Last in a series

TAMPA — Mimosas go for $2 to doctors, so early on a hot August Friday, the booths at Daily Eats filled with wired residents in powder blue scrubs, some double-fisting coffee after a long week of nights on labor and delivery.

Dr. Jewel Brown, a third year in obstetrics and gynecology, put in an order of take-home pancakes for her boyfriend. She had led interns through four deliveries overnight. She loves listening to women protest, “I can’t do it!” until they can.

She wants, one day, to be the kind of doctor a patient can trust with anything, whether it’s a prenatal checkup, a C-section — or an abortion.

Brown and fellow residents riff on all the ways medical schools and instructors make abortion so hard to even talk about. So many people dance around the word, as if it will leave them tainted.

She is determined to learn all she can.

Brown, 29, was a shy girl growing up in Valrico who put on her karate uniform to care for her stuffed animals, imagining a doctor’s white coat. Her family didn’t have health insurance, so when she was 16, her mom took her to Planned Parenthood for birth control. At home, her mom said: “Just tell me if you get pregnant. You can get an abortion if you want.”

Brown arrived at the University of South Florida medical school with loosely pro-choice ideals. Only a few lecture slides touched on abortion, she remembers, but in the school’s chapter of Medical Students for Choice, she found an education.

One semester, she crammed into the backseat of a car bound for the group’s national conference in Atlanta. There, the headliner shared that being an abortion provider does not make for an easy life.

Yet Brown could feel what it meant to him to help women other doctors couldn’t, or wouldn’t.

On the ride home, she set pharmacology test prep aside and started looking up programs that would train her. Being an advocate was no longer enough.

She thought, “I don’t know who will do this if I don’t do this.”

• • •

The medical field largely treats abortion as a specialty, not an essential part of a doctor’s toolkit.

And most ob-gyns don’t perform abortions.

Instead, a small funnel of doctors seek out training and devote themselves to clinics and side gigs despite hate mail and death threats. That kind of harassment has spiked since the 2016 election, according to the National Abortion Federation, which keeps statistics.

In medical school, stuffed curriculums typically devote less than an hour to abortion — if it’s mentioned at all.

In residency programs, hands-on training varies wildly.

Some programs worry about controversy or lost funding. Some teaching hospitals do not perform elective abortions, whether for ideological reasons or because standalone clinics pick up their slack — though anti-abortion laws can make clinic training hard to access, too. Residents sometimes work only with miscarriages, or emergency abortions. Opt-out provisions make it so a program can remain in good standing even if every student avoids the subject.

Abortion is a topic on ob-gyn board exams, but plenty graduate without becoming competent.

The vast majority of abortions are so simple they could be performed by other medical staff, except that most states, including Florida, require doctors to do it. That even goes for handing out pills.

Dr. Jody Steinauer, director of the Bixby Center for Global Reproductive Health at the University of California, San Francisco, remembers Roe v. Wade and the horror stories that once motivated doctors. In 1993, she founded Medical Students for Choice after she learned just 12 percent of ob-gyn residency programs were teaching abortion.

The newest generation, she said, demands better.

They’re fired up about class and racial divides in health care. They want universities with unapologetic training. They want access for all, part of regular practice.

“They’re coming up with an even stronger warrior mindset,” Steinauer said, “that they have to fight for the patient.”

READ EARLIER INSTALLMENTS OF THIS SERIES:

Those on Florida’s front lines in the abortion battle know change is coming

What is it like to work in an abortion clinic or pregnancy center? Our reporters visited both.

• • •

One or two Saturdays a month, Dr. A. Lowell wakes early and drives from Tampa Bay to a clinic in Kissimmee, thinking about the women.

Like when she was a resident, and a woman from India walked in, uninsured and undocumented in New York City. The woman had learned she was pregnant, but staff at an anti-abortion center insisted she need not rush to a decision. By the time the woman made it in for the procedure, she was more than 24 weeks along — past the legal limit.

