TONYA MOSLEY, HOST:
This is FRESH AIR. I'm Tonya Mosley. A new book by Portland doctor Mary Fariba Afsari opens with a vivid image of her trying to fit a red gynecology table in the back of a Mini Cooper. It's 2021, and she's 15 years into her career as a board-certified OB-GYN who walked away from a traditional practice, bought a 31-foot RV, taught herself to drive it, and turned it into one of the country's only mobile gynecology clinics. She parks it in communities with few health care options, undocumented families, survivors of medical trauma, people who need reproductive care and have nowhere else to go since the landmark Dobbs decision in 2022 overturned Roe v. Wade. But the RV is only part of the story.
Dr. Afsari is the daughter of Iranian immigrants who left Iran ahead of the Islamic Revolution when she was 3 years old. She's named after her grandmother, Mehri, a woman she never met who died attempting an illegal abortion in Iran, leaving behind four young children. That loss shaped her family and the doctor's career. Her new book, "Labor: One Woman's Work," comes at a moment when abortion access has been stripped from millions of American women. Maternal mortality is rising, and OB-GYNs are leaving states where they can no longer practice medicine without fear of prosecution.
Dr. Afsari, welcome to FRESH AIR.
MARY FARIBA AFSARI: Thank you, Tonya. I'm so happy to be here.
MOSLEY: I want to start inside of this RV clinic because you had a thriving practice. You were a surgeon. You delivered babies. By every measure, you had built really exactly what every doctor is supposed to build. So what was it about this day-to-day reality of medicine that made you think, I need to blow this all up and start over in a parking lot, basically?
AFSARI: I think there's a perception out there that OB-GYNs live in a world of celebration, bringing in new life, welcoming babies. And that's not all entirely false. That's true. That's a huge part of my motivation for going into this line of work. But when you're practicing in and out, where you're actually caring for people who need comprehensive reproductive care - so what that means is from the time somebody is old enough to cycle periods, get pregnant, have to prepare for that potential, have to face their own sexuality and have to find people that can provide for them the kind of care that meets them where they are - it's really important to have places and physicians and institutions that can meet them where they are.
And it's not that I didn't feel like I was doing that in my own office space. It's just that I felt like I could do it better. I felt like looking down the pipeline, even 10 years ago, at what was going to happen with reproductive access, it was pretty clear to those of us that were working in the world. The Dobbs decision - and I say this in my book - it didn't come as a big surprise to me on that day. We had seen that this is what the groundwork was being laid towards. We also knew that historically, in this country, even pre-Dobbs decision, even with Roe v. Wade, there were folks in certain communities from certain ethnicities - there was this implicit racism that happens in the health care system that we are aware of. And so we knew that there were already people that were not being met and that it was just going to expand and just affect more people over time.
MOSLEY: And right now, we know that 13 states now have total-ban abortion bans. Thirty-five percent of U.S. counties, in particular, are what's being now called maternity care deserts. Can you describe, though, what makes what you do better with this RV? Can you describe the inside of your mobile clinic? When patients walk in, what do they find?
AFSARI: Oh, yeah. I mean, even just as recently as yesterday, people walk into this RV that from the outside is pretty unassuming. It was something that came from Camping World. And they step inside, and they're greeted by me, the doctor in normal clothing, and my medical assistant, who is always there with me because we like to have a second person there for procedures, for blood draws. We want to try to do as much inside the walls that we can. There is a couch up front that we haven't changed. It's just the regular RV living room that you walk into. We have fairy lights. We have curtains that were sewn and designed by my good friend. And we have a little exam room in the back, where there's normally a bed that we ripped out, and we just put an exam table back there. But we also have wall hangings that let our community know that they are welcome and safe within those walls, no matter who they are.
MOSLEY: In a way, it sounds like a therapeutic experience, the complete opposite of what I associate with going to the doctor. What have you seen in the way your patients relate to you that might be different than when you're in a clinical setting, in a hospital or an office?
