More than 90 percent of the women in Tennessee county jails are serving time because of drugs, according to Tennessee's drug recovery court.
"Our rural counties have been disproportionately affected by the opioid problem," said Dr. Tara Sturdivant, Director of the East Tennessee Regional Health Office.
The office provides health services to the 15 rural counties around Knox County.
One of the outcomes of the opioid epidemic in Tennessee has been the nearly 1,000 babies born every year with Neonatal Abstinence Syndrome (NAS) since 2013, when the health department began documenting the epidemic. The babies are born dependent on the drugs their mothers used during pregnancy and are forced to go through painful withdrawals. The long-term consequences are still unknown, but many experience gastrointestinal and behavioral issues among other symptoms.
The Tennessee Department of Health, the justice system, law enforcement and non-profit organizations started working together to try to find a solution to help the youngest victims.
"When we were thinking about where do we come into contact with women who are at a higher risk (of drug addiction), we thought about the correctional system," Sturdivant said.
The health department started a pilot program in Cocke and Sevier county jails three years ago that offered female inmates long-acting, reversible contraception or IUDs and implants. The program has expanded to 41 Tennessee jails, according to the Tennessee Department of Health.
The long-acting contraception lasts 3-10 years depending on the type of device the woman chooses. The inmates are not required to receive the contraception, and it is reversible with a doctor's visit.
Since January 2014, a total of 3,500 female inmates have attended classes, and 700 of them have chosen to receive contraception in Tennessee.
NAS presentations educate inmates
"We have a problem. A big problem," Sherrie Montgomery, Director of Jefferson and Hamblen County Health Departments, told a group of female inmates in the Jefferson County Jail in early January.
It's the beginning of a 30-minute NAS presentation Montgomery and other health department officials across the state give to female inmates.
She explains the tragic number of babies forced to endure the consequences of their mother's drug use during pregnancy. She shows two videos: a news report from East Tennessee Children's Hospital and a first-hand account of a woman who delivered three babies with NAS.
Many of the inmates are visibly upset. For some, it's the first time they've ever heard about NAS.
"I've seen other people go through that (withdrawals), but never a child," said inmate Crystal Jennings.
For others, the stories hit close to home.
"When my daughter was born, she wasn't addicted to methamphetamines, but I used the whole time I was pregnant," said inmate Misty Carter. "I'm afraid she's going to have long-term effects from that."
Carter has been clean for three months, but recognizes when she gets out of jail, it won't be easy to stay sober. That's why she chose to sign up to receive an IUD from the health department. She said she's not ready to have another child.
"I'm not stable enough to take care of another child. I have a 2-year-old that my mother has right now," Carter said. "I will be a part of her life when I get out of here. Nobody who just leaves jail is in the right state of mind to take care of a baby.
"I think it's amazing. I think everyone should learn the effects of using drugs while pregnant is. The birth control they offer is great."
Sturdivant said she hears similar praises when she visits jails. She considers the option for women to receive birth control a right all women should have.
"We provide contraceptive choices to women across our region, in order to empower those women to plan pregnancies at a time when they believe it is best for their own health and that of their children. We know that pregnancy in the context of addiction and/or significant life stressors without support is not optimal, for mother or baby," Sturdivant said. "This is about conversations between women and their health care providers.
"We want every woman to have the best information and services available in planning for a healthy pregnancy."
The taxpayer cost of paying for contraception versus caring for NAS babies
Critics have called the program coercive and paternalistic.
"You're talking about women who are incarcerated, talking with people in positions of authority and who have power over their situations," said Planned Parenthood of Middle and East Tennessee CEO Jeff Teague said in an interview with NBC Nashville affiliate WSMV in November.
Jefferson County Sheriff Bud McCoig said he does not offer incentives for receiving the contraception. Drug Recovery Court Judge Duane Slone said he mandates inmates to take the NAS class, but never knows who signs up to receive birth control.
Critics have also argued tax payers should not foot the bill for birth control. At county health departments, services are charged based on a patient's income. The female inmates also receive the contraception based on a sliding income scale. No one is denied family planning services.
Each IUD at retail value costs about $600. However, the health department said it gets them at a reduced cost.
State Rep. Eddie Smith (R-Knoxville) argues the cost for birth control is minimal compared to the $82 million of the tax payer's money spent last fiscal year on caring for drug dependent or NAS babies. The Health Department said it costs about $67,000 for each baby with NAS, and many of them are covered by TennCare.