Sam Wise

A Woman’s Book of Choices: Abortion, Menstrual Extraction, RU-486 by Rebecca Chalker and Carol Downer is one of the most informative books I have ever read (and I read a lot of books). I learned more about my own reproductive organs, about abortion, and about birth control from this one book than I have from any other source — and this is coming from a woman with a reproductive disorder who was raised by a childbirth educator, so I like to think I know more about female anatomy than most people.

If I was going to recommend a single book to all pro-choice people, it would be this one. Which is… kind of unfortunate, because this book is out of print and can be very hard to find.

While I can’t share the entire book on this blog, I can share my notes from reading it. This type of sharing is protected under the fair use doctrine of United States copyright law. And of course, if anyone wants help tracking down a copy of the book, I’m happy to help! Just message me or comment on this post.

The following are my notes on A Woman’s Book of Choices, divided by chapter. Direct quotes from the text appear in quotations (“__”), and text not in quotations is paraphrased from the book. My comments appear in brackets ( [____] ).

Finding an Abortion Provider

• National Abortion Federation (NAF) has hotline for abortion referrals and financial assistance: 1-800-772-9100 [This is the updated number as of 2022.]
  • [The NAF website can also help you find a provider.]
• It’s a good idea to call clinics ahead of time. The first thing you should always ask is whether abortions are actually done on the premises. The second thing you should ask is how late in the pregnancy they can perform abortions to make sure you know what your timeline looks like.
• A lot of clinics only do first-trimester abortions, but they should be able to refer you to a second-trimester abortion provider if needed.
• BEWARE OF FAKE CLINICS
• Anything listed as an “Abortion Alternative Service” is an anti-abortion scam designed to keep women from accessing safe, legal abortions.
• These may also be listed as “crisis counseling services,” or “problem pregnancy advice centers.”
• The goal of these centers is to spread misinformation and anti-abortion propaganda
• “The surest way to identify a fake clinic is to ask if abortions are actually done on the premises. If the answer is unclear, or ‘no,’ you might do well to look further.” [emphasis in original]
• The book talks about how most states require parental notification and/or consent for abortions for minors. While many states allow minors to appeal to bypass this requirement, the bypass process can be uncomfortable, embarrassing, or even traumatic.
• [There have been some changes to the law, but as of May 2022, the following states require consent from at least one parent: Alabama, Arizona, Arkansas, Idaho, Indiana (which requires the consent to be notarized), Kentucky, Louisiana, Massachusetts, Michigan, Missouri (which also requires that any other parent/guardian be notified about the abortion), Nebraska, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina (for minors under 17), Tennessee, and Wisconsin.]
• [The following states require consent from both parents as of 2022: Kansas, Mississippi, and North Dakota.]
• [The following states require that parents be notified about the abortion as of 2022: Colorado, Delaware (for minors under 16), Georgia, Iowa, Maryland, Minnesota (which requires both parents be notified), Montana (which requires notarization), New Hampshire, South Dakota, and West Virginia.]
• [The following states require both parental consent and parental notification as of 2022: Florida, Oklahoma, Texas, Utah, Virginia, and Wyoming.]
• [In Delaware, Iowa, North Carolina, South Carolina, Virginia, and Wisconsin, another family member can consent instead of a parent.]
• If there are anti-abortion picketers at the clinic where you choose to get your abortion, the best way to deal with them is to not engage. Do not stop, and do not engage in discussion with them.
• Picketers legally are not allowed to touch you or to physically block the entrance to the clinic.
• In most cases, if there are picketers there will also be volunteer escorts who can walk you into the clinic and keep picketers away from you.
• The authors talk about a number of anti-abortion protesters who seek out their own abortions: “Female anti-abortion activists who get abortions are the dirty little secret of the anti-abortion movement. Some actually believe they are committing ‘murder,’ yet the minute their periods are late, they experience what it means to be unable to control their own reproductive lives. So they grit their teeth, have abortions to avoid having their lives dramatically altered, and often return to the picket lines to try to prevent other women from exercising the same freedom.”
• “Every doctor, regardless of his or her personal beliefs, is required by ethical standards to treat any medical emergency. If you are refused treatment for a threatened miscarriage or for an incomplete abortion, regardless of how it was started, or if signs of mental illness, especially of threatened suicide, are not taken seriously, you—or your family if you die—may have grounds for a malpractice lawsuit against the doctor and/or hospital.” [emphasis in original]
• In times and places when abortion was not legal, women have gotten “therapeutic” (aka “medically necessary”) abortions by faking a miscarriage (which is not likely to work anymore thanks to modern medical technology), claiming they had been raped (which may or may not work), claiming a mental illness that would get worse if the pregnancy continued, threatening suicide, or threatening to “self-abort” the pregnancy.
• A note on faking rape in order to get an abortion: “Only in desperate situations—such as women may find themselves in in the future if states ban abortions except for certain reasons such as rape—should women even consider resorting to faking rape. Doing so has the potential to undermine the gains of the movement against violence against women which has worked to overcome the myth used by hostile prosecutors and judges that women who report rape cannot be trusted. However, a time and place can be envisioned where a woman, her doctor, and sympathetic authorities would be forced to go through a charade of a rape complaint about some unknown, unidentifiable assailant in order to get around hypocritical, restrictive laws. This charade would be clearly recognized by all participants and it would bear little resemblance to the real thing, a genuine rape complaint.”
• If you have a miscarriage or an abortion complication and have to go to the hospital, try to avoid Catholic hospitals if at all possible, as some women report being mistreated when seeking treatment from Catholic hospitals.
• If you are at the hospital because of an abortion complication in a state where abortion is illegal, ask to speak to your doctor alone with no nurses present. State out loud that you are speaking in medical confidence, then tell him exactly what method was used for the abortion and exactly what your symptoms are. Tell him that if he calls the police, you will not talk to them unless you have a lawyer present. Do not give him the names of anyone who helped you with your abortion.
• If anyone ever threatens to withhold medical care when you are experiencing a miscarriage or abortion complication, threaten to sue for malpractice.

