EBB 387 – Doulas in the Operating Room, Risk of Repeating a Severe Tear, and White Coat Hypertension in Pregnancy with the EBB Research Team

Dr. Rebecca Dekker – 00:00:00:

Hi everyone. On today’s podcast we’re going to answer your questions about the evidence on doulas in the operating room, the risk of subsequent tears after you’ve had a severe tear with the first birth, and white coat hypertension in pregnancy. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, thank you for joining me for today’s episode. Just a quick reminder before we begin that registration for the Evidence Based Birth® Conference is in full swing and early bird prices are available through February 27th. Now our conference at EBB is fully online so you can join us from anywhere in the world. We have an amazing slate of speakers and together we’re going to cover topics ranging from pelvic floor health and trauma-informed care to aspirin for preeclampsia and the hepatitis B vaccine for newborns. Just go to ebbirth.com/conference to check out the full conference schedule, session topics, and select your ticket option. We also have applications open for equity pricing through February 27th. And now for today’s episode, we’re going to talk about the evidence on having doulas in the operating room, the risk of having a subsequent tear if you had a severe perineal tear in a prior birth, and white coat hypertension in pregnancy. 

This episode is unique in that it is taken from a live training we did with EBB Pro Members in December 2025. So the work we do here at EBB is supported in large part by our Evidence Based Birth® Pro Members who are part of a continuing education community of birth workers and healthcare workers from all around the world. Inside the EBB Pro Membership, we host a variety of monthly events, including doula mentorship calls, midwife mentorship calls, and more. We also offer all of our continuing education courses there, including a monthly live training. In this particular training that we hosted in December, myself, Dr. Sara Ailshire, and Dr. Morgan Richardson-Cayama prepared an hour-long Q&A session about six important questions we’d received from our Pro Members. In today’s podcast, we’re going to share our responses to three of those six questions. So we’re going to provide research-based responses to questions about doulas in the operating room, severe perineal tears, and white coat hypertension. If you’re curious about our responses to the other three questions about progesterone for preventing miscarriage, herbs and medications for increasing your milk supply, and microbiome seeding after Cesarean, those are going to be kept private for our Pro Members inside their monthly training archive. Our research team at EBB also personally responds to all of the research questions from Pro Members that are posted in our private community. And if you’re interested in becoming a member so that you can access our continuing Ed courses, live trainings, and community, the link to join is ebbirth.com/membership. 

So without further ado, welcome to the recording of our recent training where we shared responses to three really excellent questions posed by our members. Hi, everyone, and welcome to this month’s training for Pro Members. I’m so excited to have the research team here with me. We’re going to host an “ask me anything.” We did get the questions in advance because often you all ask really hard questions and it takes us time to gather the research. So I just wanted to let you know that’s why we’re doing some questions that were submitted in advance. So I have with me today, Dr. Sara Ailshire and Dr. Morgan Richardson-Cayama. Would both of you mind just briefly introducing yourself?

Dr. Morgan Richardson-Cayama – 00:03:56:

So again, my name is Morgan Richardson-Cayama. I have been with Team EBB for about two years now. I’m a member of the research team, recently got my PhD in public health, and I do a lot of maternal and child health work and specifically around respectful care. But yeah, I’ve been answering the questions in Circle for about the past two years and love diving into these, doing these sort of deep dives on a lot of these different topics. I’m happy to be here today.

Dr. Sara Ailshire – 00:04:19:

Hi, everybody. My name is Sara. I am also a research team at Team EBB. I’ve been here since about 2023. So if you’ve asked the question in Circle, you might have seen me there. Dr. Sara Ailshire. I recently got my PhD. So recently, in fact, that I still don’t quite know when to say doctor. It feels so new. I have a PhD in medical anthropology. My research work focused on efforts to improve women’s experiences in childbirth in India. So doulas, midwives, and also like human rights efforts around that topic. So happy to be here.

