Heads turn as a white SUV pulls onto a narrow dead-end street and parks under a line of billboards advertising 24-hour bail bonds. On one side of the street is the Monroe County Sheriff’s Department, its front doors and windows tinted opaque black.
On the other is the county jail, a low-slung red brick and corrugated metal building ringed in barbed wire. Small groups of people gather near the entrance to wait, or smoke.
Teresa Harrill gets out of the car and unloads a stack of file boxes from the backseat. She follows a deputy inside the sheriff’s department building and down a long, dark hallway to a cluttered staff kitchen that doubles as a conference room and education space for inmates at the overcrowded jail.
Harrill’s been here before. As director of the East Tennessee Monroe County and Loudon County Health Departments, she’s the tip of the spear in Tennessee’s battle against neonatal abstinence syndrome, or NAS, a condition where newborn infants experience withdrawal from opioids their mothers used during pregnancy.
Rates of NAS are persistently highest in the Eastern third of the state that hugs the Smoky Mountains and the Virginia and Kentucky borders, long hovering above the nation’s, with cases rising ten-fold in the last two decades as the opioid epidemic escalated.
In 2018, just over 11 percent of every 1,000 live births in Tennessee were babies born with NAS. In the hardest-hit eastern and northeastern counties, rates were at least three times higher.
NAS causes symptoms including seizures, diarrhea, irritability, fever, high-pitched and excessive crying, difficulty breathing, poor sleep and difficulty feeding. Infants could also be at risk for long-term developmental and educational delays.
To prevent opioid exposure in more babies, Tennessee has rolled out a number of programs to boost access to drug screening and treatment for opioid-affected pregnant women and expand family planning services. That includes outreach programs such as Harrill’s, called the Voluntary Reversible Long Acting Contraceptive, or VRLAC, Jail Initiative.
The program sends Harrill and a team of nurses and outreach workers to jails scattered around 15 rural East Tennessee counties at least once every other month with the goal of educating incarcerated women about the risks of NAS to infants. The program saw more than 7,800 inmates between 2014 and 2018.
“We started this program for one reason: because we saw so many babies being born that were drug-dependent,” she said. “And our local hospital, Knoxville Tennessee Children’s Hospital, was seeing so many babies in their Neonatal Intensive Care Unit that were born drug-dependent. And the region got together and felt like this was one way that we could possibly help with the situation and maybe reduce those numbers of babies being born” Harrill said.
Harrill cites inmate survey data presented in 2018 by faculty from the University of Tennessee Public Health and Nursing schools that finds women serving time in jails face a high risk of giving birth to a baby with NAS. Almost all of the women who’ve participated in similar jail programs have a history of drug use, most often with opiates, the study reports, and more than one-third had used drugs during a pregnancy.
Many of the inmates who participate in the health department program have already lost at least one child, Harrill said, an observation backed up by the same survey, which also reports 24 percent of women had a child in state custody.
“And that’s what’s sad,” Harrill said. “We see a lot of women that already have children, that either their child is in state custody or, you know, grandparents or family members are raising their children while they’re incarcerated.”
Losing children is a familiar experience for many of the Monroe County Jail inmates in attendance at Harrill’s presentation inside the Sheriff’s Department kitchen.
Half a dozen women in black and white or orange jumpsuits and rubber sandals with socks sit attentively around a conference table as Harrill clicks through her presentation about NAS.
“The first thing I want to say is, this program, we’re not here to judge,” she told them.
When Harrill asks if they’re familiar with the term NAS, all of the inmates nod their heads. Many volunteer that they’ve heard the signature high-pitched cry of drug-exposed babies. And several women raise their hands to share personal stories about their own experiences giving birth to babies in opioid withdrawal.
“I was on pain pills. I was an I.V. user and she was born addicted. I spent the first four years of her life in the penitentiary. What kind of life is that for her?” an inmate named Chrissy told the group. “I think it’s very selfish to bring children into this world and you’re in full-blown addiction. I just think it’s the most selfish thing in the world because there’s so many kids without parents. So, that’s why I got my tubes tied.”
While Harrill isn’t advocating for or against such procedures, she does present options to the women who attend her programs for long-term birth control options.
As she asks whether any of the inmates are interested in hearing about free, long-acting contraception, explaining the different types, images of IUDs and other forms of birth control appear on the projector screen.
All of the women at the table raise their hands. They break into small groups to privately discuss their health needs with a health department nurse.
“It’s up to you. That’s your decision. It’s your decision, not mine not anybody’s, it’s yours. If you’re interested, we’ll be able to bring you to the Health Department,” Harrill said.
