So I Haven’t Had An Abortion (According To The State)

Good news!  My cases of miscarriage and ectopic pregnancy are excluded from the legislation recently adopted by Texas in section 171.061 of the Bill.  For a miscarriage, women will still be able to take an abortion-inducing pill in their home rather than a surgical center.  And if they need a D&C and their doctor offers it in house, that is still an option.

After this was pointed out to me, my first thought was – phew!  But then I had a host of secondary questions.  What exactly is an abortion according to the State?  Why are my cases excluded?  If the requirement of an ambulatory surgical center is a measure of safety, does the State not care about my health?  Or are the abortion pill and a D&C procedure somehow safer when the fetus is dead?

Let’s take a look at semantics first and explore the term abortion.  Then I’d like to share some conversations with you – in an effort to gain clarity, I was able to speak with a staff member of the Capitol, a representative of Planned Parenthood, and a couple of friends whose abortion experiences are broader than mine.

Language Matters – What Does Abortion Mean Anyways?
Upon learning that I’d had two miscarriages and an ectopic pregnancy, a lot of people commented that I had not actually had an abortion.  And to imply that I had was presumptuous.  So I wanted to break down the definition for you – from a medical standpoint, through a popular lens, and in the eyes of Texas.

Medical definition of abortion: Termination of a pregnancy, whether spontaneous or induced.

Popular definition of abortion: Elective termination of a healthy pregnancy.

The definition of abortion in the current Texas State legislation closely resembles the popular definition with specific exclusions:

  • Spontaneous abortions
  • Ectopic pregnancies outside of the uterus
  • Pregnancies endangering the life of mothers
  • Pregnancies causing physical impairments of major bodily functions
  • Pregnancies where fetuses have severe fetal abnormalities

It’s important to note that “other psychological conditions” are specifically included in the State’s definition of abortion.

Abortions are medical procedures.  Therefore it makes sense to be respectful of the medical definition that includes all reasons for termination of pregnancy.  Yet this definition gets popularly narrowed to only include healthy fetuses.  It makes me wonder – why does the State of Texas target only crazy/healthy moms who want to kill their innocent, perfectly formed babies?

Whoa, hold up, why did I just go there?

Because by narrowing the definition of abortion to the elective termination of healthy fetuses, we covertly introduce an inherent, negative judgment.  We begin to vilify abortion and think of the mothers who seek it as misguided, immoral, and even callous.  When in reality, as I suggested in my previous post, this mythological mother does not exist.  Or she may, but in such small proportion as to make legislation directed at her (and at the expense of the rest of us) incomprehensible.

The Sorting of Women
The truth is that women seeking elective abortions are human beings, with complex circumstances, a host of valuable emotions, and decisions to make about their bodies that are neither flippant nor fun.  To siphon this group of women off from the “legitimate” women who abort is to deny their feelings, their humanity, their experiences, and their rights.

Further still, this actually dehumanizes women seeking “legitimate” abortion help.  My experience was minimized on many occasions after my original post because “it is immoral for her to say that she had an abortion” or because “a miscarriage is nothing like an abortion.”  Suddenly both groups of women have illegitimate experiences of loss.

So.  I will continue on with my use of the medical term, abortion.  And I stand by having had two spontaneous abortions and one elective abortion.  My experiences are unique, and I am thankful for them.  In no way do I compare these experiences to any other woman’s experience of abortion, regardless of the type.  And in no way should any woman’s abortion be minimized.  Especially by those who cannot walk her path.

Still, according to the State of Texas, I have not had an abortion.  Again, my first reaction was relief; the 35% of women who experience spontaneous abortions will not be affected by the newly adopted State legislation.  Except that, they just might still be affected.  When I explored my secondary questions with both the State and Planned Parenthood, a complex story of safety emerged.

Conversations with Representatives of the State and Planned Parenthood
The staff member at the Capitol was gracious in giving me time and offered a helpful perspective.  As I asked questions, a picture of two different women emerged, the woman who miscarries versus the woman who electively aborts.  And I needed to understand the differences in safety concern for these two groups.  Below is a review of our conversation.  These are not direct quotes; they are my summation.

