has had has interface in a hospital setting with women will tell you that the rate of being listened to just like the amount of people even that are in a room like that at birth is like the most vulnerable space that a person is going to be in in their life. Right and so anybody that comes into that room should be absolutely asked right that's to the partner to the birthing person, and that is often not the case. The tone and the coercion of things happens much much more with low income women than it does. Yeah, this people have private insurance I mean just that just if you were to keep it at that right and then we just know that disproportionately right lower income women because of all this history are more likely to be people of color, but it is absolutely palpable in all those ways. And more today. Yeah, thank you for sharing that. Yeah, that's, that's hard to take in, but I believe you I mean I've, I think I would in my experience in hospitals as a home visiting social worker with with teen birthing moms. Our midwives were really, really protective of the mothers. So I don't think we and I wasn't I wasn't there when they were birthing I would come after the birth. But I think there were intentional efforts and I know in a couple of cases where. So I'm not going to name the hospitals but there was one hospital where the midwives had privilege practicing privileges, and so really had control over how the birth is going to go. And if there was any kind of miscommunication or emergency and the moms went to the other hospital where the midwives did not have those privileges. You know, it was just bad every time it was just there was something that happened that was just, you know, egregious or really upsetting or traumatic for the mother so I, yeah, I don't have a hard time believing what you're saying. It's, it's like and it hurts and I don't want to write like it's like I so don't want it to be the case that even in my own mind sometimes I'm like no, this must be, you know, something else. Yeah, and to the point where a lot of people with more privilege or white right birth workers that I've seen, they were like, they'll notice it and see it before the right like their client, even if they're a person of color. Because, again, I think despite common thought that like, we're all you know that people of color always like thinking that things are racist, actually it's not true. And, and tend to get sometimes even go to like, no, I must have right like done XYZ. And so it's, it's, it's a heavy, heavy thing to, to, to think about and I think in terms of moving like what do we do. And those those agencies and finding ways to support them but also reaching out to finding who are the local lactation consultants of color we need to be supporting we need more lactation lactation consultants we need more childbirth educators like barely any I mean, I mean, we obviously could use more but we've done better with like, you know, Jula's of color and midwives right so midway free care Jula care and again comprehensive childbirth education, given to the families in and again even like sharing that information with providers is really, those are like kind of the, the key tickets to bettering this current situation for black women giving birth. So I see where we are at the time and I know we want to have Q&A but I just wanted to show one more quick visual of what has I think this was this released by Black Mamas Matter Association the black birthing right the bill of black birthing rights. National Association to advance black birth. Yes, like I have it right there on my wall. I'm sharing it. I hope people can see it. I think in terms of if we want to talk about advocacy or just empowerment of our patients or clients or people we work with this. This is a great start. I think and I know you share this in your evidence based childbirth education class and it's just so powerful. It's so basic, but it's so powerful. And this is something that I think is being distributed to patients but also to providers to be seen and heard to have your humanity recognized to be respected to be believed when you say that you're having pain or something to feel right to inform people of their pain relief options. We know that providers are typically reticent to prescribe to black patients because there's this assumption that black patients will abuse narcotics and abuse pain medication. Recognizing the right to decide deciding how to feed and not making assumptions. I work with a couple of providers who's in a wonderful department of New Haven department of public health maternal child health unit who talks about she's also a lactation consultant. When she works with her mother is how the lactation consultants will often overlook black mothers and assume that they don't want to breastfeed just because of the statistical, you know, disparity that that isn't necessarily a lack of interest there's other reasons for that right. There's so much there with breastfeeding and why the breastfeeding rates are low rate for for black women and again, thinking about going back to the history that black women were wet nurses for white children and could not feed or be around their own children. What we found in my clinical work with teenagers who often have lower breastfeeding rates is people don't often think about many teenage mothers are also victims and survivors of childhood sexual abuse. And so that enters the breastfeeding relationship and can make things very complicated. Sometimes it is not in the mother's best interest to breastfeed under those circumstances so there's right there's a lot to unpack. That's an excellent point, Tanika. Oh, yeah, no that that's I mean that's a whole. I agree and having done and I love and that's like a group I'm so so passionate about absolutely absolutely and again it's very different to right when you have someone that they can't relate to either by age or ethnicity, kind of coming in and telling them they can't do this thing. And that's again we need more representation amongst our, our birth workers right lactation consultant childbirth educators doulas midwives we need more black midwives for sure. Yes, all of that. Well, this I know we could go on and on. Yeah, yeah, I could. So we see that we already have a question in the Q&A and I want to turn it over to Dr. Shannon King to facilitate some of the question and answer part of this so Thank you Ottoman Tanika for such a generative and important