If you’re an undocumented immigrant in Tennessee, you don’t have a lot of options when it comes to birth control. You can’t get an abortion—it’s been banned with very limited exceptions since 2022. You can’t get services from state public-health clinics, which lost federal funding with the abortion ban. The state has backfilled the funding, but a Tennessee law prohibits that money from being used for family-planning services for people without legal status.
One thing you can do is reach out to a nonprofit called A Step Ahead, which will pay for you to get a long-acting reversible contraceptive (LARC), like an intrauterine device (IUD) or an implant that goes into your arm. But there’s a problem, some reproductive justice advocates say. In many regions of the state, including Memphis and Nashville, A Step Ahead will only pay for an implant or IUD, not for birth-control pills or other short-acting methods of contraception. That means many women have a stark choice to make if they are uninsured and want contraception: They can get a LARC from A Step Ahead—devices that they will need to get a doctor to remove when they are ready to have children—or they can go without birth control.
There appear to have been instances of A Step Ahead paying for LARCs for undocumented women who didn’t speak English, at times without a translator present, says Della Winters, a professor at California State University, Stanislaus, who wrote her dissertation on the use of LARCs in Tennessee. “I’m not sure my clients really understood or even consented,” one provider, an employee of a federally-qualified health center, told Winters, about the large number of Latina clients that appeared to be getting LARCs but who did not speak English. (Winters completed her work in 2019 and 2020, before the U.S. Supreme Court’s Dobbs decision. A spokeswoman for A Step Ahead East Tennessee, which serves majority Latina clients, says that the group’s call center coordinator is bilingual and the group makes sure a translator is available whenever necessary.)
The role of A Step Ahead in Tennessee illustrates how private programs have stepped in to provide ways for women to access birth control methods in the absence of state and federal funding. It also shows how those programs can push women into a specific method of contraception, depriving them of choice. “It is absolutely coercive to only pay for one class of methods and not another,” says Christine Dehlendorf, a researcher and ob-gyn at the University of California, San Francisco.
Read More: Women Say They Were Pressured Into Long-Term Birth Control.
There are other ways that Tennessee policies can limit womens’ choices. In 2017, a Tennessee judge began offering reduced sentences to women who agreed to get birth-control implants inserted in their arms. Though the judge later rescinded the order after pushback, more than 32 women received implants in the two months the order was in effect. As recently as 2020, the state was pushing LARCs on women in prison, says Winters, who interviewed the Tennessee Department of Health about a program that visited jails, showed women videos of babies experiencing withdrawal from drugs they were exposed to in utero, and asked them to sign up for LARCs. “The thing that these states will tout is, ‘Look how much money we saved by not paying for these babies on Medicaid or mothers on public assistance,” Winters says. (The Tennessee Department of Health did not return multiple requests for comment.)
There is a patchwork system of birth-control access across the country. Though the Affordable Care Act mandated that private insurance plans cover FDA-approved contraceptives without cost sharing, there are many women who still can’t access affordable birth control. This is especially true in states like Tennessee that have not accepted the federal Medicaid expansion. Around 95,000 uninsured adults in the state have an income too high to qualify for Medicaid but too low to qualify for financial assistance in the Affordable Care Act marketplace, according to the Center on Budget and Policy Priorities. States in the Southeast, including Tennessee, Mississippi, Alabama, Georgia, South Carolina, and Florida, make up the majority of states that haven’t accepted the Medicaid expansion.
In some of these states, private organizations have stepped in to provide access to birth control and LARCs. In South Carolina, a privately-funded nonprofit called New Morning partners with clinics and healthcare providers to offer free or low-cost birth control methods. New Morning initially found that many clinics in the state couldn’t afford to stock IUDs and implants, and helped pay for them to do so. But New Morning is very deliberate about providing access to eight separate methods of birth control, including the patch, the pill, and condoms, says Bonnie Knapp, New Morning’s president and CEO. The group also trained providers on “person-centered counseling,” essentially making sure doctors listened to what patients wanted when it came to birth control. “We really wanted to create an environment where every woman would have a choice of methods,” she says. “We’re very committed to making sure that we don’t do anything to add to the history of stigma and coercion that the state has and the South has.”
