Bias in Birth #007

This week we dive into bias in birth, when we see it, and what to do about it.  We'll discuss provider:provider bias, bias about the "right" way to give birth, and ways we hope to see bias diminish as we all work together.

Transcript

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Maggie, RNC-OB:   0:05
Hey there. Welcome to Your BIRTH Partners. We're here to break down 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 we'll be getting into a topic that I think is really crucial. To moving forward as our country works on perinatal healthcare. So we are talking about bias and particularly bias that happens amongst birth professionals between each other amongst people, professionals and consumers alike, about the idea that there is one right way to give birth. You'll learn a little bit more about kind of the status about what we see happening in our interactions with each other as professionals, and get a greater understanding about some things that you can do both as a consumer and as a professional to counter act when you see that going on.  On to the show!

Maggie, RNC-OB:   1:02
All right, everyone so welcome, welcome. Today I want to do something that we were able to touch on in our first community episode and just dig into it a little bit more so kind of the idea of bias. And there are a lot of different ways that that plays into health care and how we work, you know, as professionals. But particularly today, I want to have a chance to talk about kind of that bias that we all hold, and that sometimes our clients and our patients hold as well about, there kind of being this one right way to give birth. Or that there is one way that a pregnancy or postpartum is supposed to look, so how those kind of ideas about bias that we have towards birth and towards certain providers and birth professionals and what they might kind of bring into that mix and dive a little bit deeper into that.  I saw a quote from Ina Catrinescu, and she said, "confirmation bias is our most treasured enemy. Our opinions, our acumen, all of it are the result of years of selectively choosing to pay attention to that information only which confirms what are limited minds already accept as truth. So I would just love for you guys to kind of tune a little bit, you know, let us know. How do you feel like bias, do you see it, you know, coming up in your practice when you're when you're talking with people, when you're working, you know, with other birth professionals. How do you feel like it's impacting care?

Angela, CNM:   2:13
Biases that I see in my clinical setting is when a patient says "I have a birth plan." I wish that everyone's perspective or views about patient choices and desires were not viewed in such a negative light, because it really helps us to understand the things that are important to the patient and their family. And it helps us to develop our plan of care. In order to potentially, you know, help to meet some of those goals. Obviously, as long as it's safe and responsible I feel like, I always need to say that because anytime I don't backlash, for not saying, you know, "as long as it's normal."

Abby, MD:   2:58
Birth plans make me a little sad. I think they, you know, evolved as this wonderful tool to help people think about their priorities in their births and in their health care. But as an obstetrician, they tend to be often perceived as something people give us because they don't trust our judgment or because they're very worried or scared that we're gonna be overly interventional. There can't be an exact plan for your birth because you don't know what's gonna happen. Just like as a parent, you don't know what's gonna happen. You know, it has to be an exercise in being flexible. And I think for people to have overall goals or visions about how they want things to look, that's very reasonable. But unfortunately, birth plans are often only set up to accommodate the perfect birth, you know, and when things aren't that, it's hard.Yeah, I definitely think there's been something in kind of the way that the birth plan probably the vocabulary we use around it has contributed to some of that bias. I think a birth plan, you know, plan sounds very structured. I think when we, you know, as we if we can start to think of them as birth preferences, as you know, ideal ways that things are going to go that helps to kind of decrease that bias. But I've absolutely I've seen that you know, over and over again with, you know, with colleagues, and even with other, you know, other people who are giving birth that they'll refer to someone else's choices like, "Uhh, well, they're just set on all of these things happening." And so it's, you know, it's too much kind of to ask for all that. And I think we need to be really, you know, conscious about the language that we use when we're explaining about potential courses that happen, you know, during labor and delivery to help set people up to understand how preferences might play into what's going on. And then we really need be active as birth professionals, too, to pause and to look at each, you know, each new birth plan that comes across us and take it in for what it is that this is their you know, their best way of presenting what their goals are, what they hope will happen, and try to keep some of our bias about "every other time that we've seen X, Y and Z on the sheet, this happens." Because that's not, you know, that again that goes back in that confirmation bias. That's that idea that we're kind of cherry picking those moments in our mind, in our memory, that affirm that idea that "Oh, if someone's asking for all these things, you know, it's asking too much of the universe, and they're gonna end up having, you know, a higher intervention birth."

