Family planning services for incarcerated women: models for filling an unmet need

"We wish we had the option": a qualitative study of women's perspectives and experiences with contraception in a provincial prison in Ontario, Canada

BACKGROUND

Evidence suggests that women who are incarcerated desire access to contraception while incarcerated, and that this need is not currently being met. Our objective in this study was to explore the perspectives and experiences of women in prisons regarding contraception and contraception access using data from focus groups with women in a provincial prison. We analyzed focus group data collected in a provincial prison in Ontario, Canada using content analysis and a constructivist epistemology.

RESULTS

We conducted three focus groups, each approximately one hour in length. Discussions revolved around (1) knowledge and decision making about contraception, (2) accessing contraception, and (3) ideas for increasing access to contraception in the prison setting. Decision making about contraception was mainly related to concerns about side effects, consistent access to care, impacts on future fertility, and autonomy around decision-making. Participants discussed a wide range of experiences with contraception. Ideas for increasing access to contraception included information sessions, inclusion of discussions about contraception as a component of admission and release planning, and time spent in prison as a crucial juncture for decision-making about contraception.

CONCLUSIONS

More qualitative research is needed to better understand the needs of women in prisons related to contraception. The findings of this study suggest that programs should focus on consistency and continuity of access to care, education opportunities, and integration of discussions about contraception into official admission and release procedures.

Building an implementation framework to address unmet contraceptive care needs in a carceral setting: a systematic review

BACKGROUND

The provision of contraceptive care for incarcerated individuals has been largely inconsistent and has contributed to, at best, inadequate care, and at worst reproductive abuses, violence, and coercion. While previous research has identified strategies to remedy known issues, to date, very few recommendations have been implemented across the carceral system. To address this, we conducted a systematic review of policy and practice recommendations to improve contraceptive care to reproductive-aged, incarcerated individuals in the United States.

METHODS

We conducted this systematic review utilizing the Joanna Briggs Institute methodology and framed it within the National Implementation Research Network's (NIRN) Exploration stage. We searched PubMed, PSYCInfo, SCOPUS, ProQuest, Web of Science, MedLine, Social Science Citation Index and reference sections of included materials. Basic study information, explicitly stated policy and practice recommendations, and discussions and conclusions that subtly provide recommendations were extracted in full text. We utilized a thematic analysis approach to analyze the extracted text.

RESULTS

A total of 45 materials met the inclusion criteria. Seven overarching themes were identified: 1) policy changes needed to implement care; 2) need for contraceptive care in carceral systems; 3) justice agency barriers regarding contraceptive care provision; 4) policy barriers to contraceptive access; 5) funding strategies to improve care; 6) patient preferences for contraceptive care delivery; and 7) healthcare provider knowledge regarding contraceptive care. The seven themes identified shed light on the need for, gaps, barriers, and facilitators of current contraceptive care provision to incarcerated individuals.

CONCLUSION

This systematic review accomplished two goals of NIRN's Exploration stage. First, the compiled evidence identified a clear need for change regarding policies and practices pertaining to contraceptive care provision to incarcerated individuals in the United States. Second, our findings identified several evidence-based solutions supported both by research and professional healthcare organizations to address the identified need for change. This study provides an initial blueprint for correctional agencies to implement the necessary changes for improving contraceptive care provision to incarcerated populations. The correctional system is in a unique position to deliver much-needed care, which would result in many potential benefits to the individuals, correctional system, and community at large.

Social Resources, Abortion, and Contraceptive Use Among Women With Criminal Justice Histories

Women in the criminal legal system face structural barriers to social resources such as education, employment, and benefits. Little is known how these resources intersect with their reproductive lives, specifically with obtaining abortions. We explored the relationship between social resources and abortion history among women incarcerated in a county jail through a secondary analysis of survey data from a 2014 to 2016 jail-based sexual health intervention. Regression analyses determined correlates of having an abortion history. Thirty percent of participants had an abortion and were more likely to have at least a high school education (adjusted odds ratio [aOR] = 3.3; 95% confidence interval [CI] = 1.25-8.77) and a history of sexually transmitted infections (aOR = 3.2; 95% CI = 1.25-8.06). Appropriate systems-level efforts should be expanded to support women with criminal legal histories in their reproductive lives.

Perceptions of long-acting reversible contraception among women in an urban U.S. jail

OBJECTIVE

Given incarcerated women's lack of access to contraception prior to, during, and post-incarceration and concerns of potential reproductive coercion in correctional settings, the objective was to explore incarcerated women's perspective of making provider-controlled methods of long-acting reversible contraception (LARC) available in an U.S. urban jail.

STUDY DESIGN

Using a concurrent mixed-methods approach, we explored contraceptive use and method choice prior to and after incarceration among women detained in a U.S. urban jail. Focus group discussions primarily focused on incarcerated women's perceptions of LARC.

