Abortion Rights from a Medical Perspective

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Medical Perspective by Sonja Lippmann

The interviewee is a doctor who provides abortion care in a state that has trigger laws to outlaw abortion, which went into effect immediately after Roe v. Wade was overturned. She has asked to remain anonymous for privacy and security.

This interview was lightly edited for clarity.

SL: First of all, can you describe your roles as an abortion provider and what an average work day looks like for you?

Interviewee: I might be a little bit different in terms of the way my job is set up because I split my time between the university medical center and our local abortion clinic. Some of my time is spent on labor and delivery, and some in the office seeing patients for obstetric and gynecologic care. And then when I’m at the abortion clinic I see patients, perform their ultrasounds (because that’s what’s mandated by state law), and provide them with either medical or procedural abortion. I also assess medical eligibility for procedural and medication abortions. Patients have to take the mifepristone in the office based on state law. We can send them home with the misoprostol. State law prohibits us from mailing the abortion medications to patients. So we evaluate and dispense medications for patients requesting the medication abortion usually in the mornings, and then we do our procedural abortions in the afternoon. We might have anywhere from seven to like 15 patients scheduled for surgery.

You mentioned using mifepristone and misoprostal for medical abortions. Can you elaborate on how those medications work?

Yes. Mifepristone stops the pregnancy from continuing to grow and almost loosens the pregnancy sac from where it’s implanted in the uterus. It also helps soften the cervix and helps the muscles in the uterus be receptive to the misoprostol when the patient takes the misoprostol, which usually occurs about 24 hours later. Misoprostol is a medication that causes the muscles in the uterus to contract, which ultimately leads to expulsion of the products of conception.

How and why did you get into this field?

I had always been interested in reproductive health care because my father is an OB/GYN, and growing up I knew a couple of people who sought abortions for various reasons. It was really important that they were able to access the care that they did at those particular points in their lives—I think that always stuck with me.

When I started my residency, I made sure that I went to a residency program that had a Ryan Program, which is a training program that ensures OB/GYN residents get specialized training in complex contraception, meaning contraception for patients with complex medical conditions, as well as training in abortion care. When I did my family planning rotations, it was the area of obstetrics and gynecology that really spoke to me. It felt like that was where I’m meant to be because this is such important care. There are so many patients who really need to have access to this care for whatever reason it might be. And I feel like I can help people have access to abortion care and make sure that when they access it, it’s safe and that they’re well taken care of.

How emotionally painful is the abortion process for your patients?

I definitely see a range of emotions. There is always going to be a subset of patients that’s just very matter-of-fact like, “This is what’s happening. This is what I need to do. I wish I weren’t in this situation having to make this choice, but this is the best choice for me at this particular point in time.” Then you have a subset of patients that struggle with it emotionally, for example, people that have some type of abnormality with the pregnancy. It can be a little bit more emotionally difficult for those folks, but that’s not to say that someone who is choosing abortion and doesn’t necessarily have a pregnancy complicated by an abnormality doesn’t find it just as hard if not harder to make that decision.

People have to jump through so many hoops that by the time they’re actually able to see us, most people have become pretty resolute in their decision. We also have a counselor that meets with each of the patients. They always meet with the counselor before they proceed with anything, so I think that’s a good opportunity for people to talk about what’s going on. And if we feel like someone is not ready to make the decision, we do say, “why don’t you come back another day?” Not because we’re trying to be obstructionist, but if we sense that someone is having a really hard time , then it’s always better to err on the side of not doing anything because once someone takes medication or has a procedure, there’s no turning back.

Many people who want to ban abortion believe that there are very few justifiable reasons to have an abortion. Can you explain some of the different reasons you see why your patients seek an abortion?

I think that’s a very complicated decision for people, so I don’t ask my patients why they’re there, because when we get right down to it, it’s really none of my business.

I’m here to provide the patient with care, and the patient has obviously thought about this decision. It’s a decision that people spend a lot of time on and can cause a lot of mental anguish in some cases.

