Ask (Another) Abortion Provider: Roe vs. Wade, 39th Anniversary Commemorative Edition

Nearly 40 years ago, abortion was legalized in the United States. To mark the occasion, Lola McClure, a registered nurse, interviewed Dr. Nancy Stanwood, an obstetrician/gynecologist, abortion provider, mother, and board member with the Physicians for Reproductive Choice and Health.

Hello Dr. Stanwood, it’s wonderful to meet you today! I knew I would like you instantly when I saw that you were wearing a zebra print shirt under your lab coat; I thought, “Dr. Nancy Stanwood is cool.” I guess that I’ll start there: why is the only 100% true stereotype in medicine that people who work in reproductive health are the coolest super-smart people who have excellent senses of humor and are always clinically current and up to date on evidence?

[Laughs] That’s a great question. I think there are a couple different pieces to that. I think those of us who feel prompted to help women in this way, and feel capable of doing this work and handling the controversy that comes with it, have a certain baseline balance and sense of humor. I think the second thing you asked — being up to date on evidence — I think all people are hopefully out there to be excellent doctors, no matter what we do, but I know with myself that I was raised with the five-P rule: Prior Preparation Prevents Poor Performance.

Whoa.

That’s why I’m in family planning! To plan. Because I think planning is good and healthy.

Being prepared, doing the right thing, and doing it well are what matter. I think a lot of us [abortion providers] sense that extra need to do it twice as well as everybody else. It’s like those women in the ’70s and ’80s: to be able to do everything the boys can do but twice as fast.

There still persists to this day almost 40 years after Roe this perception that any doctor who would do abortions on a regular basis — not the casual, four patients once a year, but those who make it a part of their integrated practice — that they must be quacks or bad doctors. There’s this stigma of the abortionist that — two generations later — still looms large. We feel like we need to prove all that much more that we’re caring, thoughtful, educated physicians who think carefully about what we do for our patients, how we counsel them, how we understand the incredible delicacy of this issue, and how we recognize the privilege it is to help women in this way. So I think that’s primary; but we’re also cool to begin with. [But] there is this presumption of guilty-until-proved-innocent in anything that we do, which is unfortunate.

That’s part of why the stigma persists for women who have abortions, which is why some women don’t talk about it, which is how people can say “I don’t know anybody who’s had an abortion.” It’s like 20 years ago, nobody thought they had gay friends — well, yes you do, they’re just not out. Because of the stigma — it’s that whole thing all over again, silence equals death. The quieter it is, the less people recognize that it’s normal, that lots of people do this, that it’s an integrated part of medicine.

It’s so hard for anybody to be out no matter what their position is — it’s hard for people to say that they had an abortion and to tell their friends. And it’s hard for providers to come out, because there’s that — let’s call it what it is! — threat of terrorism.

Domestic terrorism, yes.

Even on an interpersonal level, you don’t want to be “impolite” or bring up a “weird” subject. But then you think, what could be more normal? I feel like it’s a radical act to just speak plainly about it.

There’s the question of how your work factors into your life, especially with pro-life friends and coworkers. How has the bigger “us versus them” manifested for you personally? How do you navigate what you do versus the fact that you have to, you know, live your life?

Day by day I think: what is the venue? What are the upsides and downsides to talking about my work? Certainly, you know, I have colleagues and acquaintances who know what I do. But in the work sphere I carry the title, I do the work, and I don’t necessarily have to keep outing myself with people. It’s who I am and what I do at work. It’s more in the social sphere … you’re out meeting with some friends and you just want to have cocktails and eat some good food. So you don’t want to — invest the energy in your advocacy work in your downtime. But there are times when it feels like the right, necessary thing to do, especially if conversation is going in the direction of “pro life, pro choice” and people are saying crazy stuff. Wrong stuff! I feel obliged to speak up — but in my downtime, I don’t necessarily seek that conflict.

Any moments that stick out to you?

One thing that comes to mind was early — I was in residency and had just started moonlighting at Planned Parenthood. I was out with some friends, and the person sitting next to me asks, “oh, what do you do?” “I’m a doctor.” “Oh, what kind of doctor?” “I’m a gyn.” The next question he asked me: “do you do abortions?” I’m like, “yes!” And he was clearly quite bothered by that. We didn’t get into the philosophical discussion of why, but apparently he felt that he needed to know that. It was early on for me, but it showed me: “Oh! If you mention this during cocktails, weird things can happen.”