Ray, CPM:   5:30
Well that's so interesting so I think, like, you know, my population is obviously different and part of their like birth plan or preferences is choosing this different health care setting where they're like, yeah, a lot of the things they're like, guarantees it unspoken like, yeah, like skin to skin, delayed chord clamping, delayed newborn interventions, doing newborn interventions on parents,, like all that stuff just happens. And then they can, like, really going to, like, the nitty gritty of like what they want. I do think the population that chooses home birth is taking this, like, extra steps..."I want these things, and then I'm gonna choose a different environment." And then when I'm like, guiding people towards thinking about if there's a need to transfer, you know, we're going for interventions, it's gonna be a really appropriate use of interventions. Choose a couple preferences: what are the big things that you want to like hold from the home birth experience. Like, is it low lights? Is it that your partner catches the baby? Is it? You know, delayed newborns interventions? Like what? Like the three big things. And then in the event of a C section, Like what are the two or three big things. So it's kind of like a stage thing because, you know, I'm just like this is your reasons that we transfer. And if we're going, we're going for interventions. So I help guide you through that. But also, what are the most important values there? 

Angela, CNM:   6:48
I think that is so important whenever we are thinking about or discussing birth plans. For example, I think that often people think about them as being this rigid idea, but I truly visualize them as preferences and like, "What are the things that are important to you?" Because it helps me to understand my patients and their families values. And I think the biggest thing is that well, patients just want to be heard. So often they feel like they haven't been heard. And so then there are some who come across as being very firm about things. And then there are some who are very relaxed about things. And what I found in my practice is just listening to patients, listening  actively listening without interrupting so that I get the whole picture and then validating them and then "hey, well, I want you to think about this because what if this doesn't happen? Would you be comfortable with this? And I'll explain to you why we would recommend X, Y, or Z.  So I wish, what I hope for is that as birth leaders that we take a different perspective on what this birth plan could be because it's not about...it is sometimes, unfortunately, about patients not trusting us, but rightfully so in many, many cases. But it is also giving us an opportunity to validate, help to clear up anything that maybe they thought was accurate, that is not accurate, and explain the rationale for things. Because I have plenty patient when I said "Okay. Why do you feel that way? Why don't you want this or why do you want that?" And then I give them a different perspective and they're like, "oh, I didn't know that, I didn't think about it that way, I don't know that with an option," you know?

Maggie, RNC-OB:   8:57
Absolutely. And so you know what are ways that you all when you're working and you're interacting with other, you know, colleagues. If you see people kind of showing some of that bias, you see that maybe they've had a little switch is flipped, and they are perhaps not really kind of seeing the perspective of what's actually happening in front of them. What are some ways that you have been able to kind of help, like guide, you know, the conversation to, you know, try to eliminate a little bit of that bias?

Abby, MD:   9:25
I think in my case, sometimes just going in and having a conversation in front of a nurse or a resident or person who hasn't necessarily been comfortable with somebody's birth plan helps. I think just a really open conversation with the patient, where everybody in the room can realize that the patient's actually not that unreasonable and where we can talk through, you know, the parts of the worst plan that are gonna make a birth special for somebody but also the parts of the birth plan that are really getting at the heart of what things are you worried about? What things are going to be really hard for you? And if those things happen, you know, how are we gonna work through that? You know, I don't know if that makes sense, but...

Angela, CNM:   10:04
It makes perfect sense. Absolutely.   

Pansay, Doula:   10:10
I want to add that, from my perspective, you know, as the doula going into the medical facility that, it happens to us a lot where, you know, once the client presents the birth plan, if she arrives before I do, or once I present the birth plan to them that you automatically see the switch in the face. Oh okay, you're one of them.  

Maggie, RNC-OB:   10:34
Mmm, the guard goes us.  

Angela, CNM:   10:35
Oh, my God, yes.  

Pansay, Doula:   10:36
Exactly. Exactly. And you know whether or not the birth plan is there because the client does not trust the medical facility. That's the truth. A lot of our sisters go into the hospitals and they don't come back. Yeah. Okay. So we might not trust medical facility. Yeah, we have horror stories from my grandmother's, from our mothers. We might not trust the medical facility. So we feel like if we at least put the desires down, the things that we have researched, we have looked at the outcomes, we have looked at whether not if we minimize this intervention I may come home alive. That should be respected.  This is a human being with rights. This is a very sacred time. We're not just another number. We're not just another bed. And all of that should be looked at as a whole, as a woman, as a human being. These are her rights and her choices that she has researched. And, yes, she wants to say, these are my preferences with my body and my baby. That should be totally okay. Totally okay.