The Best Available Abortion Care

• “When done by an experienced practitioner, early termination suction abortion is one of the safest of all medical procedures.”
• “One salient fact that the antiabortion movement cannot afford to acknowledge is that childbirth is 11 times more dangerous than early termination abortion.” [emphasis in original]
• “Complications from illegal abortions sometimes made it difficult for women to carry subsequent pregnancies successfully, but there is no medical evidence that this is true for early abortions, or for most later abortions, when they are done by trained personnel.” [emphasis in original]
• “Women who have had abortions often say that knowing exactly what was going to happen during the procedure calmed anxieties and helped them feel more in control.”
• The authors recommend avoiding general anesthesia if possible, as most abortion-related deaths are actually caused by anesthesia, which is much more dangerous than the abortion itself.
• “Under local anesthesia, you are conscious throughout the procedure and can monitor the practitioner’s behavior and conversation with assistants, and you can tell him or her how you are feeling, especially if you feel unusual pain or discomfort. You can also make sure that you are treated respectfully at all times.”
• “About 2% of women experience unusual—but normal – reactions during the procedure, such as hyperventilation, fainting, or vaso-vagal response. These reactions are not serious in any way, but can be frightening if women are unprepared for them.”
• Usually, the more relaxed a woman is during a suction abortion, the less pain she feels.
• Second trimester abortions take longer, and usually require general anesthesia.
• People who have second trimester abortions may experience breast engorgement, which can last for two to three weeks after the end of the pregnancy. The advice for this is to wear tight bras and to avoid touching or stimulating the breasts until the engorgement goes away.
• “After an abortion, both first and second trimester, you can expect some period-like cramping for a few hours or even for a day or two, although some women experience almost no cramping afterward. Most women have some bleeding, ranging from spotting to a period-like flow, which may start and stop, and may even resume again, for up to three weeks afterward. Some women may also pass large clots for a day or so after the procedure.”
• If you experience signs of pregnancy that last for more than 10 days after the abortion, a fever of more than 100 degrees, are bleeding through more than one menstrual pad per hour, or have abdominal pain that lasts for more than a few hours, this may be a sign of a complication.

