Written by Sharona Coutts for RH Reality Check.

Hospital bed

An illegal abortionist was tolerated by the state for years despite many injured women.

On August 13, 2010, an 18-year-old New Jersey resident arrived in a clinic in Elkton, Maryland, to undergo a surgical abortion. She was 21-and-a-half weeks pregnant, and had driven just over an hour from a clinic in Voorhees, New Jersey, where the day before, Dr. Steven C. Brigham had initiated the procedure.

Just 15 minutes into the surgery in Maryland, the patient suffered major injuries. Her uterus was ruptured, and her bowel had been perforated and was protruding into her vagina.

Instead of immediately calling 911 for emergency assistance, her doctors—Brigham and his associate, Nicola I. Riley—waited nearly two hours, according to findings from the Maryland State Board of Physicians. They then dressed the patient, who was still sedated and slumped over, and lifted her into a wheelchair. They rolled her outside, put her in a car, and with Brigham at the wheel, took her to a nearby hospital. Her injuries were so severe that hospital staff had her airlifted to Johns Hopkins Health Center for emergency treatment.

The patient survived, and as was reported Thursday morning in the New York Times, her story now forms a key part of the evidence that is being used in an administrative proceeding brought by New Jersey’s attorney general to have Brigham’s medical license permanently suspended or revoked.

However, what has not yet been reported is the extent to which legitimate providers in the states where Brigham practiced went to warn state officials of the threat Brigham posed to the health of the women he served.

In numerous complaints, emails and phone calls over a period of more than two decades, legitimate abortion providers from New Jersey and neighboring states alerted authorities to Brigham’s dangerous conduct, furnishing warnings they say went largely unheeded. Doctors provided copies of many of these complaints, as well as extensive logs of their calls, to RH Reality Check.

An investigation by RH Reality Check shows that New Jersey officials responsible for overseeing healthcare in that state could have prevented injuries to this and subsequent patients, had they acted on warnings about Brigham that predicted this exact scenario.

“If they had listened right in the beginning and taken appropriate action, I think these harms would have been prevented,” Jen Boulanger, a clinic administrator who has spent years amassing complaints about Brigham and his associates, told RH Reality Check. “I think state agencies were afraid of raising eyebrows about abortion, but they just should have handled it like they do any other field of medicine.”

A spokesman for the New Jersey attorney general’s office, which has ultimate oversight of the New Jersey Board of Medical Examiners, said the office could not comment on Brigham, because of the ongoing dispute over his medical license.

Attempts to reach Brigham, as well as attorneys listed as his representatives on official documents, were unsuccessful.

Brigham has now had his medical license suspended or revoked in up to six states, but public records show that he remains at the helm of an abortion chain called American Women’s Services, which is based in New Jersey, and owns or is affiliated with 15 clinics in four states. There is no requirement that the owner of a medical facility actually possess a medical license, state officials said.

The issue of abortion has once again leapt to the forefront of state and national politics. Already this year, dozens of anti-choice laws have been proposed or have passed at the state level, and a 20-week abortion ban recently passed in the U.S. House of Representatives.

Anti-choice advocates, including activists, and state and federal politicians, have capitalized on the case of another rogue provider—Kermit B. Gosnell—to falsely claim that he represented the norm in abortion care.

TIMELINE OF EVENTS

1986: Brigham graduates from Columbia University College of Physicians and Surgeons. In the coming years, National Abortion Federation leaders grow concerned about his skill level. Brigham fails to complete his NAF training, and his application for membership is denied.

APRIL 1992: Brigham agrees to voluntarily retire from practicing medicine in Pennsylvania in exchange for the state dropping a pending investigation regarding him. His license is placed on permanent inactive status, and he is ordered not to ever apply for renewal or reinstatement.

NOVEMBER 1993: The New Jersey attorney general’s office files its first complaint about Brigham with the board of examiners. Two more complaints are filed in July and December of 1994.

JANUARY 1994: New York suspends Brigham’s license, calling him an “imminent danger to the health of the people of New York.”

FEBRUARY 1994: New Jersey restricts Brigham’s license, determining that his unrestricted practice presents a clear and imminent danger to the people of New Jersey.

