Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman

Life as a doctor is busy. So, fitting children into the equation is really hard, especially for women whose physical bodies are affected by pregnancy and childbirth. This is The Nocturnists: Stories from the World of Medicine. I'm Emily Silverman. In this episode, we talked to family medicine doctor, Miriam Sheinbein, who had her entire reproductive future mapped out until life started throwing her curveballs.

Miriam Sheinbein

And for reasonings I cannot recall, I asked a colleague to pull my IUD.

Emily Silverman

Here's Miriam.

Miriam Sheinbein

I was finishing up my medical school family planning elective when my eldest son was born. Without skipping a beat, I graduated medical school on time and flew across the country to start residency in family medicine at San Francisco General, breastfeeding a six month old. About a year and a half later, I was pregnant a second time. On our sixth wedding anniversary, my husband Yaron and I scheduled our second trimester anatomy scan for a post-call afternoon.

We were excited to find out the sex of the baby and then to celebrate the news over dinner. As a family medicine resident, I could easily see it was a boy. What I did not foresee was that our 20 week pregnancy would be diagnosed with a severe heart defect incompatible with life. We were shocked. And the choice for us was unambiguous. We had a healthy two year old boy at home, our daily…I did not expect to cry, sorry. Our daily...thank you.

Our daily reassurance that we could have another healthy child. So that night, I called a trusted medical attending, who called abortion provider colleagues, who figured out where I could be seen the soonest. And the next afternoon, a teacher of mine placed laminaria to dilate my cervix. And the following afternoon another teacher performed my abortion. And without skipping a beat, I flew to Phoenix to take step three of my US medical licensing exam.

Over two days, I held my diarrhea for the test breaks. And I pressed my arms tightly against my engorged breasts, not expecting that after a 20 week termination, my milk would come in. Then, life as a resident and a young mother went on as usual. We did not take long to try to get pregnant a third time, and my daughter was born my last year of residency. When she was nine months old, on the eve of Yom Kippur, the Jewish fast day of atonement, Yaron and I climbed into bed.

Reflecting on our year, Yaron asked me how I was feeling. I broke down crying, realizing just how unhappy I was, trying to balance career with two little ones at home. Underslept and overworked. Not knowing how to find time for whom or for what. Feeling insufficient in all parts of my life. I always thought that I wanted two boys and two girls. But for me, going from one to two felt significantly more than double. So, when it came time to try for another I was no longer so sure. Finally out of training and in my dream job practicing family medicine at planned parenthood, I—I felt whole again.

With a five year old and a two year old at home, and my youngest one just started sleeping through the night. Did I want to risk giving up that wholeness for another child? And separate from that child, did I want to risk another pregnancy or birth? I was still traumatized by my first birth experience, a highly medicalized labor and a difficult C-section, followed by a failed trial of labor for my second birth. I felt like I was headed straight for a placenta accreta or some other dreaded medical complication.

None of the less and for reasonings I cannot recall, I asked a colleague to pull my IUD. A few months later, at a medical conference, I told a friend and fellow family doctor that I was hesitating to get pregnant again, and I broke down in tears. I realized just how terrified I was that if something were to go wrong with me, or with the pregnancy, that I wasn't sure that I could forgive Yaron. And I might hold it against him. So, I called Yaron to tell him that I needed to go to therapy before we tried for another.

As it turns out, I was already pregnant. I was devastated. We told no one. Feeling pressured for time, we rushed to a marital counselor, but we made no progress. Despite our imagined family of four, for me, after two, I felt like I was done. But for Yaron, "Weren't we still going for four?" Yaron's identity as a father and his notion of a family was a dinner table filled with cross conversation, forks clanging and the quieter ones trying to get a word in.

We weren't there yet. I, on the other hand, had muscled my way through the end of medical school and my family residency, all while birthing and breastfeeding and lactating and birthing. And I was enjoying the relative calm. Ultimately, yet reluctantly, Yaron left the decision to me. And as the weeks went on, my indecision meant that I stayed pregnant, and I remained heartbroken. I didn't tell anyone that I was pregnant because I was afraid they would say congratulations.

As my pregnancy roared into the second trimester, I went to see a therapist and I told her my story. "Miriam," she said, "It's okay to feel ambivalent." It was the exact medicine that I needed in that moment. She gave me the permission to feel what I was feeling—to be ambivalent. She normalized ambivalence in motherhood. For the duration of my fourth and final pregnancy, I held my ambivalence close as a reminder that my feelings were normal, including my fears and anxieties about birthing and parenting.

