This is a clinic where they kill babies!" A woman in a black beret stopped me as I entered an abortion clinic. Pamphlets in hand, she asked me with concern, "Are you pregnant? Do you need help?"
I wasn’t pregnant. I was on my way to work.
I went to medical school to promote life. I defined that loosely: I wanted to do what I could to keep individuals healthy so we could be part of loving families and build healthy communities, supporting each other and enjoying being alive. While I was in medical school, a friend became pregnant after date rape, and I supported her through an abortion.
Around that time, I attended a talk at the medical school by the journalist Jack Hitt. He discussed "Who Will Do Abortions Here?"—his powerful, eye-opening New York Times article from 1998 about the threat to legalized abortion in the United States because of the lack of providers.
Then, as now, the number of abortion providers was dwindling. The number went from 2,680 providers in 1985 to 1,787 in 2005, the latest year for which statistics are available. Hitt described the upcoming retirement of the generation of obstetrician/gynecologists (OB/GYNs) who had watched women bleed to death from botched abortions and had responded to those tragedies by staffing clinics when the U.S. Supreme Court legalized abortion in its 1973 ruling in Roe v. Wade.
But no new generation of abortion providers was being trained, Hitt told us. When teaching hospitals merged with religious hospitals where abortions were banned, abortions were no longer done—or taught—at the teaching institutions. Other programs began to make abortion training optional: OB/GYN or family medicine residents who wanted the training needed to add it to their already heavy loads of required courses. Threats to the lives of abortion providers and their families dissuaded some practitioners from providing these services, even though they were trained to perform them and the procedure is legal. More than half of all abortion practitioners were past retirement age, Hitt said. One elderly practitioner flew his own plane to reach women in four states—he was the sole abortion provider in North Dakota—despite regular death threats.
There are now an estimated 1.5 million abortions each year in the United States, making it the most common surgical procedure. Yet there are fewer and fewer abortion providers available. One-quarter of women needing abortions must travel more than fifty miles for the procedure; 6 percent must travel to another state. During my medical training, I saw many women with an unwanted pregnancy, and I witnessed wide variation in the options that doctors offered patients in that situation.
Seeing The Realities
During my outpatient pediatrics rotation at a Catholic hospital, one mother brought her teenage daughter to the clinic, concerned about possible gastroenteritis; the fifteen-year-old was vomiting every morning. The daughter’s belly was flat as she lay on the examining table, her breasts full. "An adult’s body, a child’s mind," I thought. Then I realized that her adult body could be engaging in adult activities. I asked permission to speak with her alone. Yes, she told me, she’d been sexually active. Once. A month before. She hadn’t gotten her period since. The pregnancy test was positive. Instead of giving her the three choices potentially available to a pregnant woman—motherhood, adoption, or abortion—the pediatrician who supervised my work immediately broke the news about the girl’s pregnancy to her mother, who told the girl’s father, who decided—against the girl’s wishes—that she would have the baby, and the parents would raise it.
Without wanting to, the girl would become a teenage mother. Luckily, unlike many others, she would have the support of her parents. Most teenage mothers face daunting odds. Two-thirds of families begun by young unmarried women are poor. One-half of mothers on public assistance had their first child as teenagers. Children of teenage mothers are more likely to be born prematurely, more likely to be abused and neglected, and more likely to become teenage parents themselves than is the case for children of older mothers.
During my medical training, I watched other doctors approach abortion as a matter of fact. My OB/GYN rotation was at a community hospital that provided abortions through the end of a woman’s second trimester of pregnancy. There I met a diabetic woman with end-stage kidney disease who wanted to end a pregnancy that had begun when birth control failed. She thanked me for helping her stay alive, instead of running the risk of dying during pregnancy. It meant that she could continue to care for her three children, born before she became so sick.
But I didn’t fully appreciate the importance of access to safe and legal abortions until my fourth-year rotation in pediatrics at the Albert Schweitzer Hospital, a historic missionary hospital in the Central African nation of Gabon. Gabon is a pro-natalist country, meaning that it actively encourages childbearing. Birth control became legal there only in 2000. The following year, abortions became legal—but only when the life of the mother is in danger. The philosophy of Schweitzer, a missionary doctor, was "reverence for life"; at the hospital he had founded, this was interpreted as "no contraceptives"—meaning that the one-time fee that usually covered a doctor’s visit and all needed medications would not cover birth control. Women had to pay separately for contraceptives. Often they could not afford them.
As I prepared to hospitalize a child to treat him for malnutrition, his mother begged me to help her end her pregnancy. At age thirty-six, she had ten kids already, she said—more than she and her husband could provide for. She’d wanted to use condoms, but her husband wouldn’t let her. "Please help," she begged. But I had to say no. I had to wait to see if, because of a failed abortion, she’d be brought into our emergency room. Although officially the Schweitzer Hospital didn’t provide abortions, in the year before my arrival, emergency care because of failed abortions accounted for more than 10 percent of the surgeries in the hospital. The number of failed abortions was 20 percent of the live births.