NOVEMBER 1994: New York revokes Brigham’s license, finding him guilty of gross negligence and negligence on more than one occasion in practicing medicine.

FEBRUARY 1995: Florida suspends Brigham’s license.

JUNE 1996: Florida revokes Brigham’s license.

AUGUST 1996: Upon a favorable ruling by the Office of Administrative Law on the three complaints filed by the New Jersey attorney general, New Jersey reinstates Brigham’s medical license subject to conditions that Brigham only perform abortions during the first trimester of pregnancy in the state.

SEPTEMBER 2005: A complaint lodged online by a doctor with the New Jersey Board of Medical Examiners warns that Brigham was performing second-trimester abortions in New Jersey.

SEPTEMBER 2009: Pennsylvania bans Brigham from owning or running abortion clinics in Pennsylvania.

FEBRUARY 2010: A group of New Jersey doctors, abortion clinic administrators, and counselors send a collection of complaints to the enforcement bureau of the New Jersey attorney general’s office and to William Roeder, executive director of the New Jersey State Board of Medical Examiners.

AUGUST 2010: An 18-year-old patient is injured at Brigham’s Elkton, Maryland, abortion clinic and is airlifted to Johns Hopkins Health Center for emergency treatment. Maryland issues a cease and desist order to Brigham, demanding that he stop practicing medicine in Maryland without a license.

OCTOBER 2010: New Jersey suspends, but does not revoke, Brigham’s license.

FEBRUARY 2013: A patient dies at Brigham’s Baltimore abortion clinic.

The documents provided to RH Reality Check, however, show that reputable providers tried for years to sound the alarm on a rogue provider. In Brigham’s case, they made sustained efforts to prompt officials in New Jersey, Pennsylvania, and Maryland to enforce the regulations that already existed to ensure safe abortion care. The documents provided show that authorities were often slow to respond to those warnings, if they acted at all.

For the providers who spent years trying to stop the problems they saw at Brigham’s clinic, the fact that he is still involved in women’s health—and being used as justification for restricting access to abortion—signals systemic problems with how the authorities and politicians treat reproductive health issues. They also said they believe many of these new legal restrictions—in addition to being medically unnecessary—could push more women into the hands of rogue providers, such as Brigham or Gosnell.

“It’s heart-breaking,” said Claire Keyes, who worked for more than 30 years as director of the Allegheny Reproductive Health Center in Pittsburgh, where she treated dozens of patients who had been to clinics owned by Brigham. “This isn’t throwing women under the bus. This is like backing up over and over and over them.”

A Long History of Problems

Brigham had already accrued a long history of harming patients by the time he botched the abortion in 2010.

Over a period of more than two decades, Brigham has left patients with severe bowel injuries, severed ureters and sweeping lacerations to the uterus, and requiring emergency hysterectomies for procedures that, when done by a properly trained provider, has a very low risk of complication, public records show.

In fact, Brigham first came to the attention of national abortion providers shortly after graduating from Columbia University College of Physicians and Surgeons in 1986. His prestigious education and natural charisma led many colleagues to give him a warm welcome into the professional community.

“We were very enthusiastic about this doctor when he first came,” said Suzanne Poppema, a former board chair of the National Abortion Federation (NAF) and Physicians for Reproductive Health. “He was young and socially adept and seemed to say all the right things, and asked good questions that you would expect someone just starting out to ask.”

But that impression changed quickly, Poppema said. Colleagues noticed that Brigham continued to ask the same questions at subsequent meetings, which struck them as odd. And then they began to hear troubling reports about the young physician’s medical practices.

“Right away we started hearing that he was moving into both early and later second-trimester abortions. And he had a complication,” she said, referring to a problem with an abortion procedure.

In the hands of a skilled provider, abortion carries a very low risk of complication, even after 20 weeks’ gestation, and certainly lower than the risks associated with giving birth. However, the risk of complication increases as the pregnancy progresses, and like any complex medical procedure, specialized training is required. NAF board members believed Brigham lacked those skills, and decided to confront him to express those concerns.

