And I saw the dead, great and small, standing before the throne, and books were opened.

— Revelation 20:12

I labored with my son Keats in an overcrowded hospital nestled at the base of West Virginia foothills. The room’s window view was green and lush and marred by a concrete, smoke-spewing, open-mouthed coal stack in the not-too-far-off distance. I stared out at the evening sky and hoped I’d beat the latest hours, a baby in my arms before midnight. When I’d arrived at the nurses’ desk in active labor, my hands atop my belly, waiting for another wave of pain as I signed myself in, I said a little prayer—though I’m an atheist—that I was far enough along to be admitted. There were few beds open. As a nurse walked me down the hall to an exam room, we passed a full-bellied woman who fought to stay. They sent her home and gave me her room.

Contractions with Keats were light, nothing more than a twitch in my belly, like the closing of a fist. Not the crushing kind I’d had laboring with my two girls. His labor was like the baby he is now: soft.

I asked for all the drugs anyway.

I pushed my son out in the late morning, into my husband’s hands. Keats was born limp and purple and quiet. I pulled him atop my chest, cord and all, rubbing him into his voice. We both cried out; him from the shock of life; me from the shock of that life colliding with something close to death. My husband passed our son to a mountain midwife and officially into Appalachia. Keats was born face up. The midwife had needed to twist his body to get him out of me; his collarbone broke from that turn. I wouldn’t know this until weeks later. By then we’d left West Virginia to see my husband’s family in California, a departure I hoped would also offer the time I needed to understand all that had happened with our baby and my body.

At Keats’s four-week check-up in California, the doctor felt a hard lump just between his chest and shoulder. “Of course, you know this is broken?” she asked.

I shook my head. But I’d suspected there was something wrong from the day we’d brought him home. Keats could wriggle his legs and curl his toes and punch the air with his left arm. His right arm flapped down at his side, immobile. I’d been assured by his doctors that his arm was fine. Keats was just figuring out how to live in his body, how to make it go.

The doctor placed her hand atop Keats’s clavicle where a bone callus had grown and drawn the fracture together. “Here.”

I was not born in West Virginia. My husband and I moved there three years ago with our then four-year-old daughter Josephine. We moved for my tenure-track job teaching creative nonfiction in an MFA program. I knew almost nothing about the place. If asked, I wouldn’t have been able to find the state on a map. I drove in at night the first time I went. It was deep winter, and though it was dark, the earth seemed lit silver from the inside with cold.

Our students come from all over the world. They arrive in Morgantown and are often worried about the wisdom of their choice. We’re the only state in the country with negative growth. More people are dying or leaving than are born and stay. Ours doesn’t have the usual charm of a college town. There are more churches than gas stations, and our poverty isn’t hidden. It’s a tired cliché, but many buildings are dilapidated. Some are coated black from ash and exhaust. Roads are steep and pothole-covered, chewed by coal and gravel trucks; driving is not driving as we know it in other parts of the country. Driving in West Virginia is like taking a roller coaster ride through a ghost town.

I reassure my students about their choice. I tell them they’ve arrived in a place worth writing about. It’s all here: coal, fracking, poison water, permit-less gun carry, white supremacy, Mylan pharmaceuticals, an opioid crisis that claims more people than anywhere else in the country. Good material is worth some discomfort, I say. It’s my mothering instinct to try to shield my students. If only mothers had that much power.

We came from Santa Monica, California, a thing that takes most by surprise. “California to West Virginia?” people ask, as if I’ve surely gotten this fact of my own life wrong, as if I were talking about a trip from Earth to Mars. But the path of my life, and my family’s, hasn’t been quite so straightforward. There’s a little white house on Orlando Avenue in Albany, NY. It’s 1,100 square feet and has two bedrooms. My mother grew up there, the last of five children, the unintended voyager of parents in their forties. Her father was a housepainter. Her mother was a house-cook. Her grandparents were immigrants. Nobody went to college. Mom waitressed most of my childhood. Sometimes we needed food stamps. More than once, we were homeless.

