Denial a Powerful Factor in 2nd-Trimester Abortion

For a woman having an abortion in the fourth, fifth or sixth month of pregnancy, there is no getting around that she is on her way to having a baby.

Her breasts are swollen, her belly smooth and taut, her complexion bright.

How could she wait so long?

Each woman has her own tangle of reasons, but in interviews with women and experts, certain themes recur.

For Elena, a 22-year-old single mother, it was important to find out what the father thought. But by the time she faced her pregnancy and told him, her fetus was almost large enough to be delivered as a premature baby.

Crystal knew immediately that she wanted an abortion but could not raise the money.

Wendy had no idea she was pregnant because she was nursing her younger son and thought she could not conceive. Her pregnancy had begun to show before she realized what had happened.

Marina also was unaware of her pregnancy because she had what she thought were menstrual periods (which actually were near miscarriages) until her fifth month. Then, fearful that her devout Catholic family would throw her out of the house, she went to a loan shark and was forced to pay back almost twice as much as she borrowed for the abortion.

These women, whose names have been changed, are typical of the estimated 130,000 American women every year who have abortions in the second trimester of pregnancy for reasons other than fetal abnormality, rape or incest. It is those abortions that will be under review in a case the Supreme Court will hear today, and it is the experiences of those women that suggest the case’s potential impact.

There are affluent and educated women, as well as teenagers, who wait until later in pregnancy to have abortions, but the majority of such women come from a stratum of society where life is lived close to the edge. They are rarely heard from in domestic-policy debates but, when asked, they tell of chaotic lives, absent or violent male partners, empty pocketbooks and the dangerous power of denial.

Although most women expecting a child know at least a measure of joy, these women feel trapped, alone and unable to mother the children they are carrying. “Women coming in for second-trimester abortions are truly the disadvantaged--financially, emotionally--by any measure,” said Glenna Halvorson-Boyd, a developmental psychologist who counsels women at abortion clinics in Texas and New Mexico and trains counselors and physicians. “They are in no position or condition to be adequate mothers and they know it.”

But the case before the high court could make these women’s abortions--indeed, potentially the majority of those performed in the second trimester--illegal as they are performed today.

Many States Ban ‘Partial Birth’

In recent years, more than half the states have banned a procedure in which a significant part of the fetus is pulled into the birth canal before the doctor ends its life. Abortion opponents call this a “partial-birth” abortion.

Dr. LeRoy Carhart, who runs an abortion clinic outside Omaha, has challenged Nebraska’s “partial-birth” ban as unconstitutional. The Supreme Court agreed to hear the case after the U.S. 8th Circuit Court of Appeals overturned the law last year.

The medical and legal aspects of the case have put in sharp relief the deep discomfort felt by a majority of Americans--even many who support a woman’s right to abortion--over abortions performed after the first trimester. Public support for abortion rights drops sharply as pregnancy moves further along and the fetus more closely resembles a baby.

The most recent national poll on attitudes about abortion, conducted in 1998 by the New York Times and CBS, found that, although 61% of Americans support abortion in the first trimester of pregnancy, just 15% support it in the second trimester and a bare 7% in the third trimester.

Abortions after the first trimester represent 11% of the 1.4 million abortions performed annually, and most are performed closer to the beginning of the second trimester than the end. There are no exact figures on how many abortions throughout pregnancy are performed because of fetal abnormalities, but the number is low, probably in the 3% range, according to interviews with clinic personnel and obstetricians.

Clearly, the moral quandary over abortion deepens the closer the fetus is to viability. With intensive medical intervention, some babies delivered as early as 23 weeks into pregnancy can survive, though many suffer irreparable physical and mental disabilities. At this stage of pregnancy, doctors have the terrible power to save or to kill.

All Choices Appear Bleak

For the Wendys, Crystals and Elenas, all the choices are bleak. They come to Carhart, one of the few physicians in a four-state area who is willing to perform abortions up to the 24th week of pregnancy.

His modest clinic is not easy to find. Located on the outskirts of Omaha, it occupies the second floor of a building whose nearest neighbors include an empty lot, a gas station and a car-repair shop. With the blinds drawn and some windows boarded up against anti-abortion vandalism, the place has a dismal look.

But inside, the clinic is bright and the surgical rooms are sparkling clean. In the waiting room, a television set blares. Most of the women wear jeans and sweatshirts that hide their bellies. There are a few boyfriends or husbands but most women have come alone.

The waiting room faces a nurses’ station where a price list is taped to the plexiglass window. An abortion at 12 weeks or less costs $320; at 14 to 15 weeks, $500; at 18 to 19 weeks, $895; at 22 weeks, $1,850. The most expensive is 24 weeks, with a $2,200 price tag.

Those aren’t the only costs: An abortion performed when a pregnancy is at 20 weeks or later takes three days, so a woman from out of town must also pay for gasoline, meals and two nights in a motel.

For many women, collecting the money for an abortion delays the procedure. The problem is compounded if they also failed to realize how far along they were in the pregnancy.

