There are many reasons why doctors choose to perform abortions, from simple recognition of social need, to feminist principles, all the way through to honouring the memories of great-aunts or grandmothers who had died as a result of illegal, septic abortions. Then there is pragmatism, the need for money (abortion pays well). Mostly, though, it comes down to idealism. People who perform abortions do so because they want the world to be a better place. How can the world be improved by forcing women to carry unplanned pregnancies and bear unwanted children? Having worked for ten years in an under-privileged area, I have seen firsthand the links between social disadvantage and unplanned pregnancy.

During my training in the western suburbs of Sydney, I often went to ‘real theatre’ in the eastern, more affluent part of town. The poorer parts of Sydney out west are not exactly popular work-places for doctors, and so the few of us training there worked hard. Shift after shift, eighteen to twenty-four hours straight, working or recovering from working, snatching breaks to study, psyching yourself up for the next epic shift. Going to the theatre in a different part of the city was a rare treat. One morning I had come off a twenty-four-hour shift, and was exhausted. Feet aching, I lolled in a theatre foyer chair and watched the passers-by. Not one of them looked unhealthy. No one was smoking outside. For the first time, I truly realised the link between privilege and good health. I felt unreal, disconnected from a world so very different from the one where I worked.

I also slept through the show.

Each week, I performed a couple of abortions, under anaesthetic, in the operating theatre. Note the terminology we use: actors at our tasks; the bright fluorescence of each operating room our stage. The youngest person I helped was twelve, the victim of a predatory uncle. But she was an outlier. Most patients were either in their mid-teens or older women with children already, victims of violence, drug addiction, or homelessness. Our abortions were popular, because the hospital provided them gratis to women assessed by the social work department as being in acute need. We could have operated morning and afternoon, five days per week, and we still wouldn’t have met the demand. Unplanned pregnancy and lack of money were frequent companions.

I once wrote to Helen Garner after reading The First Stone. I told her we were slaving at the coalface of feminism, trying to convince sixteen-year-old girls that pregnancy was not a great life choice, that staying in school would be better. I told her about writing a reference for a patient of mine who had to use her relative’s address on her application form because no retail employers would even interview her if she used her real address. I told her about generational unemployment and how difficult it was to escape, how pregnancy could seem the better option, how a second pregnancy might also work, though it rarely did. The author came to visit and wrote a story about my life: ‘Labour Ward, Penrith’. After the story was published, a male acquaintance from medical school rang me out of the blue. ‘That was you, wasn’t it?’ he said. ‘I knew it would be – you were always in everyone’s faces at med school, too.’

Was I?

I don’t know a single female obstetrician who isn’t made of sheet steel. The long hours, the constant stress of life-or-death responsibility, the accountability expected even before expertise has been acquired, the throw-them-in-the-deep-end style of training weed out the faint of heart. I actually never experienced gendered discrimination at my unpopular hospital – they certainly couldn’t afford to be picky about trainees. But I also was never given any particular allowance for being a woman or a mother. I appreciated this – it reminded me of my childhood in a similar working-class, immigrant area, where any kid with potential was respected, regardless of gender.

I first experienced gender discrimination at medical school, that upper middle-class microcosm of 1950s life values, where men were meant to be surgeons, women were meant to be GPs so they could work part-time and mother in the conventional, nurturing fashion. It was like a dating school, where middle-class private school kids became doctors, married, and spawned more doctors. I used to joke that medicine must have a genetic basis, because becoming a doctor was clearly hereditary. I had an alcoholic father, a crazy, violent mother, and no social skills. I had no money and when I was not at university or studying I was working as a checkout chick or doing chores at home. Poor areas felt normal and comforting to me – life was less confusing and people said what they actually meant.

A young patient once said to me – ‘You’ve had a kid since I last saw you, right?’ ‘Yeah, I had one last year, a little boy.’ ‘I knew you must have. You suck way less now than you did last time!’

As Jane Austen might say, I felt all the force of the compliment.

