Dr. G. performs abortions. He’s one of a shrinking number of specialists willing to do so–no surprise in an age when abortion doctors are threatened and shot. What is surprising is that in his other work–delivering babies, mostly–he is also increasingly alone
By Ivor Shapiro
Chatelaine, September 1998
© Ivor Shapiro
This is not illegal, of course,” says Dr. G. as he picks up a worn-looking cardboard box and heads down the hospital corridor, holding it casually by one open flap.
Of course it isn’t. So, why is the abortion machine hidden in this anonymous-looking box? And why does Dr. G.’s voice drop reflexively when he uses the word abortion? Why have police advised against publication of his name, and why will he mention nothing about today’s abortion when he dictates his consultation notes into the hospital transcription system?
To the first and last questions, the answer is that the abortion is taking place in a Roman Catholic hospital, and Dr. G.’s privileges here would vanish if word spread of procedures like this one. But 24 hours later, he’ll drive an hour down the highway to a smaller city where no resident physician is willing to conduct abortions. There, in a general hospital, Dr. G. will perform 13 perfectly official abortions; between procedures there, too, his voice will drop for the A-word, and when a stranger–a physician unknown to him–walks into the surgeons’ lounge, Dr. G. will abruptly switch topics to real estate.
What is going on here is that in 1998 in Canada, a publicly funded medical service, entirely unrestricted by law for slightly more than 10 years, is often delivered by means that are just shy of cloak-and-dagger. And this paradox is part of a larger one: as a woman in Canada, you have more reproductive freedom than ever, but the specialist health services that underpin your choices are all under threat.
It’s not just abortion. For thousands of pregnant Canadian women who choose to have their babies, a crisis of access to specialist care is looming. And for those who choose to prevent conception, access to sterilization and other contraception services is threatened too. The causes of these problems are a complex mix of politics and economics spiced with religion. Politics, most of all: around antiabortion protest and violence; around who gets paid how much for medical services; and around cuts to health-care and health-promotion services across Canada. And then there’s the influence of
Catholic hospital boards in determining the availability of sexual health services. If the causes are complex, though, the net effect is simple: in the next few years, many Canadian women will have trouble finding help to prevent a pregnancy, to end one, or to have a baby.
No one recognizes this more clearly than Dr. G., a respected, prosperous 50-ish obstetrician and gynecologist in a midsize city somewhere in Canada.
With privileges at two teaching hospitals in his home city–call them Saint X’s and Crosstown Hope–and at the hospital he visits every other week in another city–call it Elsewhere General–he provides the full range of ob-gyn services, including about 500 deliveries a year and 1,000 abortions.
The abortions account for about a fifth of his time, a third of his income, and most of his aggravation. He avoids standing near windows, and his wife draws the curtains when he or his adult son is home. Soon, as the last leaves wither and fall, Dr. G. will dig out his bulletproof vest, because the Remembrance season brings more than poppies. For three Canadian abortion doctors in the past four Novembers, it brought a sniper’s bullet.
Almost all Dr. G.’s abortions happen at Crosstown and Elsewhere; consultations in the office he maintains at Saint X’s revolve around risky pregnancies, postnatal follow-ups, troublesome periods, Pap smear reports and infertility. But sometimes, like today, the machine in the cardboard box comes into play at Saint X’s. The 34-year-old woman waiting down the hall, who is separated from her husband, already has four kids. Her family doctor took her off the Pill because of hypertension; now, she’s eight weeks pregnant. Dr. G. could have put her on Crosstown’s one- to two-week waiting list, but by then, an abortion could mean operating-room surgery. Instead, he does the deed right here by aspiration–sucking out the contents of the uterus using a catheter and the vacuum pump in the cardboard box.
Five minutes later, a small jar of what looks like clotted blood is on its way to pathology. By noon, Dr. G. will have seen 16 patients including four pregnant women close to their delivery dates, and two who have driven in from Elsewhere because their pregnancies are advanced enough to require 24 hours’ preparation for abortion. Into their cervixes, Dr. G. inserts laminaria tents–extracts of a sea-grown plant that will gradually expand, dilating the cervix to help with the fetus’s destruction and removal tomorrow.
