The intake form had a new section this year. Page three, between Mental Health Screening and Substance Use Assessment: Family Planning and Environmental Health Risk Assessment. Eight questions. I'd been coming to this office for six years and I'd never seen it before.
The waiting room was half-empty because of the holiday. Presidents' Day, 2030. I'd scheduled my annual physical because I had the day off and couldn't think of a reason not to. The receptionist had a small American flag on her desk, the kind you'd stick in a cupcake. The TV was on mute showing a parade somewhere.
Question four asked if I was currently considering pregnancy within the next twelve to twenty-four months. I checked yes.
Question five asked if concerns about environmental or climate-related health risks had influenced my family planning decisions. I looked at it for a while. The pen was one of those cheap ones with the clinic's name on the side. I checked yes.
Question seven asked for my current residential zip code for environmental risk stratification. I wrote 97701.
The nurse called me back at 10:15. Blood pressure, weight, temperature. She asked if I was current on my heat-season action plan and I said yes. She noted it without looking up.
Dr. Kessler came in ten minutes later. Mid-forties, reading glasses pushed up on her head, tablet in hand. She'd been my doctor for three years. She was thorough. The kind of doctor who remembered what you'd talked about last time.
She went through the usual things first. Lungs, heart, reflexes, the light in my eyes. She asked about sleep, exercise, stress. She mentioned the updated air quality advisories for Central Oregon and asked if I had a respirator rated for wildfire particulate. I said I did.
Then she scrolled to page three on her tablet.
"So," she said. "You're thinking about pregnancy."
"Yeah."
She nodded. "And you indicated environmental health concerns are part of that decision."
"Yeah."
She set the tablet on the counter. She folded her hands the way she did when something was going to take longer than the appointment allowed.
"What I can tell you from a medical standpoint," she said, "is that we have good data on heat-related pregnancy risks now. Preterm birth odds increase about four percent per degree of temperature increase during exposure. We monitor for that. We have protocols."
She paused.
"Your zip code does put you in an elevated risk category. We'd want to talk about timing. Seasonal planning. Air quality management during pregnancy. There are concrete steps."
"My insurance dropped maternity coverage for our zip code in January," I said.
She was quiet for maybe two seconds. Something moved across her face that wasn't in the protocol.
"I wasn't aware of that," she said. "I can look into what options might be available. There are programs."
"I know about the programs."
"Okay."
The air filtration unit humming. Paper crinkling under me when I shifted. Someone coughing through the wall in the next room.
I had a question I'd been carrying for about six months. I'd practiced different versions of it. The version I'd rehearsed in the car that morning started with the phrase "medically irresponsible" and I couldn't get it out. It sounded wrong in this room, under the fluorescent lights, with the paper gown open in the back. It sounded like I was asking her to make the decision for me. Which I probably was.
"Can I ask you something?" I said.
"Of course."
I didn't ask it. I just sat there. She waited. She was good at waiting.
"I have two kids," she said. "They're nine and twelve."
That was all she said. She picked up her glasses and put them back on her head.
"Let me check your thyroid," she said.
I tilted my head back and she pressed her fingers against my throat. Her hands were warm. The February sun was coming through the window at a low angle, hitting the floor near my feet.
She told me everything felt normal.
I said okay.
She said she'd see me next year, or sooner if I wanted to talk more about family planning. She said it just like that. Family planning. Like it was still just planning.
I got dressed and went out through the waiting room. The receptionist's little flag caught the light from the door. Outside it was sixty-one degrees. I sat in my car for a while with the windows down. I figured I'd call my husband. I figured I'd tell him it went fine.
- Heat and pregnancy risk: A 2024 systematic review in Nature Medicine documented wide-ranging maternal and fetal health harms from heat exposure, including increased odds of preterm birth and stillbirth across 66 countries.
- Doctors unprepared for climate conversations: A Dana-Farber study found that physicians incorrectly assumed patients weren't interested in discussing environmental health impacts, while patients were generally open to those conversations.
- Climate anxiety and fewer children: A systematic review of 13 studies found that climate change concerns were consistently associated with a desire for fewer or no children, driven by uncertainty about an unborn child's future.
- Insurance costs climbing everywhere: U.S. homeowners spent $21 billion more on insurance in 2024 than in 2021, with climate-driven rate increases now hitting even non-coastal states through severe storm losses.