There are many factors that play into an individual’s decision to seek abortion, and every reason is valid. Reasons people seek abortion include social factors and maternal health concerns (i.e., a patient’s life is put at risk by continuing the pregnancy). There are also fetal anomalies that are lethal—why should a patient have to carry a pregnancy to term when the baby’s not going to survive? Almost 60 percent of people who seek abortions are already parents, so they already know what it takes to raise a child. I’ll also have patients say to me, “I just can’t afford to have another child right now.”

There are also many patients who seek abortion when sexual assault results in pregnancy. Another issue pregnant people face is intimate partner violence. Many people report that abuse started or increased when they became pregnant. So some people come in because they’re worried for their own safety. Patients tell us, “I don’t feel safe. I think my partner is going to harm me because I’m pregnant.” The bottom line is, I think people seek abortion for a lot of different reasons.

Do you feel like the field of reproductive healthcare has changed a lot since you first became involved in it, and especially as this issue is coming to the center of national politics?

Definitely. I think anti-abortion sentiment has always been around, but maybe I didn’t notice it as much during my residency and training because I was in geographic areas that are very pro-choice. So it was never really that apparent to me until I moved to the state I’m in now. And I started to see this flood of legislation and all these bills being introduced to limit access to care, or create more barriers to care, basically trying to regulate abortions in a way that no other procedure or part of medicine is regulated.

Could you give a brief background on the political climate regarding abortion when you first started with reproductive health care and compare that to where it is now?

Sure. I grew up in a state that was a lot more liberal when I was young than I see it now. It was not so polarized. There weren’t really extreme people trying to do these really extreme things—or at least that was my perception. Growing up I went to a Catholic school and they didn’t really talk about abortion. There was more of an emphasis on social justice really than anything anti-abortion. More recently, I talked to some of the residents that I currently work with who have gone to Catholic school. They shared with me they were actively encouraged to attend anti-abortion rallies, which I think is unacceptable. I don’t think that you should ever be asking students to do that. Anyway, as I was growing up, nobody ever talked about abortion that I can recall. Nobody ever said that it was wrong. But I kind of knew, knowing Catholic doctrine, that it was something Catholics weren’t in favor of, but no one really spent a lot of time talking about it.

Then I went to college in a place that is a lot more liberal. Where I grew up was very homogeneous, and then when I went to college, I had the chance to meet a lot of people who were different from myself and the people I met growing up. I met people who had different perspectives and different life experiences, so I think that opened my eyes a lot.

Subsequently, I moved across the country to another very liberal area where I ended up going to medical school, and I did get exposure to organizations like Medical Students for Choice. I moved to another liberal city for residency, and chose the training program I did because they did have a Ryan Program. So I existed in these spheres where abortion was accepted and abortion rights were not something that was ever questioned. If someone needed to access abortion care, we would help them do that.

Most recently, I moved to the conservative state where I am now. Initially, the state House of Representatives was controlled by Democrats. So a lot of anti-abortion bills that were filed were always tabled and never went anywhere. But then when Trump got elected, there was a switch in the makeup of both the state House and the Senate. There was this flurry of anti-abortion bills that started to be passed. Each year there have been several anti-abortion bills that become law. These bills include mandating patients view the ultrasound and mandating that the consent that has to take place 24 hours in advance must be face-to-face. Other examples include mandating that only a doctor can do the ultrasound or having requirements for additional forms to be completed if you’re dispensing mifepristone and misoprostol.

How do you feel about the way abortion care has been politicized in this way?

It’s a little frustrating because there are so many other procedures that carry more risk—for example, colonoscopies—han having a procedural abortion. Yet you don’t see politicians passing all this legislation about how a colonoscopy has to be done and what medicine you can use and how the medications have to be administered and how you have to report what medications you give to a person who’s having a colonoscopy and so on and so forth.

It’s aggravating to me that people with no medical background are trying to dictate medical care. Abortion care has become so politicized and increasingly stigmatized. We’re always having to adjust to the new laws that the legislature passes and it’s just always ridiculous things, to be honest. Things that are completely unnecessary and they always put it under the guise of, “oh, we’re doing this to make it safer.” It’s already a very safe procedure with very few complications. There was a huge report that was published in 2018 by the National Academies of Sciences, Engineering, and Medicine, that outlines really just how safe abortion is.

How does your clinic deal with all of these additional regulations?