One time, the Saint X authorities learned of a laminaria insertion on hospital premises and rapped Dr. G.’s knuckles; he allowed them to believe it wouldn’t happen again. In an age when abortion doctors get shot, Dr. G. doesn’t lose sleep over potential loss of hospital privileges. What keeps him going, he says, are memories from three decades ago, when he was an ob-gyn resident before Canada legalized abortion (with access controlled by hospital committees) in 1969. Then, women would arrive in the emergency room after botched abortions performed by unqualified practitioners, or after infecting their own uteruses by sticking splinters of bark known as slippery elm through their cervixes.
Can he remember one particular patient, and his reaction? “Ah, not really,” says Dr. G., who tends to leave the rousing and graphic stuff to other voices. But last February, Vancouver’s Dr. Gary Romalis, who took a bullet in a thigh in 1994 for his abortion practice, provided memories for the Canadian Medical Association Journal that will serve the purpose here: “I will never forget a 17-year-old girl lying on a stretcher, with six feet of small bowel protruding from her vagina. She survived. I will never forget the jaundiced woman with liver and kidney failure who was in endotoxic shock…. We were unable to save her.”
Statistics Canada received reports of 70,621 hospital abortions in 1995.
That’s an 8.7 percent increase in the rate of abortion compared with live births since 1987–a predictable but hardly an overwhelming response to the Supreme Court of Canada’s 1988 decision that decriminalized abortion completely (by striking down the law giving hospital committees control).
The government does not count clinic procedures or office-visit abortions like today’s at Saint X’s, and no one counts how many physicians are actively providing the service. But the Canadian Abortion Rights Action League (CARAL) says, based on anecdotal evidence, that the pool of providers (mostly family physicians who now specialize in abortions) is shrinking–and its average age increasing.
To mark the 10th anniversary of decriminalization last February, CARAL issued a report on the status of abortion services under the title “Access granted. Too often denied.” It consisted largely of the stories of rural women whose searches for abortions were frustrated by distance, hostile physicians, lack of information and medicare gaps. It also accused the federal government of failing to enforce the Canada Health Act’s guarantees of access to health care. One example: Ottawa’s failure to penalize Prince Edward Island for refusing to pay for clinic abortions outside the province.
Some physicians refuse to offer abortions because of their own moral objections, but others fear unwelcome attention to them and their families.
Dr. G., whose children are grown-up, says in his understated way that it was “interesting” to have a half-dozen protesters chanting outside his house every day for several years, and to receive letters and phone calls threatening violence to himself and to his family. In those years–ironically, the years following the decriminalization of abortion–two-thirds of the abortion providers in Dr. G.’s city stopped offering the procedure.
Antiabortion violence came to Canada in 1992 with the nighttime bombing of an unoccupied Morgentaler clinic in Toronto. The first casualties followed with the November shootings of Dr. Romalis in Vancouver (1994), Dr. Hugh Short in Ancaster, Ont. (1995), and Dr. Jack Fainman in Winnipeg (1997). All three survived. In these circumstances, a doctor who chooses to provide abortion must feel strongly about it. “So far, when I weigh the risks, the balance has always come down in favor of the women,” says one family physician who offers abortions but frequently reassesses her decision to do so. “If [the militants] decide to start using bombs instead of guns, my children would be at risk.” The net result of antiabortion influence and intimidation, according to the CARAL report, is that “women have been robbed of the full promise of the 1988 decision.” But this may be overstating the case. Writer and broadcaster Judy Rebick, for one, says CARAL painted too gloomy a picture. “In Canada, access has improved. It’s improving very slowly, but it’s improving, whereas in the States, it is going backward…. I think in this case it’s important also to focus on what we have, which is almost a consensus in Canada–nearly 80 percent of the population agree that abortion is a private decision between a woman and her doctor. I mean, on what other issues do we have 80 percent agreeing in Canada?”
The truth lies somewhere between the CARAL report’s gloom and Rebick’s optimism. Most Canadian women have no difficulty finding an abortion doctor, but in lots of cities like Elsewhere, the last local abortion provider has retired or moved away. The women of Sault Ste. Marie, Ont., for instance, now travel 305 kilometres to Sudbury for their abortions; the lone obliging doctor there–the last in northern Ontario–is more than 70 years old.
