Your BIRTH Partners

COVID-19 & Birth Setting

April 06, 2020 Your BIRTH Partners Season 1 Episode 10
Your BIRTH Partners
COVID-19 & Birth Setting
Chapters
Your BIRTH Partners
COVID-19 & Birth Setting
Apr 06, 2020 Season 1 Episode 10
Your BIRTH Partners

This episode we are discussing how the threat of COVID-19 is affecting our care practices.  We will also be discussing the particular theme of birth setting choice "home vs hospital" in the face of this crisis and dispelling some myths.

Support the show (https://www.paypal.me/yourbirthpartners)

Show Notes Transcript

This episode we are discussing how the threat of COVID-19 is affecting our care practices.  We will also be discussing the particular theme of birth setting choice "home vs hospital" in the face of this crisis and dispelling some myths.

Support the show (https://www.paypal.me/yourbirthpartners)

Maggie, RNC-OB:   0:07
Hello. Welcome to Your BIRTH Partners.  We're here to breakdown barriers and cultivate community as we discuss issues that impact pregnancy, birth, and postpartum.  We welcome you, no matter what your background is and are so excited to learn together. Today I am joined by Ray Rachlin, CPM and Abby Dennis, OB-GYN and Family Medicine Physician. So we found that because of extra shenanigans that COVID is throwing into all of our lives, we weren't all able to get together for the recording session all five of us at this time. And so we still wanted a chance to talk about kind of the ways that COVID is impacting our practice right now and particular to tune into kind of the theme that seems to keep coming up about the idea of, you know, home versus hospital. Where is the safest place to give birth? And how do we help to kind of protect the safety of all involved in, you know, in both environments and as a whole, as we work to make sure that, you know, people get the right level of care that they need. That also matches up with risk picture and and everything else that's going on in their lives. So we are excited for you to learn more with us about these topics and, you know, get a little bit of a greater understanding about how COVID is impacting births across, you know, all care settings at this time.  On to the show!

Maggie, RNC-OB:   1:31
We are talking about, what is on everyone's mind, talking about COVID-19 and the impact that it has on our care, which we know has impacted everyone, obviously, on so many different levels, personal and professional, and particularly we wanted to tune in and have a chance to kind of go around the room and share how it's impacting our practices here. Since we span so many different sides of maternity care. One of these like like I scene just as I'm watching it happen in my own practice and hearing people talking on social media and, you know, on the phone with colleagues that, you know, we're just seeing that this whole crisis is really just magnifying so many of the things that are already kind of challenging points within our maternity health care system. So, you know, we want to talk about what's going on and kind of give a, you know, round-table update on that and then also kind of talk about some ideas we have for solutions and, you know, kind of tune everyone in tow different ways that we could maybe kind of helped change the tide of how this has been going so far. So, you know, whoever wants to start it, just gonna share with us. What/how is this changing in the last, you know, 3 to 4 weeks. How has this kind of changed your professional life? How you're practicing?

Ray, CPM:   2:47
Abby. You want to go first?

Abby, MD:   2:48
I'm happy, too. I mean, this is obviously changed things pretty hugely in terms of just modality of practice and the protective equipment that we're suddenly wearing for deliveries. And, a lot of unknown because a lot of the data on COVID pneumonia and pregnancy, and such is based on really small case reports. So I think we're working with a disease process that we don't know much about. It seems not to be like influenza, which has increased morbidity and mortality in pregnancy, but we don't actually know that, and we don't know much about potential for vertical transmission. That then is coupled with the changes in visitor policies in hospitals, which has been really hard, you know, on the obstetrics hospital side of things were already working in a climate where people don't always trust us to make the right decisions and not over medicalize birthing. And suddenly people are being told that, you know, at one point you know you can't have your doula or support person, and I think there are a lot of fear that patients are gonna have to labor by themselves.  I will say, in terms of like, the community of people I practice with, I've been hugely impressed by the nurses I work with, the other doctors I work with. People are really functioning, as the team, and people have been so compassionate about, you know, thinking about what it means to labor without a partner and trying to be extremely present for our patients. And to get them through this. So I've been very impressed by by that piece of things. But it's hard and scary, and there's a lot of unknown involved.

