Reporting

What This Later-Abortion Story Tells Us About a Post-Roe Future

May 31, 2022 | Garnet Henderson | Nation

In October of 2021, Kristyn Smith checked herself out of the hospital in Charleston, W.Va., where she had been denied an abortion. Bleeding and in pain, Smith drove for six hours with her fiancé to Washington, D.C., to have the procedure performed there. On the day of her first appointment at the Dupont Clinic, she was 27 weeks pregnant. “They were the sweetest, most compassionate people that I had ever met,” she said of the clinic staff, who made her feel safe and supported. The seven weeks leading up to her arrival there, however, had been a “nightmare.”

Less than two months after her abortion, Smith contacted me after finding my podcast, ACCESS. She sent an e-mail with the subject line “Abortion at 27 weeks” that detailed her story of agonizing delays and denials of care. In many parts of the country—particularly in the South and the Midwest—getting an abortion at any stage of pregnancy is difficult because of the dwindling number of abortion providers, the onerous legal restrictions, and other financial and logistical barriers. But getting an abortion later in pregnancy, particularly in the third trimester, is difficult everywhere. Twenty-two states have bans in effect that prohibit abortion starting between 20 and 24 weeks’ gestation, and 20 states impose a ban at viability, generally recognized as 24 weeks. When exceptions to these bans exist, they are often narrowly applied, and in the handful of states where third-trimester abortion is legal, there are few providers.

According to a 2014 Guttmacher Institute report, while 72 percent of abortion clinics offer care up to 12 weeks, only 25 percent offer care up to 20 weeks, and just 10 percent offer it through 24 weeks. Following the 2009 murder of Dr. George Tiller—who was relentlessly targeted by anti-abortion extremists for more than a decade because he provided abortions in the third trimester—very few doctors are willing to openly provide this care. A small number of clinics provide abortions at 26 weeks and beyond; all are independent, meaning they are not affiliated with Planned Parenthood and therefore have less public and institutional support. Hospitals are more likely to provide abortion care later in pregnancy; however, hospitals perform only about 4 percent of all abortions in the United States, and many have policies that limit abortion care.

Any day now, the Supreme Court is expected to issue a ruling that could overturn Roe v. Wade or gut it beyond meaning. In that event, 26 states are poised to ban abortion to the fullest extent possible. Many things have changed profoundly since the pre-Roe days; perhaps most significant, illegal abortions can be medically safe thanks to the advent of medication abortion. However, anti-abortion policies still endanger lives, as in Smith’s case, by delaying or denying care in life-threatening situations. What’s more, research shows that most people who need abortions later in pregnancy experienced logistical delays in accessing care at an earlier point in the pregnancy. These delays will only compound if abortion is banned in roughly half the country, because thousands of patients will be forced to travel across state lines to the few remaining clinics. The number of people seeking later abortions is undoubtedly about to increase, and our medical system is unprepared to care for them.

Smith’s pregnancy was a wanted one. She knows that stories like hers—involving fatal fetal diagnoses and health risks—are often presented as exceptional and used to undercut the needs of people whose reasons for seeking an abortion may be less sympathetic to some. Smith is unequivocal that later abortion patients deserve care regardless of the reason. “Abortion is health care; it is needed,” she said. “It saves lives, even if not physically like mine.”

Smith discovered she was pregnant just over six months after giving birth to her third child. The pregnancy was a surprise, but it quickly became a happy one. Smith and her fiancé picked a name: Kase. “We were ecstatic,” she told me.

In the early ultrasounds, Smith said, “everything was perfect and healthy, just as in my other three pregnancies.” But during her 20-week anatomy scan, things took a turn. Kase’s kidneys and bladder were dilated, and very little amniotic fluid surrounded him. Without enough amniotic fluid, the lungs cannot develop properly. The fluid also cushions the fetus and allows it to move, so low levels can result in restrictions on growth and other musculoskeletal complications.

Smith’s ob-gyn referred her to a team of maternal-fetal medicine (MFM) specialists in Cincinnati, a three-and-a-half-hour drive from her home. Smith lives near Charleston, which is one of West Virginia’s largest cities but has a population of less than 50,000. Nearly all of the MFM specialists in the US—particularly those practicing cutting-edge techniques like fetal surgery—reside in urban areas, which poses a significant barrier for those with high-risk pregnancies in rural or smaller metropolitan areas, who may not have the means to travel. According to a 2020 report from the March of Dimes, 2.2 million women in the US live in maternity care deserts.

