No Matter How You Feel About Abortion, You Need to Better Understand D&C
Whether it's needed due to pregnancy loss or abortion, the procedure is common, safe, and the same — but the silence around it hurts women.
As Alison* walked through the same New York City hospital entrance, took the elevator to the same waiting room, and met her ob-gyn to undergo her second D&C, a surge of memory washed over her. Seven years before, her marriage was ending and she was wondering where she would live. Her life felt out of control, and the ability to end an unwanted pregnancy was one way to take back her future.
She returned in the summer of 2019 after miscarrying a pregnancy that would've become the second child she, at 39, had wanted so badly. Both D&Cs were performed at about eight weeks gestation, and both were procedurally the same, despite the vastly different emotions Alison felt around them.
"Right before anesthesia was administered, my doctor patted and squeezed my hand in the same way," Alison tells InStyle. "The first time, I felt her compassion for my decision to terminate this pregnancy. The second time, I felt her compassion for my wish to become a family of four not coming true."
What is a D&C?
Dilation and curettage, the procedure in which the cervix is opened so that tissue can be removed from the inside of the uterus, is performed at doctor's offices, surgical centers, and hospitals both to remove pregnancy tissue and diagnose uterine conditions, such as abnormal bleeding. Whether the procedure is performed after a miscarriage or as an abortion, "it is exactly the same," Dr. Diane Horvath, an ob-gyn and the medical director of Whole Woman's Health of Baltimore, tells InStyle.
To start, a speculum is placed inside the vagina, just like before a pap smear. The cervix is opened a small amount, about the diameter of a pen in early pregnancy (up to 14 weeks), Horvath explains, and tissue lining the uterus is removed. Typically, this is done with a straw-like tube using suction, which is why it's sometimes called a dilation and aspiration, or D&A. The process takes between three and five minutes, and, depending on a patient's preference and where it is performed, involves different levels of pain medication or sedation. Most patients go home to rest afterward with some cramping, bleeding, and period-level pain medication; others go about their day. Made legal in the United States when the Supreme Court decided Roe v. Wade on January 22, 1973, abortion has been safe (and common) ever since.
Just how common? In 2017, 18 percent of pregnancies ended in abortion — a historic low — and about one in four women will have an abortion in her lifetime, according to research by the Guttmacher Institute. Some of those abortions involve a D&C, while others involve taking pills in what's known as a medication abortion (which accounted for 39 percent of abortions in 2017).
Meanwhile, about 10 percent of clinically recognized pregnancies end in miscarriage, according to the American College of Obstetricians and Gynecologists. While many women's bodies expel pregnancy tissue on their own through bleeding, others won't, which makes a D&C necessary (or going the medication route, which Horvath says works for miscarriage as well).
Yet the silence — and judgment — that surrounds abortion and miscarriage can keep women from knowing what to expect during the procedure. "It's really normal to have pregnancy loss. It happens to a lot of people, and we don't talk about it, but we should," Horvath says. "There's no shame in pregnancy loss, just like there's no shame in getting an abortion."
When performed by medical professionals, D&Cs are safe and effective. Mild pain and light spotting after a D&C is normal, and recovery typically takes one or two days. (Complications are rare, but heavy bleeding, fever, abdominal pain or abnormal discharge are all reasons to call your doctor, and you should ask when it's safe to use tampons or have sex afterward, according to ACOG).
But political rhetoric around terminating a pregnancy has led to "this false idea that abortion procedures are especially dangerous or deregulated in ways that other procedures are not," Dr. Horvath says. Often, that makes patients fearful of undergoing a D&C, even though it is "really one of the safest, most straightforward procedures you can have in an office setting," she adds.
It's also important to note that undergoing a safe, legal abortion won't harm your future fertility. "Some people who have had abortions and then experience pregnancy loss might emotionally connect the two, but they are not medically connected," Dr. Alexandra Sacks, a reproductive psychiatrist and the host of the Motherhood Sessions podcast, tells InStyle. "The fear that they're related is fear and is not scientifically true."
Dr. Horvath adds that the political fight over abortion has created an "artificial division" between women whose wanted pregnancies end and those whose unwanted pregnancies end. First of all, the medical procedure is identical in both cases; and then there's the fact that many times the same woman will undergo it for both reasons over the course of her lifetime.
"There are all sorts of reasons why a pregnancy would end," Sacks says, but "the same thing needs to happen: You need to clean and clear the uterus so you can get back to your healthy baseline, without discomfort or pain or infection."
Women can feel different emotions around the experience, but at the end of the day, it's about healthcare, not politics. And a major study published in the journal Social Science & Medicine in mid-January showed an overwhelming majority of women feel confident in the choices they make around abortion: 99 percent of women who had terminated pregnancies still felt abortion had been the right decision five years later.