Ray, CPM:   4:28
Yeah, I feel like on my side of things home birth, you know, myself, and other home birth midwives in Philly when all this started started getting, like 20-30 calls a day from folks that are freaking out about if they should have hospital birth or switch to home birth. And we had to get everything together really quickly to figure out how to manage an influx of home birth in our community and support each other as we expect to get sick, at some point, we'll need backup care. And, you know, we kind of came up with the community standard for cleaning supplies and for a distance visit. So, you know, now, seeing people in office like half, half as often as we're used to and like doing zoom appointments in between and limiting different ways that we were in contact with our clients beforehand, like doing less home care and also, yeah, and we've all taken on some extra births in that. It's been it's been a stressful time. I think I feel really like excited that, like my community, my midwifery communities, like, kind of come together. And, you know, we have the infrastructure in place to help more families, right now, But also, it has just been very intense to like care for people during this crisis and then, like, manage my own risk. And, you know, I have difficulties accessing enough protective equipment for myself.  Yeah, and then just all the inquiries. Like, I think for a few weeks it was like, you know, talking to like 20 people, on the phone or getting lots of emails, and it's maybe slowed down a little bit. But it was mostly people that were due like in April and May, just suddenly, wanting a change.

Abby, MD:   6:06
You know, it's interesting; it's really created support amongst our small communities, but I think in terms of home birth versus hospital births, unfortunately, a lot of this has brought to light the division and antagonism that sort of exists between the two communities. I remember there was somebody on CNN, a doula who was talking about you know, not "it's unfortunate I can't be with my women in labor to support them, but it's unfortunate I can't be with them because I won't be there to advocate against the bad care they're going to get," which is I mean, that storyline makes me sad, because it's not all bad care here in the hospitals. I worry about you guys, as homebirth providers taking on patients that aren't the right patients? Patients that haven't been thinking about this from the start. I don't know what that's gonna mean for your practice in building relationships and everything; that scares me for you.

Ray, CPM:   6:57
Yeah, I think I've never been more discerning. Because like the conversation I have often is like, "you know, like, what did you think about home birth before all this? You know, do you feel safer in the hospital? If so, you should give birth in the hospital." I am really only taking, like, the lowest of the low risk people. Because I'm attending more births when it typically would. And I'm relying, we're on, like, you know, back for my community to help me do this. So I want to make sure that we're setting setting ourselves up well, and that means yeah, like saying no to a lot more people than I'm saying yes to.   

Maggie, RNC-OB:   7:39
Yeah, I do. I feel like that It's very challenging, and I think initially there was just this whole concern, especially as we're seeing certain, you know, hospitals who were really just saying no one can have a support person.  I think that I'm sure had everyone really just feeling so anxious about what that meant for, you know, their care. And then I think it puts birthing people in such a hard position to feel like they're choosing the environment and maybe care providers who they had felt most comfortable with, or the other parent to the child you're about to have or, you know, whoever else, you know, your biggest support person is, And I think that just puts so much extra, you know, anxiety. And, you know, absolutely I think that probably made people who weren't really great candidates reach out and just kind of a knee jerk reaction like, "Oh, wait. People give birth at home. Maybe that could be me. Maybe I should be doing that. And I think, you know, I've heard from home birth midwives definitely in Philly and in Maryland, and I'm sure it's happening all over, you know, the country who same thing that they've had to tell a lot of people that yes, even with everything else that's going on, you still need to be a good safe candidate for home birth, you know, kind of in your own right that, you know COVID-19 didn't magically take away all of these other risk factors that we have to look at. Yeah, and I think that's just like, you know, there's risks and benefits to home, there's risks and benefits to the hospital. Keep who choose home birth prefer the risk picture of home. And for some people COVID tipped the scales on that a little bit more on those people, you know, if they've also had low risk pregnancies, I can work with. But, you know, if you're scared of giving birth at home like probably gonna transfer for failure progress. And also that's not the situation like I want to put myself in as a provider. Like, you know, home birth is really a partnership and, you know, to build a relationship with someone last minute in a partnership to make a safe homebirth experience possible is a lot of work. It's a lot more work than when somebody comes into my care at 16 weeks.

