Abortion In the Mountains

I am met in the parking lot by a grey haired woman in a blue vest that reads “escort” in big letters, and by a security guard packing heat.  In the adjacent parking lot is the “fetus van,” a local anti-abortion effort involving a truck emblazoned with a picture of a 7 week embryo magnified thousands of times.  While we wait for security to clear me, the clinic escort tells me how in the 70’s when she started doing this work “we literally had to step over the bodies of protesters lying down in the parking lot trying to block women from entering the clinic.  It’s gotten a lot better.”  Then the security guard gets the all clear and brings me inside.

One patient has a history of bleeding during her previous abortion, and upon talking to her, we find she hemorrhaged badly during the birth of her child.  She sits there anxiously. She looks older than her age.  She tells us she is afraid she might die if she continues this pregnancy. In Baltimore we might have sent her to the hospital-affiliated abortion clinic for higher risk patients but here in the mountains we are the end of the line.  The nearest hospital is catholic.  The nearest abortion clinic is hours away, and the time it would take to get another appointment, if she could get one, and get to it, would put her further along in her pregnancy, and with each week of pregnancy her uterus grows, and with it, it’s ability to hemorrhage more blood.  So the doctor talks through with her her history and her risk factors, and scrutinizes the ultrasound to confirm the dating.  In the end she decides the safest thing is to do it today.  The nurse readies two medications to clamp down her uterus in case she bleeds. But the procedure goes fine, with almost no bleeding, and we place the IUD the patient wanted, and then we’re done.

The first day I worked at the abortion clinic in Baltimore, the attending physician asked me I planned to do procedures or just observe.  I’ll do it, I said, feeling squeamish.  Abortion is an icky word in America.  We avoid it, slipping in the euphemisms of “choice” and “life.” Babies are the happy, life-affirming endings to our stories.  Abortion is a little painful and a little bloody.  But there have been times, and may again be times in my life where I know if I got pregnant I would get an abortion, so I it seemed unethical to deny to others what would be my own choice.

Shortly after finishing that gynecology rotation, I went camping on the beach with my parents.  My mother asked what I’d be up to at work, and I told her, including the abortions. It felt strange to say the word “abortion” to my mother.  My mother responded with a story about my great-grandmother’s sister. It was actually a story from my father’s side of the family. I knew she had died young and her children were sent to an orphanage, except for one daughter who was raised with my grandmother.

She had married young, then had four children in as many years, and it was all she and her husband could do to support them.  When she found herself pregnant again, she went and got a back street abortion, and then she died of sepsis.  The family begged her to disclose the name of the surgeon, and on her deathbed she refused.

I thought of the nurse at the abortion clinic watching us like a hawk for sterile technique, the iodine and chlorhexidine scrubs of the cervix, the autoclaved instruments, the antibiotics.  I thought of the one patient who had hemorrhaged, and “forgotten” to tell us that she had bled badly during the C-section delivery of her last child.  We gave her multiple medications, reached up with our gloved hands to remove clots from her uterus, massaged her belly hard enough that she yelled but finally the bleeding slowed.

I also thought of the woman whose baby I had just delivered who had hemorrhaged almost two liters of blood postpartum.  This is bloody business no matter how you slice it, and I am new enough in this business that the wait between when you give a medication and when it actually takes effect is agonizing.

Back to the abortion clinic in the mountains, the next few patients have more straightforward stories.  They are not thrilled to be here, and are relieved to leave no longer pregnant.  The next patient is also here for medical reasons.  She had a recent C-section, with a risk of uterine rupture if she continues the pregnancy.  Her last babies were longed for, finally conceived with IVF, and now this pregnancy happened on its own, and the timing is a sad sort of funny, and all wrong.  She too, leaves no longer pregnant, and with birth control.  It’s birth control for everyone today.  Post-abortion birth control may be the service most irreplaceable if Planned Parenthood is barred from billing insurance for routine health care.  (I anticipate that leading to more abortions.)

The last patient is a young immigrant here with her older American husband.  He tried to speak for her at intake, a red flag for staff, who get an interpreter on the phone and re-ask all the questions when she is in the exam room.  She answers without hesitation.  Yes, she wants this abortion. No, no one is forcing her.  I like to tell each patient each step before I do it. No one should have surprise fingers or instruments in her vagina.  The nurse is trying to pass the cell phone fast enough for interpretation, and finally settles for announcing each step herself to keep translation fast enough.  When I leave, her husband is smoking and pacing outside, more anxious than the patient herself. The stories get complicated here.

Abortions are actually down at this clinic, which means they are down for this whole far-flung rural, mountainous region it serves.  Delivery rates are down at most of the major hospitals as well.  The senior doctor’s best guess is it’s the IUDs.  And I think about how this little clinic nestled among the warehouses, in this town that is itself nestled among these glorious mountains, feels like a refuge in this ever crazier world.

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