TRANSCRIPT EPISODE 54 – All About Pregnancy & Birth With Dr. Nicole C. Rankins

Transcript episode #54: What We Can Do About Obstetric Violence and Birth Trauma with Cristen Pascucci


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00:00:00                               In this week's episode of the podcast, we discuss the important topics of obstetric violence and birth trauma. You do not want to miss this episode.

00:00:16                               Welcome to the All About Pregnancy & Birth podcast. I'm your host, Dr. Nicole Calloway Rankins, a board certified Ob Gyn physician, certified integrative health coach and creator of The Birth Preparation Course, an online childbirth education class that will leave you feeling knowledgeable, prepared, confident, and empowered going into your birth. Quick note, this podcast is for educational purposes only and it's not a substitute for medical advice. See the full disclaimer at for slash disclaimer.

00:00:48                               Hello there. Welcome to another episode of the podcast. This is episode number 54. Thank you for spending a bit of your time with me today. Today's episode of the podcast is a really outstanding one. My guest today is Cristen Pascucci. She is the founder of Birth Monopoly. They are an organization with over 18,000 followers on Facebook, another 5,000 on Instagram. She's also the host of the Birth Aloud radio podcast and co-creator of the Exposing the Silence Project, a documentary photography project about birth trauma and obstetric violence. Cristen got into this work after the birth of her son in 2011. At that time she left a career in public affairs and she joined the consumer advocacy organization Improving Birth as a vice president. As vice president, she spearheaded multi-year grassroots media strategy campaigns to get maternity care crisis information into the national news. She created a legal advocacy hotline for pregnant women and also just did a lot of work about raising awareness around obstetric violence.

00:02:00                               Now after six years of full time work on that issue, she's now working on a documentary film called Mother May I, which is about abuse and the coverup in American maternity care. So Cristen and I have a really informative conversation about obstetric violence and birth trauma, what it is, who's at risk for it, who commits obstetric violence, what to do if you experience it. So tons of really helpful information in this episode about an important topic. Now this episode is a little bit of a longer one, but it's really, really good. It's perhaps my favorite interview to date. So let's not wait any further and let's get into the episode with Cristen Pascucci.

00:02:45                               Nicole: So thanks so much Cristen, for coming to be on the podcast. I'm really excited to talk about this topic of obstetric violence. This is something that has become sort of an interest of mine and how we can do better about it. Taking care of women in obstetrics as physicians, and I have to say for me personally, I had a realization within the last, I would say three to five years and I've been in practice for nearly 15 that I, myself had been, I don't want to say guilty of obstetric violence, but definitely guilty of like, not explicitly asking women to do things like vaginal exams specifically that comes to mind and just sort of that realization like, wow, what are we doing in the way that we care for women? And kind of thinking about ways that we can do better. So that's how I came to find you in this topic. So I appreciate you coming onto the podcast.

00:03:39                               Cristen: Yeah, sure. Well, um, I'm really excited to be talking to you specifically about this because it really means a lot when providers take an interest and are honest about it, you know? Rather than just kind of reflexively saying, well not a problem. I don't do that. I don't know anybody who does that. And you know, there are so many reasons and excuses and you know, all of those things, but you know, it's a reality and I think it's, it's people like you who can be really valuable allies and can really make the change where it needs to happen, you know?

00:04:19                               Nicole: Well, thank you. I appreciate that. I hope so. Cause we certainly need to work together with folks to help really give women the care they deserve.

00:04:29                               Cristen: Yes. Well thank you for doing that.

00:04:31                               Nicole: Yeah. So why don't you start off by telling us a little bit about yourself and your work and even your family if you want to.

00:04:38                               Cristen: Oh sure. Okay. I have a son who is seven and he's going to be eight soon. And he is crazy and he's awesome. Don't we all say that about kids? Just blows my mind every day, that child. But yeah, so he's, you know, he's kinda my world really. It's him and obstetric violence. So I got involved in birth advocacy stuff right after he was born, because right before he was born, my provider was trying to pressure me into an induction for going past, you know, 40, 41 weeks. And I really couldn't get any solid answers out of her, like research or you know, numbers or, you know, anything definitive about what the risks were of continuing a pregnancy versus inducing. And I ended up avoiding that induction by switching providers and switching hospitals, but I was 41 weeks and six days.

00:05:49                               Nicole: Wow. You did that?

00:05:53                               Cristen: I know. Yeah. And when after I did that, I just thought, well, whoa, that was just such a crazy experience. You know, I can't believe that she thought I was just gonna say, okay. You know, didn't she know that I'm like an intelligent adult who makes decisions about my own life? You know, it was like, clearly that there was this, there was this expectation that I was just going to do what I was told and not really based on anything and my professional training, which has some politics in it, you know, I know that you're never ever supposed to take a deal that you feel pressured to take. You know, if someone is pushing you into something and it's kind of a 50/50, either way you say no, like that's just the default.

00:06:50                               Cristen: And so that's what I did, but it was just, you know, trying to figure out what had happened later was so eye opening for me, that people thought it was so wild that I had switched care because it seems like such an obvious thing to me to do. Like, wow, you know, I took my car to get fixed somewhere. The guy ripped me off. So no, I didn't go back to that same person. I'm like, this is not rocket science. And then what was way worse than that was finding out all of these other stories that were so much worse than mine. I mean, mine was nothing compared to these limitless number of stories that I started learning about and people started approaching me with once I got into the advocacy work. So, yeah. So I don't know if that answers your question, but yeah. Okay. Well, so that's how I got into it. It was my son's first year and I just got deeper and deeper and deeper and here I am.

00:08:00                               Nicole: You haven't mentioned Birth Monopoly yet and I'm sure you will at some point, but, and I go back and actually record the intro after we do the, the interview, but, Cristen has this great website called Birth Monopoly and we'll link to it and all of her work, she's kind of understating how involved she is in this and how much stuff does she does. So I'll link to all of that for sure.

00:08:23                               Cristen: Okay. And actually, let me give you a little bit more background that I think will be helpful. So I, you know, just kind of like started dipping my toe into advocacy and then like went from like dipping my toe to like, you know, going in over my head. I joined Improving Birth, which is a national consumer advocacy organization for better maternity care and became vice president like within a month I think of starting to volunteer with them and immediately was just full time, completely immersed in stories from people all over the country. And we were running, I think that year we had 170 individual rallies in different cities around the country that we coordinated into this big national rally. So I was working with all these volunteers from all these different areas and continued to do that for several years.