Maggie, RNC-OB:   9:44
Yeah, I think obviously the whole relationship-based piece, you know, of home birth like that is what we see in some ways make such a big difference, you know where people feel so safe in, you know, in care. And I think the way that we have to provide care from a public health approach right now, even in the home birth setting, like it definitely is impacting the way that you're able to build that with shorter appointment times and, you know, and even just, you know, the reality of having to wear a mask when you're talking with people, like all of that impacts that feeling that you're really connecting with someone, and definitely, you know, adds just a whole other kind of layer, you know, everything that's going on and any anxieties anyone would have already. I feel like for many people I know and for myself, you know, I've had a hospital birth and a home birth, and they were both great experiences, and very similar things about, you know, both of them and also completely different because of course, you know, every birth is different. I've heard from so many people I know who are really, you know, strong home birth advocates that this is an opportunity in many ways to kind of expand the conversation around home and hospital birth.  And, you know, who is a good candidate and how you know, how could many of these people who are, in fact great candidates be accessing? You know, those service is normally if that's saying that you know, really kind of fits with them if they had a better understanding of what it means to give birth at home. But the same time that you know, we want to be so conscious during this crisis that we're also protecting home birth and the continuation of home birth by making sure that we're really sticking to the safety guidelines that let us continue to practice it. So we want people to continue to have great experiences at home, and we don't want to see an increase in, you know, in an unsafe care or bad outcomes that are then gonna ultimately kind of tipped the scales to more people actually, thinking that, you know, home birth isn't safe. Kind of from like these false things. And I think one of things that I've heard some, you know, kind of rumblings is a lot more people are considering unassisted birth because they're so concerned about not having, you know, the right support at the hospital.    

Ray, CPM:   0:00
Yeah, unassisted birth opens up a whole other can of worms, And I think I, you know, could understand it from an agency perspective. And then also, you know, from a midwife perspective, I see the barriers to having, you know, a home birth midwife, you know, like costs being chiefly among them. But also, we don't say yes to everyone. And we have small capacities, you know, I'm one person. I can't go to 20 births a month. But you know, when you've done this care and you know how quickly things can shift, you know it does give me a little lump in my throat for sure.

Abby, MD:   11:50
It's funny listening to this, I don't mean to change the subject, but I think themes of like privilege and the common good have come up a lot.  And I don't know how to explain this, but it's funny when I think about support people and birthing, and the people that I'm most worried about right now are my, you know, teen moms who are having to decide between having the person who really can provide support in labor or like their partner with them when they have their babies. And I also have been thinking a lot about just trying to...our patients are coming to the office and not allowed to bring partners. Right now we see a huge volume of patients a day, and by doubling, you know that number, we put our staff at risk so we have made that decision. I've been trying really hard to just thank my patients for that and remind them that they're doing good by coming in by themselves by agreeing to do you know the visit with their partner with face time by making some harder decisions to benefit everybody. And you know, just like the toilet paper thing. I feel like suddenly, you know, women who are are pregnant have tried to go through. I don't know. There's been this process of like what can I do to make sure that I still get my birth experience? And I think that's a little over the top. I think in general right now, women should be focused on "what can I do to have a healthy baby?" We're still gonna try to provide women with an amazing life experience, and birth experience. But I think this is going to get worse. And I think that although we have been fighting very hard to make sure women have support people with them in labor, that might change if, if the numbers of people infected with us go up.  I feel like ethically this has brought up a lot of issues about birthing options, and what your birthing options are based on how much money and privilege and how many connections you have.