RESULTS

In the 30 days prior to arrest, 28 of 116 women (24%) were using a non-barrier contraceptive method. Methods of LARC were used the least, and the majority (n = 74, 64%) were not interested in initiating LARC in jail. Concern about the potential side effects of LARC was the main reason for disinterest followed by distrust in correctional health care staffs' qualifications. Study participants did not reference coercion as a concern.

CONCLUSIONS

Apprehension about the training of health care providers and cleanliness of the detention facility outweighed participants' concerns regarding autonomy restrictions associated with provider-controlled methods of LARC. Despite limited interest in initiating LARC use while incarcerated, participants supported making all forms of contraception more accessible in jail settings.

IMPLICATIONS

Understanding incarcerated women's reproductive and contraceptive desires, including their perceptions of LARC, will help improve the provision of equitable reproductive health care in correctional settings. Our findings highlight the importance of contextual factors in determining women's willingness to access contraceptive care in carceral settings, if available.

Jail as a Point of Contraceptive Care Access: Needs and Preferences Among Women in an Urban Jail

INTRODUCTION

Individuals who are incarcerated in the United States often struggle to access family planning care because of the common practice of jails not providing contraceptives on site. However, less is known about the contraceptive needs and preferences, including the desirability of intrauterine devices and implants, among those who are incarcerated.

METHODS

Cross-sectional, in-person surveys were administered to 148 reproductive-age women (aged 18-48) incarcerated at an urban jail in Utah to identify women's contraceptive needs and preferences while incarcerated. We used summary statistics and logistic regression to investigate relationships between demographic characteristics, the desire to access contraceptive services while incarcerated, and interest in specific contraceptive methods.

RESULTS

Surveys indicate a high interest in accessing contraceptives while in jail (73%). Participants who were more likely to prefer access to contraceptive services in jail were also more likely to be interested in the injectable (odds ratio [OR], 4.75; 95% CI, 1.03-21.94), the implant (OR, 8.44; 95% CI, 1.70-41.99), and intrauterine devices (OR, 10.04; 95% CI, 3.46-29.20) than participants indicating no desire to access contraceptive services while in jail.

DISCUSSION

Jails could be an access point for contraceptive methods requiring health care provider intervention in the state of Utah. However, care must be taken due to broader historical legacies of reproductive coercion in carceral settings.

Contraception Policies in U.S. Jails, Prisons, and Juvenile Detention Systems: A National Survey

Contraception is an important health care service for incarcerated women, yet its availability in U.S. prisons, jails, and juvenile detention systems is unknown. We surveyed 6 jails, 22 state prisons, and 3 juvenile detention systems (N = 31 sites) on their contraception policies in 2016. Twenty (65%) sites had formal written contraception policies. All sites allowed people to continue a preincarceration contraceptive method with restrictions on the type of contraception and reason for use. Two sites (6%) did not allow continuation of oral contraceptive pills, 3 sites (10%) did not allow continuation of contraceptive injection, 21 sites (68%) did not allow continuation of contraceptive ring, and 23 sites (74%) did not allow continuation of contraceptive patch. Twenty-eight (90%) sites allowed people to initiate a contraceptive method in custody. Contraception policies in incarceration settings in the United States are varied and may restrict women's ability to continue or initiate the contraception of their choice.

Perspectives on preconception health among formerly incarcerated women with substance use disorders

INTRODUCTION

Women involved in the criminal justice system have high rates of substance use disorders (SUD) placing them at increased risk for unintended pregnancy and adverse pregnancy outcomes. Little is known about the factors that influence the decision-making of formerly incarcerated women with SUD prior to becoming pregnant, in the preconception period. The goal of this study is to understand formerly incarcerated women's perceptions of changing substance use behaviors before pregnancy.

METHODS

We analyzed 33 semi-structured interviews with formerly incarcerated women in Saint Louis, Missouri. We asked questions about factors that influenced decision-making related to substance use and pregnancy. Interviews were recorded and transcribed verbatim. Transcripts were coded and analyzed using a grounded theoretical approach with ATLAS.ti software.

RESULTS

Four main themes emerged: (1) participants' understanding of preconception behavior change was influenced by their experiences with unplanned pregnancies and lack of control over outcomes; (2) substance use created challenges for women in considering their reproductive wishes; (3) while pregnant, participants weighed the medical and legal risks in their decision-making about their substance use; and (4) participants described how the internal motivation necessary to stop substance use during pregnancy was influenced by factors such as hitting rock bottom and witnessing negative outcomes experienced by others.