AFSARI: Yeah. You know, I was in a traditional office for a decade, and we provided really good care. And a good number of my patients in the RV followed me from that clinic. So they know who I am, and we already had a very good doctor-patient relationship. But in the clinic, I had three exam rooms that were running all at the same time. They had that sort of sterile exam room feel, and I would have to hop from one to the next to the next with my computer in my hand and my white coat on. And I'd come in, and we would have, you know, sometimes a 10-minute appointment, sometimes 30 depending on the situation. But there was always a sense that there was a waiting room of people that were waiting to be seen, and you have to keep things ticking along.
And I just decided when I started this RV clinic that I was going to do it the way that I wanted to provide care - sort of my daydream idea of a clinic. And in doing that, not only are my patients receiving this sort of individualized care, but I am sort of healing whatever it is that happens when you're a physician and you've worked for 15 years, and there's elements of burnout and exhaustion that can happen in the traditional medical setting. My patients are healing me.
MOSLEY: There is a story in the book. A teenage girl, and her mother brings her in with severe abdominal pain, and she hasn't even had her period yet. Can you take us into that day?
AFSARI: Yeah. So I think this girl was about, you know, 14 or 15. You would have expected that she probably would have started her periods, and she hadn't. And what I realized over the course of the appointment was that she had a congenital anomaly where the outlet which allows blood to flow out, the hymen, had not ever opened, and so there was blood that was trapped inside. So most people have a tiny little - at least a pinpoint opening from the time they're young, and that's when women start their menstrual cycles, girls start their menstrual cycles. The blood is allowed to escape. And that hadn't happened for her.
And I thought in the moment, well, this is a really simple solution. I just have to take you to the operating room, and we'll put you to sleep. And we'll just open that little, you know, tissue layer, and we'll allow the blood to come out. And it's going to give you immediate relief, and then her monthly cycles would be able to start. And what I didn't expect to encounter was the pushback from her father and a real concern that a surgery like that would deem her not a virgin. And so we ended up in sort of a - you know, I would say maybe sometimes it's a faith-based conversation. It could sometimes be cultural. It depends on sort of the family background. It's different for everybody. But that was the conversation that we ended up having with the parents in order to determine the right path to take for this teenager.
MOSLEY: You know what I was struck by in that story is something I think we all know, but we may not think about when we think about your job. You're not only just a doctor, you're a social worker. You're a therapist. You are also someone who's kind of giving cultural and medical competency and knowledge to your patients. You knew going to medical school that intellectually, you'd need to hold all these things, and you'd be meeting with patients. But how did that come up against the realities of the situations that you have come up against during your career?
AFSARI: I mean, it's a huge part of medical training that - at least when I was going through my training. And I know that things have improved. I know things are getting better here, but it wasn't a big part of my training. I actually was explaining to somebody the other day that nobody taught me how to tell a woman or two parents that I had just done an ultrasound and the baby didn't have a heartbeat, because that is something we encounter more often than anybody would like to think.
And I had to do that for the first time once I got out of my training, and I did an ultrasound, and I had to walk back into the room and let that family know that their baby wasn't going to survive the pregnancy. And so, in order to do that well, I think we have to first be listeners. I think we have to learn from our patients, I think we have to pay attention to the stories they're telling, I think we have to have an awareness of where they're coming from. And I think that patient-centered communication is the key to humanistic care. We really have to listen to our patients' needs.
And historically, a lot of times, medical care is a top-down approach with the physician as the expert. And that doesn't always keep in mind that patients also come in with their own needs, and there can be conversation. Informed consent is something we learn about. But true informed consent is really letting your patient understand what their condition is, what their options are, and then engaging in conversation to make a decision about which path to take.
MOSLEY: Yeah. Are there any trade-offs that you had to make in order to move your practice into the RV?
AFSARI: Yeah. I mean, to be honest, there's a financial trade-off. When you see one patient at a time and you don't have three people in a room, you probably see a third as many patients. So there's a real professional satisfaction in that. It doesn't really have the return that people need in order to keep businesses running, right? So there's that piece of it that's interesting and a constant, ongoing, you know, challenge for the clinic. But there was skepticism, I would say, you know?
When I started the clinic - I mean, even now, not everybody understands what I'm doing in that clinic. I've had people ask me if I was board certified, if for some reason I couldn't get a job someplace else. You know, there was just definitely the people on the outside looking in wondering why I was doing this. I had somebody ask me if I needed a place to live, and that's why I built a clinic inside of an RV, you know?