:   14:28


Ray, CPM:   14:30
Totally. I feel like one of the biggest criticisms I've heard was from a black midwife out of New York who was just like  "we've been talking about, you know, black people, like being denied support in the hospitals for years and receiving or being mistreated for years. And now that, like white people are experiencing adversity like it's a crisis." And I was like, "Yeah, that's that's really spot on, yeah."

Maggie, RNC-OB:   14:54
I know, obviously you know, the social determinants of health that have impacted people for, you know, that hasn't changed, you know, in COVID, and it's only kind of magnified that piece of it. And I do think there's a whole even we know we've talked about kind of the ability to socially distance and and to kind of follow the mandates have come out from, you know, public health officials. Not everyone is able to follow that, based on kind of how their life is set up and where they live and myself personally, like, you know, I operate from, you know, a place of privilege, right? I do. I have a house, you know, that I live in where I can kind of isolate myself and my family from the world in a different way than I would be able to if I was, you know, living in the city and had much more proximity to people. And if you know everyone in the household, there's multiple adults who need to go out and do all of these kind of essential worker jobs, you know, even more so and are not health care providers necessarily, and hence are not getting the same, even if the semblance of, you know, personal protective equipment that, you know, we get doing our job and are still having all that increased exposure, and I think it's just it continues to pile on just so much heavier for just a lot of people who already don't have kind of the same access to care. And this is just gonna impact their lives so much more.

Abby, MD:   16:26
Maybe that's a good transition, because I feel like before we started recording Maggie you were talking about some of the things that we could be doing to help this be easier for our patients particularly. I mean, you were talking about some options for getting people more support virtually or in other ways in the hospital that maybe it wouldn't have the same amount of risk in terms of exposure to asymptomatic patients of COVID.

Maggie, RNC-OB:   16:57
Yeah, I know. I mean, one of these I have been playing around with is just what we've seen so many support people, you know, needing to step back to limit exposure.  You know, we have tons of people, tons of doulas who are ready and waiting and who obviously still desire to be involved in care and still help people have, you know, great labors and births. And I would I would love to find ways to kind of capitalize on that from a more systematic approach. You know, that people are able to get access to to do, listen to other support and that from the hospital side, you know that that those of us who work in the hospital would really be advocating for that and encouraging that and really embracing that piece of it. And ultimately, I would really love it if hospitals were upping their budget to help to pay for part of it. Um, because I do feel like it's a public health need, and I think it's, you know, in so many, like Patient Bills of Rights, you know around that, you know, there's different ones for each state, you know, in the U. S. But so many of them talk about the need people have that it is a basic right to be able to choose who is there and able to support you, you know, during birth. And so while I absolutely respect the fact that we've had to limit that in the end person piece of it because we're in a pandemic and that, you know, ultimately changes how we have to practice, you know, we're seeing this limit of, you know, limited numbers of visitors and support staff. You know, we're seeing that happen in hospitals across the country, but we're also seeing it in, you know, out of hospital settings. I know, you know, Ray was speaking to how they, you know, they had to limit what's available to them to down to two support people for the client in order to kind of decrease the risk of, you know, possible spread from asymptomatic carriers. And so we're seeing that this is affecting care across, you know, the board. This isn't necessarily a home versus hospital issue, but I think especially as you know, we're seeing that we know the way that care is divied up and that in the hospital, typically, you know, care providers are caring for a higher number of patients at any given time. You know that there are gonna be these gaps in care when, you know, a trained healthcare professional isn't in the room with the birthing person and their family. And so you know, what are ways that we can kind of fill in? And, you know, the majority of births do happen in hospitals. How can we kind of build up that dedicated doula support so that there is better access? You know, across the board and kind of help to equalize, you know, the playing field a little bit more. And now I'm rambling. So I would appreciate you think that could, you know, logistically, how we could maybe make something you know, like that happen or what other kind of avenues you all see for kind of bringing a little bit more of the human touch piece of it back to birth where we can.