The Development of Menstrual Extraction

• “Dealing as it does with normal bodily functions, ME is not a medical treatment—but a home health-care technique, similar in many ways to self catheterization, at-home bladder instillations, and other health-maintenance routines.”
• “The tabloids and the electronic media have labeled menstrual extraction ‘self-abortion’ or ‘do-it-yourself abortion,’ but these terms are misleading. First of all, due to the location of the uterus, it is virtually impossible for a woman to do ME on herself. To do the procedure safely and correctly, a woman needs the help of one or more women who are trained and experienced in ME.”
• ME uses a small, flexible cannula, which is inserted into the cervix, a 50-60cc syringe, and a collection jar. One tube connects the cannula to the jar, and another connects the jar to the syringe. The syringe is used to create a vacuum in the jar, which sucks out the contents of the uterus. An automatic two-way bypass valve keeps air from being pumped back into the uterus, which historically was one of the dangers of DIY abortions.
• “Early on, it became clear to medical professionals and family planning experts that paramedics and lay people with even minimal education could learn to use hand-generated suction devices safely and effectively.”

Friendship Groups

• “Most self-help groups follow similar steps in learning menstrual extraction: reading as much as they can; discussing their feelings about menstrual extraction, abortion, and reproductive control; working out group policies and protocols; and assembling equipment and supplies. If possible, a group finds a mentor, a woman who is experienced with ME, to guide them through their first procedures and serve as an adviser as subsequent questions and problems arise.”
• Most groups do non-pregnant MEs for at least six months before attempting an ME on someone who may be pregnant.
• Some groups use sterile lubricant on the cannula to make insertion easier and more comfortable.
• “All of the women we spoke to agree that menstrual extraction cannot be done safely without a basic understanding of the location and function of a woman’s reproductive anatomy—the ovaries, egg (Fallopian) tubes, uterus, and cervix.”
• “When the speculum is inserted and locked in place, the cervix, looks like a little knob with a small hole or slit in the middle. This tiny hole, or os (Latin for opening), is where the menstrual blood and cervical mucus come out, and where the sperm go in. Some women’s cervixes appear to be more flat and do not protrude very much.”
• “The size of the uterus can be felt by another person doing a uterine size check (a two-handed or “bi-manual”exam). Two fingers of one hand in the vagina firmly press upward on the cervix, while three fingers of the other hand presses firmly on the abdomen just above the pubic hair line, so that the uterus is cupped between the two sets of fingers.”
• Before using a cannula, check it carefully for obvious cracks, including bending it to make sure it won’t break.
• Signs of pregnancy: missed period, positive pregnancy test, nausea, fatigue/sleepiness, sensitivity to tastes or odors, changes in appetite, weight gain, breast tenderness, breast enlargement, more frequent urination, softer uterus, enlarged uterus, softer cervix, change in cervix color from pink to reddish/bluish/purplish, os more open than usual.
• “Menstrual extraction checklist:
• Test Del-Em™ suction with cannula in a glass of water to make sure that suction is adequate and two-way valve is attached correctly.
• Make sure all equipment is disinfected.
• Speculums
• Flashlight with extra batteries (alt.: goose neck lamp)
• Plastic calibrated sound
• O-ring forceps, cervical stabilizer (Allis or single-tooth tenaculum) (alt.: kitchen tongs or long-handle tweezers)
• Rubber gloves (alt.: plastic wrap or plastic bags)
• Water-based lubricating
• Tissues or paper towels
• Towels
• Gauze squares or cotton balls
• Sterile container
• Disinfectant
• Cotton swabs (long and short handled)
• Small dish or glass saucer
• Strainer
• Menstrual pads
• Written acknowledgement (if someone from outside of the group is having an extraction)”
• Only freshly boiled water is medically sterile.
• If signs of pregnancy don’t go away after 10 days, the group does an examination to determine if respiration is necessary.
• (If you have to go to the emergency room with an abortion complication), “In any event, it’s not easy for a doctor to tell whether you had an abortion, diagnostic uterine aspiration, or a menstrual extraction, especially the latter two, where the os is barely dilated.”
• Tell the doctor you had a positive at-home pregnancy test, but have been experiencing cramps, nausea, and bleeding that has come and gone. Tell them you are worried you are having a miscarriage. You do not need to tell them you had a menstrual extraction.
• In order to avoid being infiltrated by or attracting attention from anti-choice groups, most ME groups only accept people they know, or who are recommended by someone they trust, as members.
• “Many of the groups we interviewed have exacting policies about what they will do in case a problem arises. The policies are designed to protect both the group as a whole and the individual member. These policies tend to assume heightened importance in groups that occasionally do an extraction for someone outside of the group.”