The flood continued; the faces changed but the need never went away. These violent delights have violent ends – but they don’t, they just keep churning over the same, few, mean, small, half-endings: new kid, new relationship, new kid, same hope broken on the wheel of poverty. It’s not just poor women who have abortions, of course, but imagine having to sit with an eagle-eyed social worker pleading your case, why your abortion is more important than those of all the other women clamouring for your spot in the queue, being judged and hoping to be the most deserving, the woman with the best and saddest story, so you can save those two hundred and fifty bucks and use the money for other pressing bills. I cringe now, even thinking about it. They needed us, and we judged them and assigned an order of merit, but in reverse. What we needed to provide was good education, free contraception, more choices than the pregnancy/pension path, the hopelessness of generational unemployment; we needed employers to look at an underprivileged girl and give her that first, most important chance. My pretensions to feminism were worth something, maybe a smidge more than nothing. But if they were, it wasn’t by much. What I did was worthy, but it didn’t effect change. 

There is more research nowadays, and a better all-round effort to understand and counteract generational poverty, but poverty amasses a momentum that is difficult to divert. It is difficult to obtain employment when you don’t know the basic conventions of self-presentation or attire for an interview. It is even more difficult if English is not your first language and if you don’t own a car. It can be difficult understanding the importance of turning up to work on time, difficult to understand why you should stay at school until Year 12 when no one in your family has done so. As for university – further education is so laughably inaccessible it never rates a mention.

In some parts of Sydney there are no compelling factors to discourage a girl from having her first child in her teens. Babies are often welcomed, and the Centrelink benefits, meagre though they are, can provide much-needed cash for a family. They can take the pressure from JobSeeker off for a few precious years, help a girl get off the endless, humiliating round of having to apply for jobs to retain her benefits. Babies are small and cute, too. This is truly where feminism is most urgent. Some girls escape poverty, myself included, but most do not. Escaping generational poverty is a lot like planning a murder – you need the means, the method, the motive, the opportunity.

In my case, my parents were Ten Pound Poms. Although neither progressed past the equivalent of Year 10, they had the immigrant respect for education common in my neighbourhood. Many of the children raised in my part of Sydney did reach university, so many in fact that the local public high school became one of the first public selective schools in Western Sydney. The population was mostly first-generation migrant from the United Kingdom, Malta, and Greece. In Girraween, money was scarce, but pretty much every man had a steady, albeit unskilled job. There is a big difference between blue-collar poverty and the generational unemployment poverty I was dealing with as a doctor. In a sense, I was protected from generational poverty by the prevalence of employment in my area and by the expectation that I would justify my parents’ sacrifice in leaving England. The children who grew up around me were likewise both protected and expected to attain success. The difference essentially came down to ambition. I like to say that immigrant western Sydney was largely composed of families genetically selected for nous.

I was formed in the context of organised poverty, and I was drawn to chaotic poverty. Most doctors have no connection to poverty at all, and few know how to use its language. If you have grown up in an educated household, attended an independent school, assumed that you would go on to university, and been given the resources to attain an HSC mark well inside the top one per cent of the population, odds are high that you will not even be able to understand the context of chaotic poverty, let alone speak the dialect required to connect with your patients. Currently, the population of greater Western Sydney is two and a half million people – one tenth of Australia’s population. A third of this population is composed of immigrants. There is little data as to where medical students come from, but from my experience, they are overwhelmingly middle-class. There can be an enormous, almost unbridgeable gulf of language and aspirations between educated and uneducated people.

My mother, herself an uneducated woman, although a voracious reader of Reader’s Digest Condensed Novels, was admitted to hospital and ultimately diagnosed with a severe, degenerative neurologic disorder, which would eventually be responsible for her death. Mild dementia was common in sufferers from this condition, although the mode of death was progressive paralysis. My mother could understand, but explanations needed to be measured and succinct. Her frozen, mask-like face could not respond appropriately to social cues. I watched as a senior registrar in neurology imparted this fatal diagnosis. The trainee was extraordinarily intelligent, she had passed her exams to be a physician, and had only eighteen months to go before she was let loose to perform in the most fraught of specialties. She spoke so rapidly, and used words and concepts so complex, that my ailing mother did not understand a single word that was said. Nobody who came from my old neighbourhood would have understood either. The difficulty lay not with my mother’s mild cognitive impairment or inability to interject and ask for clarification, it was that she wouldn’t even have known what to ask. My mother nodded, confused, trying her hardest to seem amiable and participatory. The registrar left with an audible sigh of relief. Job done, box ticked. The person who actually imparted the news to my mother was me. But what would have happened to her had I not been present?