Abby, MD:   19:51
I'm listening to your rambling because I love the idea. And I would love to hear it hashed out a little bit more. I think obviously, the limiting peach pieces so much of supporting women through birth does involve touch. And I feel like doulas who are really effective are helping women through the pain component of labor by helping them with position changes and massage and, you know, things that are gonna really help them relax and and get through the process of labor. But that being said, I do think some of that could be provided without an in person, support person, too. Or at least we could be making things a little better than they are.

Ray, CPM:   20:31
Yeah, it's so hard. Because I think for me so much of the like, yeah, like the contact, the consistent presence is like what, like we have evidence for like is having someone in the room, like sitting quietly improved outcomes. And that is the exact opposite of what we need right now to control this health crisis.

Abby, MD:   20:52
I've really seen more nurses stepping up to the plate and doing a lot of the hings, which is amazing because they're also now, you know, their job is so much harder and there's so much more risk and touch, involves more risk and deliveries are involving all this protective gear. But I really have seen our nurses, like, just be so compassionate and and really try to take on some of the role of support person to while they're doing their jobs, which has been amazing.

Ray, CPM:   21:18
Yeah.

Maggie, RNC-OB:   21:19
Yeah, and I think all of us I know there's been, you know, a lot of kind of talk about, you know, if and how you know, hospital healthcare staff can replace, you know, your support people. And so I just also want to say, like, we know, we acknowledge that, like, I know, as a nurse, I love being a nurse. I love being part of a team that gets to help, you know, people bring their babies into the world. I know I am not a replacement for anyone's chosen support person. I am not as good as you know, your partner or, you know, your mom, your sister, your best friend. Like I can't do that. And, you know, it's also I love what I doulas do and the fact that their role allows them to be there, you know, right with someone you know, through each contraction and often times because of the logistics of being a nurse, I am not able to be, you know, at the bedside with someone because I'm taking care of, you know, other people often or you know I need to check in on different things. And, you know, we're managing different aspects, you know, of the whole health picture, and and so I know I've seen a lot of, you know, nurses who absolutely are, we're stepping up and stepping into that role and doing the best that we can in those circumstances. But I also just want to be clear that, like, we know that that's also not enough. Like it's not enough in general, and, you know, even now, like we want to do the most that we can. But I also don't wanna be dismissive of anyone's, you know, experience when that is not, that's not what you want. You know? 

Abby, MD:   22:58
And I totally agree. Just like I'm not the best person to be teaching my children right now. So, you know, this is not suggesting that in any way. But I think if we could use this sort of crisis to help uncover what's not good about the birthing sort of profession in general and make things better. I think that would be a good thing, because this is a limited. I mean, this is not gonna last forever. This is hopefully a short term thing. And yeah it could make us do things better in the long run.

Ray, CPM:   23:33
Yeah, I feel like it's really bringing up like all the places where there is not integration is like so much is so much worse. You know, in all the places where there isn't enough staffing to, like, be able to provide attentive care is, like so much worse, you know. Things that insurance doesn't cover, like telemedicine, you know, and suddenly we must do telemedicine. Yeah.

Abby, MD:   24:00
Right.