Maggie, RNC-OB:   11:59
Absolutely.   

Pansay, Doula:   12:00
Especially when I see, where I have clients of a different race at the same exact hospital. And they do not receive the type of treatment where we have those those you know. You have those nurses..."Oh, she wants to use, you know, holistic modalities." They will massage her scalp. It's big. It's like, oh, okay. I never see that with [my black clients].  So why?  It's like, yes, it should be as woman to woman. You know, nurse, I'm a female, okay, you're a woman who is bringing forth life. You have a right.  This is an experience that you can never get back. We cannot turn back time. Yes, I'm going to respect your preferences and your wishes.  Of course keeping in mind that birth is so unpredictable. I've educated my client on that. Things can go awry at any time and again with normal with things going normal, a normal birth.

Angela, CNM:   13:08
Absolutely.

Pansay, Doula:   13:10
Yes. So we're not being unreasonable. We know that. I mean, they know that if they're coming to a medical facility we're there just in case something goes wrong, they are trained, you know, to treat it. Okay, that's why we're here. But as long as everything is normal, "okay, these are my preferences. And this is what I like." And we just, we just want that respect.

Abby, MD:   13:33
Yeah, yeah, yeah. It's sad, though, because those preferences shouldn't have to be voiced. We should be treating every woman period across the board, with respect. I mean...

Angela, CNM:   13:43
Yeah.

Abby, MD:   13:43
Early skin to skin, delayed cord clamping, those kinds of things and then a much broader just respect of our patients, listening to our patients, figuring out who our patients are, and what their needs are, that's the important part. And you shouldn't have to come with a plan. You know, you don't get that treatment if you don't show up with somebody who's gonna advocate for you. That part of this makes me really sad.

Angela, CNM:   14:08
Yeah, same. You know it, the part of having to have someone advocate for you. You are absolutely right. Like we should, it should just be a natural thing. As people who have chosen the path of caring for other humans, as women caring for women, as males who are choosing to care for women. It should be a natural thing to just advocate for the right thing for each and every individual, despite their circumstances, despite their background, despite how they have ended up in the situation that they ended up in. And I don't know how we have gotten to such a point in our community and health care where we are biased on certain things, and choose to neglect our patients because of it.

Maggie, RNC-OB:   15:02
Yeah. I mean, as we look at at birthing people, we need to be seeing who they are, you know, as an individual and absolutely what you're saying, Pansay, about the fact that that's not seen and then that sets people up to feel like they need to come in, and really fight for what's going on, and it creates this....We have created this system of, you know, perinatal health care that we have created in our country has led people to feel like they have to go in and fight for themselves, and that's absolutely not how it should be. People shouldn't have to feel like they're going in ready, too, you know, dig their heels on and stand for all of this. That should be like Abby was saying, those should be standard of care and so many of those things they are, there is every reason for those to be happening in every birth, they are evidence based, they are what is actually the right, you know, thing to do in those normal circumstances. And it is unfair that as a system we have, then kind of turned that on its head and chosen to see people who are fighting for themselves and what actually feels right to them and make it seem as if they're the ones who are a problem when it's absolutely 100% a systematic problem that we have created and we need to be the ones to fix.

Ray, CPM:   16:12
I started off as a doula, and I think the reason I kinda hit a wall where I couldn't do it anymore. And it was because I felt like I was a stopgap measure on this, like, gaping hole or a broken wound like it was like this tiny Band Aid because the care was inadequate. And so people had to hire someone to, like, support them throughout birth. And I just felt like "no, I want to be a partner in people's care." I want yeah, I want the care and respect to be like the central part of their perinatal care experience, and it's unfortunate that the way it's set up right now is that the people that can access this like partner in care who's like a person relationship are typically people who have more means because homebirth is more outside the system. You know this model of care isn't being replicated in other health care settings as much. So it's still like, being in a setting where you don't have to, like, advocate for yourself or feel a need to advocate or you don't have a relationship is like less common unless you're hiring this like one-on-one midwife relationship? Or like working with a really small practice, which is not accessible to a lot of folks in a lot of places.