My partner’s grandmother is the nicest lady, and this past Christmas we were preparing food and she said, “So. You know, the laws, they’re terrible. It’s going to be illegal again soon. It’s so bad. What can we do? How does someone help?” My answer for myself was — I threw myself into [being a nurse] but not everybody is going to be able to do direct service work. So I smiled and kind of … didn’t really have an answer. I had nothing to say to this helpful grandma! So, help: what should we do!?

I think the first thing is to be an informed citizen. Because this is a very polarized and hot-button topic, there’s so much misinformation and propaganda out there that’s not accurate medically. Find sources of information that are reliable and fact-based — I’ll give a shout out to the Guttmacher Institute, they’re a non-partisan public health research group that specifically looks at pregnancy, contraception, reproduction, and abortion to let us know what’s really happening. Let’s not just deal with propaganda, let’s look at a public health view of what’s really happening in people’s lives. So that’s first and foremost, to be informed and try to pass through the miasma cloud of misinformation and outright lies that are out there.

Second, find some local thing to do! You know, “live globally, act locally” is a very good strategy. There are a lot of opportunities to donate money, donate time, talk with like-minded people, build a group of local activists. Doesn’t need to be something grandiose that needs to change the world. There’s a quote from JFK that said “One person can make a difference, and every person should try.”

Sometimes people feel overwhelmed by the issue — “oh, I can’t fix that” — no, you can’t fix it, but you can be a small, incremental part of the solution. Be informed and then take some thoughtful action.

I read recently something to the tune of, “Roe was so important, but rich women could always go to Puerto Rico or England and get a safe abortion.” I absolutely see this happening again, especially since the first reason people seem to have is often a financial: “I can’t afford to have a baby right now” or “If I had a baby I wouldn’t be able to support it.” And that’s reproductive justice, right? Framing this so people can have the children that they want, not just not-have the children they don’t want. I’m curious about what you think about that — how even though abortion is “legal,” the distribution of access is so much along class lines.

Just to be a little historical here, it was that burden of morbidity, mortality, disease, and death that fell on the poor who couldn’t get a safe abortion illegally that led to the activism in the medical community to decriminalize abortion. I think theoretically, 39 years later, part of what’s happened is that not only can rich women get an abortion more easily, but they can get birth control more easily as well. So what I’ve seen is the proportion [of women] who are poor having abortions is increased. That disparity exists in access to reproductive healthcare in general, too. The most effective methods of contraception, like IUDS and implants, are unfortunately more expensive, and those can be out of reach. [This is the truth for] a lot of women in our country, and you reap what you sow … because those women have fewer resources to care for an unexpected potential child, they are then more boxed in. The circumstances of their lives unfortunately predict what they feel like they have to do.

So then I think recognizing the increasing disparity is very important, and recognizing that when those women are not able to get what they need through safe channels, some of them do unsafe things. Fortunately, it’s still relatively rare in the US, but there are reports of self-induced abortion and of women going to clinicians who aren’t well trained, and it’s harkening back to the pre-Roe era. The fundamental issue, again, is that making abortion less available doesn’t stop it from happening, it just means that more women suffer and die. It’s that simple. And that, unfortunately, is not a part of the public consciousness around abortion anymore, because it’s been safe and legal and accessible for the majority of women for the past 39 years. In that way, we can’t necessarily use that argument anymore, because people don’t necessarily remember “Oh yeah, I remember when Aunt Millie died, it was all hush-hush and 10 years later I found out she had an unsafe abortion. That’s why my cousins grew up with my brother and sister.” Not that that’s my story, but things like that — that story happened in that era. I don’t think that discussion hits anybody at the visceral level anymore, but it’s still important to make the point.

I agree! My own grandmother is first on the waiting list for when they make marrying Catholic priests legal — she’s right there. She wants one. One of the most Catholic people I’ve ever met in my whole life. She was the oldest of many, many children, and because of that, she had to give up her full scholarship to college to stay home and take care of her little siblings. She told me that it ruined her life. So she’s very Catholic, but she’s also, “Give them all birth control! I love what you do! They should have abortions!” You see it, you see what happens, and there’s that conversion reaction.

I think that what might replace that visceral reaction in the age of legal abortion is speaking very plainly about your own experiences. And what you said! Or JFK said: you have to try. It’s almost easier to make change happen with the issue of abortion rather than other issues, because there’s still so, so much silence around it as an experience that actually happens to people; that if you just talk about it, you’re doing so much good already.

Along those lines, it’s sometimes sadly easy to help my patients become grateful.