Maggie, RNC-OB:   24:01
I was speaking to a lot of doulas earlier in the week who we're talking about, a kind of credentialing for doulas. You know, if that would be something that potentially comes out of this so that they can really be a more well integrated part of, you know, the health care team, and not just for hospitals to create their own, you know, in house doula programs, because I think that has, you know, pros and cons, like anything else but a way to help that transition kind of piece of it. For if we're truly seeing, you know them as an integrated part of health team that they would have better, I guess more consistent, expectations and, you know, training.  All the concerns that perhaps healthcare institution have now about not allowing, you know, trained labor support in.  What are the ways that we can mitigate that so that they feel like they know who is there helping to provide care for their patients. And kind of uplift that role so that they're able to just be more transparent and in care. So I'm interested to see, like what kind of what will come from them that. You know, Ray, in the, within the home birth kind of community.  We're seeing obviously lots of this, I feel like, even more so the community building, you know, as you're all reaching out and forming, you know, bigger networks and and everything. What do you feel like is kind of like the big takeaway that, you know, we could have for after this? Again because we all know there will be an after this. We don't know when, but it will happen.   

Ray, CPM:   25:28
I mean, I think I'm excited with how much more back up I have right now than I've ever had, period. So I'm like, one of the first things we did as a midwifery community was set standard pricing for coverage. And that, like having that, like okay, like just knowing where everyone stands and like, feeling like, yes, like that, how we're gonna, like, help each other, do this job and, like, you know, how people are gonna help me and, like, I'm gonna help other people and then having a lot more people in our pool that we can call on because we used to assist each other births, and now we need to not see each other anymore. It's really interesting and I'm hoping that the support and community that we're building will kind of last, and we'll end up meaning that we have more on call support in the future. And also like more infrastructure to handle things as a community. One of the other interesting things that's happened is there's been a couple of emergency licensure bills, and was in the works here in PA. But like in NY, the governor issued an order allowing CPMs with licenses in other states to practice in, and from Canada, to practice until, like, the end of April. And, you know, they've been working like New York is one of the hardest states to be a CPM. There are 2 CPM's that are being, you know, charged with, like, multiple felonies right now. And so the fact that you know there like "this is such a crisis that we need you" and, like other states, are also following suit, could really pave the way for more CPM laws and integration in the future. Which is, like, the more integration we have, the better outcomes we're gonna have and licensure is a part of that.  

Maggie, RNC-OB:   27:12
Yes. Ray, I am so glad you brought up the point about you know CPM licensure. And there there is such a need for us to have the same access to licensure across the US because we also see that in all times, especially in times like this, in a pandemic where there are, you know, different needs popping up around the country. We need people to be able to provide that same level of access to care all the way across the board. And we know home birth is most safe in every study where they look at this. It is most safe when it is present in an integrated health care system. And so we need to have license so that people can have honest discussions between care provider so that there's transparency about what's going on and that we can actually keep birth as safe as it possibly can be. And if people want to just speak a little bit to like the kind of conversations you know, if you want to talk to, you know, any of the podcast listeners, kind of like whata are the conversations you're having with, you know, with clients. How are you kind of balancing out that feeling of not wanting to be scary, you know, or fatalistic but also being realistic about what you know what's happening and how things have changed?

Abby, MD:   28:33
I do think for the most part we can be reassuring. You know, the scary thing about this virus is really that there are people who could be asymptomatic carriers for two weeks and therefore just given the amount of daily contact and touch we have with other people on a daily basis, the potential for many people to be infected is high.  Despite lack of still good, solid information, most of my patients and their babies are going to be fine at the end through this and at the end of this.  That piece of things at least, is it's reassuring. It's gonna be so much harder for them than it is for most women giving birth, but they're gonna be okay for the most part at the end of this.

Ray, CPM:   29:17
It's nice that the little bit of data we have isn't, you know, we aren't seeing, like, significantly worse outcomes.  Like there may be more preterm births, there may be more C-sections that might also be because of how China was treating pregnant people.

Abby, MD:   29:34
And because people are asking for them. Yeah.

Ray, CPM:   29:37
But it's like it's nice to be like, "Well, we don't think there's vertical transmission yet, like like there's maybe two case reports, but for the most part doesn't seem that the case." I'm just recommending social distancing and, you know, I think good handwashing measures.  

Abby, MD:   0:00
Which are good things in general when you've just brought a baby home.

