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 Politics

Missouri ‘Witch Hunt Hearings’ Modeled on Anti-Choice Congressional Crusade

Christine Grimaldi

Missouri state Rep. Stacey Newman (D) said the Missouri General Assembly's "witch hunt hearings" were "closely modeled" on those in the U.S. Congress. Specifically, she drew parallels between Republicans' special investigative bodies—the U.S. House of Representatives’ Select Investigative Panel on Infant Lives and the Missouri Senate’s Committee on the Sanctity of Life.

Congressional Republicans are responsible for perpetuating widely discredited and often inflammatory allegations about fetal tissue and abortion care practices for a year and counting. Their actions may have charted the course for at least one Republican-controlled state legislature to advance an anti-choice agenda based on a fabricated market in aborted “baby body parts.”

“They say that a lot in Missouri,” state Rep. Stacey Newman (D) told Rewire in an interview at the Democratic National Convention last month.

Newman is a longtime abortion rights advocate who proposed legislation that would subject firearms purchases to the same types of restrictions, including mandatory waiting periods, as abortion care.

Newman said the Missouri General Assembly’s “witch hunt hearings” were “closely modeled” on those in the U.S. Congress. Specifically, she drew parallels between Republicans’ special investigative bodies—the U.S. House of Representatives’ Select Investigative Panel on Infant Lives and the Missouri Senate’s Committee on the Sanctity of Life. Both formed last year in response to videos from the anti-choice front group the Center for Medical Progress (CMP) accusing Planned Parenthood of profiting from fetal tissue donations. Both released reports last month condemning the reproductive health-care provider even though Missouri’s attorney general, among officials in 13 states to date, and three congressional investigations all previously found no evidence of wrongdoing.

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Missouri state Sen. Kurt Schaefer (R), the chair of the committee, and his colleagues alleged that the report potentially contradicted the attorney general’s findings. Schaefer’s district includes the University of Missouri, which ended a 26-year relationship with Planned Parenthood as anti-choice state lawmakers ramped up their inquiries in the legislature. Schaefer’s refusal to confront evidence to the contrary aligned with how Newman described his leadership of the committee.

“It was based on what was going on in Congress, but then Kurt Schaefer took it a step further,” Newman said.

As Schaefer waged an ultimately unsuccessful campaign in the Missouri Republican attorney general primary, the once moderate Republican “felt he needed to jump on the extreme [anti-choice] bandwagon,” she said.

Schaefer in April sought to punish the head of Planned Parenthood’s St. Louis affiliate with fines and jail time for protecting patient documents he had subpoenaed. The state senate suspended contempt proceedings against Mary Kogut, the CEO of Planned Parenthood of St. Louis Region and Southwest Missouri, reaching an agreement before the end of the month, according to news reports.

Newman speculated that Schaefer’s threats thwarted an omnibus abortion bill (HB 1953, SB 644) from proceeding before the end of the 2016 legislative session in May, despite Republican majorities in the Missouri house and senate.

“I think it was part of the compromise that they came up with Planned Parenthood, when they realized their backs [were] against the wall, because she was not, obviously, going to illegally turn over medical records.” Newman said of her Republican colleagues.

Republicans on the select panel in Washington have frequently made similar complaints, and threats, in their pursuit of subpoenas.

Rep. Marsha Blackburn (R-TN), the chair of the select panel, in May pledged “to pursue all means necessary” to obtain documents from the tissue procurement company targeted in the CMP videos. In June, she told a conservative crowd at the faith-based Road to Majority conference that she planned to start contempt of Congress proceedings after little cooperation from “middle men” and their suppliers—“big abortion.” By July, Blackburn seemingly walked back that pledge in front of reporters at a press conference where she unveiled the select panel’s interim report.

The investigations share another common denominator: a lack of transparency about how much money they have cost taxpayers.

“The excuse that’s come back from leadership, both [in the] House and the Senate, is that not everybody has turned in their expense reports,” Newman said. Republicans have used “every stalling tactic” to rebuff inquiries from her and reporters in the state, she said.

Congressional Republicans with varying degrees of oversight over the select panel—Blackburn, House Speaker Paul Ryan (WI), and House Energy and Commerce Committee Chair Fred Upton (MI)—all declined to answer Rewire’s funding questions. Rewire confirmed with a high-ranking GOP aide that Republicans budgeted $1.2 million for the investigation through the end of the year.

Blackburn is expected to resume the panel’s activities after Congress returns from recess in early September. Schaeffer and his fellow Republicans on the committee indicated in their report that an investigation could continue in the 2017 legislative session, which begins in January.

Commentary Contraception

Hillary Clinton Played a Critical Role in Making Emergency Contraception More Accessible

Susan Wood

Today, women are able to access emergency contraception, a safe, second-chance option for preventing unintended pregnancy in a timely manner without a prescription. Clinton helped make this happen, and I can tell the story from having watched it unfold.