What were those failed abortions that we treated in the emergency department? Sometimes a pregnant woman would insert a reed or knitting needle into her uterus to try to sweep out the fetus; this could perforate the uterus and cause infection or catastrophic bleeding. Sometimes a woman would take a poison or overdose on malaria medications to try to kill her fetus, and nearly kill herself, too. When women’s attempts to end their unwanted pregnancies also threatened to end their own lives, they came to the hospital, where surgeons would perform emergency, life-saving procedures.
I decided to learn to provide safe abortions.
Training: Day One
Dr. Gold (also a pseudonym), a family physician in a patchwork silk skirt and furry clogs, became my first abortion teacher after I returned to the United States. She was part of a new generation of providers. She created a warm and welcoming clinic in an unassuming corner building in a big city, marked only by a simple sign on the door. Like all visitors, I had to be buzzed through two doors to enter. The decor was a sort of homey chic, with boxes of herbal tea stacked next to the cooler. Information on birth control options filled the waiting room.
This would be the experience of a patient in the clinic:
She’d complete the initial paperwork, then be asked to start thinking about what type of birth control she’d prefer in the future.
She’d get an ultrasound to date the pregnancy. She’d be reminded of her three options in pregnancy—motherhood, adoption, or abortion. (Most women had already decided on an abortion.)
If she selected abortion, she’d be taught about the two types of available abortions: medical or surgical. A medical one, possible until the ninth week of pregnancy, meant stopping the pregnancy with one pill, then giving another pill to start contractions to empty the uterus. A surgical abortion meant emptying the uterus with suction, using either a manual or an electric vacuum aspirator. The surgical abortions could be done under local anesthetic or, if the woman preferred, general anesthetic. (Most patients selected a surgical abortion using manual vacuum aspiration, done the same day under local anesthetic.)
She’d go to the back of the clinic to get her vital signs checked and her blood drawn for lab tests.
Then came the procedure. It would begin like a routine OB/GYN exam. The doctor would feel the woman’s uterus and cervix, then position a speculum (an instrument that widens the vagina to allow the doctor to look inside), clean the cervix, numb it, and begin the irreversible part of the process.
First was opening the cervix, dilating it with a series of white plastic rods, the first as narrow as a Bic pen, the others ever wider.
Next was emptying the uterus with a soft, flexible, plastic tube attached to a large syringe. The doctor would pull back on the syringe, removing the products of conception, and the woman’s uterus would cramp down around a now-empty space.
After resting, she’d start her birth control, pursuing any one of a number of regimens: a daily pill, a weekly patch, a monthly vaginal NuvaRing, the first shot of Depo-Provera hormone to last for the next three months, the Implanon hormone inserted under the skin to protect her for two years. Or perhaps she’d chosen to have an intrauterine device (IUD) put in place while her cervix was dilated and her uterus empty, which would protect her from pregnancy for the next five to ten years.
She would enter the clinic with an unwanted pregnancy. She would leave no longer pregnant, but protected, so that she could try to become pregnant only when she chose.
Training: The End Of Day One
At the end of the first day, the foot bothered me most.
Identifying the second-trimester products of conception was the hardest part of performing an abortion. Before eight weeks, they’re nothing but floating membranes, cells exploding in overdrive. Between eight and twelve weeks, they shape themselves into a homunculus the size of a lima bean. Nearly 90 percent of abortions are done in this early phase. But after twelve weeks, as the second trimester begins, the fetus assumes an increasingly human form. I struggled to find a way to withstand the discomfort of identifying body parts when ensuring that an abortion was complete.
In the tiny hands and feet I could see the potential for a human life that would never be expressed. To my mind, it’s a potential life, not yet an independent one. With the union of sperm and egg and the unfolding embryonic development, the products of conception have progressed one key step further than a sperm lost in nocturnal emissions or an egg lost in a monthly period. But the developing fetus isn’t able to live outside the mother’s body until somewhere between twenty-four and twenty-eight weeks—still three months shy of a normal forty-week pregnancy.
"How do you handle this?" I asked the doctor, as we searched for the fourth limb of a fourteen-week pregnancy in the floating membranes and blood clots.
"Scientific distance," she said. "Think of them as ‘extremities’ rather than ‘hands’ or ‘feet.’"
"We don’t do this because we like it," she reminded me. "We do it to give women a choice."
"Don’t kill your baby! There is another choice!"
