A new law and the death of a local doctor have made the availability of abortion in Knoxville uncertain. In April, the Tennessee Legislature passed the Life Defense Act, requiring doctors who perform abortions to have hospital admitting privileges. While the bill's sponsors never demonstrated a real need for the regulation, which was originally suggested by Tennessee Right to Life, the consequences are turning out to be profound.
Knoxville's two licensed clinics that offer surgical abortion, Knoxville Center for Reproductive Health (KCRH) and Volunteer Women's Medical Clinic (VWMC), serve not just local women, who make up about a third of their patients, but virtually every county in East Tennessee and into Kentucky and Georgia. Chattanooga has no clinic, and more Hamilton County women visit Knoxville clinics than women from Blount or Sevier. Nearly one in 10 patients arrive from neighboring states.
At VWMC, Dr. Richard Manning is the primary physician, and he has opted not to restore his admitting privileges, which he relinquished years ago when he transitioned from full-time OB/GYN practice to the ambulatory surgery clinic. Dr. Manning is 69. As of Sunday, July 1 he can no longer perform abortions in Tennessee.
His colleague at KCRH, whose family requested we not use his name, applied for and received admitting privileges at University of Tennessee Medical Center. Days later he suffered a stroke, and two weeks ago he died. Another local doctor who worked at the clinic earlier in her career has stepped in temporarily, but she is unwilling to assume duties at either clinic permanently.
We will refer to her as "Dr. Sub." She spoke with Metro Pulse under a promise that we keep her anonymous to protect her not only from domestic terrorists in the anti-abortion movement, but also from social and professional repercussions. And while it takes little effort to find the name of the late KCRH doctor, we agreed to call him "Dr. C" out of respect for a family in mourning, some of whom are unaware that he performed abortions.
Corinne Rovetti, co-director and family nurse practitioner at KCRH, says that doctors who perform abortions tend to be older, having practiced prior to the Supreme Court's 1973 Roe v. Wade decision that legalized abortion. For younger generations of doctors, the dangers of back-room abortions are abstract, so many see abortion as a controversy to steer clear from rather than a social justice concern to tackle. Rovetti says this shift in attitude has limited the pool of potential recruits to replace Dr. C.
"There used to be wards in hospitals dedicated to septic abortions, but those faded away after Roe," Dr. Sub says. Septic abortions are uterine infections caused by partial miscarriage, incomplete removal of fetal tissue from the womb, or unsterile procedures, and they can be lethal or cost a woman her ability to bear children. Medical schools are required to provide abortion training for students who request it, and it was Dr. C who trained local students.
A month ago, East Tennessee women "had two mature, seasoned doctors providing abortion services," Rovetti says. As of July 1, there is no dedicated physician.
KCRH Director Kim Denison says "We don't have a plan beyond the next few weeks." They hope to recruit a doctor who already has local hospital admitting privileges, otherwise services will be curtailed until a new physician can get the necessary licensing and certification in place.
Kerrie Harless, physician services director at UT Medical Center, says an application for admitting privileges costs $100 and takes 30-60 days for processing. It then must be approved by three committees. A doctor from out of state would first have to acquire a Tennessee medical license, which Harless says would add four to six weeks to the process.
Between the challenges of finding candidates for the two vacancies and the paperwork delays, the clinics could be unable to offer surgical abortions for several months, and this will create financial strains that could force staff reductions or even closure, they say.
"There is interest among local doctors in keeping the clinics open," Dr. Sub says, "but so far I am the only one who has put their name on the line." (Though her name has not been disclosed publicly, it is on various forms and reports protected by patient confidentiality laws.) She performed abortions early in her career for supplemental income, but as a focus of practice she says "I don't know whether the income is adequate."
Income is an issue on the patient side as well. A woman with the necessary funds may discretely retain services from a private physician or travel out of state. Clinics are "much cheaper," Dr. Sub says, noting that she frequently refers low-income and uninsured patients to the local clinics.