CONCLUSIONS

Preconception health services must be provided to women with SUD during opportunistic times such as during incarceration or while in SUD treatment. Services need to be non-judgmental and supportive rather than penalizing and should increase internal motivation to adopt behavior change.

Reproductive healthcare in prison: A qualitative study of women's experiences and perspectives in Ontario, Canada

OBJECTIVE

To explore women's experiences and perspectives of reproductive healthcare in prison.

METHODS

We conducted a qualitative study using semi-structured focus groups in 2018 with women in a provincial prison in Ontario, Canada. We asked participants about their experiences and perspectives of pregnancy and contraception related to healthcare in prison. We used a combination of deductive and inductive content analysis to categorize data. A concept map was generated using a reproductive justice framework.

RESULTS

The data reflected three components of a reproductive justice framework: 1) women have limited access to healthcare in prison, 2) reproductive safety and dignity influence attitudes toward pregnancy and contraception, and 3) women in prison want better reproductive healthcare. Discrimination and stigma were commonly invoked throughout women's experiences in seeking reproductive healthcare.

CONCLUSIONS

Improving reproductive healthcare for women in prison is crucial to promoting reproductive justice in this population. Efforts to increase access to comprehensive, responsive, and timely reproductive healthcare should be informed by the needs and desires of women in prison and should actively seek to reduce their experience of discrimination and stigma in this context.

Reproductive Health Care for Incarcerated Pregnant, Postpartum, and Nonpregnant Individuals: ACOG Committee Opinion, Number 830

ABSTRACT

Obstetrician-gynecologists and other women's health care practitioners can support efforts to improve health care for incarcerated pregnant, postpartum, and nonpregnant individuals. The majority of incarcerated women are parents and are of reproductive age, which has important implications for their reproductive health care needs. The legacies of racism and resulting racialized medical outcomes shape inequities in reproductive health for all people, including those who are incarcerated. Reproductive health care for incarcerated individuals should be provided in accordance with the same guidelines and recommendations as for those who are not incarcerated, with attention to the increased risk of infectious diseases and mental health conditions common to incarcerated populations. Ensuring that incarcerated individuals receive respectful, consistent, high-quality reproductive health, pregnancy, and postpartum care is essential for ameliorating inequities and affirming these individuals' dignity. This revision provides comprehensive recommendations for pregnant, postpartum, and nonpregnant individuals and expands upon guidance to advocate for access to safe, quality, and dignified care.

Contraception among women on probation and parole on the United States-Mexico border

OBJECTIVE

Effective contraception prevents unintended pregnancy which disproportionately affects women in the criminal justice system. This study examined selected variables associated with contraceptive use by women on probation and parole living on the United States-Mexico border.

DESIGN

This quantitative correlational study examined individual and interpersonal variables-age, parity, ethnicity, prior contraception, self-efficacy, pregnancy attitudes, and reproductive autonomy-that may influence contraception among 52 women under community supervision.

MEASURES

Variable were examined with bivariate, multivariate analyses, and hierarchical logistic regression. Data were collected from a demographic and contraceptive use survey, and validated scales measuring reproductive autonomy and pregnancy attitudes.

RESULTS

Contraceptive methods were used by 89% of the women; 65% used effective methods, but this decreased to 35% among those released within the past year. Reproductive autonomy was associated with effective contraceptive use. Prior contraception and contraceptive self-efficacy were significant, but wide confidence intervals suggested instability. The remaining variables were insignificant.

CONCLUSION

No known studies have examined contraception use among women on probation and parole on the border. More women used some form of contraception than might be predicted. Collaborative efforts between correctional facilities and the community are needed to expand access to contraception.

Access to Reproductive Health Care in Juvenile Justice Facilities

STUDY OBJECTIVE

The juvenile justice system houses adolescents with unique and unmet reproductive needs, including family planning. The purpose of this study was to identify access to contraceptive counseling and methods for young women in the juvenile justice system.

DESIGN

We administered a cross-sectional survey that was used to examine services related to reproductive health care, including contraceptive counseling, and ability to initiate or continue contraceptive methods in custody.

SETTING

Juvenile justice systems in the United States.

PARTICIPANTS

State-level health care administrators in juvenile justice systems.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We analyzed responses to determine the ability of young women in custody to continue or initiate specific contraceptive methods, in addition to other measures of reproductive health access.

RESULTS

Twenty-one respondents representing systems in 20 US states were included in analysis. All participating sites provided contraceptive counseling and all allowed at least 1 form of preincarceration contraception to be continued. Eighty-one percent (17/21) of systems enabled young women to initiate contraception while in custody, with the most common method available on-site being birth control pills. Twenty percent (4/20) of sites provided long-acting reversible contraceptive methods.

CONCLUSION

This study shows that it is feasible to provide contraception in this setting. However, there exists considerable variability in availability of methods across the United States. Continued work is needed in increasing access to contraception and standardization of care in the juvenile justice system.

