Avoiding the TRAP: Defending Legal Abortion, with David A. Grimes, M.D.

January 19, 2016

This week Point of Inquiry welcomes Dr. David Grimes, a board certified physician in obstetrics and gynecology and author of the new book Every Third Woman in America: How Legal Abortion Transformed Our Nation. Dr. Grimes talks with host Lindsay Beyerstein about the enormous good that’s been done as a result of the legalization of abortion, and the horrors that women used to face — and face anew — as access to abortion services is chipped away.

A powerful movement is relentlessly fighting to turn back the clock to the pre-Roe v. Wade era, when abortions were just as common as they are today, but far more dangerous and life-threatening. States across the country have seen the introduction and passage of “TRAP laws” (Targeted Regulation of Abortion Providers) that harshly restrict access to abortion, birth control, and even cancer screenings, all under the pretense of protecting patients’ health.

This is point of inquiry for Tuesday, January 19th, 2016. 

Hello and welcome to Point of Inquiry. A production of the Center for Inquiry. I’m your host, Lindsay Beyerstein. And my guest today is Dr. David Grimes, a retired obstetrician gynecologist and the author of the new book, Every Third Woman. The book explores the scientific evidence for abortions, medical safety and public health benefits. It also documents the ways in which reproductive choice is increasingly under attack, not only by terrorists, but also by restrictive bad faith regulations. The Supreme Court has recently announced that it will hear the biggest challenge to an abortion law since Planned Parenthood v. Casey in 2007, making this a very timely volume indeed. 

David, welcome to the program. Thanks so much. 

You practiced back in the bad old days before abortion was legal. What was that like? 

Well, actually trained right at the cusp of when the laws were changing. North Carolina, where I trained, changed this law in 1970. So I was in medical school at the time and we were doing abortions in my department at that time. Roe v. Wade came down my senior year of medical school. So during my O.B. June residency, I occasionally took care of women who had been damaged by illegal abortions that were still going on in small numbers. 

And what would you see when somebody would come in from an unsuccessful illegal abortion? 

Well, let me describe what these horrors were like. For example, I remember very clearly being called to the emergency department once as a young doctor to see a woman who reportedly had a temperature of 106 or 107 degrees Fahrenheit. I thought it was a mistake, but it proved not to be. And when I examined her, I found a red rubber catheter protruding from her uterus that a dietician in the next town had put in as a way of inducing abortion. On another occasion, I was called to the emergency department to see a coed from the university campus who is in septic shock with virtually no blood pressure and a dead fetal foot hanging out of her cervix is 17 weeks pregnant under very suspicious circumstances. Physicians younger than me, and that’s most physicians today do not recall the bad old days and thus lack the motivation that I have. 

Was that a common thing to be using objects like catheters to to induce abortions in those days? 

Yes, they were the most effective ways of inducing abortion. That is to put some going to form body in the uterus, such as a knitting needle or a coat hanger or something. They were also among the most dangerous in that they risk both trauma to the uterus as well as infection. But these were the stock and trade of illegal abortion providers before Roe v. Wade. And that’s something very important for your listeners to understand that Roe v. Wade did not start abortion in America. Abortion has been with us as long as pregnancy has been. Indeed, studies done before Roe v. Wade estimated that anywhere from 600000 to one point two million illegal abortions were done annually in the United States. So what Roe v. Wade did was not so much to increase the numbers of abortions, but just move them to the back alley into safe care even when abortion was legal. 

You write that rich women still manage to have safe illegal abortions while poor women had to suffer with the back alley providers. How did rich women go about getting those those safe but illegal abortions? 

I think Gloria Steinem’s account of how she managed to go to England to get a safe abortion back in the pre road days is typical of women who had money and had connections, could find a safe provider either here in the United States or could go to a place like Cuba or Sweden where abortion was more widely available. So it remains a very classes business even today. And we’ve seen this especially since the Hyde Amendment, which is profoundly discriminatory. The majority of abortion patients today are women who are poor and their operation in many ways. And so this discriminates against those in our society who are the most vulnerable. 

Can you talk about the three eras of abortion access? 

