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What you learn doing abortions after 20 weeks

Residency doesn’t prepare you for listening to someone you have never met pleading over the phone for help, their breathless desperation as they try to tell their sad story between sobs, intertwined with intimate details. They would say random, heart breaking things like, “What do we do with the crib?”

They were similar in many ways. A state with a 20 week ban on “elective” pregnancy terminations. The ultrasound that diagnosed the catastrophic collision of chromosomes performed too late. Often there was the suggestion that the doctor might have been offensively “pro-life,” the kind that orders the second trimester scans a little later than recommended for those women they know are pro-choice.

I didn’t set out to do post 20 week abortions, I just kind of ended up doing them because with each turn in medical school and residency it seemed no one else was. I was always pro-choice. I remember riding my ten speed to Dr. Henry Morgentaler’s clinic in Winnipeg to show support when I was 16. I hadn’t even been on a date or had sex so pregnancy and abortion were abstract, yet I knew women deserve autonomy. That we get to decide what happens to our bodies. My parents were very conservative in many ways, but they were very pro-choice so maybe it came from them. Our basement library was also filled with books by the likes of Margaret Atwood and Betty Friedan and so I read a lot of feminist literature and non-fiction growing up.

In medical school the lectures about abortion were given by men. That bothered me. I don’t think you have to be a woman to be a good OB/GYN, but I had hoped for equal representation. The same in my OB/GYN residency, only men did abortions and for any woman who thinks it’s weird for a man to be an OB/GYN let me say these men were full of empathy and kindness and were very skilled and there was nothing odd about them wanting to do OB/GYN. The subject interested them and they felt women deserved the best care. Basically, they thought about it just like I do.

Once in residency I remember rolling my eyes about someone who was past 20 weeks and needed an elective procedure. There a firm grip on my arm and a firmer lecture about privilege. Before the world was online some women were told by their doctors that abortion was illegal and they had no idea that not only was it legal in Ontario but also free. The delay explained by the time it took to find out through a network of whispers where to go and to raise the money for one bus ticket. I had the luxury of a basement library, two homes, music lessons, and trips to Europe growing up and I was going to judge someone who had to work two jobs to buy a bus ticket to travel alone for her abortion? A good doctor teaches you these things.

To learn abortion in my residency required going out of my way. That unspoken marginalization bothered me. The default should be learning the procedure, because otherwise there is a clandestine air. The other thing that troubled me was the only other people who went out of their way to learn were men. They thought as I did, that we should all just learn so we then can all be safe and offer good care.

After residency I figured I would offer my patients abortions and it would be just one part of my practice. I naively thought everyone would do that. I moved to Kansas to do a fellowship in infectious diseases and learned very quickly that unlike the Canadian Midwest in the American Midwest it was best to not discuss abortion and choice. I was shocked by the fact that there were four clinics for the state, but only two for later term.

Along the way people found out I had the mechanical skills. It probably started because I did a few dilation and evacuations on labor and delivery for women at 22 or 23 weeks with ruptured membranes, infections, and fetal demise. It’s technically a very hard procedure when there is an infection and helping a woman not need a hysterectomy to save her life is something only people who have learned how to do late-term abortions can do. It’s nerve wracking because with infection the uterus is like soft butter and you are using hard instruments. And it’s all by feel. In those days we didn’t use ultrasound.

I guess word quietly got out. Our clinic nurse, a kind soul and a ringer for Professor Sprout, pushed me a little to help this woman and then that one and so on. I didn’t know this would lead me to care for women who had almost no other options.

Many had been given Dr. Tiller’s name or told about Planned Parenthood, but if they had medical conditions they needed a hospital and that left me. Some didn’t want to go to Dr. Tiller or Planned Parenthood, often they were of the persuasion that believed abortion was wrong and obviously if you go to an abortion clinic everyone knows what you are doing. A hospital offers other potential explanations. Often they came because they had no money and I worked at a teaching hospital and we didn’t ask for cash up front, so maybe just maybe?