Herbs and Other Traditional Methods of Fertility Control

• Breastfeeding naturally reduces fertility for a while.
• “In spite of little scientific evidence that these methods work, all are still employed today. Some are patently useless, and others, while they might terminate a pregnancy, are so dangerous that they are as likely to maim or kill as they are to be effective. Nonetheless, salted away among this catalog of horrors are methods that have been used in the past to safely terminate unwanted pregnancies, and which may be used again as abortion becomes less accessible. For the most part these are methods of last resort.” [emphasis added]
• “Most of the herbs said to promote menstruation or induce a miscarriage fall into one or more of these categories: abortifacients, herbs that cause miscarriage; emmenagogues, i.e., herbs that ‘promote menstruation,’ perhaps by stimulating contractions of the uterine muscle; oxytocic herbs,which imitate the action of the pituitary hormone, oxytocin in stimulating uterine contractions; stimulants, herbs that stimulate uterine contractions; and vasoconstrictors,which contract blood vessels, perhaps cutting off the fetal blood supply.”
• Herbs said to be emenagogues:
• Angelica
• Black cohosh
• Blue cohosh
• Celery
• Cotton (seed or root)
• Ergot
• Ginger
• Motherwort
• Parsley
• Pennyroyal
• Tansy
• Herbs said to be abortifacients:
• Cotton (seed or root)
• Ergot
• Mistletoe
• Pennyroyal
• Tansy
• Herbs said to be oxytocic:
• Blue cohosh
• Cotton (seed or root)
• Ergot
• Peruvian bark
• Herbs said to be stimulants:
• Angelica
• Black cohosh
• Ginger
• Horseradish
• Herbs said to be vasoconstrictors:
• Ergot
• Shepherd’s purse
• “… those most frequently mentioned as potential abortifacients are black and blue cohosh, pennyroyal tea (not pennyroyal oil), and tansy, often used in combination with each other and with other herbs. These herbs may be the most effective, but they can also be toxic and may even cause death in extreme cases.”
• Vasoconstrictors should not be used by a person with high blood pressure, because they increase blood pressure.
• “In 1978, a woman in Denver, apparently thinking that she was pregnant, died a slow and painful death from taking a high dose of pennyroyal oil. The woman lived for seven days after she took one ounce of pennyroyal oil, suffering two heart attacks, liver and kidney failure, and disseminated vascular coagulation.”
• “… herbalists have been adamant that pennyroyal oil not be used in trying to bring on a menstrual period or precipitate a miscarriage. Others have noted that this is an extremely isolated case, and that other preparations using pennyroyal tea have been used safely, and sometimes successfully, by thousands of women to bring on a late period. In any event, it is clearly unwise to exceed the recommended” dose.
• Signs of toxicity: “nausea, vomiting,sweating, chills, fever, headache, ringing in ears, dizziness,low blood pressure, difficulty in swallowing, extreme thirst, diarrhea, rapid pulse or heartbeat, muscle spasms, restlessness, drowsiness, unusual talkativeness, fatigue, and tremor.”
• Toxicity may also cause hallucinations, mania, collapsing, convulsions, and/or coma.
• If you experience any signs of toxicity after using herbs, go to an emergency room or call Poison Control.
• “Some herbalists point out that if bleeding has not commenced after having missed a second period, or after having taken an herb at the recommended dosage for two weeks, it seems useless and perhaps dangerous to continue. Prolonged ingestion of some herbs may cause nerve damage or other negative effects and may cause fetal abnormalities if the pregnancy is carried to term.” [emphasis added]
• In the pamphlet, Self-Ritual for Invoking Release of Spirit Life in the Womb: A Personal Treatise on Ritual Herbal Abortion, Deborah Maia described the herbs, baths, and spiritual rituals she used to bring on a miscarriage.
• “Initially she took fresh ginger root tea for five days, then switched to a combination of blue cohosh, black cohosh, and rue, in tincture form (distilled herbal essences in an alcohol base).”

