Inside the abortion clinic
With Congress and the president taking aim at reproductive rights, the politics of abortion are about to get a lot more tangled, in Sacramento and beyond
The staff claims to have seen women scream, cry and loudly repent their decisions to abort, but on a series of days in January, the women who arrived with their sisters, their partners and their friends were, at worst, pensive, their eyes tinted a glossy red. Others joked easily about the endless forms or intentionally tried to lighten things up with conversation. While a young black woman sat stone still, her companion smiled good-naturedly and asked the room whether the current romantic soundtrack featured a well-known blues singer. A man across from him nodded slightly, his dark face barely visible inside the hood of his down coat, his arms crossed defensively; his girlfriend already had disappeared into the clinic’s private rooms.
In a smaller waiting room behind a secured door, the mood was so somber as to be palpably unpleasant. Women sat knee to knee in the near dark, watching another TV in their immodest hospital gowns. Most awaited first-trimester abortions (a simple suction procedure performed in the first three months of pregnancy). But every week, the clinic serves at least a few women who are deep into their second trimesters, which necessitates a more-complex procedure performed up to the end of the sixth month—California’s legal limit of 24 weeks.
According to clinic staff, women who wait past the first three months of pregnancy do so for countless reasons, some of them tragic, such as when a wanted pregnancy develops some fatal abnormality. Other women can’t decide whether to risk parenthood as teenagers; have partners who discourage abortion; didn’t know they were pregnant (extreme athleticism can disrupt normal menstruation); have partners who die or leave; have a condition in which pregnancy dangerously affects their health; can’t handle the financial burden; are in denial; or postpone their decisions because of drug addiction. Sometimes, women seek abortions because they only want boys, and they’re pregnant with girls.
“It’s different every day,” said Britta, the tall, bright-eyed brunette who directs the clinic, which sits quietly among neighborhood homes in East Sacramento. (Because of past violence against the clinic, staff members are represented by first name only; client names have been changed.)
The women who work the clinic seem younger and hipper than your average nursing staff and are passionate about abortion rights—a characteristic that distinguishes them from their clients. In general, according to staff members, clients care little about the legal and political turmoil surrounding abortion; some believe that they are uniquely justified in terminating their pregnancies or that they will never need the clinic again. Young women, especially, seem uninformed about the historical fight over abortion rights.
“It’s one of the most frustrating things for us,” said Victoria, the sharp, fast-talking staff member who acts as assistant director. “It’s not like it’s taught in schools.”
Except for a tendency toward political disinterest, the women who come through the clinic seem to differ in every variable: race, age, economic status, marital status and even legal status. Though most women walk in of their own volition, the clinic recently hosted two prisoners. One was escorted through the clinic waiting room in a belly chain while the other sat on a cot in her orange jumpsuit, two uniformed police officers watching her from a corner of the room.
In a year, the clinic handles between 2,000 and 3,000 first-trimester abortions, estimated Britta, and anywhere from 500 to 800 second-trimester abortions. For all women, the procedure begins with an ultrasound, a physical exam and a counseling session.
In a tiny office, a Chinese-American woman 23 weeks pregnant sat stony-faced before Iliana, a clinic counselor whose job was to confirm the woman’s medical history and, in this case, walk her verbally through a second-trimester abortion.
“Have you ever had a pap smear or a pelvic exam?” Iliana asked in her gently accented English.
The young woman shook her head no.
“You’ve never had a pap or pelvic exam?” asked the counselor again, looking more closely at the woman beside her—slim, with a long ponytail and not visibly pregnant in her sweats and with a backpack at her feet.
Her face still unreadable, the young woman shook her head again.
Though she showed the composure of someone much older, Leslie was only 17 years old. Had Leslie waited one more week, under California law, Iliana would have had to send her home to deal with motherhood, or Leslie would have had to leave the state to visit one of the very few abortion providers in the country who perform elective abortions in the third trimester.
“Can I use the phone?” Leslie asked after Iliana finished asking questions. She wanted to call her mom and cancel her ride home from high school.
Later, Iliana asked her co-workers if she had to consider Leslie the victim of statutory rape because the young woman was under 18. Though California protects the privacy of minors seeking abortions, the state does insist that providers report statutory rape if a minor is under age 16 and her partner is over 21, which was not the case for Leslie.
