Navigating Women’s Health: Tennessee
In its annual Health of Women and Children Report, the United Health Foundation ranked Tennessee the 43rd healthiest state for 2024. Researchers measured a number of wide-ranging factors—from lack of dental care to firearm deaths to insufficient sleep—that affect health outcomes. However, Tennessee’s landscape for expecting mothers is especially concerning; numerous organizations highlight the poor outcomes for new moms and their children in the state. While a number of these metrics call for policy reform, this piece focuses on three critical issues that contribute to Tennessee’s poor outcomes for pregnant women: maternal care availability, unintended pregnancy rates (including teens), and drug overdoses during pregnancy.
Challenges
A Worsening Landscape of Maternal Healthcare
Prenatal care is essential for the health of both mother and baby. Forgoing prenatal care is associated with higher rates of low birth weight and fetal mortality, both of which are relatively high in Tennessee. According to Tennessee Department of Health data, over 8 percent of pregnant Tennesseans either forgo prenatal care or do not start until the last trimester.
This is largely a supply problem. Over half of rural hospitals in Tennessee do not offer obstetric services. Forty-six percent of counties are without OB-GYNs, and almost a third of Tennessee counties are “maternal care deserts.” This means that both prenatal and postnatal care for women and their children is hard to come by, especially in rural regions. Lack of access to doctors has actually worsened—in 2023, the state’s obstetric residency applications declined 21 percent from 2022, when the state’s abortion ban went into effect. Since medical residents can no longer learn abortion services in Tennessee’s healthcare facilities (a requirement for OB-GYN accreditation), many are choosing to train elsewhere. Current residents in other states are not likely to practice in Tennessee post-residency either; nationally, over 57 percent of OB-GYNs remain in the state where they completed their residency. A dwindling resident population will exacerbate the supply issue, meaning maternal health outcomes are unlikely to improve without reforms.
Unintended Pregnancy
Like the rest of the nation, Tennessee’s teen birth rate has declined over time. Overall, a number of factors contributed to this trend, including better access to effective contraceptives, a decrease in reported sexual activity among teens, and better sex education. However, Tennessee’s teen birth rate (23.7 per 1,000) remains significantly above the national average (16.7 per 1,000). In 2019, Tennessee counties had varying rates of teen pregnancy, with rates as high as 87.4 (Lake County) and as low as 4.0 (Williamson County). The state’s teen pregnancy rate ranks 40th in the nation. In 2019, this meant that over 5,600 teens in the state became pregnant.
The overall unintended pregnancy rate in Tennessee is also high. Over 35 percent of pregnancies were unintended, and an additional 14.4 percent of women were unsure about their pregnancy’s timing. Further, less than half of women in Tennessee who became pregnant in 2020 reported using contraceptives prior to pregnancy.
Unintended pregnancy in both teens and adults can bring significant challenges. Teen moms are more likely to drop out of school, which lessens economic opportunities, and unintended pregnancy at any age lessens the likelihood of receiving prenatal care.
Drug-Related Deaths of Pregnant and Postpartum Women
Another critical factor underlying pregnancy-associated harms is the decades-long overdose crisis. In Tennessee, annual overdose-related deaths nearly doubled from 2020 to 2022. During this same period, 34 percent of pregnancy-associated deaths—deaths occurring during or in the first year after a pregnancy—were due to an overdose. As with overdose deaths nationwide, overdoses in Tennessee are most often caused by opioids, including fentanyl. Many of these deaths could be prevented—and the health and well-being of mother and child improved—if pregnant women in the state had better access to harm reduction and evidence-based treatment services.
Pregnant women seeking harm reduction services in Tennessee face two significant structural hurdles. First, only a handful of organizations provide harm reduction in the state, and most are clustered near cities. Despite having some of the nation’s highest opioid overdose rates, Tennessee has only 835 buprenorphine prescribers and 24 opioid treatment programs (OTPs). Second, even if a woman is able to access a harm reduction organization, not all are equipped to work with pregnant or parenting people. Further, pregnant women who successfully access a medication for opioid use disorder provider or clinic may find they are hesitant to prescribe the medications due to stigma or misinformation.
Policy Recommendations
Boost the reproductive healthcare workforce. Tennessee has taken steps to boost the in-state healthcare workforce, such as changing residency requirements for immigrating physicians, but more is required to meet current and future needs. Tennessee could find ways to bolster OB-GYN residency programs via supplemental training allowances.
Reform state telehealth laws. Telehealth could also further the workforce in meaningful ways. Research shows that telehealth can improve prenatal, antenatal, and opioid use disorder (OUD) recovery outcomes. Requiring out-of-state physicians to register with the state to provide telehealth services rather than pursue duplicative licensure while licensed in good standing elsewhere is one way Tennessee can make healthcare more accessible for mothers and children.
Enhance provider scope of practice. Scope of practice reform for non-physician healthcare providers can also help with Tennessee’s provider shortage. For example, federal law allows healthcare providers authorized to prescribe controlled substances—including physicians, physician assistants, and nurse practitioners—to prescribe buprenorphine in private practice. Tennessee law has historically placed strict limitations on the buprenorphine-prescribing privileges of non-physicians, but the prescriber pool will hopefully begin to grow when a new law takes effect in July 2025. Further, Tennessee can expand the scope of practice for nurse practitioners more generally like other states have.
Protect and increase contraceptive access. In a 2025 measure, Tennessee policymakers codified protection of contraception in state law to reduce concerns over restricting access. However, legislation to roll back contraceptive access is still possible in the future. This is usually achieved through age restrictions, reduced state funding for contraception distribution, and restrictive scopes of practice for prescribers.
Utilize the newly formed Tennessee Maternal Health Equity Advisory Committee. The state legislature passed the Tennessee Maternal Health Equity Advisory Committee Act in 2024 to establish a new committee under the Tennessee Department of Health tasked with addressing disparities in maternal health, particularly for women of color and those living in rural and urban areas. The committee should identify innovative ways to provide better access to services, including contraceptive access, OTP services, and prenatal care.
Increase OTP availability for women with OUD. Methadone and buprenorphine are the gold-standard treatments for OUD, reducing overdose risk and improving a range of health and social outcomes. Because they are far safer for mother and infant than illicit opioids, doctors recommend them over medically managed detox and abstinence-based alternatives. Although the potential to expand buprenorphine access via more providers would be a step in the right direction, the limited number of OTPs remains a concern. OTPs are the only places where people with an OUD can access methadone maintenance treatment. Due to the potency of fentanyl, which dominates Tennessee’s supply, methadone is the preferred treatment for some people with OUD. However, many OTPs require individuals to visit the clinic almost daily to take their dose under supervision. This, coupled with the scarcity and geographic dispersion in Tennessee, makes engaging in treatment a disruption to people’s ability to work, meet family obligations, and more.