Tuesday, May 3, 2011

The Repeat Abortion Patient


In talking about abortion with my friends, colleagues, and others, I frequently get asked, "Is it true women have like ten abortions?" First of all, no. However, about half of abortion patients report having a previous abortion.

The patients who have had more than three abortions are few and far between. But, the fact of the matter is there are women who will present in a clinic five, six, seven times for a procedure.

This makes a lot of people, myself included, uncomfortable on some level.

In this situation, we have a couple of options. We can get weirded out and/or judge the woman, or we can delve a little bit deeper into her history. Figure out the why. Because there is so much built into why that woman is getting pregnant over and over again -- lack of education, lack of access to health care, lack of resources, lack of transportation to get to the doctor, lack of time to get to the doctor's office when it's open, lack of funds to pay for the birth control, lack of a partner who is respectful of her request to use a condom, etc. I could go on forever. There are so many reasons why a woman may get pregnant several times.

What this really shows, to me at least, is how broken the reproductive health care system is in this country. The United States has an extremely high unintended pregnancy rate. Not coincidentally, the abortion rate is pretty high here. Western Europe has a very high contraceptive use rate and the lowest abortion rate in the world. It really frustrates me that anti-choicers get all worked up about women who have abortions, but don't want or care if that woman has access to birth control. Those two go hand in hand!

And no woman wants to have six abortions.

Do repeat abortion patients make you feel uncomfortable at all? Why? Are there other thoughts you have the topic? Are there patient situations you feel uncomfortable? Please comment!

13 comments:

  1. Thanks for taking this on. It's difficult to air these uniquely-abortioneer-type problems in public! Kudos to you, Mr. Banana Grabber.

    My question is do we have the same discomfort with a woman who gets pregnant and carries to term repeatedly, year after year? I guess it depends on who you ask, but I'm still struck by how abortion stigma plays into this.

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  2. Anecdotally speaking, my experience from the clinic I worked at was that repeat abortion clients rarely made me uncomfortable. If anything, most of them seemed the most clear about their decision and confident in making this choice. It also spoke highly of the trust they had with our clinic if they came to us every time, rather than going to a new clinic for each one in order to avoid being judged (our town had at least half a dozen clinics).

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  3. While some people are unhappy because they think this is a moral problem, many of the professionals I meet are just sad because they feel they've failed. How come I didn't get her to spend enough time thinking about contraception? Maybe I didn't give her clear information. Maybe I rushed that consultation. Maybe I missed the warning signs that something was wrong in her relationship. It's good for professionals to constantly evaluate their own practice, but not to project their anxiety onto women. In our experience most women who have multiple abortions within a short space of time have complex problems in their lives that are way beyond the scope and remit of sexual health practitioners. Equally we should remember that most women are trying to be sexually active without having a baby for about 25 of their 30 fertile years so a couple of unwanted pregnancies over that time period is hardly a moral crisis.

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  4. To be clear, some of us DO feel OK with the idea of having multiple abortions. Speaking for only myself: We spend approximately THIRTY YEARS at risk for pregnancy, so I feel like whether you're careless or careful, with great birth control access or none, the math says that over one's lifetime, one or more unplanned pregnancies is really not surprising at all. (Sometimes I think it's miraculous that it isn't even more common than it is.)

    MBG, thank you for bringing this up. We're all individuals and have different feelings about particular issues, and it's so helpful (and interesting!) to hear others' perspectives.

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  5. Oh, just saw VV's comment too -- and totally agree about appreciating the trust women put in our care when I am seeing them for a second time!

    One kind-of dilemma: One of our docs always says to second-time patients, right before the procedure, "So I see we've had you here before; we're happy you're comfortable seeing us here again, and of course happy to provide your care, but I just want to make sure you had a chance to talk with the counselor about your birth control options, including long-acting reversible contraceptives like the IUD or the implant...". And, well, I always feel a little iffy about that! Like, yes our counselors always ask about birth control desires; and also is right-before-the-procedure a great time to bring it up again? Plus, there ARE valid reasons NOT to choose an IUD or implant, and for a few people (as we've written before) taking a chance that they'll need an abortion really is the safest way to manage THEIR fertility, because of whatever combo of medical conditions (ex. hormone sensitivities) or life situation (ex. controlling partner) they may have...

    But I've never said anything to the doc, because (as Lisa said!) I think providers have their own feelings about the "right" thing to do and their responsibility to do "well enough" in helping patients a similar situation in future...So, um, what should I do? Nothing?