When a woman has a verified dead fetus, can she take abortion pills in her own home or will she need to make an appointment at a surgical ambulatory center?

She would be able to have pills prescribed by her doctor, fill the prescription herself, and take the pills at home on her own.  She would follow up as instructed by her doctor.  A woman who elects an abortion of a living fetus would need to go to a surgical center for administration of the pills.

When a woman has a verified dead fetus, will she still have access to a D&C in her doctor’s office, or will she need to make an appointment at a surgical ambulatory center?

If the doctor’s office offers the procedure in house, she can still have it done in the doctor’s office.  A woman who elects an abortion of a living fetus would need to go to a surgical center for the D&C.

Are there disparities in safety that I may not understand when a woman with a dead fetus ingests abortion pills versus when a woman with a living fetus ingests abortion pills?  Why is it safe for a woman who miscarries to take the pills at home, but a woman electing an abortion of a live fetus needs to be in a surgical center to be safe?

I’m not really sure that a doctor administering the pills makes it any safer.  The issue is the after care of the patient.  The legislation is really intended to ensure doctors see patients for follow up.  When you are under the care of an OBGYN and know your pregnancy is ending, that doctor is more likely to follow up to make sure the pregnancy fully ends.  And you are more likely to follow up when you have a relationship with a physician.  In clinics, doctors travel and may not be available for follow up if a patient has a problem the next day.  By requiring the doctor at an ambulatory surgical center to meet with a patient and give the patient their number and contact information, you set the patient up to be able to follow up.  They may not do it, but they have the option – where they may not have this option in a clinic.  They may not have talked to a doctor at all in a clinic.  The difference is that you have a personal relationship that’s being monitored.  Also, a person with a miscarriage is much more likely to seek medical care.

Are there disparities in safety that I may not understand for a D&C performed on a woman with a dead fetus versus a living fetus?  Why is it safe for D&Cs for miscarriages to happen in a doctor’s office but D&Cs for elective abortions must happen in an ambulatory surgical center to be safe?

There is a difference in standard of care between a physician and those who perform abortions in a clinic.  The doctor who is able to perform abortions in his office has admitting privileges.  If something goes wrong, he has easier access to a nearby hospital.  Clinics don’t have doctors with admitting privileges.  Even though it’s possible that doctors in clinics are more experienced at doing abortions, there aren’t the same doctor-patient relationships, a patient may have an unexpected reaction, a uterus could be punctured, or the clinic may not have life saving equipment onsite.  In some clinics there’s not enough room to get a gurney down a hallway.  An ambulatory surgical center has life saving equipment, oxygen, and cleanliness standards.  And this legislation sets up a relationship between doctor and patient for follow up care.

I also spoke with a representative of Planned Parenthood, who equally gave time and provided further perspective.  Below is a review of our conversation.  These are not direct quotes; they are my summation.

Does Planned Parenthood offer services for miscarriage?

It really depends on stage of pregnancy.  That would have to be evaluated individually.

Are there follow up procedures for abortions?

All patients are requested to have routine follow up visits.

Do you know statistics on what percent of women have complications from the pill or a D&C in a clinic versus under an OBGYN?

There are lots of theories and musings, but very little empirical data to point to.  If data existed supporting the State’s claim that we have a women’s health care safety issue, they would have put it out there.  It would strengthen their case.  You would think they would produce that data when all major medical groups say they oppose this legislation.  But they don’t.  The doctors of clinics are just as credentialed and certified as hospital affiliated doctors.  Based on belief rather than data, the State is making assumptions about the safety abilities of clinic versus hospital affiliated physicians that simply aren’t backed up.

If there is an emergency related to an abortion, what life saving equipment do you have or not have that is different from an ambulatory surgical center?

