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 provider.
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. Tiller.
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.
