The excitement of new beginnings was infectious. Four years of medical school and three years of residency had landed me my first job at the end of 2019 as a general practitioner caring for those experiencing homelessness in San Francisco. I was diagnosing, prescribing, ultrasound, and making connections with patients.
With newfound stability in place, my husband and I started trying for a baby. When a yet-to-be-named novel coronavirus out of Wuhan, China, led the World Health Organization to declare a global health emergency in January, I learned I was four weeks pregnant.
The next nine months were agonizing as I navigated risks, ever-evolving protocols, and constantly wondering if I was being safe or too cautious. I wanted to keep working, but I wanted my unborn son to be healthy. Those two things felt dangerously at odds with one another more often than not. To guide me, I had limited data and limitless worry.
Shortly after receiving my positive pregnancy test, the pandemic and panic spread. I was designated as an essential worker. Our clinics remained 100% in person with minimal opportunities for phone visits or conversions to telehealth.
At eight weeks, I was deep in the throes of morning sickness and hadn’t yet told my supervisor I was pregnant when I was assigned to work at a newly created Covid-19 testing site in San Francisco. There, doctors swabbed symptomatic patients in daylong shifts to preserve personal protective equipment. I felt moved to be part of a clinic rapidly formed by necessity — a call to action where I’d be in the fray.
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But also, my God, what if I caught Covid-19 and, ergo, my baby did as well? At this point, we knew so little about the virus and what that could mean.
I wanted to continue helping but felt in my gut that the risk was too much. I disclosed my pregnancy four weeks earlier than I had planned and asked to stay at my current assignment at the clinic rather than work at the Covid-19 site. Nervous, I opened with a salvo regarding my dedication to the cause — to medicine, to be flexible with my schedule, to working — before asking for relocation. My supervisor said she understood and that a different provider had recently been reassigned when his beard prevented a proper N-95 fit. “Oh, thank god,” I thought, relieved by that detail but also annoyed at myself for being so apprehensive to ask for this accommodation. “Baby trumps beard, so if beard counts as a reason for reassignment, pregnancy most certainly does, too.”
As many of my friends converted their spare bedrooms into home offices and became intimate with the functionalities of Zoom, days at my in-person clinic continued ostensibly unchanged. Except, of course, for the ongoing, ever-growing, all-consuming shroud of Covid-related anxiety that hung like a wall of fog over our clinic and lives. My pride at being an essential worker was tempered by the endless uncertainty surrounding the health and safety of the staff, the patients, myself, and my unborn son.
Was I being careful enough? Was I doing enough to mitigate my risk?
Pregnant women are already subjected to hyper-conservative medical advice. During my first prenatal visit, my provider instructed me not to drink coffee, suggesting instead just one cup of white tea a day. This is a common recommendation based on poor-quality data that shows just how excessive and comically circumspect prenatal counseling has become. If I wasn’t even supposed to have a cup of coffee while pregnant, I definitely wasn’t supposed to get Covid-19.
Throughout the winter and spring, I had been regularly scouring the internet for information on Covid-19 and pregnancy. At that time, the CDC reported that Covid-19 didn’t seem to affect pregnant people differently, though it urged pregnant women to “take precautions” to avoid contracting the virus. The early studies on pregnant women in Wuhan who became infected with Covid-19 showed that the moms fared fine, and upon delivery, so did their babies.
“See?” I showed my husband. “It was fine. I am fine. Baby boy is fine. Right?” I was trying to convince us both.
But those same reports noted that the women in Wuhan were all well into their third trimesters when babies are sturdier and far more resilient. It wasn’t possible to extrapolate fetal outcomes if infections occur earlier when babies are more susceptible to all viruses, Covid-19 included. I was still in my first trimester when organ development occurs and fetuses are at their most vulnerable.
The limited data was not encouraging, but it wasn’t discouraging, either. I decided to keep working.
Iwas at the end of my first trimester when San Francisco’s shelter-in-place order began in March. Some of my department’s older and medically at-risk workers asked for accommodations to work from home. My husband wondered if I too should limit my patient contact, if not work from home completely. I obviously wanted to decrease my exposure risk, but the thought of not seeing patients for the foreseeable future was painful.
At 18 weeks, just as I was feeling the first fluttering kicks of my baby boy and just as cases were surging around the world, I asked for guidance from my OB.
“Well, the data is limited,” he began.
“No shit,” I thought.
“We do know that pregnant women are susceptible to more serious complications from any virus—take the flu, for example—and so very likely that is also true for Covid-19.” As a doctor, I was well-versed in this kind of non-answer answer-speak: I don’t know the answer to your question, but here is a related fact! It is a tried-and-true doctor ground.
It often seemed my decisions boiled down to two options: hermetically seal myself into a fully isolated, contactless bubble or continue in-person work and put my fetus at risk as a Covid-exposing baby-killer.
He suggested I limit my exposure to patients with acute respiratory symptoms or fevers. This felt reasonable but challenging, given that a majority of my patients smoke or suffer from a chronic cough. And because the city started offering isolation hotels to homeless residents with Covid-19 symptoms until test results came back, some overstated their respiratory symptoms to receive some much-needed housing. Was that cough due to cigarettes, a cold, Covid-19? Or a desire to get indoors for a bit? Nothing was easy to discern.