A later abortion is thousands and thousands of dollars so when people had nothing I would beg and plead with my anesthesia buddies and they would forget to turn in their billing slips. I wouldn’t charge and the hospital administrators often looked the other way. I don’t know if they were pro-choice, the billing truly sucked, the stories tugged at their hearts like they did mine, or they accepted my explanation that this was for resident education.

Several times there was no money for a funeral home to receive the body (they can charge hundreds of dollars), but a several hundred or more mile drive to get the body back home. It became my job to figure that out. I’m 28 or 29 and I’m scrambling to find a suitable box for a tiny body and convince the morgue that this is somehow okay. I’m pretty sure my genetic counselor gave people gas money from time to time.

If we did an induction the nurse would wrap the baby up ever so carefully for viewing, but sometimes the birth defects were so much that we presented hand prints and foot prints or a face carefully swaddled to show the chin or whatever part looked perfect. It takes a special kind of nurse to do this and they did it with such tenderness. However, as the doctor it was left to me to explain why we thought it best they not look. All the things no one knows how to do or wants to do are left to the doctor. Do you show a woman that her baby really is a cyclops? I know she knows because she told you between sobs when she called, or rather her husband did because she was crying so hard she couldn’t speak anymore. But is that the image I should lock in her brain for the rest of her life or the five toes? You just do the best you can. I like to think that my patients knew that.

At the time I was told we got all these out-of-state calls and desperate women because Kansas had a lax abortion law. The story was the previous chair of the department had been around for so long that he had done abortions for so many mistresses and delivered babies out-of-wedlock for so many daughters that he had massive coin in the political bank. I don’t have proof of that, but the laws were lax and it was to my hospital reporters came calling when there was a suggestion that Bob Dole had a girlfriend way back who had an abortion.

But times change and the former chief of the department was elderly and all those maybe secrets and those affected by them aged with him. A law was passed to prevent abortions at KU medical center unless the life of the woman was in jeopardy. It wasn’t a back door TRAP kind of law, it was a blatant “not here” tacked on to a funding bill. Want state funding, stop abortions. No one beats around the bush in Kansas.

Guess who gets to decide if a woman passes the Kansas state government’s test for being sick enough to die from her pregnancy? Not the cardiologist who calls at 3 a.m. in a panic or the nephrologist who breathlessly corners you in the hallway or the intensivist who tracks you down on your vacation. Not any of the people who manage the illness trying to kill the pregnant woman. Not me either, but the politician who crafted the mayhem via a three-way phone call set up by the hospital attorney. And yes he was shocked beyond belief that such a scenario existed. Politicians swallow the anti-abortion rhetoric so completely that they truly believe the health of the mother is just some pro-abortion lie doctors tell. Why couldn’t they just go somewhere else? Try explaining the idea that if a woman is sick enough she might die from her pregnancy that her abortion needs a skilled anesthesiologist, a blood bank, and an intensive care unit to someone with zero medical background.

But the law worked. Women were still sick, especially in the rural Midwest where many had no health insurance so medical conditions went unmanaged, but people learned to refuse the transfer. Not sick enough. Call us when she’s really dying. Abortions at KU stopped, but the need didn’t stop, just diverted elsewhere and possibly to less experienced hands.

Soon after I moved to another state where there were several skilled providers, some at hospitals, and so I gradually did fewer and fewer. I stopped doing abortions over 12 years ago along with deliveries. Partly because I wasn’t needed anymore, but mostly because of PTSD. Being around pregnant women is really hard for me given my terrible pregnancy outcome. It’s hard to explain, but my son died in a labor and delivery room and so the idea of having to go into onto labor and delivery makes me feel physically unwell. I don’t even like going to one to meet up with a friend for lunch.

