When there is no good choice

Vargas’s doctor first inserted seaweed sticks known as laminaria into her cervix to prompt it to dilate. The next day, she took misoprostol, a medication that encourages the cervix to dilate even more. Later, the doctor ended her pregnancy.

For any kind of later-term abortion, the details are graphic and difficult even to read about — so fair warning for what follows if you are squeamish. The standard D&E that Vargas underwent involves a physician taking the fetus from inside the uterus in parts. A D&X (aka intact D&E) entails using a pair of forceps to remove the fetus from the uterus intact until all that remains inside is the head, which is then drained to permit passage through the cervix. In essence, the federal ban permits the killing of the fetus inside the womb, but not immediately outside of it.

The nonmedical term partial-birth abortion, coined by the anti-abortion movement, grew out of the idea that the D&X procedure “most resembles infanticide because the baby’s body is outside the uterus already,” says Mailee Smith, a staff counsel for Americans United for Life, a pro-life law and policy group in Chicago. “In order to prevent the blurring of the lines between infanticide and partial-birth abortion, it’s necessary to ban partial-birth abortion,” she adds.

The Vargases, like other families, were intent on minimizing their son’s suffering. But the question of how to do that has also become medically and politically controversial. It’s unclear if or when a fetus is capable of feeling pain: In a 2005 study published in The Journal of the American Medical Association, researchers at the University of California at San Francisco found that, based on existing studies of how babies’ brains develop in utero, pain is unlikely to be experienced before around 29 or 30 weeks. Yet a proposed federal law would require doctors to warn women aborting at 20 weeks or after that their baby may feel pain and to offer anesthesia for the fetus; several states have also passed or proposed bills on the issue. Little or no data exists on whether attempts to provide fetal anesthesia would help the fetus or harm the mother, leading the UCSF researchers to write that it “should not be recommended or routinely offered for abortion because current experimental techniques provide unknown fetal benefit and may increase risks for women.”

The D&X technique is so uncommon that many doctors who perform second-trimester abortions, including Dr. Nichols and Dr. Greene, have never used it. Nevertheless, they worry that in an emergency, it would no longer be available to them. “The law makes no exception for a woman’s health, only if her life is at risk,” says Dr. Nichols, also the medical director of Planned Parenthood of Columbia/Willamette in Oregon. “If during a standard D&E a woman has lost a quart of blood and I consider her to be dying, and I perform a ‘partial-birth abortion’ to save her, I fear there will be an expert witness to testify that I intervened too soon.”

In this new, threatening climate, doctors don’t want to leave any opening for prosecutors. As a result, hospitals around the country have begun to require that all abortions after 20 weeks be preceded by lethal injection — when the fetus is killed in utero via a shot of digoxin or potassium chloride. The doctor typically injects the drug into the umbilical cord, amniotic fluid or fetal heart via a needle through the patient’s belly the day before the scheduled termination. These injections can be painful for the woman and increase her risk for infection and spontaneous delivery away from the clinic or hospital. “Nowhere else in medicine do doctors require a patient to go through an invasive procedure like this purely for legal reasons,” Dr. Nichols says. “As doctors we take an oath to do no harm, yet these injections — while the risk is low — are potentially harmful to the mother. And we make patients get them not to benefit them, but to protect ourselves from going to jail. I’m forced to choose my well-being over that of my patients.”

A controversial doctor
Audrey, a public affairs officer from northern Virginia, was at her 28-week checkup when her obstetrician told her that her belly looked bigger than it should. Then 33, Audrey (who asked SELF not to publish her full name because she and her husband work in government) hadn’t had an amniocentesis, but her other screenings had come back normal. She had been diligent in taking care of herself and her first child, forgoing sushi, diet soda and even sugarless gum. Until that point, she says, “mine was a regular, healthy pregnancy.”

A high-resolution sonogram revealed her son had a vein of Galen malformation, a defect that interferes with drainage from the brain and swells it with fluid — the reason she was carrying so large. She was told her baby would die inside of her or immediately after he was born. “My baby was alive and kicking, and the thought of waiting for him to die in utero was unimaginable,” Audrey says.