00:09:18                               Cristen: And so I got this really intense education around what people were experiencing, both parents and birth workers from all these different pockets, you know, different places. And then I did a legal advocacy hotline because we had so many people who were in need of legal advice. And a lot of them in very urgent situations. So did that for awhile and then started doing Birth Monopoly when I wanted to start doing education around legal rights to birth workers, to parents, to providers. And I've done a whole lot of raising awareness around obstetric violence, a lot of consumer campaigns and social media campaigns and try to get the story out into the national media, which I have done.

00:10:14                               Nicole: Well that's a great segway into what exactly is obstetric violence.

00:10:24                               Cristen: Yeah. So there is not one definition, but Venezuela actually put a definition into law and I really like parts of this, so I'll read you a little piece of that. So the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment and abuse of medication and to convert the natural processes into pathological ones. And this part is important, bringing with it loss of autonomy. So I think the kind of important pieces there are appropriation, dehumanization and loss of autonomy. So it's a concept. It's not a legal cause of action. You can't sue for obstetric violence, but some of the things that fall into the obstetric violence spectrum would be considered actionable legally. Does that make sense?

00:11:24                               Nicole: Yeah, it totally does. And maybe if you can give like a couple of practical examples.

00:11:27                               Cristen: Yeah. Yeah, yeah. So, um, so it covers everything from, I would say disrespect, including ignoring someone to, you know, which we might call kind of benign, right? Or even making jokes, in a way that is demeaning or undermining of someone's desires or wishes or of their pregnancy. But then it runs the whole gamut to forced treatment, including, you know, physical force or legally coerced force or the use of say, child protective services. You know, if you don't agree to this C-section, I'm going to call social services. And as soon as your baby's born, there's going to be a social worker in your room. So kind of runs the whole whole gamut.

00:12:15                               Nicole: If I recall, you have a great infographic on your website that kind of what the spectrum is and we can link to that.

00:12:28                               Cristen: There's the obstetric violence culture pyramid. Yes, I will provide that. Yeah. Thanks.

00:12:36                               Nicole: Awesome. Awesome. So how is obstetric violence different than birth trauma?

00:12:42                               Cristen: So obstetric violence might be the cause and then birth trauma is sort of the outcome.

00:12:47                               Nicole: Got it. Okay. You'd be a really simple way to explain it.

00:12:51                               Cristen: I would say a lot of birth trauma is because of obstetric violence. And let me, let me back up a little bit on that term birth trauma because for most of history, birth trauma has meant like an injury to a baby because of the birth process. That's generally what we've thought of it as. And then it sort of evolved into, we're now acknowledging that it includes psychological trauma. So say the birthing person is fearful for their life or their baby's life, and then it keeps evolving into also loss of dignity, which might not sounds like that, you know, severe. Right?

00:13:38                               Nicole: But it is though.

00:13:39                               Cristen: Yeah, it is. It is. I mean, and that's, and that's what we find in the research is that it's really a big deal. You can walk out of childbirth with PTSD, like on the level that a combat veteran would have after not risking your life, if that makes sense. After a birth that maybe didn't really have any medical complications, you know, there wasn't any major emergency, but the way you were treated in that very vulnerable state at a very vulnerable time leaves you with such a catastrophic loss of dignity and loss of autonomy, you know, that you're left with these really severe psychological effects. So I just wanted to like kind of differentiate a little bit that was really important.

00:14:31                               Nicole: Yeah, I appreciate that.

00:14:33                               Cristen: Yeah, sure. What we also know from the research is that the majority of what we call birth trauma is actually that second category that has to do with the loss of dignity and the loss of autonomy. It's not because of medical emergencies, which is what most people think of it, of you know, a birth trauma as being so, you know. So for that reason I think it is really important to focus on obstetric violence because if it is, you know, one of the major drivers of the majority of birth trauma, that's a big deal.

00:15:06                               Nicole: Absolutely. Absolutely. And I think we as a profession have done a really bad job of recognizing the importance of how a woman feels after birth and how that is such a crucial component of her overall health. For sure. I mean I've heard the expression before and I can't remember where I heard it from, but we treat pregnancy like a piece of candy and once the wrapper is unwrapped and the candy is out, then we just throw the wrapper, the mother, away and kind of forget about her in a sesne. And we don't, and we do the thing that I hate with well as long as your baby is healthy, which drives me insane.

00:15:45                               Cristen: Just the first item on that infographic that you mentioned, the one at the very bottom is all that matters. It's the healthy baby. It's so much more than that. Yeah, I think that's a really a really sneaky, sneaky way of being obstetrically violent.

00:16:04                               Nicole: For sure. Now, how common do you see or hear stories? I mean, I know there's not like any sort of national measurements or anything, but how common do you hear stories of women experiencing obstetric violence?

00:16:19                               Cristen: Boy, I mean, yeah, I really wish we could put some numbers on it. So, I hear the stories like all day, every day because people know to contact me, you know? But I will say that I have spoken with so many doulas, birth workers, nurses who say it's so pervasive where they are and they have more of, you know, a bird's eye view of it. So, you know, I can think of a doula recently who said, I've literally never attended a birth where there hasn't been some measure of obstetric violence. Now that that just might mean that you had, you know, in a 24 hour labor, you had one nurse for 20 minutes, you had a really bad attitude. And rolled your eyes at the patient, you know? But it's also, but we also know that it's really, really common to for example, you know, do a, do a vaginal exam without asking, without communicating the risks and benefits without presenting it as a choice. And that is obstetric violence like in its most pure sense. And of course there's a lot of nuance around that. A lot of nuance. And I've spoken with so many providers who, I mean like you mentioned earlier of "Oh my God, like, Oh, Oh I think I may have done some things that fall in this category".

00:17:39                               Nicole: Yes. And it's very, it's heartbreaking actually when you think about it. And I think especially for, for me as an African American woman feeling like who's already a member of a vulnerable and then kind of perpetuating this what a thing has been something that I've had to grapple with. But the truth is that yes, I've certainly done vaginal exams without getting explicit consent. Now I'm not like forcing women down or anything like that. But there wasn't that explicit consent.

00:18:05                               Cristen: Right. Which, you know, it's a cultural norm, right? Like so many other things that, you know, as awareness is being raised about all of these issues, social issues, I think so many of us are wrestling with these things, you know, I've been a bully in the past, you know, I've been racist, I've been sexist, but all of us have to honestly face who we are and what we've done. And the important part is, you know, it's not about feeling guilty. It's about making change. And that's really what matters. I thought a lot about this, you know, you can't help it, that you're a product of your environment. We all are. Every one of us is, it's once, you know, once you have that awareness though, it's your responsibility to change.