Dr. Rebecca Dekker – 00:04:56:

Yeah, I’m so thrilled that we have Dr. Morgan and Dr. Sara on our team. They’ve really contributed a lot over the past few years to the research we put out. And we thought it would be fun to answer six questions, kind of all unrelated. So I’m going to read them out loud and so you’ll know what we’re talking about. We have, what is the evidence on doula presence in the operating room? Hot topic. This next one is a question we get a lot. What is the risk of severe perineal tears in subsequent births? So, if you had a severe tear in your first birth, you know, we see a lot of OBs recommending a Cesarean. If you’ve had a severe perineal tear the first time. What is the evidence on vaginal seeding after a Cesarean? What is the evidence on white coat hypertension in pregnancy and how is it related to preeclampsia? We’ve been getting that one a lot. We also have a really interesting question about the evidence on progesterone for prevention of miscarriage, which I know has impacted a lot of us and our clients. And we’re going to end with the evidence on galactagogues for increasing milk supply. So six unrelated but fascinating questions that you all asked. So Dr. Sara Ailshire was assigned to look at the research on doula presence in the operating room. So take it away, Sara.

Dr. Sara Ailshire – 00:06:15:

Hi, everybody. So, the question we got, it was from Magdalena and she said, “Do we have any studies on doula presence in the operating room, benefits for breastfeeding, bonding, and birth satisfaction?” We were able to find a little bit of research about this. Lanning et al is a 2019 quality improvement study of an effort to bring hospital-based volunteer doulas into the OR to support clients giving birth via Cesarean. So this was a quality improvement project that took place at a big academic hospital medical center in North Carolina, where labor and delivery unit staff had already attempted to implement skin-to-skin care in the operating room, but they were finding that they weren’t always able to succeed at this implementation effort. And observations by the researchers and also personal communication from the hospital staff revealed that the biggest barrier was a lack of sufficient staff. So they wanted to help people have skin-to-skin, but there wasn’t always enough hands in the operating room to support that. So they thought that it would be good if they could find a way to bring doulas into the OR to better support people giving birth by a Cesarean. Volunteer doulas from the hospital-based volunteer doula program participated in a four-hour training course that focused on providing care to people in the OR. The course was offered by the researchers and the labor and delivery nurse, and it also included a birth simulation on the unit. So they were actually able to go into the OR. In addition to that, their training included information about where to be in the OR, how to stand occupational safety, as well as how they could help their clients initiate breastfeeding shortly after a Cesarean. 

The second part of the study looked at collecting data for about 12 weeks about this new doulas in the OR program. And what they found with this data collection was that women who had Cesarean births supported by the doulas felt that they had a really important and positive birth experience. The labor and delivery nurses who were working alongside the doulas also responded that they felt like the doulas were a positive addition to the OR. And all of the medically stable mother-infant dyads in this study were able to initiate skin-to-skin in OR with the labor doula support. So in cases where the baby was not doing well and needed some additional support, they couldn’t initiate skin-to-skin right away. But in cases where the baby did not need some help with breathing or other things, they were able to do that. There was a follow-up to this study looking specifically at the doulas and their experiences. 55 of these volunteer doulas went through this program and they reported that having this specific training helped them feel more prepared and helped them feel like they knew what to do in the OR, which is important. So that’s a study looking at a hospital-based volunteer doula program. But a lot of doulas we know are not volunteers based in a hospital. They’re independent professionals. So there was a more recent 2025 quality improvement study that looked specifically at how hospitals could incorporate professional doulas in labor and delivery, including in the operating room. And this study addressed some of the challenges that this particular interaction could pose from the perspective of a hospital. Because doulas are not hospital employees, this ultimately meant that they weren’t involved in drafting some of these new policies that this quality improvement study was about. And that’s because a hospital had concerns about information sharing. So some of the improvements that the hospital initiated were being more specific about treating doulas as professionals. So that includes providing doulas with name badges that identify them as a doula rather than just as a visitor. They also provided a private space for doulas, kind of like a recovery lounge. So doulas could rest if their client, you know, they needed to take a break. And they also, maybe most importantly for our purposes here, talked about how they could bring doulas into the operating room and what training they could possibly provide to doulas. And this was kind of a big question they had because they’re not hospital-based volunteers. A range of doulas could be coming in. So they had to figure out what the training could look like kind of on the fly. So in this study, the policy that they developed was identifying a hospital employee who would be responsible for the doula, so typically a nurse, and then identifying a specific place in the OR where the doula could be, all the time, like different, different cases, so they could provide support to their client. 