As soon as I was old enough to make my own choices, I left home.

I promised myself I’d never go back.

Since moving to West Virginia, I’ve learned that many people don’t even know it’s a state. They think we’re Virginia’s western arm. Just a place off Interstate 95 on the way to the beach. The official state motto of West Virginia is “Montani Semper Liberi” (Latin for “Mountaineers are Always Free”). “West, by God, Virginia!” is the unofficial state motto. Mountaineers yell it in bars and on streets and in churches, countering the assumption that they are invisibles, people from nowhere in a nothing place.

I’ve learned that when people from the coasts think of West Virginia at all, they think about banjo music, and Trump country, and sad miners and blown-apart mountains. What I observed as I settled in didn’t exactly match those stereotypes. There are progressive activists, and live-off-the-land farmers, and a vibrant community of artists. There are people living high off old money from coal, and people living even higher off new money from fracking. It’s a place with a long history of taking. The people and the earth carry that pain.

West Virginia has always been God-fearing. Unlike other red states, religion wasn’t always the central voting value. West Virginia used to be deep blue, driven by union-based politics. Bill Clinton won West Virginia by 13 percentage points in 1992. Trump took it by more than 40 in 2016. It’s complicated, but coal’s death brought about a cultural shift, a retreat away from progressive economics in favor of cultural conservatism. Poverty in the state is staggering; nearly 20 percent of residents are poor.

In an interview with the news site 100 Days in Appalachia, Davitt McAteer, the former head of the federal Mine Safety and Health Administration under President Bill Clinton said, “The old maxim used to be that miners went home to Jesus and John L. Lewis. Now you just see Jesus Christ.”

Faith is what is left.

According to a recent Pew forum study on culture and religion, only 20 percent of people in the state believe in evolution “due to natural processes,” 83 percent believe in heaven, and 58 percent of West Virginians believe that abortion should be outlawed in all or most cases—cases that include rape, incest, or a pregnancy that endangers the life of the mother.

We’d welcomed our second daughter—one of Keats’s two older sisters—a year after we moved to West Virginia. I had struggled to get pregnant with Iris; there are five years between our two girls. Throughout my pregnancy, I imagined Iris as a perfect partner for Josephine, a better sibling than I’d been to my own identical twin sister Cara.

I named Iris after a tattoo Cara had inked on her forearm to cover her track marks. By then, Cara had been dead for a decade. She was twenty-eight years old when she jammed a needle filled with fentanyl-laced heroin into her arm on a sunny June morning.

In the last days of Cara’s life, she and I weren’t speaking. I’d thrown her out of my Massachusetts home after I caught her shooting heroin in my bathroom. On the day she died, seven days after I’d told her to leave, Cara was living back at home with our mother. I woke that morning with a feeling of terrible remorse. I had the keen worry that I had abandoned my sister; I’d left her thinking I didn’t want her in my life. All I ever wanted was for the sober her to come back to me.

I dialed Cara’s number right after breakfast. She didn’t answer. I kept calling. I called more than thirty times. She never answered; she was already gone, her head tipped forward, her face purple and still with blood. The sun shone through a window behind her; in death, her body was warm with light. When I heard the news, it was sundown. I screamed so hard that the force of my voice, and the tension of my body, tore the straps of the dress I was wearing.

Twelve years later, I birthed my son on my sister’s death day.

I thought I was done with our story. I’d even written an entire book about grieving her. I packaged and published that story into something past tense—a thing with a beginning, middle, and end; sisterhood, life-exploding trauma, a new chance. But twins have boundary troubles; they’re always stepping uninvited into each other lives.

Now I know we are never done.

I’m in a haunted place, in my home and in my body. I’m bargaining. I can’t let that darkness touch my son. My love, she died; but we are still here. I tell myself that a baby arrives when he wants. Sometimes a day is just a day. But sometimes, too, a person is unable to manage the weight of the meaning of the thing right in front of her.