There is equipment for safety and to save lives.  There are many specifications for ambulatory centers that have no bearing on safety for abortions.  For example, I’m not sure how having 8-foot wide janitor closets makes anyone safer.

Do you feel there is a difference in women’s willingness to follow up after an abortion if they’ve had a miscarriage versus an elective abortion?  Have you found these two groups to be fundamentally different in any way?

I can’t really speak to this, but I’m not connecting how the requirement of doctors to provide a phone number makes any woman healthier or more likely to follow up.

With the majority of clinics closing in the State of Texas, what routine health care services will be unavailable to women?

To name a few: breast cancer screening, hypertension screening, HIV screening, STD testing, anemia testing.   When Texas refused federal funding for women’s health in 2011, it caused over 60 Planned Parenthood clinics to close – not one of those provided abortion services.  Planned Parenthood clinics that provide safe abortion are operated as a separate non-profit.  When Texas took away “abortion”, what they actually did was close women’s health clinics, claiming concerns for women’s health as impetus.  Women in those communities affected have literally no options.  And the State has yet to reinstate those funds.  With the new legislation, all other clinics that provide both health services and abortions are in danger of closing.  Women’s health care services across the State will further be limited.  Is it safer and beneficial to women to have literally no options for health care in her town or the next town over?

Anecdotes from Everyday Women
The staff member of the State described two very different women to me: 1) The woman who miscarries and has access to a physician.  She has a relationship with her doctor.  She cares about both the baby she lost and her health.  She is likely to responsibly follow up.  She is likely to make safe choices on her own and can be excluded from the State legislation.  2) The woman who electively aborts at a clinic.  She doesn’t have a relationship with a doctor.  She did not want her baby.  She is not likely to responsibly follow up.  She is likely to make unsafe choices on her own, and legal measures must be put in place to set up a potential relationship between her and a qualified physician.

And I thought – with a 35% miscarriage rate, surely there are women who both miscarry and electively abort healthy fetuses.  Do they have dual personalities?  Depending on circumstance, are they more or less likely to be responsible about their health?

Here are the testimonies of two such women:

Testimony #1.

“I’ve had one ectopic pregnancy, four miscarriages, two elective abortions, and I have two children.

I don’t think the standard level of care at abortion clinics is unsafe.  They had the same level of care at a fraction of the costs.  I couldn’t afford a surgical center, I would have just figured out home remedies to abort – meat tenderizer, papaya, or just ask my doctor for a packet of birth control pills and take a week’s worth at a time to see if that would have done it.

I had follow up appointments for my abortions with Planned Parenthood.  The follow up care for my miscarriages at my doctor’s office wasn’t better, they just tell you to go home and they’ll redo the pregnancy test next week.  It wasn’t a big deal.

With my abortions, I never felt dismissed like I did at my regular doctor’s office.  I had a Christian OBGYN when I wanted my first abortion, so I actually didn’t tell him I had the abortion since I knew he was against it.  At Planned Parenthood, they were always very sympathetic, understanding, and supportive.  If I’d had any complications, I would have felt more comfortable going back to Planned Parenthood.

I did notice the access to drugs and painkillers was better during my abortion.  They cared about my pain level and addressed it, whereas my doctor didn’t. When I miscarried, I just had to suffer through it.  The doctor saw it as menstrual cramps.

The follow up care stuff is ridiculous. The care isn’t better at a doctor’s office or a surgical center.  It’s a huge assumption that I would trust my doctor to follow up on an elected abortion if he believes it’s wrong and that I’d killed another human being.  Miscarriages aren’t your fault so they don’t tend to give you shit afterwards.”

Testimony #2.

How many miscarriages/elective abortions have you had?

“Abortions – 4 (2 as a teen and 2 before I turned 23)
Miscarriages – 2 (in my early 30’s)”

How was your follow up care the same or different for your miscarriage versus your elective abortion?