“I sat down with him and three other physicians, and we said to him, ‘You have to promise that you will not do any second-trimester abortions until you have spent two weeks with one of our senior physicians,’” Poppema recalled.

But Poppema said Brigham never completed that training. NAF rejected his application for membership, and lodged their concerns with Pennsylvania authorities, including the attorney general and the State Board of Medicine.

By 1992, however, Pennsylvania’s board of medicine had already become concerned about Brigham’s conduct. In April of that year, Brigham reached a deal with the board in which he agreed never again to practice medicine in Pennsylvania. In exchange, the board dropped an investigation against him, according to court documents later filed in Florida. RH Reality Check was unable to ascertain what prompted that investigation.

“We thought that just getting his license revoked would take care of it,” Poppema said. “But it turns out, it didn’t do any good to revoke his license. He just goes to another state, or better yet, he figured out he doesn’t need a license to open a clinic.”

Indeed, two weeks after he agreed to stop practicing in Pennsylvania, Brigham botched a 23.5-week abortion in New York, leaving his patient with a lacerated uterus, a severed ureter, and a colon so damaged that she required a colostomy—a form of bowel surgery that frequently leaves patients needing an external bag to drain their digestive systems.

And in November 1993, a 20-year-old patient who had gone to Brigham in New York for an abortion at 26-weeks’ gestation required an emergency hysterectomy after Brigham lacerated her cervix, uterus, and uterine artery.

In its ruling following these incidents, New York’s State Board for Professional Medical Conduct concluded that Brigham was an “imminent danger to the health of the people of New York,” found him guilty of gross negligence, and suspended his medical license. Relying partly on those conclusions, Florida also stripped Brigham’s license to practice in that state.

The New York board also drew damning conclusions about the doctor’s character.

“[Brigham] repeatedly exaggerated his medical training, experience and skill,” wrote the committee that heard Brigham’s case. He “has demonstrated he lacks appropriate judgment and insight as to his own limitations.”

The New York regulators also echoed Poppema’s concerns that Brigham lacked the skill and training required to perform later abortions. Brigham inflated his qualifications, but eventually “testified that what he referred to as special training in preparation for his activities in the abortion field consisted of limited interludes of observation of other physicians,” the board wrote.

New Jersey initially followed suit; the state restricted Brigham’s practice in February 1994, and banned him from performing second-trimester abortions, and required him to hire someone to supervise his practice, and to review patient records.

Brigham fought the decision to suspend his license, and eventually prevailed. The New Jersey medical board found in August 1996 that Brigham had not violated the required standard of care, and restored his medical privileges.

Brigham would soon expand his activities to multiple other states—including those where he could no longer legally practice medicine himself.

Brigham Finds Loophole, Continues Pattern of Harm

By the mid-2000s, Brigham’s abortion clinic network had grown bigger than ever. At its peak, American Women’s Services and its affiliates had at least 17 locations in New Jersey, Florida, Pennsylvania, Virginia, and Maryland, public records show.

Brigham also established multiple other companies with interlocking ownerships and linked addresses, which were associated with numerous nonprofit entities. He hired other physicians, technicians and administrative employees—some of whom have also faced disciplinary proceedings from multiple state medical boards.

Physicians in surrounding states were now receiving frequent complaints from patients who had been treated at a Brigham clinic, according to doctors interviewed by RH Reality Check.

“We had a standard complaint form, believe it or not,” said Claire Keyes, whose clinic in Pittsburgh often treated patients who had been seen at a Brigham clinic. She said they developed the form specifically for patients from those clinics. “We never got them from any other place, only from Brigham’s clinic, where patients were mistreated or they were so uncomfortable that they left, or they left but they discovered that they were still pregnant but they wouldn’t go back there.”

Keyes said that she and her staff regularly sent the complaint forms to the Pennsylvania Department of Health or occasionally to the state attorney general.

“I kept hoping that the evidence that we were giving the state would prompt them to want to do something,” Keyes said. “But as far as I know, that was not the case.”