"There's not one kind of person who has an abortion, and one kind of person who has a miscarriage and needs a D&C, and one kind of person who has a baby. That's the same person at different points in their life," Horvath says. "Plenty of people who have had a miscarriage may go on later to have a healthy pregnancy, carry to term and have a delivery, and then may go on to have an abortion after that, or vice versa. This is the same person experiencing these things at different life stages."
D&C After Miscarriage
In 2012, Alison, who works in communications in New York City, told only a few of the people closest to her about her decision to terminate her pregnancy and went to the hospital alone. "While I was waiting to be called, I wondered about the circumstances around why the other half a dozen women were there. It was a time we all needed support, but no one spoke to one another. Some women were there with their partner or a friend, but there was silence," she remembers.
Alison remarried three years later and gave birth to her first child in 2018 after seeing a fertility doctor. When she became pregnant again in 2019, she was elated. But when she went in for her seven-week appointment, "there was no yolk sac, no heartbeat, no growth. The pregnancy wasn't viable," she says. "I knew my options were to either miscarry naturally — which could begin in days or weeks, take days or weeks, and could still mean I'd need to have a D&C — or have the D&C." That's because even if a pregnancy is no longer viable, pregnancy symptoms can continue. For many women, nausea, swollen breasts, exhaustion, and a surge of hormones make coping with the emotions around a miscarriage even harder. Alison chose to have the procedure. "I didn't want to feel or look pregnant if I wasn't, and I wanted to have more control over the process."
This time, Alison brought her husband along, she texted friends from the waiting room, and even shared her miscarriage story on a Facebook group of 7,000 local moms, but she's never spoken openly about the abortion. "I was at peace with my decision, but it would have been helpful at that time to have connected more with others, even virtually." Now, she says, "I'll reference having had two D&Cs and one miscarriage, leaving the door open in a subtle way if anyone wants to connect with me."
‘We made the right decision for us’
At first, Marcy*, 30, worried even friends and family wouldn't understand her decision to end the pregnancy she had wanted so badly. The New York City-based media professional was 12 weeks pregnant for the first time in April 2018 when she went to her ob-gyn for a nuchal scan, a routine ultrasound to detect fetal abnormalities.
After a few heart-wrenching days, Marcy says she was given the diagnosis of trisomy 18, a chromosomal abnormality that prevents the heart and other organs from developing properly and, according to the National Institutes of Health, causes many fetuses to die in utero or shortly after being born. Often they are miscarried.
The thought of waking up and wondering if each day would be the day she would lose her pregnancy was too much to bear. "I knew I wouldn't be able to start moving on until it was complete," Marcy says, and she scheduled a D&C.
She was unconscious for the procedure itself, and woke up feeling surprised at how simple it had been. The feelings that came after were less simple. "I remember feeling completely empty. It was as if I had been whole, and now I was only a fraction of what I had been before. But I also felt relief," Marcy says. "I knew in my heart that as hard as it had been, we made the right decision for us. I was relieved to not have to spend every day wondering if today was the day I would lose the baby. I was relieved to know that I had spared our baby the pain of a life he or she could never really live. I was relieved that all the worrying, questioning, and debating was over."
Marcy and her husband told their immediate families and closest friends, who were supportive, she says. But it took her a lot longer to tell people outside her innermost circle. "There's still a lot of stigma attached to the process of ending a pregnancy, no matter what the reason," she says, and she feared how people would react.
But she also felt "immense gratitude," both for her doctor, who had given her the information she needed without judgment, and for the staff at the facility who treated her with kindness and respect.
"I was 13 weeks pregnant when I went through this, and there are many places where this would not have been legal," Marcy says. "I can say with certainty that the emotional trauma I would have gone through had I been forced to carry the baby to term would have been completely devastating."
Dr. Horvath says that's why it's so crucial that abortion care, including D&Cs, remain accessible. "If the idea of having a miscarriage at home is traumatizing for someone, then I want to be able to offer them a few-minute procedure in my office with sedation medication so that they can be done with that episode of their life," she says.
Fifty-eight percent of women of reproductive age in the U.S. (nearly 40 million women) live in states that were considered hostile to abortion rights in 2019, according to the Guttmacher Institute, and the disparities in access between urban and rural areas and coastal and midwestern regions has grown. With reproductive healthcare at risk, Alison, too, finds herself thinking about what life would have been like if she hadn't been able to make that choice.
"My doctor helped change the course of my life, and not everyone is as lucky to have control over their life," she says. "This shouldn't even be about politics."
Indeed, Horvath explains, it's about healthcare. "When we don't have access to abortion care, we also reduce access to treatment for pregnancy loss."
*Names have been changed at subjects' requests.