The doctor thinks about women who can’t afford abortions and others who tell her, “This pill is like freedom.”

Lowell, 33, requested that her first name be abbreviated for fear of backlash at her full-time job at a health center for the underserved. There, in her contract, she quietly negotiated a clause saying she can also provide “full-spectrum reproductive health care” — in other words, that she can moonlight as an abortion provider.

At the clinic, she usually gets a text from her boyfriend, also a doctor: Let me know when you’re in the building. Once past security, she changes into scrubs and works from 9 a.m. through the last of 30-some patients, driving home in the dark.

Recently, she gave a talk to fellow family doctors about how to discuss pregnancy plans. She brought up a hypothetical patient, mentioning abortion briefly, as an option.

The response nearly made her cry.

Not relevant, some doctors said. Not my job. One sent a comment that, as a physician in his eighth decade of life, the presenter seemed to him like she was high-school age.

If patients can’t talk about abortion with their family doctor, she worries, who can they turn to? And if they want one, whether it’s because they can’t afford a baby or their relationship is rocky or they want to go to school, she doesn’t want to have to send them to a clinic. She’s perfectly capable — and willing.

As for her patients, “They can take ownership of what they want.”

She would know. In her early 20s, when she was scheduling medical school interviews, she found out she was pregnant. She braced for her mom’s reaction. Born and raised in the Philippines, a woman of Catholic faith, Lowell’s mom never spoke of birth control. But she said: “It happens.”

Lowell’s long-distance boyfriend didn’t come, so a friend of her mother’s drove her, after Virginia’s 24-hour waiting period. Lowell ducked past protesters shaking Bibles. Once inside, state law required that she listen to the heartbeat. The doctor, an older white man, spoke little. He told her to count down from 10. She stayed alert enough to remember the aftermath, placed in a hazardous waste bin.

Let me give back, she thought in med school. She wanted to remove the shame and make it all less clinical. She wanted women to look at her and see themselves.

She has done hundreds of abortions now, and posts pro-choice links on Facebook. But fear lingers. She hasn’t yet told her mother what she really does on Saturdays.

“You feel like you’re a hero but you can’t reveal it, like it’s your secret identity,” she said.

On Dr. A. Lowell’s long drive to the clinic, she listens to progressive podcasts, downs coffee and thinks about what patients have to endure to get to her. A family doctor, she wishes she could integrate abortion into her regular job. [ MONICA HERNDON | Times ]

• • •

Campus was green and still, the kind of collegiate Sunday made for sleeping in. In a windowless classroom, Kerry Ellenberg paced with her thermos of coffee. By 9 a.m., two dozen future doctors shuffled in for a workshop hosted by her group, USF’s Medical Students for Choice.

Under fluorescent lights, they ate Publix bagels and griped about how few residency programs embrace abortion. They groaned about the Pensacola lawmaker who calls fetuses “unborn human beings.”

When Dr. Lowell took the lectern and told them how she had made a career without a single med school lecture on abortion, they listened, rapt.

Her slideshow encouraged them to “Resist/Persist!”

Ellenberg, 25, now in her fourth year of medical school, never really wanted to be a crusader. Like Lowell and Brown, she just wants to provide everything patients might need when they come to her in their best and worst moments.

She and a few classmates at USF have pushed administrators for more lecture time on abortion and contraception. They proposed an expanded curriculum, with willing faculty in the wings. Ellenberg felt like USF was listening.

Still, Tampa General, the main teaching hospital, doesn’t perform elective abortions, so Ellenberg spent a couple of days at Planned Parenthood. She shadowed doctors counseling patients and saw one procedure. Her abortion education, she knew, would be largely self-determined.

