ESSAY | summer 2004
* This essay was nominated as a National Magazine Awards finalist. Congratulations to Martha Mendoza.
Between a Woman and Her Doctor
A Story About Abortion You Will Never Forget
I could see my baby's amazing and perfect spine, a precise, pebbled curl of vertebrae. His little round skull. The curve of his nose. I could even see his small leg floating slowly through my uterus.
My doctor came in a moment later, slid the ultrasound sensor around my growing, round belly and put her hand on my shoulder. “It’s not alive,” she said.
She turned her back to me and started taking notes. I looked at the wall, breathing deeply, trying not to cry.
I can make it through this, I thought. I can handle this.
I didn’t know I was about to become a pariah.
I was 19 weeks pregnant, strong, fit and happy, imagining our fourth child, the newest member of our family. He would have dark hair and bright eyes. He’d be intelligent and strong — really strong, judging by his early kicks.
And now this. Not alive?
I didn’t realize that pressures well beyond my uterus, beyond the too bright, too-loud, too-small ultrasound room, extending all the way to boardrooms of hospitals, administrative sessions at medical schools and committee hearings in Congress, were going to deepen and expand my sorrow and pain.
On November 6, 2003, President Bush signed what he called a “partial birth abortion ban,” prohibiting doctors from committing an “overt act” designed to kill a partially delivered fetus. The law, which faces vigorous challenges, is the most significant change to the nation’s abortion laws since the U.S. Supreme Court ruled abortion legal in Roe v. Wade in 1973. One of the unintended consequences of this new law is that it put people in my position, with a fetus that is already dead, in a technical limbo.
Legally, a doctor can still surgically take a dead body out of a pregnant woman. But in reality, the years of angry debate that led to the law’s passage, restrictive state laws and the violence targeting physicians have reduced the number of hospitals and doctors willing to do dilations and evacuations (D&Es) and dilations and extractions (intact D&Es), which involve removing a larger fetus, sometimes in pieces, from the womb.
At the same time, fewer medical schools are training doctors to do these procedures. After all, why spend time training for a surgery that’s likely to be made illegal?
At this point, 74 percent of obstetrics and gynecology residency programs do not train all residents in abortion procedures, according to reproductive health researchers at the National Abortion Federation. Those that do usually teach only the more routine dilation and curettage — D&C, the 15-minute uterine scraping used for abortions of fetuses under 13 weeks old.
Fewer than 7 percent of obstetricians are trained to do D&Es, the procedure used on fetuses from about 13 to 19 weeks. Almost all the doctors doing them are over 50 years old.
“Finding a doctor who will do a D&E is getting very tough,” says Ron Fitzsimmons, executive director of the National Coalition of Abortion Providers.
My doctor turned around and faced me. She told me that because dilation and evacuation is rarely offered in my community, I could opt instead to chemically induce labor over several days and then deliver the little body at my local maternity ward. “It’s up to you,” she said.
I’d been through labor and delivery three times before, with great joy as well as pain, and the notion of going through that profound experience only to deliver a dead fetus (whose skin was already starting to slough off, whose skull might be collapsing) was horrifying.
I also did some research, spoke with friends who were obstetricians and gynecologists, and quickly learned this: Study after study shows D&Es are safer than labor and delivery. Women who had D&Es were far less likely to have bleeding requiring transfusion, infection requiring intravenous antibiotics, organ injuries requiring additional surgery or cervical laceration requiring repair and hospital readmission.
A review of 300 second- trimester abortions published in 2002 in the American Journal of Obstetrics & Gynecology found that 29 percent of women who went through labor and delivery had complications, compared with just 4 percent of those who had D&Es.
The American Medical Association said D&Es, compared to labor and delivery, “may minimize trauma to the woman’s uterus, cervix and other vital organs.”
There was this fact, too: The intact D&E surgery makes less use of “grasping instruments,” which could damage the body of the fetus. If the body were intact, doctors might be able to more easily figure out why my baby died in the womb.
I’m a healthy person. I run, swim and bike. I’m 37 years old and optimistic. Good things happen to me. I didn’t want to rule out having more kids, but I did want to know what went wrong before I tried again.
We told our doctor we had chosen a dilation and evacuation.
“I can’t do these myself,” said my doctor. “I trained at a Catholic hospital.”
My doctor recommended a specialist in a neighboring county, but when I called for an appointment, they said they couldn’t see me for almost a week.
I could feel my baby’s dead body inside of mine. This baby had thrilled me with kicks and flutters, those first soft tickles of life bringing a smile to my face and my hand to my rounding belly. Now this baby floated, limp and heavy, from one side to the other, as I rolled in my bed.
And within a day, I started to bleed. My body, with or without a doctor’s help, was starting to expel the fetus. Technically, I was threatening a spontaneous abortion, the least safe of the available options.
I did what any pregnant patient would do. I called my doctor. And she advised me to wait.
