Q&A: As Supreme Court weighs abortion rights, OB/GYN recalls practice before Roe v. Wade

The Supreme Court decision on the Dobbs v. Jackson Women’s Health Organization abortion case is expected at the end of June, although a leaked draft opinion indicated that the justices intend to overturn the precedent set by Roe v. Wade.

According to CNN, 13 states have passed laws that would ban abortion as soon as Roe v. Wade is overturned, and many other states may enforce stricter laws, making abortion access more difficult.

Additionally, there are seven states that still have pre-Roe v. Wade laws banning abortion, although these are currently unenforced, according to the Guttmacher Institute.

While some of these laws predate the 1973 abortion decision, there are fewer OB/GYNs today who were in practice before Roe v. Wade was decided.

Healio spoke with Washington C. Hill, MD, a senior OB/GYN and a maternal-fetal medicine physician in the Sarasota Memorial Healthcare System in Florida who began practicing following his 1965 graduation from Temple University Medical School, about the impact of Roe v. Wade and how the upcoming Supreme Court decision on Dobbs v. Jackson Women’s Health Organization will affect practice.

Healio: What was OB/GYN practice like before Roe v. Wade?

Hill: There are two things that I clearly remember in medical school. One was they had gallon jars of specimens when you were on pathology. There could be a heart or a limb or an appendix in the jar. I remember in this jug, a perfectly shaped uterus, a fetus and a knitting needle — this was pathology, it wasn't a surgical specimen — and the knitting needle had completely missed the fetus. The fetus was still there. That burned an image in my brain that here was someone who did not want this pregnancy. Thinking back, it was maybe a 10- to 12-week-old fetus. [That woman] found a knitting needle and completely missed it, perforated the uterus, probably became grossly infected and died.

The second thing I remember very well — and this is probably during my medical school training in North Philadelphia, where there’s a large population of Black and Brown people — was being called on more than one occasion with the resident to go to the emergency room to see someone who had gone to a back alley or somewhere and tried to have an abortion and was simply septic. In fact, that's how I learned how to take care of sepsis in a uterus: evacuate the uterus, antibiotics, fluids and pray. This was not a rare occasion.

I tried to find a couple of articles for something I may write and one very succinctly talked about the methods that were used [for abortion] that I could remember. There were things that were “pumped” into a woman's vagina, and one was permanganate. I haven't the slightest idea what we used permanganate for in the first place, but that was used. When they say pumped, it could be from a “douche bag,” or it could be that somebody actually pumped something with a turkey baster or something like that into the vagina. Permanganate was one. [The articles also] mentioned Lysol, which I certainly can remember. And they could use homemade remedies. Certainly, knitting needles. All kinds of unsanitary materials. And these women would go to someplace where someone knew someone, who knew someone, who knew someone, who said, “I think I know somebody who can help you out.” And people would come up with some money and try to get the deed done. That was not unusual. It was very sad.

I can remember before, they would completely miss the pregnancy and the pregnancy would continue. You would get a patient who was 6 months or so pregnant. And you take their [medical] history and she would say, “Well, I had an abortion 4 months ago.” No, ma'am. I think they missed it; your pregnancy is still there. And sometimes they wouldn't even try. [They would] put the woman up in stirrups, do a few things down there [and say], “OK, you're all good. You're going to have some bleeding.” You talk about a clandestine abortion ... all kinds of things could happen. Say that she was in early pregnancy, and this person — and many of them were not doctors — would say they can take care of you. They may put a clamp or something on the cervix. They may nick the cervix, [the woman] would have bleeding for a couple of days. [They’d say], “Put a tampon in there, you'll be OK,” collect the money and disappear. Eventually at 20 weeks, [the women would say], “I think I'm pregnant.”

Healio: How did the Roe v. Wade decision affect practice?

Hill: Initially, it affected practice by having clinics available where a woman could go — usually with a friend — to terminate a pregnancy. There were rules that were developed, depending on the state, on the gestational age. The clinics were usually inspected. It was legal. I’ve worked in some in my past. And it was safe. If there were complications, patients could be sent to the hospital. It wasn't a back-alley thing; it was medical care. The majority of obstetricians and gynecologists feel that abortion is health care, and therefore, we should do it as safe as we can. After Roe v. Wade [was decided], that was indeed the case. We didn't see a lot of sepsis anymore. We didn't see botched abortions, incomplete abortions; someone saying [the pregnancy was] all out and it wasn't.

Healio: If Roe v. Wade is overturned by the Dobbs decision, how comparable will OB/GYN practice be to practice before Roe v. Wade?