What is it like doing late abortions? It’s mostly very sad because no one is there because they are happy. A wanted pregnancy causing serious physical harm, well, no one is happy they are sick or that they have to terminate their wanted pregnancy to live. I know these women were happy they met me and some even returned to be my patient. That always meant a lot. “You saved my life, how could I go to someone else?” What about a wanted pregnancy with severe malformations? No joy there either. Only a tiny minority are unwanted pregnancies and then the woman almost always wishes the pregnancy never happened and that she could have terminated sooner. Women who access abortion care after 20 weeks for what we call elective reasons are in that situation because of laws designed to restrict abortions.

Doing sad stuff is part of medicine, but add in the hoops you have to go through to learn abortion, the TRAP laws, the fear, and then the price that many have to charge to cover expenses and you get a very narrow field of providers. And it’s getting smaller.

What bothers me about abortion are the lies politicians and supposedly pro-life individuals tell others and themselves. That doctors make lots of money doing these procedures, that these are callous women who just decide on a whim at 22 weeks (no women ever decides any abortion on a whim), that there are other options, that women don’t try to do home abortions, that no one is sick enough to need an abortion, that laws reduce the need for abortion as if doctors are standing on the street corner offering two for one deals. These laws are built on an equal mix of privilege and lies.

Focusing on abortions after 20 weeks tells me that politicians have invested nothing in learning what that means. That forcing a woman to carry a fetus not compatible with life to term is kind. That serious intrauterine infections at 23 weeks don’t happen. That women have thought nothing about what they are doing. Let’s be clear, if you are truly “pro-life” you’d agree with these procedures because they save women. Not in an abstract way, but sometimes it is in a this-infection-is-killing-you-and-we-need-to-help-you-right-now kind of way.

The one thing I’ve learned from my experience is that efforts to stop abortion after 20 weeks are nothing about life or compassion or good medicine, it is simply wielding the misery of women (and those who love them) as a political tool.



I want to thank the woman who gave the interview to Jezebel about her experience with her abortion at 32 weeks. I am so sad that you had to fly out-of-state to have the hardest procedure you will have. I am so sorry it cost you so much money. Your story helps fight the narrative that abortion after 20 weeks is some abstract thing that no one needs.




132 thoughts on “What you learn doing abortions after 20 weeks

  1. Please read this. Abortion in no an evil thing selfish women do. It is a heartbreaking decision made with great sorrow and grief. My mother had to have an abortion because she was in such fragile health that her doctor said she could not survive her pregnancy, but all abortions were illegal. Her doctor found someone who was capable and qualified to do an abortion for her. What was the choice here? My parents were staunch Christians so what were they supposed to choose? If Mom died Dad would be left a widower with four motherless children; would this be a correct choice? They chose an abortion, an extremely difficult decision for them. But what else would you do if you were in this situation? Think about it personally. Think about you mom and dad, your sisters and brothers, the women in your life, the wives and mothers in your life. Be honest and real about your decision.

    Posted by Joy Mauser | October 21, 2016, 10:14 pm
  2. My daughter chose to be induced at 20 weeks due to severe anencephaly in her baby, there was no chance at survival as the baby had very little brain and not much more skull. She was treated with kindness, understanding and respect and the nurses took great care to wrap the baby so her little face was visible but the extent of her abnormality was not. I am thankful for Dr’said and nursing staff who see beyond a “this is right and that is wrong” mentality. God bless you.