Women come in expecting to be judged, treated impolitely, and degraded, and if you show them even the slightest bit of normal human courtesy — not even going to the point of affirming your trust in them, and your belief that they’re doing the best they can — it’s so easy to make them grateful. Because sadly, they expect to be disrespected. They expect to be treated shamefully.

Or they’re being punished. Or like they should act like they’re going to a funeral.

Part of the way I envision it when we talk about “when does it feel safe, or good, or worthwhile to speak out and step out of the silence, or the closet” — the times when I do that, one of the things I envision is that all of my patients are standing behind me. I have this big group of patients standing behind me and they want me to share what I know, because they can’t. And it’s that much more important, for their sake, that I let people know the truth, that aside from what we talked about, we doctors who do abortions are not just “abortionists,” that we’re thoughtful, caring, compassionate people who have chosen this work because we want to, not because we want to do anything or else or that we’re in it for the quick buck. That we have made a conscious, moral, ethical decision that this is important. I think the flipside there—

Pause for high five. [high five]

I think the flipside there is there’s this narrative of women who have abortions that goes along with the welfare-queen narrative of the ’80s. The idea that these are fallen women, women who allowed their sexuality to run rampant. This incredibly negative, demeaning perception that also has a lot of sexism, racism, classism in it — it’s all the isms tied in together. For me to share the stories of my patients and portray them accurately, to let people know that’s not who we’re talking about here — we’re talking about your mother, sister, daughter. People you know who are thoughtful, careful, compassionate, and doing the best that they can with what they have. It’s that idea of: how can we get our society to trust women, and to realize that this is something that women know best, and that needs to remain private, in the sphere of the doctor-patient relationship?

Was abortion what took you to Ob/Gyn, or was it something you found in residency along the way?

I would say that my feminist awakening came when I was a resident. I had been a passive feminist, passively pro-choice … raised in a relatively liberal family, where I was taught that girls were as good as boys, that girls can do anything they want, and that having access to abortions is important. I went into Ob/Gyn to go into Ob/Gyn and kind of figured … of course I’ll do abortions! Don’t all of us? And … there was some naivete to it.

And I really had my feminist awakening just with my patients — that’s part of why they call it practicing medicine, because your patients teach you. I was awed and at times terrified by what women had to go through in childbirth and the dangers that could occur. Like many laypeople, gradually, as your medical training occurred, you realized, “Oh! Not all pregnancies go well. Not all pregnancies are safe, and even things that look safe can suddenly become emergency situations.” I think I was just incredibly impressed by the fortitude of women in the obstetrical world, and then it started extending to [abortion].

I remember when I was in residency, I had a patient come to me for her first prenatal visit. Nobody had discussed options counseling with her before. So I naively went in there and took this full prenatal history and then she said, “You know, I actually kind of want to have an abortion.” I went, “Oh! Okay! Let me figure this out for you.” That’s not where my brain was going, you know? I hadn’t had any experience with options counseling before, so I’m sure I didn’t give her my best, but I gradually began to realize that wow, not every Ob/Gyn does this. And this is really important. She shouldn’t have to go through that emergency c-section. If a woman doesn’t feel ready to have the child of her abuser, she shouldn’t have to. If a woman doesn’t feel prepared for the rigors and responsibilities and joys of motherhood, she shouldn’t have to do that if she’s not ready. I think it was that commitment to how important motherhood is, and that it should be voluntary as opposed to drafted. I think that military analogy is kind of apt.

I think it’s perfect!

It’s similar to some of the language from the early 20th century. Margaret Sanger, one of her campaigns was “voluntary motherhood” — that’s why she’s talking about birth control and decriminalizing education about birth control. It’s the same thing: I think motherhood should be voluntary. It’s the toughest job you’ll ever love, and that’s what I came to see in the trenches as a resident — that it’s so important to do motherhood well, and to feel ready to do it. And women know when they’re ready. And I trust them to know that. And I recognize that a woman is the only one who CAN know that for her own life. Other people can tell her what to do, and have all kinds of assumptions and preconceptions about what her life is “really like,” but I think that’s immoral. And I use that term provocatively because I think, unfortunately, the idea of providing abortion or women having abortions has all been laden with this idea that it’s the “immoral” thing to do. I think it’s immoral to tell a woman to stay pregnant when she’s not ready.

How about that having an abortion is not “taking responsibility for the pregnancy?”

Right! And that the actual responsible choice is to wait until you’re ready. I see my patients as being very thoughtful, deliberative, and responsible in what they do in their lives. I want to support them in that.

