When Safe Abortion Isn't a Choice

By Dr. Jen Gunter, Wielding the Lasso of Truth

30 May 12

f she is brave enough, she will ask around. Someone will know someone who knows someone. Or something.

Someone’s grandma might know about the old days. Drinking turpentine or Clorox, which is what the poorest women often did. They also took massive doses of quinine. Equally dangerous and, like the household cleaners, not a particularly effective abortifacient. Although as faded memories become urban myths no one seems to remember that these methods don’t work and often kill, and so they remain in the lexicon of “options.”

An Internet search, if she has access and doesn’t have to worry about the prying eyes of parents or an abusive partner, might lead her to misoprostol. A friend from Latin America or Asia might be more familiar with this “option.” Assuming she gets the right dose of the real medication and not some sugar pill or poison passed off as the real thing, she might have a 30-40% chance of inducing her abortion early on. Ironically, it gets more effective as the pregnancy advances. Like most women she’ll take the pills by herself, cramping and bleeding on the toilet or squatting on the ground. No one to hold her hand. No one to wipe her brow. No one to recognize when she has a fever or has lost too much blood.

Many women find their way to people who offer certain “skills.” Procedures, if you can even call them that, offered in back rooms. Rooms that don’t have an autoclave to sterilize tools or even basic resuscitation equipment. Some rooms have the essence of respectability, many do not. Almost none are operated by anyone who has more than a cursory knowledge of the reproductive tract.

On kitchen tables these women lie. Some might be offered a Valium or a Vicodin. For a price. It might ease the pain a little. These medications may also makes them less likely to cry during the sexual assault that can be part of the deal. After all, who is going to complain about getting raped at their illegal abortion?

Maybe their vagina and cervix is cleaned before hand, but maybe not. An instrument is pushed through the cervix by hands that do not know how to atraumatically dilate the opening of the cervix. Too much force is dangerous. The practitioner may not know (or care) that the wall of a pregnant uterus is like butter and any instrument, no matter how soft, is like a knife.

If they can’t navigate the opening of the cervix, or if they haven’t even bothered to look, the instrument is just forced up until there is no more resistance or until the screaming stops. This blind stabbing often leads the instrument to puncture the top of the vagina, weaker than the cervix, traveling alongside the uterus where the major blood vessels are found.

Ultrasound machines are not used. They cost hundreds of thousands of dollars. Even if one were available, the chance that such a provider would know how to use one is slim. Gestational age is therefore a guess. Unfortunately, knowing about the long bones and skull is crucial in the 2^nd trimester. An unskilled hand can easily push splinters or larger pieces through the uterus into waiting bowel and blood vessels.

If blood vessels are transgressed, the bleeding is catastrophic and requires emergency intervention. Many women don’t get to the hospital in time. Who is going to call the ambulance?

If fecal material announces a bowel perforation a caring provider might stop and say, “You need to get the hospital.” Most are not that caring. Better she stagger home and call.

Even when the procedure seems to go smoothly, the risk of infection is high. Pretreatment with antibiotics to lower the risk of infection, standard with a safe abortion, doesn’t happen. Products of conception left behind by untrained hands and unsterile equipment take their toll in 2-3 days. If the woman is not too ashamed or afraid to go to the hospital she will need advanced care. She may need her uterus re-evacuated to remove what was missed and is now the nidus of infection. As there are fewer and fewer providers skilled to perform abortions, there are fewer and fewer hands experienced enough to do this without the back wall of the uterus falling apart from the currettage. Many will now get hysterectomies.

A CT scan might show abscesses in the belly and a punctured bowel. In these dire circumstances surgery, a colostomy bag, and a prolonged hospital stay will be the result. Infection and blood loss may also cause the body to attack itself, losing the ability to clot. This is disseminated intravascular coagulation and even with prompt, expert, intensive care it is often fatal.

But if she is so alone, so alone that she can’t fathom asking anyone she might take a stick, or a coat hanger, or a knitting needle and stick it up her vagina. She won’t know about the cervical os, the opening of the cervix, or that she has no hope of finding it blindinly. She’ll push. It will hurt. A lot. But she’s desperate. She might stick it into her uterus, or right through the uterus into bowel. After two or three days of fevers and cramping and vomiting she might go to the hospital and hopefully the damage and infection will be confined to her uterus. She might also slice through blood vessels and bleed to death by herself on her bathroom floor.

“It’s going to be challenged, of course, in the Supreme Court and all — but literally, we stopped abortion in the state of Mississippi, legally, without having to– Roe vs. Wade. So we’ve done that. I was proud of it. The governor signed it into law. And of course, there you have the other side. They’re like, ‘Well, the poor pitiful women that can’t afford to go out of state are just going to start doing them at home with a coat hanger.’ That’s what we’ve heard over and over and over.

“But hey, you have to have moral values. You have to start somewhere, and that’s what we’ve decided to do. This became law and the governor signed it, and I think for one time, we were first in the nation in the state of Mississippi.”

- Mississippi GOP state Rep. Bubba Carpenter

Dr. Jennifer Gunter is a nationally and internationally renowned obstetrician/gynecologist. She is the recipient of numerous research awards and has published extensively in medical journals and authored many book chapters. "The Preemie Primer" is her first book. Her writing has also appeared in USA Today, the A Cup of Comfort series, KevinMD.com, EmpowHer.com, Exceptional Parent, Parents Press, Sacramento Parent, and the Marin Independent Journal. Dr. Gunter also writes a sexual health column for examiner.com. She has been interviewed by numerous national media outlets and magazines, including CNN.com, More, US News and World Report, Runner's World, Glamour, Redbook, Woman's World, and Shape.

Dr. Gunter was born and raised in Winnipeg, Canada, and graduated from The University of Manitoba School of Medicine in 1990 at the age of 23. In 1995 she completed her OB/GYN training at the University of Western Ontario and moved to the United States to complete a fellowship in infectious diseases at the University of Kansas. After completing her fellowship she continued her studies in pain medicine and currently is the only OB/GYN in the United States who is board certified in both OB/GYN and pain medicine. Dr. Gunter is one of the select few physicians in the United States who holds four board certifications.