In the end, my baby girl was born via a family-centered C-section on what would have been my beloved Bubby's 100th birthday. At uterine incision, they pulled the drape down so I could see her born. They allowed my uterus to clamp down around her and she let out a loud scream. And after delayed cord clamping, they put her on me skin to skin. And right there, still on the operating table, they placed my third Mirena IUD.

Unlike my older two who are born looking like me, my daughter was born with a dark head of hair just like my husband. We like to say that due to my ambivalence in utero, Yaron's genes finally won out. But, he forgot about round two. As soon as my daughter latched onto me and I to her, all of her dark hair fell out and dirty blonde hair grew in. Yaron and I like to say that our daughter was our sweet compromise. I have come to understand that choosing to continue a pregnancy or to end it are part of the same story.

With my first three pregnancies, the choices were black and white for me. Yaron and I were ready to have children and I got pregnant. Our second pregnancy had a severe congenital defect, and we chose abortion. And by choice, I got pregnant again. When I grappled with ambivalence, I felt inextricably connected to centuries of women before and after me, grappling with ambivalence.

While our society may look unkindly upon a woman's mixed feelings about pregnancy and motherhood, it is exactly in these gray and murky areas where every woman deserves the right to wrestle, the right to choose, and in spaces like these, to tell our stories. I am telling you mine so that one day, you might tell yours too. Thank you.

Emily Silverman

So, I am sitting here with Miriam Sheinbein. Miriam, thanks so much for coming in.

Miriam Sheinbein

Thank you for having me.

Emily Silverman

I'm so glad that we're able to bring your story on to the show and that we're able to meet for the first time. So, can you tell me a little bit about your path to family medicine?

Miriam Sheinbein

Sure. So as I shared in the story, I was very interested in the topic of abortion from a young age. My mother had a friend who was a lobbyist for Planned Parenthood, and she would come over for dinner and tell me stories. And I was truly inspired. And I think this was in sixth grade. And then, the following year actually, my father was diagnosed with colon cancer. And the most obvious symptom that he developed was due to the brain metastases.

And I at that point decided I wanted to be a doctor, and I was going to become a brain surgeon to figure out—you know, I would solve, you know, the ailments from which he has suffered. And I, you know, applied to college knowing that eventually I would want to become a doctor. But, I really wanted to focus on my liberal arts education. So, I deferred all my sciences till the end. But, I took a class at the end of college on, it was “Introduction to Gender and Sexuality.”

And I was like, okay, I'm going to go into medicine. And these are the issues that I'm going to discuss. And then I was introduced to family medicine, where I realized that it would just be a part of my core training, to be able to provide whole person care. And as part of whole person care, to be able to provide reproductive care. And as part of that, abortion care.

Emily Silverman

So as we're talking about family structure, and that intersecting with health, I want to bring us into your story a little bit. Because, it was such a gripping story, and I was just like, crying as I listened to it. Especially because, full disclosure, I'm not a parent. I hope to be a parent someday. And I'm really kind of grappling with some of these questions of ambivalence, fear of the physical sacrifice. And so, I'd like to get to all of that in a bit.

But first, one of the moments that I loved most in your story is where you have, I think, at this point one child or maybe two, and you're juggling everything as a doctor and your husband, Yaron, approaches you and he says, "How are you feeling?" And then you just kind of break down. And so I was wondering if you could bring us a little bit into that feeling. Like, what—what was going on there for you?

Miriam Sheinbein

I had finished residency three months prior. I had started a fellowship. I was exploring a research project. I was straddling three departments. I was practicing in my own continuity clinic and teaching residents, and then starting school to obtain a Master’s in Epidemiology. And I had a nine-month-old at home, as I described in the story, who didn't like taking the bottle and therefore breastfed all night. And I was exhausted. So when he asked the question, the exhaustion was at the forefront, and I collapsed.

Emily Silverman

Do you think he had any idea that you were feeling so exhausted?

Miriam Sheinbein

Yes. Certainly. We often spend our Yom Kippur reflecting on the year before, and then thinking about the year forward. And I think he was asking the question to make sure that I was giving myself the space to reflect. And to ensure that I was making purposeful choices.

Emily Silverman

One of the lines that really stood out to me was "Going from one child to two felt significantly more than double." Can you tell me a little bit about that?

Miriam Sheinbein

I'm not alone as a mother, particularly a working mother, in feeling that having a second child changes the dynamic and changes the work-life balance. There are very clear studies, particularly, I think, women in white collar work who, when they have their second child, quit working. Despite the education and the time that they had put into their careers, and expectation that they would have a robust career. But certainly, when you're—when you're in it, you feel very alone.

