Dr. Toub Discusses the Safety of at Home Abortions.
Question: Molly, on her blog Molly Saves the Day, has posted at home abortion instructions. If there came a time that abortions were no longer legal, could someone without any medical training perform an abortion following Molly’s directions? What would be your concerns about someone having an at home abortion without trained medical assistance?
Dr. Toub: The blog post on abortion technique was well meaning, to be sure. But as I responded on that blog, I have some concerns. In theory, yes---it is possible for a nonclinical person to perform an abortion. But I would say that it is also possible for anyone to perform an appendectomy; indeed, it’s been done. Just because something can be done doesn’t mean that it should be done. Abortion, particularly early suction curettage, gives the impression of not being a very difficult procedure. It’s fast, very safe and highly effective. However, impressions can be misleading. Ninety-nine times out of one hundred, everything goes very smoothly. But it’s that one time that can be associated with complications, some of which are very serious, even deadly. Surgical abortion in and of itself is not that difficult to do, although there’s a bit of an art to it and is more challenging in the second trimester, particularly since it is essentially a “blind” procedure when ultrasound is not used, which is how it’s generally done. The real skill comes in with regard to preventing, recognizing and managing those infrequent complications. I used to tell residents that anyone can teach a monkey how to operate; the real skill in surgery involves clinical judgment. The same is true of surgical abortion---it is feasible for nonclinicians to do it, but without question the risks are greater in terms of infection, incomplete abortion and uterine perforation, and even more importantly, it’s not clear to me how effectively those complications would be recognized and managed.
I look at it this way: all of us who are well-trained to provide abortions and who have considerable clinical experience still have complications. About once a year, the average experienced abortion provider may perforate a uterus. Indeed, a pregnant uterus is much more easily perforated than a nonpregnant one. When managed appropriately and in a timely fashion, such perforations may heal without any long-term complications. But we know from many papers in the literature that abortion-related complications decrease with experience. So if the best abortion providers still have occasional complications, nonclinicians who may provide such procedures on an infrequent basis will undoubtedly have a higher incidence of complications. Very importantly, some of these complications won’t even be recognized in a timely fashion. Some ectopic pregnancies will be missed because the well-meaning nonclinician will not know how to examine fetal/embryonic tissue to ensure completeness of the procedure. Subtle signs of uterine perforation will not be recognized, certain abortions that are best dealt with under ultrasound guidance would be done without such equipment, and there is no facility to deal with some other complications that could arise, including bleeding.
There are other important issues, namely pain management, estimation of gestational age and follow-up. Abortions are not comfortable procedures. While I know that they are often done using nothing more than a paracervical block, I’m not convinced this is adequate in all circumstances, and the level of pain control can vary depending on how the block is done. While early menstrual extraction generally does not require cervical dilatation, which is perhaps the most painful part of the procedure, later abortions certainly do. While this could be gotten around through the use of osmotic cervical dilators such as laminaria, how many people would feel comfortable inserting them properly without any training? Hopefully none, because they shouldn’t feel comfortable. Even ob/gyn residents and some attendings may not do it right.
Estimation of gestational age is critical. In trained hands, this doesn’t require ultrasound, but even some skilled gynecologists have blown it, thinking they were dealing with an 8-week pregnancy when they really had a midtrimester pregnancy on their hands. I’d also want to make sure that the woman had a reliable pregnancy test- in the first place; no point in assuming this risk if the patient isn’t pregnant. Follow-up is also very important to make sure that the abortion really was complete, uncomplicated, etc. And let’s not minimize the need for good, skilled counseling. That’s something that a trained professional is best at.
Question: Slate’s article, The Road From Roe. (3/4/2006) discusses how medical technology might help to resolves some of the issues around Roe. Do you think advances in medical technology will help to resolves some of the issues around Roe?