Britta said that the clinic also chooses to report whenever they get an “icky feeling” about the dynamics of a relationship and especially if, as in some cases, women of 15 arrive with their partners of 35.
In a larger office, another counselor, Laura, a petite blonde with large, solemn eyes and pigtails, does the majority of the counseling sessions. She asks a few pointed questions.
“Are you sure about your decision?” Laura asked Angela, a tired-looking blonde in a blue, velvet tracksuit.
Angela laughed in a guarded way. “Pretty much,” she said. “We were sitting in the waiting room, going, ‘We can still go.’”
Laura looked concerned. “I want you to be 100 percent sure of your decision,” she said.
Angela nodded. “I’ve done it before.”
Occasionally, counseling sessions lead women to change their minds. That same day, a patient said all the right things during a session but then confided second thoughts to another counselor and was sent home. Laura had a hard time estimating how often that happens. She threw out some numbers tentatively. “Maybe 30 percent are kind of talking through doubts,” she said. “Maybe 5 percent go away.”
Though clinic counselors educate women about options besides abortion, they’re protective of women’s right to choose and acutely aware of any potential threats to legal abortion. The most recent has come in the form of the Partial Birth Abortion Ban of 2003, the first of a series of similar proposed bans to make it past Congress to gain the president’s signature.
As if to prove Victoria’s point that those seeking abortions were not particularly interested in the law, of approximately 15 clients and their companions questioned in the clinic waiting room, only five of them were familiar with the ban. Most shook their heads and said they knew nothing about it. Only two asked where they could find further information, and only one asked what the ban outlawed.
Of those who were familiar, one man put a voice to the fear of abortion providers. “They’re trying to make [the ban’s language] as vague as possible,” he said, “so they can ban it all.”
The Partial Birth Abortion Ban of 2003 was signed in October to outlaw what is commonly known in the medical community as intact “dilation and extraction” or D and X, a rare procedure usually used to terminate late-term pregnancies. The ban’s language is considered by abortion providers to be strategically vague, criminalizing the behavior of any physician who “vaginally delivers a living fetus until … any part of the fetal trunk past the navel is outside the body of the mother for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus.”
This definition is not nearly as colorful or precise as the language Congress used in its findings in support of the ban: “a physician … punctures the back of the child’s skull with a sharp instrument, and sucks the child’s brains out before completing delivery of the dead infant.”
Doctors like Mark Maltzer, who owns the Pregnancy Consultation Clinic and is the head physician, find the ban’s language vague enough to potentially target abortion procedures much more common and less controversial than the D and X.
Between the 12th and the 20th weeks of a pregnancy, suction is used to remove the fetus from the womb. If the fetus’s heart is still beating, such a procedure may be considered a “partial-birth abortion” under a broad interpretation of the law. Because the term “partial-birth abortion” is a political construction and not a medical term, it has no clear medical definition.
“From the doctor’s point of view and the patient’s point of view,” said Maltzer, “this particular act bans the ability of women to choose what’s best for their health with their physician. … Now the Legislature’s in the room with them.”
Though the case is outside the scope of this story, last summer, Maltzer was named a defendant, along with Planned Parenthood, in a Los Angeles lawsuit brought by the family of a woman who died after a second-trimester abortion; in an interview with SN&R, Maltzer denied performing the procedure, claiming that he was supervising another physician. The case is still in litigation.
For abortion providers, the ban on partial-birth abortion is just another skirmish in an ongoing war with politicians and activists who oppose abortion rights. According to the Alan Guttmacher Institute, a nonprofit studying reproductive health and sexuality, D and X procedures “are quite rare: eighteen providers reported 1,274 such abortions in 2000,” which is less than two-hundredths of a percent of abortions performed in America. According to clinic staff, no physicians in California, including Maltzer, offer D and X procedures. But if providers’ fears are realized, the next battlefield could be other second-term abortion procedures, including the one that the high school-aged Leslie was about to receive.
