I was paged by labor and delivery three times during the 10-minute drive from my house. I headed straight from the parking lot to the labor ward expecting a patient of mine to be close to delivery. I was wrong.

The chief resident and attending obstetrician were waiting. They looked tired and worried.

A woman had arrived on Friday with ruptured membranes. She was 21 weeks along in her pregnancy, and now there was no amniotic fluid left at all. She and her husband wanted everything done. Despite the dismal prognosis for her baby, in respect for the patient’s autonomy, antibiotics were started. Within 24 hours, it was clear she had an infection.

Delivery was recommended as these infections are potentially deadly. The parents refused. “The antibiotics might work,” they said. And no amount of discussion about the overwhelming medical evidence that supported delivery could sway their decision. Inducing labor at 21 weeks while their baby was still alive was abortion.

The infection worsened despite the antibiotics. The patient, who was  rapidly deteriorating, and her husband reluctantly consented to an induction of labor.

And now it was clear why I was needed. Infected uteruses don’t contract very well. Prostaglandins and oxytocin both failed to produce even a cramp.

“They are very pro-life,” the resident warned. “It took several hours of convincing just to get them to agree to talk with you.” Considering I practiced in the bible belt this was not an unfamiliar scenario. I shrugged and walked into the room.

My patient was clearly very ill. Flushed, sweating, and drifting in and out of consciousness. The smell of anaerobes unmistakeable.

I reviewed what had transpired to date. The infection. The prognosis. And what I could offer. A dilation and evacuation.

They had two concerns. The first, their baby was still alive in spite of the infection. The second problem was that I was an abortionist. Couldn’t a doctor who didn’t perform abortions do the procedure?

“I understand your baby is still alive, but he or she cannot live. It is sad, and it is unfair, but the pregnancy is now killing you. It is not a matter of if you die, but when.” I paused. “You have other children at home and they will be without a mother. If it is any consolation, at 21 weeks, babies do not feel pain.”

The husband’s body language said it all. “How did you learn to do these procedures?” he asked.

“By doing abortions. Lots of them. I have done more late term abortions than most doctors of my generation. That makes me very skilled. But the privilege of helping women end their pregnancies safely also gave me the skill to help women like your wife. There is no other way. You have to do a lot of these procedures to become proficient. Even more to do them safely for women at 21 weeks who has an infection.”

There was no response, so I continued. “This is a very precarious situation. An infected uterus is easy to damage. I could make a hole and injure other organs. Even if the procedure goes well, the bleeding might not stop. A hysterectomy could still be needed. The infection in the blood stream might still get worse. But without the procedure, your wife will die.”

My patient spoke. “I don’t want to die.”

Within the hour, we were in the operating room. The procedure went well. The bleeding, though profuse, was controlled without a blood transfusion. Within 24 hours, she looked like a completely different woman.

Several months later I was surprised to find her name on my schedule. Especially given the reason was a first prenatal visit. After the appointment was over, I expressed my pleasure to have her in my practice, but also my surprise.

She looked at me and said, “I don’t like that you do abortions, but if you didn’t, I would probably be dead and not celebrating this new life. My husband isn’t thrilled that I am seeing you. He just can’t wrap his head around the fact that women sometimes really need someone who can do what you do. But I don’t see how I could go to anyone else. You saved my life.”

I think of the many times I have been in this exact situation over the years and it makes me wonder what happens now to the women who rupture their membranes at 21 weeks in Idaho, Nebraska, North Carolina, and Ohio. These women can’t choose to have a dilation and evacuation or even an induction of labor. They must wait until their baby succumbs in utero or for a spontaneous delivery, almost always a grim prognosis for their baby. Unless, of course, an infection develops and her life and health are in danger. Only then, when it is more dangerous, can a woman terminate her pregnancy at 21 weeks with ruptured membranes.

And if the induction of labor fails, as they often do, will these women be able to find a provider in one of those states skilled enough to safely perform a dilation and evacuation at 21 weeks in the presence of an infection?