I opted to follow my doctor’s suggestion. I was guilt-ridden to be putting my colleagues at greater risk by sending these patients to them instead. It felt self-interested. Yet it also felt right for my boy. I was worried I wouldn’t be able to see anyone, but there was no shortage of patients to see with foot pain, abscesses at injection sites, congestive heart failure, and hepatitis. I prescribed buprenorphine for patients with opiate use disorder. I kept on doctoring. It felt good.
AsI continued my second trimester in May, I found myself still questioning if I was doing the right thing. I heard of other hospitals pulling pregnant residents out of clinical work and other San Francisco clinics that conducted care for patients with Covid-19 symptoms over the phone. (They’d come to the clinic and use a phone in an exam room.)
“Should I even be in the clinic?” I thought, going down this mental road again.
Spooked, I emailed my supervisor to ask if there were any non-patient-facing shifts I could take at the clinic’s separate call center, which had notably increased volume due to Covid-19. But after percolating on my own request, I withdrew it. It seemed unlikely that all my shifts could be transferred, and substituting one or two seemed unlikely to meaningfully decrease my risk. I wanted to keep working, as safely as possible, in person. As for symptomatic patients, I disliked the idea of doing phone visits while the patient sat one room over. But to keep frontline workers working, not getting Covid-19 was paramount. So, somewhat reluctantly, I started using the phone method for these patients, too. As a small upside, it allowed me to “see” these patients, evaluate them, and refer them to isolation rooms (where they were tested) without having to tax my colleagues to see them instead.
In June, during the end of my second trimester, just as I fully switched over to maternity clothes, new studies showed that in the United States, pregnant women infected with Covid-19 seemed to have worse outcomes when compared to non-pregnant Covid-19-positive reproductive-age women. The CDC noted that pregnant women were “significantly more likely” to be hospitalized, put on ventilators, and have premature labor. Due to these findings, the CDC revised its declaration on pregnancy and Covid-19, stating that new evidence showed pregnancy might increase a person’s risk of severe illness.
But the studies were dangerously flawed: Given that the United States had no system of widespread testing and was only being done for people who had symptoms or exposure, they didn’t take into account asymptomatic and mild Covid-19 cases among pregnant patients. If there’s no denominator of total known infected patients, there’s no real knowledge.
I spent hours evaluating studies, doctors’ opinions, official recommendations — they all felt like trying to use divining sticks and Ouija boards to make essential decisions about the health of me and my baby. I felt like I was wading through a quagmire, sinking in useless words as I looked for solid ground on which my growing body could stand.
I would read one article and feel safe, then another and feel at risk. I would see a patient I was treated for HIV and feel proud of my work, and then I would see another with a surprised cough and would feel panicky and fearful. My thoughts swirled in a dizzying array of contradictions and wild pendulous swings. It often seemed like my decisions boiled down to two options: hermetically seal myself into a fully isolated, contactless bubble or continue in-person work and put my fetus at risk as a Covid-exposing baby-killer.
What I so deeply desired from my OB, the DPH, the CDC—anyone, really—were definite, line-in-the-sand recommendations to limit my risk: Do this; don’t do that. What I desperately wanted was someone to tell me the best course of action; that I was doing right by my body and, most urgently, by my boy. I didn’t want to make the call myself, because that would mean having to live with the overwhelming guilt if something, anything, went wrong.
Ikept working, focused on minimizing my risk. During my eight-hour shifts in urgent care, I often asked every single patient to please pull their mask up over their nose. Some of my patients didn’t wear their masks correctly because they were under the influence of substances. Some thought the virus was a farce.
We stopped seeing patients in our two smallest exam rooms and instead used the two largest, where we could sit six feet apart. Despite the San Francisco chill, I diligently pushed open the one functioning window in the exam room each morning and left it open for the duration of the day for better airflow. I continued seeing patients with Covid-19 symptoms solely over the phone. I started wearing an N-95 instead of a surgical mask. I started getting myself tested for Covid-19 intermittently.
Perhaps most important, I attempted to surrender to the uncertainty that had left me feeling at different turns guilty, melancholic, frantic. I had incomplete data with which to make challenging decisions. I knew only what I knew when I knew it. I was doing my best in my pregnancy and would keep doing that for what I was sure was going to be 18 more years of demanding decisions.
During one of my last prenatal visits, a new doctor urged me to leave work at 36 weeks. I told her I planned to leave much closer to my due date. “No one needs you that badly at work,” she told me. “You cannot get Covid-19 right before you deliver. You’d have to wear a mask and gloves with your baby — it’s a mess.”
Another classic doctor-talk trope: advocating for the most conservative course of action. I was wholly unconvinced but felt arguing would only elongate the visit.
I nodded, took in her worry, her anxiety. “Hmm,” I replied. “That would be hard.”
“It’s interesting,” I thought, “that she could know how badly, or not, I was needed at work.”
I wanted to tell her I was going to continue my shifts, my overtime, and the Saturday clinics. That I was working more than ever. That I had spent eight months already deconstructing the risk of Covid-19. That I happened to be pregnant and essential.
I left work at 39 weeks, and in October, while wearing a mask, I delivered a healthy baby boy.
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