Smith made two trips to Cincinnati, initially hopeful that she might be able to continue the pregnancy with the help of fetal surgery. “Looking back,” she says, “I was naive.” Only after speaking with the specialists did Smith realize just how serious the situation was. Kase’s urinary tract appeared completely blocked, and as a result his lungs were severely underdeveloped and his heart looked small. Even if surgery successfully corrected the obstruction, it would be a difficult road ahead.

“He would have been in the NICU up in Cincinnati for at least six months,” Smith said. “And that would have been with 10 to 20 surgeries in his first year of life, [and] monthly doctor appointments back up in Cincinnati. And to put my three kids’ lives on hold for that? My relationship with my fiancé, my whole life would have been turned upside down. And we’re not wealthy. We don’t have money to do those things.”

Still, they tried. Smith underwent tests and procedures in preparation for the surgery, but there were complications during one of the procedures. The doctors told Smith she wouldn’t be able to have the surgery the following week as planned. By this time, she was 23 weeks pregnant. They counseled her on her options, including terminating the pregnancy or allowing “nature [to] take its course,” meaning that she could go home and wait to have a stillbirth.

However, even though the doctors assured Smith that the decision to end the pregnancy was a valid one, the hospital never offered her that option. The state of Ohio bans abortion at 20 weeks postfertilization, or about 22 weeks’ gestation, with an exception only for the critically compromised health of the pregnant person. At the time, Smith’s diagnosis had to do only with the fetus’s health, not her own. Even so, there are risks in continuing any pregnancy, said Dr. Matthew Reeves, the founder of the Dupont Clinic, where Smith eventually got her abortion. “Forcing someone to continue and endure those risks when you know there’s going to be a lethal outcome for the newborn is not a wise decision,” he said. But abortion bans rarely account for these nuances.

“Many people I’ve interviewed who had a fetal health issue assumed [their state’s] abortion ban wouldn’t apply to them, and yet it did,” said Katrina Kimport, a medical sociologist in the Advancing New Standards in Reproductive Health (ANSIRH) program at the University of California, San Francisco. “And in practice, people are denied care even when they ought to fit into those exceptions.” For Smith’s part, she felt there was an implicit judgment in the fact that she was told she could have an abortion but wasn’t offered that option directly. “It wasn’t really put on the table as it should have been,” she said.

Many elements of Smith’s story reflect experiences that are common among people who have abortions in the third trimester. For a recent journal article, Kimport interviewed 28 people who had abortions after the 24th week of pregnancy. When people have abortions at this point, they tend to arrive there through one or two “pathways,” she said.

The first pathway is initiated when new information is obtained during, or just before, the third trimester. Many diagnoses related to fetal health cannot be made until the middle of the second trimester or into the third. New information might also be related to the health of the pregnant person, as well as to a later recognition of the pregnancy. “There is a persistent and small number of people that do not recognize their pregnancy until somewhere in the third trimester,” said Kimport, adding that preexisting health conditions often play a role.

The second pathway to third-trimester abortion comes about as a result of barriers to care. These include a lack of funds to pay for an abortion, a lack of access to nearby care providers, an inability to get time off from work, and other roadblocks. “Some people also experienced less common but nonetheless pretty serious obstacles, including things like being prevented from leaving their home by a parent,” said Kimport. In a previous paper based on data from the Turnaway Study, which tracked the long-term effects of having or being denied an abortion, Kimport and her coauthor, Diana Greene Foster, found that 94 percent of the participants who had abortions at or after 20 weeks experienced a delay in accessing care.

In a situation like Smith’s, new information can itself be the cause of delays. An abnormal finding on an anatomy scan often leads to further tests and visits with specialists, Reeves said, which means it can be weeks before a person knows whether their pregnancy will ultimately be viable or not.

