When the Delta variant hit Mississippi, the Morbidity and Mortality Weekly Report (MMWR) published alarming statistics for maternal and perinatal deaths. Pregnant women were dying at three times the pre-COVID baseline rate. These young, healthy women would rapidly deteriorate in a matter of days, with three weeks as the average time to death. And those were just the moms. Fetuses under 20 weeks gestation aren’t counted in the mortality rate of COVID infections, but they are the most innocent victims of this pandemic.

Trying to rationalize outcomes, OBGYNs turned to Facebook, WhatsApp international group texts, frantic phone calls to our peers, and the rabbit hole for critical care protocols. At first, the poor outcomes were anecdotal, then clustered in outbreak epicenters, then studied formally. Finally, there was confirmation; miscarriages were increasing, and not just the first trimester ones.

In July 2021, the American College of Obstetricians and Gynecologists (ACOG) “emphatically” recommended vaccination in pregnancy and boosters when appropriate. Pregnancy and COVID statistics were scary. Pregnant women with COVID experienced higher rates of ICU admission, more invasive ventilation, and higher mortality rate. Hypertensive disorders in pregnancy increased tenfold, as did growth restriction and preterm deliveries. It seemed like a convincing argument for vaccination.

Many times I’d recite this to a patient, she would call me brainwashed, argue that I was just trying to scare her, and tell me that ultimately it is her choice to disbelieve the government. Every preconception visit of an unvaccinated woman involved counseling about COVID and a discussion about the risks and the benefits of vaccination, complete with up-to-date journal citations. But they laughed it off.

One stuck out. I’d been seeing her for five years. She came to me two weeks after ACOG‘s statement, stating that she was ready to conceive and fixated on the best brand of prenatal vitamin to take. “But which is the best? I saw these online, and my friend took these others.” I reviewed her history thoroughly, noted the recent COVID infection (mild, “why are you making a big deal about this, doctor?”), and recommended a standard vitamin, as well as COVID vaccination.

The tone immediately changed in the room.

“Doctor, I didn’t come here to talk about COVID. I just want to get pregnant.”

Great, and I said I was looking forward to the pregnancy but I recommended vaccination to prevent all the aforementioned risks. I asked her if she could ever imagine a scenario where the cost of her illness is the life of her baby. She said that it wasn’t true, “why would you try and scare me like that? I’ll deal with it.” I asked if she would be able to live with herself if she ended up COVID positive and either miscarried or had a stillbirth. That nearly broke me, even to ask.

Just three years prior, I had influenza A at 27 weeks pregnant. It probably infarcted my placenta. I was restricted from everything: work, gym, playing with my dog. I worried that one misstep (not literally, I was stepping only to the doctor) would prevent me from meeting my son. Even when he was born, I couldn’t bond right away because of that fear. That flu season was brutal. Pregnant women were being intubated. There were three in my hospital that winter. I was lucky to not be one of them.

After some more hostility from the patient, I finished the annual exam, wrote the prescription for prenatal vitamins, and gave her the link to the ACOG COVID patient information website. It was an emotional appointment, and she left crying. I didn’t feel great about it either. There was nothing satisfying about making an obstinate woman cry.

Sharing that vulnerable story with the patient should have made me relatable, but it made me a subject of ridicule instead. How do I come to terms with this? Where do my needs as a person supersede my needs as a physician, and where do the needs of my patients fall with all of this?

I thought of her with each miscarriage I saw in COVID+ mothers, and during each delivery of premature rupture of membranes due to infection. I thought of her every time I gave steroids, increased the oxygen flow for someone struggling to breathe, or held the hand of someone before their emergency delivery. I saw her face when I was frantically calling a pulmonologist to help me manage oxygen on a deteriorating patient on the unit. She stayed with me through each obstetric emergency.

She probably never thought of me. I was the doctor who made her cry when she was most excited to tell me that she wanted children.

I don’t know if she’ll be back, and I don’t know if I am better or worse at explaining the urgency. All I know is that we all make choices. With COVID, some choices will save lives, whereas other choices might end with the unimaginable.

Yuliya Malayev is an obstetrician-gynecologist.

Image credit: Shutterstock.com