Jen Boulanger, who was executive director of the Allentown Women’s Center at the time, also recalls dozens of patients reporting problems with Brigham’s clinics, ranging from confusing information, exorbitant fees, and allegations of improper sexual conduct by a doctor who worked for Brigham. (The doctor was stripped of his New York medical license after the Board of Medical Examiners found that he had sex with a patient at one of his clinics and was accused of sexually abusing three others.)

Boulanger maintained a log both of these complaints, and of her attempts to alert officials at the Pennsylvania health department, attorney general’s department, and medical board. The log, a copy of which she provided to RH Reality Check, includes names and contact information for officials who were later implicated in that state’s failure to perform basic inspections of abortion facilities, or to act on warnings about the criminal conduct of Kermit Gosnell.

“It was almost one complaint a month on average that we received from a patient,” Boulanger said. “It was so frustrating because I felt like we did everything we could do.”

A spokesman for the Pennsylvania Department of State said he could not comment on complaints of investigations into individual practitioners.

New Jersey doctors were also trying to alert authorities there of what they saw as the threat posed by Brigham and his associates.

In a complaint lodged online with the New Jersey Board of Medical Examiners in September 2005, a doctor alleged that Brigham had resumed performing second-trimester abortions at his clinic in Voorhees, despite the fact that his facility lacked the license required to do abortions past 14-weeks gestation. A copy of the electronic receipt confirmation was provided to RH Reality Check.

The doctor outlined the procedure that patients had described to her. They said Brigham would commence the abortion procedure at his private offices in Voorhees, by inserting laminaria, a type of seaweed commonly used in abortion procedures to soften the cervix in preparation for a later abortion. Because the cervix can require more than 24 hours to dilate, some providers ask their patients to return the following day to complete the procedure.

Reputable clinics usually require patients to stay for a short period of observation after laminaria are inserted, and ask them to remain under the supervision of a responsible adult until they return. In normal circumstances, a registered nurse and doctor are on call at all times in the event that a patient requires urgent treatment.

New Jersey law also requires all abortions at more than 14-weeks gestation to take place in a hospital or licensed surgical ambulatory facility—Brigham’s office did not fall within those definitions.

According to the doctor who filed the complaint, Brigham’s patients reported that he did not follow any of these best practices.

Instead, when patients returned the following day, he would inform them that they had to drive themselves to another clinic in a neighboring state to complete the operation. Brigham would often lead a group of patients, all traveling in separate vehicles, to an out-of-state clinic, in what was described in legal filings as an abortion “caravan.”

“These methods are not within the normal national standard of care for second trimester abortion services as put forth by the American College of Obstetrics and Gynecology (ACOG), the National Abortion Federation (NAF), and other nationally recognized experts in abortion care,” wrote the physician who lodged the complaint. The method posed “a serious threat to the health, safety and welfare of the public,” the doctor wrote.

But if New Jersey took any action on those warnings, the person who filed the complaint didn’t hear about it. In fact, over the following years, the parade of injured or distraught patients swelled as doctors continued to file complaints and write letters to New Jersey authorities.

On February 17, 2010, a group of New Jersey doctors, abortion clinic administrators, and counselors collected their complaints and sent a 24-page packet to Sandra Murray, an investigator in the enforcement bureau of the New Jersey Office of the Attorney General, as well as to William Roeder, executive director of the New Jersey State Board of Medical Examiners. Fax records indicate that the complaints were received at the number listed on Murray’s business card.

The complaints centered on a company called Grace Medical Care, one of Brigham’s many companies, as court filings would later show.

“Patients are being directed through Grace Medical to another state, likely after their initial laminaria insertion, and probably to Maryland, where there exist no guidelines for monitoring outpatient second trimester termination of pregnancy, and where the law is unclear at which point in the pregnancy termination becomes illegal—leaving murky waters for providers like Brigham to expand their reach unnoticed,” one doctor wrote.

“In my professional opinion, this practice is dangerous,” wrote another doctor who contributed to the complaint. “To ask a woman in the midst of second trimester abortion to cross state lines to an unfamiliar facility, which may be hours away, is potentially life-threatening.”

Neither Murray nor Roeder would comment for this story, but some seven months after Murray’s office received the packet, the precise scene predicted in these complaints played out when Brigham and his associate had the 18-year-old patient drive herself from Voorhees, NJ, to Elkton, MD, botched the abortion, and left her requiring emergency surgery at Johns Hopkins Health Center.