Folk Remedies That Are Dangerous and Don’t Work

• Knitting needles, coat hangers, sticks, wires, etc.
• Caustic substances such as soap, bleach, quinine, lye, kerosene, castor oil, etc.
• Physical abuse such as a fall from a high place, hitting the abdomen, jogging, gymnastics, horseback riding, or other such jarring activity
• “It is known that hot baths will cause harm to a developing fetus, but there is no evidence that it will reliably start a miscarriage.”
• Street drugs such as alcohol, marijuana, crack cocaine, heroin, LSD, mescaline, or PCP (angel dust), etc. (“… they are more likely to harm the fetus than cause an abortion.”)
• Not eating (“Starving does deprive the fetus of nutrition and may ultimately damage it in numerous ways, but the major damage is to the mother, whose body begins to digest its own muscles and other tissue in order to support the fetus.”)
• “If women are injured or die trying to abort unwanted pregnancies because safe, legal facilities are outlawed, the blame rests not with them or with those trying to help them. It rests squarely on the shoulders of the religious right, on state legislatures that have passed regressive abortion restrictions, and on the U.S. Supreme Court, which has chosen to limit access to safe abortion facilities.” [emphasis added]

Is RU-486 the Wave of the Future?

• RU-486 = mifepristone
• “RU-486 blocks the production of progesterone in the uterus by competing with progesterone for receptor sites in cells in the uterine wall.”
• About 95% of women who use mifepristone with misoprostol will have a miscarriage within 4 hours.
• In the rare case of a failed abortion with Cytotec (misoprostol), fetal abnormalities are known to occur.
• Side effects of an abortion with mifepristone and misoprostol: moderate to severe cramping, bleeding for an average of about 10 days, and (less commonly) dizziness, nausea, vomiting, and/or diahrea.
• Because nothing actually enters the uterus, RU-486 abortions have lower risks of infection or perforation.
• “As a result, it appears that RU-486 compares very well with other methods of abortion, especially early termination suction abortion, both in terms of short-range risks and of effectively terminating unwanted pregnancies.”
• RU-486 abortions may be slightly more dangerous for people who smoke, especially if they are heavy smokers.
• “Nevertheless, given the experience thus far, RU-486 appears to be about as safe as taking a dose of penicillin.”
• [Note: since this book was published, RU-486 has become widely available and is now one of the most common methods of abortion in the United States. It is incredibly safe, cited as being safer than Tylenol, and is between 95% and 98% effective.]