KCRH is a non-profit that derives all of its income from fees charged to patients. In addition to abortions, it provides a full range of services, from routine gynecological care to birth control to counseling and STD testing and treatment. Abortion prices start at $490 for a medically induced termination of pregnancy and go up as a pregnancy progresses. A 16th-week abortion, the latest they offer, costs $950.
KCRH performs around 1,600 abortions per year, with a quarter of those being non-surgical. According to Rovetti, half of their abortion clients are in the 18-to-25 age range, a quarter between 26 and 30, and the rest older. Patients under 18 constitute less than 1 percent of abortions, and Rovetti estimates "we may see about six to eight judicial bypass clients per year," who are women under 18 who obtained consent from the courts rather than from a parent.
The Knoxville Planned Parenthood office only offers medical abortions, which must be induced prior to the 10th week of pregnancy. House sponsor Matthew Hill (R-Jonesborough) said the intent of the bill was to only require hospital admitting privileges for doctors who perform surgical abortions. Uncertainty remains as to whether medical abortions might also fall under the new law, however, since the bill's sponsors were sometimes unclear on facts.
At times they directly contradicted each other. During debate in the House, Rep. Hill said, "Facilities that perform abortions must be licensed and are regulated for good reason," but when the bill progressed to the Senate, sponsor Mae Beavers (R-Mt. Juliet) said the state "cannot require licensing and inspection of abortion facilities" due to an unspecified court ruling. Both Knoxville clinics are licensed as ambulatory surgery centers and are subject to inspection by the state Department of Health. (Neither sponsor of the bill responded to repeated requests for comment.)
Opponents asked why only abortion providers were being held to this standard. "There are a multitude of procedures done in ambulatory surgical centers," said Rep. Gary Odom (D-Nashville), listing Lasik, dental, and orthopedic surgeries as examples. He said singling out abortion providers could form the basis for a constitutional challenge.
On Sunday, a judge in Mississippi issued a temporary restraining order preventing a similar law from taking effect in that state. The legislation, also passed this spring, requires doctors at any abortion clinic in the state to have admitting privileges at a local hospital and to be board certified in obstetrics and gynecology. The lawsuit filed by the state's only clinic alleges that the new law violates the 14th Amendment of the United States Constitution. Jordan Goldberg, the state advocacy counsel at the national Center for Reproductive Rights, said the picture in Tennessee is different, as there is more than one abortion provider statewide, but that the legislation was likely unconstitutional under Tennessee state law, given its broad privacy protections.
Opponents to the bill also asked whether there were incidents or data demonstrating a need for the law. Responding to Sen. Beverly Marrero (D-Memphis), Sen. Beavers said, "I have no personal knowledge of anyone who has had complications." The Guttmacher Institute, which provides comprehensive data on abortion, reports that "fewer than 0.3 percent of abortion patients experience a complication that requires hospitalization."
Every East Tennessee senator voted for the bill, with Reps. Joe Armstrong and Harry Tindell being the only members of the local delegation to vote against it.
Sen. Becky Massey was strongly in favor of the bill, saying "We need to make sure young mothers are protected." Asked whether there were specific instances that brought need for the bill to light, she says, "There were nominal instances." As executive director of the Sertoma Center, she works with adults with intellectual disabilities. "A lot of the folks we serve are the people folks are aborting," she says. Nine out of 10 abortions occur before the 12th week of pregnancy, which is too early to detect most fetal abnormalities.
Guttmacher data shows a sharp increase in legislation relating to abortion and reproductive rights in the past two years. After a decade that saw about 20 new restrictions per year nationally, 80 new restrictions were enacted in 2011. Guttmacher reports "87 percent of all U.S. counties lacked an abortion provider in 2008; 35 percent of women live in those counties." If Knox County joins that list, the number of women affected will be substantial.
This story has been updated to include a more specific comment from the Center for Reproductive Rights that was not available at press time.