Back in his office, the doctor demonstrated how powerful a grip can be used with the Bierer forceps. He clamped them down on a surgical scrub gown I held in my hands. "Pull," he instructed. I pulled. "Really, really pull!" he yelled. I really, really pulled. The only way to break the bond between forceps and cloth was to tear the cloth; I inwardly winced as I realized that in the operating room the cloth could be a uterine wall, and with one misplaced pull by the forceps, a perforation could occur.
"This is why I hate overuse of forceps," the doctor commented. "Things tear." Rubbing a hand across his forehead, the doctor looked straight at me: "There are only two kinds of doctors who have never perforated a uterus," he added, "those that lie and those who don't do abortions."
Dr. Ann Davis, an OB/GYN at Columbia University's College of Physicians and Surgeons, says there are no formal studies demonstrating that an intact D&X is the safest method of performing an abortion in the second trimester because so few doctors now perform the procedure. The size of such a study would be too great, she says, and the procedure is only performed an estimated 650 times per year.
"Both procedures are very safe, so you would need 10,000 women in each arm of the study to get even minimal differences in outcomes," she said. Davis, who has been active in Medical Students for Choice, a group dedicated to ensuring abortion training in medical schools and residency programs across the country, says those trained to perform the intact procedure believe that it is safer but they have no way to prove it.
Dr. Curtis Cook, in a press release for the Physicians Ad-hoc Coalition for Truth (PHACT), a group known for its antiabortion stance, says that the intact D&X "has now been demonstrated as a potentially dangerous procedure." But risks outlined by PHACT are dangers inherent to any second trimester abortion, regardless of the procedure. Dr. Cook, who specializes in maternal and fetal medicine, conceded in a telephone interview that he had never performed or observed an intact D&X procedure. He says he does not perform abortions except in the rare case when a fetus has died inside a mother's uterus, and he believes that the best procedure for abortions done after 20 weeks is induction of labor.
Induction requires at least 6 centimeters of cervical dilation and an average of 12 hours of labor. Though it can be a long and grueling process, taxing physically as well as emotionally, induction, like the intact D&X, results in a whole fetus, which is thought to be helpful to create a sense of closure for the woman. In fact, many women who have undergone an intact dilation and extraction, to terminate a pregnancy marred by severe birth defects, point to the psychological benefit of an intact fetus to hold, grieve over and finally bury as a reason the procedure should remain legal.
"For me, this [intact dilation and extraction] was the most humane procedure," says Claudia Ades Crown, who at six months into her first pregnancy at age 33 was devastated to learn her fetus was severely deformed by a chromosomal abnormality called trisomy 13. "There is a grieving process that I believe is helped with the ability to hold your child and then see him buried." Crown added that an intact fetus allows for a more thorough autopsy, which can be important for planning future pregnancies.
Dr. David Grimes, past chief of abortion surveillance for the CDC, characterized the induction method as "maxi labor followed by a mini delivery," adding that the procedure often is the method of choice for doctors not skilled in the D&E or D&X procedure.
One concern raised by Cook of PHACT does stand out: The issue of cervical incompetence, a condition in which a pregnant woman's cervix prematurely dilates for unknown reasons, often leading to a spontaneous abortion. A study in the Journal of Reproductive Medicine found that in most instances, cervical incompetence is the result of prior trauma to the region. Cook maintains that the amount of dilation needed to do an intact D&X -- somewhat greater than what is needed for D&E procedures done at the same stage of pregnancy -- will cause this kind of trauma and predispose women to risk in future pregnancies. (Cervical incompetence can also result from trauma sustained during an induction abortion, which also requires greater dilation than a D&E procedure.)
Next page: A doctor runs the risk of breaking a commitment to provide the best care available