What Practitioners Need To Know About Abortion Complications

• This chapter was written by Shauna Heckert, Executive Director for the Federation of Feminist Women’s Health Centers
• “This information is intended for practitioners who may not be familiar with abortion, but who may be called upon to do one, or who may be put in the position of treating abortion complications on an emergency basis. It may also be of interest to counselors, health educators, and others who want to learn about abortion in greater depth…”
• To keep complications to a minimum: use flexible cannulas only and avoid the use of metal or stiff plastic, avoid the use of general anesthetic, carefully screen for preexisting conditions that may cause problems, and “estimate gestational age as accurately as possible,using the woman’s own estimation of her last normal menstrual period, and a uterine size check.”
• Preexisting conditions to look out for: asthma, epilepsy (especially if triggered by stress), a history of pelvic inflammatory disease (PID), a history of tubal (ectopic) pregnancy, and fibroids.
• For people with asthma, using their inhaler before the abortion just in case may be a good idea.
• People with a history of pelvic inflammatory disease (PID) are more susceptible to infections and may take antibiotics as a precaution.
• People who have had an ectopic pregnancy are at a higher risk of having another ectopic pregnancy.
• Large fibroids may give the impression that the pregnancy is further along than it actually is.
• “The vast majority of abortions are completed without incident, but occasionally, unusual physical reactions can occur, and when they do, it is essential that they be handled appropriately.”
• Possible unusual reactions: allergic reaction to local anesthetic, asthma attacks, seizure, shock, and cardiac or respiratory arrest.
• “Nearly all abortion complications occur at the time of the abortion and will manifest themselves within the first few days after the procedure.”
• Possible complications: incomplete abortion (some tissue is left in the uterus), continued pregnancy, uterine infection, excessive bleeding, perforation of the uterus or nearby organs, reaction to anesthetic, uterine tear or laceration.
• “The three most common signs of a problem after an abortion are:
• pain in the abdomen or extreme cramping
• hemorrhage, gushing blood, large blood clots or prolonged bleeding, usually occurring only in later abortions
• a temperature over 100.4, sometimes accompanied by chills, which is not associated with other illness and develops within a few hours to a few days after the procedure.” [emphasis in original]
• “By far the most common complication of an abortion is an incomplete procedure. This problem can usually be avoided by carefully inspecting the tissue before a woman leaves the clinic. Unless she is less than three weeks pregnant, the distinctive types of tissue formation – chorionic villi and the placental sac—can be seen with the naked eye. Chorionic villi are white or yellowish, feathery cellular structures that help attach the placenta to the uterine lining. In early pregnancy, there should be a clump of villi about the size of a pencil eraser. The gestational sac is a very thin but sturdy transparent membrane that eventually develops into the ‘bag of waters’ as the pregnancy nears term. Two distinguishing characteristics of the sac are that it is difficult to tear, and it floats when immersed in water.”
• “If an incomplete abortion is suspected, the most important thing that should be done is a second aspiration (often called reaspiration).” [emphasis in original]
• If an infection is caused by retained tissue in the uterus, treating it with antibiotics won’t help until the tissue is removed.
• All signs of pregnancy (except breast engorgement) should be gone within a week of a successful abortion. After three weeks, a pregnancy test should be negative, but the most reliable way to check for continued pregnancy is with a uterine size check.
• “A uterine infection that is unrelated to an incomplete abortion will most likely linger, frequently spreading to the egg tubes and ovaries and becoming full-blown pelvic inflammatory disease (PID). Symptoms of PID are general pain in the abdomen, or a sharp pain on one side or the other. Over time, the infection can cause abscesses and scarring of the egg tubes and can result in infertility.”
• Rushing an abortion can lead to perforations.
• Minor perforations may heal on their own, but more serious perforations can be life-threatening.
• “If the woman is not in pain and has no fever or hemorrhage, she will probably need no further medical attention. In this case, many practitioners give oxytocin and a course of antibiotics, but this is more of a precaution than a necessity.”
• “If the perforation happens in the middle of the abortion, after some but not all of the tissue has been removed, there is the potential for infection and hemorrhage just as there is for incomplete abortion.”
• “If the perforation goes through the uterus and punctures the bowel additional surgical measures must be undertaken to repair the bowel, generally involving removing the damaged portion. If a significant portion of the bowel is removed, the woman may need a temporary or permanent colostomy. This drastic procedure was much more common in the days of illegal abortion when metal instruments were routinely employed in terminating pregnancies.” [emphasis in original.]
• “If the perforation involves the uterine artery, heavy bleeding may result, and if left untreated, could lead to shock and ultimately, cardiopulmonary arrest. Unfortunately, artery involvement is not always evident at the time of perforation. If the woman is still in the clinic,the standard practice is to monitor pain and look for signs of internal bleeding for a couple of hours. In rare instances where a uterine artery has been damaged, hysterectomy(removal of uterus, but not the ovaries) may be the only remedy.” [emphasis in original.]
• If a person has a positive pregnancy test, but no tissue is obtained during the abortion, this may mean that the pregnancy was ectopic. Ectopic pregnancies may resolve on their own, but if they don’t, the only treatment is surgery.
• If an ectopic pregnancy is not removed, at between 8 and 10 weeks gestation it will rupture the Fallopian tube, which is life-threatening.
• Following up in the first two weeks after an abortion is important for detecting complications.

The Del-Em™

• This chapter contains a complete list of the supplies for a Del-Em™, the device used for menstrual extractions:
• “Canning jar (1/2 pint; alternative: any jar or glass the rubber stopper will fit tightly)
• Rubber stopper (#13 two-hole, chemistry lab variety)
• Medical or aquarium tubing (15″ and 30″ segments; clear tubing is ideal, but rubber catheter tubing is also acceptable)
• Cannulas (4mm, 5mm, 6mm)
• 60cc syringe (disposable plastic)
• Automatic two-way bypass valve
• 5mm cannula (to be cut for valve adaptor and adaptor for 4mm cannula)
• 6mm cannula (to be cut for adaptors for rubber stoppers)
• Water soluble lubricating jelly
• Toothpicks or coffee stirring sticks
• Knife or single-edged razor blade
• Cutting board”
• [Note: After reading this chapter, I did some checking out of curiosity. All of the above is available on Amazon, except for the cannulas, which can be purchased online from medical supply stores.]