What was actually going on here was an example of the chasm between the language and ideas of an educated person – a doctor who had grown up in a world where sentences like ‘an accumulation of a protein called Tau in a part of the brain called the basal ganglia’ made sense – and of an uneducated one. Worse, there was the desire of an uneducated woman, and an impaired one at that, not to make a fuss, not to be intrusive or demanding, to respect rather than question a person in a position of authority. My mother did not see that woman as a doctor, a healer or provider of services; she saw her as a remote figure of power and herself as a supplicant rather than a participant in the conversation. My mother ultimately died of the disorder, but not before making some foolish medical choices that were not thought through. She was too infirm to make decisions at crucial moments, and she was never allowed to exercise her options in soundness of mind. My advocacy for her, my desire to avoid unnecessary suffering, were perceived as little short of manslaughter.

As T.S. Eliot said, set down this, set down this: if we truly desire to open a dialogue regarding privilege, we must understand the voices and experiences of those who have none.

Meanwhile, I kept performing abortions, until I had one myself.

It would be true to say that I was the victim of a sudden marital breakup, but with the wisdom of hindsight ‘victim’ is technically correct but reductive. The pregnancy was planned, the break-up was unexpected, and I was left alone and distraught, with two young children and a third on the way, and no job for a year. I had no money. The obstetrician who would have delivered my third, and much-wanted, child performed my abortion instead. I heard the theatre staff chatting quietly, women I knew well, as I lay on the cold, narrow table, shivering with agony and grief. I woke in a trice, no consciousness of time having passed – bleeding, cramping, sobbing. I was numb. I wanted to die.

We talk about ‘losing’ a pregnancy as if it were a set of car keys, a game of checkers. We refuse to disclose miscarriages, call them ‘failed’ pregnancies, likening carrying a child to an exam or a driving test. We announce our pregnancies only when the danger period has passed, though everyone around us has already guessed. We have a culture of secrecy regarding pregnancy, unless balloons are called for, cards, a bassinet, the tiny onesies. We do not know how to discuss a pregnancy that does not end happily. Our friends don’t have the tools to console us, our grief unwomanly and therefore furtive, our game-face on for the world to trivialise our pain, or better yet, ignore it. It’s only a loss. If you fall off the horse, you should just get right back on. But this was not an option for me. My husband had gone, and I was left to raise my children alone.

There was grief, you can be sure of that, hacking, exhausting grief that felt almost too overwhelming, like sitting on a manhole, pushing downwards with all my strength, while a monster, horrible and eerily strong, thrust up from beneath. There was a time when I felt out of control, drunk all night and nasty every day; a time when my friends feared for my sanity and I wondered whether I could go back to the world of pregnancy and my work with women again. I threw my only ultrasound image ceremoniously in the bin, I cramped my way through a pelvic infection, and broke down entirely when I opened the pathology bill, for ‘examination of products of conception’.

I didn’t stay quiet, my lost pregnancy was not swept under the rug, I told everyone about my abortion. There was a terrible loss, and I would not pretend it had not happened, I wanted to shout from the roof: It happened, this happened, to me. I made this awful decision to spare my children, my other children, who were too small to understand that Daddy was gone but Mummy was still having a baby. I crashed my car on the way to hospital for my third shift back at work. I laughed it off. After my abortion, what was a mere crumpled car?

I never went back to performing abortions, but not by design. I was offered training in diagnostic ultrasound and moved away from general obstetrics, although prenatal diagnosis and abortion are inextricably linked. I believe I could have gone back to abortions, but there would have been tremendous pain and probably lasting damage to my psyche. That knowledge would not have stopped me because, ultimately, I learned about grief from my abortion. I also learned that grief does not always march hand in hand with guilt or regret. There was never any doubt in my mind that I had done the right thing, for my children and myself. The sensation of loss is not the same as wishing the lost to come back again.