    Posted by Dionne Bouknight | October 23, 2016, 5:59 am
  3. Just explain this to me: what happens to the baby when it’s being extracted? Extraction is such a benign word to use when explaining a dilation and extraction. Please explain what the “extraction” entails. The other reason I’m responding is this: I would like to see a study conducted on how women cope after they’ve had an abortion. In my research, the vast majority of women who are post abortive suffer from depression, suicide impulses, self mutilation, relationship problems, guilt, shame, sorrow, unable to forgive themselves, anger, anxiety, remorse, grief, alcohol abuse or drug abuse, sleep disturbances, nightmares, flashbacks and the list goes on and on! Do any of these woman have counseling available to them? No, they are expectd to walk boldly thru the doors yelling “I am woman hear me roar”, (well at least at Planned Parenthood they do) so when they don’t feel that way, they think something is wrong with them, hence the secrecy. The reason why women have a hard time dealing with what they have done is because as women we are hard wired to love, protect & nurture our off spring. Abortion is the exact antithesis of how we are hard wired. You can talk all you want about the medical side of abortion, “a woman having the right to do with her body what she sees fit”, for the health of the mother, but do you ever think about the ramifications and emotional affect the abortion has on the mother after wards? The baby isn’t the only one destroyed, the mother is too! I’m not talking from a place of judgement, I’m speaking from a place of experience. I had an abortion 18 years ago( I wanted that abortion, I told very few people what I planned to do, but I wanted that baby OUT of me) Planned Parenthood certainly didn’t try and stop me or give me any idea how this might affect me……I can’t begin to tell you how it affected my life, how it affected my relationships, how it affected my relationship with my two children , the flashbacks (the horribly rude Planned Parenthood doctor who performed the abortion…screaming “stop moving your legs!!!!)
    No one, especially Planned Parentood wants to talk about after……there are many on line blogs that are dedicated to post abortive women that enable them to share their story! 99% of their stories are like mine. Planned Parenthood knows about these blogs, so what do they do? They started their own blog or maybe it’s on their website “share your abortion story” like its a good thing. The most insidious story came from Gloria Steinem who was shown in a picture with her arms over her head in celebration. Her t-shirt read “I had an abortion”. As a Doctor, don’t you think it’s important to know what your patients go through after the fact and share with them what very well might happen to them? Don’t you think it’s important to share with them how this will affect them the rest of their life? I so wish Planned Parenthood had shared this info with me, because they do know. They just choose not to disclose the info; they certainly don’t want to lose any revenue…….

    Posted by Angie Snellenberger | October 27, 2016, 7:34 pm
    • That’s all been studied. Women cope just fine.

      Posted by Dr. Jen Gunter | October 27, 2016, 7:49 pm
    • So, Angie, because you are still hung up about your abortion, then nobody else should be able to have one? All women and girls should be forced to continue their pregnancies, no matter whar the situation, because the anti-choicers got inside your head? “I don’t want others to have a choice, because I regretr mine”. Sounds totally fair.

      The strongest predictor of mental health after an abortion was the woman’s mental health before it. It’s as simple as that. There is no evidence of lasting trauma, physical or mental, as a result of elective abortion. Given that some 50,000,000+ in the US have had at least one abortion, I think you’d notice if they were all psychologically decimated.

      You know what does have lasting, quantifiable, genuinely poor psychological, physical, and social outcomes? Forcing people to carry unwanted pregnancies to term, and then give birth. Everybody suffers in that scenario – parent, child, society.

      But, as mentally damaging as birthing and raising an unwanted child can be, the Ebola Gay-sized bringer of appalling mental health outcomes is – relinquishing a child for adoption. Forcing girls and women to continue with unwanted pregnancies in order to give up the baby for adoption is, unsurprisingly, associated with psychological problems..

      Tell me, Angie, how many “adoption agencies” inform girls and women of how devastating relinquishment can be? How many of these agencies divulge the tens of thousands of dollars they command for each child, precisely none of which goes to helping the person forced to carry said child?

      How many of these agencies insist upon girls and women undergoing extensive psychological testing and counseling (from an unbiased third-party provider), as opposed to essentially holding them captive in “mother and baby homes”, where they’re evangelised at, and indoctrinated into believing that this is for their benefit? How many agencies are there, to pick up the pieces, if someone (who has relinquished her child) regrets her decision, is traumatised by what has happened, and is wracked by grief?