Kerry Ellenberg, a fourth year in the University of South Florida’s medical school, wishes abortion were a bigger part of the curriculum. She worries students get the message that it’s not important. Through Medical Students for Choice, she pushes for more. [ MONICA HERNDON | Times ]

So in the med school classroom, Ellenberg stood before a dozen Hawaiian papayas atop white trash bags. Today, the fruit was a uterus, six to eight weeks pregnant, and the students would abort its seeds.

“Pick the squishiest ones,” Ellenberg said.

Their tools were simple: Handheld vacuum pumps, called aspirators, which work like a syringe. A thin, clear tube. A dilator rod that looked like a bendy straw.

They’d be practicing manual vacuum aspiration, a common, quick method to end early pregnancies and empty the uterus after a miscarriage. After eight weeks, they’d usually use the electric vacuum to work a little faster. In the second trimester, they’d take a more advanced approach.

The students held the green papayas in their palms, stem-end toward them.

“Picture the anatomy,” Ellenberg said. “She’s going to be lying on her back.”

She guided them to press the small, white rod into the fruit, dilating the “cervical opening,” coaxing it wider.

Then Ellenberg slid in the plastic tube, called a cannula. To that, she attached the aspirator, its plunger pulled tight.

Before the medical students begin the papaya workshop, simulating a common procedure to end an early pregnancy, one laments: “We don’t have the education in our medical school system to create more providers.” [ MONICA HERNDON | Times ]

“If all goes well, when I release the suction here, it will suction out uterine contents,” Ellenberg said. With a click, she squeezed its buttons, and a black seed flew into the tube.

“Oh! Did you see that?” she said.

“I definitely felt it,” said a lone male student.

“It’s a twirling motion,” Lowell explained, as other students released splashes of orange pulp and constellations of gummy seeds.

Ellenberg and her boyfriend planned to “couples match,” ending up in the same place for residency. But how many good options would she have, when so many schools skim over training? How would she come off, asking residency directors straight-up about how many abortions she would get to perform?

In California, Ellenberg helped counsel a young woman who learned that heart anomalies destined her baby to a short life in the NICU. A week after the woman's abortion, she came back feeling relieved, an awful burden eased. To Ellenberg, it confirmed: “This is the work I want to do.” [ MONICA HERNDON | Times ]

In later months, seeking more experience, she would fly to a rotation at the University of California, Irvine. Some days, she’d talk with patients. Others, she would insert an IUD or rupture the amniotic sac. Elective abortion was part of life in the school hospital. Insurance covered it.

“This is not Florida,” Ellenberg would joke.

On campus, in one of the day’s last talks, a Tampa abortion provider told the students, “Family planning is under attack.”

She talked about the minutiae of restrictions, the duty to honor patients, the ways non-white women have suffered. She changed slides, and let them sit with a black-and-white photo of life before legal abortion. In it, the corpse of a naked woman with blood-smeared thighs was bent over a puddle of black.

• • •

Ed and Mary Ortiz met a reporter for 11 a.m. salads at an empty mall restaurant, shared what they’d seen, and then spoke no more. The privacy and peacefulness of retired life in Sarasota were hard-earned for the doctor and nurse practitioner, who lived the before and after of Roe v. Wade. In her mid-70s and his mid-80s, they have new routines, like delivering communion to parishioners who can’t make it to church.

Pre-Roe, Mary Ortiz was 20, a hospital nurse in New York state. Women came in blood-soaked from botched procedures. “A lot of knitting needles,” she said.

Ed Ortiz, a young Georgetown doctor from Puerto Rico interning in a D.C. emergency department, saw women feverish with infection, women who had inserted a caustic chemical they’d heard might work. Ed tried to repair the holes burned in their tissue.

Others, they saw bleed to death on hospital floors.

Detectives asked questions, investigating the crime.

In 1973, Roe was decided. A friend told Ed that a clinic was opening in D.C. “Absolutely,” he said.

Mary had been volunteering with Planned Parenthood in exchange for childcare, visiting housewives while their husbands worked. She’d fit them with diaphragms, explain their fertile times and how to say no to sex. “It was dead serious,” she said. A job opened at a clinic in the D.C. area. She was asked: “Are you willing to work with abortion?” She’d never seen one, but said, “Absolutely.” Ed worked Saturdays, too.

