This is a common refrain from my collaborating physician, a woman who has worked in this community for decades and whose spirit betrays her lack of ability to maintain empathy. I’m not sure what she had to begin with, but now it is worn pretty bare.

It was hard to imagine those first few weeks. It can’t be that bad, I thought. Most people probably have some level of interest in taking care of our health, have some buy-in. Especially pregnant patients, right?

***

Every week, there are patients who show up toward the end of pregnancy, realizing it’s time to have the baby, having not been in prenatal care for months, maybe at all. They know they need to get the baby out. But they didn’t come in for their second trimester anemia follow-up, the anatomy scan ultrasound, the diabetes screen. They didn’t necessarily take their prenatal vitamins and likely haven’t been eating healthy. Maybe they were smoking weed or drinking or having high risk sex. They don’t know if the baby is going appropriately or if the baby is “okay,” but they come in…they come in.

Everyone I work with, even those who have been working in this community for years, still seems surprised that our patients don’t reverence prenatal care the way they did, or the way they think everyone should. “I went for every one of my prenatal appointments, I took my vitamins, I showed up, why can’t these people?”

“These people.”

And it’s true. In the narrowest sense, all pregnant patients in my state can get prenatal  care. For undocumented mamas, it can be more difficult. No public health clinic is going to turn you away, that I know of. And for our patients, getting insured, getting Medicaid, is possible. Not saying the state doesn’t make you jump through hoops that may at times be humiliating and exhausting, but in theory pregnant women at least can get insured. But at least there is some assurance that the state will cover the cost of your care. It’s free!

And then there is coming in.

There is, of course, a wide variety of reasons patients don’t come in until midway through the second, or even until late in the third, trimester to establish care or to pick up where they left off after the initial dating ultrasound. I can’t pretend to understand all that goes on outside the clinic, in my patients’ lives, but I can say that moralizing about patients not showing up doesn’t actually help get them in the door or make them feel welcomed when they do show up.

No, this isn’t a rural community in subsaharan Africa, where there isn’t modern medicine. Oh, here, we have it all! We are in the heart of a wealthy American city!

***

…A wealthy city in which fifty public elementary schools were just closed, almost all in black and brown neighborhoods; in which the majority of my patients only ever see white faces in their health clinics, maybe their kids’ schools, and in blue uniforms; in which there are few grocery stores and terrible transportation systems in the neighborhoods that are majority people of color; where in some areas youth are tracked into the criminal injustice system and in others, they are offered the world.

When the City doesn’t really give a shit about you, doesn’t value your basic human needs, let alone your higher aspirations…why would you necessarily adhere to the proscribed regimen of care for the baby you are carrying?

And even in these terrible circumstances, most of our patients are active participants in their care — they show up, get excited each time they hear the baby’s heartbeat, they worry when anything isn’t normal, they ask great questions about their bodies and the life growing inside of them.

But just as you can’t compare yourself, who did everything “right” when you were pregnant, to the few patients that don’t show up for care, you also cannot compare these “delinquent” patients to those mamas in the (other) third world who would be so grateful to have access to the kind of care that our patients take for granted.

And what if your managed care Medicaid company has you tied to your primary care provider at a clinic where every time you meet with the doctor, you feel like she doesn’t have time for you, doesn’t explain where your cervix is, doesn’t follow up on your look of bewilderment with a simple question about how she can help you understand?

I might not keep showing up either.

***

It is frustrating and scary as hell to be a prenatal care provider in those situations. When you accept a pregnant patient into your care so late, you just don’t know what you’re going to get. Intrauterine growth restriction? Fetal alcohol syndrome? Uncontrolled gestational diabetes? Preterm labor? You feel like you’re scrambling to catch up, to find out what is going on physiologically, with the pregnancy, and what motivates the woman carrying the pregnancy. You worry she might expect everything to go perfectly, while it appears she hasn’t done her part to reduce risk, since you haven’t seen her for so much of her pregnancy. You might become the type of provider you swore you’d never become. You might not even recognize yourself after years of seeing the same social problems reflected in the faces of your beautiful young patients.

Until we fight for and win from the system quality affordable housing, excellent free public education, decriminalization of our youth and of blackness, safe and affordable food and water, expansive mass transit, and a single payer health care system, the circumstances under which we utilize any and all of these basic human needs will be less than ideal. And so will our provision of such care and services.

I look forward to working in healthcare in which women’s and children’s lives will be truly valued, and in which we will collectively trust, not scrutinize–but also, enhance–women’s decisions and lives.

For now, I am grateful for having a worldview that helps me find empathy alongside righteous rage against the system. I’m grateful for education that gave me the tools to provide evidence based care, so I can continue working to do my best for patients as they show up in my clinic, whenever they’re at in the lifecycle. I’m grateful for lunchtime office yoga or forest preserve walks that preserve my sanity. And I’m grateful for intersectional (anti-racist, anti-sexist, environmental justice approach) social and economic movements in the city, country, and world, that can make things better inside and outside the clinic walls. Because good lord, things need to get better, soon.