So, those types of sort of skeptical questions, I mean, I take it all with a grain of salt. I understand that we created a vision. And when you try to do something new, you're just going to have to be prepared that a lot of people aren't going to understand what you're doing or why you're doing it.
MOSLEY: Let's take a short break. My guest today is Dr. Mary Fariba Afsari. Her new book is titled "Labor." We'll be right back after a short break. This is FRESH AIR.
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MOSLEY: This is FRESH AIR. I'm talking with Dr. Mary Fariba Afsari, a board certified OBGYN, the founder of FemForward Health, one of the only mobile gynecology clinics in the country, and the author of the new memoir "Labor: One Woman's Work."
Doctor, your parents left Iran when you were really young, 3 years old. And it was just ahead of the Islamic Revolution. And so that meant you grew up in California while your cousins and other loved ones were still in Iran. And they grew up under a very different reality. What did you understand growing up about that decision and what it cost your parents and what it really gave you?
AFSARI: My parents were in the United States when I was born. My father was recruited to complete his medical residency and training at John Hopkins University, and then again in Illinois. And I think the intention was to return back to Iran in order to be with family and to provide his medical service in Iran. I think that was always the goal. And so we moved back when I was young, and we spent about 18 months. This was the late '70s.
And at that time, there was a real undercurrent of regime change and the Iranian Revolution. And so my parents made the decision to leave the country, like, you know, thousands of other Iranians, sort of anticipating what that might look like for life in Iran versus, you know, raising children in America. And they made the decision that they wanted to raise their children in America.
MOSLEY: How young were you when you realized about your parents' choices and what that actually meant for what it gave you?
AFSARI: You know, I do talk about being 5, 6, 7 years old. And because we had so much family in Iran, we had the television on. The Iran hostage crisis was occurring. That led to the Iran-Iraq war. I had cousins that were at that point still, you know, living under the threat of bombs. And I was very aware of that. And so I knew that there was a difference between the life that I got to live as, you know, Fariba - with my name changed to Mary in order to protect me as a kind of a California kid - versus what it was that my cousins were enduring at that time, also young, in Iran.
MOSLEY: Much later, though, you come to learn something else pretty profound, that your mother named you Mary after your grandmother, a woman named Mehry. And that's when you started asking questions. So you write about this in the book - that your aunt, she visits from Iran. You two step outside for a cigarette one day, and she tells you something that she wasn't supposed to tell you. Can you take us to that moment?
AFSARI: Yeah. At that point, I had had an understanding that I had a grandmother named Mehri and that my Mary had actually been chosen after her. I wasn't aware of that until I was into my late 20s, early 30s. And I felt this connection to her. And the more I sort of tried to learn about her, the less I could really glean as to what had happened to her in her life. She died when she was only 26 years old. And then I learned she was pregnant when she had died and had left behind four young children, including my mother, who was only 4 years old. And when I asked my family members why she died - and then at the moment of that scene, I was a practicing OB-GYN. And so I kind of felt like I am an expert in this topic. I should be able to understand what killed my grandmother. I know what the risks are in pregnancy. And yet, why would something kill her at 26 years old after she'd had four normal, healthy pregnancies? And nobody really had a good answer for me.
And so one night, I did have an aunt who was visiting from Iran, and she pulled me outside. And she shared with me that she had heard that my grandmother had drank a drink during the course of that last pregnancy with the intention to end the pregnancy and that they believed in the end that that is what had killed her.
MOSLEY: Mary, I'm just thinking about you as an OB-GYN. You know exactly what drank a drink might mean clinically, what she was trying to do, how it likely took her life. And what you have done in this book - it's one of the most powerful parts of the book for me, is that you kind of reconstruct her last days from the inside. You give your grandmother this fully lived interior life with her own voice and her own experiences, and you come to this point where you are kind of fully in conversation with her, just based on what you know and based on your deep feelings. It's the kind of knowledge and wisdom that many cultures believe in fact and truth. But here you are, a doctor rooted in science and fact. I mean, how did you hold those two truths to come to this understanding of how she died and how that actually drives your purpose?