So in general, there’s not a lot of research on doulas in the OR. And I think part of the issue that we see in these two studies, the North Carolina study, all the doulas are volunteers and the hospital had a lot of authority over them and their training. This made it a little bit easier for a hospital to incorporate them more regularly into the OR and gave them a little bit more capacity because they had that hands-on training. The hospital knew that they knew what to do. So they might have had a little bit more flexibility, but it doesn’t really create a good space for professional doulas. The other study that we looked at, professional doulas were the focus of these new policies, but because they’re outside of the hospital system, they were shut out from the decision-making that was really important to their ability to fulfill this capacity. And the hospital policy around doulas in the OR, this lack of training meant that doulas could be present, but they might not be doing everything that they could do, including supporting skin-to-skin care or nursing in the OR. So, it’s early days, but I think there’s some good news. When we were doing research on this question, we found some additional policy guidelines about doulas in the OR out of systems in California, but also Missouri. So it seems like there’s a growing interest. And I think it’s going to be important to kind of like pay attention to how doulas, nurses, midwives, obstetricians, and anesthesiologists, all the members of the team in the OR can come together to figure out how they can better provide support to people giving birth by a Cesarean. So, in addition to sort of limited research on this topic, the Skin-to-Skin Care Signature Article has some additional evidence. So if like you’re kind of interested, you want to learn more, you want to like you’re a little bit curious about like what are the possibilities about skin to skin care in the operating room? Not maybe specifically about doulas on the OR, but a related topic. That’d be a place to look.

Dr. Rebecca Dekker – 00:12:53:

Thank you, Dr. Sara. One question I had for our participants here today is let us know in the chat or have any of you been able to, as a doula or a birth worker who maybe is not a labor and delivery nurse, have you been able to go into the operating room with your clients at all or how many times or is this still not an option where you live? So let us know in the chat and kind of see what’s going on. And is it only specific hospitals that are doing this or are there some that do it and others that don’t? Okay, so some people are saying only if you’re the primary support and you don’t have the partner in the room. New York City doulas are allowed in the OR. Not all hospitals allow it, though. Some hospitals in Phoenix offer two-hour orientation that then allow presence in triage and OR. There’s a new law in Virginia. Oh, wow, I wonder if it’s based on this research then, since some of this research was from Virginia. It seems simple, but it’s not. You know, I know it’s complicated to get these policies changed, but it can make such a huge impact on the family’s experience. It looks like there’s mixed comments in the chat. Which is I think what I would expect. All right. So the next question, Dr. Morgan, do you want to talk about severe tears and then going into labor with a subsequent birth?

Dr. Morgan Richardson-Cayama – 00:14:20:

Yes. Yeah. So this question was from Lisa. So yeah, it was just in general recommendations for someone who had a precipitous labor with their first birth that resulted in a third degree or severe perineal tear. And just wanting to know what the evidence is on subsequent tearing or tearing in the next birth. And then Cesarean as well, because I think her OB was recommending a 39-week induction or a scheduled Cesarean as Rebecca had mentioned earlier. It’s something that we’re kind of seeing a lot. So thank you, Lisa, for that question. And I’ll summarize it first, and then I’ll kind of go into a few specific studies. But overall, the research does suggest an increased risk, even if a slight risk, but an increased risk for third- and fourth-degree tears and an increased risk of or a likelihood of elective Cesarean birth in people with a history of tears. And that elective Cesarean could again be because it’s being recommended by the provider. So they’re choosing to do it maybe out of the sphere of a subsequent tear. But we do see increases in both of those for people who have had a birth where they have previously had a severe tear. And that risk for repeat tears appears to be higher for those who had more severe injuries in their prior birth, as well as those who are older in age and those who are giving birth to bigger babies. And that big babies is what seems to carry the highest risk overall, the studies have found. 

So looking at a few specific studies, there was a big systematic review and a meta-analysis that was done in 2016 or published in 2016. And it included 16 studies with almost 100,000 people. And they found that the risk of a perineal injury in a subsequent birth was about 6% in those with a history of tears, but only about 2% in those who had not experienced a tear in a birth. So 6% versus 2%. There was also a large study from Scotland that had about 182,000 people. In their study, they found that third and fourth degree tears occurred in about 3% of participants and that those participants were four times more likely to have a repeat tear in their next vaginal birth. And they were also more likely to have an elective Cesarean birth for their second birth. So the people that chose to have a vaginal birth were four times more likely to have a repeat injury. The people who had had a birth who then electively chose to, sorry, who tore in their first birth, then were more likely to also choose to have that Cesarean for their second birth. And again, repeat tears were higher among those who were older and who had a bigger baby weighing at least, you know, 4,500 grams. Another study from the UK included about 2,000 people with a history of perineal injury and also looked at this increased risk in subsequent births. They found that among those people, so all 2,200 participants had had a birth or had a tear in their first birth, about 78%. So most of the study, three quarters, went on to have a subsequent vaginal birth. And 10% of those did experience a repeat injury. Of the remaining 22%, that chose to have a Cesarean birth. 80% of those opted for an elective Cesarean. So about three quarters chose to have a vaginal birth and 10% tore. And then the other quarter or so chose a Cesarean birth and 80% of those, it was elective. So it was a decision that they were making.