I heard [pediatrician and family-planning specialist] Rachael Phelps give a talk once, and she said something that really stuck with me: she said that no matter where you are in this issue, pro life or pro choice, whatever, everyone wants all children to be born wanted. We all want a baby to be born to a person who wants to become a parent and have that child. We all have different options that we consider and that other people consider, but that’s what it comes down to. And she’s a pediatrician, not an Ob/Gyn, who felt called to become a provider because she saw how unplanned parenthood was damaging to the families in her practice.

Again, I think it’s the idea that abortion is about motherhood — people think that they’re polar opposite things, but they’re not. More than half of women who have abortions are already mothers. They know what it takes to become a mother. Which is why they sometimes say, no, not now.

For myself — I’m a Unitarian Universalist, and one of the ministers became a friend of mine. We ran the Reproductive Rights and Social Justice task force at the church. She came to see me about three weeks after my daughter was born and I was on maternity leave. She came as a friend and a minister, reflecting on the amazingness and hardness of it, and she asked me, “How does it feel for you, doing what you do providing abortions for women and your dedication to that idea of helping women, how does it feel to be a mom now?” “Oh my god, all the more dedication to it, because nobody should have to do what I did unless they’re ready.” Parts of it are really, really hard and scary, and this is from an obstetrician who has been delivering babies for 16 years! To say, “that was really hard and should only be chosen” and you wonder why some people have PTSD after delivering. Certainly for me the transition to becoming a mother was that much more affirming of my work and my advocacy for my patients.

Did you see how in 2011 they enacted 135 provisions that restricted abortion — that graph that goes like that. [draws air squiggly line with finger, then points straight up]

I’ve seen the same graph.

One of the things that seem to be moving is policing practice — the “demand” side instead of the supply side, laws like waiting periods. I’m thinking about the Texas ultrasound law, or something like reading scripts to patients with medically inaccurate lies in them. I’d like to talk about that — it’s very fascinating to me because I can’t imagine working in a clinic in Texas right now.

Restrictions that are placed on medical practice within abortion care — and only in abortion care, singled out and stigmatized within medicine — are because there’s this presumption that we’re not doing it well, that’s part of it, and there’s the harassment factor to scare physicians away or make it harder to do their job.

Specifically to the requirement that a woman would need to see ultrasound images before having an abortion — I think I can sort of understand what the anti-choice side thinks they’re doing. They think that women don’t understand, and that it’s going to change their minds. But in my experience, that’s just not the case. Women know why they feel the need to have an abortion, and seeing an ultrasound image doesn’t change the facts of their lives. They don’t feel ready for a baby, and having an ultrasound doesn’t suddenly make them ready. Again, it comes back to that respect for the responsibility of motherhood and the wish to do it well. It’s misguided to say that being shown an ultrasound will change your whole life. No! It won’t! In many cases this is a very difficult choice, let alone for people who wanted the pregnancy but now have to terminate.

And I think that it’s important to see that even if abortion were no longer safe and legal, women would still do it. Which is why thinking about the anniversary of Roe v. Wade … my entire medical career has been after Roe. I have to think back to the things that my mentors taught me in residency — the old graybeards who were almost all men, but who became ardent feminists when they saw what was happening to women, and who advocated for the decriminalization of abortion. In medicine, if something is an intern’s task, it means it’s kind of — repetitive, not particularly important, kind of menial. And what interns end up doing is sometimes telling of how things are considered to be important in medicine. I had an old graybeard attending in residency who told a story from his residency, pre-Roe, in an inner-city hospital in Detroit. The intern every morning had to mix up the IV pressors for the women who would come in septic after an abortion, and they would use these pressors to avoid dying. The ward where they put them — gallows humor, you have to deal somehow — they called the septic tank. And that’s what he saw as a trainee. He saw women incredibly sick and incredibly maimed, dying, and dead. All because of their determination and recognition of “I am not ready to be a mother. I cannot do this.” Women will take really  frightening risks when they don’t have access to safe care.

Let’s say, thought experiment. Let’s say Roe v. Wade got overturned. There’d be 1.5 million women who had been seeking abortions who can’t have a safe one. Someone will have an unsafe one and will die or be damaged for life; some women will have the child and not be capable of taking care of it. And we know that women who have unplanned pregnancies who go on to deliver have a higher risk of complications in pregnancy, high rate of pre-term birth, a higher rate of the children having behavioral difficulty, poor achievement, cycles of poverty, domestic violence. And the whole idea that somehow adoption can solve it all is just not how the American public thinks. Only 1% of women with an unplanned pregnancy go forward with adoption in the US — very, very small. And I hear it from my patients for all different reasons: they never could do it, the interesting thing they say is that they don’t trust anybody else to raise their child. Will the child be loved? Will the child be well cared for? Again, it gets to the idea that they understand how important motherhood is — I don’t necessarily see out there the American public ready to adopt 1 million babies. So just from a practical point of view, if you do a thought experiment of making it illegal or ridiculously more restricted than it is now, more women will die, more families will suffer, and that’s not good. That is not a moral good.

