"I actually went down on my knees begging him-but I think he felt he had been doing too many lately, and his hospital had been breathing down his neck. I walked out of there shaking…."

"I groveled and flattered him as much as I could. I sweet talked him. Finally he caved."

These are two stories of women physicians imploring male colleagues on behalf of patients who need abortions. The two events took place more than forty years apart, but the dynamics are eerily similar. The first speaker, Dr. Ethel Bloom (not her real name), now a retired general practitioner, is recounting for me her memories of what it meant to be an abortion-sympathetic doctor before Roe v Wade.

The daughter of her best friend, about to leave for college, had become pregnant. Dr. Bloom tried to obtain an abortion for her from an ob/gyn colleague who occasionally took risks and did abortions in his hospital, violating the rules of that time by claiming "medical necessity." (Bloom's gutsy, and ultimately successful, strategy for obtaining an authorized abortion in this case was to lie to another doctor that the young woman had tested positive for rubella, also known as German measles. The hospitals in the area had just begun to approve abortions for women with rubella, as evidence accumulated of the severe birth defects associated with the disease. As the first generation of tests were expensive, Bloom gambled — correctly — that the hospital would not retest her.

The second speaker, Dr. Margaret Riley (not her real name), is a vibrant and witty ob/gyn in her forties. In a just world, a woman like this would not have to "grovel," as she put it, before colleagues to get needed care for her patients. She currently is the medical director of a freestanding abortion clinic in an East Coast state and I recently heard her speak at a conference. A small portion of the patients who come to her clinic are too sick to have their abortions performed there safely and require having the procedure done in a hospital. This is when the groveling starts, as Riley has to deal with individuals and institutions beyond the clinic.

The case she discussed at the conference concerned a 17-year-old teenager with a history of recurrent pulmonary embolism (blood clots in the lungs). When the teen became pregnant, her hematologist suggested termination as the safest course, as pregnancy could dangerously exacerbate her condition, possibly leading to death. With the hematologist's backing, Dr. Riley arranged to perform the abortion in a local hospital. The young woman was admitted to the hospital, and prepared for surgery.

Literally as she prepared to leave for the hospital to do the procedure, Dr. Riley was informed by a clinic staff member that someone from the patient's insurance company had just called to announce that the company refused to authorize payment for the abortion. An in-hospital procedure would cost thousands of dollars, money which the family of the teenager did not have. Riley called the medical director of the company. "He said they would only pay if the ‘condition is life-threatening.' Of course, I wanted to shout, ‘You moron! Don't you know pregnancy in a patient with pulmonary embolism is life threatening?!' But I restrained myself. I calmly kept telling him how sick she was. I told him that the she had been on the pill but had to go off because of her condition….Finally, the breakthrough came when I got the hematologist to call him, and confirm how sick she was. Then he agreed. Of course, he thought that I, the abortion doctor, was doing this just for the money — but a hematologist, well that was a a different story."

This case of the 17-year-old with pulmonary embolism was just one of several that Dr. Riley discussed which described the challenges she faces when advocating with gatekeepers for women too sick for clinic abortions. The negotiations that Riley has to undertake routinely with hospital administrators, insurance executives, and physicians in other specialities in such instances gives us yet another window into the chaotic and Kafkaesque world that is contemporary abortion provision, even as Roe remains technically legal. Some of those with whom Riley must plead are quite upfront with her on their anti-abortion views, others have different motivations. When I asked her, in a follow-up interview, whether she thought the insurance director was motivated primarily by anti-abortion sentiments or by a desire to cut costs, she gave an answer that seemed to encompass both: "I think it was sexism actually."

Margaret Riley's situation, in fact, is in some respects better than that of her fellow clinic directors in other areas. She operates in a fairly liberal state, and over the years, has worked out an "understanding" with a local hospital that usually lets her perform abortions for very ill patients in its facilities. But in other places, hospitals' refusals to deal with seriously ill women seeking abortions is so egregious that a new term has entered the vocabulary of abortion advocates — "ambulance cases." Mainly, but hardly exclusively, occurring in Catholic hospitals or hospitals which have merged with Catholic institutions, the phrase refers to situations in which very ill women are sent from one hospital to another in an ambulance because the first hospital refuses to treat them. Here the pleading done by abortion providing ob/gyns with members of hospital ethics committees or heads of departments often falls on deaf ears.

Two particularly notorious cases occurred a few years ago in a Chicago suburbs, in a community hospital that merged with a Catholic institution. In the first case, a woman with an ectopic pregnancy — a potentially life threatening situation — was discharged from the hospital and sent by ambulance to another hospital. Because a fetal heartbeat was detected, the first hospital refused to perform an abortion (though they did offer to remove her fallopian tube, which would have compromised future fertility).

In the second case, a patient's water membrane burst prematurely at 18 weeks, putting her at risk of chorioamnionitis, an infection of the uterus that can cause high fever and is associated with sterility. Though the typical course in such situations is to induce labor before the infection develops, the hospital refused to do so until the patient developed a fever. The frustrated admitting physician sent the patient to another hospital for immediate treatment.

As Leo Tolstoy famously said at the beginning of Anna Karenina — "all unhappy families are unhappy in their own way" — we can say of the contemporary abortion scene, that all sites of provision are deeply challenged in their own way. The clinics, of course, have no shortage of problems, facing onerous restrictions and constant harassment. But hospital-based abortion care, especially when very ill patients are involved, pits the abortion provider against a host of more powerful forces, some truly astonishing in their disregard for women's health and wellbeing. And proud physicians like Margaret Riley are resigned to the fact that they will be doing a a lot of begging.