00:18:58                               Nicole: Absolutely. Well, we're just going to make some change today with talking about this issue. How about that? Oh, I hope so. Anyway. Who do you see are, for lack of a better word, perpetrators of obstetric violence? I assume that it can come from anyone? Doctors, nurses, midwives.

00:19:22                               Cristen: Yeah. I've even heard it applied to family members. But I would say that to me, one of the really important characteristics is that there's a power dynamic.

00:19:34                               Nicole: Oh my God, that is exactly the word that I think of in terms of how we approach maternity care in the U S in general. It's very much so a power dynamic.

00:19:46                               Cristen: Yes, yes. So to me that's, that's, that's a really important distinction. So I have heard all the stories from, you know, about everybody you just named obstetricians, anesthesiologists, you know, hospital administrators, hospital legal teams who come in a room and speak disrespectfully or violently or threateningly or coercively. Yeah. So it can, it can come from a lot of places. And I think it can, it's perpetrated on kind of a couple different levels. There's the individual level and then there's the systemic level. And sometimes people focus, it's interesting to me actually, I think there's like some interesting psychology to this, whether people focus on the individual or the system, like we use words like perpetrators or abusers, right? And to me that's individual. But then there's also this systemic component, the idea that you are a product of your culture and that you're a system that is incentivizing you to be abusive, that is structured to be abusive in so many ways. So, it's sort of an interplay of I think those, those two levels.

00:21:02                               Nicole: I mean for sure. And my God, I am trying not to make this episode about me, but I can't help but think about my own experiences and being in a culture, not intentionally so, but I mean like we roll our eyes at people's birth plans and stuff like that, which is totally not appropriate. I obviously don't do that now. I actually have a free class on how to make your birth plan, so I've done a 360, 180, whatever you want to call it. But definitely that systemic factor is really important.

00:21:34                               Cristen: Well, yeah. I mean you train people to roll their eyes at birth plans. Like that's what you're going to get. But I mean I can't say enough. I think it's such a big deal that you are talking about it though. And you're saying this wasn't cool. I changed and are sort of like giving platform to the voices that have been silenced for so long around this, which is, you know, patient's voices.

00:22:03                               Nicole: Women should be at the center of their birth experience, period. Full stop. Which is what we don't do. So I think this is certainly another piece of that puzzle. And, again, I'm really glad that you're here talking about it so we can bring awareness to it.

00:22:20                               Cristen: Yeah. Thank you. Yeah.

00:22:22                               Nicole: So are there women who are at particular risk for obstetric violence? Do you see any patterns or anything?

00:22:29                               Cristen: Yeah, yeah. Definitely black women. I mean, we could have, we knew this without research evidence.

00:22:38                               Nicole: The sky is blue, you know?

00:22:41                               Cristen: Yeah, yeah, yeah. A major study was released a couple of months ago from the birthplace labs around mistreatment and I think black women were, I think about twice as likely to experience mistreatment, which is what they termed it, which I think we'll talk about that later. Maybe you'd like the different terminology and then you know, anybody else you can think of as a marginalized group or an other, you know, people who are differently abled, people who are maybe gender nonconforming or people who are young teenagers, people from really any color other than white, people whose first language is not English, people who are using state insurance. Yeah, there are a lot of different layers of oppression that stack on top. I mean it kind of is really consistent with what we see in society in general, you know.

00:23:44                               Nicole: Gotcha. Yup. For sure. For sure. Now you mentioned terminology, you said mistreatment. Are there other terms that we should be kind of aware about?

00:23:53                               Cristen: Yeah, so obstetric violence was a term that was claimed by South American activists, so people who had experienced obstetric violence and witnessed obstetric violence or you know, what they then named obstetric violence. So they came up with that term, that is something that they literally defined themselves. And we've seen the world health organization has termed it disrespect and abuse. That birthplace lab study generally called it mistreatment. So there are these different kind of ways of talking about it. And I think we do have to use whatever's appropriate in the setting for a long time though. I will say, I remember back in the day when nobody was talking about obstetric violence at all and we were saying, okay, are we even gonna use this term? Because providers really do not react well to it.

00:24:50                               Nicole: You know, that is something that I wanted to ask you for sure. Like how, what kind of, I'm even talking to some of my friends, it's like they hear it and they just bristle.

00:24:59                               Cristen: Oh totally. Yeah. Completely. Yeah. I mean that was my experience. And then, you know, in my circle of colleagues, you know, that was the feedback we were all getting and like directly getting was, well, I mean, but could you use a different word or could you use a different term? Because that is, you know, it's really a turnoff. And I wrestled with that for a long time and I eventually just personally, because I am a communications person, so that is super important to me to know that I'm using something that is going to land for people. But, I eventually just came down on the side of centering the birthing people and if that is the term that they came up with, then that's the term I'm gonna use. And if I'm speaking to providers, sure I will probably use different terminology. I'm going to mention obstetric violence, but I might not beat them over the head with it.

00:26:01                               Nicole: Because there's this balance. So you don't want to minimize it for sure. So you don't want to, you know, change it and feel like you're minimizing the importance of it. But you do want to approach it in a way that's productive and move the moves the conversation forward.

00:26:18                               Cristen: Yeah. And the other thing of course is that a lot of people think of violence as being something physical. And it doesn't have to be physical, but having to explain that every single time, you know, is not helpful. It's not, not great communication. So yeah, so I use whichever term I think is appropriate in the setting. But also am really conscious to center obstetric violence as the term that was first coined and was coined by the people who actually survived it. So.

00:26:53                               Nicole: Gotcha. That makes a lot of sense. Okay. Now one thing I was curious about, do you ever hear stories of obstetric violence for birth outside of the hospital?

00:27:04                               Cristen: Yeah, yeah I do. So it can happen anywhere. Birth happens. It doesn't have to be in a facility. I tend to think it's more prevalent in facilities because you have that systemic. So outside of hospitals you might have individuals who are obstetrically violent, but generally speaking, if you're outside of a hospital, you're using some kind of midwife. And the model of care is different for midwives, you know, it is based on informed consent. It is very patient centered already. So that removes, I think some of the space where obstetric violence happens very naturally in a setting where it's, it's institutionally centered and you know, you're going through the institution versus the institution working around your needs.

00:27:58                               Nicole: Got it.

00:27:59                               Cristen: So, but yeah, to answer your question, yeah, definitely, have absolutely heard about obstetric violence in birth centers and at home.