And in U.S. history so far, the three areas would be a pre ROE in which abortion is widely done but dangerous. Then we had the second phase, which was regional availability. Those be the early 1970s. In those years, what I call the sandwich year, almost all abortions were performed in just two states, New York and California. What that meant was long distance travel for abortion patients, which came at a terrible price. And then the third phase or the more widespread availability after Roe v. Wade in 1973. But now I think we’re starting into a fourth phase, which will be the retraction of abortion access, as we’re seeing, for example, in Texas and Ohio. 

What do we know about sort of the history of the original criminalization of abortion in the US? What were the reasons put forward for doing that? Was it a religious thing? Was it a public health thing? And the rationale? 

Well, it’s ironic because the American Medical Association was very active back in the late middle and late eighteen hundreds and trying to make abortion illegal because doctors of that era saw the terrible carnage that was being caused by untrained, unskilled, dangerous practitioners. The irony is that a century later, they they took a up pull. Roberts’s opinion saying it’s time now to take this away from unsafe practices and let gynecologists and others provide safe abortion care. So it’s purely based on public health. Public health was the driving force 100 years ago, and then more recently, it did. 

Safe abortion care exists in the eighteen hundreds. Did doctors have the technology in those days to give relatively safe abortions if they’d wanted to? 

No, they really didn’t. Again, women have tried throughout the centuries, throughout the millennia to induce abortion. But the methods were quite ineffective and often dangerous. For example, the Kurata, an instrument used by a gynecologist to do a DNC sharp Kuratov, wasn’t invented until the mid eighteen hundreds by a Frenchman named were me. So the tools weren’t really widely available. Surgical abortion got a jumpstart in the 1960s with suction critize, which is a vacuum procedure. 

And then medical abortion came several decades thereafter and we’ve come to associate abortions with clinics and hospitals. But is it true that some terminations can even be done safely in a doctor’s office? 

Oh, absolutely. And in the early years, a number of abortions were done in doctors’ offices. The magic is in the magician, not in the wand. And that’s not really widely understood that if you’ve got a skilled provider, he or she can do a safe abortion in almost any setting, almost any setting. And you don’t need all the trappings of a hospital in an operating room or ambulatory surgery center to provide a safe abortion. It’s a matter of the skill of the practitioner. 

What does a typical early abortion look like medically? I think people have a lot of misconceptions about how much anesthesia and cutting and bleeding and stuff might be involved. 

Well, it’s one of the most common procedures in the United States. Indeed, one out of every three American women has been down this path in her lifetime. So it’s very, very common. And it’s also very minor procedures, though, medically. Most of women who have abortions have it done within the first eight weeks of pregnancy, a time at which the embryo is so tiny. You can’t even see it. You’re naked eye for a surgical procedure. A woman will commonly get counseling, have a brief physical and history taken. She’ll then receive pain killing drugs. She’ll have local anesthesia. The cervix is open to a small diameter. By that I mean about the width of a pencil and a small suction to this place in the uterus. And the contents are aspirated. In a minute or two, patient waits of half an hour to 45 minutes and then goes home, usually with contraception for medical abortion. The woman receives the counseling, an examination, and then she receives a pill or several pills to take and then takes more at home, essentially inducing a medical miscarriage. The bottom line is that both these procedures are exceedingly safe and very effective. 

What’s the rate of complications and how does it compare to something like wisdom, tooth removal or colon ASCAP or other things that are done outside of hospitals routinely? 

Abortion is extraordinarily safe. The risk of having complications in a few percent. And if a woman does not have an abortion or have a spontaneous miscarriage, she then goes on to have a delivery, which is dramatically more dangerous. Indeed, according to most recent data from the CDC in Atlanta, the risk of having one or more complications during pregnancy, childbirth or the postpartum period is 60 percent. That’s six zero given about four million births a year in this country. That translates into more than two million women suffering pregnancy complications each year. The number of women suffering abortion complications is tiny with regard to other procedures. It’s probably the same risk as poll and ask to be or having dental work done here in North Carolina, where I live a couple of years back, we had two deaths in dental chairs. So we have an at a death from abortion in the state in decades. 