We’re very fortunate because we have a skilled legal team that helps us be in compliance with all of these new laws and regulations. There’s a very strong possibility that the clinic would be shut down if we’re not in compliance, especially If we didn’t have the governor that we have currently, who is a Democrat. There is no doubt in my mind that a Republican governor would be sending inspectors to the clinic on a regular basis trying to find some reason to cite us or shut us down.

You’ve expressed that you want to stay anonymous for privacy and security purposes. Do you often fear for your own safety and do you feel the need to hide what you do from your community or your kids’ friends and things like that?

So personally and professionally, I never changed my last name, and I’m sort of glad that I didn’t because I feel like that gives us a layer of protection. People don’t necessarily know that my kids are my kids or even that my spouse is my spouse. I didn’t keep my last name for that reason, but it has turned out to be helpful.

I don’t have a social media presence. I’m not on Facebook, I don’t have Instagram, Twitter, none of the above. And some of the professional societies that I’m a member of, such as the National Abortion Federation, will give out tips for how to scrub the internet so that people cannot find things out about you. I’ve done a lot of those things. I haven’t really had to go one step further, but there are companies that you can hire who will really do a full-on scrub of the internet for you. I don’t know that I need to do [that] at this point in time. Basically, I’ve sort of managed to fly under the radar for a lot of this, so that’s been good.

But when I meet people, I tell them about my role at the university. I don’t really volunteer that I work at a clinic that provides abortion care until I’ve had a chance to get to know somebody a little bit better. I do feel like I have to be careful. The measures that I’ve taken, even though they’re not super intensive, have made me feel fairly safe. The clinic also has a lot of security features, like a gated parking lot and people have to be buzzed into the waiting room.

There was one time though, where this person who was with an extreme chapter of an anti-abortion group actually found us and came into our university clinic through a door that was unlocked in our office suite. He didn’t say anything to anyone or do anything, but he left some anti-abortion literature in the waiting room and the office staff recognized that he was not a person who was supposed to be there. So, we definitely bumped up our security measures after that.

If somebody does want to get in contact with you to receive an abortion, do they always have to go through the clinic? Is there no online way to contact you because of the privacy issue?

No one would ever contact me directly, unless they were a patient in our university practice who happened to know that I work at both places. For the most part, there are organizations and local abortion funds that help connect patients. There’s also word of mouth.

Are there often protestors outside the clinic?

Yeah. It is especially bad because they don’t respect boundaries at all. So many patients say “they got really close to me, they touched me, they tried to grab my arm, and I told them not to touch me, but they did it anyway.” Different patients have different reactions to that, but it can definitely be very traumatizing for someone to get in your face and tell you you’re going to hell or whatever vitriol they’re spewing. One thing that has helped is that our city council passed an ordinance for a buffer zone, which went into effect in September of last year. So that gives us a 10-foot buffer zone outside of the entrance to the clinic. And I think because that buffer zone exists, the police have to pay attention and now more people are getting cited for violating the buffer zone and getting charged with things like trespassing and assault.

Have you ever considered leaving your job due to the fear of people who are anti-choice and why have you chosen to stay?

Well, I never really have considered leaving my job because I really think it’s important for people to access abortion care. It’s difficult enough for people in this state to be able to access it, so if I were to leave, then that leaves an already small group of providers even smaller than what it is currently.

Also, I’ve always been sort of like, “no one’s going to tell me what to do. No one’s going to bully me.” And I sort of see it as the protesters trying to bully me into leaving, and if I leave my job, then in some respects, it’s kind of like they’ve won.

Have you ever felt like you wanted to be able to be a more outspoken advocate for reproductive rights?

I think that’s kind of difficult. Because of litigation that I’m involved in, I’ve been advised by my attorneys not to really speak publicly on the matter, so that kind of eliminates speaking out at rallies and things like that. When I first moved to the area, I would travel to the capital and testify in front of legislative committees, which I think is important, even though I know they don’t really care —they’re not really listening. I still think it’s important for that to be documented. But because of all the laws they started passing and all the legal challenges, I had to stop speaking out in person like that. So, now I feel like I do as much as I can without being visible..

What would happen to yourself and your coworkers and clients if Roe v. Wade was to be overturned?