00:28:07                               Nicole: Yeah. And I hope guys need, I'm not trying to bring that up to like say, Ooh, it happens everywhere. What I'm trying to make the larger point is that I think a lot of times there's a lot of discussion that Oh, women should give birth at home or Oh, women should give birth at birth centers or you should definitely have a midwife. And for me, my philosophy and thought on that is that it's not, although obviously the place where you give birth is important and without question, midwifery care is associated with better treatment for women. It's a model of care that other people can do. So you really need to look for someone who supports you, whether you choose a home birth or birth center, birth or hospital birth, instead of looking for a specific type of provider, look for someone who's going to care about you wherever that setting is. I hope that makes sense.

00:29:02                               Cristen: Yeah, I mean, it makes sense to me. So in my experience, like if a parent were to ask me about this, I would say I would always be aware of this. I would always be on the lookout for it. I would also be smart about it and know that walking into a hospital is going to make it, I would say, and this is just my opinion, more likely than not.

00:29:33                               Nicole: Yeah. Yeah. Unfortunately.

00:29:38                               Cristen: Yeah. And then I think later we'll probably talk about some solutions. So then I'll finish that thought. So I don't mix up our topics.

00:29:47                               Nicole: Got it. Perfect. All right. So when you talk to healthcare providers about obstetric violence, what has been your experience? You kind of touched upon this a little bit earlier, but yeah, to bring it to those forums, what happens?

00:30:04                               Cristen: I get a lot of blank faces. Sometimes people get really defensive and I can hear the trauma coming off of them. You know, I have a lot of experience dealing with trauma. Well trauma period. Trauma, secondary trauma. And so I can sense it when there's trauma underneath, when there are maybe feelings of guilt. And so sometimes, so sometimes I can just, I can like smell it. And I often do not have the time and it is not the place to get into it. But what I usually want to say is like, I just want to give you a hug right now. I want to tell you that I want you to get some therapy. I want you to go get some professional help. You need to talk this stuff out. There's a lot going on in there that I know that you haven't processed or unraveled and it comes out because like, you know, a lot of times I will, you know, we'll start off talking about like a topic, but then they go off into some sort of story about it that maybe doesn't exactly, it's not exactly applicable to what we're talking about.

00:31:22                               Cristen: And I think to myself, Oh, this is something they haven't processed. They absolutely need to be going in doing some therapy around, you know, whatever is coming up for them right now. But anyway, sorry, I didn't mean to get off on a tangent on that, but yeah. So I would say definitely, definitely hostility and defensiveness, but I have also been pleasantly surprised that there have been so many providers who have said like, thank God people are talking about this. Finally. I'm so glad that you're talking about this.

00:31:54                               Nicole: Any doctors? I'm curious, you know, I hope.

00:31:59                               Cristen: Yeah, it's interesting for me because I would say for every, you know, for every positive person, there's a negative person, which is, you know, you speak, that's not a fun place to be as a speaker. But it's, it's worth it, I think because for those providers who look at it as, yes, this is real, this is true, this is information I need to know. It is really liberating for them. And I have stayed in contact with a lot of providers who, you know, maybe I met at a speaking engagement, who then follow up to say, Oh my God, after your talk. And I don't mean to make it about me. It could be any sort of like moment they had, you know, where they go, Oh my gosh. Like after that, you know, after I had that realization, you know, I started talking to my one colleague and she said, you know, yeah, same thing. Like what are we going to do? And they've changed the way they practice and they've started making changes at their facilities in their environments.

00:33:00                               Nicole: I mean, that's exciting to hear.

00:33:01                               Cristen: Yeah, it's really awesome. I do think it's one of those things that once you become aware of it, you know, once you see it, you can't unsee it. And at that point it becomes kind of a driving force for people. It's hard to go back to treating people in a way that you know is harmful once you know that it is harmful and you care, you know, if you're a person who cares about that. So I think that's really awesome. I love hearing those kind of success stories. So there's work to do, but there's some hope as well.

00:33:33                               Nicole: Yeah, totally. Yeah. So let's talk about what should a woman do. What are your thoughts about what she can do when she experiences obstetric violence?

00:33:47                               Cristen: So I will go back to what I said about providers and therapy. I think that your mental health is your first priority and we know that the sooner birth trauma is addressed, the more fixable it is in a nutshell. So for the most part, if you've experienced obstetric violence, you're dealing with some level of trauma. So, you know, that might not be true across the board, but most of the time that is true. So a lot of people contact me with, you know, with their stories and what do I do now? And I always emphasize to people, you've got to prioritize your mental health because any thing that you think you're going to accomplish about what happened to you, those efforts are going to be totally hamstrings if you are not prioritizing your mental health. So to illustrate that, so I'll say like, you know, somebody contacts me, they're super upset, they're very anxious, they're saying I want to, I want to hold this person accountable.

00:34:56                               Cristen: You know, I've done this, I've done that, I've done whatever. And I know that at some point that they're actually still in a trauma response in that it's all they can think about. You know, they can't sleep at night and they're using that action as a way to process their trauma, which is, which is not unhealthy. Let me just say that that's not a criticism, but I also know that, as you process you, you change, you shift, you go through these phases and you might get to the next phase where you find yourself unable to do anything and that's just a stage, you know, it's just the thing you have to go through. But people would be, will be debilitated by that if they haven't proactively address their mental health, you know, throughout it. I'm so sorry, that was a very roundabout way to answer your question.

00:35:48                               Nicole: The fact that you said that it's really hard to do some of the other pieces like report to the hospital administration or, you know, it's hard to do that if you haven't taken care of yourself first.

00:36:03                               Cristen: Totally. Well, and think what's the first thing you have to do? You have to write your story down, right? If you're going to complain, that can be the hardest thing on the planet, right? You're dealing with trauma, it's revisiting the trauma to document it. You know, that could be like totally impossible for a lot of people. You know, at that time. So generally speaking, if you have experienced it, I just want to say that about prioritizing your mental health. And then as far as accountability goes, that is a really tough one. I have not cracked this code yet and I've been working at it for years now.

00:36:40                               Cristen: There are a few different channels you can go if you are looking to get some sort of accountability for what happened and you can complain directly to the hospital. I will say that they don't have an obligation to respond to you and they very well might not respond. And often when they do respond, it's, I'm trying to think of a nice way to say this, dismissive or so from the other side of it, from the hospital side of it, they're receiving a complaint and they're going, how much of a liability is this complaint? And that's how they are assessing how they respond. It's not centered around your healing. Let me put it that way. Right? So there's the hospital complaint and then there's the, so you can also file a complaint with the state board that licenses the provider. Whether it's a physician or a nurse or a midwife.