Kind of interesting in the sedation. Dentistry is getting more and more popular and deaths are going up with it. Whereas you write in the book that with abortion care as a species getting less and less invasive or has gotten less and less invasive over the history of the procedure so that you’re not getting those same kind of anesthesia complications that are rising in dentistry right now. 

Exactly. The problem is lack of adequate supervision of patients who’ve received intravenous drugs in a dentist office. They have very careful monitoring in an abortion clinic or operating them with trap laws. 

And what role are they playing in in abortion regulation these days? 

Trap is an acronym for targeted regulation of abortion providers. And these are laws primarily at the state level, which are designed to restrict access to. And deprive women of their constitutional rights to abortion. They’re all done under the banner of patient safety, but that’s a specious notion. Very few politicians and these are all Republicans. Very few of them have the honesty to acknowledge what the ultimate goal is, and that’s to make abortion unobtainable. But they come in many forms ranging from provision of specifications for how wide your quarters must be, how big the operating room has to be, how many air exchanges per hour. All of these things have nothing to do, nothing to do with patient safety. They’re all about making the hurdle so high that providers and patients can’t provide care. He can’t receive care. 

What is the rationale? I keep hearing about this corridor with requirement for ambulatory surgical centers, which are, you know, the kind of facilities millions of dollars can place. And you could do coronary bypasses out of hospital. But why does even the ambulatory surgical centers need these corridors? 

That would be for access for a wide stretcher, for example. I’ve worked in the military surgery centers and they do the full range from, you know, surgery on one seat and open surgery, mastectomies. All sorts of things are done in an arbitrary surgery centers. And you need very wide hospital kinds of beds to move through the doors and in the hallways. That’s not true for an abortion. I worked at the Centers for Disease Control and Prevention for a number of years. And one of my jobs was to investigate every abortion related death in the country. So I know about how women can and rarely do die from abortion. I can say with certainty, with absolute certainty that no woman in America is ever died from an inadequate width of a quarter in abortion clinics. 

How about those janitorial closets? I understand that balancing. 

Exactly. That’s a very big leap of faith from suggesting that having a designated janitor’s closet or designated changing room for medical staff is going to have any impact at all on a woman’s safety during an abortion procedure or the number of air exchanges, six air exchanges per hour. It’s total nonsense. Again, the the underlying objective here is to make abortions so expensive and so impractical that women cannot exercise their constitutional rights that they’ve had for over four decades. So it’s a very ugly tactic that all has come to us since the Planned Parenthood v. Casey decision in 1992. 

The Supreme Court announced recently that they’re going to hear a challenge to Texas law, which involves an ambulatory surgical center requirement. What do you think is going to happen? 

I’m optimistic that the court will rule that these Trappe laws are unconstitutional. The Casey decision said in 1992 very firmly that constitutional protections guarantee a woman access to abortion. They reaffirm Roe v. Wade, but they had some very, very unfortunate language when they said that states cannot have laws that pose an undue burden on the woman’s access. But undue burden is hopelessly vague term. And since 2010, Republican legislatures across the country have created an epidemic, a literal epidemic of trap laws designed to minimize or prohibit access to abortion, because they’re saying, well, these are in the patient’s best interest, but they’re not. Because you’ve already seen in a recent report out of Texas where these trap laws have been particularly onerous. The estimates are that more than 100000 Texas women, primarily poor Latina women, have tried to abort themselves. So what the Republicans are trying to do is to return women to the back alley. I lived through that era and we should say never again. Never again. Never again. 

Is there any kind of epidemiological research? And I know that the famous Texas study was done by Dan Grossman and his reproductive health think tank. But is there any epidemiological effort for it to sort of track women coming into emergency rooms with things like self reported, attempted misoprostol abortions? 

To my knowledge, there’s no systematic assessment of this at present. However, I can report that these sporadic reports are popping up in the emergency medicine literature, women trying to abort themselves with old abortifacients like quinine tablets or inserting foreign bodies in the uterus. There are also reports of women shooting themselves in the abdomen with pistols. These are the kinds of desperate things that women will do and state legislatures have. 