It’s scaring people.

It’s to scare people, to tell them lies, it’s a version of domestic, psychological terrorism. It’s not in any way, shape, or form medically necessary to mandate these things. It’s apparently politically necessary and politically expedient. But it doesn’t help the issue. I think the other piece that I’ve been neglecting on the Roe anniversary is the whole “Where are we with birth control? Where are we with comprehensive sex education?” issue. Not so great. Half of all pregnancies are “oops” — it’s been that way for a really, really, embarrassingly long time. It’s all too much “blame the victim” — “oh, she didn’t take her pills” — but maybe it’s just that pills aren’t the right thing. Why blame women for the fact that methods most of them are presented with don’t fit into their lives? So, it’s that incredibly sad situation of creating the victims and then blaming them for their situation. We don’t put our money where our mouth is when we talk about women and children first. We’re looking at restricting funding to WIC, restricting funding to early childhood programs, and, I mean, this is not helpful. We need to support families, we need to help people rise up out of poverty, and then they won’t feel like they have to have an abortion because they can’t afford another baby. And the whole sex-education issue — we just had a whole generation come of age in the era of abstinence-only education. And people who don’t feel empowered to have responsible sex lives are still going to have sex lives, they just won’t be as safe, because they haven’t been equipped with the knowledge and access to contraception.

Have you had any patients recently that stick out in your mind?

I had a patient recently — and I think this gets to the issue of second-trimester abortion, which is of course is much more of a hot-button topic and has been used for the anti-choice side both out of proportion statistically for what it is and out of misunderstanding its complex nature. There’s what I call the triad of delay. It’s a natural question: “why did she wait? Why wasn’t she there at six weeks rather than 18?” Maybe she had irregular periods, she didn’t have Mother Nature’s early warning system. All kinds of reasons. Maybe she was raped — there’s another level of denial that goes with that. There’s also the decision-making process. Women assess all their responsibilities and resources, and ask — do I have enough to be a good mom and have a baby? For some people they do that really fast, and for other people it takes longer. Conversations about stress in a relationship, changes in employment status. Those decisions take longer. And then there’s the access to care — that gets into that issue of disparities. Poor women have to make the arrangements: time off work, time off school, childcare, travel. If you have a waiting period, you have to travel twice and it’s that much more expense. Those factors can all delay a woman.

And we know that statistically women who show up in the second trimester are younger, poorer, and have lower education, typically, then women in the first trimester. They are a more vulnerable population who need that much more care, counseling, consideration, and compassion, so that it’s really unfortunate that that whole aspect of it is being demonized when actually those are the people who need our help and thoughtful compassion the most.

The patients who suffer most from the bureaucracy that’s been imposed on them.

Yes, I was thinking about a recent patient — since you’re asking about the stories that stand out in my mind — I had a patient who had an unplanned pregnancy, and she thought she and her partner could make it work. She was getting prenatal care, but at 20 weeks she found out that he was married, had children with his wife, and also had children with another woman. She had to totally re-evaluate her life plans. She had two children from a previous relationship who were a bit older, and she had been in a partnership to raise them, and now she was looking at, “Do I have this baby while I’m with this big fat liar? Do I have this baby alone?” So that she found out late that she need to reconsider her ability to have another child. And she needed a long time to think about it correctly … and she had complete support from her family. I am, again, day by day, impressed by the genuine concern and thoughtful deliberation of patients referring to this issue, and I was so impressed by her careful thought process and that of her family and support people. So she did; she did decide to have an abortion. It was later.

I can’t even imagine that kind of being blindsided. I’ll finish with my funny protester story?

Okay.

It was a procedure day at this clinic, so there were a ton of protesters outside. Suddenly, a woman — this stately matron in a power suit — comes up to the group of protesters and yells, “EVERYBODY GET OUT OF MY WAY!! I HAVE A YEAST INFECTION!!” and busts through them, pushing everyone aside, to get to the clinic entrance. Took any of the power out of the protesters. It was magnificent.

Thank you for that story.

Previously: Ask an Abortion Provider.

Lola Pellegrino is a registered nurse. Here is her tumblr.

Photo via Jess Silk.

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