AFSARI: I really think that my grandmother serves as a moral conscience for our time and that when we understand what our ancestors suffered, it teaches us what we can do to prevent that moving forward, and yet we are still faced with the similar challenges today. So that's an interesting part of this for me.
I mean, what was amazing is, as I engaged with my grandmother's story, we had a patient present to one of the hospitals that I work at who was near death with sepsis. And as we took her to surgery and went through all of the steps that were required to save her life, it slowly dawned on me that that had been my grandmother's story and that in a different time, in a different place, under different circumstances, she could have been saved.
And so when you lose a mother, you lose an entire family system, especially when you have young children. A baby died that she was carrying. The 1-year-old child ultimately ended up dying, as well, just from sheer you know, inability to care for him. And so my mother, her brother and sister, at a very young age, lost a sibling and their mother and a future sibling, you know, all within a year. And I can't say that they are not still impacted by that today, more than 50 years later. And that gets passed on now to me. And so that moral conscience, that understanding how critical it is to be able to provide women with lifesaving care in order to prevent this type of tragedy to an entire family system - I mean, that's what came to light to me and for me over the course of engaging with the ghost of my grandmother, essentially.
MOSLEY: Our guest today is Dr. Mary Fariba Afsari. Her new book is titled "Labor." We'll be right back after a short break. I'm Tonya Mosley, and this is FRESH AIR.
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MOSLEY: This is FRESH AIR. I'm Tonya Mosley, and my guest today is Dr. Mary Fariba Afsari. And her new debut memoir, "Labor: One Woman's Work," is a book about her life as a practicing OB-GYN, her Iranian heritage and the discovery that her grandmother's death may have been caused by an illegal abortion.
You knew you were going to be a physician of some sort. And you initially dreamed of being a pediatrician until you spent time in Bolivia. I'd love for you to tell us just a little bit about what you saw there that made you change course.
AFSARI: I went down to Bolivia for a one-month rotation as a third-year medical student. I received a fellowship, and I flew down there for this great adventure. And the pediatrics rotation was incredible. We were in orphanages and in hospital settings and in outpatient clinics with Indigenous folks. And we were in the main cities. And yet, that was a time in Bolivia, back in the early to mid-2000s, where contraception was still illegal. So not just abortion, but also birth control.
And so we were encountering families. So these moms would bring in their babies to have us do an exam on, and they would be No. 10 or No. 11, or No. 12th baby. And over and over and over, we heard about stories where some of the children in that family had not survived childhood. There was just a lack of resources to go around for 12 kids. And so then if one had a condition or one got sick, then that child didn't survive past 7 years old.
So then we were met with these mothers who had lost their children. And I ended up in a very remote village and in a hospital where one of the OB-GYNs had taken it upon himself to allow women to bring IUDs in that they had obtained from the black market. They would bring them in, in their purses. And he would surreptitiously, I would say, place those IUDs. The curtains were down, there were no records made, we didn't even take down names.
And he would place an IUD. And an IUD has a little string that comes out of the cervix in order to allow it to be removed easily at some point down the road. But he would cut those strings super, super short so that even a husband might not be aware that their wife had had birth control placed, because culturally and politically, that might not have been OK in some families. And I watched him do this over and over and over again.
And that's when my mind was sort of blown and also changed because I really realized that in order to best serve the children of the family, you have to first take care of the mother. And so if you can take care of a mother, the healthier that a mother is, more likely the family and the children are also going to be healthy. And that's when I changed my mind. And from then on, my path was towards becoming an OB-GYN.
MOSLEY: Wow, doctor, I'm just thinking about 20 years later. And these are realities in our country right now, as well, post-Dobbs and abortion bans. Are you beginning to also see people who are crossing state lines to see you? Kind of give us a sense of what you are now experiencing in this new reality.
AFSARI: The new reality is that it's very, very difficult for people to cross lines and to get care in other states. There are a lot of challenges. There's financial challenges. There's legal challenges. There's a lot of fear that if people want to cross a border and get care that's not legal in their state, that somehow, they would be discovered doing that and that they would be in trouble for doing that. There are insurance challenges because state by state, you can't necessarily accept insurance.
