The Next Generation of Providers: One Doctor Shows the Way

Sheila Bapat

Dr. Marianne Knox is a young abortion provider working in the South -- defying statistics, and the fear factor.

When Dr. Marianne Knox* began her ob-gyn faculty position at
a university hospital in a conservative Southern state just a few years ago,
abortion care was not covered in any of her students’ classes. Dr. Knox has
successfully added an abortion lecture to the curriculum. As a result, the 150
third-year medical students she teaches every year learn about the procedure.

Dr. Knox is also one of just a handful of abortion providers
in the South. She is a young woman in her early thirties – defying the statistic
that the majority of abortion providers are over the age of fifty. 

"I am a young provider and I am also an academic. I am
interested in integrating abortion into academics rather than sidelining it,"
she says.

The murder of Kansas abortion provider Dr. George Tiller on
May 31 brings into sharp relief the gravity of Dr. Knox’s decision to be a

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Despite the fear of violence that has for decades cloaked
their work, providers like Dr. Knox are scattered throughout red and blue
states, quietly doing their part to make good on the promise of Roe v. Wade.

Overall the number of providers in the United States remains
staggeringly low. Approximately 87 percent of all American counties do not have
an abortion provider.

The low number of abortion providers in the United States is
the result of a number of factors. There is the political factor: several
states have passed restrictive laws and policies, including ones that prohibit
any medical professional other than physicians from performing abortions. This
precludes physicians’ assistants or other qualified medical professionals from
being providers.

There is the fear factor, crystallized by the murder of Dr.

And, there is the professional factor: abortion is often
marginalized within major medical institutions and teaching hospitals. Most
medical school curricula do not include any discussion of abortion. In 1996 the
Accreditation Council for Graduate Medical Education required that all American
ob-gyn residency programs include at least an elective abortion training
option, but training is not mandatory. A survey published in Family Planning Perspectives in 2000 found that less than 50 percent of all
ob-gyn residency programs included routine abortion training.

Further, residency training alone does not ensure that
ob-gyn programs will yield abortion providers. According to the American
Journal of Obstetrics and Gynecology, of the residents who express an interest
in being an abortion provider upon beginning their residency, 52 percent
actually become providers.

Defying these odds requires a deep commitment to
reproductive freedom and health care. Dr. Knox’s passion for her work becomes
clear after just a few minutes of meeting with her. She is proud of how
receptive students have been to her abortion lecture, and how she has worked
with her department chair to mainstream training.

"I am pleased with how much I’ve been able to accomplish in
a short time," she says.

Her commitment may lead one to assume that Dr. Knox was
raised in a politically liberal family, or at least in a "blue state." In fact,
she grew up and attended college in the conservative South. "I never discussed
the issue with any women in my family or any other family members," she says.
"I came to the conclusion on my own that I am pro-choice."

Dr. Knox worked on feminist issues like domestic violence
awareness as a college student, but she did not grapple with the question of
abortion until her third year of medical school, when a student organization
that called itself Medical Students for Reproductive Health educated her class
about the issue. (At the time, the student group was discouraged from using the
word "choice" in its name.)   

This student group is a chapter of a national organization,
Medical Students for Choice (MSFC). Formed in1992, MSFC aims to educate and
engage medical students so that Dr. Knox can become the rule rather than the
exception. On its website, MSFC says it is committed to "de-stigmatizing
abortion provision among medical students and residents, and persuading medical
schools and residency programs to include abortion as a part of the
reproductive health services curriculum." There are currently 134 active MSFC
chapters throughout the United States and Canada.

"I have seen a number of classes of students move into their
careers and many of them are providing abortions," says Lois Backus, Executive
Director of Medical Students for Choice. "But they are doing it by and large
quietly, especially in communities in the southeast and Texas and the West
where it is a little less accepted."

As an ob-gyn resident Dr. Knox saw first-hand the problems
caused by the dearth of providers in the United States. She was stunned by how
difficult it was to arrange abortions for her patients, even when doctors had
recommended abortions due to patients’ health concerns.

"I was setting up my patients’ abortion treatment, and it
was often hard to find a provider. The difficulties and delays involved caused
me to wonder, how could it be that there were no networks in place to ensure
these women had providers?" she says. "Those experiences solidified my resolve
to become a provider and work on research in the field of abortion."

Dr. Knox went on to complete a family planning fellowship
where she could focus on reproductive health care. In the early nineties, only
one university offered such a fellowship. Now, approximately 20 medical schools
across the country offer family planning fellowships, which collectively
support 15-23 doctors per year. Some of the fellowship graduates become
providers, while others work in health policy.

The fellowship program offers Dr. Knox and other graduates
support and a sense of community, which their work environments often lack. The
challenges she faces at work are shared by most providers: increasing access
for as many women as possible; navigating office politics and colleagues who
disagree with legalized abortion; ensuring compliance with laws and
regulations; tuning out angry, shouting protestors on her way to work; and, of
course, looking out for her own safety.