But if only I had known then what I know now. We should have done more for those women in Western Sydney, those who begged for our services. They should have been given a language to speak, an opportunity to make other choices. We should have been women who walked by their sides, who understood and worked with them to better their lot. They deserved to love men who didn’t just have sex with them and walk away, partners who were kind, non-violent, hard-working. They deserved better schooling, better jobs, better lives. None of those were things I was able to give, so I offered them what I could: a step back, a second chance, a loss with no regret. There was no meaningful assistance, however, in enabling these women to avail themselves of this second chance. Why do we live in a world in which the least worst option may be a free abortion?

The goal of feminism is and has always been equality, but when we speak of equality using the words of privilege, when we discuss microaggressions and ignore our sisters, when we debate opportunity while failing to even see those with none, we do our cause a great disservice. Feminism is a broad church, but surely there is room to understand that providing opportunities for poor women – be it education, contraception, relationship advice, job assistance, and free abortions without question – would do more to alleviate chaotic poverty than almost anything else?

I believe in women, and their ability to shape the world, and I believe that given an exit strategy, few women would proactively choose chaotic poverty. I believe that we doctors need to do better, and that until we see as many medical students from Bidwell as we do from Randwick, our job is not done.

In my work in prenatal diagnosis, I remain peripherally in the field of abortion, although I now work in a tree-lined street in a wealthy suburb. When a wanted pregnancy is likely to result in a poor outcome, abortion is one of the options I canvass with frightened parents. There is still never an easy way to broach the idea that ending a pregnancy may be the kindest action. The circumstances change, not the loss or the pain.

Abortion is both a testament as to how far our rights as women have come and a strong indicator of how far we still have to go. The right to control our own bodies, to be able to weigh our choices and their consequences, the right to end a potential life in the service of existing life, that is something that should have been a given long, long ago. Although abortion has been available and obtainable for many years, it has only technically been legal in New South Wales since 2019. We were performing abortions thirty years ago, but abortion was in fact illegal – unless the life and health of the potential mother were at risk. It was only when ‘health’ was defined as ‘social well-being’ that abortions could be performed outside the backyard. We were offering a service so repugnant it was deemed criminal. Every woman who sought and obtained an abortion began as an exception that eventually enabled this felonious act to be performed without fear of prosecution for both the provider and recipient. The fact that patients and providers could break the law routinely yet still receive a Medicare rebate, unquestioned, was hypocrisy of the highest order, and a fair indication as to where women stood in terms of status.

Abortion is also an indication as to how far we, particularly feminists, have to go. Feminists cannot stand by as young, impoverished women fall pregnant repeatedly due to lack of other options. Eliminating poverty doesn’t require money, it requires education and opportunity, freely available contraception, and the use of abortion as a backup when all other plans have failed. The Colorado Family Planning Initiative in the United States provided free or low-cost contraception for at-risk women and teenagers for five years, resulting in a forty per cent drop in the unplanned teen pregnancy rate, and a thirty-five per cent decrease in abortions. Even without providing education and opportunities, this initiative, funded secretly by Susan Buffett, was so successful that it scandalised Republicans and was scrapped when funding was exhausted. As the feminist who inspired me said, in this instance, there is no place for sitting on the fence. When we debate equality, we must reckon with poverty and not let feminism be a middle-class phenomenon. We must make abortion available on demand, at little or no cost, and recognise the plight that drives women to seek the procedure. We must work to make abortion unnecessary, in the near future.

My own abortion, on reflection, was necessary and also the most emotionally painful experience I have endured. I wasn’t poor, and the decision was made for good reasons. I am glad the service was available and that afterwards I was surrounded by compassionate and caring staff and friends. It is an example of the care I try to give my own patients who seek abortion due to foetal abnormalities. I care for them as I wish I could have cared for myself, and I can see my own pain in their eyes too.

One day I hope to see less of this pain. Most of all, I hope to live in a world that my teenage daughter can navigate without fear, and with all the intelligent options of womanhood. I hope that one day our work will make her world safer and that I too will feel safe in it again. Until then, I guess I will continue to shout my abortion in the hope that someone will hear. 

This commentary is generously supported by the Judith Neilson Institute for Journalism and Ideas.