00:37:39                               Cristen: Unfortunately those complaints don't seem to be very effective either. There's not very much transparency generally. A lot of times they will, you know, take the complaint and you may or may not be involved in the investigation beyond the initial complaints I've heard of. So many people have said, you know, they never contacted my witnesses. They just sent me a letter that said, you know, we received your complaint and we won't be, you know, we're not pursuing an investigation or you know, we've investigated and we've concluded our investigation and they won't tell them what the outcome is. So that's not unusual. I say these things just so people can have realistic expectations. I am not discouraging people from doing these things because if anything, I think we need to continue absolutely making noise. But having realistic expectations, this is probably not going to be a big healing process. You know, it's probably not going to end with an apology to you and an acknowledgement that something was wrong and a commitment to change. So I just want people to be aware of that.

00:38:54                               Nicole: What are your thoughts about posting about the experience on social media? What is the impact of that?

00:39:02                               Cristen: I think that's a great idea. I think that is, you know, I think it's one of the only things people can do really where it is you're putting out your story in your words, you're not leaving it up to some biased entity to decide whether or not your story is worth looking into. Does that make sense?

00:39:24                               Nicole: Absolutely.

00:39:25                               Cristen: So I think it can be very healing in that it's on your own terms. I would also caution that it can be also traumatizing to see the responses. You know, often people will tell me they feel very validated when they posted their story, you know, maybe like on their Facebook page or something because so many other people said, Oh my God, the same thing happened to me. Or Oh, it was Dr. so-and-so. Yeah, he did something like that to me. Or yeah, I experienced something like that, but I didn't even recognize it as abuse until you just said that.

00:40:01                               Cristen: And now I'm realizing that I wasn't the only one. And if this wasn't a one off with me, then this is an abusive, you know, practice that this person is doing. So I think that's awesome, getting that validation from your peers and your circles I think is so important to people for their mental health as opposed to literally being, you know, like offering it up to an authority that is supposed to take care of you and having them invalidate what happened to you. So, yeah. And then I have a resource on my website where people can submit their stories and then they're pinned by location to a map and you can share whatever you want there. Let me share what happened. And I think having all those stories in one place is really powerful.

00:41:00                               Nicole: Yeah, for sure. I looked at that map and looked through some of those stories then it was certainly like, it gives you an extent of how common it is, unfortunately.

00:41:10                               Cristen: Yeah. And I think, you know, there would be so many more stories there if people weren't dealing with all of the trauma, you know, for sure.

00:41:22                               Nicole: There's certainly some element of wanting to get past it. Like you don't want to talk about it. You don't want to, and you want to focus on the happy part of having this baby. So I can see how it can be very complicated for women to make those decisions.

00:41:36                               Cristen: Yeah, yeah, it is. But you know, one thing I want to say about that are two things actually. It's, I want to say about that is trauma doesn't go away on its own. It's not something you can put in a box and lock away and have it never affect you again. It just doesn't work that way. Especially, especially, especially if you ever plan on having more kids. I don't know how many people I've talked to. I've said it was, you know, the second I found myself pregnant again, I was right back in the absolute worst of my trauma that I had locked away for four years and thought I was over it. And then, Oh my God, there I was pregnant. And having it all rushed back to me. So having to deal with it on that, you know, shorter timeline with all of the stress of, you know, an upcoming birth and everything else.

00:42:28                               Cristen: So I just want to say to people that you have to go through it, you can't go around it. But the second thing I want to say is that you absolutely can heal from it. There is so much potential for healing and growth after birth trauma after obstetric violence. And I have seen amazing things happen and I work with amazing therapists and psychologists and researchers who, you know, can lay it out in very like black and white terms. Here's how you heal. You know, this is fixable. And I don't mean to make it sound like we're machines and you can just tinker with some parts and maybe maybe I should back that up and say that you can be better than what you are now. It can be better. The trauma can be mitigated. So, I just want to get people that kind of message of hope about it, that it's absolutely something that you don't have to, you don't have to just, just take it and um, and think that that's going to be your life from now on.

00:43:41                               Nicole: Yeah. That's really important to hear that it doesn't, you can get past it. Yeah. Yeah.

00:43:48                               Cristen: You have to go through it though. That's the thing.

00:43:50                               Nicole: You can't just stuff it in a box. And you know, back to the social media, I forgot to say that I can tell you that if you post things on social media and tag hospitals or that can very often be a way to get people to actually pay attention because they detest that sort of public negative attention.

00:44:13                               Cristen: Yeah. Yeah. I always say that's bad. PR is the only thing hospitals are more afraid of than lawsuits.

00:44:20                               Nicole: Pretty much. Exactly. Exactly. So how about what do you think needs to be done to eliminate obstetric violence? And I say eliminate intentionally opposed to reduce because I really think this is something that could be eliminated with some things like cultural shifts and you know. So what, what do you, what do you think could be needs to be done to eliminate it?

00:44:43                               Cristen: Sure. I don't have a great answer for this, because I don't know where it has been completely eliminated. But I can say that there's a whole lot we can do for one. I think starting with an awareness, not awareness isn't a strong enough word. Acknowledgement and commitment to our rights in birth. I think that is, that would fix, you know, the majority of the problems right off the bat because everyone is entitled to informed consent and refusal in their health care. So if every person around every aspect of their healthcare was getting that proper informed consent, you know, that would naturally fix the coercion and the pressure. And the force and the offering or you know, presenting procedures as if there's no choice.

00:45:45                               Nicole: So, and then maybe this is the time for you to talk a little bit about, and I know this is probably, it could be a whole nother podcast episode, but what is informed consent and informed refusal?

00:45:56                               Cristen: Oh, sure. Well, so those are, those are basic human rights and legal rights, legal rights in the United States and in most of the world. So it's based on the concept of autonomy that you own your body and if someone else is going to do something to your body there, they need to explain to you why all of the factors about that and then ask you for permission in a very general sense. So informed consent means that if a provider is suggesting to you that they want to do X, Y, or Z , that they must, must have a discussion with you about the risks and benefits of that procedure. That they are suggesting the risks and benefits of any alternatives to that procedure and the option of doing nothing. And you know what that might look like. And it means that you have time to ask any questions.