conversation. I have a question from Nicole Paradise. How are we supporting mid midwives and birth doulas who are working in systems that cause this level of harm slash disparities for black and Latinx birthing people. I imagine the stress level, etc, would be so high. Yes, yes. And the answer is right now, we're not doing enough and the birth workers we have are fabulous that are of color, but absolutely at risk of burnout and even trauma so we didn't there's so much to talk about here but our birth trauma are one in three, and that is the same for labor and delivery nurses right now one in three labor and delivery nurses have experienced a birth that was so traumatic that they meet. Teria proposed dramatic stress disorder. One in three labor and delivery nurses gotta say that again, you're right now meet the criteria for post traumatic stress disorder based on the traumatic birth that they were present for. There are doulas, right, even sometimes our lactation consultants are there like right after and there might still be traumatic experiences occurring. That absolutely that our doulas and midwives right and lactation consultants certainly puts them at risk and so the best ways one to support them is by we what we need more of them. We're looking at who are who are the local midwives of color right taking some time midwives of color who are the local doulas of color and asking them to what do they need, because they'll tell you, you know, sometimes, you know, it might be, you know, advocating for a certain thing in a certain way. It might be trying to support their work, right a lot of most doulas especially most doulas of color are trying to support other folks that might not have access or access to pay for a doula. So a lot of them will have like donations right or have like a community doula kind of program where you can donate so that they or they can partner with other doulas to support right more women so that they also aren't in doubt from having to go go go go go and certainly, you know, witness some some difficulties in that setting and hospital setting in particular. But I would identify, you know, there's a tremendous Connecticut birth professionals page so that's a great way. But even if you just type in like doulas doulas of color. You can make it, you know, the midwives and like honestly reach out to them and ask them specifically what they need because they're all like, you know, might be doing different work in different places. But one is we need more so that there's not a few carrying all that weight I mean that's number one we need more. And two is asking them what are specific aspects that they're working on. So as a doula that that that could be supported sometimes that's financial sometimes that might be, you know, helping them get a word out about certain information or class they're running. But those are, those are definitely some of the best ways for now. Thank you. So I also had a question. I wondered, what are the ways that some of it, some of a lot of the information that you're sharing can be shared in a more community oriented way so are folks actually visiting black churches or beauty shops or those kinds of spaces where they could potentially speak to not only black women but several generations of black women is that kind of work being done. That's awesome and yes it is by a lot of black birth workers and there's a lot. You know, Dr King that are that are working to try to create like community centers and get funding to to do that sort of great to really be able to like permeate which again like it takes time. Yes, a lot of doulas of color are working and connecting with. I'm in the New Haven area right so I'm thinking about local community mental health centers and clinics, working with iris that's a new Haven. And really, really like getting out and just going to anywhere there are people and likely break pregnant people that knows a pregnant person I would say, again that's a reason to really reach out to there's going to be a whole list serve, and maybe we can add that to this for people to reach out because that might be a great way to help do this that are trying to do that work and like form coalitions, there's work. There's a lot of doulas that are working to try to like push for more birth centers in their community right or that are just trying to create community centers where it's like you're pregnant you can come in and get a massage get perinatal therapy. All of those things and that is predominantly done which is great by the women of color, but there certainly could be a lot of support in both getting the word out and just knowing people right when we're talking about like privilege. There's certainly money but just the spaces you're in right and like statistically speaking right folks. That might have more privilege right are going to tend to maybe know people that might have access to a building or a space right so it's not always money or know somebody that you know has a connection that can donate time for you know for. Those kinds of things are really important so that's why I say really reaching just reach out how can I help you. Black women have very seldom been and specifically that are doing this work been in a position where people are asking them what can I do for you, you're doing this really important healing work so that's the that's the biggest thing I want to see. Okay, we have two more to more questions and they will be the final questions and so I'll ask them together and the questions. I invite both to make an autumn. So, Jenna, and I apologize if I mispronounce your name. Autumn and Tanika this presentation in your work are important and necessary. I know that there are midwifery students here in this webinar, based on all of your research and experiences and paternal maternal child health, could you each share one suggestion of something they could do slash implement tomorrow or next week, when they are in the clinical setting to best support black patients and families, thank you. And then Doug Edwards asked, can you talk about the role of that during the birthing process, can their involvement mediate inequities. Oh, excellent. Excellent. So yes. So Jenna, I want to jump in what what doesn't happen now and in general with women but particularly women of color is they're not given they're not listened to right and they're not actually given information on whatever is being presented to them. So the first things I tell