Rosalina

Rosalina was 17 and a resident of the poverty-ridden Mexico City slums when she decided to come to el norte to start a new life and make money for her family. En route, she was raped by the cojote (guide) who transported her, and she was beaten nearly to death. Somehow managing to stay alive, she recuperated in the Spanish barrio of Dallas and finally got a job as a migrant worker. But after a month, she learned she was pregnant. Relatives in Farmingdale, Long Island, convinced her to come east for help, and by now she had earned enough for bus fare. Shortly after her arrival in New York, and after speaking with her relatives, she decided that she simply couldn't carry the baby of the man who had raped her. She wanted an abortion, but she had neither money, insurance, nor Medicaid. One of her relatives told her about an old woman who performed abortions for $25. Rosalina was so desperate that she agreed to the procedure. At the clandestine meeting place, she met the woman in an old abandoned room. She was given something alcoholic to drink, and a half hour later, when she was semi-conscious, she recalls something being shoved into her, and a good deal of pain. Shortly afterward, she was sent home and told to expect heavy bleeding in 2-3 days.
But she didn't bleed. What she developed, instead, was a 103 degree fever, chills, and abdominal pain. Friends who had previously been to our facility brought Rosalina to us on a day we were doing procedures. We immediately suggested that she go to a hospital, but as an illegal alien with no money, Rosalina was terrified. She begged us to examine her for free -- and we agree. During the exam, it was soon apparent that something traumatic had been shoved into her uterus -- a coat hangar? A knitting needle? -- but, insteading of causing her to abort, had left her with a trememdous infection. Our sonogram showed that her uterus contained a dead fetus and a collection of pus. Unless this was evacuated immediately, she would die.
We didn't feel we had any choice. This, after all, was what we were in business for: to help pregnany women in trouble, and maybe, in rare cases like this, to try to save the lives of pregnant women in dire straits. So we began by giving her massive doses of antibiotics intravenously, cooling down her fever, administering steroids, and giving abundant fluids. After several hours, when we felt she was as stable as she would get, we performed a suction currettage, eavcuating the dead fetus and large amounts of foul-smelling pus. This had been the easy part. The next twenty-four hours would prove critical.
One of us -- a doctor, nurse-anesthetist, or registered nurse, was with her in the recovery room in our office 24/7. After a rocky first 8 hours, Rosalina's condition stabilized, as evidenced by a dropping fever and significantly less abdominal pain. Her post-op bleeding slowed to negligible levels. After 24 hours, she felt well enough to leave, but we insisted she stay for another 12 hours, after which we were convinced she'd recovered.
Today, several years later, Rosalina has her green card, pays taxes, and is blessed with a beautiful baby girl. Although she never paid us in cash, each year she brings the baby by and gives us homemade cookies. I'd say that we've been repaid more than enough -- for after all, what more could you wish for?

Teen pregnancy, the good and the bad

First the good news: those of us who deal with abortion obviously deal with teenagers, both from the standpoint of procedures and contraception. The teen pregnancy rate has come down dramatically between 1991 and 2004 by 35%! The reason is not clear, because half of all teens are having intercourse. It may be that there is more widespread use of contraception, a fear of AIDS or other sexually transmitted diseases, or other factors. Still, teen pregnancies pose a tremendous problem because of the social, emotional and individual consequences that acompany them. The following paradigm may illustrate this. Social disorganization, such as lack of parents, lack of positive family influences, or poor socioeconomic status, lead to teen pregnancy, which in turn leads back to social disorganization. It's a vicious cycle. For the moms, they're very likely to lead a large portion of their lives in poverty. Of course this is not an argument in favor of abortion, but favoring contraception and a war on poverty. Hopefully, these battles will be successful and see the decrease in teen pregnancy go even further. Teen pregnancy costs all of us about 30 billion dollars a year, so the savings to society can be considerable.

The angst of abortion

Many people, especially those who oppose termination of pregnancy, think that those who choose abortion have a nonchalant, couldn't care less attitude in their decision-making. I have not found this to be true. In my three-plus decades of performing procedures, it is the extremely rare patient who requests a termination without much forethought and with total indifference. Yes, there are such patients, but they are the exceptions rather than the rule. Other rare individuals use abortion as a form of birth control and show up pregnant repeatedly, much to my chagrin and the befuddlement of the staff. We view these as failures on our part, for follow-up birth control is a large part of what we do.