      It’s sad that you regret your abortion, Angie, but there are trained therapists out there, who can get you the psychological help you need. Wouldn’t alleviating your mental health issues feel better than trying to deny everyone else bodily autonomy? Wouldn’t you feel more at peace if you weren’t hung up on some non-existent conspiracy to trick people into abortions, and seeing every mention of abortion rights as a personal dig at you? That’s no way to live, Angie. I hope you can get the help that you need to feel better.

      Posted by Boostick | October 28, 2016, 12:04 am
    • Angie I feel your post is very unfair, and for you to target this Dr due to your personal experience. Every single woman will experience their own situation differently. Have you ever sat and considered that you were the one who went to the clinic and asked them for their help, you were the one who made the decision to not continue the pregnancy – no one forced you to do it. Have you sat and considered how continuing with the pregnancy you were not prepared to have may have affected you emotionally, socially and financially at the age of 18? Have you considered how that may have actually affected you more?

      I feel for you Angie because you are clearly struggling to come to terms with the decision that you made, and looking to blame anyone to remove the responsibility from yourself.

      I can’t speak for the services in the US but the abortion care services I work in, in England ensure women are fully aware of the risk of psychological issues after the treatment and are offered counselling services if they feel they are struggling to come to terms with the decision they made after the event, however this is very rarely needed.

      I really do feel that you will benefit from some counselling and really do hope you find the help that you need.

      I wish you well.

      Posted by YourBodyYouDecide | October 28, 2016, 4:41 pm
    • Angie, put me in the group who is NOT regretful, depressed, suicidal and all that other crap. How did you conduct your survey? Oh yeah, after ALL the posts here, after A REAL DOCTOR shared her experiences, do you think you have a pony in this race?

      What do you bring to the table? You just reiterate REFUTED SCIENTIFIC EVIDENCE.

      How about you take care of YOUR life and stop worrying about an organism WHICH CANNOT FEEL and CANNOT THINK. Many do not have functioning organs. But YOU know better than science and real experiences? Ha ha ha ha.

      Posted by jennylens | October 30, 2016, 4:22 pm
  4. I have never read anything that captures the truth of abortion care any better. A wonderful post. I feel like you have written about my own personal beliefs and the lengths you will go to, to help a woman in desperate need. I work as a Nurse Practitioner in abortion care in England and so I can relate very much to much of what you have written.
    Thank You for your very honest post revealing the real truth and sensitivities about abortion care.

    Posted by YourBodyYouDecide | October 28, 2016, 4:24 pm
  5. Thank you for such an eye opening article… I wish there could be more levels of conversation instead of hateful rhetoric and name calling

    Posted by Robert Torres | October 30, 2016, 6:44 am
  6. One of my pregnancies screened positive for trisomy 13. By the time I got the results, was scheduled for an emergency amnio in a big city (our small town does not have this capability) and got the results, I was past 20 weeks. I did everything right, everything on schedule, and yet still, it was over 20 weeks. As you know, trisomy 13 has absolutely zero chance of making a healthy baby who could live to even toddler hood.

    Thank you for your thoughtful article. I’m so pissed off that we still have assholes like trump who think they have the right to enter into the exam room with me and my doctor!

    Posted by Erin mitchell | November 2, 2016, 10:08 pm
  7. Doctor, your warm heart infuses even such tragic narratives with loving compassion, wisdom and profound human understanding. As a man i am horrified -daily- by my gender’s woeful incapacity to empathise with the awesome responsibility of reproduction women withstand, even when things go swimmingly.
    Your writing is grounded, realistic and extremely moving. The moral and ethical considerations are clearly spelt out without drama, and the conclusion, stated so objectively, is inescapable.
    I was also very touched by the love expressed so copiously in the slew of intelligent comments.
    Thankyou for your service and for taking the time for superb blogging about your life. I am so sorry to hear of your own loss, which in some ways makes your work even more admirable.

    Posted by Michael Dunkley | December 5, 2016, 5:11 pm

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