Motherhood is Optional: Getting an Abortion in Arkansas

September 18, 2005
Under Din of Abortion Debate, an Experience Shared Quietly

New York Times

LITTLE ROCK, Ark. – At Little Rock Family Planning Services, the women filed in without making eye contact, a demographic that remains unrecognized.

Leah works in a clothing boutique. Alicia is in high school. Tammy pulls espresso. Regina is a sergeant in the Army, recently home from Iraq.

Far from Washington and the Supreme Court confirmation hearings of Judge John G. Roberts Jr., here in Little Rock on an August weekend, 26 women from as far away as Oklahoma joined the more than one million American women who will probably have abortions this year.

Their experiences, at one of only two clinics in the state, offer a ground-level view of abortion in 2005, a landscape altered by shifts in technology, law, demographics and the political climate.

Brittany, 17, brought her mother for support. Linda, 39, brought her daughter.

Alexia, who wore a cross pendant, prayed all through the two-and-a-half-hour drive from Delta State University in Mississippi. At 23, she was having her third abortion. “My religion is against it,” she said, adding that she is a Baptist. “In a way I feel I’m doing wrong, but you can be forgiven. I blame myself. I feel I shouldn’t have sex at all.”

Venetia Grunder, 21, viewed an ultrasound image of the fetus in her womb. She was 12 weeks pregnant, though she had taken birth control pills as directed. “I feel pretty messed up,” she said after seeing the image. “It’s different, just knowing. My husband told me not to look. This changes my feelings, but I’m sticking by it. Damn it, $650, I’m sticking by it.”

More than 25 million Americans have had abortions since the Supreme Court decided Roe v. Wade and Doe v. Bolton in 1973. Often kept secret, even from close friends or family members, the experience cuts across all income levels, religions, races, lifestyles, political parties and marital circumstances. Though abortion rates have been falling since 1990, to their lowest level since the mid-1970’s, abortion remains one of the most common surgical procedures for women in America. More than one in five pregnancies end in abortion.

In the squat, nondescript brick building here, the lofty rhetoric that has billowed through public debate for the last 32 years gave way to the mundane realities of the armed security guard and the metal detector, the surgical table and the settling of the bill before the procedure – $525 to $1,800, cash or credit card only.

While public conversation about abortion is dominated by advocates with all-or-nothing positions – treating the fetus as a complete person, with full rights, or as a nonentity, with none – most patients at the clinic, like most Americans, found themselves on rockier ground, weighing religious, ethical, practical, sentimental and financial imperatives that were often in conflict.

Regina cried on the operating table.

Kori, 26, who was having her third abortion, asked to watch the procedure on the ultrasound monitor. “I wanted to see what it was like,” she said. “It was O.K. to watch. Once you had your mind made up to do it, you just suck it up and go with it.”

The solitary protester outside , Jim Dawson, 74, stood a court-mandated distance from the clinic with a video camera, taping women as they entered, and promising them hellfire if they went through with it – as he has for a decade. Mr. Dawson drives 40 miles from Vilonia, Ark., bringing cardboard signs that say “Abortion Kills,” and usually departs by midmorning. On days when the clinic is closed, he pickets the Clinton presidential library. “I don’t stop many of them,” he said, “but a little bit goes a long way.”

The Women

At the clinic, patients allowed a reporter to attend their consultations and even operations, but most spoke only if they could use just their first names. “It’s not something I would talk about,” said “M,” a high school teacher who agreed to be identified only by her middle initial. She wore a miniskirt and T-shirt, her blond hair pulled back from her forehead. She said she had never discussed abortion with relatives or colleagues. Only two friends knew she was here.

“I’d lose my job,” she said. “My family’s reputation would be ruined. It makes me nervous even being in the waiting room. You don’t want to know who’s here, you don’t want to be recognized, and you don’t want to see them ever again. Because in society’s eyes, you share the same dirty secret.”

Even most staff members at the clinic insisted on using only their first names – “to protect my identity from the antichoice people,” said Lori, a nurse practitioner. Several said they had not told family members what they did for a living, or were ostracized if they had.