Ray, CPM:   0:00
Yep.I think the harder part is just, like not having as much postpartum support. You know, family members can't travel to be here.

Maggie, RNC-OB:   0:00
Yeah, I know. I feel like that piece of it is like from a again, like the big public health thing. I think both from people, just everyone, obviously, who's going through this crisis, you know, we all come into it with different resource, available to us, and, I think we're all concerned about, you know, how we'll kind of see mental health suffer, you know, through this, and especially as this continues to go on.  And I I worry about how that's gonna play out, you know, within our postpartum community, you know, where we know that there's already kind of a breeding ground, obviously, for having, you know, more mental health concerns and then having changes that happen during pregnancy and, you know, births and all of those things that kind of set us up to feel like perhaps we failed or, you know, unexpected care delivery that we already know kind of can increase trauma and how people kind of respond to it and then adding, on top of that that you're returning to, you know, a place where you're really more isolated and you perhaps don't have you know, any support? I'm concerned. And again, that's one of the issues that I would love for there to be kind of more broad strokes efforts to how are we kind of addressing all of these people who are, you know, postpartum and adjusting to just a huge change in, you know, themselves in their family dynamic. 

Abby, MD:   31:35
Amidst all of this other upheaval, I feel like we're finally making some momentum and acknowledging that there was a void of care after delivery. And yeah, now those are the patients that are easiest to just "okay, you don't need to be in the office. Just go home."  But again, I think strategizing and figuring out ways that we can support women without actually being physically present is probably going to be an important part of this.

Ray, CPM:   32:00
Yeah, I think one of the things I'm most excited about through all this is like the advent of, like, online breastfeeding support groups and just being like, "Yeah, why wasn't this already happening?" Like it is so hard to leave the house with a baby or some people can't because they're caring for other children. And it was like, I hope this stays because I think there's ways that probably these mediums of in person and online can be better mixed.

Abby, MD:   32:26
Tele medicine in general to for medical care. It's really interesting how much can be accomplished, not in person.

Ray, CPM:   0:00
 Yeah.

Maggie, RNC-OB:   32:31
Yeah, I think it will be introducing how that plays out in terms of like when things get back to normal. How much of that will change and kind of for the better. Like, how can we kind of better integrate these different technologies in different ways to kind of help maximize everyone's, you know, benefit from the situation. 

Maggie, RNC-OB:   32:51
And behalf of all of us obviously just a big shout out to everyone right now who is working through this. So for all of our health care workers in, you know, all of these different settings who are really coming together to try to do more and do better, you know, by the people in our care, even when under, you know, extraordinary circumstances.  I really am so encouraged by all the stories we hear of, like more communities coming together. People really kind of stepping up to fill their roles as much as they can. And you know, to all the people who are out there giving birth right now and getting ready to do this like, you're just so incredibly strong to, you know, be bringing life into the world amidst all of this. And you know that strength is it is not going unnoticed. And so we really applaud you for for stepping up and for also for, you know, letting us know as your care providers what it is that you need and how we can help to get a better support you, you know, and as much as we we can during all this. Thanks you all for being here. I appreciate you.

Maggie, RNC-OB:   0:00
 Yes.

Maggie, RNC-OB:   33:56
Yeah, absolutely.  Be well. Be healthy.

Maggie, RNC-OB:   33:59
Thanks for tuning in. We love to talk birth and would love to talk about it with you. Please join the conversation by finding us on Facebook, Instagram, or Twitter, we're Your BIRTH Partners on all platforms. Especially during this really trying time when things are constantly changing and everything feels very up in the air, we really want this opportunity to connect with you and understand what your concerns are and, you know, band together so we can come up with solutions that help all of us to, you know, improve birth experiences for those in our care. So we would love for you to comment on our show notes blog at yourbirthpartners.org or you know, find us on social media and let us know what your concerns are and how we can all draw together during this time.  Till next time!