What you learn doing abortions after 20 weeks

Residency doesn’t prepare you for listening to someone you have never met pleading over the phone for help, their breathless desperation as they try to tell their sad story between sobs, intertwined with intimate details. They would say random, heart breaking things like, “What do we do with the crib?”

They were similar in many ways. A state with a 20 week ban on “elective” pregnancy terminations. The ultrasound that diagnosed the catastrophic collision of chromosomes performed too late. Often there was the suggestion that the doctor might have been offensively “pro-life,” the kind that orders the second trimester scans a little later than recommended for those women they know are pro-choice.

I didn’t set out to do post 20 week abortions, I just kind of ended up doing them because with each turn in medical school and residency it seemed no one else was. I was always pro-choice. I remember riding my ten speed to Dr. Henry Morgentaler’s clinic in Winnipeg to show support when I was 16. I hadn’t even been on a date or had sex so pregnancy and abortion were abstract, yet I knew women deserve autonomy. That we get to decide what happens to our bodies. My parents were very conservative in many ways, but they were very pro-choice so maybe it came from them. Our basement library was also filled with books by the likes of Margaret Atwood and Betty Friedan and so I read a lot of feminist literature and non-fiction growing up.

In medical school the lectures about abortion were given by men. That bothered me. I don’t think you have to be a woman to be a good OB/GYN, but I had hoped for equal representation. The same in my OB/GYN residency, only men did abortions and for any woman who thinks it’s weird for a man to be an OB/GYN let me say these men were full of empathy and kindness and were very skilled and there was nothing odd about them wanting to do OB/GYN. The subject interested them and they felt women deserved the best care. Basically, they thought about it just like I do.

Once in residency I remember rolling my eyes about someone who was past 20 weeks and needed an elective procedure. There a firm grip on my arm and a firmer lecture about privilege. Before the world was online some women were told by their doctors that abortion was illegal and they had no idea that not only was it legal in Ontario but also free. The delay explained by the time it took to find out through a network of whispers where to go and to raise the money for one bus ticket. I had the luxury of a basement library, two homes, music lessons, and trips to Europe growing up and I was going to judge someone who had to work two jobs to buy a bus ticket to travel alone for her abortion? A good doctor teaches you these things.

To learn abortion in my residency required going out of my way. That unspoken marginalization bothered me. The default should be learning the procedure, because otherwise there is a clandestine air. The other thing that troubled me was the only other people who went out of their way to learn were men. They thought as I did, that we should all just learn so we then can all be safe and offer good care.

After residency I figured I would offer my patients abortions and it would be just one part of my practice. I naively thought everyone would do that. I moved to Kansas to do a fellowship in infectious diseases and learned very quickly that unlike the Canadian Midwest in the American Midwest it was best to not discuss abortion and choice. I was shocked by the fact that there were four clinics for the state, but only two places for women after 20 weeks.

Along the way people found out I had the mechanical skills. It probably started because I did a few dilation and evacuations on labor and delivery for women at 22 or 23 weeks with ruptured membranes, infections, and fetal demise. It’s technically a very hard procedure when there is an infection, but it is sometimes the only was to prevent a hysterectomy or save the woman’s life. It is a skill that only people who have learned how to do abortions after 20 weeks posses. It’s nerve wracking because with infection the uterus is like soft butter and you are using hard instruments. And it’s all by feel. In those days we didn’t use ultrasound.

I guess word quietly got out. Our clinic nurse, a kind soul and a ringer for Professor Sprout, pushed me a little to help this woman and then that one and so on. I didn’t know this would lead me to care for women who had almost no other options.

Many had been given Dr. Tiller’s name or told about Planned Parenthood, but if they had medical conditions they needed a hospital and that left me. Some didn’t want to go to Dr. Tiller or Planned Parenthood, often they were of the persuasion that believed abortion was wrong and obviously if you go to an abortion clinic everyone knows what you are doing. A hospital offers other potential explanations. Often they came because they had no money and I worked at a teaching hospital and we didn’t ask for cash up front, so maybe just maybe?

A later abortion is thousands and thousands of dollars so when people had nothing I would beg and plead with my anesthesia buddies and they would forget to turn in their billing slips. I wouldn’t charge and the hospital administrators often looked the other way. I don’t know if they were pro-choice, the billing truly sucked, the stories tugged at their hearts like they did mine, or they accepted my explanation that this was for resident education.

Several times there was no money for a funeral home to receive the body (they can charge hundreds of dollars), but a several hundred or more mile drive to get the body back home. It became my job to figure that out. I’m 28 or 29 and I’m scrambling to find a suitable box for a tiny body and convince the morgue that this is somehow okay. I’m pretty sure my genetic counselor gave people gas money from time to time.