midwifery students specifically to that I work with or nursing students is talk through the benefits and risks with the patient so your students if they go in like tomorrow or next week. The acronym I like to use and maybe you're familiar with it is brain right like talk to have them take the time to do the B R A I N so be is discussing the benefits of whatever it is, maybe it's like exercise right or maybe it's not really a visit you're talking about nutrition, but have them talk about with the patients the benefits, the risks, alternatives. Give them space for the eyes is intuition so like having them acknowledge and give hey do you want some time to talk about this or we can come back and I don't know a few minutes. If you're going through if if the patient decides not to move forward, you know, and is nothing so be are a I N benefits risks alternatives intuition, and nothing, and just holding space and making sure that they're really going through that with patients is giving them some form consent. Right and that is their legal right and unfortunately that process often isn't gone through with with with birthing patients but in particular, women of color right and they often feel forced or talk to in a way right that they are coerced to do a thing that that provider thinks is best without checking in with them. And we know that there are three pillars to evidence based care. It is having the current research evidence it is having a provider that knows how to articulate that evidence, and that third pillar is the values of right the values and desires of that birthing patients and we cannot have evidence based care without those three. And so having the your students go through that process be our I N with them isn't really is tremendous if everyone was doing that that in itself would just be such in it again giving patients informed consent which is their legal right. And, and, and having them be able to really make a decision about what's best for them versus this kind of historical, you know, more paternalistic way that that we tend to do it in our, in our country. Thank you. I think see I just wanted to really quickly add one of the things I learned in my clinical work was that as, as families come with different customs and stories and narratives and approaches to pregnancy and also to child wearing and infant care. Oftentimes the instant can be very quick to say, well that's not what the research says. But that's and as much as we're emphasizing evidence based approaches which is really important. I think it's also important to sometimes say, Well, tell me more about that. What you know why do you think it's important. I had a young mom once tell me that she wasn't going to breastfeed her baby because her grandmother got very angry and had a fight with her husband and then went to breastfeed her son and he died. And that was the family narrative. And so instead of immediately saying, but breast is best for the baby and these are the reasons why we had to get behind the, what what you know how did that story come about and well here's some other information that maybe help you make a more informed decision, but this had gone through three generations of the family and not realizing that your moods don't make your breast milk poisonous. Sometimes you need to get the clarification of the family story first. And that's huge right and I think that speaks to Tanika right this being culturally acknowledged you know like acknowledging and just being sensitive to ask that question and again I know in our system right now it's so rushed. You know the the average amount of time for most OB visits is like 12 to 15 minutes. Right, you know, and that is long with midwives it tends to be about 45 minutes or an hour so our care everything is so rushed. But we really have to be able to slow it down because what the fact of the matter is women are dying in particular our black women and babies are dying because we're not slowing down to ask those questions and we're not slowing down to explain things to them and go through the brain. So what about the dads. No dads so dads and partners are huge, huge, huge piece of, of care, and really the partners roll through pregnancy and even the birthing process is being able to be there to advocate. And I say, you know the biggest thing is that I think people feel like they can't right or like oh if our doctor says something like that's it right we have to go with it. And so the biggest thing I want to say is for dads, I think the biggest piece is going to be to really I would say get into and really try to take a comprehensive childbirth education class. That's going to like be able to go in depth on how, how, how, and what does your role look like when you're advocating you know and what can you say but one I want to say the same thing listen to your intuition into your partner. And unless there is like a crisis which medical providers are great at letting you know right if there won't be a problem, but unless there's like really imminent crisis, you always have time. If you feel pressured in any situation dads partners, whoever's there you can say we want time to think about this. Another thing I tell me I work with even as a doula or in childbirth class is what's known as like the Ellis prayer method you know so again if you're feeling like they're not giving you space if you say we'd like to take a moment just to pray on it, whether that's something you do or you know or don't do. But that really can be an effective tool for clearing the room like people aren't going to push you on that, unless again there's really an imminent, you know situation. So I think that's for partners one of the biggest things that can be easy to feel like pressure, and your role in advocating a lot of the times in those situations is going to be, let's take, like take space, let me talk with my partner and then decide what it is I need. Again, really take getting into one of those comprehensive childbirth class like an evidence based birth classes really where you talk really about like specifics of how to communicate and best the best ways to handle staff and even talking a little bit about like understanding staff lingo and what what they're kind of going through and how to how to kind of get through in that way will be really really important. So I wanted to thank Tanika and autumn and thank you all for coming have a good evening and have a good night. Thank you. Bye. Thank you.