Iris was a year old when the test came back positive. Two pink lines for one new boy.

Caring for two young girls while working full-time was exhausting; and though I relished watching Josephine and Iris share their lives, I felt I’d given enough of myself, of my body, and our girls had each other. I was forty years old. I didn’t want to be pregnant again. I felt there was not enough of me.

As a young woman in New York, I’d had an easily-accessed surgical abortion during my junior year of college. Cara had helped me come to the decision to terminate my pregnancy; she wanted the best for me, to see me into a life where I lived up to my potential. We were twenty years old and sat huddled together on the floor of the apartment we shared, talking through my options. We both knew that carrying a pregnancy to term would effectively end my career and leave me in a position to raise the child alone—most likely in poverty, just like our mother had raised us. I didn’t make the choice to abort lightly—it was the hardest decision I’ve ever made—but it was a choice I was lucky to have the ability to make, and that I’d hoped I’d never have to make again.

I think often about the women I waited with in the recovery room all of those years ago, all of us covered with warming blankets. We were asked to fill out long forms and to reveal our race, our income, our birth control method. Those forms struck me as a kind of control. We deserved our privacy. We deserved to grieve alone. I refused to fill one out, my protest. The women beside me quietly scribbled their names.

After my positive test years later in West Virginia, I called my OBGYN to make an appointment. I have a history of ectopic pregnancies, so I was seen right away by a young physician on call. I lay on his table and stared at the ultrasound monitor as the doctor pointed to a beating heart that looked like a flashing star. I was six weeks gone.

“I want an abortion,” I told the doctor.

He looked at the floor. He was sorry he couldn’t help, he told me, but that’s just the way it was. He stood up from the little wheelie stool where he’d been sitting, wished me well, and closed the door.

Maude, an activist doctor friend, told me that my OBGYN’s practice would perform an abortion— I just needed to see the right doctor. I called the office again. I told the receptionist that I wanted to get in as soon as possible to have an abortion, please. I was raw and scared; there was no hiding. The line went silent. “I don’t know what you’re talking about,” she said. Then more forcefully, “We don’t do things like that here.”

“But you do,” I countered. “Help me.”

“I can get you in two months from now,” the receptionist answered, amused.

That was too late, as she knew: a woman must be fewer than ten weeks along to be prescribed RU486. I lay down on my living room floor and curled into a ball.

I called every doctor I could find in Pittsburgh, the nearest city, who performed abortions in-office. None would see me because I wasn’t already an established patient. And anyway, it was a two-hour drive and clinics require a waiting period.

The only abortion clinic in West Virginia offering out-in-the-open RU486 prescriptions and surgical abortion is in Charleston, a three-hour drive. After an initial consultation, I would need to abide by a twenty-four-hour waiting period. I’d take pills to end the pregnancy, and that process would take days, too. After that, I’d have to return to the clinic to make sure my uterus was clear of the pregnancy. If my husband traveled with me for the support I needed, who would care for our daughters while we were gone? Would we stay in a sterile motel as we went through the hardest moment of our marriage?

A few hours after I hung up with the receptionist, my phone rang. It was the doctor at my OBGYN’s office who could help me. Maude had called her on my behalf. The doctor told me she could end my pregnancy by prescribing RU486, but I shouldn’t tell a single nurse—or anyone on staff—why I was there. If I had complications, I’d be better off calling her cell phone. Not too long before, she’d helped a teenager have a surgical abortion and a nurse had seen it on the girl’s chart. It caused upheaval; her staff and nurses had filed a formal complaint against the doctor. She feared for her job and probably for her life. This, though abortion is legal.

The doctor told me that she must provide mandatory counseling advising me against the procedure. She recited the list of all the bad things that could happen to my body should I terminate, the least of which was regret.

