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Having an abortion clinic in town is not enough

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Linda Prine MD, Natalie Hinchcliffe DO, Shauna Gallagher MD

 

Linda Patient 1How many times have we heard the refrain: “We don’t need to do abortions in our family medicine practice, we have a XXX (fill in the blank with the name of your local abortion care clinic) in town.”? Too many times. Comments like these reflect a lack of understanding of what so many women’s lives are like and just how difficult it can be to access care at a dedicated family planning clinic. Here are our (patients’) true stories[1]:

 

#1) Shauna’s story:

My patient came into the clinic with a man who was supposedly her partner, after a positive urine pregnancy test at home. Nadia was a 26 year-old non-English speaking woman who appeared quite anxious, had poor eye contact throughout our encounter and didn’t interact with this man throughout discussion. He chose not to involve himself in the conversation, sitting silently in the corner staring at the ground.

I learned quickly that her medical history included an ectopic pregnancy, a pregnancy which implants in the fallopian tubes. For Nadia, the ectopic required an extensive surgery for resolution. I had initially assumed that her fidgeting was a result of her troubled medical history. I offered her options for continuing the pregnancy or not, explaining that we provided care in our health center either way. She replied with hesitance that this was a surprise but she would continue the pregnancy. I explained that, with her ectopic history, we should do a transvaginal ultrasound today and she quickly told her partner that she would feel more comfortable if he stepped outside. He hesitated, so I stepped in quickly and assured him that we would bring him back into the room shortly.

Once he left the room, I reiterated with the patient her available options. She immediately looked at me in desperation stating that she wanted an abortion and that he must not find out under any circumstance. She assured me that she was not in any danger, lived in a safe place but this was by no means the right time for her to have a child. She had recently started a new college program that she had invested in with her own money after working and saving for many years. I immediately assured her that she was in the right place and her partner did not need to know what we had discussed. I was happy to let her know that we could provide her with an abortion which could be done here at the clinic. She expressed a big sigh of relief but remained fearful, anxious and felt that she needed to report back to her partner as soon as possible.

She ended up getting her abortion at our clinic the following day, in a quick visit, through a collaborative effort from our providers. I wondered if I had needed to refer her to an abortion clinic for her procedure if she would have made it. I doubt she was allowed to travel to her doctors’ appointments without her partner’s supervision.

The take home lesson for me is that going forward I will always ask the partner to step out of the room during options counseling visits.  I now wonder how many women aren’t able to access their preferred choice when options counseled, aren’t making it to the abortion clinic when referred, or not even getting the right message to their provider of what they really want, simply from a barrier of not having the partner step out of the room.

 

#2) Natalie’s story:

My patient was 12 years old. No one knew Annie was having sex—especially not her parents. The nursing note in the chart said “here for a pregnancy test”, so when I walked into the room I was startled to see a nervous child. She looked every bit her young age and was terrified, sitting next to her equally young and nervous boyfriend.

She had come into clinic worried she was pregnant when she missed her period. When I counseled her on all her options, taking care to make sure she understood everything, it was clear she knew what she wanted: she had come here for an abortion. She knew about our clinic because her boyfriend’s aunt had come to us for her own abortion. I asked her if she wanted to talk to a parent or another adult she trusted about her decision. Her eyes widened in fear as she told me no one could know. When I spoke to her without her boyfriend in the room, she was even more adamant. I told her we could perform her abortion that day and watched her shoulders drop and her face soften in relief.

She came to see me twice, once for her abortion and once for follow up. Each time she came directly after school with her boyfriend and told her parents she was staying late at school to study. She couldn’t miss school to make an appointment because her school called parents if the kids were absent and if the parents had not called in the absence. There would have been no way for her to miss school for an appointment at the local abortion clinic. Our clinic’s teen friendly hours allowed her to make the right choice for her. It also allowed us to take extra time to talk through the pelvic exam, and to have the support of her boyfriend by her side during the procedure.

When I saw her for her follow up appointment, she and her boyfriend were joking and laughing. They were playing on the rolling chairs, teasing each other about the pelvic models—they were having fun. She was no longer the nervous girl I had met the week before, she was a kid again. She ended up choosing an IUD for contraception which can last her through middle school and high school before she needs a new one.

 

#3) Linda’s story:

My patient’s husband took her everywhere. Her religion and culture dictated that she not travel alone. Magda had four children under the age of five and was exhausted. She came to me asking for birth control that her husband would not be able to detect, because he was trying to get her to have another child. But, when we did the pregnancy test, she was already pregnant! Magda broke down in sobs and begged me to help her. Her spouse was in the waiting room and she was terrified. There was no way he would take her to a family planning clinic, the only hope she had of getting an abortion was if I could give her one, in the privacy of our family medicine office, behind closed doors.

She was only one day late for her period. I explained the medication abortion process and that it was impossible for anyone to know the difference between it and a miscarriage. Or, for that matter (at that gestational age), it could just be a slightly late and slightly heavier period. She begged me to give her these medications, and to keep it a secret from her husband. She signed the consent, I gave her the medications. She asked me to explain her “miscarriage” to her husband, should he call me the next day when she began to bleed and I agreed.

Magda came back the next week for a follow up visit for her miscarriage and her pregnancy test was now negative and I inserted an IUD. We did discuss the helplessness she was experiencing in her marriage and I started to plant the seeds with her that perhaps our health center could help her in other ways to gain independence. She knows I will be her physician for the long haul, and that she can come to me with her children, who she hopes she will be able to give a better life to than what she is experiencing, especially her daughters.

 

These experiences reinforce for us that abortion services must be widely available, in the privacy of one’s own doctor’s office – just as was the original intention of Roe v Wade. As clinicians, every time we have to send women out of our practice to a stand alone health center that was created for the sole purpose of offering abortions, it contributes to the stigma associated with abortion. Not caring for them but sending them away implies to our patients that we disapproval of their choice.

Providing abortion care isn’t that complicated, especially medication abortion. Every primary care clinician can provide caring counseling and offer a pill.

State legislation mandating surgical centers and hospital privileges only makes abortion less caring and less available. The most vulnerable women, like our patients, are forced to be pregnant when they don’t want to be. Instead of giving women the space to have families on their own terms, parenthood is being forced on them, often the result of coercive relationships or other extremely difficult life circumstances. We encourage all family physicians who are patient-centered to offer abortion care in the privacy of their own offices, even if it means a fight with the state legislatures. If not us, then who?

 

[1] All patient names and identifying information have been changed.

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