There’s been a rush also to criminalize women’s behavior during pregnancy on the assumption that having a less than optimal pregnancy outcome represents the same thing as abuse to a born child. 

It’s part of the same broad spectrum of misogyny of many people in our society. The Republicans in particular view women as some kind of Tupperware container, or, as Katha Pollitt described in her recent book, Potting Soil. They deny the fact that women are autonomous, constitutionally protected, full citizens in our society. They view them as something less. It’s it’s a profound manifestation of misogyny. It needs to be called that. We need to use the N-word. It’s a. Disrespect or disdain for women, which is the definition of misogyny. 

Do you feel that anti-abortion rhetoric has stepped up in recent months and years to the point where, you know, mainstream anti-abortion groups are flirting with some really incite story language, rather, you know, in terms of baby killers and that kind of thing? 

Absolutely. And I think this summer is a good example with the surreptitiously filmed and heavily edited films about Planned Parenthood and other providers, which has then fueled the flames. We’ve seen it in Congress. We’ve seen in state legislatures demonizing abortion providers and then women who have abortions that most recently manifested by the tragedy in Colorado Springs. Here was a man who was clearly a religious zealot. I had previously vandalized a Planned Parenthood clinic in Charleston, South Carolina, and bragged about it, and then he was pushed over the brink into murder. It’s a tragedy, as pointed out by Katha Pollitt recently and just today in the Philadelphia Inquirer by Johanna Schoen. Words matter in ramping up. The language clearly pushes some of these people who are not mentally competent or not stable, but they’re well armed into violence. 

Do we know anything else about deer in terms of his assailant, in terms of his connections to any kind of organized anti choice groups? 

I’ve seen nothing in the literature in the last few days from what I’ve been reading. But he clearly had a standing opposition to abortion. I was a staunch opponent of abortion, according to one of his ex-wives. He was a violent man and a cruel man and had bragged about the fact he had glued locked shut at the Planned Parenthood facility in Charleston, South Carolina, some years before. So this man was a man on a vendetta who’s also a Goldstar misogynist, by all accounts. He has a history of had several wives and he beat them. He was a terrible, terrible abuser of women. Again, I think that shows prima facie evidence of misogyny. Anyone who would treat a wife in that way is is despicable. 

When you were working as a provider, did you have to deal with threatening and hostile protesters? 

Yes, I think any of us who have worked in clinics have been exposed to harassment and intimidation. I’ve been picketed at home in two different cities. I’ve had kidnaping threats, have had obscene phone calls, hate mail. I left my job at the CDC in the mid 1980s after my writings were centered by the Reagan administration. I’ve had to walk through the picket lines and deal with it. My name was on the Nuremberg Web files site for a number of years, were an implicit invitation for someone to kill me. George Tiller was murdered several years ago in his own church. He and I were friends and we started providing abortions about the same time. So all of us who were involved in this field are under threat at all times. 

And as somebody who’s taught a lot of young medical students and residents in abortion care. Do you feel like it’s getting more difficult for doctors to pass on those skills to the next generation? 

Indeed, I think your point is well taken. They may be motivated, but they made the same time be intimidated or concerned about the security of their families. Some of these folks, will these picketers or protesters will follow people home and threaten their children, things like that, which are really abhorrent. It’s really despicable. Plus, it doesn’t pay very well either. For example, when I was leaving Atlanta, I tried to get some of my former residents to fill in behind me at the clinics I’ve been working at. And they told me, quite frankly, we’re certainly committed to the field, but we can make more money in our offices seeing vaginitis with no threats. The McCambridge in the clinic. 

Can you talk a bit about your work at the CDC and how you went about monitoring whether the national abortion system is working and safe? 

The Centers for Disease Control started to investigate all known deaths from abortion in the United States in 1972. That would include spontaneous, illegally induced and legally induced. And that surveillance system continues to the present time. Now, they’re certainly going to be some underreporting, but there’s always underreporting of maternal deaths of any ilk. The CDC also involved with a very large scale, a national study of abortion complications called the Joint Program for the Study of Abortion and the Population Council in New York City, started it at the CDC, then continued it through 1978. And between the three phases of that study, they gathered almost a quarter of a million detailed individual case reports on abortion. And those two studies, the surveillance of abortion deaths in the study of abortion complications, dramatically improve the safety and effectiveness of abortion care in the 1970s and 1980s. 