Well, some people just wouldn’t be able to access abortion care anymore because, despite the number of organizations that are out there to assist people, some folks are unable to access those services for a multitude of reasons. The Guttmacher Institute has really good statistics on this, but basically right now, the average distance someone in my state has to drive to obtain an abortion is 70 miles. If Roe is overturned, that distance increases to approximately 240 miles.

It’s hard to know for sure what would happen to the clinic. We would stay open long enough to be there for follow-up for those folks that had done medication abortions and need to have access to follow-up care. But because the state has a trigger ban that goes into effect immediately, if, and when, the Supreme Court overturns Roe v. Wade, the trigger ban goes into effect, and we won’t be able to do anything.

Overturning Roe would not just limit access to abortions, but also to essential obstetric and gynecological care and treatments. So what would be the effect of restricting those in your state?

There’s this vague language in the trigger ban that kind of makes one wonder if it would even continue to be safe to take care of a person who has an ectopic pregnancy, which we all know in the medical community, is not viable. Is that going to be viewed as providing an abortion even though an ectopic pregnancy is not a medically viable pregnancy and is in fact life-threatening? Or what happens if we have a person who is less than 24 weeks along and is bleeding pretty heavily, but there’s still a fetal heartbeat? Are we going to be penalized for acting and doing a procedure on somebody who’s actively hemorrhaging just because there was still a heartbeat? The way that it’s written, it’s not very clear and it seems like a person could find themselves in trouble for providing medically appropriate care.

Also, the Roe v. Wade decision was based on a person’s right to privacy. So, that may creep into other aspects of life. I think Justice Thomas has talked about its potential impact on marriage equality, access to birth control, and things like that. It’s a slippery slope.

Can you explain what some of the risks and injuries associated with back-alley and at-home abortions are?

I think people are going to be able to order medications online, so you’ll probably see more self-managed abortions. Or maybe people will have a friend go across the border, for example, into Mexico and purchase medication. The vast majority of patients will be successful if they purchase medication that actually is what it says it is, but there’s always a risk if you’re getting something online and you receive medication that isn’t what you thought it was.

The majority of people who buy medications will probably get misoprostol and if they’re too far along in their pregnancy (i.e., greater than 12 weeks), the misoprostol may not be enough to cause expulsion of the products of conception. So there’s the potential for emergency rooms to see many more patients who are bleeding with incomplete abortions in states where they are unable to access legal abortions. If you have retained products of conception that not only puts you at risk for bleeding, but potentially infection, too.

I suppose there could always be people who try to access procedural abortions from someone who has not been formally trained in how to do them. We might expect to see some of the same things, like incomplete abortions and, or potentially perforation of the uterus from people trying to do it either themselves or with someone who has no formal training and not the right instruments to perform the procedure.

As an abortion provider, is there anything specific that you’d like to share with the jGirls+ readers who are coming of age as abortion rights are on the line?

To the extent that people feel comfortable, I think we need to be bold and speak out about it. And if it’s something that you’re really passionate about, write op-eds and go talk to legislators and go to rallies.

Within the last few months, I was talking with someone who was very active in the sixties and early seventies, prior to Roe being passed. She basically said, “I don’t know where the younger generations are. I was out there fighting, and I feel like I don’t see as many of the younger generation out there fighting now. Now it’s somebody else’s turn, it’s not as easy for me to attend rallies and things like that anymore.” So I just thought that was kind of interesting how she felt like there weren’t as many voices in the younger generation speaking up about abortion rights.

I think it just goes to show that there’s still a lot of stigma surrounding abortion. The more people talk about it, the better it will be, but it can also be kind of scary and overwhelming for people to talk about it, too. That being said, there are people out there who aren’t scared and even if there might be some backlash, they’re still out there fighting. Of course advocacy on this issue can be very difficult when you have legislators who won’t listen to you or completely discount what you’re trying to say.

I think the other important thing is that people vote because I still think there are a lot of people who don’t exercise their right to vote, and voting can be a very powerful tool, even though it might not feel that way. If we have more people voting, we can get the people in office who will actually listen to the things that we’re saying and support the causes we support.

For more information about abortion and reproductive health, check out our resources page.
This article is one of four published in our Pro-Choice: An Interview Series. See the introduction and all four interviews here.
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