For almost all others, terminating a pregnancy is an agonizing, gut-wrenching decision. Virtually every patient is aware of the pregnancy growing inside her, and as early as six weeks, many patients have begun to develop strong emotional bonds to their future child -- fantasizing about it, wondering what it will look like, guessing about its sex, etc. For the most part (except, for example, in cases of rape or nonconsensual sex) such thoughts are normal and even healthy. But, and this is a big but, they complicate what might have been an easy decision to abort. Guilt and shame often come into the picture, and they immediately complicate the decision. This is further compounded by the patient's religion, upbringing, and sense of morality. The decision goes from what might have been a snap to a tear-filled, often ambivalent mind-set.

This is a common picture. And it is these patients who require the utmost in emotional support, hand-holding, and reassurance. In my facility, we never try to force a patient in one direction or another; and it is not unusual, after counseling and discussion, that a patient opts to continue her pregnancy. If she chooses, we will happily refer her for prenatal care. It is our job to answer questions and offer advice and support, not to suggest a decision.

Bottom line: What to do with an unwanted pregnancy is an intensely personal matter, and it is rarely a decision that is made lightly.

Is abortion killing?

My goal, as I began this blog, was to present medical facts, news, and controversies as they relate to abortion from the perspective of the physician who performs them. I wanted to stay away, as much as possible, from the theology, morality, philosophy, and ethics that surround such a controversial subject and simply tell it straight -- as I see it -- from the doctor's mouth. I still intend to steer clear from the muckraking, name-calling, and foul language sometimes used by those on either side of the controversy. Not that I haven't personally been on the receiving end of such language; I've been called every f-word in existence, sundry varieties of other questionable speech, and, of course, baby-killer and murderer.

Not to split hairs, but I know I'm not a murderer since murder is a legal term invoked by judges and juries, not to be found in any textbook of medicine, and this blog is devoted to medical fact. But, is it killing? Many pro-choice advocates consider an embryo or early fetus to be a lifeless blob of cells. I may have thought that before the advent and widespread use of ultrasound, but these days, beginning at around six weeks, we can see the fetal heartbeat, and later, moving fetal structures. When I wrote my New York Times fictional bestseller, THE UNBORN, I included a quote that "the brain of the human fetus exhibits recordable electrical activity as early as the eighth week." During a book tour in England, this provoked many questions from listeners and viewers about fetuses and life. A century ago, a Supreme Court Justice, when asked about pornography, said, "I know it when I see it." The same thing applies to human life: once a child of any gestational age is born and breathes and has a beating heart, I know it's alive.

But what about the pre-born? A fetus at ten weeks has a definite heartbeat and all its parts, though it's not yet breathing and can't survive independently, outside the uterus. Yet, is it alive? Certainly, it has the potential for life -- but is that dodging the question? And I must admit, as rapidly pass through middle age, that it probably is living human tissue, although not exactly a living human being. That's how I see it. The question then becomes, is destroying living human tissue killing? I've already opined that it's not murder, but is it killing? And after many years of wrestling with this question, I concede that it probably is.

Yet to me, that opinion, in and of itself, does not automatically make it wrong. And those of you who may read this, please, spare me your high-handed concept of the Hippocratic Oath. You see, we, as individuals in a society, have said that certain types of killing are, under come circumstances, permissible: punishment by execution; killing in defense of one's country, or to uphold societal laws; variations on doctor-assisted suicide, etc. In other words, types of killing are allowed in societies where the majority of that society's citizens say it's allowed. To me, the same is true of abortion: yes, it may be a type of killing, but it has been sanctioned time and time again by the will of the majority of our society's citizens.

