One young woman sits and waits patiently, scrolling on her phone to pass the time. A couple sits across the room talking softly to each other. The air feels light in the quiet room. A woman arrives, checks in, walks with heavy steps to a chair and sits down with a sigh. Now, something in the air feels tired. I offer a smile, remember my mask is covering my face and follow up with a nod of acknowledgement. A few minutes pass as we each sit there in our own heads and worlds. Then suddenly, a jingle playing from a phone and the rustling of coat sleeves announces a family’s arrival. Bustling out of the elevator come two parents and four girls; the girls run excitedly to find seats. The youngest — no older than three — claims a chair and starts talking loudly to her sisters.
Sitting in the obstetrics and gynecology waiting room, I feel the atmosphere fluctuate from still to chaotic, light to heavy, open to anxious. Each person comes carrying their own stories — their own struggles and successes, worries and hopes.
Working here on a research project, I approach patients about participation in a study addressing maternal mental health and improving access to mental health care for low-income Black and African American pregnant persons. As I ask participants questions about anxiety, depression, social support, stress and prior adverse experiences, they share their stories and a view into their worlds. I am repeatedly touched by their openness, inspired by their resilience and amazed by examples of selflessness amid challenging circumstances.
One of the first patients I met was Mrs. K, a 23-year-old woman with a 10-year-old son and a three-year-old daughter. She and her husband live in a rented apartment currently infested with bedbugs that spread from their next-door neighbors. With a check they received from the apartment complex, they rented one hotel room for three nights before transitioning to stay with her husband’s mother. But the mother-in-law had “lots of rules,” so they returned to their apartment, where they are also now three months behind on rent. Mrs. K is 28 weeks pregnant and wants to be in a new home by the time the baby arrives. As she quantified and qualified her stress in questionnaires on paper, she thought out loud, partly to process the questions and partly for conversation. During our exchange, she shared that she works at Chick-Fil-A where her coworkers call her baby “nugget.” She looked at me then and cracked a smile.
Ms. S is a single mother with a seven-year-old daughter and a two-year-old daughter; she is pregnant with twins. When we met, she was navigating the stress of trying to gain full custody of her oldest daughter and the guilt she felt about her situation. Two weeks before, the daughter’s father had taken her away and not brought her back. Ms. S had been to court, found a lawyer and involved the police all while carrying twins, managing a household, looking for a remote job and caring for her two-year-old. Our conversation was interrupted by a call from a new case manager. On the phone, Mrs. S described how she wants a bigger space for her growing family to live. She wants to sign up for supplemental income for food and nutrition, and she would appreciate any support she can get. As she talked, I read to her two-year-old, who giggled with delight at the flip of each page. I looked up to see Ms. S’s expression soften a little with each giggle.
Another woman, Ms. H, has four children at home and her fifth on the way. She is also a single mother, and she works six days a week. She thinks that she could use mental health support during this pregnancy and would love to participate in therapy or groups to meet other pregnant people, but she does not see how she will fit time for either into her schedule. Working hard to provide and care for her family, she struggles to find time to care fully for herself.
Maternal anxiety, depression and stress can arise from a variety of factors, including the baby’s development, the mother’s wellness, financial security or physical safety. As I described the research study and the intervention being explored, along with the 50-50 chance of receiving an extra layer of support, rarely did a person say that they were uninterested in taking part. Patients consistently saw the study as an opportunity, and they hoped for help and support. Partners often asked if they could be involved too. The need for mental health care for pregnant, low-income persons and for adequate access to such care was clear.
I appreciate that patients are open with me about personal and social stressors that, while beyond medicine, influence their health. I recognize that their experiences are different from my own, which makes their willingness to be open with me and participate in the research study crucial. And while I notice my own strong emotions in response to their stories, I am careful not to project any of my feelings for I do not know what it is like to walk in their shoes.
Throughout this research and throughout my medical school rotations, I have thought a great deal about the racial differences between me and many of the patients I see. Given the study’s race inclusion criterion of Black/African American, I was aware of race each time I walked into a patient’s private exam room to ask for a commitment to the study. Although patients were surely aware as well, no one ever acted in a way that made me question whether race was affecting their openness to considering the study or their openness to me as a white woman. For my part, I aimed to be friendly but sincere, warm but professional. My hope is that each person felt comfortable and respected by our rapport and would respond in kind. I cannot escape the racial history or imbalance in the roles, but I can be sensitive to the situation. I feel I must be cognizant of the underlying context if I am going to do this work, and hopefully the work helps ameliorate the imbalance over time.
Sometimes when describing the study to a patient, I would acknowledge the race inclusion criteria. In doing so, I mentioned disparities in mental health care and how the study aims to reduce those gaps. I found patients expressed agreement and understanding, often nodding along. Acknowledging the significance of race to the study kept it from being an “elephant in the room” and from distancing me from the patient, too. I hope that giving patients a better sense of the study goals also helped them understand the race criteria. Ultimately, I hope that my approach struck a good balance of addressing the racial difference without accentuating it and of being respectful without being awkward or apologetic.
While I conducted surveys, I felt more like I was getting to know people than like I was studying them — in large part because of how the surveys led to conversations, whether I asked follow-up questions or people began sharing on their own. I see the surveys as a means to improve care and wellbeing, rather than to gather information alone, which makes me personally feel more comfortable using them. Of course, there is significant historical context to consider and a responsibility to ensure patients understand and are comfortable with the purpose of the surveys.
I came into medicine knowing that I want to reach underserved communities and that often the patients I will treat will be of different races. I expect that reflecting on these differences and how I can ensure the best possible outcomes for my patients in all facets — care, comfort, connection and trust — notwithstanding these differences will always be part of my career.
Back in the waiting area, one woman is talking loudly across the room to a pregnant mother: “You’re smart to have [your kids] close together, saves money that way.”
“Yeah, I guess so! These two were in Pampers at the same time.”
“How many are you going to have?”
“This is my third, then I am done.”
“Oh, I had 10! I just went until I couldn’t anymore, until my body was done.”
I smile to myself as I observe these two women carrying their own stories and connecting over the experience of motherhood. It is a privilege to witness their experiences and play even a small role in their care.