Women Must Be Informed, Political Collaborators in Their Own Care

Dr. Tiller's clinic in Witchita, KS, one of the few in the country that provides late-term abortions, is closing. With his murder, in addition to wiping out the life of a husband and father, the anti-choice movement has taken away women's access to critical, necessary services. And while the current political make-up shows that the anti-choice movement cannot overturn Roe v. Wade, Dr. Tiller's death is a reminder that all it takes is a sniper to reduce our choices even further. And since OB-GYN's aren't racing to provide abortion services at the risk of their own lives, Dr. Tiller's practice may not ever be replaced.

When I'm not a doula, I work as an abortion counselor. Although most of the women I meet with are between 4 and 7 weeks pregnant, the clinic where I work provides abortion services up until the 23rd week of pregnancy, which is the legal limit of abortion care in the state of Massachusetts.

Your reaction may be visceral, no doubt. At 23 weeks, abortion can be extremely difficult to understand or justify, and it is not uncommon to shake your head and say "I have a real problem with that," even if you are pro-choice. It is tempting, if not comforting, to separate yourself from a woman who would make this choice by assuming that she must be a monster. And I'll be honest and say that once I sat down with a woman who seemingly had no feelings about having an abortion in her 23rd week of pregnancy. It chilled me, her apparent lack of feeling. But many more times than just once, I have sat down with couples who are heartbroken: a routine ultrasound in the 20th week discovers massive deformities; an amniocentesis details profound genetic abnormalities that at are incompatible with all but the briefest of life, and suffering is certain; a doppler at 22 weeks returns no heartbeat, reducing a wanted and cherished baby into a diagnosis of fetal demise. And sometimes, due to the time it takes to run tests, or to the human inconsistencies of those who administer those tests, or the varying reliability of technology, a pregnant woman in those situations can be beyond 23 weeks. And so what do we do in the state of Massachusetts? We tell her she can deliver her dead, deformed, or doomed baby in a labor and delivery unit of a hospital -- which is as monstrous as it sounds -- or we recommend she travel immediately to one of the few clinics in the United States that can terminate her pregnancy. And with the death of Dr. Tiller and the closing of his clinic, there is now one less place where a woman in this delicate and devastating situation can go for care that is humane and treats her with dignity.

And on the other end of pregnancy, women are also losing choices in childbirth. In my line of work, I hear many birth stories from women, and the majority of them have the same eerie arc: first, induction; second, confinement to a bed; third, bone-crushing pain; finally, forced pushing while lying on their backs. Statistically, more than 30% of those stories end in c-section, and these are in pregnancies that had been normal, low-risk, and healthy. It's also the basic formula for reality birth shows on cable TV, where birth is boiled down to a medical event that skirts death practically every time.

VBACs are becoming harder to access, despite evidence that indicates that VBAC is lower risk than repeat C-section. Providers, among both OB's and L&D nurses, have attended fewer and fewer low-risk, healthy childbirths that are purposefully unmedicated and without interventions. What results over time is that if a laboring woman wants a natural birth, she could go to a hospital and have no medical professionals with the experience or willingness to support her desires. Birth centers are losing funding, and homebirth is either criminalized or unregulated in half of the US. In the other half of the country, the standards of care that do govern it are so limiting that its practice is nearly impossible but for a few renegade midwives who are essentially providing care without the benefit of professional support in case of a true obstetric emergency. Healthy women who could experience the normal physiological process of birth are beholden to the artificial constructs of time, liability, and television drama. The art of childbirth, and the choices that encourage birth as a safe, non-medical event, are being lost.

Unless we have a vision that is greater than the arguments of pro-life vs. pro-choice, homebirth vs. hospital, natural birth vs. epidural, we will lose what is truly at stake at the heart of these issues: choices. The quality of women's health care is dependent upon choices and access to qualified care providers, and women must expect no less than to be informed, political collaborators in their own care.