——
“Can you push for just a moment now?” asks Dr. G., and he reaches down with a fingertip to pilot the baby’s cranium through its cramped channel between the mother’s spread legs. A half-inch of movement, and a wet ear bursts through. The specialist stands back, eyes on the fetal heart monitor, while a seated ob-gyn resident gingerly supports the emerging head. Not long now–a push, a pause, a shoulder, gliding, gliding–“It’s a boy!” cries the resident as Dr. G. suctions away the mess around the baby’s face.
Even after three decades, deliveries still give Dr. G. a surge of vicarious joy. But the range of his practice–encompassing abortions, obstetrics and general gynecology–is increasingly unusual. Just as relatively few ob-gyns provide abortions, hundreds don’t deliver babies, either. While the number of specialists practising obstetrics is falling only a little faster than Canada’s birthrate, they are carrying a bigger burden because family doctors are dropping precipitously out of maternity work. According to the Canadian Institute for Health Information, physicians’ billings for deliveries in 1989-90 were divided equally between ob-gyns and family doctors. Just four years later, the GPs’ portion was down to 45 percent. In a 1994 national survey, family doctors overwhelmingly cited personal and office disruption, as well as financial disincentives, in explaining their departure from obstetrics.
So far, ob-gyns have filled the gap in big cities, but smaller hospitals find it increasingly hard to staff obstetrical services. In Dr. G.’s city, 10 specialists share deliveries, so he’s on call just one night in 10. But in one-obstetrician towns like Fort Frances, Ont., the delivery man or woman is on call every night of the week. In Trail, B.C., the sole ob-gyn retired early this year; months later, the hospital was still searching for a permanent replacement.
Then there’s liability: who wants to spend five years fighting a lawsuit for lifetime support over a brain-damaged newborn? Not to mention professional membership and insurance fees ($29,028 this year for obstetricians, of which provincial governments refund varying amounts). But it’s medicare fees that lie at the heart of obstetricians’ job actions that have hit the headlines in Newfoundland, Manitoba and Alberta this year, and Quebec last year, and Ontario before that.
A few doors down the hall from Dr. G.’s delivery room, an ophthalmologist has just wrapped up a series of 11 cataract operations–each taking just 15 minutes. “That’s a nice morning’s work for him,” says Dr. G. mildly, tapping the operating-room schedule as he passes by. A cataract removal brings in $504.30 a pop in Manitoba (to name a province that is not Dr. G.’s). By contrast, a routine delivery pays $250 in the same province–roughly the same as most ob-gyn procedures, including tubal ligations and removal of ovarian cysts. Even a modified hysterectomy, which takes about an hour, pays just $385.
As long as obstetrical services are relatively unrewarded, the specialties that offer fewer call-outs and lower insurance rates will remain more attractive. “Obstetricians are feeling frustrated and demoralized,” warns Janice Willett, an ob-gyn in Sault Ste. Marie. “And younger obstetricians don’t see a future.” The ranks of departing doctors have been partially filled by newly registered midwives in Ontario (since 1994) and British Columbia (since last January). But that’s no help to someone who’s at risk for birthing problems. One in five problems during delivery is not predictable, so even if you prefer a midwife, you probably want to know there’s an ob-gyn on call. And the answer, except in the big cities, could soon be: there isn’t.
——
The brightly colored image on the TV screen could be the view from the bridge of the Enterprise as the ship is swallowed by a space monster and gulped down, down, down through a chaotic throbbing tunnel until the screen is engulfed by a pink pulsating blob. Suddenly, two terrifying needles appear from the left and–BANG!–tie off the blob with a white band. The screen goes blurry as Dr. G., whose hands are working around his patient’s left hip while his eyes remain fixed on the screen, pulls his laparoscopic camera and suturing equipment out of the patient’s pelvis, lays them down, thanks the nurses and anesthetist, and then leaves the room to check on one of his other patients, who is in labor.
The procedure just completed–about as fast as a cataract extraction–was a tubal ligation, and yes, this is still Saint X’s hospital. But in this instance, Dr. G. is not defying hospital policy. The Catholic Health Association’s guide for hospitals states that “direct sterilization…may not be used for the regulation of conception.” Still, says association president Richard Haughian, the procedure is permitted when the true purpose is to promote the patient’s “health and well-being.” Variations in theological interpretation from diocese to diocese mean there’s some leeway at some Catholic hospitals for physicians to offer elective sterilization to their patients.