States Take Action

In the wake of that botched abortion, Maryland authorities raided the Elkton clinic, where they discovered at least five fetuses, though news reports said there were many more.

Based on the size of the fetuses, officials allege that Brigham—who had never held a license to practice medicine in Maryland—performed abortions up to 26-weeks gestation at the Elkton clinic. Additional patient records produced by the New Jersey attorney General in proceedings in that state indicate that Brigham performed up to 50 abortions between January and August 2010 at the Elkton clinic, including on fetuses up to 31-weeks gestation.

New Jersey’s Board of Medical Examiners temporarily suspended Brigham’s license in October 2010, and alleged almost identical facts to those contained in the multiple complaints lodged to its own office over a period of more than five years.

“Dr. Brigham has constructed an elaborate sham to allow him to do an end-run around New Jersey’s regulatory requirements,” the board wrote.

“Dr. Brigham’s deceptions extend even to his patients, who are kept uninformed of information as basic as where their procedure would be performed and even, in some instances, the identity of the physician who would be performing the procedure,” the board said. “His willingness to do so, and the lengths to which he has gone to further his scheme, manifestly support a conclusion that his continued practice would present clear and imminent danger.”

But Brigham’s clinics remained open. Doctors working nearby continued to receive complaints from patients who’d had a brush with his clinics, and they continued to write to the Board of Medical Examiners, pleading with them to take action.

On October 14, 2011, William Roeder, the board’s executive director, replied to yet another series of complaints from doctors who worked near Brigham’s New Jersey clinics. He informed the doctors that the board “appreciated” their “interest in this matter.”

“Please be advised that Dr. Brigham’s medical license has been temporarily suspended,” he wrote. “However, he can open another facility.”

A Patient Death

New Jersey’s administrative proceeding to permanently strip Brigham’s medical license is ongoing, but in February of this year, a patient died at the Baltimore office of Associates in OB/GYN Care, a group of four clinics listed on Brigham’s website as the Maryland facilities for his network, American Women’s Service.

Following the death, inspectors from Maryland’s Office of Health Care Quality found that all four OB/GYN Care facilities—located in Silver Spring, Cheverly, Frederick, and Baltimore—had an “unwritten protocol” that allowed unlicensed staff to perform and interpret ultrasounds and administer drugs, without any supervision.

“These deficiencies… could have resulted in serious or life-threatening harm or death to the patient,” the report found. On May 23, 2013, the state department of health decided to continue a temporary suspension because Associates in OB/GYN Care had not shown any compelling evidence as to why it should be allowed to reopen.

As recently as mid-June, callers to American Women’s Services were told that they could obtain abortions at their clinics in New Jersey or Virginia.

Staffers also told reporters that the Maryland clinics were temporarily closed “for renovations.” When asked directly by RH Reality, the person answering the company’s 1-888 number denied that the closures were related to regulatory problems. Maryland officials declined to comment when told about that answer.

A Florida clinic, American Family Planning, is controlled by one of Brigham’s companies and continues to operate from its premises in Pensacola, according to state officials.

However, American Women’s Services’ web site tells patients seeking treatment in Pennsylvania that they can attend Brigham’s New Jersey clinics. Since September 2009, Pennsylvania has banned Brigham from owning or running an abortion clinic, making it the only state to do so. Pennsylvania officials said they were prevented from commenting on complaints or investigations into medical practitioners.

For the doctors who had tried for decades to stop Brigham’s dangerous conduct, this reality comes as a blow.

“You feel completely powerless,” said Poppema, the former chair of NAF and Physicians for Reproductive Health. “We spend enough of our time trying to beat back harassment, threats, and anti-abortion legislation. The fact that we have to spend time policing someone in our own profession is just depressing.”

Correction: A version of this article incorrectly identified Jen Boulanger as a physician. She is in fact a clinic administrator. We regret the error.

Imani Gandy, RH Reality Check‘s senior legal analyst, contributed to this report.

This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Photo by José Goulão released under a Creative Commons Share Alike license.