The first few years passed quietly, as people seemed to accept the need for safe abortion care.

“Then all hell broke loose,” Mary said. In the late 1970s, protesters complained of tax dollars funding abortion. In the ’80s, the Religious Right went to war.

Protesters picketed the junior high Mary’s daughter attended. Their cars were egged on Mother’s Day. Twice, they said, opponents tried to set their home on fire.

Ed said he managed to fly under the radar because protesters assumed he was a janitor.

They remember: At their clinic, bomb threats made staffers flee. Activists broke a nurse’s arm in a frenzied scuffle. A protest leader chained himself to an exam table while a patient lay there, so 5′4″ Mary dunked a hazardous waste container over his head.

On occasion, Ed said, he performed abortions on the daughters of protesters.

In the early 2000s, after a move to Florida, Mary and Ed worked at Planned Parenthood clinics. He wore a Kevlar vest.

“Then after a while I said: ‘What’s the point? They aim for the head.’ ”

These days, they follow the restrictive laws snowballing across the U.S., with the potential to imprison providers. They weigh when to bring up their life’s work in conversation, torn between being ready to move on and their concerns about younger Americans’ complacency.

“They’ve never lived without it, so they don’t know what to fear,” Mary said.

“We’re going backwards,” Ed said.

In their condo down by the water, they keep their medical licenses active.

• • •

Almost three out of four ob-gyns saw a patient in the past year who wanted an abortion, according to a recent survey of U.S. doctors. Yet fewer than a quarter of them would — or could — perform one.

Personal reasons, religious or moral, made up a third of objections. Others worked at Catholic hospitals, feared office blowback or had bosses who said, “No way.”

Other research shows that still more, however willing, lack the training.

The provider pipeline has seen worse days. Panic took hold in the 1990s, as the first post-Roe generation of doctors began to gray. Protegees balked as clinics were firebombed, and the medical establishment backed away.

Not long after, the profession decided ob-gyn residency programs had to include training or at least “access to training.”

The University of California, San Francisco, helped multiply the number of highly trained providers through two programs: The Fellowship in Family Planning and the Ryan Residency Program. In just two decades, Ryan has built training into ob-gyn residency programs at nearly 100 institutions.

In family medicine, nearly 30 institutions now have “RHEDI” training, building in reproductive health education.

Now, the most likely ob-gyns to provide abortions are those under 35.

Still, more than a third of ob-gyn residency programs do not offer routine training, according to UCSF’s Bixby Center.

Florida only has one Ryan site, at the University of Miami. Faculty at USF have floated a Ryan program, but the push has stalled.

Retired Dr. Kathi Aultman of Jacksonville, now a scholar at a conservative think tank, is among the doctors who speak out against abortion. She wants it outlawed, with few exceptions.

“You should not learn to do abortions because it has a deadening effect on your conscience,” she said.

She became an abortion provider early in her career, when a fetus’ arms and legs seemed no different to her than the chick’s embryo she dissected in college.

She’d had an abortion herself, afraid she wouldn’t be able to go to medical school otherwise. She believed no woman should be forced into having a baby.

Three patients changed her mind after she had her first child. One had already come in for several abortions. Another yelled, “I just want to kill it!” The third insisted she could not have any more children, and wept throughout.

“At that point, I knew I was killing little people,” Aultman said.

She began referring seekers elsewhere. That wasn’t enough for friends who shared her Christian faith. They gave her an article that considered abortion in context of the Holocaust.

“I never understood how the German doctors could do what they did,” Aultman said. She said she realized: It’s because they considered Jews inhuman.

To med students, she says, “Opt out.”

But emergencies happen. A woman’s life or future fertility could be at risk. Even staunch anti-abortion doctors must reckon with that.