Dr. Rebecca Dekker – 00:17:30:

And I just wanted to jump in and say, Morgan, that of those 10% who experienced a repeat injury, most of those experienced a less severe tear known as a second-degree tear. And only about 4% overall experienced a repeat injury that was a severe tear.

Dr. Morgan Richardson-Cayama – 00:17:46:

Yes. Yeah.

Dr. Rebecca Dekker – 00:17:47:

Okay.

Dr. Morgan Richardson-Cayama – 00:17:48:

Yeah. Good catch. Yes. And like many of those other studies, they found an increased risk in that subsequent perineal injury among people who are older, who had bigger babies, and again, who had more severe injuries in their first birth or experienced an episiotomy in that first birth. All that said, I did find one study, so this was kind of an outlier, that did not find an increased risk in severe perineal tears. That was conducted in Wales. It was a pretty large study. It had about 510,000 people, including around 3,000 who experienced a severe tear in their first birth. They compared outcomes between those with and without severe tears, and they did not find any differences in those. But so, again, that was just one study. But we had another larger study in Scotland and that big systematic review that did find an increased risk. And I see a question too, were they electing to have their Cesarean? That’s a good question. I didn’t see that. I could definitely look back into the studies, the individual studies from that review and dive into those and see. But yeah, that was just kind of a question I had as well as they could have elected to have a Cesarean because of the fear of that or being told that they had a big baby. So it’s also important to consider the risk, whether induction increases the risk of a perineal tear. 

So I just wanted to give Lisa a little bit of information on that as well when I responded to this question. So there was a 2020 meta-analysis found in multiple studies that augmentation of labor overall increased the risk of perineal injury. Although induction of labor specifically did appear to increase that risk in a few studies, it wasn’t significant when they did their big meta-analysis and combined all of that data. There was another 2024 review and meta-analysis, so again, combining a lot of different studies, that also did not find any difference in the risk of severe tears between those who were induced compared to those who received expected management. It was about 3% in both groups. So just something else that could impact people if they are being induced to think about whether that increases their risk. And it doesn’t necessarily show that, but it’s good to think about. And so just to summarize, most studies have found a higher risk of severe tears in people with a history of tears, although that risk appears to range anywhere from 6% to 10%. And that 10% was second-degree tears. And it is highest for those with big babies and those who are older in age. And we have a few other resources at EBB for people whose clients or birth workers who might be really interested in how you can reduce the risk of perineal tears. We actually have a few podcast episodes on this topic and a whole series on protecting the perineum. So I think it’s like episodes 210, 216, and 221 all have great information on protecting the perineum and what the evidence is on things like warm compresses and hands-on versus hands-off and things like that.

Dr. Rebecca Dekker – 00:20:27:

That is awesome. Thank you so much for sharing the numbers, because I feel like a lot of people don’t know what to say when their clients are like, should you know, what should I think about this offer to have an elective Cesarean? And now you can say, well, around six percent will have a repeat tear. And for some people that might be too high of a risk. And for others, they might think, well, I have a 94 percent chance of not tearing, you know, and there are things I can do to lower the risk. So thank you, Dr. Morgan. That was really helpful. Anybody in the chat want to share if they are seeing this recommendation to have Cesarean if the client has a previous injury, perineal injury. Let us know in the chat if that’s something you’re seeing occasionally. We do get that question regularly submitted through social media as well. So it seems like, something that’s happening. And I thought it was interesting, Dr. Morgan, you talked about the rates of elective Cesarean were fairly high. It’s hard to know, was that the client’s idea or was it the OB’s, you know, strong recommendation? Right. So far, nobody’s really seeing that. But yeah, I think it’s a valid space because severe perineal injury or sometimes called an OAC tear can be really traumatic for some people. So I can see how they would consider having a Cesarean. 