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Fence-Sitting

I told a good friend that, unexpectedly, I was pregnant. She said to me, "But you work as a doula. You are surrounded by pregnant women and newborn babies all the time. It's not that surprising that you're pregnant!" Another good friend's response was "You also work as a counselor in an abortion clinic. You know how these things happen -- how could you be surprised that you're pregnant?"

So that's what it's like sitting on a fence. My husband and I agreed not to make any decisions right then and there, and gave ourselves permission to ride a rollercoaster of emotions, come to any number of decisions, and then change them again until we finally settled on something that felt right.

A fellow doula offered her congratulations, saying "What a gift it is to go through a 3rd pregnancy, knowing all that you know about childbirth." And true, if I chose to continue the pregnancy, I had a plan for my prenatal care and very definite goals for my labor and birth. But the truth is symmetrical; I also knew every step of the abortion procedure. I knew exactly where to go, nothing to eat or drink after midnight until after my procedure was done, and that I needed to ask for an anti-nausea agent in my IV sedation. I knew that the doctor would write words on my medical report to indicate that the procedure was complete, and the likely words would be "fetal parts", "villi", "sac" or "POC," which stands for Products of Conception.

This is actually my 4th pregnancy, as I had a miscarriage between my two daughters. The gravity of the loss I felt at that time took me by surprise. I grieved as if someone had died, and I was barely 7 weeks at the time. Ironically, four years later, here I was waiting to be 7 weeks, so that if I were to terminate, there would be less likelihood of complication. But unlike my miscarriage, this time I had a choice, and I had never felt such ambivalence. I didn't want to bring another child into the lives of my daughters just because I was afraid to have an abortion. How was it that I could offer support and smiles and reassurance to dozens of women who make that choice every week?

I do occasionally sit with ambivalent women at the clinic. Women who take more than 20 minutes to fill out a single registration form, women whom we see through our security cameras sitting in the car long after they've shut off the engine. When I talk with them in counseling, I tell them that it is one thing to consider abortion, to look it up online, to make the appointment. But it is a different thing altogether to show up, to sit in the waiting room with a dozen other women who are there for the very same reason, and then actually go through with it. Some of them, especially if they are very early in the pregnancy, I counsel to go home, (I always wish I could open the front doors and shout out to the protesters, "Letting one go!") because a 1st trimester procedure can be done up to 14 weeks into the pregnancy. Because she has the time, I suggest she talk to her friends, garner the support she needs, and then if she returns, I assure her it will be easier. I imagined myself as the patient with any of my fellow counselors sitting in the room with me, explaining to me all that I already knew. And in my mind I could see them sending me home, and with a kind smile, saying "Maria, you are not ready to make this decision today."

Nine weeks into my pregnancy, I had my first prenatal appointment with a midwife. I chose not to share with her that my pregnancy was due to an act of carelessness. I also didn't disclose that abortion was still an option (which makes me feel silly in hindsight, as I rarely sit down with a woman at the abortion clinic who is voluntarily terminating her pregnancy despite having begun prenatal care). Nine weeks was also when I began spotting. I had been spotting for a few days by the time I saw her.

She sent me for an ultrasound, and I remembered my previous pregnancy loss. I wondered if maybe God was punishing me. For getting pregnant so thoughtlessly and then responding with indecision, my penance would be miscarriage, and then my husband and I would never, ever, ever take a chance again. I would continue my thriving doula career, coaching women through childbirth and breastfeeding, knowing that I would never again be a laboring or nursing mother, because we would never again let an accident like that happen. I lay on the exam table in radiology, the technician rolled the transducer over my belly, and there it was: a tadpole with a little flashing light, a heartbeat. I cried through the rest of the exam, which I hadn't done years before when the ultrasound had shown no heartbeat. I felt relief that I wouldn't have to experience that again, the bleeding, the clots, the pain that wrapped around my waist from back to front - the labor of a miscarriage. And though it would be a while yet before I would feel a rush of attachment for the image on the screen, I knew that my third journey into motherhood had already begun.