Chattanooga became the largest metro area in the United States without an abortion clinic when the city's only clinic closed in 1993. Although abortion rates for Hamilton County residents and Southeast Tennesseans are below that of the state, women have continued to obtain the procedure.
"Just because abortion becomes more restrictive doesn't mean that people don't need it anymore," Mikaela Smith, a research scientist at Ohio State University's College of Public Health, said in an interview by phone.
The U.S. Supreme Court's decision in June to overturn abortion rights will have far-reaching consequences in the states that surround Chattanooga, because Tennessee, Georgia and Alabama all had laws in place to further restrict the procedure in the event of such a ruling - forcing many of those residents who need an abortion to travel farther for care.
Currently, Tennessee has banned abortion after six weeks, and nearly all abortions will be banned when the state's "trigger law" goes into effect Aug. 25. Alabama is already under a total abortion ban, and Georgia has banned abortions after fetal "cardiac activity" is detected, which typically occurs around six weeks into pregnancy and before a woman realizes she's pregnant.
But for some Tennesseans, abortion has long been difficult to obtain or out of reach, Gretchen Ely, a professor of social work at the University of Tennessee, said in a phone interview. Ely studies access to reproductive health care for vulnerable populations.
"You're burdened by your area of birth in the United States in a similar way that people living in developing nations are," Ely said. "For pockets of people, access was already pretty severely limited."
She pointed to poor regions of Appalachia in East Tennessee and areas of the Mississippi Delta surrounding Memphis to the West where people face "extreme difficulty" accessing basic health care, not just abortion.
The Tennessee Department of Health, U.S. Centers for Disease Control and Prevention and the Guttmacher Institute all track some degree of abortion data, which sheds light on past trends and the types of people who will be most affected by new restrictions. Here's what we know:
Mostly young moms
The majority of women in Tennessee who get abortions are single moms in their 20s, with abortion rates highest among Black women.
Ely said women who get abortions are often also "financially strained," meaning they're either poor or low-income and face barriers to other types of health care, including preventative care and contraceptives.
"They already usually have about two children, and so they're situated to understand the economic demands of parenting, and they often cite economic issues as the reason for getting an abortion," Ely said. "Another child that somebody's not economically able to take care of can be really difficult - it impacts the rest of the family for long periods of time."
Abortions in Tennessee by the numbers
Under 25-year-olds accounted for 38.6%.Ages 25-39 accounted for 58.7%.Black women accounted for 51%.Married women accounted for 14%.63.6% had a previous live birth.69.8% occurred under 10 weeks gestation.51% were medication-induced.Source: CDC data from 2019 for roughly 9,700 reported abortions
Smith said abortion restrictions will disproportionately harm Black women, who already are at much higher risk of dying during childbirth and pregnancy than white women.
In Tennessee, non-Hispanic Black women are 2.5 times more likely than white women to die from pregnancy-related causes, according to a report from the Tennessee Department of Health based on 2017-2020 data. Cardiovascular and coronary conditions were the leading underlying causes of pregnancy-related death for Black mothers, according to that report.
"In terms of pregnancy risks, I think we have to acknowledge the differences by race," Smith said.
Limited access
Abortion access was already sparse in Tennessee, with the only abortion clinics operating before abortion rights were overturned located in Memphis, Nashville, Knoxville and Bristol, Tennessee.
Though hospitals will sometimes also perform abortions, in Chattanooga, those have been limited to cases in which it was medically necessary to safe the mother's life.
As Tennessee's abortion clinics close or prepare to in the coming weeks, accessing care will become even more difficult, particularly for low-income residents.
(READ MORE: A month after abortion ruling, closed clinics and uncertainty in Tennessee)
"If you think about adding long-distance travel with fuel cost and lodging and that kind of thing, sometimes across multiple states, it's going to get very, very expensive and be really hard for people," Ely said.
She said abortion bans also put people in a "loop" in which they're forced to come up with more money to travel, which also usually takes more time.
"When so much time has passed, then the pregnancy is further along, so it is now more expensive and complex, and then the person has to go back to square one gathering more money," Ely said.
Hamilton County residents and Southeast Tennesseans already obtained fewer abortions per person than residents of other major metropolitan counties and rural regions in the state, according to metro and regional health district data from the Tennessee Department of Health - which calculates the number of abortions per 1,000 women age 15-44 by place of residence.
Because that data is reported by place or residence, it includes women who traveled to other counties or out of state for care - a practice that was common even before the new laws went into effect.
In an email, Ely said abortion rates in Southeast Tennessee could also be lower because of social, cultural or religious norms in the Appalachian region that differ from those in other parts of the state.
