/ Maggie Koerth-Baker / 7 am Mon, Jul 15 2013
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  • A gynecologist on how abortion restrictions lead to dangerous abortions

    A gynecologist on how abortion restrictions lead to dangerous abortions

    Maggie Koerth-Baker interviews OB/GYN Dr. Jen Gunter, who has personal experience of treating patients forced to seek out distant or questionable abortion providers, and the complications they suffer as a result.

    PHOTO: Texas Democrat Wendy Davis during her filibuster of Republican-led abortion restrictions, which ultimately became law after a special session of the state legislature. REUTERS/Mike Stone

    Several states recently passed (or aim to pass) restrictive abortion bills that will close most local abortion clinics in those states. Texas’ effort became famous when Senator Wendy Davis filibustered against it for more than 11 hours to wide acclaim. But that bill differs little to ones that slipped through quietly in Ohio, Wisconsin, and North Carolina.

    In the wake of all this, Dr. Jen Gunter, a blogger and obstetrician gynecologist (OB/GYN), tweeted about her experiences treating patients who had been forced to seek out cut-rate, low-quality abortions and suffered complications as a result. These were women who didn’t have access to safe, clean clinics, she said, either because those clinics were too far away from them, or because they didn’t have the means to afford the clinics’ services, or because they were immigrants (some undocumented) who didn’t speak English and were worried about confrontations with authorities.

    Today, Gunter works in California, a state with less-restrictive abortion laws, and she said she no longer sees cases like this. But 15 years ago, she worked in Kansas. When politicians limit access to safe abortions, she says, the result is more women willing to accept any abortion they can get access to -- even if it’s a riskier one. If states are going to pass bills that close safe clinics, then they need to hear the stories of what happens when no safe clinics are available. I spoke with Dr. Gunter about what she saw, why the new laws make women less safe, and the simple solutions that are proven to actually reduce the number of abortions.

    Maggie Koerth-Baker: Tell me a little bit about where you worked in Kansas. What was the context in which you were seeing the complications of badly done abortions?

    Jen Gunter:I worked at Kansas University and we were the big academic hospital in the state. There was a perception that care was free at the academic hospital, so that was often where people who had complications and no insurance often ended up. We saw several cases. It didn’t happen all the time. There were a couple places where we figure this was happening but nobody wants to tell you anything. Nobody wants to talk about abortion, for one thing, but also if you’re here in the country illegally you’re going to be afraid of the police and you’re not going to want to report anything. So we have, unfortunately, a lot of medically disadvantaged people.

    MKB: I think a lot of us imagine poorly done abortions as being something that happened in the past, when abortion was illegal. When you’re talking about this today, are we still talking about somebody in a back alley? Who is doing this today?

    JG: I don’t know, because people don’t want to talk about what happens. You see poorly done procedures not just with abortion, right? People often get transferred in with complications for various things. Sometimes it’s just bad luck. But sometimes, the doctor was in over their head and shouldn’t have been doing the procedure. People have complications from back surgery or getting dental work done. The doctor might be practicing outside their scope or just might not be well trained. It’s just with abortion there’s also that other layer of it being clandestine and people can’t talk about it. You can ask 30 people where they had their back surgery done, but how many people are you going to ask at a dinner party where they got their abortion.

    From what I did hear from the patients I saw in Kansas, it sounded like they were going to actual medical practices. Or at least thought they were. And, from what I can tell, they went there because the price of an abortion was about a third of what it was at Planned Parenthood. It sounded like the patients thought this person was a physician. Whether they really were or not, I don’t know. You don’t know if these are doctors who have desperate patients in their practice that they really just want to help, or if these are people taking advantage of a desperate situation. I don’t have an answer for that.

    MKB: When we talk about “a complication” with an abortion, what does that actually mean? What kinds of problems did you see?