I was wearing my everyday clothes, on my way into another abortion clinic. The moment I stepped out of my car, alone, a group of six protesters began shouting at me from the sidewalk: "You can still become a mother! Don’t murder your baby!" A security guard came to my side, and together we walked to the front door.
I wondered what the protesters would say or do if I were wearing my medical scrubs—or if they knew that instead of coming to obtain an abortion, I was there to learn how to provide them. A popular poster among abortion providers reads: "Our doctors have learned everything there is to know about making abortion safe—except what to wear to work." This continual threat of violence has dissuaded some of my colleagues from providing abortions. The obstetrician/gynecologist who runs this clinic, a man creeping toward retirement age, has endured daily protesters sometimes seventy strong, survived death threats, and lived through times when his work clothes included a bulletproof vest.
"Baby killer!" the protestors shot at my back as I entered the clinic, the final harassment of what they thought was a pregnant woman making a difficult choice. That day, I cared for a forty-three-year-old woman. She was there to end the pregnancy that had begun the day she was gang-raped, beaten, and left in a dumpster for dead. She, too, had needed to pass the protesters to enter the clinic. I was angered by the insult they added to her deep injury, the emotional abuse of a vulnerable woman.
After completing the month-long abortion elective within my family medicine residency training, I had hoped to integrate abortion care into my routine primary care practice. Then I found an ideal job that would allow me a partnership with an academic medical center while fulfilling a scholarship obligation at an outstanding community health center. I enjoy working in a clinic that provides comprehensive health services to a deeply underserved population, teaming doctors with nurses, caseworkers, social workers, and psychologists. But there’s a catch. The center was founded by monks, and its board doesn’t allow health care providers to incorporate abortions into routine primary care.
For now, I’m one of the abortion providers lost to American women because of the preponderance of anti-abortion religious institutions providing health care—whose charity care probably disproportionately affects poor and underserved populations. Nationally, new "conscience rules" protect people who believe abortions are wrong from having to provide information or medications they think would end a life. But there aren’t any conscience rules in place to protect people who, if their home institution believes otherwise, provide medications or procedures they believe would save a life—the mother’s.
Instead of providing abortions, I help patients avoid unwanted pregnancies. By asking about whether pregnancy is desired and reviewing birth control options for all my female patients of reproductive age, and by teaching the teenagers both the value of abstinence and the effectiveness of different birth control options, I hope the women I care for will become pregnant only when they want to.
But sometimes the situation seems hopeless.
I met one teenager in the clinic who boasted: "I’m not going to get pregnant. I’m wearing this!" She showed me the abstinence ring on her finger. She was in my clinic room with her best friend, another sixteen-year-old who had also made a virginity vow. But then she’d had sex, unprotected. She was there to discuss birth control options to use after her intended abortion. She was leaning toward the vaginal NuvaRing, along with condoms to protect herself from diseases.
"But remember what our teacher told us about condoms," the girl with the abstinence ring reminded her friend. "She said that viruses and diseases can get through because the end of a condom looks like this. [She drew a chicken-wire fence.] Condoms don’t work."
"Latex condoms do work," I said, taking the opportunity to provide some reeducation. "They’re not perfect, ’cause they can slip or break, but when you use them right, every time, they protect against diseases and pregnancy."
"Really?" the girl with the ring asked, suspicious of the dueling authority figures giving her very different information.
Without accurate reproductive health education, she’s at higher risk for an unintended, unwanted pregnancy. If she didn’t have the financial, social, and emotional resources to sustain a life when it arrived in the world, currently she’d have access to a legal, safe, medically supervised abortion. But medical abortions will remain safe only if there are enough trained, practicing abortion providers to meet the need.
Looking Toward The Future
To promote continued access to safe abortions in the United States, we need to ensure that there are enough abortion providers. We can start by making abortion care a routine part of medical training and clinical care. All physicians who care for reproductive-age women should have opt-out, rather than opt-in, abortion training during their residencies. This approach would have the added benefit of strengthening skills in other aspects of early pregnancy care, and it would make medical providers more comfortable dealing with the spontaneous abortions that, sadly, end one in eight known pregnancies.
Medical training should include all aspects of reproductive health—contraceptive counseling, pregnancy options counseling, and abortion services—along with the current training about treating sexually transmitted diseases and managing normal pregnancy and childbirth. And those physicians who choose to provide abortions as part of their routine practice shouldn’t be restricted from practicing in any hospital or clinic across the country. Abortion should be recognized and accepted as a key component of comprehensive medical care.
For those of us who grew up after Roe v. Wade, it’s easy to forget the deadly consequences of the lack of access to safe, medically supervised abortions. History tells us that many women will choose to pursue an abortion at any cost, even risking their lives. My time in Gabon reminded me that, legal or not, safe or not, abortions will continue. I strongly support continued access to safe abortions for all of the women who turn to me or another doctor for care.