Officials would transport any of the women inmates who request to receive a birth control method to a health department clinic at a later date.
After about an hour, the NAS-prevention workshop wraps up and Harrill heads out to her car. Piling her boxes back into the backseat, Harrill said it’s critical to educate incarcerated women about the dangers of NAS before they’re released, and before they’re at risk of an unintended pregnancy that could expose a fetus to opioids.
“We looked at them as a population, obviously we would have their attention and obviously that we could get to. ”
Tennessee Department of Health officials credit state NAS prevention programs with contributing to an overall decline in NAS rates last year, the first such decline since the state began tracking the condition in 2013.
Promoting the option of long-acting, reversible contraception to prevent unplanned pregnancies among women affected by opioids is in line with the 2017 American College of Obstetricians and Gynecologists Committee Opinion on opioid use and opioid use disorder in pregnancy, which cites research findings that, “unintended pregnancy rates among women with substance use disorders are approximately 80 percent, considerably higher than in the general population. Use of reliable contraception is also lower among this group of women when compared with a nondrug-using comparison population.”
Maternal-fetal Medicine Physician Dr. Craig Towers sees hundreds of women with opioid addiction at his Knoxville High Risk Obstetrical Consultants practice that also specializes in treating drug-exposed babies. Most of his patients, he said, have had more than one baby and roughly half have had two or more. Towers said an overwhelming number of his patients ask to discuss birth control options during their prenatal and postnatal care visits.
“A lot of them have had previous babies with NAS. They’ll also tell us we are the first ones that ever talked to them about whether they wanted long-acting reversible contraception and so 100 percent of the women that come to our program, we talk about birth control, all their various options and we make a plan so that as soon as they deliver [their baby] that plan is instituted,” he said, “before they leave the hospital.”
Still, some health advocates question Tennessee’s long-acting reversible contraception program targeting incarcerated women.
Lesly-Marie Buer is the research director at the Choice Health Network clinic in Knoxville, which provides primary care, mental health, substance abuse and addiction, contraception and other services. She previously worked for the Tennessee Department of Health in an unrelated role.
Buer said the long-term effects of NAS may prove to be “overblown” in a way that hearkens back to the crack epidemic of the 1980s and early 1990s, when stigma surrounding so-called crack babies sparked widespread alarm about the health effects of drug use during pregnancy on unborn babies. While some initial research, including a study from Dr. Towers, shows children exposed to opioids in utero could face long-term effects, Buer said the research is still ongoing.
Still, she believes more Tennessee residents need access to basic health care, sexual health education and contraception in the abstinence-only state, where schools are barred from talking about even condoms.
“People are not taught about sexual or reproductive health in a meaningful way from the beginning. And so we know that there is a lot of either lack of education or miseducation,” she said. “What’s important for us is that the whole range of contraceptives are offered to everyone and that there is meaningful education around those contraception choices as well as what their efficacy is and what the side effects are, which I think is really important, especially that people know that if they do get a long-acting reversible contraceptive, that they know where to get it taken out, because that’s a huge issue as well–– having transportation or access to actually go get something taken out if you are to have that.”
The Monroe County Health Department’s contraception program often serves a much broader public-health role in rural East Tennessee communities, said Harrill, who lives just a few miles from the Monroe County Jail. She said the department is working on expanding NAS-prevention programs into probation programs for both men and women.
She acknowledges the reality that many opioid-affected women across the landscape of rolling hills and mountain views, horse farms, Family Dollar discount stores and churches outside Knoxville struggle to access basic health services, mental health care or drug treatment, or prenatal care services during pregnancy.
“If someone needs something to that degree, they have to go to Knoxville, which is an hour drive, but for the folks here that have no transportation, that it’s an issue, she said. “One of the things that we tried desperately hard to do with the health department is, when we have a patient in for a service we want to make sure we do everything we possibly can for that patient because chances are they might not have a ride next time.”
And, Harrill said, most of the inmates she visits at county jails end up coming home to the community. She hopes the NAS-prevention education they receive behind bars could also empower them to take charge of their overall reproductive health after incarceration.
She stresses to the inmates it’s up to them whether to accept a contraceptive method. Sometimes, only a handful of women express interest in following up for birth control at the health department clinic afterwards, Harrill said.
“But that’s OK because if we can just prevent one pregnancy of a baby that’s born drug-dependent, then it’s been a success.”
This story is part of the series Born Exposed, exploring access to medical and rehabilitative care in Appalachia for opioid-affected women and their babies. Born Exposed is a project of 100 Days in Appalachia, West Virginia Public Broadcasting and the Ohio Valley ReSource.