    Dr. Jen Gunter

    JG: It can range from infection -- so maybe they didn’t receive their antibiotics before the procedure -- or it can be as catastrophic as putting the surgical instrument through the wall of uterus and into the belly and ripping bowels apart, ripping blood vessels apart. Those blood vessels, when you’re pregnant -- there’s a dramatically increased amount of blood flow to the uterus. Cut one of those major vessels and the patient can “bleed out” very, very quickly. I always remember one of my first lectures in medical school where the OB/GYN was telling us about a D&C [dilation and curettage], which is basically the same procedure as an early abortion, and he said a pregnant uterus is like butter. And it’s true. It requires a certain touch and skill to do it safely. When people don’t know what they’re doing they can easily damage something catastrophically. And I think a lot of times that happens when people misjudge how far along the pregnancy is. So they think somebody is only 8 weeks, and they’re really 14. At that point, you have a fetal skull to deal with and once you start shattering bones, those can start sticking through the uterus. You can see some really catastrophic injuries.

    MKB: Given that, does it actually make sense to have some of these laws states are passing, like the stuff that requires abortion providers to have admitting privileges at hospitals? Are these laws solving a problem that really exists and shutting down clinics as a side effect, or are they “solving” a problem that doesn’t exist in order to shut down clinics?

    JG: I really think it’s the latter. You don’t have to have admitting privileges to get your patient cared for. A physician doesn’t have to formally transfer somebody to get admitted. All you have to do is show up in an emergency department. So the idea of having to have admitting privileges is ridiculous. In fact, many doctors might already have admitting privileges, but the closest hospital isn’t the one where they have it. So what are you going to do? Take the patient across town when there’s a closer hospital?

    Abortions done by trained providers in proper settings have an incredibly low complication rate. It’s like a colonoscopy, in terms of things with a similar complication rate. And we don’t make gastroenterologists have admitting privileges. People can die from liposuction and there are risks to getting anesthetics at the dentist’s office to have a tooth pulled. There are tons of procedures that have a very small risk associated with them and which are done in surgery centers and doctor’s offices, and we don’t try to ban all of those on the grounds that they’re dangerous.

    I don’t think a D&C is different from any other surgery. You have to be trained to do a procedure. I couldn’t go in and set a bone unless I was trained to do it. But I really think it’s just a matter of training and practice. You have to have the right skill set, no matter the surgery. I don’t think abortion is a harder surgery to perform than any other. It’s just that fewer people are trained to do it.

    MKB: So is abortion not something that all OB/GYNs get trained in?

    JG: I don’t know the statistics. It’s supposed to be offered, but there are a lot of barriers put up. For example, in Kansas, they’re not allowed to do any abortions at KU Medical Center. Residents who want to learn the procedure have to make arrangements to go to other places. They were trying to pass a law to make it illegal for the residents to even go outside on their own time to learn procedures. That was only thrown out because it would have meant KU losing their accreditation for the residency program.

    MKB: It seems to me, like that would affect the doctors’ ability to do both elective abortions, and the kind of abortions that happen in tragic circumstances when women really do want to have a baby. I had a D&C last year, for example, when I found out that my fetus wasn’t going to live into the second trimester. That counts as a miscarriage to most people, rather than “an abortion”, but it’s the same procedure.

    JG: Well, that’s really the rub, isn’t it? Sadly, there are enough miscarriages that happen early on that the skill to do D&C at 8 weeks is never going to be in jeopardy. But the further along you get... people sadly do still miscarry at 18 weeks, or even later. And not everybody wants to have an induction of labor when that happens to them. Say you have somebody who, through a horrible sequence of events, has a fetal loss at 22 weeks, and she doesn’t want to go through an induction of labor. And I could understand that. It could take you two days. You’d have to be in a hospital room with all these women having babies and being happy. I mean, who would want that? Your only other option is a D&E. [This stands for dilation and extraction. It’s the same thing as the procedure referred to as a “partial birth abortion”. --- MKB] But if there are no providers who know how to do it, then you don’t really have that option.

    There’s also, you remember the case with Savita Halappanavar in Ireland? Her fetus still had a heartbeat but she was septic and she needed to have her uterus emptied to save her from the infection. Those are really difficult procedures to do, once the uterus is infected. That’s when you really need somebody with a strong skill set in this. And if there aren’t people who know how to do the procedures, then what happens? People could end up having to have hysterectomies.

    MKB: How do you think what you experienced compares to the kind of complications seen when abortion was totally illegal and it was even harder for doctors to get training?

    JG: I don’t want to give the impression that this happened every week. There were just a few cases in my time at this hospital. But I talked to one of our senior staff many years ago as a resident, and when abortions were illegal, they would see two or three patients every single night with horrendous complications from home abortions. And that’s in just one hospital.