“The loss and trauma after either procedure is horrible.  You’re in a state of loss but just need to try to move on.  I think most women have minimal follow up and try to move forward.  There is little emotional or psychological support in either case. Abortion and miscarriage are stigmatized to further alienate the woman who has experienced the loss. The miscarriage experience for me where I naturally miscarried was worse than the miscarriage when I had a D&C.  I learned on the day of the procedure I could have the same procedure done as an abortion for half the cost. I was very upset. There was no psychological or other follow up other than me paying to see a mental health professional or more doctor’s visits to be put on antidepressants for postpartum depression, which were my own responsibility.  There was no formal process.”

Did you feel like one was safer over the other, having an elective abortion versus miscarrying?

“The psychological impact on me was bad in all cases.  I don’t think a miscarriage was in any way “better”.  When I miscarried the second time I was under so much stress waiting for the fetus to pass naturally.  It made my loss experience more traumatic.  The D&C for the first miscarriage was still traumatic, although I was not worried about my physical safety.  The psychological impact needs to be addressed more systematically.  I think safety risks from not following the guidelines from the doctor about what to avoid like tampons and intercourse for the specified timeframe are real.  Everyone should follow those guidelines.  The mental health follow up does not exist as a systematic discharge process and it should for miscarriage and abortion.”

How do you feel about the State of Texas’s requirement that elective abortions be done in an ambulatory surgical facility?

“I think forcing anyone in a desperate, hopeless, traumatic situation, whether abortion or miscarriage, into a specific type of medical facility should be approached with caution.  There should be ongoing funding for the psychological needs of the woman who makes a decision or must make a decision to have either an abortion or a miscarriage related D&C.  It’s the long term impacts on the woman’s body and mental health that should be funded in the case of abortion and miscarriage.”

What Does All This Mean?
After really listening to the staff member of the State, to the representative of Planned Parenthood, and to my two friends, my take home message was this: All parties are genuinely interested in their vision of safety in women’s health.  And it is clear that those visions are inextricably interwoven with their beliefs, their experiences, and their compassion for women.  I am grateful for the opportunities I had to listen and to digest.

While I have my own beliefs, biases, and interpretations of the above conversations, you too will come to your own conclusions.  We may not agree, but that’s OK – most important is that we’re having the conversation.

My Two Cents
For weeks, we have listened to the State of Texas say that this conversation is about safety.  The safety of ALL women.  Strange then that many cases of abortion are actually excluded from the Bill.  Does the State care about the safety of women who don’t have access to a doctor and miscarry naturally on their own?  What if they don’t have complete abortions and need follow up care?  Are women who treat their ectopic pregnancies with oral medication in any less need of mandated oversight?  Just because a woman has access to a doctor for her miscarriage, does this really make her more likely to follow up?  Why do we trust her and not “the other” group of women?

If the State genuinely cared about safety, efforts would be made to:

  • Make sure all women have geographical and financial access to health care
  • Accept federal funding related to women’s preventative and health care services
  • Partner with existing clinics and surgical centers to evaluate safety – work together to fund agreed upon modifications so that necessary safety standards are in place
  • Make sure women who experience any type of medical abortion have access to affordable and safe intervention
  • Fund mental health services for women who experience spontaneous as well as elective abortions
  • Fund and promote sex education
  • Actively work to lower abortion rates via access to education and contraception

But I don’t think the State’s fundamental motive is safety.  I believe that this conversation is about fear, judgment, and control, driven by a moral obligation of some to stop elective abortions of healthy fetuses by any means.  When faced with difficult choices about her body, the State fears that a woman will act immorally and kill her baby, an inherent judgment.  So the State uses noble sounding language, hiding their objective to target and control this perceived immoral group.  They are bullying a woman who elects an abortion into medical care that is expensive, inaccessible, humiliating, and qualitatively no safer because they simply disagree with her.  Texas women will now be presorted into “responsible” and “irresponsible” based on their choices.  And for those women deemed untrustworthy, Texas is denying them of their right to autonomy.  For now.  This is a battle I believe the State of Texas will not win.  We are, after all, half the vote.

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