Many students come to the conference in need of practical instruction. Depending on their university and their residency, without MSFC, medical students might find themselves stuck learning how abortions are performed from YouTube. On the conference’s second day, it offered two-and-a-half hours of intensive instruction broken up into first and second trimester sessions, for the attendees who needed it. Chiavarini, with her hyper energy and theater background, presided over the first overview. “Trigger warning!” she announced too late as the image slid in. “Whoops! Anyway, those are fetal parts.” Humor is one of Chiavarini’s ways to shock the students a little, to get them thinking less like civilians. She tells jokes that would make most people blanch.
Because knowledge about the uterine reproductive system is taboo even within medical schools, it was hard for Chiavarini to know where to start. She quickly glossed the curiosities of what the “first trimester” even means. For laymen, the math seems easy: nine months, three trimesters, three months each. But doctors measure pregnancy from the first day of what they call the last normal period. The first trimester lasts 13 weeks, but by the first day of the first missed period, the official count is already at four. To an uninformed public, the confusion around this measurement could imply that patients have taken longer to seek out treatment than they actually have. It also means that abortion bans based on weeks are counting days prior to conception.
Chiavarini explained the different procedures for medication abortion and surgical abortion to the full and rapt conference room. The medication regimen she recommended involves doses of mifepristone and misoprostol, which together block progesterone (“Pro-gestation, get it?”), dilate the patient’s cervix, and induce uterine contractions that expel the products of conception. As an instructor, Chiavarini consistently acknowledged—then sliced through—the thin film of embarrassment that covers the subject, even for med students.
Patients might prefer medication abortion for the sense of control, Chiavarini said, or because they can expel the products of conception in the relative comfort of their own homes. Still, medication abortion requires patients to return to their provider and undergo an ultrasound to make sure all tissue has passed from the uterus.
If patients are coming from out of town—which is common, since 9 out of 10 counties in America lack their own providers—a surgical procedure is a safer and more efficient choice. Chiavarini told the story of a college student who had an incomplete medication abortion and, unaware she was still pregnant, returned to campus. She didn’t get to the clinic until a day before her state’s 22-week ban would have forced her to bring the pregnancy to term. Chiavarini performed what should have been a two-day procedure in the legally available one day. She cited this as an example of the “flexibility” required by the job.
To begin a first-trimester surgical abortion, the provider administers a paracervical block, which is two painkiller shots into the cervix. “Vaginas are not sterile,” Chiavarini reminded the audience as she demonstrated her “no-touch” technique for handling the metal dilators (small rods with the ends tilted at angles and tapering to different widths), flipping one between her fingers laterally to access either side. Passing the dilators around, the attendees mimicked her movements automatically.
After the provider dilates the cervix, they insert into the uterus the cannula, a rigid or semi-flexible plastic tube averaging around 10 mm in diameter, which is narrow—the size of a pearl, significantly smaller than a dime. In the first six weeks of a pregnancy, it’s possible for the gestational sac to fit through the tube whole. Chiavarini mentioned receiving a texted picture from her friend, another provider, of a sac pulled successfully intact, a sort of abortionist’s bull’s-eye. “You’ll do these things,” she told her audience about texting gestational sac photos. “You think you won’t, but you will.” The abortionist evacuates the products of conception through the cannula and attached tubing, into the aspirator, which is emptied into a bucket.
Despite what the name might imply, surgical abortion is quicker and simpler than medication abortion, and it’s the more common procedure. “The truth is, doing most abortions is technically easy,” Chiavarini said. “But patients bring with them their stories and their complex lives and situations, and that’s the part that’s hard.” Whether surgical or medication, serious complications are rare. Chiavarini listed penicillin, driving, and (indeed) giving birth as statistically riskier.
“We’ve been put on the periphery of medicine because we do the dirty work.”
While American maternal mortality has increased alarmingly in recent years (an increase of almost 60% from 1990 to 2015), the number of abortion mortalities is so low that the Centers for Disease Control and Prevention (CDC) calculates using five-year averages. Over the last three years for which there are data (2011–2013), the CDC reported 10 total abortion deaths, and the agency has not recorded a fatality due to an illegal abortion since 2004. It’s in the interest of pro-abortion-rights protesters and antis alike to dramatize the dangers around the procedure, but the numbers are a testament to the quality of care at the clinics—most visibly, Planned Parenthood—that perform 95 percent of abortions in the United States.
One reason abortions are safer than they used to be is that the patients who seek them do so earlier. At legalization in 1973, fewer than 40 percent of abortions occurred in the first eight weeks of pregnancy; now, it’s up to two-thirds, and over 90 percent are performed in the first trimester. That means that most patients who choose to terminate a pregnancy do so during their first missed menstrual cycle and before the embryo develops into a fetus.
Factual statements like these have a political quality to them, but they’re also essential to understanding the procedure. As the only group eager to talk about specifics, antis have defined abortion in the public imagination. But compared to the “baby-killing” picture Americans of all ideological positions have internalized to a certain degree, the tools are incredibly small. The smallness of the cannula, for example, presents a problem for anti-abortion propagandists, who insist on depicting products of conception as having visibly human features, rather than the actual pearl-sized cell clusters they are.
But as overwhelming as the antis are—both vigilante and in government—the providers and students seemed most frustrated with a medical establishment that has marginalized them and overloaded them with work at the same time. There’s pride to being part of the small corps of abortionists, both in the work they do and in the obstacles they have to overcome to do it. They’re idols in the progressive feminist communities they belong to. But not everyone who wants to perform abortions also wants to be brave for a living. Today, they’re not left with much of a choice.