For Smith, the waiting became unbearable after she was sent home to West Virginia, which has a law that is nearly identical to Ohio’s, banning abortion at 20 weeks postfertilization. The West Virginia ban does include a vague exception for a “nonmedically viable fetus”; however, the state’s sole remaining abortion clinic performs abortions only up to 17 weeks and six days. Smith’s obstetrician wasn’t willing to intervene as long as the fetus had a heartbeat, but the heart never stopped. With each weekly ultrasound, Smith felt more distress. Her Cincinnati doctor’s description of the condition disturbed her. “His exact words were ‘Imagine if you were wrapped in Saran Wrap, vacuum sealed, then wrapped again in a thick, tight blanket. That is what your baby is experiencing with no liquid around him.’ With every kick…I broke down, knowing my baby was struggling to move, and how uncomfortable he had to have been since week 16, when this abnormality typically occurs,” she said.

Finally, a midwife told Smith about the Dupont Clinic. She took the first available appointment, which was two weeks away. Because abortion is legal at all stages of pregnancy in D.C., people from all over the region who need later abortions travel there when they are unable to obtain care where they live. Reeves estimates that at least half of the clinic’s patients come from more than 100 miles away. “Some weeks it’s 70 or 80 percent,” he said. The clinic’s website states: “We do not require any particular ‘reason’ to be seen here—if you would like to terminate your pregnancy, we support you in that decision.”

But then, about a week before her appointment, Smith started bleeding. She described the blood as coming in “gushes” accompanied by sharp pain, comparable only to what she had experienced during labor. After two days, Smith’s obstetrician admitted her to the Charleston Area Medical Center (CAMC) Women and Children’s Hospital for monitoring. There, she was placed under the care of an ob-gyn named Byron Calhoun. As reported by Caroline Kitchener in The Washington Post, Calhoun is well-known for his anti-abortion views. A former president of the American Association of Pro-Life Obstetricians and Gynecologists, Calhoun is an outlier even among physicians who oppose abortion: He believes abortion is never necessary to save the life of a pregnant person. In fact, he advocates cesarean sections to deliver fetuses that won’t survive birth, a practice most experts consider not only dangerous because of the risk to the pregnant person, but also unnecessary.

Calhoun also has a long history of trying to discredit abortion providers. In 2013, he called a former patient up out of the blue, gave her the phone number of a lawyer, and encouraged her to sue an abortion clinic and its doctor. Calhoun told the woman something shocking: that he had found a 13-week fetal skull in her uterus while treating her for pain and bleeding following an abortion the previous year. However, she had been only nine weeks pregnant at the time of her abortion, and Calhoun had said nothing about a skull at the time. The woman did sue, but a pathology report from CAMC found no evidence of a fetal skull. In dismissing the lawsuit, the judge called Calhoun’s assertions “sensational.”

Also in 2013, Calhoun claimed that he was caring for patients experiencing abortion complications on a “weekly” basis. The claim was dubious on its face, given that such complications are rare. One of the most comprehensive studies on the subject found that minor complications, such as bleeding and mild infection, occur in about 2 percent of abortions. Major complications, including hospitalizations, surgeries, and blood transfusions, occur in just 0.23 percent of cases. Overall, abortion is 14 times safer than childbirth. Once again, Calhoun’s claims were contradicted by his employer, CAMC, which provided data showing that the hospital had treated only two patients for abortion complications in the previous year. Despite a public outcry following these incidents, CAMC continues to employ Calhoun.

He is also the only maternal-fetal medicine specialist in Charleston.

“Immediately, before even saying ‘Hi, hello, how are you?,’ he asked me what type of drugs I had been doing,” Smith said. Calhoun also told her that she wasn’t bleeding consistently enough to justify intervention: “His words were ‘Until you start bleeding at a rate of a fountain of blood, then I can’t intervene with a c-section,’” she said. Even after she pressed—through tears—for a possible explanation for her pain and bleeding, Smith said, Calhoun continued to imply that she had done something to cause the complications, but eventually concluded that her placenta was likely separating from her uterus as a result of the procedures that were performed to save her baby. In severe cases, this condition, called placental abruption, can cause hemorrhage, a leading cause of maternal mortality.

“He said he wanted me to lay in that bed for weeks or months until it got bad enough for him to intervene,” Smith told me, adding that Calhoun advised medications that are typically given during preterm labor to speed up fetal brain and lung development.

Shortly after her first conversation with Calhoun, Smith started experiencing sharp, intense pains that came on quickly. A nurse administered the narcotic Stadol, which Smith said made her feel extremely disoriented. “It just felt like they gave me that medication to shut me up,” she said. During her time in the hospital, she continually asked the doctors to induce labor in order to end the pregnancy and allow her to hold and comfort her baby until he died. “[Calhoun] said I was requesting an abortion and his beliefs did not align with that, therefore he would not be doing that,” she said.