Abby, MD:   17:25
That's often why you see this discrepancy that you talked about, Pansay. I think in health care settings where women are getting really different kinds of care. It's funny, I was late on labor & delivery one night recently where some of our nurses were having a conversation where they sort of said, "I wish we just had a doula, I wish we had, like, a couple doulas on our unit who were people that really helped us understand our patients, who helped patients through labor, who helped patients, you know, with strategies for pain management in labor, particularly patients who wanted unmedicated births, but also people who recognize that we're all part of the same team."  I thought that was interesting. I mean, certainly we have those doulas that show up in labor and delivery, and I know them well, and I know that we're going to collaborate together. And then that's not always the case. Just like I'm sure when you show up on labor and delivery with certain patients you you don't feel accepted and you don't feel like you're part of a team.  

Pansay, Doula:   18:34
Definitely.

Maggie, RNC-OB:   18:35
Yeah. And I think as we're [continuing], I love that some of the nurses were talking about that and having that, you know, that acceptance piece of it, cause I know we talked a little bit about, you know, kind of that bias that most of us we come into, however we came into birth work, you know, we were informed by our own cultural and educational experience about what that means and who should be involved, and how it all is supposed to work. And then as you keep working through it ideally, constantly. For the next 80 years, we're all growing and we're learning new stuff. And we're not just accepting what we learned was in school or what someone once told us one time.

Pansay, Doula:   0:00
Right, exactly.  

Maggie, RNC-OB:   19:10
es.

Maggie, RNC-OB:   0:00
es.

Maggie, RNC-OB:   19:41
nd so I love that, you know, these nurses are, you know, accepting and advocating and wanting to see doulas and recognizing the wonderful role that they can help to play, because it's very much complimentary. I am always psyched if one of my patients has a doula, because I know. "Okay, great. There are even more people who are here dedicated to this person having an amazing birth that meets their needs." And, you know, a lot of time there's a lot of, you know, pressure on the people who are taking care of someone during birth. Because it is a high stakes situation, and this is gonna last with someone for their entire life.

Pansay, Doula:   0:00
Yes.  

Maggie, RNC-OB:   19:41
And so we want it to be everything. And so the more people we have in there who are dedicated to, you know, making that happen, it helps. And I feel I from where I came up in birth I didn't have, I alwasy saw doulas in a very like, positive light, but I absolutely know that for some nurses, that's hard. It feels like people are coming into kind of their territory. And it can feel, you know, difficult that you're worried about how care is going to be, how we share and that you don't want to have to be, you know, fighting about anything. And so I would love it if you guys can peak to kind of, What are some of the situations where you have seen your own practice kind of grow and shift to be perhaps more accepting? Because obviously, you know, as I was reaching out in starting this organization I wanted all of you to be a part of it, because I see you all as such accepting people who really see the team approach, you know, behind. But I know we all didn't necessarily start feeling that way.

Angela, CNM:   20:33
I would say the biggest thing that I personally done is remind myself that ultimately it is not about me.  And when I was in private practice, it's just so different that in military medicine Everyone has access to good collaborative health care, right in one setting. You literally can come in with 10 issues and you walk out the door wrapped in a bow because we fixed it already.  When you work in the real world, you see and hear everything, and you are working with providers who have come from all over the place who don't necessarily maybe have the same beliefs or standards, are not held to the same standards, because they're not basically, they're not run by the government so to speak. And so, what I really had to do is learn to humble myself, not let myself get so upset about the things that I have no control over or no power over and just accept that this is the way this person is going to be, this position is going to be, this midwife is going to be, this patient is going to be, and I need to calm down and meet them in the middle somewhere. And maybe, just maybe, if I respect them, then they will grow to listen to me and to trust me and even, you know, take my opinion for certain things, and maybe we can work together collaboratively. I build a lot of bridges that way with patients who absolutely didn't trust midwives. Even the first practice I worked in, she never worked with midwives before. She had been a physician for 30 years, and she ended up hiring two more midwives to work with her practice. You know, it was just about building the bridge and being humble, and it hurts sometimes, you know? Because sometimes people people don't come to meet you half-way, no matter how much you try.