And so I have to say that the vision of being able to provide care for folks that are in states where they don't really have reproductive access is not exactly what my clinic is able to provide at this time. My clinic, at this time, is truly a model of care, for how we could envision ourselves outreaching to other communities. We've sort of demonstrated now that it is very possible to do and it's not that difficult.
MOSLEY: I want to talk to you just a little bit about the realities of this moment, not just in our health care system, but just overall the political fighting over women's reproductive rights. And you have written about how you have this visceral aversion to slogans, particularly around abortion, pro-choice, pro-life. You write that it's an affront to our shared humanity to reduce these decisions to words that fit on a bumper sticker. How do the political fights we're all witnessing from the outside kind of obscure the realities of what you are seeing every day.
AFSARI: I mean, the political fights aren't working, right? We can see it. We're not moving forward in terms of providing better care for women. And I write about a scenario in the book where a couple comes in, and this woman is basically in full organ failure. She had a preexisting condition. She knew the pregnancy might kill her. She had been advised by every doctor to not get pregnant. And then when she became pregnant, she was advised to end the pregnancy early in order to increase her chances of surviving. And I say in the book, everybody wants to believe that they're the miracle case. And a lot of people want to have that baby, and they want to grow that family, and they don't want to believe that that's not going to be possible for them.
That scenario where she kept the pregnancy and she came in pretty advanced, you know, stage sickness, but not far enough in the pregnancy to deliver a viable baby - and then they were in this impossible space of having to make a decision about what to do because there was going to be no saving the baby if the mom didn't survive. And so that is a situation when I talk about this is not a slogan. And this is not a black-and-white, it's easy to choose one side situation. And most people that make a decision about what to do about a pregnancy are usually not making one easy decision. It's almost always multifactorial.
MOSLEY: I want to ask you about the realities of being an OB-GYN under the Trump administration. The CDC, which tracks maternal mortality - they're the people who help us understand why American women are dying in pregnancy. A whole team of researchers there at the CDC were placed on administrative leave earlier this year. And that data collection has stopped. And I'm wondering, as a doctor who relies on this research, what does it mean to practice medicine when the country is actively choosing not to measure what's happening to women?
AFSARI: I mean, all of this could feel like an impossible situation until you're on the ground. I will just say that. So when you hear the stories from physicians that are being criminalized in other states, that is terrifying. I heard about an OB-GYN who had an ankle bracelet because she was being accused of, you know, committing some sort of crime just for trying to provide standard of care, lifesaving care in another state. I have heard from multiple colleagues in other states who are not able to even advise their patients to maybe leave the state in order to obtain - we're talking about truly lifesaving care, like women who might not survive a pregnancy if they were to continue it.
For me, I work with people, fortunately, who on a local level and a hospital level and then a regional level and then a state level we are tracking. I mean, we are still doing all of the data collection, and we meet sometimes weekly. We definitely meet monthly. We have quality review committees. We are on top of what is happening for the women and the patients that walk onto our units. So I am fortunate enough to be a part of a hospital system and a greater system within a state where we are doing this work every single day. And so what's happening locally is still really good work.
MOSLEY: Our guest today is Dr. Mary Fariba Afsari. Her new book is titled "Labor." We'll be right back after a short break. I'm Tonya Mosley, and this is FRESH AIR.
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MOSLEY: This is FRESH AIR. And today, I'm talking with Dr. Mary Fariba Afsari, a board-certified OB-GYN and the founder of FemForward Health, one of the only mobile gynecology clinics in the country, and the author of a new memoir, "Labor: One Woman's Work."
You write about how, I mean, you used to shake and sob after caring for patients, but somewhere along the way, you kind of have to stop that because if you do it every single time, every single day, I mean, just everything would be taken out of you. I mean, it just also made me wonder, is numbness inevitable in the work that you do, and how does that impact the work?
AFSARI: I mean, it's such an important question, and people don't necessarily know how much the burnout of physicians impacts their overall sort of mental state and physical well-being. Physicians in this country and especially - so female physicians in this country have four times the suicide rate of any other profession.
MOSLEY: Really?
AFSARI: They absolutely do.
MOSLEY: And why do you think that is?