    I think there’s a common thread, though. The people who will be affected most by all these legislations will always be the medically disadvantaged. If you have money and you have some education you can fly somewhere or find somebody. It’s always going to be the people who don’t “know people” or don’t have access. It’s just really sad.

    And the whole thing smacks of hypocrisy. Because, in Texas and Ohio and all these states, if they really wanted to prevent abortions, they would make long-acting, reversible contraception free. Study after study after study shows that when women have access to long-acting contraception like IUDs, and when they don’t have financial or access barriers, their risk of abortion just plummets. The irony is that this is all just posturing. Because the answer is right there. If you actually wanted to make abortion very rare, the answer is there. It’s long-acting, reversible contraception.


    / / /

    Notable Replies

    1. It's not that they're unavailable, it's that either insurance isn't covering it (not for long), or the uninsured simply can't afford it.

      I take back the unavailable part, kinda. There are pockets of extreme assholishness in this country where asshat "christians" pretend at lady-doctoring (I'm looking at you "Dr." Ron Paul). These moralizing dickwads will refuse to provide IUD's or any other kind of BC they don't "agree" with.

    2. When I was an office nurse many years ago, our PA-C told hair raising stories about his time working in an ER in a place where abortion was not available back in the day. If you had money you could cross state lines, but that left impoverished women with no options. He said, despite being super conservative in all the normal ways, he was adamant about being pro-choice.

      He was haunted by his experiences, and because of that, he really educated me on this issue. I'm young enough that at the time I had never lived in a time where it was illegal, or was under fire for stupid crap restrictions.

      Now when I see all these wangholes trying to restrict abortion, my first thoughts are always of my old coworker, and the stories he had, and the women that died on him.

      I really never thought we'd be back to this fight.

    3. I have a close friend in Minneapolis who had to go to multiple OBGYNs before she found somebody who would give her an IUD at age 22.

      She got denied over and over for several reasons:
      -Some docs didn't want to give her a more-permanent form of birth control because she was "too young". IUDs are reversible at any time, of course, but they were acting like she didn't know her own mind well enough to decide she wanted to make an investment in a form of birth control that would last her a decade. There are plenty of doctors who think young women aren't competent enough to make their own decisions about when (and whether) they want to have children.
      - Other docs were uncomfortable giving her an IUD before she'd had kids, but for medical reasons. My understanding is that the only IUDs available in the US are of a "larger" size, designed for women who have given birth before. It can be tricky (and, depending on your body, potentially more painful) to insert one of those IUDs in a woman who hasn't given birth. It's certainly not impossible. And it's not OMGDANGEROUS. But if it's something the doctor isn't used to doing, they might just want to avoid it. Why the smaller size IUDs aren't available here, I have no idea. Right after my friend got her IUD she found out that smaller sizes are available in Europe.

    4. I had the same problem in 1991. I shopped it all over, but it just wasn't available. I was twenty at the time, and didn't want any children, and then shopped for a doc for a tubal ligation. It took 12 docs before I found one that would actually see me. I lucked out to find him. Everyone else thought it was find if I decided to make a life altering decision to have kids, but I was too young, and dumb to make the life altering decision not to.

    5. Actually, doc #12 still forced me to get another human beings permission to make decisions about my own body. He was more about the liability issue if my husband sued him, than about anything else.

      I think I'd be a great parent, because I did really well in psych nursing. It's remarkable how many similar issues come up.

      But in the end, I don't want to be. When you are young, and present as female, you get a lot of crap thrown your way about how you will regret it, and you don't know what you are doing, etc.

      I guess I just can't wrap my head around how it was just assumed that because of being a woman, that I shouldn't be allowed to follow through on the decision to NOT have kids, whereas having kids was fine. I know a lot of great young women these days that also fought for permanent birth control. Hell, even getting an IUD can be a fight.

      Why is it culturally okay to question a woman's choice about that, and not about say. . . getting a tattoo, or going to graduate school, or giving birth? I think it has more to do with how we think about gender, and women as nurturing caregivers. If you don't want to get pregnant, or have kids, you go against a cultural role, and that is a tough upstream swim.

    Continue the discussion bbs.boingboing.net

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