“My oldest son won’t let me see my grandchildren,” said Sherry Steele, 57, a surgical assistant who started working at the clinic after her daughter had two abortions. The New York Times agreed to anonymity to encourage candor and to get a representative sample of women. (Those who volunteer their full names are by nature an unrepresentative minority.) On this August weekend, the women entering the Little Rock clinic resembled those who have abortions nationwide. They were mainly in their 20’s, more likely to be poor and African-American than the area population. Most were already mothers, many single. They arrived as a result of failure of one sort or another: a poor sexual decision, a broken relationship, a birth control method that just did not work. More than half of all women who have abortions say they used a contraceptive method in the month they conceived, according to the Alan Guttmacher Institute, a research group that supports abortion rights.

While abortion rates have been falling generally since 1990, the decline has been steepest among teenagers, and rates are lowest among educated, financially secure women. Researchers attribute the drop in teenage abortion to reduced rates of pregnancy, as a result of better access to contraception – including the three-month Depo-Provera injections – and abstinence.

Conversely, for poor and low-income women, rates increased during the 1990’s, possibly in response to the 1996 welfare overhaul, which reduced support systems for women who carry their fetuses to term. At every income level studied by the Guttmacher Institute, African-American women were more likely to terminate their pregnancies than white women.

Leah, 26, said money was a factor in her decision to have an abortion. A former college track athlete, she works in a clothing boutique, a job that she said did not pay enough to support a child.

Like many women at the clinic, Leah had conflicted feelings about what she was doing. “I always said I would never, ever have an abortion,” she said. “I probably will regret it. I’m pro-choice for cases of incest or rape, but if it’s your own fault, you should accept responsibility. And it’s my own fault.”

In Arkansas, as in many states, abortion providers are required to offer women their ultrasound images before an abortion. Because Leah was just five weeks pregnant, her image showed a formless mass. “If I saw an actual fetal baby on the ultrasound, I wouldn’t have been able to go through with it,” she said. She said she felt selfish, “but hopefully this will set me on a straighter path.”

The procedure took only minutes. Afterward, in a recovery area, she said she was less shaken than she had expected. “I thought I’d be crying,” she said. “I feel goofy now, but not in a bad way. I feel relieved more than anything. I know I’ll never forget it, but I’d rather do that than have a child I can’t take care of.”

Karen, 29, who arrived at the clinic 20 weeks pregnant, expressed no qualms about ending her pregnancy. Like nearly half of all women who have abortions, she had had one before, when she was 18. She did not look on abortion as shameful, she said, adding, “All of your past goes into making you who you are.”

She has a 9-year-old son, and she said she felt she could not start again with a newborn child. This, too, is common. More than half of all women having abortions have had children, a percentage that rose in the 1980’s but has not changed since 1990, according to the federal Centers for Disease Control and Prevention.

Karen and her boyfriend have an unstable relationship plagued by money problems, and they lived with a relative after being evicted from their home. She did not come in earlier in the pregnancy, she said, because she did not have the money. In the end, because she was so far along, her abortion took two days and cost $1,375, nearly three times what it would have cost if she had come in at 12 weeks.

“People tell you you can put your child up for adoption,” she said. “But if your kid has medical problems, no one wants to adopt him. And you never know.”

For many women at the clinic, their desire to end their pregnancy clashed with their religious beliefs. Tammy, a Muslim, had her first abortion a year ago, after having three children. She is married and works in a coffee shop in Tennessee. She became pregnant this time after erratically taking her birth control pills.

“I know it’s against God,” she said of her abortion. “But you have three kids, you want to raise them good. My friends and sister-in-law say, ‘You care about money problems but don’t care about what God will do.’

“I believe it’s wrong. I pray to God to forgive me. This will be the last one. Never, never again.”

