by Rebecca Chalker
Menstrual extraction (M.E.), a technique that can remove the contents of the uterus safely with a hand-held suction device, was developed in the days before abortion was legal by women who grew tired of waiting for the Supreme Court to legalize abortion. In those heady years of the emergence of the modern women’s movement, thousands of women learned about M.E. and many formed self-help groups and were instructed in this simple but revolutionary technique. But when abortion rights presumably became secure, and with mountains to be moved in the name of full social equality for all women, M.E., for the most part, ceased to be a pressing issue. However, with the continuing assault on abortion rights, and ever-decreasing access to safe, legal abortion, renewed interest has been sparked in M.E. and other safe methods of fertility control.
The Safety of Menstrual Extraction
Some physicians and family planning advocates have expressed concerns about lay practitioners performing M.E. These concerns are usually expressed as fears of medical complications, although the same complications can occur when abortions are performed by physicians. Some critics have also expressed fears that desperate women who are unfamiliar with their own anatomy and with the M.E. equipment will harm themselves.
These concerns are well intentioned, but they are based, for the most part, on a lack of understanding about how M.E. is practiced by women in the United States.
These criticisms include:
The lack of a formal diagnosis of pregnancy. Most women know when they are pregnant, and diagnose themselves, either by recognizing the signs and symptoms of pregnancy, or by using a home pregnancy test. Ultrasound, an image of the body’s interior made with high-frequency sound waves, is not necessary to confirm pregnancy in most cases, even though it is now widely employed by abortion clinics. How far the pregnancy has advanced is usually determined by a uterine-size check, which experienced self-helpers have become quite efficient at doing.
|I realized that if |
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Missed tubal (ectopic) pregnancy. In pregnancies under eight weeks, when most abortions and M.E.s are done, the first indication of a tubal pregnancy is the lack of pregnancy tissue when the uterus is evacuated. Chorionic villi, the feathery tissue that is characteristic of pregnancy, is not difficult to identify, and can be readily recognized by women in M.E. groups as well as by doctors. In any event, in clinical practice, tissue examination is usually done by nurses or lab technicians, rather than by the doctor.
The failure to recognize existing injections or unusual conditions such as fibroids or ovarian cysts. If women in M.E. groups want to make sure that they do not have an asymptomatic infection such as chlamydia or gonorrhea, which could be introduced into the uterus during a menstrual extraction, they can go to a clinic or to their own doctors to have the appropriate screening tests done. If a woman is receiving regular gynecological care, she will probably be aware of having fibroids, cervical scarring called “stenosis” that may be caused by surgery on the cervix, or rare conditions such as a double uterus. Fibroids are not a contraindication to abortion or M.E., but may make the pregnancy seem more advanced than it really is, or may cause more bleeding than normal.
If a woman has significant scarring of the cervical canal, chances are the cannula would be difficult to insert, and her group will probably be aware of this condition, which may or may not make an M.E. more difficult or painful. If this is the case, she and her group can evaluate whether or not it might be better for her to have a clinical abortion.
Prophylactic (preventive) antibiotics are given routinely in most clinics for early abortions, but they are essential unless a woman has a history of pelvic inflammatory disease, or is predisposed to infection because of diabetes or other conditions. Menstrual extraction groups do not routinely use any drugs, but if antibiotics or other drugs become necessary, a woman could see her own doctor or go to an emergency room.
Use of sterile technique. Sterile technique simply means getting the cannula – the straw-like instrument that is inserted into the uterus in M.E.s or abortions – “sterile,” and keeping it that way during the procedure. There is no doubt that self-helpers can learn this simple technique as well as doctors can. In abortion and in many surgical procedures, “sterile” actually means “high-level disinfection,” since true sterility is nearly impossible to establish and maintain. In M.E., the cannula can be adequately disinfected by soaking in certain chemical germicides such as Zephirin or household bleach. Some self-help groups have been able to make arrangements through a friendly practitioner to have cannulas sanitized in a commercial gas sterilizer at a hospital or clinic.
Although there is very little blood involved in M.E. and what there is goes directly into a collection jar, taking universal precautions, such as using disposable gloves, is necessary, and wearing goggles, masks and plastic gowns is recommended. Each group needs to assess how rigorously the precautions must be followed.
Use of local anesthesia. Local anesthesia, an injection of a novacaine-like drug into the cervix, is not necessary in either early abortion or M.E. In clinical abortion, the injection is given to relax and soften the cervix, but it does nothing to mask or diminish cramping. Some women actually find the injection more uncomfortable than the two or three minutes of suction in clinical abortion.
Risk of uterine perforation. The small (4 or 5mm) cannulas used in M.E. are highly unlikely to perforate the uterus. In clinical abortion, perforations typically happen when metal instruments, such as a curette, are used, or when doctors are tired, pressured or distracted. Perforations also occur more often when women have general anesthesia, since doctors are sometimes not as careful when a woman is asleep and unaware of pain.