In the midst of election-year talk and debates about political controversies, we often forget examples of candidates’ past leadership. But we must not overlook the ways in which Hillary Clinton demonstrated her commitment to women’s health before she became the Democratic presidential nominee. In early 2008, I wrote the following article for Rewirewhich has been lightly edited—from my perspective as a former official at the U.S. Food and Drug Administration (FDA) about the critical role that Clinton, then a senator, had played in making the emergency contraception method Plan B available over the counter. She demanded that reproductive health benefits and the best available science drive decisions at the FDA, not politics. She challenged the Bush administration and pushed the Democratic-controlled Senate to protect the FDA’s decision making from political interference in order to help women get access to EC.

Since that time, Plan B and other emergency contraception pills have become fully over the counter with no age or ID requirements. Despite all the controversy, women at risk of unintended pregnancy finally can get timely access to another method of contraception if they need it—such as in cases of condom failure or sexual assault. By 2010, according to National Center for Health Statistics data, 11 percent of all sexually experienced women ages 15 to 44 had ever used EC, compared with only 4 percent in 2002. Indeed, nearly one-quarter of all women ages 20 to 24 had used emergency contraception by 2010.

As I stated in 2008, “All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.”

Now, there are new emergency contraceptive pills (Ella) available by prescription, women have access to insurance coverage of contraception without cost-sharing, and there is progress in making some regular contraceptive pills available over the counter, without prescription. Yet extreme calls for defunding Planned Parenthood, the costs and lack of coverage of over-the-counter EC, and refusals by some pharmacies to stock emergency contraception clearly demonstrate that politicization of science and limits to our access to contraception remain a serious problem.

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Today, women are able to access emergency contraception, a safe, second chance option for preventing unintended pregnancy in a timely manner without a prescription. Sen. Hillary Clinton (D-NY) helped make this happen, and I can tell the story from having watched it unfold.

Although stories about reproductive health and politicization of science have made headlines recently, stories of how these problems are solved are less often told. On August 31, 2005 I resigned my position as assistant commissioner for women’s health at the Food and Drug Administration (FDA) because the agency was not allowed to make its decisions based on the science or in the best interests of the public’s health. While my resignation was widely covered by the media, it would have been a hollow gesture were there not leaders in Congress who stepped in and demanded more accountability from the FDA.

I have been working to improve health care for women and families in the United States for nearly 20 years. In 2000, I became the director of women’s health for the FDA. I was rather quietly doing my job when the debate began in 2003 over whether or not emergency contraception should be provided over the counter (OTC). As a scientist, I knew the facts showed that this medication, which can be used after a rape or other emergency situations, prevents an unwanted pregnancy. It does not cause an abortion, but can help prevent the need for one. But it only works if used within 72 hours, and sooner is even better. Since it is completely safe, and many women find it impossible to get a doctor’s appointment within two to three days, making emergency contraception available to women without a prescription was simply the right thing to do. As an FDA employee, I knew it should have been a routine approval within the agency.

Plan B emergency contraception is just like birth control pills—it is not the “abortion pill,” RU-486, and most people in the United States don’t think access to safe and effective contraception is controversial. Sadly, in Congress and in the White House, there are many people who do oppose birth control. And although this may surprise you, this false “controversy” not only has affected emergency contraception, but also caused the recent dramatic increase in the cost of birth control pills on college campuses, and limited family planning services across the country.  The reality is that having more options for contraception helps each of us make our own decisions in planning our families and preventing unwanted pregnancies. This is something we can all agree on.

Meanwhile, inside the walls of the FDA in 2003 and 2004, the Bush administration continued to throw roadblocks at efforts to approve emergency contraception over the counter. When this struggle became public, I was struck by the leadership that Hillary Clinton displayed. She used the tools of a U.S. senator and fought ardently to preserve the FDA’s independent scientific decision-making authority. Many other senators and congressmen agreed, but she was the one who took the lead, saying she simply wanted the FDA to be able to make decisions based on its public health mission and on the medical evidence.

When it became clear that FDA scientists would continue to be overruled for non-scientific reasons, I resigned in protest in late 2005. I was interviewed by news media for months and traveled around the country hoping that many would stand up and demand that FDA do its job properly. But, although it can help, all the media in the world can’t make Congress or a president do the right thing.

Sen. Clinton made the difference. The FDA suddenly announced it would approve emergency contraception for use without a prescription for women ages 18 and older—one day before FDA officials were to face a determined Sen. Clinton and her colleague Sen. Murray (D-WA) at a Senate hearing in 2006. No one was more surprised than I was. All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.

Sometimes these success stories get lost in the “horse-race stories” about political campaigns and the exposes of taxpayer-funded bridges to nowhere, and who said what to whom. This story of emergency contraception at the FDA is just one story of many. Sen. Clinton saw a problem that affected people’s lives. She then stood up to the challenge and worked to solve it.

The challenges we face in health care, our economy, global climate change, and issues of war and peace, need to be tackled with experience, skills and the commitment to using the best available science and evidence to make the best possible policy.  This will benefit us all.


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