I love my country and respect its laws. So if the day ever comes that out society completely outlaws abortion, I'll be the first to stop performing the procedure.

types of abortions

Basically, abortion procedures are divided into "surgical" and "medical." Surgical methods are variants of the traditional D&C, or dilatation and currettage, performed for hundreds of years. Dilation means dilating -- opening, or stretching open -- the cervix to allow other instruments to be inserted into the uterus. Most women are familiar with the term "dilating" from labor, when the cervix dilates or opens to allow the baby to pass through. Once dilated for an abortion, currettage is then performed. This means "scraping," as whatever is in the uterus is scraped out and removed -- for visual examination, testing, or pathological exam. In the past, abortions were performed in precisely this manner, by stretching the cervix open and curretting out the pregnancy, which in medical parlance is referred to as "POC", or "products of conception. An abortion is a blind prodecure. It is done largely by touch; thus, training and experience are paramount. That is, the surgeon cannot see into the uterus to verify that all the POC or other tissue has been removed. Thus, in the past, there were a fair number or "incomplete abortions" where not all of the POC were removed, possibly leading to hemorrhage, infection, or other complications. Nowadays, most abortionists employ post-op ultrasound to "see into the uterus" to ensure that the procedure has been completed.

But even before the widespread use of ultrasound, another instrument was added to the physician's armamentarium to ensure completeness of the procedure. This was the suction/aspiration cannula. The cannula, usually made of sterile, disposable plastic (but it can be reusable stainless steel), is a long hollow tube analogous to a straw. By connecting the end of the cannula to a suction (or vacuum) apparatus, the POC can be aspirated or suctioned out of the uterus. The addition of the suction tip helped removed other pieces of tissue that the currette might miss, thereby making the abortion more complete, or successful, and lowering the chance of "retained products," a term for pregnancy tissue that has been inadvertantly left in the uterus. Nowadays, most early surgical abortions are done by the suction technique, though in some cases the metal currette is additionally used.

The term early abortion refers to procedures twelve weeks of less, dating from the first day of the last normal period (not the time of conception, which is usually two weeks less.) Beyond twelve weeks, the procedure may become a D&E, or dilatation and extraction. Here. the dilation remains the same, although it may be augmented by the overnight insertion of a substance called laminaria, which slowly, safely dilates the cervix. The extraction, however, differs from pure suctioning (which may also be employed.) An extraction forceps is used to grasp parts of the pregrancy and extract, or remove them, from the uterine cavity. Suctioning then removes the remaining tissue.

Medical abortion is a term applied to the use of medications to cause the patient to abort, or miscarry. Medical abortions are most effective when done within the first seven weeks of pregnancy, or forty-nine days from the last normal menstrual period. But medical abortions are not simply one magic pill after which poof, the pregnancy is gone. Rather, they are a series of pills administered two days apart. The first series of pills, called mifepristone (or RU-486,) interferes with the pregnancy's viability. The second medications, called misoprostol (or Cytotec,) causes the uterus to contract, and thus the pregnancy is expelled.

Many factors, both medical and emotional, determing whether the patient opts for the medical or traditional surgical method. Your doctor should thoroughly discuss these with you to arrive at a decision.

How it all began

I've been a physician since 1969 and a board certified OB/GYN since the mid-seventies. Before I began my residency in 1971, I took a year off and quickly ran out of money. This was 3 years before the Roe v. Wade decision, but New York was one of three states which began permitting legal abortions in 1970. I wound up working in an abortion facility doing histories and physicals and soon developed great compassion for the patients, who were emotionally needy. This was the impetus for my going into OB/GYN. During my residency, many of the pregnant patients took their pregnancies for granted, and just as many were't happy to be pregnant at all. Of those, there were frequently groans of "Oh, no" after their child was born, because there was another mouth to feed. This is not to say that other patients weren't overjoyed, because they were. But with abortions, which I began performing in 1972, the patients were uniformly grateful to have been medically cared for in a safe manner. Remember, only a few years before, they had to resort to illegal, often back-alley procedures which cost more than a few maternal lives. Yes, there were all shades of emotional overtones, including grief; but what I recall most was the gratitude for being being treated safely and respectfully. And I've been doing abortions ever since. This wasn't my only field of endeavor, of course. As a Board-certified OB/GYN, I delivered over 5000 babies before retiring from OB. And while most of the new parents were extremely happy, it's hard to adequately describe the the look of utter relief on the faces of abortion patients -- women who, shortly before their procedures, felt trapped, boxed-in, and hopeless.