Bonnie Steinbock, professor emeritus of philosophy at the State University of New York at Albany, said freedom of conscience must be weighed against other ethical dilemmas: Patients’ needs. Children born into destitution. The profession’s responsibilities. The heavy burden on the few willing.

“If you’re just trying to avoid, ‘Oh, who wants to get involved in that,’ that’s not a moral conflict,” Steinbock said. “That’s just being a coward.”

• • •

Jewel Brown’s alarm goes off around 5:15 p.m. for night labor and delivery. She opens the blackout curtains, blearily steps into the scrubs with a Tampa General barcode, tugs a brush through her dark hair and swabs on a coat of Great Lash.

Her Keurig espresso, she takes to go. Another dirty cup in the sedan.

Sometimes after work, Brown has a hard time shutting her brain off and sleeping. She's tired of the medical world shying away from abortion. “People don’t want to deal with the mess,” she said. [ MONICA HERNDON | Times ]

She catches NPR snippets on her short commute, dipping into the bans and court battles and assault on abortion in America. She reminds herself: “All I can do is be a provider.”

The first abortion she performed came in her fourth year of med school, at a family planning elective in the Bronx. By then, she had delivered her first baby, a girl, and learned to biopsy cancers. She’d led her own papaya workshop.

The girl was 14, late in her first trimester, tiny and giggly. Her older sister sat with her. Big decisions by small girls, Brown thought. Maybe this would give the teenager a new opportunity. Brown went home satisfied — even honored.

She stayed at USF for residency, though there is not as much hands-on experience as she’d have wanted. She poured herself into the program’s monthlong rotation at Planned Parenthood, driving extra miles to Orlando and Sarasota to observe and assist. Soon, she could do routine abortions on her own.

“Women come in business clothes on lunch breaks,” she said. “Like a pap smear or a teeth cleaning.”

The ones who sob, she checks to make sure they’re sure. Then she soothes them: “This is the right thing you’re doing for yourself right now.”

She’s comfortable with how the language shifts from moment to moment. She’ll talk to an expectant mom, look at a wiggly ultrasound and say, “Look, she’s dancing!” She’ll talk to a woman just as far along, look at the ultrasound and order a termination.

“It’s about the mom,” Brown says — that simple, even when it’s not.

Afterward, she must account for all “products of conception,” to make sure no fetal parts have been left behind. The work doesn’t shake her. If anything, it intensifies her calling, because she knows not all doctors can handle it.

She wants to believe things will never get as bad as they seem in states like Alabama, where a total abortion ban is tied up in the courts. But she’s considering joining what some call the Peace Corps of abortion, flying twice a week to wherever need is highest. She jokes she’d sail the Gulf of Mexico and perform abortions in international waters. In her laughter lies an undercurrent of unease.

Women will always seek abortions. Should the worst come, those with means would fly elsewhere. Others would go underground. In that world, she’s certain, doctors would still need to know how to treat the bloody aftermath.

Contact Claire McNeill at cmcneill@tampabay.com. Follow @clairemcneill.

"We need to show people how dire this is," Dr. Lowell said. [ MONICA HERNDON | Times ]

About this story:

In writing this story, the Times did not seek to grapple with the morality of abortion but to explore an under-reported part of the debate: the people who feel called to provide this procedure. Because of the nature of their occupation, the story leans heavily on doctors who are choosing this path.

The story is based on multiple meetings with abortion providers, medical residents and students, as well as interviews with experts, advocacy groups, academics and ethicists. Staff writer Claire McNeill read dozens of stories and research about abortion in medical education. The doctors quoted in this report spoke for themselves and not on behalf of their employers or affiliate institutions. The Times agreed to abbreviate Dr. Lowell’s first name to address her concerns about patient and coworker safety.

Previously in this series were profiles of an abortion clinic and an anti-abortion pregnancy center in Jacksonville, and a look at two Florida politicians ready for battle.