Tell Your Birth Story with I Be Black Girl

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Thank you for sharing your story and experience with us in order to achieve quality and culturally relevant maternal health services that center Black women, femmes, girls and folks with uteri.

By filling out this form, you acknowledge and entrust us to lift up your story during the maternal health initiative campaign. We would like you to share all (both positive and negative) experiences with the medical care you received:

- trying to get pregnant
-during your pregnancy
- after giving birth
- 6 months to 2 years after giving birth
- the care of your newborn

First Name *

Last Name *

Home zip code *

Phone Number *

Email Address *

Do you identify as a Black women, femme, girl or person with/had a reproductive system? *

Yes

Age *

19 and under

20-30

31-40

41-50

51-60

61+

If you are under 19 years of age, please list your parent/guardian's first and last name + phone number

In 250 words or less, please describe and share both positive and negative experiences with the medical care you received while trying to get pregnant, during your pregnancy, giving birth, and/or 6 months to 2 years after giving birth. If you prefer to be interviewed- please list the word INTERVIEW in the box below. *

Can we follow up with you about your story? *

Yes

Maybe

Other:

Do you want your story to be anonymous? *

Yes

Would you be willing to be interviewed by News outlets or tell your story in other places?

Yes

Maybe

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