Ray, CPM:   22:49
Yeah, I really relate to the last part of what you said. I think something I want to mention before I talk about overcoming my own biases is some of the really extreme biases against home birth and the people who provide home birth care and the clients that seek home birth care. And how hostilely  many of my clients have been treated when interacting with other health care providers. When I have sent someone in for an ultrasound or had to, you know, get an NST at three o'clock in the morning...And, yeah how much that impacts care. And also, like, ends the conversation and that, like, it doesn't seem like anything I say or do can change that.  And how much people dislike home birth, and the people who provide home birth, and the people who believe that this is a reasonable option. So I think for me, like a lot of my bias has shifted in having good transfers, in having and also letting go of my ego and seeing how yeah, I don't know, planning a home birth is not about the place of birth. It's about providing safety and shepherding people through this tremendous experience of meeting a child. And sometimes you know, and sometimes we need more help. To have been met many times now by sometimes providers I didn't know, and sometimes providers I did know with open arms who helped us use these interventions that are feared in really good ways to help provide safety. And also for some of my clients, who have had to have births that were the exact opposite of what they had planned and intended on and were cared for so lovingly has really helped me remember that we want the same things. We want people to like have good care. We want people to have like healthy outcomes. We want people to be safe and be able to bond with their baby.  And the way that the systems do that is different and there's a lot of barriers in each system to providing that. But we have the same goals and, like the folks who have bias towards me, also have those goals and just don't realize that were in alignment on those things. And I think that's kind of I think I got both, like, continue to have these, like, positive experiences and then have these experiences that give me pause and that kind of [breath sucking in] feeling of, like, how are we gonna go forward? And it's kind of a challenging line to walk.

Angela, CNM:   25:29
That was very well said, Ray. Oh, my gosh, it is. It's so crazy how, like you will sometimes feel like "Oh my gosh, I'm making all these leaps and bounds,  moving forward, progressing." And then, yeah, one thing happens, and it like stains the entire picture of all the great things that you built.  It is scary because sometimes, it's difficult to come back from it and you build a wall and you start not trusting again. And it just it further creates the divide with bias and tears down the relationships that that should be built between interdisciplinary clinicians.

Ray, CPM:   26:22
It really does. And I think I want to maybe name an experience I had recently in the last few months.  Which is, I was in an area I don't attend births commonly and needed to transfer to the hospital quickly so we couldn't go to our preferred backup hospital. So I called the local hospital to give report. A midwife picked up the phone and I told her why we're coming in, she said, "I don't accept your transfer." And I was like "Wait, what? Like that's illegal. Like what? And I was like, I I need to come in now. I'm transferring for heart tones." And she's like, "we do not accept your transfer," And I was like, "Okay, um, we're gonna be there in 10 minutes by ambulance, so I'll see you soon." Oh, and it's just like, you know, my client was treated fine and we had an okay outcome. But that level of hostility is gonna stay with me for years. And I have this, like, initial impact of like, "Oh, my God, I do not want to attend births in that area anymore. I do not want to be near this hospital." It was, like, a nonstarter. And it was with a midwife. I think there are these little and big pieces of trauma that we catch and carry, as you know, people who attend birth. And, like, you know, the 20 great transfers I've had to the local hospital in Philly are totally overshadowed by this, like, one really scary experience. And it was scary because of how I was treated as this person trying to transfer care.

Maggie, RNC-OB:   27:57
Oh, my gosh. I mean, I'm so sorry that you experience that and that, you know, as a result, your client was a part of what was already a scary and unexpected transition in care becomes so much worse when we don't just come together. And you know, I think it's like you said, obviously, it's two steps forward, one step back, and it does it makes such an impact when we have these really negative experiences.  And, you know, people get used to seeing things in, you know, in their one sight.  And so it's really unfortunate that whatever has kind of fueled that midwife, that provider's experience about transfers that resulted in them having such a terrible interaction with you.  And I will speak, again personally obviously, at one part of my career, I was probably less comfortable with, you know, home birth. It's certainly not talked about in nursing school, you know, that's not, that wasn't ever a part of, you know, how we viewed birth and how it could look. And certainly though then, as I continue my practice and learned more and and I had to actively seek out and understand that safety, you know, there was at one point that I was really, I was biased. I was really uncomfortable with whatever the CPM qualification meant.  I didn't understand that you know, I knew what nurses were, I knew what nurse midwives were, and I was unclear about the safety that would be provided by a CPM.  Or you know, by another midwife who didn't go through, you know, the same training. And so I had to really actively search for that information. I had to take on that responsibility to better inform myself so that I could have a better understand of care. And I think the problem comes when we're not able to do that or we're not willing to put in that work to better create understanding and to eliminate that bias. Because obviously now I feel very comfortable with understanding CPM's and the education and, you know, qualifications that you all do and have and the safety really provide during birth. And I am so desperate for us as a perinatal health care system to do better, to better inform everyone who is involved in care so that we understand these roles that people have, and we're able to be accepting of each other and not have these kind of egregious acts that go against everything we believe in, you know, as as health care providers,