It all made me uneasy. A medical procedure shouldn’t be a hidden thing. There are always risks. I worried too that some nosy nurse would see my name, that I would be outed and publicly shamed in our small town. I worried that I might suffer infection, or be turned away from the hospital if I needed help. I worried that I would bleed to death. I didn’t just walk out of my abortion in my twenties and back into normal life. I bled for weeks. There was cramping and pain. I’d slept the whole car ride home, and when I got home I crawled into bed and cried. I didn’t stop crying for days, and not because I’d made the wrong choice, but because sometimes the right choice hurts.

And sometimes you don’t have much of a choice after all. In the weeks after my conversation with the West Virginia doctor, I’d like to be able to say that my anger and shame over my lack of choice disappeared, but it didn’t. Caged by my body, reduced to a vessel, I grew angry and bitter. I’d done what good girls do, by default, and got myself slow with children. What I wanted to do was fight. I wanted to kick and punch and scream. My body was heavy. And I had to pee. I could only breathe by half.

I dreaded prenatal appointments. The kind doctor would touch me and I’d recoil. The depletion that comes with a full-bellied, unintended pregnancy—with every swift kick and turn that is the miracle of your baby thriving—it’s a primal reminder that the state believes it knows better than you do. You know less than nothing, and even less than that about yourself.

Yet it was never the feeling that it was me against Keats, my life for his life. We both lived in my body. We both needed that body to be considered and cared for.

Slowly, I let down my guard. I let myself love Keats. I played him music. I talked to him. He heard all about his sisters. I promised he belonged and was wanted in our family. I promised I would protect him. I knew how hard that would be.

According to the United Health Foundation, West Virginia has among the highest infant and child mortality rates in the country. The mountain terrain is so rugged it can defy progress. West Virginia also has one of the lowest rate of internet connectivity in the country, meaning some people have extremely limited access to information. Many women here must travel two hours for prenatal care, and then to give birth.

Over the years, reproductive rights in the state have been eroded. If a woman wants an abortion, she must receive state-directed counseling designed to discourage her from terminating her pregnancy. Following that session, she must wait twenty-four hours before moving forward with the procedure. If a minor needs an abortion, her parent must be notified and provide consent. All abortions after twenty weeks of gestation have been outlawed. A recent amendment to the state’s constitution makes it illegal for Medicaid to fund most abortions; that’s nearly all of them. In 2014 there were five clinics in the state that provided abortions. Today there is one.

There is a clear connection between diminishing abortion access and higher mortality rates for mothers and infants. Across the country, states that make abortions hardest to get also tend to be the least generous in providing safe and successful care for women and children. In Texas, the maternal mortality rate grew after the state closed more than half of its abortion clinics and severely cut funding for Planned Parenthood. South Carolina, with numerous restrictions on abortion, saw a 300 percent increase in maternal mortality, the highest since the turn of the century. Their outcomes for children are among the worst in the country.

Six years before Cara died, she was a young MFA student in Massachusetts. On an October afternoon, while out walking her dog in the woods in a crime-heavy area, she was brutally raped and tortured by a stranger. He dragged my sister down a rocky and secluded path. He smashed her teeth. He tore her clothes. He held a broken bottle to her throat. He used her body until she felt it no longer belonged to her. In the wake of the attack and all that it cost her, she suffered crippling anxiety and depression. She was rage-filled. She turned that rage inward. She lost all faith.

Strangers who have read my book often ask me what I think would have happened to Cara had she not been raped. Most people asking that question want me to tell them that regardless of the attack, Cara would have died. They want to hear this because it puts Cara’s fate in her own hands; one event can’t tip fate. Nobody wants to believe that they stand on the blade between sanity and madness. But I tell them what I believe: I imagine she would be a married mother living in suburbia now. That’s what she most wanted; to be rescued and lulled by motherhood, to be able to choose those things.