Part of the excitement of having a baby is the public announcement a swollen belly makes, inviting perfect strangers to ask detailed personal questions. Audrey couldn’t bear the thought of the parking attendant inquiring about the sex of the child, or the dry cleaner wondering if she had picked out a name. “I had read to this baby inside of me, and I had sung to it,” Audrey says. “Now I was carrying a pregnancy that was a deathwatch.”

She asked her obstetricians when she could terminate. The head of the practice replied, “We call that murder.” Another doctor in the practice was willing to induce, but, Audrey says, warned her “she couldn’t prevent a nurse from running into the OR with life support. The idea of holding a baby as its organs failed — we couldn’t think of anything worse.”

Finally, a specialist Audrey had consulted handed her a piece of paper with three words on it: “Dr. Tiller. Wichita.”

George Tiller, M.D., is the medical director of Women’s Health Care Services in Wichita, Kansas, and one of only a handful of physicians nationwide who perform late-second- and third-trimester terminations. As a result, he has become a last-chance abortion doctor for women who can’t find a provider in their home state. And his clinic, an anonymous, windowless brick building along a major thoroughfare in the southeastern part of Wichita, has become ground zero in the battle over later-term abortions.

In 2006, Republican Phill Kline, then Kansas attorney general, filed misdemeanor charges against the doctor, accusing him of performing 15 illegal postviability abortions; among other charges, Kline alleged that Dr. Tiller did not correctly determine the viability of the pregnancies or if continuing them was a threat to both the physical and mental health of the mother (as is required by state law). Voters ousted Kline in an election driven by abortion politics; his replacement, Democrat Paul Morrison, did not pursue the charges against Dr. Tiller, saying that they were based “on [Kline's] personal political beliefs and not the law as it was written.”

But Dr. Tiller’s troubles are not over. Kansas is one of the few states where citizens can petition to convene a grand jury, and anti-abortion activists in Wichita have done so with hopes of indicting Dr. Tiller on the same issues Morrison set aside last year. Meanwhile, Morrison filed 19 new charges: Kansas law requires that two doctors independently make the determination for abortion, and Dr. Tiller is charged with having financial ties with another doctor who referred him patients.

Morrison has since been replaced himself. But the charges are still pending, says Lee Thompson, Dr. Tiller’s attorney. Thompson argues that the two-doctor requirement is unconstitutional, placing an undue burden on patients; he expects the case to be decided this fall at the earliest. “Thankfully, we’re now dealing with a traditional law enforcement office, which is a pleasant change from the fundamentalist, religiously motivated politics of Mr. Kline,” he says.

Kline, for his part, has gone on to be appointed the district attorney for Johnson County, south of Kansas City and 175 miles from Wichita. And he has continued his crusade, filing 23 felony and 84 misdemeanor charges against Comprehensive Health of Planned Parenthood of Kansas and Mid-Missouri in part for performing what he alleges were unlawful second-trimester abortions. A citizen grand jury in that area — again convened at the request of anti-abortion activists — spent three months investigating Planned Parenthood but cleared it of those charges in March.

To Audrey and her husband, the controversial Dr. Tiller and his staff became a godsend. Within a few days of getting the doctor’s name, they flew to Kansas. “They were amazing to us. We went from being called murderers to being completely cared for,” Audrey says, adding that clinic staffers helped arrange counseling for the couple’s mothers. She also turned to a local rabbi for spiritual counseling.

Audrey’s son died via lethal injection administered by one of Dr. Tiller’s physician colleagues; two days later, labor was induced. Although she didn’t expect to want to, Audrey held his lifeless body after he was born. Despite the swelling in his brain, “he was a perfect, beautiful little boy,” she says. “I was worried he would be grotesque and that he wasn’t made it harder. But I knew he wasn’t OK inside.” She has since had two more sons and regularly brings her boys to visit the grave of her first child. “I live with this decision every day,” she says. “But I have never regretted it.”