The Law

Since 1992, when the Supreme Court recognized states’ authority to restrict abortion as long as they did not create an “undue burden,” states have enacted 487 laws restricting patients or providers, in many cases calling for mandatory counseling, waiting periods and parental consent for minors, according to Naral Pro-Choice America. The result is a patchwork of laws and regulations that vary from state to state, some of which may come before the United States Supreme Court. In surveys, Americans largely support these restrictions, even if they say abortion should be legal. This fall, the court will consider whether New Hampshire’s parental notification statute creates an undue burden because it does not include an exception to protect the health of the woman.

Arkansas, which before Roe v. Wade had one of the nation’s most liberal abortion laws, now has one of the most restrictive, requiring state-scripted counseling at least a day before the procedure and, since mid-August, parental consent for minors. At 20 weeks, doctors are required to tell patients that the fetus feels pain, though this is medically disputed.

At the clinic in Little Rock, patients and staff members said the restrictions were more inconveniences than roadblocks. Patients nodded dutifully as the staff members asked questions like, “Do you understand that the father of the child must provide financial assistance if you deliver the pregnancy?” Like the protester outside, the regulations seemed simply part of the drill.

In a pre-operation holding room, Alicia, 17, awaited an abortion for which her parents were not asked permission. Under Arkansas law, as in 33 of the 34 states that require parental consent or notification, juveniles can bypass their parents if they persuade a judge that they are mature enough to make the decision themselves, or that it might be in their best interest.

Alicia, who was 17 or 18 weeks pregnant, said she did not have the abortion earlier because she was afraid to confront her parents. When she finally told her parents she was pregnant, she said, her mother threw a stool at her and kicked her out of the house.

“But I can’t give a baby a life it should have financially,” she said. “My boyfriend didn’t want me to go through with it, but he realized he couldn’t support a baby either.” Her parents ultimately gave her $1,700 for the abortion, but she arrived from Oklahoma without their formal consent.

Getting a judicial bypass was not difficult, she said. The clinic scheduled her appointment early in the morning, and after taking a pregnancy test, for which she paid $200, she met with a judge briefly in his chambers.

If you go to the judge and say, ‘I’m afraid to tell my parents because they might harm me,’ that’s all you need to say,” said Dr. Tom Tvedten, who has been performing abortions in Arkansas for 20 years, and now works part time at the Little Rock clinic. “It doesn’t have to be true, because how would anybody know?”

He added, “But every time a restriction is placed on us, it increases our costs, and that cost is passed on to the consumer.”

The Practice

For the clinic, the regulations add paperwork and require extra staff members, said Dr. Jerry Edwards, the chief physician, who owns the clinic with his wife, Ann F. Osborne, the director. Penalties can include lawsuits or criminal prosecution.

“Normally, if someone’s a flagrant violator of medical regulations, they get disciplined by the profession,” Dr. Edwards said. “But these guys go for the pocketbook or put you in jail. It’s much more punitive than the doctor who commits Medicare fraud.”

New licensing laws, enacted in 28 states, require providers to comply with state codes for equipment, record-keeping, building grounds and other areas, which small businesses can find onerous. In Arkansas, these laws – which clinics call TRAP laws, for targeted regulation of abortion providers – do not apply to existing clinics, but they make it expensive for anyone who wants to open one, Dr. Edwards said. “We look at TRAP laws as a major barrier for people who want to become providers,” said Vicki Saporta, president and chief executive of the National Abortion Federation, a trade group of providers.

Dr. Tvedten likened the regulations to “death by a thousand scratches.”

In part because of the legal, financial and emotional pressures, the number of doctors in Arkansas who perform more than occasional abortions has fallen to three, down from six in the late 1990’s. The youngest, Dr. Tvedten, is 59.

This reduction mirrors a national trend. Nationally, 1,819 facilities provided abortions in 2000, down from a high of 2,908 in 1982, according to the Guttmacher Institute.

Dr. Edwards, 63, said he felt an obligation to stay in business. “If we retired, I’m not sure anybody else would come to Arkansas and practice,” he said. “We can’t get residents from the hospital to come over and see what an abortion is like.”

Threats against abortion clinics are on the decline, in part because of sterner laws to protect clinics. But picketing has remained steady, at 80 percent of clinics.