Because she was near the end of her sixth month, Leslie was scheduled to return the next morning for a dilation and evacuation (D and E), a procedure similar to the banned D and X, with one crucial difference: The physician uses a needle to inject the fetus with digoxin to stop its heartbeat. At the same time as Leslie received the injection, sticks the width of pencil lead made of seaweed and known as laminaria were placed inside Leslie’s cervix, where they would slowly absorb fluids and expand overnight, forcing the cervix open. The tissue of the fetus, once the heartbeat had ceased, would begin to degrade, allowing the sharp bones to soften and lowering the risk of harm to the uterus. Leslie was sent home overnight with the laminaria in place. The next day, through the dilated cervix, the physician would use forceps to pull the fetus from the uterus, possibly intact but most likely in parts.
Leslie was one of two women getting late-term abortions at the clinic on a Friday in early January. The other was a mild-mannered IV drug user with hepatitis and an abusive boyfriend. She’d gone through counseling at the clinic early in her pregnancy and was so conflicted that she repeatedly canceled appointments and didn’t show up for the procedure until she was 18 weeks along. Though her decision to abort was difficult, she looked much more composed than another woman who’d had the procedure two days before. That woman had nurtured a wanted pregnancy for months before learning that her fetus was developing abnormally. At best, such children are born with Down syndrome; at worst, they can’t live outside the womb. Such cases are heartbreaking for families but unfortunately familiar to abortion providers.
Vicki Simpson, a human-resources specialist for Planned Parenthood, looks like a regular healthy mom, with her glossy, brown, shoulder-length hair and her big, comfortable sweaters. But it wasn’t easy for her to have a family. Though she now has a healthy
6-year-old daughter, her first two pregnancies failed.
In 1994, Simpson, who had miscarried an earlier unplanned pregnancy, was expecting a baby that was “very much planned, very much wanted,” she said. At about 20 weeks, in the middle of December, Simpson received a call from her doctor’s office. Test results had come back abnormal, but Simpson assumed it was nothing serious. She did, however, make an immediate trip to her doctor’s office.
During the resulting ultrasound (an internal X-ray), Simpson kept her eyes on her husband’s face. “It’s going to be OK,” he kept saying, but as doctors flowed in and out of the room, whispering, Simpson realized that it wasn’t going to be OK.
“One doctor came back,” said Simpson, “just like in the movies. They said the fetus was in very bad shape. … All of his organs were developing outside his body.” There was no chance of survival.
“Sobbing, I told the doctor I wanted to terminate,” said Simpson.
The doctor offered to induce labor so that Simpson could see the fetus, which, at 20 weeks, normally would be about seven inches long. Or, said the doctors, Simpson could opt for a D and E. “Chances are,” the doctor warned her, “you won’t want to see the fetus.”
Simpson chose the D and E and began her 48-hour dilation process.
Simpson recalls nothing about the procedure but remembers waking up feeling like dead weight and realizing where she was. “I started sobbing,” she said, “hyperventilating.” And right then, she remembers, the nurses began decorating the hospital for Christmas.
Simpson was depressed for a long time, but she remembers surprising details, like when her mother, an adamant women’s-rights activist, told her to be careful explaining her sudden loss to friends and associates. Don’t call it an abortion, Simpson’s mother advised. “Just tell them you lost the baby.”
For Simpson, the harried and painful days before her procedure were not spent thinking about the law, other people’s opinions or her legal right to an abortion.
“I was thinking about surviving,” she said.
Though Simpson’s abortion was based on the condition of the fetus, she personally makes no moral distinction between her situation and that of a woman at 24 weeks who simply can’t manage parenthood—for whatever reason.
“I would never judge anyone who chose to terminate solely because they didn’t want a child,” she said, insisting that a woman can be trusted to choose for herself. “I’m not living her life.”
Committed to a woman’s right to choose, Simpson does not support the partial-birth-abortion ban, especially considering that it doesn’t include an exception for protecting the health of the woman.
Erin Greenough doesn’t look much different from Simpson, but she has very different opinions about partial-birth abortion. Perky in pigtails and a ball cap, she explained that she, too, had to terminate a wanted pregnancy in 2000. Whereas Simpson chose D and E, Greenough chose the second option. Her doctor induced delivery so that she could see the fetus.