So, as I described, Yaron and I both come from families of four, and very happy families of four. And we are so lucky to have the relationships that each of us have with our siblings, and with our now abundant nieces and nephews. And we wanted that for our children. And that was probably what attracted us to each other, you know, early. We were dating from college and got married soon after. So, we've really grown up together.

And that was a shared connection. And certainly, when we had one, you know, that the scope changes, you know, so we'll take one at a time. But for me, certainly, when we had the second, I couldn't even imagine that we would have another. But, you know, as I described, but Yaron was like, "Wait a second, we're supposed to be going for four!"

Emily Silverman

What is it about having a second kid that makes it feel like more than double?

Miriam Sheinbein

I think generally with one, you can pass one back and forth and still have independent time as you. Like, as your own person. But when you have two, it either means that each of you have one, or that one of you is outnumbered. Right? So I think that's, to me, some of the dynamic. And certainly one—you know, with people who have one, there's a transition to having one. I would say for Yaron and me, that was not a big transition. And it was very smooth. We were young students, energetic...Just, it felt just very fun.

But two is real, like you are in it. And I think the other piece, which I have to admit—and this brings it back to the doctor part of the story—is that I had a baby in medical school and in residency. And my husband, Yaron, was the primary caretaker for our baby. And when my daughter was born, my second, I was toward the end of residency and transitioning out of residency. So, sometimes I wonder if some of the difficulty for me is this feeling of actually going from zero to two.

So, when we were considering having a third, and something that helped me as I asked a few parents who had three what it was like for them. And they would describe to me. The first was the excitement and chaos of having a baby. The second is balance and how you manage that. And consistently, when they talk about the third, they would say and the third is just a joy. And I obviously did not feel that way in the moment before she was born. But there is no question that with our third, she brought balance back into our life.

And I am so grateful for that. And some of it, I think, is just because you're thrown over. The balance is totally tilted, that I think I had to also give up, right? So I think, when I only had…when it was just two, if Yaron were away, and it was just me, like, I was just nervous the whole time. And I certainly would not want to have any other children around. Like, I was managing my two and felt all the tension there. With three, like, you let go. And I'm like, "More kids, like, just bring them over, like no problem." You know? So, it's just a totally different dynamic. It's amazing.

Emily Silverman

I love that. I love that description of adding more brought balance. Like, it's just not very intuitive. And thank you for sharing that.

I did want to talk a little bit about what you were saying earlier, around your background and Yaron's background. Both coming from happy, boisterous families of four. So, my husband also comes from a happy, boisterous family of four. He's the second of the four. And he—his instinct was to want for us what he had. I am an only child. I was adopted. So, my mother was never pregnant. And I'm not biologically linked to my parents.

And my parents, for whatever reason, just haven't really been pushing me to have kids, haven't really been like, asking too much about, you know, "When are we gonna have grandkids?" Like, they adopted me when they were in their early 40s. And so with me, they say, you know, "Wait till you're ready," and things like that.

And so, the reaction is just not the same as my husband's mother, who's like, you know, so into it. And like, ready to retire immediately and like, move in and like, help and all of that. So, what do you think it's about? This need to, like recapitulate our own childhood? Like, that we just have to let history repeat itself? Or, what do you think that's about?

Miriam Sheinbein

I am…my mind is sort of spinning and what you describe, I...we were describing earlier, personality types. So, part of the description of my personality type is that I have a very hard time deviating from a structured path. Or if there was, if there was a plan, and the plan changes, I have a very hard time redirecting. Unless there was a new…there needs to be a new plan set up very quickly. And I think similarly, for me, and I always, not only wanted four children, but I came from two boys and two girls. And Yaron's family is, not in that order, but also as two boys and two girls.

So, not only did I want four children, but I wanted two boys and two girls. And I'm someone like, you know, I have a strong belief like, if you will it, you can do it. As you heard from my story, I breastfed through my intern year at San Francisco General. You know, and I just sort of ignored the external voices. Like, it was something I was gonna do. And I was just gonna make it work and didn't think so much about it.

And you hear in my story that I've been pregnant four times, with two males and two females. And so imagine, for me, like, deviating from that set path. So, I don't…so I would say for me, you know, that was my…I had a positive childhood experience that worked well, it was a great model. Let's try it. Let's try it now. And I don't know if that would be the case. If I didn't, you know, have positive foundational experiences.

Emily Silverman

One of the parts of the story that really stood out to me was how you were kind of looking back at all of the hours that you spent breastfeeding, and pumping, and just the physical toll of this. And I don't know, for me, it's one of the things I'm most afraid of when it comes to getting pregnant. Just having gone through residency and having gone through that sleep deprivation and having no control over my own body, and when it was asleep and when it was awake, and when it was working and when it wasn't.