Different challenges permeate her personal life. Every day
Dr. Knox negotiates how to discuss her job with family and close friends.
Providers often grapple with questions like, what will my family think if I become an abortion provider? Writer Patricia
Meisol discussed some of these more personal struggles in her November 2008 Washington Post piece, "A
Hard Choice
," which follows a medical student who is trying to figure out
whether she wants to become a provider.

Dr. Knox’s own journey has led to revelations within her
family. When she told her family that she would specialize in reproductive
health care, she learned for the first time that her mother, a conservative
Southern woman, is pro-choice.

Dr. Knox’s husband first balked at her interest in being a
provider, but has since become a source of great support. When they first
discussed it, she printed out facts from the Guttmacher Institute’s website
about the lack of providers. He was shocked to read the statistics. While he
still felt concerned about his wife taking this on professionally, primarily
for safety concerns, he began to understand her passion for the issue.

Her husband, a businessman and a fellow Southerner,
relocated with Dr. Knox when she accepted her family planning fellowship, and
the two continued to discuss the implications her career decision could have on
their lives. "The conversation evolved over the course of a year with a lot of
questions about how this would affect our family and our careers."

"Many of our questions still remain unanswered," she says,
but it is clear that she and her husband are in this journey together.

They both still feel concerned about her safety. "If my
safety was ever in jeopardy, we’d be back to square one in our conversation,
deciding whether we can really do this," she says.

Her husband’s support is particularly important given that
Dr. Knox often feels she cannot discuss her work with some family members or
close childhood friends who disagree with her. "I used to think I needed to
spread the gospel with everyone. Now, I think it would create an unnecessary
divide that would not further the cause at all."

So, she reserves the gospel for her job, and to good effect.
While legislators and activists can change policies and the political climate,
the power to actually provide comprehensive reproductive health care lies in
the hands of medical professionals like Dr. Knox who choose not to be deterred
by fear.

"When we know something is important enough, we can’t wait
for others to do it," she says. "We have to do it ourselves."

*The provider’s name
has been altered to protect her privacy.

News Health Systems

Complaint: Citing Catholic Rules, Doctor Turns Away Bleeding Woman With Dislodged IUD

Amy Littlefield

“It felt heartbreaking,” said Melanie Jones. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

Melanie Jones arrived for her doctor’s appointment bleeding and in pain. Jones, 28, who lives in the Chicago area, had slipped in her bathroom, and suspected the fall had dislodged her copper intrauterine device (IUD).

Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“I think my first feeling was shock,” Jones told Rewire in an interview. “I thought that eventually they were going to recognize that my health was the top priority.”

The doctor left Jones to confer with colleagues, before returning to confirm that her “hands [were] tied,” according to two complaints filed by the ACLU of Illinois. Not only could she not help her, the doctor said, but no one in Jones’ health insurance network could remove the IUD, because all of them followed similar restrictions. Mercy, like many Catholic providers, follows directives issued by the U.S. Conference of Catholic Bishops that restrict access to an array of services, including abortion care, tubal ligations, and contraception.

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Some Catholic providers may get around the rules by purporting to prescribe hormonal contraception for acne or heavy periods, rather than for birth control, but in the case of copper IUDs, there is no such pretext available.

“She told Ms. Jones that that process [of switching networks] would take her a month, and that she should feel fortunate because sometimes switching networks takes up to six months or even a year,” the ACLU of Illinois wrote in a pair of complaints filed in late June.

Jones hadn’t even realized her health-care network was Catholic.

Mercy has about nine off-site locations in the Chicago area, including the Dearborn Station office Jones visited, said Eric Rhodes, senior vice president of administrative and professional services. It is part of Trinity Health, one of the largest Catholic health systems in the country.

The ACLU and ACLU of Michigan sued Trinity last year for its “repeated and systematic failure to provide women suffering pregnancy complications with appropriate emergency abortions as required by federal law.” The lawsuit was dismissed but the ACLU has asked for reconsideration.

In a written statement to Rewire, Mercy said, “Generally, our protocol in caring for a woman with a dislodged or troublesome IUD is to offer to remove it.”

Rhodes said Mercy was reviewing its education process on Catholic directives for physicians and residents.

“That act [of removing an IUD] in itself does not violate the directives,” Marty Folan, Mercy’s director of mission integration, told Rewire.

The number of acute care hospitals that are Catholic owned or affiliated has grown by 22 percent over the past 15 years, according to MergerWatch, with one in every six acute care hospital beds now in a Catholic owned or affiliated facility. Women in such hospitals have been turned away while miscarrying and denied tubal ligations.

“We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions,” said Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU of Illinois, in a phone interview with Rewire. “It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves.”

