The Comfortable Abortion
I had two abortions ten years apart. The first was traumatic. The second one let me keep my dignity.
Image: Edward Badley/Flickr
A while back I reluctantly attended a girls' movie night with a few other women in their late 20s. When I arrived, I was informed we were to watch Obvious Child. I was less than one beer in when I deduced none of the women there had ever had an abortion. I quietly observed them, giddy and giggling—one even suggested that we listen to "Brick," by Ben Folds Five, to get in the mood. Then I began furiously texting my friends, who urged me to impart my firsthand knowledge of the procedure.
I couldn't. The abortion stigma is intense, even for me, someone who writes about sex and tells perverted secrets very regularly. Ultimately, I realized, it's an important thing to share. And now I do so from the safety of my computer and on the internet of all places.
An estimated one in three women will have an abortion at some point in their lives. At 29 years old, I have had two. My first was at 19, a couple weeks before I left for college, and it was traumatic in more ways than one. The second was three years ago in Brooklyn at Early Options and, as far as the actual procedure went, was smooth and forgettable. It certainly helped that I was older and less ashamed to tell my friends. I even tried to make it lighthearted, hosting a party complete with a cake that read "LOL, oops!" Of course, abortion is never easy, and even if I'm incredibly grateful for having the choice to terminate both my pregnancies, it's still a difficult decision to make.
Though it will likely always be a troubling predicament to discover an unwanted pregnancy, technological and environmental developments continue to make the procedure itself much easier to go through. While currently abortions in the US are mostly outsourced to private clinics, there is a movement to bring them home, both literally and by creating a more comfortable environment for the experience. Once society and politics catch up, access to these methods in the US and worldwide could both revolutionize and destigmatize abortion.
Early Options, founded by Dr. Joan Fleischman, has been performing cutting-edge abortion procedures since it opened in 2000. Her mission is to integrate abortion into primary care, putting it on par with a pap smear. She believes every doctor should be trained in residency to perform an abortion—that normalizing it will create a better experience for everyone. Eliminating the need to go to a specialized abortion clinic and instead just having the procedure performed by your own doctor would make the experience all around easier.
"Abortion since the 70s has been provided in a clinic. This is not to say anything negative about clinics, clinics are necessary and heroic in their efforts," Fleishman said.
But my clinic experience made me feel like the human equivalent of a poorly sewn blouse going down an assembly line in a foreign factory. My first abortion went down in a clinic I learned about from Planned Parenthood, because I was scared to go to my family doctor for guidance. I had to stop eating and drinking the night before, like I was preparing for surgery. Well, I was.
I sat in a waiting room before I was taken from the friend I chose to come along. From there, I was alone. I got my blood drawn and had an ultrasound, then I was wheeled on a stretcher into an operating room. I can still remember the nice anesthesiologist who put me to sleep, but I have no idea what happened next. I woke up next to a dozen crying women that I'd never seen before and got wheelchaired back into the waiting room. The whole process took about five hours.
Best-case scenario abortion revolves around two options: manual vacuum aspiration (MVA), and a pharmaceutical cocktail commonly referred to as "medical abortion" or "the abortion pill."
A relatively simple procedure, MVA was introduced to the United States in the late 1960s, but it wasn't integrated into the mainstream medical community until the 1990s. What we now know as MVA is the refined version of a technique called "menstrual extraction," which women performed on each other during the " our bodies, ourselves" movement in the 70s, to remove "a woman's menses to avoid an inconvenient period or, more importantly, to end a pregnancy at an early stage."
MVA works like this: The doctor inserts a speculum into the vagina, dilates the cervix, and puts a tiny tube—smaller than the circumference of a pencil—into the natural opening of the cervix. The doctor attaches a syringe to the tube and a manual aspirator to the syringe, and then gently applies pressure. This releases the pregnancy lining from the uterus into the syringe for disposal. MVA is similar to its counterpart, electrical vacuum aspiration (EVA) in safety and effectiveness, but since it's manually operated, it may be preferable to patients because it doesn't involve buzzing, noisy machines. Because of the scare factor with EVA, women are often unnecessarily put to sleep during the procedure, which involves a longer recovery and more complications.
"The big advance here is that it creates a gentle release of the tissue and the uterus is left completely intact," said Fleischman. "If you do this with a miscarriage, a woman can start trying again the next month."
It's a far cry from more barbaric procedures, such as dilation and curettage, which involves scraping the pregnancy lining from the uterus using a long metal scoop. This is still done, but ideally only in later term abortions or when MVA/EVA are unavailable, like in more remote, pro-life areas.
"The whole myth of abortion causing infertility is based on these procedures," said Fleischman. If a doctor were to scrape too aggressively, it could cause Asherman's syndrome, a scarring around the uterus that can end your period forever. "With MVA, the fear of fertility problems is taken away, which transforms abortion into a non-scary procedure," she said, comparing the advance to "the difference between a hysterectomy and an IUD insertion."
With MVA, you could be in and out of the office in 90 minutes, but the actual procedure takes less than five. You get a painkiller, but you're awake. It hurts, but it's a manageable pain. At Early Options, the person with you can come in and hold your hand while it happens. That's pretty radical.