00:46:53                               Cristen: You might have to share any information you might have about your own body or your own situation or circumstances. Like a very quick example might be somebody with high blood pressure who says, Oh well I always get, you know, my heart races every time I walk in a doctor's office. Well that's really relevant information, right. But, but as a provider, you're not going to know that unless the person tells you that. So my point is that patients often have very valuable information. It's kind of a lame example, but patients information as well, it's not a one way street. So then after that would be respecting whatever decision you make. And certainly there's room in there for the provider to give advice to say, well, you know, this is what I would recommend you do. This is what I would suggest. But that's only a long side, unbiased information about the procedure and its risks and benefits and its alternatives.

00:47:57                               Cristen: And finally, the provider needs to support the choice of the patient. It's not the provider's body and the patient gets to decide what happens and then the right of refusal is just the right to refuse medical treatment preemptively to stop in the middle of it. You know, the vaginal exam has come up a few times. You know, I've heard a lot of people say, I had a provider, I consented to a vaginal exam and then it ended up being very painful and at that point I said stop, but the provider wouldn't stop. So that would definitely be a violation of that person's right to refuse or the provider was doing a vaginal exam and went ahead and stripped the membranes or broke the water without asking. That's also a total violation of informed consent. Does that sum it up?

00:48:54                               Nicole: Yeah, absolutely. Okay, sure. Okay. Sure. Okay. And I know that obviously, you know, those things are crucial and critical. I think, not to, I guess to add a piece that you probably often hear from a provider perspective, is that the medical legal piece of that, particularly when it comes to obstetrics and you know, the thought of possibly being sued because if a choice, God forbid leads to an undesired outcome. So I think that there's that, that sort of difficulty on the part of the provider side of like, you know, you're not going to get sued if at the end the baby is physically healthy so to speak.

00:49:44                               Cristen: Well, yeah, and I think, you know, this is a reflection of our priorities. You know, we can say, well, you know, it's a liability issue. You know, it's just tough and we can leave it at that. Which I think people have for years and years, they have just said, well, you know, gosh, providers are just in a really bad spot because the vast majority of Obs will be sued at least once. And it's such a litigious environment. But we could be asking the question, how do we respect patients' rights without increasing our liability or even reducing our liability? Which I totally believe is a very real possibility. So if we kind of shifted our thinking around that, if we said respecting the patient's rights is the priority, I do believe that we can absolutely do that in a way that doesn't increase liability and probably decreases it because I mean if you think about it, you know, just common sense tells you that if a provider is practicing more robust, informed consent and refusal, they're going to be more in alignment with their patient's desires. And that means less conflict, which means you know, lower chance of a lawsuit

00:51:06                               Nicole: For sure. And, I was going to follow up that I have yet to meet or have a circumstance where if you have a good relationship and you've been respecting the person's wishes and you get to a point, usually this centers around cesarean almost quite a bit, where you've established that I've been putting your cares in, you know, putting you at the center of your experience. When you get to that discussion and you say what your concerns are and you say that, yes, I believe this is the healthier thing for your baby. I have yet to had a woman who refused or felt bad about the decision or felt uncomfortable. I think when you truly do, like you said, informed consent that it actually works out well.

00:51:55                               Cristen: Yeah. And I, you know, I think there's research to support that too.

00:51:58                               Nicole: Yeah, yeah, that's true.

00:52:00                               Cristen: So if we kind of shifted our thinking around that from fear-based thinking by providers, you know, and into, we're going to have to trust each other here. You know, I'm going to have to trust my patient. And my patient is going to trust me because I trust my patient.

00:52:19                               Nicole: Exactly. So, exactly.

00:52:21                               Cristen: That's true. I think of it as like a woman with like a boyfriend or a husband who they're terrified they're going to cheat and they go, so I looked through his phone and I track him and you know, I know where he is at all time and I asked his friends where he's supposed to be and I did it. It's like, or you can spend all that energy on building your relationship so it's not a person who's going to cheat on you.

00:52:49                               Nicole: Exactly. That is a great way to look at it. For sure. For sure. Because, and like I have never met a woman who doesn't want a healthy baby and for her to be healthy after her birth, there's no woman on earth who doesn't want that to happen. So yeah, I think if you stop using things like fear tactics and all those kinds of guilt, it just ends up being better.

00:53:15                               Cristen: Well, let me give you a little anecdote here, if we have time.

00:53:18                               Nicole: Yeah, go for it.

00:53:21                               Cristen: Okay. I'm going to impose my anecdote on you. So Dr. Jess Cooper is an OB in Birmingham, Alabama, and she kind of transformed her practice when she came at it from, not from an outcomes perspective, but from a feminist perspective. She said, you know, I'm a feminist and it's really important to me that women are in charge of their own bodies. So we are just going to start leaving the decisions up to our patients. And she started doing that at her practice and she saw all of their outcomes improve as a result of doing that. And I think that is an amazing case study that doesn't surprise me in the least, but it's really cool that she actually recorded those numbers from, you know, we went from this type of care to that type of care. And the difference was we started trusting our patients. And by the way, this is a high risk population. This isn't the type of, you know, birthing person you would think of as, you know, particularly informed and empowered. But these are people who are more marginalized in every way and in fact completely capable of making wonderful decisions about their healthcare when they're trusted to do that.

00:54:49                               Nicole: Absolutely, absolutely. Truly a shared decision making process as opposed to us making decisions for people. So what else? We talked about like good informed consent, informed refusal as important to eliminating obstetric violence. What are the things that you think are important?

00:55:10                               Cristen: Well, I think culture shift is maybe the most important thing in institutional culture. And why is that a biggie? That's not an easy, it's not an easy thing to change. I'm not even sure where to start with that. I know of a couple of facilities where they have successfully done that and it takes everybody, you know, you can't have just one great physician who wants to see culture shift. They can't do it all by themselves. It's gotta be, it's gotta be top-down. Administration absolutely has to be actively pursuing that positive patient centered respectful culture. And that includes staff. I mean, that includes, you know, anybody who works for her at the hospital. You can't abuse your staff and your physicians and then expect them to turn around and offer compassionate patient centered care. So another piece of that is the trauma that providers suffer.

00:56:18                               Cristen: Providers are trained in a system that violates their human rights all over the place. And then, yeah, and then they're supposed to turn around and offer something completely different to their patients. That doesn't really make sense. And you know, there's so little trauma support in hospital culture, generally speaking, the majority of providers I speak to don't have access to any kind of trauma support or if they have, you know, maybe there is a psychologist available or something like that. There might be barriers because a physician doesn't want that on their record that they had to seek mental health support for job-related trauma, which is a real problem. So there are a lot of pieces here that need to change. But I do think that having healthy institutions with healthy providers is kind of a no brainer. Like, you know, I don't know how, I don't know how you create a healthy culture without being healthy, you know?

