Denver — FOURTH-year medical student Megan Lederer recently helped deliver a premature baby at barely six months gestation. The newborn was tiny, unimaginably fragile, but she survived.
Caught up in the moment, Lederer didn't think about the implication for her chosen career. Later, though, she wondered: Could I have aborted that pregnancy?
She could have, she decided. She would have felt an obligation.
Lederer, 30, can't relate to the images that drew an older generation of physicians into abortion work. She can barely picture it when they talk about life before legal abortion: the blood-spattered apartments, the women racked with infection from stabbing sticks into their wombs.
But she and other young doctors-in-training have found their own motivation to enter a field that they know will put them at risk of isolation, harassment and hatred. For them, doing abortions is an act of defiance — a way of pushing back against mounting restrictions on a right they've taken for granted all their lives.
"It's like when your big brother says you can't do something," Lederer said. "That just makes you want to do it even more."
Abortion is one of the most common surgical procedures in the U.S., terminating about one in four pregnancies, not counting miscarriages. Yet the number of providers has fallen steadily for decades, dropping 37% between 1982 and 2000, the last year a census was taken. (During the same period, the number of abortions fell 17%.)
Antiabortion activists attribute the drop to a growing aversion to killing fetuses. "It's corrosive to the soul," said Douglas Johnson, legislative director for National Right to Life.
Abortion rights advocates counter with a litany of other reasons, starting with aggressive picketing of doctors, at work and, increasingly, at home. Physicians who choose to provide abortions also chafe at a lack of autonomy. In many states, every detail of their practice is regu-
lated: the width of clinic hallways, the number of air vents, even how often their staff must take physicals.
On the federal level, Congress has banned a particular technique for ending mid-term pregnancies, known by critics as "partial-birth abortion." The Supreme Court last month upheld that ban; doctors can be prosecuted for using the method even if they determine it's the safest approach for a given patient.
Listening to news of the Supreme Court's ruling, third-year medical student Lysie Cirona, 24, found herself shouting at her radio in frustration. Then she took a hard look at her career plans. She had always been interested in psychiatry, but now she envisioned herself flying to North Dakota or Nebraska a few times a month to perform abortions.
"It wasn't on my radar screen" a year ago, Cirona said, but her priorities have changed as she's learned more about the history and current state of abortion rights. Cirona has taken to badgering her professors to include information about abortion in their lectures. She attended workshops on how to respond effectively to antiabortion protesters.
Some days, she still wants to be a psychiatrist. Other days, she thinks of the women who drive 10 hours to reach the nearest abortion clinic. "This is what I'm going to do," she tells herself.
Her roommate at the University of Colorado, Michelle Cleeves, is also drawn to abortion work; simply voting for liberal politicians, she said, no longer seems like an adequate response to the abortion wars.
"It doesn't matter what you believe if you don't back it up with action," said Cleeves, 24. "The right to abortion doesn't mean anything if women don't have access."
NEARLY one-third of metropolitan areas and 97% of rural counties have no abortion providers, according to the Guttmacher Institute, a research group affiliated with Planned Parenthood. One in four patients must travel at least 50 miles to end a pregnancy.
Guttmacher researchers are working on updated statistics, but as of 2000, they reported that the United States had about 1,800 abortion providers — many of them near, or past, retirement age. By comparison, the American Medical Assn. reported that the same year, there were about 6,200 plastic surgeons, 9,700 dermatologists and 10,600 gastroenterologists.
Each spring, the advocacy group Medical Students for Choice brings several hundred students — nearly 90% of them women — to a weekend convention to nudge them into considering abortion work. One of the most effective tools: introducing them to veteran providers.
"It was amazing to see all these people who have made this [a career] and it works for them," Lederer said.
That upbeat message was a marked contrast from the lecture Lederer and her friends heard last fall at the University of Colorado's medical school in downtown Denver. Medical Students for Choice had invited Dr. Warren Hern, a legend in the abortion rights movement, to give them encouragement. He offered none.
None of you will be an abortion provider, he told the students. You don't have it in you.