Though Greenough believes in the legality of medically necessary abortions at any fetal age for women like herself and Simpson, she supports the partial-birth-abortion ban, believing the procedure described in Congress’ findings to be barbaric and inhumane.
“I’ve read the entire debate. I’m fully for the ban,” she said, though she agreed with Simpson and others who support a health exception. “I believe in [the ban] because I know there are other ways,” she said, referring to procedures like the D and E and induced delivery.
In her own case, Greenough chose to abort because her daughter was found to have a potentially fatal heart condition. According to ultrasound images, Greenough said, “almost the entire left side of her heart was gone.”
Greenough remembers the first question she was asked by her doctor: How are you with termination? Greenough’s decision was more complex than Simpson’s. Whereas Simpson’s child was fatally disfigured, a series of surgeries and an eventual heart transplant might have saved Greenough’s daughter, though she would have been severely handicapped.
“Me and my husband decided we didn’t want her to suffer,” said Greenough, who began the procedure at 23 weeks and six days with an induced delivery that lasted approximately five hours.
“We gave birth,” said Greenough, who explained that the process didn’t include the usual contractions. “She came out on her own.”
When Greenough thinks back on the procedure, she has no regrets about her decision, but she does wish that she had been more interactive, taking the opportunity to hold, bathe and dress the fetus that arrived with recognizable facial features. “I was scared to death of her. No one explained that she would be perfectly formed,” she said.
Greenough treasures the mementos she does have, the pictures and the footprints the hospital provided.
Now, Greenough works with a local chapter of Sharing Parents, meeting regularly with 25 other women who are dealing with the decision to terminate wanted pregnancies for medical reasons. Unlike Simpson, Greenough doesn’t feel much kinship with women who choose to terminate not for medical reasons but for what she referred to as “lifestyle reasons.”
“I would never have an abortion just to have one,” she said, “but I believe in quality of life.”
Victoria estimated that the majority of the clinic’s D and Es were performed not on young women like Leslie, but on “genetic patients” like Greenough and Simpson who realize near the end of their sixth month that their fetuses are developing abnormally. Maltzer said his clinic gets a lot of referrals from other medical facilities that don’t provide abortions up to the legal limit—this includes Planned Parenthood.
With first-trimester abortions, the procedure can be completed in one day, but second-term abortions begin on Tuesdays and Thursdays with laminaria and end on Wednesdays and Fridays.
On Friday morning, Leslie sat sideways in a chair in the cramped, dark waiting room in East Sacramento. She pulled her knees up to her chest and held a small, well-loved stuffed tiger to her cheek as if she had a toothache. Occasionally, while waiting, she’d walk around the clinic, seemingly experimenting with the duck-footed walk that pregnant women sometimes use.
Every time someone asked how she felt, Leslie responded perfunctorily: “Fine.” She complained neither of cramps nor of pain from the dilation process. It was even hard for her to admit that she’d suffered morning sickness. Young women, said a clinic staffer, often suffer the least mental and physical discomfort.
“You’re a trouper,” staff members told Leslie, getting the shyest smile out of her every time.
Minors in California can get abortions without parental consent, and Leslie hadn’t mentioned anything about the procedure to her family members. They’d noticed nothing different about her the night before, she said. In fact, they didn’t know she’d been seeing a boy for about a year.
“I didn’t know how they’d respond,” said Leslie, explaining why she kept her pregnancy secret. She is still not sure why she took 23 weeks to make her decision, but her youth finally convinced her to abort. “I can’t take care of it,” she said. “I’m still in high school. Some [friends] told me to keep it, but …” Her voice trailed off.
The procedure, even for second-term abortions, is very quick, approximately 10 minutes. Under general anesthetics, women remember nothing of the process, but within half an hour or so, they are ready to dress by themselves and leave, as long as someone else is driving.
In the clinic, a lab sits between the two procedure rooms. After a first-trimester abortion, the physician’s assistant passes the instruments into the lab through a small door, along with a jar with a narrow cloth bag inside that holds the removed tissue. For early pregnancies, the lab technician rinses the bag in a shallow bowl of water to make sure the feathery tissue of the early fetus was fully removed. Everything is then collected in small vats that are sent out as medical waste. The vats for the second-term abortions are filled with tissue, as well, though at that stage, the fetus is no longer a feathery half-inch of tissue. Small limbs are clearly visible.