“They are just out of touch with their bodies in every way,” said Halvorson-Boyd. “They don’t track their menstrual periods, they don’t notice when they miss one, they come in and they are huge and you can’t imagine how they could not have noticed. But they just let it go.”

In a large study, the Alan Guttmacher Institute, a leading researcher on reproductive health issues, found that among women with fetuses of 16 weeks or more gestation, 71% said they did not realize how far along they were and 50% were delayed in arranging the abortion, usually because they had trouble raising the money.

By the time many women finally get enough money together to pay for an abortion at a local clinic, “it is too late in the pregnancy for that provider to do the abortion,” said Jacqueline Darroch, a sociologist who is Guttmacher’s senior vice president for research. The woman must then find a new provider and raise more money.

For Crystal, who has traveled four hours from Sioux Falls, S.D., to reach Carhart’s clinic, strapped finances, denial and a life in disarray have led her to seek an abortion.

With creamy skin and frizzy dark blond hair, she looks younger than her 21 years. This is her third unplanned pregnancy.

She first got pregnant in the ninth grade--and was left by her family to deal with it largely alone. Her mother said nothing but left an early pregnancy test by her bed. When the results were positive, there was no discussion of options. Crystal simply heard her mother calling abortion clinics.

But she miscarried.

Crystal failed to detect her second pregnancy until she was six months along. Then she could not find a doctor to perform an abortion. So, 18 months ago, she gave birth to a baby boy, whom she gave up for adoption.

Personal Finances a Problem

Her denial is hard to miss. In her last pregnancy, she convinced herself she was not pregnant because she was not gaining weight--even though, she admits, “I could tell something was wrong because, when I went out, I would puke easy.”

This time, she noticed the pregnancy earlier--in her third month.

Reluctant to give up a second child for adoption, she was faced with a financial dilemma: “I would have done it [had the abortion] as soon as I’d found out but I didn’t have the money up front. I’d just bought a Grand Cherokee [sport utility vehicle] and the payments were starting.”

Her life is lived paycheck to paycheck. Since graduating from high school, she has worked the night shift as a nurse’s aide in a home for the disabled elderly. She earns barely $350 a week after taxes by feeding and washing those who cannot take care of themselves.

But Crystal hopes to make something better for herself. Her plan is to become a surgical technician and she has enrolled in a training program that starts next fall.

“I’ve always wanted to be a nurse,” she says wistfully, adding, “[But] I knew I couldn’t stay in school that long.” She thinks having a child would dash her hopes of making it through the surgical technician program.

She finally pulled together the money for the abortion by borrowing from her roommates and her sister, as well as by saving some of her pay.

By then, she was 16 weeks along.

When she thinks about how she got pregnant--it was sometime around her 21st birthday, when she was drinking in bars legally for the first time--it bothers her that she cannot be sure which of two men is the father. “That’s a bad thing when you don’t know,” she says sheepishly. “If I did know . . . then I could ask one of them for money,” she explains.

But she did suspect one man more than the other. She told him, hoping, it seems, that he would tell her that he cared about her and maybe even wanted her to have his baby, which would be a profound kind of acceptance.

But she was disappointed. “I don’t think he cares because he didn’t try to stop me.”

The further along a pregnancy is, the more logical it seems to many that a woman would think about carrying the child to term and giving it up for adoption. But that option seems unacceptable for many women. For Wendy, whose husband is in prison for drug dealing and who works as a secretary and raises their two small children alone, adoption at first seemed attractive. But the more she thought about it, the more frightening it became. She was afraid that if she delivered a baby in her small town, her husband might find out and be angry. He would know that her pregnancy was the result of an affair with another man. So, the blond, blue-eyed 22-year-old, who lives in the same rural town of 1,000 where she grew up, turned to friends to help her raise the $2,000 she needed for the abortion. Instead, she encountered a wave of pressure to continue the pregnancy.

“I had friends preaching to me: ‘You’re killing your baby.’ And I had one girlfriend offer me $5,000 for it. She said: ‘I’ll feed you. I’ll take you into my house.’ ”

The money was tempting but she realized that the situation would be unbearable.

“I said: ‘You think it’s that easy to just walk away and watch you walk around town with my kid?’ ”

Then she gets angry. “I don’t want anybody to preach to me. . . . Let them walk in my shoes.”

Her pregnancy, like Crystal’s, is the result of casual sex. It happened the first time she had gone out since her husband went to prison nearly a year ago. She ran into a high school acquaintance who asked her out for a drink. In a matter of hours, they were in bed.

In her recounting of this episode, which Wendy calls her only “bout with adultery,” there is a longing for physical affection and relief from the grind of work and child care.

“After being so lonely and devastated . . . and taking care of two babies on my own, something like this comes along. . . . It’s the first time I’d gone out after having a baby and I’d gotten my figure back and this guy noticed me and I felt special and attractive.”

Since realizing she was pregnant nearly a month ago--she is almost 22 weeks along--Wendy feels she has fallen apart as a mother.