So with that, the research that popularized some of the new safer surgical and anesthetic techniques. 

Yes, indeed. One of the most important was the discovery that one could do surgical abortions in the second trimester. As recently as when I was a resident. I was taught that one could not do a surgical abortion beyond two a week. Just couldn’t be done. But when we began looking for the scientific basis for that, we could find none. He was apparently a holdover from the era of illegal abortion. What we found in this joint program, but the study of abortion was that pioneering providers out in the private sector had been doing this, not just doing them, but very safely, indeed, safer than the alternative, which was a labor induction of abortion. So almost overnight, labor induction abortion disappeared from the American scene in the 1970s. 

What is partial birth abortion and how did it become a legal category? 

Well, partial birth abortion is a nonentity. There’s no such term. It is a new low jism that was conducted by anti-abortion activists. It’s been a resounding public health success for them, but it’s a conflation of diametrically opposed terms, birth and abortion. The same phrase which is contradictory to what it is, essentially is surgical procedure in which the cervix is dilated and the fetus is delivered intact. That’s it. And in an anomaly, this is now illegal. The United States Congress declared this being illegal as of 2003, which is the first time, to my knowledge, in United States, the Congress has declared a surgical procedure illegal. And to my knowledge, according to my reading, the Constitution, they are not even authorized to do that because regulation of the professions is delegated by the Constitution to the states. 

So this is another example of congressional overreach to self regulating professions. 

Indeed, unless one views the practice of medicine as interstate commerce. But I, having practiced medicine for more than four decades, have a different view. I think that practicing medicine is different in interstate trucking. 

Well, it certainly seems like the regulatory oversight that it is just the system that self-governing, that we accept that there are self-governing professions that are supposed to set those standards rather than legislators who have no particular technical expertize in medicine or public health necessarily. 

Exactly. Plus, it’s what I call public health perversion. In public health, we identify a problem, formulate solutions, implement those and then monitor the success. Here we had a very brisk legislative response to a nonproblem. Abortion in the second trimester is extraordinarily safe, much safer than the alternative of not having an abortion. So here we had the regulation of a nonproblem and that’s a total waste of government resources. 

And then you have these these restrictions that are forcing women to travel and then therefore move later in their pregnancy, and it is true, right, that second trimester abortions have a much higher rate than first trimester abortions, that it’s better and safer to get it done as early as possible. 

That is correct. The maxim is the earlier, the safer and also the less expensive. There is no abrupt cut point, but just a continuum to further along in pregnancy. A woman is the greater is her expense and the greater is the risk of complications, including rarely death. So anything, anything that delays a woman seeking an abortion, whether the travel difficulties, trying to gather the money for the procedure, mandatory waiting periods. We have a three day waiting period here in North Carolina. All of these have the net effect of increasing the risk to the woman. And that defies the ethical principle of beneficence. Thus, it’s unethical. All these laws that delay women are themselves unethical. And we physicians, we health care providers must reject them. 

Also, the idea of waiting periods flies in the face of the principle of autonomy ethically, too. 

You’re right. These trap laws and things such as mandatory waiting periods or hospital privileges violate all three of the ethical principles of beneficence, meaning doing well for our patient’s autonomy. I mean, the woman can make a free choice based on the best available evidence and justice, equitable distribution of health care resources. And that’s certainly not the case in places like Ohio and Texas, where the legislators say, oh, no problem, she can just drive in New Mexico, which is right next door. 

What does history teach us about the effects of huge interstate travel for abortion access? 

Well, we know that these will have the effect of delaying women in the attic dramatically to the cost. Imagine if you’re living on a McDonald’s wage trying to support a child. And most women who have abortions already have one or more children at home. So imagine how you’re going to pay for this. Plus, overnight travel. It’s it’s just mind boggling. I mean, someone is going to be deprived Brett’s shoes for school or food for the table. So it’s terribly, terribly punitive, especially for poor women and women of color. The important point is if you make abortion safe and legal, women’s health improves, you can make abortion inaccessible. The opposite occurs as happened in Romania. 