“It’s a medical procedure,” said Britta, who explained that the clinic staff view their work and examine tissue scientifically, just as other medical professionals do.
In the post-op clinic, Tammy, a tall, thin blonde with Midwestern good looks, cared for the women who entered one after another in wheelchairs. She helped them negotiate the transition from wheelchair to bed, the anesthesia making their limbs heavy but their faces visibly peaceful.
“When you work here,” said Tammy, “people assume you’re anti-baby. But we go to church on Sundays. We care about women. We don’t want it to go back to the way it was.”
One woman woke with a start after napping. “What happened?” she asked loudly.
“You’re in the recovery room,” said Tammy. “It’s all over.”
Another woman shifted a little as the most serious cramps ran through her.
“Do you feel hot and sweaty?” Tammy asked her.
“I feel cooler now,” said the woman. Tammy brought her a hot water bottle to hold against her abdomen.
Petite, with a pointed chin and big eyes, the woman said her son was now 4 years old. She had been on birth control, but it apparently had failed, and after only two months back in the working world, she’d realized she was pregnant again. During those two months, she’d unintentionally threatened the health of the fetus by working with X-ray machines and taking regular doses of medications that a pregnant woman normally would avoid. Her husband didn’t mind a second child, but the risks, the financial burden and the fact that she hadn’t expected more kids led her to abort. “I just felt like I’d be taking a four-year step backward,” she said.
Another woman already had borne four children; her youngest was just 2 years old. Asked if she had considered adoption, the matronly woman shook her head, her eyes hardening. “I don’t believe in adoptions,” she said. “I just wouldn’t give up my child for adoption.”
The nurse, Tammy, reiterates that the clinic sees a variety of women with a variety of situations. “A couple people have come from Mexico for second-trimester abortions,” she said. “We had recently a rape victim from Mexico.” Tammy couldn’t remember whether the girl had been 13 or 15.
When Leslie was wheeled into the room, Tammy helped her stretch out, checked her vital signs and asked how she was feeling. “A little tired,” whispered Leslie.
Tammy pressed down on Leslie’s abdomen to make sure that a large amount of blood hadn’t pooled in the bowl of her uterus. The signs looked good, and Leslie was left to rest quietly.
Under a sheet, the young woman lay still on her back, her eyes closed, her lips slightly upturned, as if she were dreaming of something pleasing—it was probably the anesthesia.
Leslie’s right hand reached out slowly and began to explore, very gently, the outline of the backpack lying beside her. Keeping the rest of her body still, her eyes closed, she gently touched the back, the front and the top and then finally located the zipper. Slowly, she opened it, reached in and pulled out her stuffed tiger. She pressed it to her hip and, with her head turned away, went to sleep.
Tammy watched over her with visible affection.
Married and living in another state, Tammy had found out when she was as far along as Leslie that her own wanted pregnancy was in danger. The developing fetus had water on the brain, said Tammy, hydrocephalus, a condition potentially fatal.
As committed Christians, it was hard for Tammy and her husband to decide what to do; Tammy knew she had the medical knowledge to care for a disabled child, but she realized she couldn’t bear to go through with the birth of a child that might not survive. After wondering what was fair to the child and wondering if God would hate them, Tammy and her husband chose to terminate.
Years later, the couple has a healthy daughter, and Tammy’s extremely grateful. “It’s still hard,” she said, thinking of her first pregnancy. “But I feel like I made the right decision.”
Though it might seem surprising to find a dedicated Christian working in an abortion clinic, considering that so much national debate seems to fall along religious lines, Tammy doesn’t mind the incongruity. “Nobody really knows what God thinks,” she said.
“If it wasn’t OK,” said Tammy. “I would never have felt like it was OK. If I wasn’t supposed to be here, I wouldn’t be.”
But political attacks on the legality of abortion call into question whether nurses like Tammy always will be there for women like Leslie or Simpson or Greenough. And the hopes of abortion providers rest on court challenges to new laws like the partial-birth-abortion ban, which likely will go before the Supreme Court, a body that has struck down similar bans in the past but may not always do so in the future.