Researchers are also looking at ways to control the pain for both methods of abortion
Because "procedure" is a scary word, some may be drawn to the second option: a one-two punch of medications, mifepristone and misoprostol (which markets as Cytotec), that disable the placenta and cause the uterus to contract. I spoke with Dr. Beverley Winikoff, a medical abortion researcher at Gynuity Health Projects, to get an idea of exactly what's involved.
Though mifepristone was invented in the 1980s, it is still widely unknown and unavailable around the world, which is truly tragic as it would allow for women to take abortion into our own hands, just by placing pills in our mouths. As Winikoff put it, "Mifepristone works against the placenta, which is what keeps the embryo alive. Once that is turned off, the embryo dies. The second pill… is the same thing that makes you get menstrual cramps. The uterus contracts and then expels the contents."
According to Winikoff, both MVA and the abortion pill are so effective, choosing between the two is a matter of preference—patients just need to decide "what kind of experience they want."
Fleischman is less supportive of the pill. "I feel more generally positive about the MVA procedure because you come in and you're done, you leave, your hormones go down quickly, you're in the care of a doctor's office," she explained.
There's definitely something to be said for the fast relief from pregnancy hormones—at least for me. It's fair to say I was a completely unhinged pregnant lady. "The problem with the pill is that some women can have hours and hours of excruciating pain, weeks to months of bleeding, or it simply doesn't work," said Fleischman. It's that last bit that led me to choose MVA the second time around, though it seemed like the scarier choice. When you are pregnant and you don't want to be anymore, you don't want to risk going through something only to find out that you're still pregnant.
I asked another researcher at Gynuity, Erica Chong, if taking the pill could lead to some unsettling discoveries as you pass the fetus. "Early on in your pregnancy you're likely to have clots, but they won't look like much. Around nine to 10 weeks, you start to see something more substantial. That's part of the counseling that women get if they elect to do the medical instead of the surgical," she says.
The pills are 95-98 percent effective when combined. But in places where women don't have access to either a doctor who can perform MVA or mifepristone, the second pill, misoprostol—easily obtainable as cytotec because it's used to treat stomach ulcers—is more than 80 percent effective on its own. This off-label use began in Brazil, where abortion is illegal, when women noticed the miscarriage warning labels on bottles of cytotec and began to take it as an abortion home remedy.
To provide safer and more effective alternatives to women in countries where there is no legal way to obtain the gold standard of abortion, Dutch doctor Rebecca Gomperts founded organizations Women on Waves and Women on Web. Her whole story is crazy and fascinating: "The idea was to have a ship that can sail to countries where abortion is illegal, then women can board the ship and sail to international waters and have a legal abortion with medicine. As a result of the campaigns on our ship, we started getting a lot of emails, so we started Women on Web," Gomperts says. Women on Web delivers abortion pills to women after an online consultation with a doctor.
Gomperts believes the future of US abortion looks bleak, noting violence against clinics and doctors, along with the political climate. The pill especially could be a lifeline, but access to it is currently held up in many places by partisan lawmakers. Thirty-eight states require that the abortion pill be administered by licensed physicians, and 16 states say that the licensed physician must be present when the pill is administered, which gives little hope for cutting out the middleman.
Carafem, which opened earlier this month in Maryland, has been hyped as a spa-like abortion destination
If the abortion pill were to be made as easily accessible as Plan B is now, telemedicine could be used to enable women in even the most remote, conservative areas of America to have abortion access. In practice, it might involve a single visit to a Planned Parenthood location and a video conference with a physician, who unlocks a cabinet with the necessary pills once a woman makes a decision. The patient takes the first set of pills on video, and the second set at home later. Telemedicine is already a widely accepted intervention for many other types of medical issues, such as diabetes, Gomperts explained. "It is the political systems in place that are undermining every improvement and every attempt to let women benefit from scientific advancements," she said.
While women are still fighting for their right to choose in the United States, there are a few things that could improve the two very good options we currently have for abortion. The first is obvious—making these techniques much more readily available. "In New York, we're in a foreign country compared to women in Texas, where they have to go five hours to get to a clinic, and then they have to go back three times. It's not the procedure we need to make better, it's the access," Winikoff said.
According to Winikoff, researchers are also looking at ways to control the pain for both methods of abortion, and, for the electrical aspiration method, they need to figure out how to quiet the startlingly loud noise of the procedure. They're also working on pregnancy tests that will help women know if the pill method was effective without a return visit to their clinician. According to Chong, they are currently testing the efficacy of the pill in pregnancy up to 11 weeks. She said the current cutoff is 10 weeks, but many clinics stop at nine.
"The future of abortion is now," Chong says. "The abortion pill is about 20 to 25 percent of all abortions. A lot of women just don't know what it is." Now you do.
Perhaps the most drastic improvement of all when it comes to the future of abortions, is what Fleischman seeks to create at Early Options: a much more private and personal experience. The intimacy of a doctor who knows your name, your partner by your side, and a small-setting doctor's office is the future of abortion, according to Fleischman. "For this procedure, environment is everything," Fleischman said. "It's a cultural advance that we need."
And the future is already looking promising for this prospect: Carafem, which opened earlier this month in Maryland, has been hyped as a spa-like abortion destination—complete with plush robes and hot tea. It sounds kinda... nice.