This is a very personal column for me-the last I will write in this role. In 2019, I wrote about some of the births that I remembered from almost 40 years in healthcare as a nurse and a midwife. The other side of the mirror of births-beautiful and painful alike-is the care that is not received because it is too expensive, too inaccessible, or because someone has internalized that they do not deserve equal care.

In taking on a role in healthcare, every professional has a responsibility to provide the care we are trained to provide, to those who seek our help, as well as those we choose to care for. Every individual who seeks our care should have the balancing right to receive healthcare.

It was still early in my work with HIV-positive pregnant women, before the availability of antiretrovirals. A young woman came into the office, defiant, at 20 weeks pregnant. When asked what had kept her from coming, her reply was that "last time they made me have an abortion, so I waited until it was too late for one." Her baby was born vaginally at term, free from disease. Many providers at that time incorrectly believed that HIV transmitted to infants in most or all cases. This is not true now, and it was not true before we had effective therapy.1 A standard recommendation for women positive for HIV was to have abortions, more frequently than abortions were recommended for parents with serious transmissible genetic conditions.

These issues do not occur only around pregnancy, of course. One day in a community clinic, I saw an older woman with persistent postmenopausal bleeding to discuss her test results; the endometrial biopsy indicated that she had uterine cancer. Her question was: "Can this wait until I turn 65 next year? In eighteen months, I will have Medicare." I had to say no, cancer cannot wait. We discussed how best for her to present at the hospital, gain access to treatment, and see a social worker who could walk her through ways she might access the care she needed but could not pay for.2

Access to medications can be a challenge as well. This author has a chronic autoimmune disorder that is easily controlled. The medication costs between $11 000 and $13 000 a month. Every month. Others among my close friends have similar or higher costs for different lifesaving medications. If someone has good-quality insurance with a broad formulary, or has been shown how to access the right pharmacy benefits program, the co-pays may become manageable. If not, the cost will overwhelm family finances rapidly.

These factors-stigma, social determinants limiting access, provider availability, and cost-illustrate lost chances in the US healthcare system. There are remedies for all of these, but the will to change must be there. For example, this country is short of all healthcare workers, including nurses and midwives. Causes of the increasing disparity in numbers versus positions include an aging workforce, stress resulting from changes in the healthcare models and the demands of the recent pandemic, and shortages in teaching faculty and clinical placements.3 Lack of diversity in the professions can contribute to both perceived and real bias and to inequities in education and practice.4 Policy issues that limit access to qualified clinicians such as midwives or nurse practitioners also contribute to shortages in areas of high need.5,6 Quality of care at the patient level suffers from these inequities and shortages.

There are also policy issues inherent in the uneven access to care. The United States lacks a coherent policy that provides at least basic care to all individuals. Without universal access to at least basic care guaranteed, the same groups most impacted by stigma, poverty, and provider shortages will have worse health outcomes. There is both a human rights basis for care and, in the specific case of perinatal care, a reproductive justice basis for a system that provides care for all.7

Until there is the will to change, this country will continue to have worse health outcomes costing more money. Continuing on the path that created our current health inequities is not an ethically sound route to better outcomes.

These are truly my "Parting Thoughts." It is with deep gratitude for the opportunity to write this column for 5 years that I take this chance to say goodbye, and thank you for all the work each of you does to bring a better future into life.

-Jan M. Kriebs, MSN, CNM, FACNM

Adjunct Professor

Midwifery Institute at Thomas Jefferson University

Philadelphia, Pennsylvania

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