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  6. "is right-before-the-procedure a great time to bring it up again?"
    Certainly at that point the doctor could be absolutely sure the patient is not distracted by anything else and likely paying close attention. Has any patient ever commented to you that they felt it was poor timing, or been visibly upset or insulted? It's really about whether it distresses the patients. Have any patients asked for your help, or could you be projecting your own discomfort? If patients have said something to you outside of the doctor's presence, it would be reasonable and professional to pass that information along, but most doctors aren't receptive to having their professional skills critiqued by the staff.

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  7. I dunno, the more I talk to people about it I come to find that some women simply don't want to use hormonal/unnatural contraception. Period. And these are not always poor, disadvantage, unaware women. Just as responsible and knowledgeable women make the choice to have abortions, those same women sometimes choose not to use anything. And that's still OK!

    I tried to explain this once to a friend who just couldn't believe it, and understandably so. But I think it's unsafe to typecast the "repeat offenders". Of course, most women are not outright refusing to use contraception, but I think it's an overlooked issue.

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  8. Also Steph, you make an EXCELLENT point! If you have more kids in rapid succession than you can reasonable care for, you're still getting to heaven faster than a repeat ab patient. Ack!

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  9. Speaking from personal experience, I've had 2 abortions. One when my then-boyfriend refused to take "No" for an answer and coerced me/raped me (and I took his unemployment check to pay for the abortion), and the second when my IUD failed to keep me from getting pregnant. I have son from when my birth control pill didn't work, so there are good reasons for women having multiple abortions, other than they just don't want to use birth control. As for judging those women for having multiple abortions - their lives, their bodies, their money, none of our business what they do with any of them. As long as they have the information they need about birth control, it's up to them how/if/when they use it. That being said, all women should have access to effective, affordable birth control if they want it and no one should have the right to take that access from them.

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  10. ah yes, the judge-y conundrum. God forgive me, but I think of it this way: Aren't the patients I'm most uncomfortable around the ones I want to have abortions the most? :/

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  11. PS. At the risk of sounding flippant, I don't really care how many abortions a woman has (as long as she feels all her questions have been answered). The day this concern makes my list will be a fine day indeed because the rest of the world will have to be damn near perfect.

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  12. Wow!

    1) Thanks for all the great feedback.

    2) @Steph -- I definitely have similar feelings for a patient who gets pregnant and carries to term over and over and over. If she wants to have the kids, more power to her, but if the pregnancies were unintended, I do think what Lisa said has some role in the feelings.

    That said, I am perfectly okay with any woman who chooses to have several abortions or several births -- it's her choice, after all. (ALA Vesta44)

    3) I also agree with the points that Placenta Sammie and Lisa bring up -- because women spend such a large portion of their lives being fertile that statistically, pregnancy isn't a shocking crisis or anything.

    I do agree with all of your points!

    Thank you so much for all the feedback.

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  13. I am way more likely to feel a sense of womanly shame for the Nadya Suleman's of the world who purposely reproduce excessively (and are unable to properly care for them) than a women who recognizes that she cannot properly provide for her pregnancies and subsequent child(ren) and aborts them all.

    What if my IUD fails me? Like my birth control pills did 5 yrs ago, I wouldn't hesitate to have another abortion because I want to concentrate on my midwifery apprenticeship and the family I already have (a husband and one very planned and wanted daughter).


    Food for thought -

    Abortion vs. Repeat Abortion
    According to the 2006 Guttmacher Institute report Repeat Abortion in the United States, women having a second or higher-order abortion are substantially different from women having a first abortion in only two important ways: They are more than twice as likely to be age 30 or older and, even after controlling for age, almost twice as likely to already have had a child. (Among all women having an abortion, six in 10 are mothers.)

    Just as with women having their first abortion, however, the majority of women having their second or even their third abortion were using contraceptives during the time period in which they became pregnant. In fact, women having a repeat abortion are slightly more likely to have been using a highly effective hormonal method (e.g., the pill or an injectable).

    This finding refutes the notion that large numbers of women are relying on abortion as their primary method of birth control. Rather, it suggests that women having abortions—especially those having more than one—are trying hard to avoid unintended pregnancy, but are having trouble doing so.
    http://www.guttmacher.org/pubs/gpr/10/2/gpr100208.html

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This is not a debate forum -- there are hundreds of other sites for that. This is a safe space for abortion care providers and one that respects the full spectrum of reproductive choices; comments that are not in that spirit will either wind up in the spam filter or languish in the moderation queue.