And not having time to like, cook myself nutritious food or exercise. Like, I just feel like I've regained control of my body and agency over my body, and the idea of sacrificing it or putting it in danger, putting it in jeopardy, surrendering and losing control of my body again? It's just really scary. And so as you contemplated getting pregnant again, were there any fears that came up based on your medical knowledge and your experience as a family doctor, or your experience having been pregnant once before?

Miriam Sheinbein

One of the pieces of a story that still brings up a lot of anger in me, is the consent for my first C-section. And in this consent, they talked about the immediate risks of having a C-section. But there was no mention for a woman who knew that this was not going to be my only pregnancy and was hoping to have four, of what the risks are of a C-section. And that that isn't a requirement in the way that we consent women to the surgical procedure, seems to me egregious. And I still really like…that piece of it really still affects me.

Emily Silverman

For our audience members / me, who may not know what you're talking about...So, short term risks, talking about bleeding, talking about infection, things that are going to happen in days, weeks. But, you're talking about long term risks of C-sections, so can you share with us what are some of those long term risks?

Miriam Sheinbein

Yes. So, there are multiple risks. And one is certainly that if you become pregnant again, that the pregnancy could actually implant into the scar tissue, which is dangerous. Both, it can constrict the growth of the pregnancy, but then also there's a risk of rupture of the uterus. And that can lead to hemorrhage and death. Later, and closer to labor, there's also concerns about the placenta implanting into the scar tissue, and then the degree to which the placenta then implants into layers of the uterus.

And the deeper that it implants, the more dangerous it is for risking hysterectomy. And again, complications of hemorrhage and death. So as I mentioned, in the…in my story, I talked about a placenta accreta. That's like, the worst kind. And so, I remember the relief in each of my pregnancies when they told me that my placenta was posterior. Because the anterior, you know, my scar is anterior in my belly.

So, I wanted to ensure that the placenta wasn't ever on the anterior surface and concerned about being in that scar tissue. It's also the poles of what you know, and don't know, right? And that sometimes, unfortunately, what you do know makes things more complicated, and the anxiety more grave.

Emily Silverman

So, between you and Yaron, you were the parent who had to deal with the physical aspects of the pregnancy, because of the female reproductive equipment. So, I'm just wondering, how did those discussions play out in your conversations with each other?

Miriam Sheinbein

Um, I think some of the tension was that because of my medical knowledge, I had anxieties about getting pregnant again, and childbirth, that Yaron and I could not…that he could not fully understand. In the sense because I think it was a combination. Like, I don't want to say like, I was the irrational, anxious woman, but in some ways, I think that may have, a little bit, been seen as it was perceived. Even though in my mind, it was grounded in understanding the risks of really the medical risks associated with me actually having another pregnancy and labor.

Emily Silverman

It's one thing that I wonder, as I contemplate the idea of getting pregnant myself is, you know, it isn't a process that is without risk. And yet, a lot of the times it goes fine. And so, on these days where I'm like, oh my god like, hemorrhage, death, like...I'm like, am I just delusional? Like, am I just completely blowing this out of proportion? Or am I appropriately concerned that putting your body through this is really, you know, probably one of the most medically risky things that you could do to a young healthy body?

But then on the other hand, it's like, you know, most of my friends have just, they're all having kids now and they're all fine. And so, I don't know, I've….What advice would you have for a young person like me who's afraid of the medical and physical aspects, as somebody who has seen a lot of the complications, but also a lot of the normal healthy uncomplicated births? Like, how do you recommend that young women put this into perspective?

Miriam Sheinbein

Sure. So, I would say as a family doctor, this is I think, where that perspective is really important. I…most births are normal, right? And it is a problem when we, I think, unfortunately, in the medical setting, when we've seen so many of the complications, we look at what would otherwise be a normal appearing birth and see complications in it, right? And are worried that it's going to be a complication. And therefore, I think there's a concern about medical intervention unnecessarily in those settings. So, I try to put on my family doctor cap to say that complications are unbelievably rare. And that pregnancy—and this is a personal, putting back on my personal cap—pregnancy was one of the most empowering experiences of my life. I have never felt so grand and beautiful and powerful as a woman.

Emily Silverman

Well, I've learned a lot from this. I will definitely take pieces of this conversation home with me. Because as I mentioned, these issues have been very much at the forefront of my mind lately. And so, I just want to say thank you for sharing this really vulnerable and intimate story with us. I just had so much fun talking with you.

Miriam Sheinbein

Me too. Thank you.