St. Michael’s is not one of those hospitals, as patients at Wellesley Central discovered last spring when their secular downtown Toronto hospital was absorbed into the larger St. Michael’s by government fiat.
Unsurprisingly, “St. Mike’s” policies rule at the new combined hospital–including a requirement that every tubal ligation be officially approved as an exceptional case, and a ban on vasectomies and on information about artificial birth control (except in the context of disease prevention).
Kathleen Howes, a spokeswoman for Catholics for Free Choice Canada, says she fears a growing threat to contraception services as Catholic and nondenominational hospitals amalgamate under funding pressure across Canada.
Hospital boards typically operate at arm’s length from government and therefore are free to dictate hospital policy within the bounds of law and medical ethics. But Howes believes this freedom has gone too far. “If a service is accepted as being valid, legal and medically necessary,” she says, “then a publicly funded hospital should provide it.”
Outside the hospitals, family planning clinics are fighting against cuts to community-health funding across Canada. Bonnie Johnson, executive director of the Planned Parenthood Federation of Canada, says many clinic bosses now are obliged to spend more time lobbying than running their services. Even the oldest of all the centres, the Planned Parenthood Society of Hamilton, Ont. (founded 1932), is operating on a month-to-month basis while supporters lobby against government cutbacks tantamount to a close-down order. These clinics play a vital role in the fight against unwanted pregnancies and disease. Many teenagers would rather risk unprotected sex than visit their family doctor and, according to Johnson, many doctors still won’t prescribe contraceptives to minors without parental consent.
If, as Johnson says, governments have failed to “get their heads around” the critical need for birth control services, Dr. G. sees the consequences in his gynecology practice. “The abortion rate and birthrates haven’t changed much in the past 10 years,” he says. “Gonorrhea is declining, but chlamydia, bacterial vaginosis, herpes and human papillomavirus are all coming back. So I can’t say we’re making much progress in providing birth-control and sexual-health advice.”
Even this mild-mannered man can get “exercised” (as he would call it) over this issue; he points the finger of blame at religious groups who apply anticontraception pressure on schools and health-policy makers. “These are the same groups who don’t believe in abortion,” he says, his voice rising just slightly. “But excuse me, we have a problem here. You’re going to have one if you don’t have the other.”
—–
“I don’t know if I should tell you this story,” says Dr. G. a little after 7 a.m., still wearing yesterday’s blue operating-room vestments, biting into a doughnut-shop muffin as he accelerates to 120 on the highway to Elsewhere.
The doctor is tired, and he’s going to be late for his first abortion, due to a night in which, among other things, he cleaned up after a 13th-week miscarriage, assessed the health of a pair of unborn twins growing at alarmingly unequal rates, pronounced another pair of fetal twins dead and induced labor in their “quite exercised” mother, delivered a healthy baby for a happy patient he’d attended through three previous confinements and, between 12:30 and 4, grabbed some sleep at the hospital.
The story he’s not sure he should tell is about another day he began late, exactly two weeks ago. As the day went on, he kept getting later, until he arrived at Crosstown around 7 p.m. for a series of second-trimester abortions scheduled to start at 4 p.m. “No one’s happy,” he recalls. “Not the anesthetist, not the nurses, not me, and certainly not the patients.”
Especially one of them. She is 17 years old, and 20 weeks pregnant, meaning her abortion will be a grisly procedure of physically cutting apart the fetus inside the womb and suctioning out the pieces, with Dr. G. keeping watch to make sure all body parts are present. Five laminaria tents in the patient’s cervix have been expanding for 24 hours to make room for what has to exit. But Dr. G. is late and the patient has decided she can wait no longer. Standing, clothed, in a hospital room, she tells Dr. G. she has changed her mind. She’s from a small town just beyond the city limits, and the person who gave her a ride in to the hospital today now has to go home. “So, I explain, ‘Your cervix is now wide open, and if we don’t carry on with this procedure you could lose the pregnancy in a day to five days or maybe a couple of weeks, and maybe you could have a baby who is born extremely premature and brain-damaged.’ She then says, ‘I can look after a brain-damaged baby; I just gotta get out of here; my son’s waiting at home, and I can’t wait any longer.'”
Dr. G. drives along in silence for a moment. “Fortunately, I was able to convince her she was now on a one-way street, but that kind of whimsical reaction really at times makes you wonder.” He sips his coffee. “It’s sometimes daunting to see how close it is to being a life or not a life.”
