How Private Donors Shape Birth Control Choices

IIf you are an undocumented immigrant in Tennessee, you don’t have many options when it comes to birth control. You cannot get an abortion – it has been banned with very limited exceptions since 2022. You cannot get services from state public health clinics, which lost federal funding with the abortion ban. The state filled 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 contact a nonprofit called A Step Ahead, which will pay for you to get a long-acting reversible contraceptive (LARC), such as 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, Step Ahead will only pay for an implant or IUD, not for birth control pills or other short-acting contraceptive methods. This means that many women have a difficult choice to make if they don’t have insurance and want contraception: they can get a LARC from A Step Ahead – devices that will need to be removed by a doctor when they are ready to have children – or they can go without birth control. birth.

There appear to have been cases of A Step Ahead paying LARCs to undocumented women who didn’t speak English, sometimes 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 at a federally qualified health center, told Winters of the large number of Latino clients who appeared to be receiving LARCs but who did not speak English. . (Winters completed her work in 2019 and 2020 before the U.S. Supreme Court Dobbs decision. A spokeswoman for A Step Ahead East Tennessee, which serves mostly Latino clients, says the group’s call center coordinator is bilingual and the group ensures a translator is available whenever needed.)

A Step Ahead’s role in Tennessee illustrates how private programs have intervened to provide ways for women to access contraception in the absence of state and federal funding. It also shows how these programs can lead women to adopt a specific contraceptive method, 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 gynecologist at the University of California, San Francisco.

See more information: Women say they were pressured to adopt long-term contraceptive methods.

There are other ways Tennessee policies can limit women’s choices. In 2017, a Tennessee judge began offering reduced sentences for women who have agreed to have contraceptive implants placed in their arms. Although the judge later rescinded the order after resistance, more than 32 women received implants in the two months the order was in effect. As recently as 2020, the state was pushing LARCs against women in prison, says Winters, who interviewed with the Tennessee Department of Health about a program that visited prisons, showed women videos of babies suffering withdrawal from drugs they were exposed to in the womb, and asked them to sign up for LARCs. “What these states are going to trumpet is, ‘Look how much money we saved by not paying for these babies on Medicaid or mothers on public assistance,” says Winters. (The Tennessee Department of Health did not return multiple requests for comment.)

There is a patchwork system of access to birth control across the country. Although the Affordable Care Act mandates that private insurance plans cover FDA-approved contraceptives without cost-sharing, there are many women who still cannot access affordable contraception. This is especially true in states like Tennessee that have not accepted 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. Southeastern states, including Tennessee, Mississippi, Alabama, Georgia, South Carolina, and Florida, make up the majority of states that did not accept 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 health care providers to offer free or low-cost birth control methods. New Morning initially discovered that many clinics in the state did not have the money to stock IUDs and implants and helped pay for this to happen. But New Morning is very deliberate in providing access to eight distinct birth control methods, including the patch, the pill and condoms, says Bonnie Knapp, president and CEO of New Morning. The group also trained providers in “person-centered counseling,” essentially ensuring doctors listened to what patients wanted when it came to birth control. “We really wanted to create an environment where every woman could choose her methods,” she says. “We are very committed to ensuring that we do nothing that contributes to the history of stigma and coercion that the state and the South have.”

This tension between providing access to birth control but also not pressuring 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 concerned about the number of women who came before her who had difficulties with housing or other issues and who did not have child care options for their children. . The magistrate asked women on the pill if they had taken it before appearing in court, but no women did so, says Nikki Gibbs, current executive director of the A Step Ahead Foundation, who was working as a state investigator at the time. . “We saw firsthand what happened,” says Gibbs, “when a woman had too many babies before she was financially ready for them.”

Step Ahead Foundation, Memphis branch, primarily serves Black and Latina women. Through radio and television advertisements and events in low-income communities, it seeks to teach women about the most effective contraceptive methods and how using contraceptives can help women get “one step ahead” in life. The organization will pay for the LARC and its insertion procedure, as well as transportation to the medical appointment. It doesn’t offer short-acting contraception, Gibbs says, because LARC is the most effective form of contraception and because, she says, women can easily get the pill for free elsewhere.

See more information: Why health care for mothers is underpaid.

But even some of A Step Ahead’s affiliates believe it is coercive to choose a woman’s birth control method. Step Ahead has expanded to five other locations since 2011, and the Knoxville, Chattanooga and Johnson City locations now offer free short-acting birth control methods, like the pill, and do not promote one form of birth control over another. “That would be coercive,” says Taylor Phipps, executive director of Knoxville-based A Step Ahead East Tennessee. “Our organizational values ​​regarding access to contraceptives are not fully aligned.”

A step forward East Tennessee had no choice but to provide LARCs when it first launched, Phipps says. That’s because it received funding from A Step Ahead Foundation, the original Memphis-based organization, and that funding had a stipulation: new affiliates must commit to offering LARCs only for the duration of their affiliate agreement. A Step Ahead East Tennessee’s affiliation agreement ended in 2019, and the group has decided to begin providing access to the Pill and other short-acting contraceptive methods in 2022, after the Dobbs decision and the pandemic. It is now partnering with a telehealth clinic, which opens up options for women who can receive short-acting methods in the mail. “Given how the reproductive health landscape is changing in Tennessee,” says Phipps, “we felt it was our mission to provide as much information as possible so that women can make their own decisions about their own bodies.”

Limiting access to birth control to LARCs may deny access to some women, such as those who can’t get transportation to a clinic but can schedule a telehealth appointment to take the pill, Phipps says. Other women prefer the Depo-Provera shot because it is not noticed by the woman’s husband or partner, who may not want her to take birth control. “If we could provide short-acting methods to our customers without transportation or cost barriers, it would be a no-brainer,” says Phipps.

Still, A Step Ahead’s Memphis and Nashville branches, which only provide LARCs, are thriving. The Nashville nonprofit said in 2023 it was expanding to serve 11 more neighboring countiesbringing the total to 29. Charitable contributions to 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 over the same period, according to a TIME analysis of the groups’ tax forms.

The Dobbs decision and Tennessee’s subsequent abortion ban created a huge increase in the need for A Step Ahead East Tennessee’s services, Phipps says. As of 2022, the group provides approximately 250 contraceptive prescriptions per year; it now supplies about 750. But in contrast to the Nashville and Memphis affiliates, she says, “we’re struggling.”

This article was produced as part of a project for the USC Annenberg Center for Health Journalism’s 2023 Impact Fund for Reporting on Health Equity and Health Systems.