An alternative: perinatal hospice
Directly across a parking lot from Dr. Tiller’s clinic is a facility with a different take on what to do about ill-fated pregnancies. Choices Medical Clinic, a privately funded nonprofit, opened in 1999 and is one of as many as 2,500 “crisis pregnancy centers” nationwide that exist to persuade pregnant women to avoid abortion. Choices was one of the first centers to offer perinatal hospice: end-of-life services for fetuses akin to the standard hospice care available to the sick and the elderly.

The facility doesn’t provide primary medical care; deliveries or inductions are done at local hospitals. But women who enlist its hospice services are invited to have free sonograms every day of their doomed pregnancy and, if they find it a comfort, can have free professional pictures taken of them and their dead or dying children after they are born. “Our job is to start from the womb to the tomb,” says Scott Stringfield, M.D., a family physician in Wichita and medical director of Choices. “We try to comfort women and facilitate greater closeness to their child.”

Kim Ortmeier, a 35-year-old stay-at-home mom, first learned about perinatal hospice from her obstetrician. She was 16 weeks pregnant with her second child and living in Wichita in December 2006 when routine testing revealed the fetus had holoprosencephaly, a condition in which the brain doesn’t develop properly. A perinatologist told Ortmeier and her husband, Jeff, that their baby could not survive for long outside the womb; she could be stillborn or miscarried at any time. “Abortion was never a consideration,” says Ortmeier, a devout Catholic. “We told our doctor we’d do whatever we could to give her the best possible life she could have.”

When her obstetrician recommended they contact Choices, Ortmeier hesitated. “Because the services were free I wondered if they were quality,” she says. But she decided to check it out anyway. She started working with the center in her 28th week of pregnancy, when delivery seemed imminent. She had two sonograms taken of the baby, a girl they named Madeline, and made plans for both her birth and her funeral. “They offered me constant support in an environment that was very pro-life,” she says. The staff’s positive approach cheered her: “They would be happy when they saw my baby, not all gloom and doom.”

An alternative for women
Byron C. Calhoun, M.D., medical director for the National Institute of Family and Life Advocates in Fredicksburg, Virginia, helped conceive the idea for perinatal hospice. In hopes that women facing pregnancy with an adverse diagnosis will choose to carry to term, Dr. Calhoun determined to make spending time with those children — before and after birth — a more compassionate experience. Today some 60 U.S. hospitals, hospices and crisis pregnancy clinics offer perinatal hospice services; in Minnesota, women seeking to abort fetuses with fatal anomalies are required by law to be informed about hospice as an alternative. “Women appreciate the grieving process and being able to spend time with their babies,” says Dr. Calhoun, vice chair of obstetrics and gynecology at West Virginia University School of Medicine in Charleston. “Perinatal hospice gives women an alternative that is a better choice than abortion.”

Ortmeier took her pregnancy to 37 weeks before her doctors advised her to have an induction: Madeline's head had grown so large with fluid that doctors worried she couldn’t be delivered full-term. Ortmeier had arranged for her family to travel from Missouri, Nebraska and Wisconsin for the birth, and for her priest to perform a baptism. And she had a photographer on hand to take pictures of Madeline during the 30 minutes she lived and for several hours after she died.

“We kept her until the nurses said they had to take her,” Ortmeier says.

Those pictures now sit in the living room of the Ortmeiers’ new home in Naperville, Illinois, alongside other family photographs. “It was a very hard pregnancy,” Ortmeier says. “But holding my baby was the biggest reward I could ever have had. I would do it again, although I pray I don’t have to.”

Ortmeier is convinced that hospice was the best option for her family. But having only that choice could be devastating to other women, says Paul D. Blumenthal, M.D., professor of obstetrics and gynecology at Stanford School of Medicine in California. “Forcing a woman to carry a fetus with a lethal anomaly can be tremendously psychologically traumatic,” he says.

The kicks and rolls Ortmeier enjoyed during her doomed pregnancy were, for Audrey, an absolute nightmare. Ortmeier welcomed strangers’ interest in her growing belly, whereas Audrey shrank from it.

“Every woman should be offered the opportunity to choose what is best for her,” Dr. Nichols says. “I have cared for many women who have chosen not to terminate and to give birth and be with their baby when it died. But I would hate to have the situation where women had no choice but to do that.”

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