The nearest hospital to St. Paul Island, Alaska, in the middle of the Bering Sea, is 800 miles away.
There is a clinic on the island, so most prenatal appointments happen there. Pregnant women usually visit Anchorage only a few times before they move to the city about a month before their due date.
But that's not how it worked for Cara Lestenkof-Mandregan.
She is part of the Indigenous Unangan community that lives on the island. Remote towns and Native villages in Alaska do not have maternity wards. That makes pregnancy difficult in a normal year, and the coronavirus pandemic has only intensified the strain.
Early in her pregnancy, Lestenkof-Mandregan and her boyfriend, John Melovidov, found out they were going to have twins.
"And I had the doctor come in and tell me all these things that could potentially go wrong," she says.
Pregnant people are already at higher risk for serious illness due to COVID-19. And the doctor told her that twins are also considered to make a pregnancy high risk.
"After 16 weeks, I would need to travel out to Anchorage every two weeks for appointments. My jaw dropped," says Lestenkof-Mandregan.
Her island stayed free from COVID-19 while case counts began to rise in Anchorage, where she was traveling for checkups. But that travel started to feel like a gamble. She didn't want to get sick or be the one who brought the coronavirus back from the city.
"I was going to have to go to COVID-ville and possibly contract the infection," she said.
Eventually doctors at Alaska Native Medical Center advised that she go to Anchorage and stay there to prevent multiple trips back and forth.
As a health aide, she had seen colds and flus spread across her small island like wildfire and didn't want to see that happen in her village with COVID-19 because of her pregnancy.
"So, we decided that we were going to leave and just stay out in Anchorage until it was time to deliver."
Separation and isolation
The pandemic has put a spotlight on the hardships of separation and isolation during pregnancy.
"We really need to start working on how do we support these moms as best we can, because they're not delivering near their families," says Dr. Matt Hirschfeld, a pediatrician.
He leads maternal child health services at Alaska Native Medical Center.
"They're not delivering with their aunties and grandmas and, you know, everybody around them," he says.
That separation from home and family is hard, but Hirschfeld says it's done for a good reason.
"Back in the '80s and before, Alaska had one of the highest neonatal mortality rates — which is defined as kids who die before the first 30 days — in the country," he says.
Hirschfeld says transition to hospital births has correlated to a 75% drop in infant mortality — deaths before age 1 — over the last few decades.
Expectant mothers, like Lestenkof-Mandregan was, stay in hospital housing, which has communal kitchens and play areas for families to gather in when they're away from home. But COVID-19 shut down the community rooms. Residents now stay in their individual rooms most of the time.
"It was kind of a blur," Lestenkof-Mandregan says. "We were there for a long time."
For four months, she and her boyfriend left their small room only for medical appointments. She says she was grateful her partner was there. Many women make the trip alone.
"We spent our days, you know, keeping to ourselves in our room. [We] watched a lot of Netflix and enjoyed the fast Internet," she says.
When Lestenkof-Mandregan, her partner and twins, Anna and Mila, got home after so long away from St. Paul Island, it was time for celebration with family.
She says it's a story her girls will hear for the rest of their lives.
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