If we did an induction the nurse would wrap the baby up ever so carefully for viewing, but sometimes the birth defects were so much that we presented hand prints and foot prints or a face carefully swaddled to show the chin or whatever part looked perfect. It takes a special kind of nurse to do this and they did it with such tenderness. However, as the doctor it was left to me to explain why we thought it best they not look. All the things no one knows how to do or wants to do are left to the doctor. Do you show a woman that her baby really is a cyclops? I know she knows because she told you between sobs when she called, or rather her husband did because she was crying so hard she couldn’t speak anymore. But is that the image I should lock in her brain for the rest of her life or the five toes? You just do the best you can. I like to think that my patients knew that.

At the time I was told we got all these out-of-state calls and desperate women because Kansas had a lax abortion law. The story was the previous chair of the department had been around for so long that he had done abortions for so many mistresses and delivered babies out-of-wedlock for so many daughters that he had massive coin in the political bank. I don’t have proof of that, but the law had no gestational age limit and it was to my hospital reporters came calling when there was a suggestion that Bob Dole had a girlfriend way back who had an abortion.

But times change and the former chief of the department was elderly and all those maybe secrets and those affected by them aged with him. A law was passed to prevent abortions at KU medical center unless the life of the woman was in jeopardy. It wasn’t a back door TRAP kind of law, it was a blatant “not here” tacked on to a funding bill. Want state funding, stop abortions. No one beats around the bush in Kansas.

Guess who gets to decide if a woman passes the Kansas state government’s test for being sick enough to die from her pregnancy? Not the cardiologist who calls at 3 a.m. in a panic or the nephrologist who breathlessly corners you in the hallway or the intensivist who tracks you down on your vacation. Not any of the people who manage the illness trying to kill the pregnant woman. Not me either, but the politician who crafted the mayhem via a three-way phone call set up by the hospital attorney. And yes he was shocked beyond belief that such a scenario existed. Politicians swallow the anti-abortion rhetoric so completely that they truly believe the health of the mother is just some pro-abortion lie doctors tell. Why couldn’t they just go somewhere else? Try explaining the idea that if a woman is sick enough she might die from her pregnancy that her abortion needs a skilled anesthesiologist, a blood bank, and an intensive care unit to someone with zero medical background.

But the law worked. Women were still sick, especially in the rural Midwest where many had no health insurance so medical conditions went unmanaged, but people learned to refuse the transfer. Not sick enough. Call us when she’s really dying. Abortions at KU stopped, but the need didn’t stop, just diverted elsewhere and possibly to less experienced hands.

Soon after I moved to another state where there were several skilled providers, some at hospitals, and so I gradually did fewer and fewer. I stopped doing abortions over 12 years ago along with deliveries. Partly because I wasn’t needed anymore, but mostly because of PTSD. Being around pregnant women is really hard for me given my terrible pregnancy outcome. It’s hard to explain, but my son died in a labor and delivery room and so the idea of having to go into onto labor and delivery makes me feel physically unwell. I don’t even like going to one to meet up with a friend for lunch.

What is it like doing abortions after 20 weeks? It’s mostly very sad because no one is there because they are happy. A wanted pregnancy causing serious physical harm, well, no one is happy they are sick or that they have to terminate their wanted pregnancy to live. I know these women were happy they met me and some even returned to be my patient. That always meant a lot. “You saved my life, how could I go to someone else?” What about a wanted pregnancy with severe malformations? No joy there either. Only a tiny minority are unwanted pregnancies and then the woman almost always wishes the pregnancy never happened and that she could have terminated sooner. Women who access abortion care after 20 weeks for what we call elective reasons are in that situation because of laws designed to restrict abortions.

Doing sad stuff is part of medicine, but add in the hoops you have to go through to learn abortion, the TRAP laws, the fear, and then the price that many have to charge to cover expenses and you get a very narrow field of providers. And it’s getting smaller.

What bothers me about abortion are the lies politicians and supposedly pro-life individuals tell others and themselves. That doctors make lots of money doing these procedures, that these are callous women who just decide on a whim at 22 weeks (no women ever decides any abortion on a whim), that there are other options, that women don’t try to do home abortions, that no one is sick enough to need an abortion, that laws reduce the need for abortion as if doctors are standing on the street corner offering two for one deals. These laws are built on an equal mix of privilege and lies.

Focusing on abortions after 20 weeks tells me that politicians have invested nothing in learning what that means. That forcing a woman to carry a fetus not compatible with life to term is kind. That serious intrauterine infections at 23 weeks don’t happen. That women have thought nothing about what they are doing. Let’s be clear, if you are truly “pro-life” you’d agree with these procedures because they save women. Not in an abstract way, but sometimes it is in a this-infection-is-killing-you-and-we-need-to-help-you-right-now kind of way.

The one thing I’ve learned from my experience is that efforts to stop abortion after 20 weeks are nothing about life or compassion or good medicine, it is simply wielding the misery of women (and those who love them) as a political tool.

 

 

I want to thank the woman who gave the interview to Jezebel about her experience with her abortion at 32 weeks. I am so sad that you had to fly out-of-state to have the hardest procedure you will have. I am so sorry it cost you so much money. Your story helps fight the narrative that abortion after 20 weeks is some abstract thing that no one needs.