The importance of follow-up. Women in M.E. groups keep in close touch with the woman who had a procedure and with each other after an M.E. Just as in clinical abortion, a woman who has had an M.E. monitors her own cramping, bleeding and temperature, and reports anything unusual to her self-help group. If the procedure appears to be incomplete, the group will evaluate the situation and decide if a second aspiration is necessary.
The signs of complications of M.E. and early abortion are very specific: Heavy bleeding, defined as bleeding through one pad an hour, pelvic pain, a temperature over 100 degrees, and signs of pregnancy that do not go away. These signs are very specific and can be recognized by anyone who knows what to look for.
Menstrual extraction done by committed, trained women can be done as safely as clinical abortion. Pointing to rare conditions, or denigrating the skills and abilities of experienced self-helpers is an unfair and incorrect indictment of M.E. The lack of safe, legal abortion is far more dangerous to women’s health, and is the real risk factor for women who experience unintended pregnancies.
Over the last 20 years, M.E. has been practiced by women who are highly aware of self and body. These women work in tight-knit, friendship groups, often referred to as “self-help” groups. These normally consist of up to a dozen women who meet monthly or more often to discuss their feelings about M.E., study the reproductive anatomy, and polish their skills. If a woman enters an already-existing group, she may observe extractions for several months before she has one herself, or actually tries her hand at moving the cannula in the uterus. If the group is new, its members may practice the basic skills of vaginal and cervical self-examination, and do uterine-size checks to learn to estimate the size of the uterus. Knowing how to do accurate uterine-size checks is essential in order to avoid doing a procedure on a woman who is too far pregnant.
Women in a new group may seek out an experienced member of another group, or even a sympathetic doctor to serve as mentor and supervise extractions until the group feels confident to do them on its own. As a member of one group told me, “Our first three years were one long learning process.” Women in self-help groups know the abilities of the others in the group and can therefore depend on a high level of skill and commitment.
In the week or so after an M.E., the group keeps in close touch with the woman who had the extraction to monitor any signs of a complication. The woman herself monitors her temperature, bleeding and cramping, just as women who have abortions do, and she reports anything unusual to the group.
Every group ideally has a back-up plan – a trusted physician or nurse practitioner to call in the event of any complication. This is far preferable to going to an emergency room where many of the physicians are unfamiliar with the pathology.
Menstrual extraction is not something that can be initiated overnight. It takes a considerable amount of resourcefulness and commitment just to assemble the equipment. Parts of the Del-Em are easily accessible – the glass jar and aquarium tubing – but it can take several weeks to find a source for cannulas and order the chemistry lab stopper and two-way bypass valve. By the time all parts have arrived, pregnancy would probably be too far advanced for M.E. to be effective.
The Legality of Menstrual Extraction
So far, M.E. has not been held up to legal scrutiny, and is unlikely to be, unless a serious complication occurs and a complaint is filed with local prosecutors. Nevertheless, there are interesting questions about M.E. that bear exploration.
|Just how far can |
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With the exception of Vermont, which allows physicians’ assistants to do abortions, all other state laws require that abortions be done by physicians. Today, so few doctors know how to do abortions, or are willing to do them, one wonders how long they can justify retaining exclusive control over the practice.
According to a recent nationwide survey done by Dr. Trent MacKay, assistant professor of obstetrics/gynecology at the University of California, Davis, just 12 percent of approximately 270 training hospitals with programs in ob/gyn now require training for first-trimester abortions and 7 percent require residents to learn to do second-trimester abortions. A little over 56 percent were found to offer optional training.
Any legal challenge to M.E. would probably be made under state Medical Practice Acts, most of which specify that abortions can only be done by licensed physicians.
A legal challenge to M.E. would probably also raise a number of questions about the constitutionally guaranteed right to privacy. Just how far can the government go in dictating what people can or can’t do in the privacy of their own homes with adequate knowledge of the risks and consequences of their activities?
The Whats, Hows and Whys of M.E.
Women who have learned M.E. tend to agree that the training is too arduous and the commitment too profound for the technique to be widely practiced. Only women who have a specific interest in taking more control over their reproduction, and in meeting regularly for several years, will spend the time required to acquire the necessary skills. Nonetheless, these same women feel that the concept of M.E. is a powerful tool for the prochoice movement.
Any woman can start a self-help group, and, in a reasonable amount of time, could learn the technique and practice it quietly and confidently, away from the prying eyes of the authorities and the taunts of antiabortion zealots.
At the very least, that could be a lifesaver.
Rebecca Chalker is an internationally known abortion counselor and an active speaker on women’s health issues.