What are some of the effects that the legalization of abortion has had on the health of women and their and their children? 

The effective legalization of abortion was beneficial for both women, their children and families. Of the risk of death from abortion dropped precipitously in the 1970s. Indeed, nationwide. In a nation of over 300 million people, there are only about 10 abortion deaths every year in this country. In contrast to hundreds of deaths related to pregnancy and childbirth, the risk of dying from childbirth today is about 16 per 100000 live births. The risk of death from abortion has been less than one for decades now. So a dramatic difference there. Spacing children further apart improves the health of children and that of the family. And being able to control one’s fertility is fundamentally important for the security of the family and the health of the family, both financially and otherwise. So in every respect, abortion has been a profound moral good. It’s been a medical good. It’s been a social good enhance. It puzzles me as a doctor to hear people demonizing this very common, very safe and very normal procedure. 

Is a really chilling case study in the book about the experience of Romania with abortion bans. Can you tell us about that? 

In the 1950s and 60s, Romania, like most Eastern Bloc nations, had easy access to abortion. And when you ask who came into power, he clamped down on that, made abortion unobtainable because he wanted more workers for the proletariat. What happened was that the birth rate remained very little in the years thereafter. However, the maternal mortality ratio in Romania climbed to be the highest in all of Europe. Women were clearly controlling their fertility, but they were doing so by reverting to the back alley once again. They literally were paying for this with their lives. And then when Kaczynski was deposed in the parliament, introduced abortion the very next day, birth remate rate remained largely unchanged. But the maternal mortality rate plummeted. 

One striking thing about that case study was the fact that there was a surveillance state of women and their menstruation and possible miscarriages. That sort of reminds me of some political stuff that’s going on in the U.S. these days. 

You’re right, that notion of pregnancy police which actually monitor women known to be pregnant, to make sure that they they didn’t do anything to interrupt the pregnancy, is very, very frightening scenario. We’re now starting to see some states impose on women with claims about doing harm or taking drugs that might damage a pregnancy. Again, it’s. Only profoundly do Sipek full of women. The notion they are nothing more than breeders or incubators. 

It seems I mean, the composition of the Supreme Court is fixed for now and I think pretty unlikely to change in the near future. What do people do now to to advance abortion rights in their state? 

I think it’s important to be active. Carl Sagan, one of my heroes, talked about the dangerous combination of ignorance and power today. I think there’s another very frightening image, and that’s the combination of misogyny and apathy. And to a large extent, abortion has become illegal. Abortion has become a victim of its own success. An entire generation of Americans, women in particular, have grown up unaware, unaware of what the bad old days were like, and thus they are not frightened about the prospect of returning to them. Since the 1980s, that the Republican Party has had an official plank in its platform for a constitutional amendment to overturn Roe v. Wade, with no exceptions, no exceptions for rape, incest or life endangerment period. 

They want to return American women to the back alley once again and invariably want no restriction for even the life of the mother. No exceptions, no provision for them. 

Like, look, you can look it up on the Web in the 2012 GOP platform. You just Google it. There’s no mention in there for any exceptions. Period. They’re willing to have women die and suffer in large numbers for political reasons. They simply don’t respect women. American women need to wake up and understand what the Republican Party is doing to them. They need to get politically active. They need to speak out. They need to vote. They need to vote against people who are undermining their constitutional rights. 

That’s all the time we have. Thank you so much for coming on the show. My pleasure talking with you. 

Lindsay Beyerstein

Lindsay Beyerstein

Lindsay Beyerstein is an award-winning investigative journalist and In These Times staff writer who writes the blog Duly Noted. Her stories have appeared in Newsweek, Salon, Slate, The NationMs. Magazine, and other publications. Her photographs have been published in the Wall Street Journal and the New York Times’ City Room. She also blogs at The Hillman Blog (http://www.hillmanfoundation.org/hillmanblog), a publication of the Sidney Hillman Foundation, a non-profit that honors journalism in the public interest.