00:57:24                               Nicole: Absolutely. For sure. You can't really fake it. That was so very true. So very true. I think also too, there's some room in medical education to improve as well. So people from the beginning know that this is important.

00:57:41                               Cristen: Yeah. And something I hear all the time is that people were educated in one way and then they were trained in a different way. So maybe they learned about informed consent and you know, I don't how many nurses I've heard say, yeah, well I learned it's, you know, if you don't get consent, it's assault. You know, if you do this, it's assault. If you don't do that, it's assault. And then they go to train in a hospital and they're like, it all went right out the window. Like it was like, that wasn't even a thing at the hospital, you know? Or they did what you might call a lot of microaggressions or they learned a lot of microaggressions as part of their job. And it never really thought through, Oh, this actually fits the definition of that assault that they talked about in nursing school.

00:58:27                               Nicole: Yup. Yup. So yeah, really, really important point. For sure. It has to be more than talk. It has to be actual action.

00:58:36                               Cristen: Yeah. But you know, the cool thing is this isn't like a big capital investment. You know, it's not like, ah, you know, every room needs a new, like $250,000 piece of equipment to make this work.

00:58:48                               Nicole: You know, the, the fundamental concept is actually very simple and straight forward. Like it's not, it's not complex.

00:58:57                               Cristen: You don't need, right. We're right. This isn't like you need a college course in informed consent or something, or patient rights. Yeah, it is super, super simple. You're absolutely right. And a lot of it, it's just a willingness, you know, it's an attitude change.

00:59:15                               Nicole: Absolutely. For sure. For sure. So anything else that you can think of before we wrap up?

00:59:22                               Cristen: Yeah, there was just one thing that I kind of wanted to add on to what I said earlier about trauma. I've mentioned psychologists and therapists a few times and paying for therapy is out of reach for a lot of people. And I want to acknowledge that and also say that there are lots of ways you can heal from trauma that you don't have to pay for. And that is definitely not to discount, you know, the wonderful trauma professionals. But often that's just, that's just not a possibility. You know, even if it's not a financial concern, it might be that you have three little kids at home and there is no way you're going to be going across town, you know, for an appointment. So I just want to say that, you know, there are a lot of ways that you can heal from it. You know, it's not even another podcast that's another, like it's a world of information.

01:00:13                               Cristen: But I do want to encourage people to look into that, that there are so many options out there. You know, beginning with storytelling. You know, indigenous, traditional cultures, dance and sing and you know, storytelling all in a community way. There are so many things that you can do. If you listen to your body and really dig into how you can get better from this trauma because your trauma lives in your body and your body, if you really know how to listen to, it can tell you how to heal from it. So I just want to encourage people in that way. So I have had access to amazing therapists and psychologists and also body-based therapy. And that body-based therapy is at least as valuable if not more. So I really liked that. I really like that. There's other ways are, and it can be complimentary or that you can get better.

01:01:13                               Nicole: So yeah. So just just to wrap up a couple of quick questions. What is the most rewarding part of your work?

01:01:19                               Cristen: I really like it when somebody I met because they were a victim, becomes an advocate and a fighter and it usually takes a number of years.

01:01:34                               Nicole: Gotcha. I can see how that can be very, very rewarding and validating for what you do.

01:01:40                               Cristen: Yeah. I love, love, love seeing that I can look at somebody and go, God, I remember when they were so broken. Right? And look what she has done. Look how far she's come, look at what she's done for herself and then is out there fighting for other people. I think that's just incredible.

01:01:59                               Nicole: Absolutely. So now on the flip side, what's the most frustrating part of your work?

01:02:05                               Cristen: Boy, there's probably more than one that will, I'll just say off the top of my head is that people don't believe women.

01:02:15                               Nicole: Oh, you have said a word right there.

01:02:19                               Cristen: And there are so many things, but you know, that's, you know, and I think it into like all kinds of different aspects of what's frustrating. But right off the bat is like that, you know, that is the thing that having to prove over and over and over and over the same thing is exhausting.

01:02:36                               Nicole: Yes, yes, yes, yes. Absolutely. I mean, happens time and time again.

01:02:43                               Cristen: Yeah. I mean it's just like sexual harassment or rape or you know, these things that we've seen more culturally and legally from, that's not a thing to, Oh, I guess maybe it is a thing and like, Oh, maybe it is a thing and there should be legal recourse and we should have policies about it and maybe we should believe people when they say that this happened. So, yeah, I think we're, we're just coming out a little bit of the stage of like, wow, it's like beating my head up against a wall every time.

01:03:16                               Nicole: Oh, so last thing, what's your favorite piece of advice to give to expectant parents or families?

01:03:25                               Cristen: Oh, sure. So I think that your provider is the most important piece of the equation. I'm assuming that you have some education around your rights and the evidence, but that provider is, can be either like the facilitator for those things or they can be like the biggest barrier to that. And you know, so many parents just have this idea that that their birth will unfold the way it's going to unfold, no matter the environment or, or the people present. And that is absolutely not how it works for the most part. That mainly your provider, but the people around you, if you're in an institutional setting are going to determine how your birth goes. And you know, there's tons of research around that. Now we know that the hospital where you go is your number one determinant for whether or not you're going to have a C-section, not your health, that what's going on with your body or your baby, but literally the, the facility you walk into.

01:04:28                               Cristen: And I just really want people to understand how important that is because it is really frustrating to me to hear somebody who has done all this work to be educated, you know, knows what kind of birthday want they prepared for it. They've planned for it, they've done, you know, they put all the pieces in place only to be stymied by a provider who just isn't supportive and you know, tells them, you know, undermines their confidence or you know, maybe misinforms them and do they have an idea that it's misinformation but it's just such a vulnerable place to be. They're just not really sure what to do about it. And, next thing you know, they're having the birth they didn't want to have and you can see it coming from a mile away, you know, as an outsider and, but then you just watch it. So, and then on the other hand, you can have people who aren't that informed, maybe didn't prepare all that well, but they have a provider who really cares about them and listens to them and wants to support them.

01:05:30                               Cristen: That provider can help fill in those gaps for them and can help guide them, you know, into a safe, respectful, respected, supportive, supportive birth. And my last little tip on that though is how do you find those providers? There's not an easy way to do that. I recommend people talk to the birth professionals in their area, especially the doulas who work with different providers because they see how those providers actually practice like an everyday way and they see all kinds of different providers, you know, you might work with or you might talk to, you know, a nurse who works in a hospital who, you know, maybe sees how, you know, 10 different providers practice, but you talk to a doula and they know how, you know, not just that hospitals, physicians, but how that hospital and that hospital, they really do get to see, you know, the cross section of how different providers act. And you know, sometimes there's a big difference between how a provider acts before the birth and how they act during a birth. So that's my, that's my biggest tip. Local doulas and, and, and usually they are very happy to talk. They're not going to, they're not going to be irritated. They're not going to say, you know, I'm going to charge you for my time. They're probably going to be totally thrilled that you're seeking to be informed and you really want to give your business to a provider who's respectful.