This tension between providing access to birth control but also not pushing women to choose one method over another is present in many groups that have stepped in to provide access, including A Step Ahead. The organization was founded in 2011 by Claudia Halton, a former Tennessee juvenile-court magistrate who was troubled by the number of women who came before her who had difficulties with housing or other issues and who didn’t have childcare options for their children. The magistrate would ask women who were on the pill whether they had taken it before appearing in court, but not a single woman had, says Nikki Gibbs, the current executive director of A Step Ahead Foundation, who worked as a state investigator at the time. “We saw firsthand what happened,” Gibbs says, “when a woman had too many babies before she was financially ready for them.”
A Step Ahead Foundation, the Memphis branch, primarily serves Black and Latina women. Through radio and TV ads and events in low-income communities, it seeks to teach women about the most effective contraceptive methods and how using contraception can help women get “a step ahead” in life. The organization will pay for the LARC and the procedure to insert it, as well as transportation to the doctor’s appointment. It does not offer short-acting methods of birth control, Gibbs says, because LARCs are the most effective form of contraception, and because, she says, women can easily get the pill elsewhere for free.
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But even some of A Step Ahead’s affiliates believe it is coercive to choose a woman’s method of birth control. A Step Ahead has expanded to five other locations since 2011, and the Knoxville, Chattanooga, and Johnson City locations now provide free short-acting methods of birth control like the pill and do not promote one form of birth control over another. “That would be coercive,” says Taylor Phipps, the executive director of A Step Ahead East Tennessee, which is based in Knoxville. “Our organizational values relative to contraceptive access do not fully align.”
A Step Ahead East Tennessee had no choice but to just provide LARCs when it was first launched, Phipps says. That’s because it received funding from A Step Ahead Foundation, the original organization based in Memphis, and that funding had a stipulation: New affiliates must pledge to only offer LARCs for the term of their affiliate agreement. The affiliate agreement of A Step Ahead East Tennessee ended in 2019, and the group decided to start providing access to the pill and other short-acting birth-control methods in 2022, after the Dobbs decision and the pandemic. It now partners with a telehealth clinic, which opens up options for women, who can get short-acting methods mailed to them. “Given how the reproductive health landscape is changing in Tennessee,” says Phipps, “we felt that it was our mission to provide as much information as possible so that women can make their own decisions about their own bodies.”
Limiting birth control access to LARCs could cut off access for some women, like those who can’t get transportation to come into a clinic but could do a telehealth appointment for the pill, Phipps says. Other women prefer the Depo-Provera shot because it’s not noticeable by a woman’s husband or partner, who might not want her to be on birth control. “If we could provide short-acting methods to our clients without transportation or cost barriers, it was a no-brainer,” Phipps says.
Still, the Memphis and Nashville branches of A Step Ahead, which only provide LARCs, are thriving. The Nashville nonprofit said in 2023 that it was expanding to serve 11 more surrounding counties, bringing the total to 29. Charitable contributions to the Nashville A Step Ahead grew 80% between 2021 and 2022, to $1.2 million, and the Memphis group saw charitable contributions grow 8% to $2.3 million in the same time period according to a TIME analysis of the groups’ tax forms.
The Dobbs decision and subsequent abortion ban in Tennessee has created a huge boost in need for the services of A Step Ahead East Tennessee, Phipps says. In 2022, the group provided around 250 contraceptive prescriptions a year; it now provides around 750. But in contrast to the Nashville and Memphis affiliates, she says, “we are struggling.”
This article was produced as a part of a project for the USC Annenberg Center for Health Journalism’s 2023 Impact Fund for Reporting on Health Equity and Health Systems.