"Do something else. Fix broken legs," he often advises. "No reasonable person would do this."
Hern, 68, practices in Boulder, Colo., a liberal college town. Still, he's afraid to open his blinds at night for fear of a sniper hidden in the bushes. His clinic is protected by a fence and four layers of bulletproof glass.
Abortion is so stigmatized, Hern said, that his fellow physicians shun him. Even his patients often regard him with disgust: "They've absorbed so much antiabortion rhetoric, they feel a sense of revulsion that they have to come into my office and seek treatment."
Hern specializes in late second- and third-trimester abortions; his patients come to him from around the world, many with late diagnosis of fetal deformity. Though he feels certain he's doing right by the women, Hern still feels conflicted when he steps into his basement surgery.
He once wrote that "the sensations of dismemberment flow through the forceps like an electric current" — and after three decades, he is not inured to that feeling. "We are hard-wired as a species to protect small, young, helpless creatures," he said. "The fetus is not a baby, but it's close. Some are very close. It's difficult."
Lederer does not know how she will handle such emotion; the closest she's come to performing an abortion was suctioning the seeds out of a papaya to learn a first-trimester technique. She may, in the end, restrict her practice to early abortions. But that's not an easy solution to accept. She can't see how she could ever justify taking one woman as a patient while turning away another because her pregnancy is a few weeks more advanced.
She also knows that the few doctors who perform late second- and third-trimester abortions are mostly in their 60s or 70s. "Who's going to do this when they leave? Someone has to," Lederer said. "I feel in my heart of hearts that it's the right thing to do."
Lederer grew up talking women's rights around the dinner table. "I still have a signed Gloria Steinem book that my mom bought me when I was 2," she said.
Her first year in college, she sampled a woman's studies course — and instantly felt at home. "It was like, 'These are my people!' " she said.
Lederer majored in women's studies at the University of Colorado-Boulder, but also took pre-med requirements with the goal of following in the footsteps of her father, a pediatrician. In her junior year, she combined her two interests with an internship at a family planning clinic that offered first-trimester abortions.
"It was an incredible, life-changing experience," she said.
She was surprised that the clinic's patients included women of all income, ages and education levels. Lederer helped out a bit, sterilizing instruments, but spent most of her time observing these women as they ended pregnancies that, for one reason or another, they felt they could not handle.
"This was something tangible you could do for people," she said. "You could make a difference in these women's lives."
She completed the internship determined to perform abortions one day: "It was my mission."
As Lederer soon learned, there's no straightforward career path to an abortion clinic. Most medical schools barely mention the subject and it's rarely included in post-graduate clinical programs, known as residencies. Just half the nation's obstetrics-gynecology residencies — and only 20 out of 400 family practice residencies — integrate abortion into physician training, according to Lois Backus, executive director of Medical Students for Choice. Most residents interested in the field must study on their own, often through after-hours electives in abortion clinics.
"They have to be enormously committed to work it in," Backus said.
Lederer plans to apply for residencies that offer abortion training, but beyond that, she's uncertain how to shape her career.
Does she want to perform abortions full time? She might serve more women that way. But she'd miss the rich variety of women's healthcare — especially delivering babies. Once settled, how public does she take her abortion practice? Her instincts are to speak up, but would it be wiser to keep quiet, to protect her family?
EXTREME violence is always a threat. A Texas man was indicted this month on charges of planting a bomb filled with nails outside an abortion clinic in Austin. The National Abortion Federation is so fearful of attack that officials don't announce the dates of the annual conference, much less the location.
But the violence has subsided greatly since the mid-1990s, when seven doctors and clinic workers in the U.S. and Canada were killed and dozens of clinics were targeted with bombings, arsons and acid attacks. Doctors today are more likely to face pickets and pray-ins.
Lederer encountered such a demonstration recently at the national convention of Medical Students for Choice. A truck covered with grisly photos of fetal parts was parked outside. One demonstrator appeared to be taking pictures of the students' name badges as they walked in and out of the hotel.
Far from being intimidated, Lederer found the protest exhilarating. "Everyone sat up even taller," she said. "The general vibe was very empowering."