At this and several other moments in conversation, it’s clear how much Dr. G. does not enjoy conducting abortions. He says that whenever he senses uncertainty in a patient–including those already counseled at length by women’s health centre staff–he sits down and has a talk with her, at some point in which he usually says this: “Whatever decision you make will be the right decision for you at the time, and nobody else can decide for you.”
Sometimes, the patient walks away having decided to carry on with the pregnancy. In fact, at the Crosstown health centre, one in four patients changes her mind during the counseling and one- to two-week wait.
However, when the patient chooses abortion, Dr. G. says he goes ahead without moral qualms, because he believes his patients have an absolute right to choose, and because he remembers what happens when that right is taken away. He just doesn’t have to like doing it.
He certainly doesn’t like doing late (or second-trimester) abortions–those that take place between 14 and 23 weeks’ gestation. Dr. G. knows no one who will do an abortion later than that, not just because it’s technically horrendous but because, by the end of that period, the fetus is considered to be “potentially viable.” And this, for Dr. G., takes the job onto a new moral plane. As it is, the second-trimester abortion is often “disturbing,” he says.
“This was a perfect little fetus inside and now it–it no longer is. I try not to focus on that too much; I try to keep cognizant of the issue that brings this situation to pass, of the patient herself, being confident that, you know, the greater good is being served by doing this. But certainly, at times, it is upsetting, and it’s embarrassing as well.”
“Embarrassing?”
“Mm. I always feel uncomfortable if other people are watching me do this.”
Dr. G. says he hides the products of these abortions from attending nurses.
“I don’t like to expose them to this, well, carnage, if you like. Because all it does is upset them as well, and they are not among the decision makers. It’s just–well, it’s quite disgusting, there’s no question about it.”
“You’ve been doing it for a long time.”
“And it gets no easier. One of my colleagues told me that he had to stop doing late abortions when he started dreaming about them at night.
Fortunately, that has not occurred with me, yet.”
“Pro-choice.” It sounds like such an easy word–a word without cost. But allowing choices means, among other things, allowing the choices you’d prefer not be made. It also means putting in place the conditions for a free choice. Right now, Dr. G. is the angel of choice. Or of death, as the antichoice militants see it–and they are certainly right to see doctors like him as all that stand between us and the old days, when abortion was a crime.
Doubtless, more family physicians would stand with Dr. G. if RU486 became available in Canada. That’s the oral drug, freely available in Europe and strongly opposed by the antiabortion movement in North America, that will stop almost any pregnancy up to nine weeks in gestation. So far, no one has even tried to market the drug in Canada–a state of affairs that Dr. G. blames on “religion and politics, same as in the States.”
But even when or if it becomes available, RU486 won’t affect the 95 percent of abortions at Crosstown Hope that take place between eight and 14 weeks.
It takes that long for most women to realize they are pregnant and decide what they want to do. Even if fewer delay, thousands of women will continue to look for abortion specialists.
Will they find them? Staff at the women’s health program for the Hamilton Health Sciences Corporation have surveyed medical schools across Canada and found that abortion training is “patchwork, at best,” says the program director, Dr. Pat Smith. Abortion is touched on in some undergraduate courses, but the techniques are taught in few, if any, residency programs.
So far as Dr. G. knows, not one of the ob-gyn residents he’s worked with has gone on to provide abortions. If that’s how things keep on, then what will be the meaning of free choice when the doctors of Dr. G.’s generation–the ones who remember slippery elm–retire?
Similar questions shadow the other choices tomorrow’s women will make.
Unless something happens to change the politics, economics and demographics of reproductive health care, the future of access to specialist abortion, obstetrics and birth control services could be this: if you live near a big city, you’re okay, and if you don’t, you’re out of luck.
At noon, 13 abortions done in four hours, Dr. G. will drive back to his hometown, attend a meeting, conduct his rounds and spend three more hours performing second-trimester abortions at Crosstown.
At 7, he’ll return to Saint X’s to deliver the twins of unequal size, who will, to his relief and slight surprise, arrive healthy in the world and begin thriving in neonatal incubators. Forty hours after his shift began, he’ll take off his surgical blues, put on shorts and a T-shirt, go home to his wife, and sleep.
Small wonder they’re not breaking down the doors to replace him.