AFSARI: I know. I'm always asked, like, why? What is that? And I don't have the exact answer for it. I don't have the statistics or the data or the understanding of why that is. But I do know that there's something about the compassion fatigue that I believe happens alongside sort of the expectations of what it is to be a working woman in this country or a working mother in this country. And I think there's got to be something in that tension that has made it even more difficult for female physicians, even though I know plenty of male physicians who have also felt that emotional burden.
And, you know, we don't do a very good job of taking care of our doctors. We don't have a lot of support. We tend to go from trauma to seeing the next patient within minutes. There's not a lot of recovery because physicians, for the most part, they're a pretty resourceful bunch. They have a pretty high resilience. And so if physicians are feeling the burnout, I really think it's from a lack of advocacy for what it - what needs to happen in order to support the doctors who you are putting out on the front line - things like technologic support, things like having more time with patients, things like not expecting somebody to work for 24 hours. People don't realize that we still take 24-hour shifts as OB-GYNs. And some of us will do a 24-hour shift, and then we'll show up at our clinic the next day and see patients for another 12. That is the type of thing that is sort of - you know, it's sort of under the radar right now. I don't think people still understand that that is how the medical system functions in our country today, and the toll is being placed on the doctors. And then there's a ripple effect, obviously.
MOSLEY: Doctor, I want to ask you about a patient that you write pretty extensively about. You named her Amelia in the book. And at the time that you met her, she was a teenager, and she had arrived at your clinic with her aunt. And it's clear to you that she is so young, that she is still a child. She, I think, was wearing a SpongeBob T-shirt when she came into your office. Can you tell us about her?
AFSARI: Yeah. It was one of those situations where you look at your schedule for the day and you realize somebody's coming in. They are younger than anybody you've ever seen pregnant, and they're coming in for a new pregnancy visit. And then you find out when you walk in the room that their pregnancy is fairly far along - you know, four or five months in. So the pregnancy had been kept a secret until it couldn't be kept a secret any longer. So when I met that patient who was so young and looked so young - you know, people get pregnant for different reasons, as we know. And sometimes it's consensual, and sometimes it's not. And most of the time, we can discern that as their doctor, sort of what was the situation that led to the pregnancy. I think the most challenging part of this, yes, it was her age. It was also that we never ever learned what had led to her becoming pregnant. And Emilia herself told me over and over again that she could not remember how she got pregnant.
And that is what stuck with me through the entire course of her pregnancy is that, how could a pregnancy possibly be a choice if you can't even remember how you became pregnant? And there was a story being told. And whether that story was coming from her or whether it was coming from somewhere else, I don't think I will ever know. But it led me to a place where I had to learn my limitations as a doctor.
MOSLEY: What do you take from situations like that to help inform maybe the next patient that you come across that might be experiencing something similar?
AFSARI: I mean, with the Emilia situation, it happened, you know, maybe 10 years into my career. And I think the way I write about it is that, you know, you can go into this profession a little bit puffed up and thinking that, you know, you are going to, you know, save people. And that you play this role where you might feel like you can do more than you're actually truly capable of.
And so when I encountered a situation where no matter what I did, I was not going to be able to ultimately affect the outcome of her life - I was able to affect her pregnancy outcome. I was able to guide her through a very, very intense labor and delivery, but I wasn't able to then be a participant in the future of her life. I had to let it go. And I do think when people ask me, how do I now navigate my life? How do you not take everything home? How do you remain compassionate but not allow it to swallow you up? How do you not become a percentage of female physicians who find themselves in despair?
I think that that acknowledgment that there's a limit to who we are and what we can do. I want to be a place where people know they can show up. And I want to be able to provide them with everything that I'm capable of providing them with. And then I also understand, at some point, I also have to let them go. And I just have to trust and hope that there are also other systems and people in place that are also able to catch them, and it's not just me.
MOSLEY: Doctor, thank you so much.
AFSARI: Thank you, Tonya.
MOSLEY: Dr. Mary Fariba Afsari is the author of FemForward Health. Her new memoir is called "Labor: One Woman's Work." Coming up, rock critic Ken Tucker reviews a new biography about Bob Dylan. This is FRESH AIR.
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