Okay. So I am up next and my question came from Kelsey. Kelsey submitted this question. She said, “I’ve had five out of nine clients have preeclampsia this year.” She says some cases were questionable due to having white coat syndrome. Is there research on preeclampsia versus white coat syndrome? I want to know more about this topic so I can help my clients advocate for themselves. So one of the first things I recommend people do is that all of us should be aware of the American Heart Association guidelines on how to take a blood pressure correctly. Even if you’re not the one taking blood pressures, you should be able to send people that information. Because we need to know the facts. Is this true hypertension, or is it just improper technique of taking a blood pressure? And we’ve all probably had our blood pressures taken improperly in the past, but improper techniques. Include taking a blood pressure while someone’s talking with the patient, not having back support, your legs dangling. So the chair is too tall for you or your arm is dangling, there’s nowhere to rest your arm or using an incorrectly sized cuff. So taking a blood pressure while you’re talking can increase your reading by 20 points. Taking it with a full bladder can increase your reading by 33 points. If your arm is hanging, it can increase it by 22 points. So if you really want to have an accurate reading, don’t smoke beforehand, don’t have caffeine beforehand or alcohol, and you shouldn’t have just come from exercise. You want to make sure they’re using the correct cuff size for your body. You want to empty your bladder beforehand. You’re going to be sitting quietly and not talking while they’re taking your blood pressure. You want to sit upright with your back supported, your feet on the floor, and your legs uncrossed. So crossing your legs can also affect the reading. The cuff should go directly over the skin, not the clothing. And there should be two readings taken one minute apart. 

So I don’t know how often you all are seeing blood pressures taken correctly, but I have a feeling that a lot of clinics are still being done incorrectly. And I will post a link in the chat to a good handout from the American Heart Association that you can print off and use about how to take a blood pressure correctly. Yeah. So Chanté is like, I need that in a handout. There’s a handout. And we’ll put that in the replay links as well. So there are three articles. About white coat hypertension, I’ll also link for you in the replay. And all three of these research papers are free full text. So you can really dive deep if you want to. For those of you who are not familiar with the term white coat hypertension, it refers to high blood pressures that seem to only be present in a clinical setting. And it’s nicknamed white coat because you have this health care worker who might be wearing a white coat. And they’re taking her blood pressure. And it’s historically thought that if you only have high blood pressure when a health care worker is taking it, it’s due to the increased stress of being in a health care setting. 

However, now we have research. You know, they used to think, well, it’s just white coat. It doesn’t mean anything. But now we have research showing it’s not benign. There are actually health risks associated with white coat syndrome. So if you think about it, the fact that if your blood pressure was going up when confronted with a health care worker, it’s showing that your body is increasing its blood pressure under stress. That maybe it shouldn’t be going up that high when you’re confronted with a stressor. So it’s almost like being in a clinic and, you know, having your blood pressure taken is a little bit of a stress test for your body. So if your blood pressure is going up in that little mini stress test, it might indicate you have underlying issues that might pop up later in pregnancy. Or later in life. And that’s exactly what research has found so far. So there was one literature review published in 2020 that combined data from 12 different studies, and they define white coat hypertension as a disorder when you have an elevated clinic blood pressure greater or equal than 140 to 90, but a normal blood pressure when it’s taken at home or at work. This happens in about 25% of the population. So if any of you know you have white coat hypertension, you can mention it in the chat. It should be about one out of four people. And rates are similar in pregnancy. Up to 30% of pregnant people will have white coat hypertension. So in this review, they combined the 12 studies on blood pressure, white coat hypertension, and pregnancy. And when they compared those who had the white coat hypertension with those who had normal blood pressures in the clinic, the white coat group had more than two times the risk of preeclampsia and more than two times the risk of giving birth to a small for gestational age newborn and a three times greater chance of preterm birth. When they looked at only those who had white coat hypertension diagnosed early in pregnancy before 20 weeks, there was a more than five times higher risk of preeclampsia later on. 

