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“This is the Women’s Center. We need an ambulance ASAP,” a woman’s voice says on the thirty-second television ad. Emergency lights flash across the screen. “You’re listening to an actual 911 call,” says the narrator. “Tennessee has compromised the health and safety of certain women. Some Tennessee abortion facilities are not regulated like other surgical centers. This has to change.” Ad Policy

One of the year’s most heated battles over abortion access is playing out in Tennessee, where voters are considering a constitutional amendment that would open the door to a flood of anti-abortion legislation. With early voting underway and the election a week off, supporters of the ballot measure—known as Amendment 1—are amping up a campaign built around misinformation and fear. Voters have reported meddling by poll workers. And some abortion opponents are trying to use procedural trickery to lower the threshold of “yes” votes needed to pass the measure.

The fight over Amendment 1 has been more than a decade in the making. In a 2000 ruling striking down a slate of abortion restrictions, the Tennessee Supreme Court declared that the state’s constitution contained a fundamental right to privacy, which covered a women’s decision to terminate a pregnancy. As a result, Tennessee lawmakers have not been able to impose the kind of anti-abortion laws, disguised as safety measures, that other southern states have in recent years, such as mandatory waiting periods.

Ever since that constitutional right was declared, conservatives in the Tennessee legislation have been trying to gut it. They failed, repeatedly, until the 2010 elections brought a Republican supermajority to power in the state legislature, which passed the amendment in 2011. “Nothing in this Constitution secures or protects a right to abortion or requires the funding of an abortion,” it asserts. While technically the measure by itself wouldn’t change any regulations, supporters are clear about where it leads. “After [Amendment 1] passes, I have several ideas,” state senator Stacey Campfield told the Family Action Council of Tennessee. “I doubt there are any ideas I would oppose that would restrict abortion in Tennessee.”

“If this amendment passes, the floodgates will open,” warned Hedy Weinberg, the executive director of the ACLU of Tennessee. “In January 2015 when the Tennessee legislature convenes, we will see a lot of egregious and irrelevant legislation introduced.”

As of last week, groups had spent $2.4 million on more than 3,000 television ads related to ballot measures in Tennessee, with most of the focused on Amendment 1. Nearly $1 million was spent by both sides ads in the week when early voting started. Planned Parenthood, the ACLU, other reproductive-justice groups and even some members of the clergy are leading the fight against the amendment.

What they’re up against is an increasingly misleading, and even shady, “yes” campaign, led by Tennessee Right to Life. Based on the rhetoric of the amendment’s supporters, you’d think there was some sort of abortion free-for-all happening in the state. Advocates for the amendment warn that the state has become “an abortion destination” and that clinics are unregulated and unsafe. At a recent press conference outside a Nashville clinic on Monday, a physician named Brent Boles warned that “a lack of licensing and inspections allows these places to be totally unprepared for the horrible things that can go wrong.”

That’s the message of the ad featuring the 911 call from the Women’s Center (a clinic in Bristol, Tennessee), which implies that the call for an ambulance was due to complications from an abortion procedure that took place at a facility that was “not regulated.” However, according to a lawyer for the center, the emergency wasn’t directly related to the woman’s abortion. (How she feels about her medical history becoming the subject of a political ad is an open question.)

And Tennessee’s clinics are regulated—nothing in the 2000 Supreme Court ruling bars the state from overseeing health and safety standards. All of the state’s seven clinics are treated like any other doctor’s office. Four are licensed as ambulatory surgical centers, which among other things requires them to meet standards for room sizes and door widths. The Tennessee Department of Health inspects these clinics yearly. And the court ruling hasn’t prevented Tennessee lawmakers from implementing even stricter standards, such as a 2012 law that requires all abortion providers to have admitting privileges as hospitals—a requirement that forced two clinics to close.

Misleading ads may be par for the course, but early voters have been given more troubling forms of misinformation directly. Voters reported to the ACLU of Tennessee that poll workers in at least four precincts in Monroe County handed out a “misleading” voting guide that had been created by a state representative. The guide claims, among other things, that voting “no” on Amendment 1 indicates “that abortion clinics to not need to be licensed or inspected” and “you believe late term (partial birth) abortions need fewer restrictions.” As the ACLU’s Weinberg wrote in a letter to election officials, distributing “material designed to mislead and confuse voters is tantamount to influencing that person’s vote.” In response, the state’s election coordinator said he sent a letter to all ninety-five counties to reiterate the prohibition on explanatory language.

The voting guide, reviewed by The Nation, was created by Republican Representative Kelly Keisling. It’s not clear how it made it’s way to poll workers. Keisling was not available for comment, but one of his staffers said she was not aware of reports that it had been shared by poll workers. “It sounds like it needs to be investigated,” she said.

Early voters in another county reported that touch-screen voting machines turned their “no” votes to “yesses” on amendment one. “Sometime between when I cast my vote and when I got to the review page, the machine had changed my vote to a ‘yes,’ one man told local news. Although the ACLU has asked state officials to monitor the situation, Weinberg said that the problem is not ‘rampant’ and is probably only technical.

The most bizarre tactic employed by supporters of the amendment is an attempt to leverage a provision in the state constitution to lower the threshold for the number of “yes” votes needed to pass the amendment. Passing an amendment in Tennessee requires more than half the number of people who vote in the gubernatorial election—regardless of how many people vote on the amendment itself. Because Republican Governor Bill Haslam is sure to win, advocates for the amendment are urging other supporters not to vote at all in the governor’s race. “The less people who vote in the governor’s race means it takes less votes to pass the amendment,” explains a video on a new website, truthon1.org. “In other words, if you vote yes on 1, but don’t vote in the governor’s race you’ll double your vote.” Tennessee Right to Life and other groups pushing behind the amendment say they don’t know who started the website.

“Discouraging individuals from voting in any race undermines the heart of our democracy. It’s certainly unfortunate that that message is being promoted by the proponents of the amendment,” said Weinberg.