Dr. Edwards and Ms. Osborne said they felt isolated from the local medical community and the community at large. Even the patients often have a negative view of abortion. “I very often hear, ‘I don’t believe in this, but my situation is different,’ ” Ms. Osborne said.

Though the clinic has developed an equilibrium with its lone demonstrator, Ms. Osborne is wary of any opposition to abortion rights. In 1994, when she was executive director of Preterm Health Services in Brookline, Mass., an abortion opponent named John C. Salvi III came into the clinic and started shooting, killing the receptionist.

The Technology

As laws become more restrictive, technology has gone the other way, making abortions possible both earlier and later in pregnancy, and by pill or surgery. Doctors can perform abortions as early as eight days after conception, and 59 percent of women having abortions do so within eight weeks, according to 2001 data from the Centers for Disease Control and Prevention.

Fewer than 1 percent have abortions after 20 weeks. A late-term procedure called intact dilation and extraction, sometimes known as partial-birth abortion, accounted for less than two-tenths of 1 percent of all abortions in 2000, according to the Guttmacher Institute. Fewer than one in 50 providers performed those.

Since September 2000, when the Food and Drug Administration approved the drug mifepristone, sometimes called RU-486, for early abortion, more than 460,000 women have chosen this option, according to the manufacturer’s data. Mifepristone is given in conjunction with a second pill, misoprostol, usually over two or three days, and requires a follow-up exam with a doctor.

At the Little Rock clinic, few patients chose the pills over surgery. “With medical termination, the discomfort is significant because they have to go through mini-labor,” Dr. Tvedten said. “There’s a lot of hard cramps and usually significant bleeding. It’s cheaper, safer and less painful to have a surgical termination.”

Each technological advance has led to new legislative and legal wrangling, which may ultimately reach the Supreme Court. On Aug. 31, the director of the women’s health office at the Food and Drug Administration resigned in protest over delays in approving over-the-counter sales of the morning-after pill known as Plan B, which has emerged as a front in the abortion battles.

The Procedure

Regina, 28, blamed a faulty contraceptive Depo-Provera shot from an Army nurse in Iraq for her pregnancy. In Arkansas, she receives the injection in her hip, where it is most effective, but in Iraq she got it in the arm – she remembered by the soreness she felt slinging her rifle. “I was in Iraq 13 months,” she said. “I guess I got a little happy when I got home.”

She arrived at the clinic with a cut on her nose and bruises on her forehead and lip, which she sustained after telling her boyfriend she was pregnant. “He flipped out because he wasn’t ready,” she said. She had thought, upon learning of the pregnancy, that she “was about to get married,” she said. She came in with two fellow sergeants, who wore their uniforms. Her boyfriend was in jail, she said.

“I’ve done this once and swore I wouldn’t do it again,” Regina said. “Every woman has second thoughts, especially because I’m Catholic.” She went to confession and met with her priest, she added. “The priest didn’t hound me. He said, ‘People make mistakes.’ ”

In the operating room, a team of nurses gave her injections to relieve anxiety and pain. Dr. Edwards inserted a speculum and maneuvered a plastic suction device around her uterus. “Don’t leave,” she entreated Ms. Osborne. The procedure lasted about five minutes.

As she lay on the table, Regina wept and put an arm around Ms. Osborne, asking how things looked “in there.”

“I’m not a baby, that’s what’s so sad,” Regina said. “Thank you, ladies, for being here for me. I’m too old to make these mistakes.”

She said the experience was emotional because she had expected more of the father.

She spoke to Dr. Edwards. “Thank you, sir,” she said.

Ebony, 28, an operating room supervisor, rinsed the blood off the aborted tissues for Dr. Edwards to examine. Ebony, too, had a story. When she was 15, her aunt and grandmother had made her carry her pregnancy to term. Later, she had an abortion. As a Baptist, she still considered abortion a sin – but so are a lot of things we all do, she said. She squeezed Regina’s hand.

“No problem, sweetie,” Ebony said. “We’ve all been there.”

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