My sister’s death was a woman’s death. It was a death of choice, but not hers. What happened to her was a matter of place and time. When she was alive I couldn’t reckon that. I never said so to her, but I sometimes thought she bore some responsibility for the attack by having been in those unsafe woods in the first place.

Our house in Morgantown, West Virginia sits atop a hill. There are deer that sleep on our front lawn, like in a fairytale. Cardinals sing so loudly at sunup I have to close the windows to sleep. They perch on a power wire and stare blankly at me as I draw the blinds. In June the fireflies number in the thousands. Our daughters run after them barefoot, Mason jars in hand. Wild flowers blossom everywhere, their perfumes sweeter than cake. The neighbors bring food and comfort and kinship; there’s the feeling in town that we’re all in this together. Leaving feels impossible; even when it is done out of love, it’s betraying another loyalty. We invest in one another to make this place survivable. We don’t speak poorly of our state the same way we don’t speak ill of the dead.

But when the foliage falls and winter begins, the view from our back porch changes; the place is not what it appeared to be. Where there had been green, the town’s waste transfer station flanks the river, spewing acrid fumes that smell like burning tires, as if it hadn’t been there all summertime and for decades. Coal and gravel trucks plow through town day and night; some trucks carry radioactive coal ash with nothing but a flimsy tarp as cover. The deer that were pretty on the lawn are dead along the highway. There’s a majestic old bridge in walking distance from our house; beneath it, people sleep heroin’s dead sleep. Sometimes they never wake up. The place serves as a painful daily reminder of my sister; I can’t look away from the dealers on the bridge or the people shuffling around them like zombies, their pupils the size of pins. That bridge offers the fastest walk to campus, but most faculty avoid it; it’s much safer to take a different route. But that’s the way I take. I do it out of a kind of responsibility: I feel I should be able to.

The first night of his life, I held Keats against my breast, trying to nurse him. The IV poked into my hand during labor was covered with soggy medical tape. I struggled to keep his weight from pulling at the needle. Keats arched his head and wailed, his arm against his side, his body turned toward mine for warmth. He nosed around at my nipple, smelling for his life-food, unable to latch. By the next morning his skin had yellowed, and continued until almost goldenrod. And though Keats was scoring dangerously high for jaundice and was a probable candidate for phototherapy—a treatment with ultraviolet light that reduces bilirubin levels in the body—the doctors sent us home. There was no room in the hospital. We packed to leave. My hair remained uncombed. Dried blood streaked my legs. I could barely hobble back and forth to the bathroom. I yelled at every nurse, staff member, and doctor I saw. “I’m a writer,” I warned them. “Do something.” Writers tell. But the threat of words was nothing next to the reality of not enough resources.

My baby, my bird, my Keats; brown eyes at the brim, he looked like a hatchling forced ruthlessly from the nest. I’d brought us to this godforsaken state. Mothers can be so wild and cruel.

I took Keats to see the pediatrician every day. He needed his blood drawn to check his bilirubin levels. The results of each test showed he was only a hair away from needing to be hospitalized. When I pleaded with the doctor to give my boy light therapy, the doctor told me to place him in the sun beneath a window at home.

In the summer’s first heat wave our air conditioning was broken. It was too hot to put Keats in the sun. I lay naked in bed with my son atop my chest, him in nothing but a diaper, our sweat running together. Unclothed, I walked him over to the window and put us both in the light, moving in and out, so the heat wouldn’t touch him. I didn’t even think about the neighbors. I held my baby son and it felt like I was a skydiver pulling the ripcord. We were falling together and I couldn’t hold him hard enough. He was going down on my watch, just like Cara did.

Keats’s little head tipped back and over my arm during those hard days. The fact of him almost made me believe that Cara had come back to me. If I believed, there was a reason for all of that pain. And at the bottom of my life, that fantasy held me like I held Keats. I prayed to the past and hoped it would spare him.