Dr. Toub: Aside from advances in contraception, I’m not sure they will. The author of the Slate article, which I enjoyed reading, is possibly a bit too optimistic in this regard. Abortion after the first trimester may be made less frequent through tools we already have: a simple pregnancy test. Were pregnancy diagnosed as soon as possible and the woman could avail herself of an abortion provider in the first trimester, then there would be less of a need for the less socially-acceptable second trimester procedures. But not all women learn that they are pregnant in the first trimester. Teens in particular are not always as in touch with their bodies, nor are their cycles typically regular, so I’m hard pressed to see how technology will solve that situation. Indeed, it’s not uncommon for many people from both sides of the political divide to “blame” the woman for not recognizing her pregnancy sooner. But given that some women have irregular cycles, it’s unfair to blame anyone. And also remember that for some people, abortion at any point is unacceptable, even in the first trimester, so technology won’t solve that issue aside from making birth control more effective.
Question: How concerned are you, as a doctor, about women’s access to resources that would make abortion less necessary, such as sex education and birth control?
Dr. Toub: This is something that greatly concerns me. The way you reduce abortions isn’t by making them illegal, but instead by making them less necessary. Increased access to sex education that discusses all options, not just abstinence, and ensuring access to contraception, including emergency contraception, is something that people from all points of view should be able to find common ground upon.
Question: Considering the current political and legal environment, from a medical perspective, what should women be concerned about and what action should we take to protect ourselves if Roe is overturned?
Dr. Toub: First, the worst thing to do is panic. At this time, I suspect that there is little interest in reversing Roe among the right wing. They know it will cause a firestorm, and probably lead to a political backlash, which is what the Slate article proposes and I concur. I do believe that reversing Roe, from the perspective of the other side, is quite unnecessary. Why go through all that tsuris when you can simply make abortion almost impossible to obtain in most states very easily? Using onerous TRAP (Targeted Regulation of Abortion Providers) laws on a state-by-state basis, making it more difficult to obtain abortion training in residency programs, etc., is a strategy that is working quite nicely, unfortunately, for those on the other side. And they’ve augmented it by spreading disinformation, using terms like “partial-birth abortion,” “late-term abortion” that do not exist in clinical medicine and are essentially meaningless, but make it sound as if abortion providers are committing feticide and providing abortions at 36 weeks’ gestation.
Question: What one thing would you say to a young woman about why it is important that she protect her reproductive rights?
Dr. Toub: When you lose a right, you never get it back. Ever. There will always be a need for abortion, and without the right to control one’s reproductive destiny, one is never really free.
Question: You have a very interesting blog, where you write about diverse topics, such as medicine, politics, music and IT. Why do you blog?
Dr. Toub: I got involved in blogging towards the end of 2003, in part because I put up a Web site for my family and wanted to add items to it, and mostly because I thought it was an interesting medium. I didn’t think anyone really would care that much about what I might think about something, and still don’t. But I have a lot of interests, including new music (I also compose, and contribute to a blog for new music composers called sequenza21 ( https://www.sequenza21.com/forum.html )), information technology and politics, besides medicine, and thought it would be helpful from time to time to get some information out there, such as if I am using a new piece of software or if I want to get the word out about something in medicine or politics. Also, it’s fun to do, and interesting to see where people are coming from. I get occasional readers from Mongolia, Iran, the UAE, and many other countries, and it always boggles my mind as to what is possessing them to come to my very low-end blog.
Dr. Toub is a Fellow of the American College of Obstetricians and Gynecologists and a Diplomate of the American Board of Obstetrics and Gynecology. After postgraduate medical training in obstetrics and gynecology at Brigham and Women’s Hospital, Massachusetts General Hospital and Albert Einstein Medical Center, Dr. Toub completed a fellowship in pelvic surgery at Graduate Hospital He served as an attending physician at Pennsylvania Hospital, where he held teaching appointments at both Thomas Jefferson University and the University of Pennsylvania. In 1995, he received the Champion of Choice award from Pennsylvania NARAL.
Dr. Toub is Chief Medical Officer at MedCases, a company in Philadelphia that develops online continuing medical education for physicians. He received AB and MD degrees from the University of Chicago, and earned an MBA with a concentration in management information systems from Drexel University. He has been the author or coauthor of several peer-reviewed papers. In addition to his professional activities, he is a board member of the Philadelphia ACLU, a volunteer for ActionAIDS, and remains active in the reproductive freedom movement. Dr. Toub’s personal Web site, including his blog, is at https://homepage.mac.com/dtoub .
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