Jones left her doctor’s office, still in pain and bleeding. Her options were limited. She couldn’t afford a $1,000 trip to the emergency room, and an urgent care facility was out of the question since her Blue Cross Blue Shield of Illinois insurance policy would only cover treatment within her network—and she had just been told that her entire network followed Catholic restrictions.

Jones, on the advice of a friend, contacted the ACLU of Illinois. Attorneys there advised Jones to call her insurance company and demand they expedite her network change. After five hours of phone calls, Jones was able to see a doctor who removed her IUD, five days after her initial appointment and almost two weeks after she fell in the bathroom.

Before the IUD was removed, Jones suffered from cramps she compared to those she felt after the IUD was first placed, severe enough that she medicated herself to cope with the pain.

She experienced another feeling after being turned away: stigma.

“It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

The ACLU of Illinois has filed two complaints in Jones’ case: one before the Illinois Department of Human Rights and another with the U.S. Department of Health and Human Services Office for Civil Rights under the anti-discrimination provision of the Affordable Care Act. Chaiten said it’s clear Jones was discriminated against because of her gender.

“We don’t know what Mercy’s policies are, but I would find it hard to believe that if there were a man who was suffering complications from a vasectomy and came to the emergency room, that they would turn him away,” Chaiten said. “This the equivalent of that, right, this is a woman who had an IUD, and because they couldn’t pretend the purpose of the IUD was something other than pregnancy prevention, they told her, ‘We can’t help you.’”

News Health Systems

The Crackdown on L.A.’s Fake Clinics Is Working

Nicole Knight

"Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options," Feuer said. "And therefore every day is a day that a woman's health could be jeopardized."

Three Los Angeles area fake clinics, which were warned last month they were breaking a new state reproductive transparency law, are now in compliance, the city attorney announced Thursday.

Los Angeles City Attorney Mike Feuer said in a press briefing that two of the fake clinics, also known as crisis pregnancy centers, began complying with the law after his office issued notices of violation last month. But it wasn’t until this week, when Feuer’s office threatened court action against the third facility, that it agreed to display the reproductive health information that the law requires.

“Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options,” Feuer said. “And therefore every day is a day that a woman’s health could be jeopardized.”

The facilities, two unlicensed and one licensed fake clinic, are Harbor Pregnancy Help CenterLos Angeles Pregnancy Services, and Pregnancy Counseling Center.

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Feuer said the lawsuit could have carried fines of up to $2,500 each day the facility continued to break the law.

The Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act requires the state’s licensed pregnancy-related centers to display a brief statement with a number to call for access to free and low-cost birth control and abortion care. Unlicensed centers must disclose that they are not medical facilities.

Feuer’s office in May launched a campaign to crack down on violators of the law. His action marked a sharp contrast to some jurisdictions, which are reportedly taking a wait-and-see approach as fake clinics’ challenges to the law wind through the courts.

Federal and state courts have denied requests to temporarily block the law, although appeals are pending before the U.S. Court of Appeals for the Ninth Circuit.

Some 25 fake clinics operate in Los Angeles County, according to a representative of NARAL Pro-Choice California, though firm numbers are hard to come by. Feuer initially issued notices to six Los Angeles area fake clinics in May. Following an investigation, his office warned three clinics last month that they’re breaking the law.

Those three clinics are now complying, Feuer told reporters Thursday. Feuer said his office is still determining whether another fake clinic, Avenues Pregnancy Clinic, is complying with the law.

Fake clinic owners and staffers have slammed the FACT Act, saying they’d rather shut down than refer clients to services they find “morally and ethically objectionable.”

“If you’re a pro-life organization, you’re offering free healthcare to women so the women have a choice other than abortion,” said Matt Bowman, senior counsel with Alliance Defending Freedom, which represents several Los Angeles fake clinics fighting the law in court.

Asked why the clinics have agreed to comply, Bowman reiterated an earlier statement, saying the FACT Act violates his clients’ free speech rights. Forcing faith-based clinics to “communicate messages or promote ideas they disagree with, especially on life-and-death issues like abortion,” violates their “core beliefs,” Bowman said.

Reports of deceit by 91 percent of fake clinics surveyed by NARAL Pro-Choice California helped spur the passage of the FACT Act last October. Until recently, Googling “abortion clinic” might turn up results for a fake clinic that discourages abortion care.

“Put yourself in the position of a young woman who is going to one of these centers … and she comes into this center and she is less than fully informed … of what her choices are,” Feuer said Thursday. “In that state of mind, is she going to make the kind of choice that you’d want your loved one to make?

Rewire last month visited Lost Angeles area fake clinics that are abiding by the FACT Act. Claris Health in West Los Angeles includes the reproductive notice with patient intake forms, while Open Arms Pregnancy Center in the San Fernando Valley has posted the notice in the waiting room.

“To us, it’s a non-issue,” Debi Harvey, the center’s executive director, told Rewire. “We don’t provide abortion, we’re an abortion-alternative organization, we’re very clear on that. But we educate on all options.”


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