I took Keats to the doctor’s office for ten days straight. I’d place him on a table to be weighed. A nurse would measure his head, then stick his heel with a pen-like push-needle. He’d yowl as she squeezed his blood out. Next the doctor would come in and blame me, my milk— I was the problem—yet I’d nursed both my girls beyond their first year.

I didn’t trust them. I took Keats to a dental surgery center in Pittsburgh. The doctor strapped him into a Papoose atop a surgical table. He laid hands on Keats as if he were putting together a valuable broken thing. A surgical lamp illuminated Keats’s mouth, which he kept open. We all marveled that he didn’t cry or try to break free. He just stared up at the light. The doctor looked inside Keats’s mouth and nodded. The diagnosis? A severe lip and tongue tie. He could take care of it. “There will be a moment of pain,” he said. “Keats won’t remember a thing. You, you’re a different story.”

When I’d just started my job in West Virginia, I’d gone to a dinner with a group of academics. We sat around a table talking, finishing a bottle of wine and a meal made from scratch. The conversation turned to origin—from where and when we had come to America, ourselves and our ancestors. I was the only one in the group who didn’t know my bloodline. All the people who would remember in my family are dead. My mother lost her parents when she was young. Both of Mom’s brothers are dead. They were the eldest of her five siblings, and the only ones who talked to the many aunts and uncles from Italy who have now passed. Our family rushed to assimilate, as so many immigrants do. There had been poverty and hardship in Italy; all that was past held that stain. Immigrating offered a chance at a better life. As a result, little was preserved. Our family forgot.

Once I’d unpacked the last of our boxes in Morgantown, I took Josephine to New York to visit my mother. I insisted Mom hand over whatever information she had about our family’s immigration from Italy to the United States. I refused to believe there was nothing left of our history. Mom went into the attic and brought down a large plastic container that held her dead brother’s belongings. He’d been into genealogy right before he died. She pushed the box over to my side of table; that box was the only worldly thing she had of her brother’s.

We rooted through the box together. Mom told me her grandfather had wanted to be a painter. Instead, he worked as a glass blower. All day he stooped over, torching color into vases for rich people. In the box, she found a map folded into a square. I opened it up and spread it over the table. It was a crude illustration of the town where her grandfather had lived and worked, the place he had come to from Sicily. The town was in West Virginia, ten miles from my new front door. I was home.

As you make your passage into West Virginia from western Maryland or up from Virginia, you drive over peak after peak. Before you know it, you’ve crossed state lines. There’s the feeling of being swallowed as you go in—as if you can’t turn back, the same way you can’t relive yesterday. Where you are headed and where you have come from are indistinguishable. The view is such a miracle that you don’t mind that you might never leave. There are fewer people. Rest stops dwindle. Homes are like teeth in a rotten smile. There is a convergence of the hideous and the divine. The mountain is an embrace, and all those houses are in briar-tangles and the view is vast and you know you are in God’s hands because the hills don’t end and the fog is the dividing line between the earth and the afterlife.

I know how I’m supposed to end this story, with the good mother’s admission that our children are proof of how life continues. In my case that seems demonstrable: there was Cara and there is Keats, as if they are one out of the world for one in.

But I don’t believe. That idea negates the severity of my loss of choice, and of every other woman who has lost hers. It erases my pain and replaces it with a child. That’s not how it works. Don’t you think I wish it did?

What remains: Keats was born into a world that hurts women—through physical violence and politicized restrictions, through scorn and blame and silence. I can take my experience of that fact and let it break me like it broke my sister, or I can release it with faith that someone hears.

Writers tell.

I love my son. I love how his hair is actually a kind of fuzz, a downy, sparse, and unnamable shade of brown. I love his dark eyes and long toes and blond lashes. I love the bald flat spot on his head, from where it meets his mattress. Nine months later, I’m still tracing my fingers over his collarbone. When I hold him sometimes it feels like we’re breathing together, that we’re body travelers sharing the answer to the world’s greatest riddle and the answer to that riddle is love.

I love my son, now and always. His is the face of my God.