01:07:03                               Nicole: Exactly. Yeah. It's one that you have hit the nail on the head. It's one of the things that have this free online class on how to make your birth plan. And the very first thing I say is that the two of the most influential factors in your birth are your provider and your hospital, and you have to understand those by asking tons of questions before you get to the hospital. Because if you don't, you may be potentially setting yourself up for major disappointment.

01:07:33                               Cristen: Yeah. Well, and then the crazy thing is even if you ask all the right questions, you might not get the truth.

01:07:40                               Nicole: Yeah. That's one of the things that is really hard for me. It can be frustrating too in some ways. There's still some uncertainty about it that is just hard to get around.

01:07:52                               Cristen: Totally. Yeah. You still need to ask the questions. Yes. Don't get me wrong. You definitely do. It's just like, and I'm sure you run into this, it's like how do you even talk to parents about that? You know what I mean?

01:08:03                               Nicole: Right, exactly.

01:08:09                               Cristen: You know, to get like the real, like the insider info, go to the doulas.

01:08:15                               Nicole: They do know. I have said that I'm like, y'all, they have an insider view y'all for real, they see different types of births and then often like providers, physicians, midwives, whatever, they're not thinking that that person is really observing them.

01:08:31                               Cristen: They're like a witness in the room. Yeah.

01:08:33                               Nicole: Yes. So they, they, I agree 100% with Cristen that doulas are great in general, but they are certainly great for having that insider information of seeing how different providers actually are during birth. Yeah, for sure. Okay. So thank you so much Cristen. This has been a really, really, informative interview and I'm so glad that you were able to come on.

01:08:58                               Cristen: I'm glad we got to talk for a long time.

01:09:01                               Nicole: So where can people find you?

01:09:03                               Cristen: My website is I am making a film and that is I know, I'm forgetting like 50 things.

01:09:14                               Nicole: Yeah. Are you on Instagram? Facebook?

01:09:16                               Cristen: Yes. Yes. Slash birth monopoly for Facebook and Instagram.

01:09:21                               Nicole: Okay. Yeah. And what is your film about?

01:09:24                               Cristen: Obstetric violence and birth trauma.

01:09:25                               Nicole: Okay. Well why did I even ask that? Like of course it is.

01:09:31                               Cristen: Yeah. There's a trailer there right at the top of the page on the, on the homepage if you want to, if anybody wants to check it out. And we are actually updating that. There will be a new one within the next few months and I'm excited to see what that is. So, and I, you know, I also do a know your rights training for birth professionals, which is on my website. So if anybody wants to learn more about it,

01:09:55                               Nicole: We still have quite a few doulas who listen to the podcast, so I will link to that in the show notes as well. Well again, thank you so much for coming on and I appreciate it even through our couple of technical glitches here. All right, Cristen take care.

01:10:10                               Wow. Wasn't that something, lot of great information about a tough but important topic that definitely needs to be discussed more. Now after every episode where I have a guest on, I do something called Nicole's notes, which are my top takeaways from the episode. So here are my top two takeaways from the episode with Cristen today. Number one is change providers if you need to. I've said that before and I'll say it again and I'll say it again and again. Cristen changed providers at 41 weeks. Now I don't necessarily recommend that you wait to do it then if you can at all help it because it can be quite challenging to do it at that point. But if during your pregnancy you realize that the person you have chosen is not right for you, then do find another provider. Don't be afraid to switch. Now I have a few resources to help make sure you have the right provider and my free online class on how to make a birth plan that works. I give you a set of questions. It's like seven or eight questions to ask your doctor and hospital to make sure you have the right person that's a good fit for you. Also on episode three of the podcast, how to be sure you have the right doctor. There is more information there and then episode four of the podcast, how to be sure you have the right hospital. There is more information there so I will link to all of those in the show notes.

01:11:38                               And then the second thing that I want to say, or my takeaway from this episode is that if you experience obstetric violence or have experienced it in the past or you have some birth trauma as a result of that or for any other reason, please do what you need to do to process it and heal starting with your own mental health. Those feelings do not go away and they can rear their head. Again, like Cristen said, especially if you're planning to have another baby. So do take the time to care for yourself and really process it. And I would humbly ask you or challenge you to consider sharing your story. I know that that's very hard, but I know that women's collective voices have the power to make that deep cultural change that we need to make in our maternity care system so that women do not experience obstetric violence. This is not a problem that's particularly difficult to address in the sense that the fix is pretty simple, but I think that making that deep cultural change can certainly go faster if there's a groundswell of women complaining and talking about it. So if you've had this experience or you know someone that has and please do, consider sharing your story in a way that works for you.

01:13:09                               All right, so that is it for this episode of the podcast. Be sure to subscribe to the podcast in Apple podcast or Spotify, wherever you listen to podcasts. And if you feel so inclined, I'd love it if you leave an honest review in Apple podcasts. It helps other women find the show and I very often do shout outs on podcasts for folks who leave reviews. I really appreciate reading your kind words. Also do come join me in my free Facebook group All About Pregnancy and Birth Community so we can talk about this issue even further. It's a great group, tons of supportive and helpful information and women. So you can find the group by searching for All About Pregnancy and Birth on Facebook or you can link to it. We'll link to it in the show notes for sure.

01:13:59                               Now next week on the podcast, I have another first, it will be the first time I actually have a pregnant woman on the show. Can you believe it? I've been doing this show for almost a year, over year rather, and this is the first time I have a pregnant woman on, but anyway, her name is Amber Manning and we are going to talk all about how she is approaching, getting educated for her pregnancy and birth. She's a first time mom and I think you will find it really, really helpful. So come on back next week. And until then I wish you a healthy and happy pregnancy and birth.

01:14:36                               Today's episode is brought to you by Women's Wellness Coaching by Dr. Nicole Calloway Rankins. Head to to check out my free one hour mini course on how to make your birth plan as well as my comprehensive online childbirth education class, The Birth Preparation Course, with over eight hours of content and a private course community. The Birth Preparation Course will leave you knowledgeable, prepared, confident and empowered going into your birth. Head to to learn more.

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