Abby, MD:   30:23
it's funny this conversation's making me think of, like, the systems-based things we could do to improve this cause I think, I mean, home birth is not going away. And, you know, I think as a physician, I've been on the other end, I am often on the receiving end of deliveries that haven't gone well. And when you're dealing with a mom and a baby who are sick and you're not the one who's provided the initial care and you don't have a bond of trust with that patient, and we're living in a malpractice environment that's really broken and serves to penalized physicians, and not help families that have babies in need, so I feel it's the system is really broken. It's funny, though, Ray, the delivery, the experience that you were talking about makes me think I mean little tiny things like, "Wow, if you have a home birth in the area where the local hospital is one that you don't know, like should we be having a phone call that says there's somebody laboring and they may be coming in. And here's their background, just in case." And I think that the unfortunate answer is that a lot of physicians will be like, "No way. I don't want that liability." There's not gonna be a simple fix to this, but I think that we have to do something to improve care for patients and relationships and communication,

Angela, CNM:   31:46
Yes.

Ray, CPM:   31:47
So much of it has to do with relationships among providers because at the wonderful Hahneman Hospital in Philadelphia, which has since closed. You know, there's a midwife who is in town for many years, Christy Santoro, who built a real relationship of trust with the primary obstetrician and midwives in that practice. And so when I had a birth that I was like, "I don't love what's happening here..." I would just call the midwife on labor and delivery and be like, you know, I have this situation and I'm not sure if I'm gonna come in, we would like, chat about it, and they're like, "Yeah, I can see, like maybe I'll see you later. Maybe give it a little bit more time." And, you know, just like the relationship of trust the relationship of, like those folks that have, like, a one appointment with that practice. So they were in their system and that, like, I would send records that, like, felt good to them and they, you know, asked us for what they liked, which was an anatomy scan and GBS, which sometimes our cliennts consented to, and sometimes they didn't, and because of that, when I, you know, had transferred people there for heart tones urgently, we were received well, because they trusted me and they trusted my judgment. And so I definitely understand, like being in an area where they don't know me and they, like, receive something scary, that it would feel scary. But also, there's this general mistrust that, like home birth, is bad and dangerous and that home birth providers are unskilled and that, like people, were like making these crazy decisions that are gonna kill their babies. And like, those biases are, you know, you could not understand, you cannot agree, you could be like,  "yeah, that's not the decision for me," and also be like this person was making autonomous decision with their body, and we're now transferring because it's no longer appropriate for home birth.

Maggie, RNC-OB:   33:28
And we're going to continue to support them in making decisions that best respect them and the actual situation they're in.  

Angela, CNM:   33:34
And not treating them like trash.

Maggie, RNC-OB:   33:35
And I know, we're definitely going to talk about this more and, a future episode we have planned is for kind of that idea about hospital birth and out of hospital birth and safety and how we we build, you know, that trust and and talk about transfer care because it's a huge issue. And I'm sure there are people potentially listening right now who have no idea that it would be that complicated, that providers aren't able to have those conversations openly in every environment, because that seems very logical that we would all be supporting each other, you know, in this and the fact that it's not happening is, you know, it's a huge detriment to our clients and outcomes that they end up having.  And so, you know, I know we obviously we talk about this forever. But I want us to be able to kind of just close and think about, how we care for each other during birth. Those relationships that we create between other birth professionals, and us all actively working to fight against our own bias about what we think birth is supposed to look like, what we would like our birth to look like. Whatever ideal birth means in our head that we need to realize that's fine to have those, but we need to kind of put that aside and be, you know, in the moment where we are with the person that we're caring for.  I liked this quote by Anais Nin who said, "we don't see things as they are, we see things as we are." And that is something that we need to be very aware of and conscious, as we, you know, provide care and try to direct how things go that we're making sure that all of our own, you know, biases aren't getting in the way of what's actually happening in front of us. Well, thank you all so much for talking about this with me today. It's always a pleasure to see you.

Angela, CNM:   35:23
Thank you. Thank you. I love these conversations. Real talk, girl talk, yes.

Maggie, RNC-OB:   35:31
All right. We'll talk soon.  

Maggie, RNC-OB:   35:32
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