“My children are alive. They are all I have left. I haven’t been able to focus on them and say: ‘Let’s go for ice cream.’ There wasn’t a day that I didn’t think about abortion and suicide just because I felt so low, so embarrassed,” she says.

To afford the abortion, she has borrowed money, had her phone disconnected for nonpayment and let her other bills pile up.

“I just want to get a normal life, go back to where I had the will to survive,” she says.

The Time Comes for Crystal’s Abortion

When it is time for Crystal’s abortion, Carhart gently removes the suppositories used to dilate her cervix and then begins to insert thick metal dilation rods to open the cervix further. She is getting an intravenous dose of Pitocin, a drug often used to help the labor contractions of women at full-term pregnancy. In later abortions, the drug is used to help expel the fetus.

The doctor reaches in and punctures the amniotic sac, causing a cup or so of almost clear fluid to rush out. He hopes to extract the fetus intact so that its bones, which are just beginning to harden, do not scrape Crystal’s uterus and cause dangerous bleeding. Using a forceps, and guided by ultrasound, he reaches into her uterus.

What comes out next is a tiny foot, then a leg about 1 1/2 inches long. Carhart is unable to remove the fetus in one piece.

By the time he is done, there are six major pieces floating in the surgical pan. Carhart is not sure when the fetus died. It could have been before he began the extraction--when he cut the umbilical cord, ending the delivery of oxygen to the fetus--or it could have been just moments later, when he was pulling the fetus through the vagina.

The latter scenario would have made the procedure illegal under the Nebraska law were it in effect--enforcement has been blocked by the federal appellate court at least until the Supreme Court rules. The law specifically bans “delivering into the vagina a living unborn child or a substantial portion thereof, for the purpose of . . . kill[ing] it.”

Although the state maintains that the law applies only if the fetus is extracted intact, the federal appellate court ruled that the ban is so broad that most second-trimester abortions risk violating it, since in many such abortions the fetus dies when a “substantial portion” is pulled through the vagina.

Staring at the tiny fetus in the dish, it is hard to say that any one part is less than a “substantial portion”--the arms, a leg attached to the lower torso, the head. Either intact or dismembered, the end result is a fetus that looks a little like a salamander in its size and almost translucent fragility. In form, however, it is unmistakably human.

As soon as the doctor tells Crystal that the procedure is over, she swings her legs down from the operating table.

“I’m fine. Can I see what it looks like?” she asks.

Crystal clutches the surgical gown around her and looks at the fetal remains. She stares at it for several seconds.

Is she feeling sadness, regret--or is she trying to find a way to close off the experience and distance herself? It turns out to be the latter.

Turning to the nurse, she says: “It stinks,” and all but runs out of the room.

Most women can barely face such moments.

Elena wavered every day for four months until she made her decision. A single mother, she knew both the happiness and the stress of rearing a child and hoped that the father would tell her he wanted it. But he left her to struggle alone and, at the end, told her the choice was to rear the child by herself or have the abortion and pay for it--by herself.

She sold her car and used her income tax refund to pay for the abortion.

Still, it bothers her that she is ending her pregnancy so late--at 22 weeks. She has felt the fetus moving inside her for nearly a month and has decided it would be a boy.

“He was already big enough that it makes some difference to me that life’s going on inside,” she says, gesturing to her womb.

During the procedure, Elena’s slender face is gray beneath her olive skin. She cries and sometimes clings to one of the nurses.

Later, she is asked how she felt about the procedure. She shakes her head and looks away.

“The nurses, the doctors, they were telling me how they were going to do it. I didn’t want to hear anything,” she says.

What will she do next? “Before I came today I told my boyfriend we are going to break up and I am going to quit my job and go back to school. I want to be able to take care of my big boy,” she says, referring to her 22-month-old son.

But that is a lot to think about.

“Right now I don’t want to be awake,” she says, as she closes her eyes and pulls a blanket up to her chin.

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When Women Have Abortions

Abortion is constitutionally protected in the United States throughout pregnancy to preserve the life and health of the mother. But the vast majority of abortions occur near the beginning of pregnancy.

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54%: of abortions occur in the first eight weeks of pregnancy.

34-35%: occur in weeks nine through 12.

6%: occur in weeks 13, 14, 15.

4%: occur in weeks 16-20.

1%: occur at week 21 or later.

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There are roughly 1.37 million abortions annually, according to the Alan Guttmacher Institute, a New York-based nonprofit reproductive health research organization. Roughly 137,000 abortions are performed at later than 12 weeks of pregnancy. About 13,700 abortions occur at week 21 or later.

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Number of Reported Abortions, 1973 to 1996

The number of abortions nationwide rose precipitously after 1973, when the Supreme Court declared that abortion was constitutionally protected. The numbers peaked and remained at the roughly 1.6 million mark from 1985 to 1990 but then began gradually to decline, leveling off in 1995 and increasing very slightly in 1996, the last year for which numbers are available.

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1996: 1,365,700 abortions performed

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Source: Alan Guttmacher Institute