Hill: Well, we have a couple of things going for us that we didn't have in 1965. I think that may be a way to look at it. The first thing that comes to mind is we now have medication abortion so that early pregnancies will be safely terminated with the abortion pill, which is very, very good. We won't be getting to 18 weeks or so and having had no attempt or successful termination of pregnancy. But there are states that are now looking at, “How can we keep medication abortion from happening in our state?”

The other thing that will help is that in those states where abortion is not going to be possible — let's pick Oklahoma for example — there are going to be ways to transport and help women in those states who want to terminate their pregnancy. Helping them with transportation, housing, counseling, out-of-pocket expenses, etc. There are grants and financial support to do that. Of course, some women still won't be able to get off work and go to another state. But they may just have to, or they may find that they have to continue the pregnancy.

If you’re going to terminate a pregnancy, we have to find a way — and organizations are — to educate women and men about the importance that it has to be safe. With the [COVID-19] vaccination efforts, many of us did that. There are all kinds of misinformation out there that is simply not true, and we have to be about the business of getting that information out there in an understandable form from trusted messengers. There's so much misinformation. I've asked patients where did you hear that? “I read it on the internet.” Well ma'am, that's not true. We experienced that with vaccination, and we know it will come [with abortion]. You'll be able to Google how to have an abortion. You probably can Google it now and information will come back and somebody will try it. Because they can't take the time off. Because they don't know that they could get some help with their money issues, with who is going to take care of their kids while they go out of state.

Healio: Do you think patients will revert back to abortion methods implemented before Roe v. Wade?

Hill: Only if they feel they can't engage a safe provider. They may not be able to take off for work; they may have too many other obligations; they don't want anyone to know because of rape or they just got pregnant. If you go out of town for the weekend, [people ask], “Where are you going?” The safe options are going to help a lot of people, but there are going to still be women who have to use alternative methods as a resort. We have to get that message out [about safe options]. That won't be easy.

Healio: What challenges does the Dobbs decision present to practice?

Hill: From a maternal-fetal medicine and perinatology standpoint, we're going to have to try to diagnose abnormalities as early as possible. There's been a fair number of courses looking at diagnosis of congenital anomalies in the first trimester. We can do that with some, but some things do not appear until 20 weeks. I've had to say to a patient, “Oh, your first ultrasound was fine at 13 weeks, but your baby has such and such.” Or they have genetic testing late, and their genetic testing shows that they haven't done well. So, from a maternal-fetal medicine standpoint, we have to try to diagnose problems and conditions as early as possible and certainly know the laws in our states. I can see from our major societies what is going on in individual states, when you can have a termination and when you can't. That type of information will be very helpful.

Another problem will be unsafe terminations in spite of the fact that we have in this country states where you can have it done safely.

Another thing — it's not a problem but it's something that we will continue to get at — is providing accurate information. I remember sitting with our executive director and saying we have to find a way. We've had this experience over the last 2 years [with COVID-19 misinformation], so we know what we're up against and we know how we have to do it. We now just have to be about the business of doing it as well as we can.

Healio: How will clinicians continue to support the medical needs of the women they see if Roe v. Wade is overturned?

Hill: By providing them accurate information, early diagnosis, support when they need it, calling up someone who can help them. I've done that now. When I was actively practicing every day, I would have a patient who would come in late — and she may already have a bad diagnosis — she was just going for confirmation. We knew who we could call in the state they were in for help.

Healio: Is there anything else you would like to add?

Hill: A friend of mine, Dr. Ken Edelin [who was convicted of manslaughter in 1975 for performing an abortion and later acquitted], told a story where he would go to the emergency room and he would see and treat septic patients. I will repeat what he and others have said, and that is terminations will continue to occur in the United States of America. Our job is to make them safe. It's a part of health care. Therefore, we have to find a way to do that. There are ways in this country to do that. If [a clinician] does not believe in termination and abortion, then they should refer that patient to someone who does. That's not new.

References:

• Abortion conviction of Boston doctor upset. New York Times. https://www.nytimes.com/1976/12/18/archives/abortion-conviction-of-boston-doctor-upset-abortion-conviction-of.html. Published Dec. 18, 1976. Accessed May 27, 2022.
• Abortion policy in the absence of Roe. Guttmacher Institute. https://www.guttmacher.org/state-policy/explore/abortion-policy-absence-roe. Published May 17, 2022. Accessed May 31, 2022.
• Wolfe E. 13 states have passed so-called ‘trigger laws,’ bans designed to go into effect if Roe v. Wade is overturned. CNN. https://www.cnn.com/2022/05/03/us/state-abortion-trigger-laws-roe-v-wade-overturned/index.html. Published May 3, 2022. Accessed May 31, 2022.