I lay in my bed, not sleeping day or night, trying not to lose this little baby’s body that my own womb was working to expel. Wait, I told myself. Just hold on. Let a doctor take this out.
I was scared. Was it going to fall out of my body when I rose, in the middle of the night, to check on my toddler? Would it come apart on its own and double me over, knock me to the floor, as I stood at the stove scrambling eggs for my boys?
On my fourth morning, with the bleeding and cramping increasing, I couldn’t wait any more. I called my doctor and was told that since I wasn’t hemorrhaging, I should not come in. Her partner, on call, pedantically explained that women can safely lose a lot of blood, even during a routine period.
I began calling labor and delivery units at the top five medical centers in my area. I told them I had been 19 weeks along. The baby is dead. I’m bleeding, I said. I’m scheduled for a D&E in a few days. If I come in right now, what could you do for me, I asked.
Don’t come in, they told me again and again. “Go to your emergency room if you are hemorrhaging to avoid bleeding to death. No one here can do a D&E today, and unless you’re really in active labor you’re safer to wait.”
More than 66,000 women each year in the U.S. undergo an abortion at some point between 13 and 20 weeks, according to the Centers for Disease Control and Prevention.
The CDC doesn’t specify the physical circumstances of the women or their fetuses. Other CDC data shows that 4,000 women miscarry in their second trimester. Again, the data doesn’t clarify whether those 4,000 women have to go through surgery.
Here’s what is clear: Most of those women face increasingly limited access to care. One survey showed that half of the women who got abortions after 15 weeks of gestation said they were delayed because of problems in affording, finding or getting to abortion services.
No surprise there; abortion is not readily available in 86 percent of the counties in the U.S.
Although there are some new, early diagnostic tests available, the most common prenatal screening for neural tube defects or Down syndrome is done around the 16th week of pregnancy. When problems are found — sometimes life-threatening problems — pregnant women face the same limited options that I did.
At last I found one university teaching hospital that, at least over the telephone, was willing to take me.
“We do have one doctor who can do a D&E,” they said. “Come in to our emergency room if you want.”
But when I arrived at the university’s emergency room, the source of the tension was clear. After examining me and confirming I was bleeding but not hemorrhaging, the attending obstetrician, obviously pregnant herself, defensively explained that only one of their dozens of obstetricians and gynecologists still does D&Es, and he was simply not available.
Not today. Not tomorrow. Not the next day.
No, I couldn’t have his name. She walked away from me and called my doctor.
“You can’t just dump these patients on us,” she shouted into the phone, her high-pitched voice floating through the heavy curtains surrounding my bed. “You should be dealing with this yourself.”
Shivering on the narrow, white exam table, I wondered what I had done wrong. Then I pulled back on my loose maternity pants and stumbled into the sunny parking lot, blinking back tears in the dazzling spring day, trying to understand the directions they sent me out with: Find a hotel within a few blocks from a hospital. Rest, monitor the bleeding. Don’t go home — the 45-minute drive might be too far.
The next few days were a blur of lumpy motel beds, telephone calls to doctors, cramps. The pre-examination for my D&E finally arrived. First, the hospital required me to sign a legal form consenting to terminate the pregnancy. Then they explained I could, at no cost, have the remains incinerated by the hospital pathology department as medical waste, or for a fee have them taken to a funeral home for burial or cremation.
They inserted sticks of seaweed into my cervix and told me to go home for the night. A few hours later — when the contractions were regular, strong and frequent — I knew we needed to get to the hospital. “The patient appeared to be in active labor,” say my charts, “and I explained this to the patient and offered her pain medication for vaginal delivery.”
According to the charts, I was “adamant” in demanding a D&E. I remember that I definitely wanted the surgical procedure that was the safest option. One hour later, just as an anesthesiologist was slipping me into unconsciousness, I had the D&E and a little body, my little boy, slipped out.
Around his neck, three times and very tight, was the umbilical cord, source of his life, cause of his death.
This past spring, as the wild flowers started blooming around the simple cross we built for this baby, the Justice Department began trying to enforce the Bush administration’s ban and federal courts in three different cities heard arguments regarding the new law.
Doctors explained that D&Es are the safest procedure in many cases, and that the law is particularly cruel to mothers like me whose babies were already dead.
In hopes of bolstering their case, prosecutors sent federal subpoenas to various medical centers, asking for records of D&Es. There’s an attorney somewhere, someday, who may poke through the files of my loss.
I didn’t watch the trial because I had another appointment to keep — another ultrasound. Lying on the crisp white paper, watching the monitor, I saw new life, the incredible spine, tiny fingers waving slowly across my uterus, a perfect thigh.
Best of all, there it was, a strong, four-chamber heart, beating steady and solid. A soft quiver, baby rolling, rippled across my belly.
“Everything looks wonderful,” said my doctor. “This baby is doing great.”
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Martha Mendoza is a working journalist and a winner of the 2000 Pulitzer Prize for investigative reporting. She recently gave birth to her fourth child, a beautiful and healthy baby girl.