Both Calhoun and Smith’s regular ob-gyn told her that if she gave birth at this point—she was 26 and a half weeks pregnant—the hospital would be required to give her newborn medical care under a West Virginia law that mandates medical intervention for fetuses “born alive.” Even pulsation of the umbilical cord—before it has been cut—qualifies as a sign of life under the law. Smith found the thought of prolonging Kase’s suffering after birth unbearable. “I signed myself out and prayed I would make it to D.C. the next week,” she told me. (Neither Calhoun nor CAMC responded to multiple requests for comment.)

The family’s cars weren’t reliable enough to make the six-hour drive to D.C., so Smith and her fiancé rented one. She paid $200 to put a deposit down for her appointment. The remainder of the $9,000 fee was paid by an abortion fund, as were her travel costs. In the end, three different abortion funds pitched in.

Smith’s mother, who is strongly opposed to abortion and took her to anti-abortion rallies when she was growing up, drove from her home three hours away to care for the children. “She wasn’t as bad as I thought she would be, but she did say, ‘You know, if you decide not to go through with this, I’ll help with the baby. I’ll raise him, I’ll take him to doctor’s appointments,’” Smith said. “She was living in this fantasy world of ‘Just do anything to save the baby.’”

Still experiencing pain and heavy bleeding every few hours, Smith traveled to the Dupont Clinic. It was while recalling her experience there that she teared up for the first time during our conversation. “It was the worst experience of my life, but they made me feel some type of comfort,” she said. At Dupont, Smith was paired with a specially trained doula to support her through the process. Most important, the medical team made it clear that the way Smith had been treated in West Virginia was unacceptable. For the first time, she felt she was being listened to.

The doctor also confirmed that Smith’s placenta had been separating from her uterus and said her baby’s kidneys were the biggest he’d ever seen. Smith was able to hold the baby after he was delivered—the outcome she’d wanted but was denied in her home state. “The doula suggested I may not want to uncover him from the neck down due to how small his chest was in comparison to his belly. These are just some reassurances that I’d done the right thing,” she told me. “I truly don’t know how I’ll ever get over it,” she added. “But knowing I put my Kase out of suffering and he will never know an ounce of pain is the only thing that helps.”

Smith’s story is unusual in that she encountered a doctor so vehemently opposed to abortion. But even if a different doctor had advocated for her to have an abortion in West Virginia, the bid may have been unsuccessful. “Often doctors first have to defend these decisions to their institution. Before you even get to the state, you have to defend it to the administrators,” Kimport said. A 2020 study by some of her colleagues found that 57 percent of teaching hospitals, mostly in the South and the Midwest, placed limits on access to abortion that went beyond the dictates of state law. Catholic hospitals in particular are known for their refusal to provide abortion and many other types of sexual and reproductive health care, and the number of Catholic hospitals in the US is growing rapidly: As of 2020, one in six hospital beds is now in a Catholic facility. However, Protestant and secular hospitals limit abortion as well, especially in the South. These hospitals often rely on committees to determine whether doctors can perform medically indicated abortions, and their institutional policies are rarely straightforward or transparent.

Abortion regulations also have a chilling effect, making medical providers reluctant to offer care for fear of punishment or even criminalization. Shortly after SB 8, Texas’s near-total abortion ban, went into effect, reports began to surface of doctors hesitating to treat ectopic pregnancies, which must be terminated without delay for the health of the pregnant person. Dr. Shanthi Ramesh, the chief medical officer of the Virginia League for Planned Parenthood, says she heard several such stories through colleagues.

State laws and institutional policies already interfere with a patient’s decision, Ramesh said. “It really should be the patient and a doctor that they trust having a conversation together about the risks, about the benefits, about the treatment, and then honoring the decision that they come to.” And she fears a future in which states could ban abortion outright, a near certainty following the demise of Roe: “I think that there are good people that will be harming patients in an attempt to comply with the law, or [because] of confusion over it, and that’s really scary to think about.”

“Looking back,” Smith told me, “my life was 100 percent in danger…. The fact that [Calhoun] got to choose when enough was enough is terrifying to me. How I was treated was medically unethical. Something has to be done, or laws need to be changed.”