Destination unknown
Georgia has long been a destination for Southeast Tennesseans and residents of many other Southern states who need abortion services.
Over time, the number of abortions performed in Tennessee and Alabama declined as access to the service became more limited, whereas in Georgia, the number of abortions reached an all-time high in 2020, according to data from the Guttmacher Institute.
In states such as Tennessee and Alabama, where abortion providers are hard to come by, the rate of abortions performed in those states has declined at a much faster pace than the national decline.
The overall decline of abortion in the United States is largely attributed to the increased availability of contraceptives - including hormonal birth control, long-acting contraceptives such as intra-uterine devices and emergency contraceptives like the "Plan B" pill.
Though the rate of Tennesseans obtaining an abortion overall has also declined, that decrease has been much slower and leveled off in recent years as residents seek care in other states, which Smith said illustrates the continued need for the procedure.
From 2019 to 2020, there was an increase in Alabamians obtaining abortions, though the number of procedures performed in the state continued to decline.
With Georgia abortion laws now much more restrictive, the Southeast will face an even larger gap in care.
"In regions where you're going to have to go across multiple states, you're going to see people where it's just not an option for them anymore, unless they can find a way to self-manage by ordering medication in the mail, which people will do," Ely said.
Abortions on the rise
Nationally, abortion rates peaked in the late-1970s and early 1980s after the Supreme Court's landmark ruling in the Roe v. Wade case, which legalized abortion in 1973. Rates steadily declined each year since, with a few exceptions.
The pattern of decline reversed briefly in the late 2000s, around the time of the most recent recession, which both researchers said makes sense given the cost of having children would be an even greater burden on more women during times of widespread economic hardship.
In the late 2010s, the CDC reported modest 1% and 2% increases in abortions in 2018 and 2019, respectively, while Guttmacher reported an 8% increase in abortions over the three-year period from 2017 to 2020.
Ely said the recent uptick is likely due in part to abortion providers - namely Planned Parenthood - losing access to Title X funds under the administration of former President Donald Trump in an effort to "defund Planned Parenthood."
Health care providers use Title X funds to offer contraceptives to people who otherwise can't afford them based on income levels, and in turn many poor and low-income people lost access to family planning care as a result, Ely said.
"Planned Parenthood was one of the primary recipients of that Title X funding, because they provided all that family planning in their clinics, even in the clinics where they didn't do abortions," Ely said. "And they primarily serve low-income women, so it's likely that that contributed to the uptick in rates in 2019."
Future trends
Both the CDC and Guttmacher track and publish abortion data, but their numbers differ because so do their data collection methods, and neither source is perfect.
The CDC asks each state's central health agency, as well as the health departments in Washington, D.C., and New York City, to document and voluntarily report legal induced abortions. But there are gaps in the data because not every state tracks abortion the same way or reports to the CDC.
The most recent report, which was published in November 2021, uses 2019 data and does not include data from several states.
Guttmacher uses multiple sources, surveys abortion providers directly and then uses predictive estimates to fill the gaps for those that don't report.
"My sense is that the Guttmacher data is more reliable, and at the same time, they do these predictive estimates. So as a scientist, you could kind of argue either way," Smith said.
A downside of Guttmacher's data is that although some data is available over time, many data points are missing years. Smith said the CDC data is particularly helpful for longitudinal analyses because it's been collected consistently for a long period of time.
The Pew Research Center, a nonpartisan American think tank that refers to itself as a "fact tank," said in a recent article that "while the Guttmacher Institute supports abortion rights, its empirical data on abortions in the United States has been widely cited by groups and publications across the political spectrum, including by a number of those that disagree with its positions."
Smith, whose research team also collects and tracks abortion data, said it can be especially challenging to gather data on abortion because many people are hesitant to say they underwent the procedure.
"Abortion is so stigmatized that it's hard to get accurate data in general, which is why it's helpful to have the Guttmacher and CDC doing these kinds of things, but it's often underreported if you're doing surveys of the population in general," she said.
The Tennessee Department of Health's numbers are even lower than the CDC, and an overall lack of data makes it impossible to know how many abortions occur each year in the United States.
With abortion bans now effective in many states, Ely said more women will be looking to manage abortions "off the grid" using medication, while some other health care providers fear more people will resort to potentially harmful means of terminating pregnancies.
Ely said self-managed medication abortions are safe and common, but the difference is that more people will be getting pills from sources that don't report data to public health agencies.
"We won't be able to track how many people do that," she said. "So it'll be harder to understand what the trends are if people have to go underground in order to navigate this."
Contact Elizabeth Fite at efite@timesfreepress.com or 423-757-6673. Follow her on Twitter @ecfite.