In contrast, if the white coat syndrome started showing up after 20 weeks, there was no higher risk of preeclampsia. So it seems to be that it’s early pregnancy blood pressures. If they’re white coat and they’re normal at home, that this indicates a really high risk of preeclampsia when it’s seen early in pregnancy. However, when they compare those with white coat hypertension to those who have officially diagnosed gestational hypertension or chronic long-term hypertension, the white coat group did have a lower risk of preeclampsia than those people with the official diagnosed hypertension. There are guidelines I’ll post under the replay. There are global guidelines for how to diagnose and manage hypertension that include recommendations for white coat hypertension in pregnancy. And they say as long as there is no severe hypertension, you should be averaging out multiple home readings over several days to determine what to do. But basically the evidence says that if you have white coat hypertension, you should be monitoring your blood pressure at home regularly. Let’s see, in terms of what experts say, you should never just take one reading when you do a home BP. You should always do two readings at least a minute apart. And you should use a diary to report your blood pressure and when you woke up and when you went to sleep. You should also educate people with white coat hypertension on symptoms of preeclampsia, such as headache, visual disturbances, and abdominal pain. And interestingly, Kelsey mentioned the high rate of preeclampsia in her doula practice this year. And according to the Preeclampsia Foundation, the rates are going up. I had trouble finding the exact rates. I did see that there was an analysis of 51 million births from 2007 to 2019, found that the cases of new onset hypertension of pregnancy doubled in the 2000s and the 2010s. And the risk is higher in rural areas of the United States. There was an interesting NPR article about the increase in preeclampsia. They were looking specifically at preeclampsia in rural Montana. Really fascinating because these are otherwise healthy women, very active lifestyles, you know, living on farms and ranches and things like that. And they were at much higher risk for hypertensive disorders. And there are other certain groups at higher risk of hypertensive disorders, including those exposed to racism and prejudice. 

And I found another study looking at global rates of preeclampsia. They found that over the past 30 years, the global incidence of hypertension disorders of pregnancy has grown from 31 million cases per year to 36 million new cases per year. And the countries with the highest rates in the world include the South Sudan, Niger, and Chad. The countries with the lowest rates include the Republic of Korea, Guatemala, and Canada. So researchers still don’t know why rates of preeclampsia are going up, but they believe it’s complicated and there’s probably a combination of factors going on. So I think for birth workers, the takeaway is that, you know, continuing your education on preeclampsia is going to be really important. And home blood pressure monitoring is also going to continue to rise in importance. It’s probably a good idea for everyone who’s pregnant to have a home blood pressure monitoring cuff and to know how to use it correctly. And yeah, that’s what I found. So how do you get diagnosed with white coat hypertension? So if you have an elevated blood pressure in the clinic and you should be given instructions and equipment to check your blood pressure at home. So if it’s elevated in the clinic. Greater or equal than 140 over 90, but when it’s taken at home, it averages out to less than 135 over 85. So that would indicate white coat hypertension. And again, it seems to increase your risks if it’s identified early in pregnancy. And the Preeclampsia Foundation is a really great resource. They have a ton of articles about preeclampsia. Recently got a cuff in the size I need exactly. And you can’t be afraid to say that cuff doesn’t work for me. I mean, it can increase your reading by 30 or 40 points. If you’ve ever had that done to you or seen someone where they use the inappropriate cuff, same for children. You know, anybody who’s small, if they use too big of a cuff, that can also affect the reading. So it’s really important that people have the correct size cuff. And we do have a training in your monthly training library about hypertension, preeclampsia, and pregnancy. If you haven’t watched that one yet, it’s with Dr. Shannon Vogt. All about evidence-based care for someone, evidence-based management of hypertension and pregnancy. It’s a really good training. 

So that wraps up our podcast episode where we looked at three of the responses that we gave to our Pro Members. If you’re interested in learning about our responses to the other three questions about progesterone for preventing miscarriage, microbiome seeding after a Cesarean, and different herbs and medications that can help support lactation, just go to ebbirth.com/membership to learn more. Thanks, everyone, and I’ll see you next week. Bye! Today’s podcast was brought to you by the Evidence Based Birth® Professional Membership. The free articles and podcasts we provide to the public are supported by our professional membership program at Evidence Based Birth®. Our members are professionals in the childbirth field who are committed to being change agents in their community. Professional members at EBB get access to continuing education courses with up to 23 contact hours, live monthly training sessions, an exclusive library of printer-friendly PDFs to share with your clients, and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans, as well as scholarships for students and for people of color. To learn more, visit ebbirth.com/membership.