Expanding Contraceptive Access for Women With Substance Use Disorders: Partnerships Between Public Health Departments and County Jails

CONTEXT

Law enforcement has been the primary strategy for addressing the opioid epidemic. As a result, the incarceration rate for women in county jails has increased more than 800% since 1980, and most women inmates struggle with substance use disorders. There is a large unmet need for contraception among women in county jails.

PROGRAM

The East Region of the Tennessee Department of Health partnered with county correctional facilities to provide comprehensive family planning education and voluntary long-acting reversible contraception (LARC) to women in 15 jails.

IMPLEMENTATION

Incarcerated women were invited to attend a comprehensive family planning education session conducted in the jail by health department nurses. The sessions included information on neonatal abstinence syndrome. The nurses explained that the women could receive intrauterine devices, implants, and injectable progesterone while incarcerated and come to the health department for all contraceptive methods upon release. Between January 2014 and June 2017, nurses conducted 182 education sessions, and 794 women received a LARC. Method placement occurred in the jails or at the local health department. No adverse effects were known to have occurred.

EVALUATION

We collected pilot data to explore the accuracy and the comprehensiveness of the family planning education session and whether the incarcerated women experienced the program as voluntary. All 18 women inmates interviewed reported experiencing the program as voluntary. Using published and administrative data, we roughly estimated that the program prevented between 270 and 460 unintended pregnancies and between 40 and 52 cases of neonatal abstinence syndrome in the first year after the women received a method. This represents a cost savings to Medicaid of $1.4 million.

DISCUSSION

The partnership demonstrated the feasibility of providing voluntary comprehensive family planning education and access to highly effective contraception for women inmates who, as a group, face a host of political, socioeconomic, and personal barriers to reproductive health care.

Contraception need and available services among incarcerated women in the United States: a systematic review

Context

Seventy-five percent of incarcerated women are of reproductive age, most of whom are at-risk for unintended pregnancy. Women who are incarcerated come disproportionately from socioeconomically disadvantaged backgrounds and often lack access to desired reproductive health care. While the carceral system provides a unique opportunity to fill this gap, a better understanding of the contraceptive needs, desires, and plans of incarcerated women is needed to optimize health care provision within the carceral system. A review of current contraceptive services available to women inmates may both identify model care programs and shed light on areas for improvement.

Evidence acquisition

PubMed electronic database used to identify relevant articles published between January 1975 and September 2019 using a systematic review method.

Results

Twenty-five articles met the inclusion criteria and answered four key questions surrounding contraception in the carceral system. Most articles (48%) represented scientific research. Other publications identified by this review were expert commentaries, policy briefings, guidance and recommendations reports, and law and bioethics reviews.

Conclusions

Incarcerated women desire access to standard and emergency contraception from carceral health care systems. Knowledgeable family planning practitioners providing patient-centered and trauma-informed care and public health interventions linking newly released inmates to community clinics can help alleviate inmates’ concerns regarding initiating desired contraception while incarcerated.

Contraceptive needs among newly incarcerated women in a county jail in the United States

PURPOSE

The purpose of this paper is to examine the risk of unintended pregnancy among women during Cook County Jail intake by assessing basic contraceptive history, the need for emergency contraception (EC) at intake, and contraception at release.

DESIGN/METHODOLOGY/APPROACH

This is a cross-sectional study of women 18-50 years old at Cook County Jail in Chicago, Illinois from June 2011 through August 2012. The authors administered the survey at the time of intake on 33 convenient evenings. Surveys consisted of multiple-choice close-ended questions administered via interview. Topics included contraceptive use, pregnancy risk and pregnancy desire. The authors computed frequencies to describe the distribution of question responses and used logistic regression modeling to identify factors significantly related to the use of contraception at intake and to the acceptance of contraception at release.

FINDINGS

Overall, 194 women participated. Excluding women not at risk for pregnancy (4.6 percent currently pregnant, 17.5 percent surgically sterilized/postmenopausal and 4.6 percent using long-acting reversible contraceptives), 73.2 percent of women were at risk for pregnancy ( n = 142) and, therefore, had a potential need for contraception. Among these women at risk for unintended pregnancy, 68 (47.9 percent) had unprotected intercourse within five days prior to survey administration. When asked about EC, most women (81.4 percent) would be interested if available. Additionally, 141 (72.7 percent) of women would be interested in contraceptive supplies if provided free at release.

ORIGINALITY/VALUE

Newly incarcerated women are at high risk for unintended pregnancy. Knowledge about EC and ability to access birth control services are both significantly limited. These conclusions support providing an intake screening in jails to identify women at risk for unintended pregnancy.

A Contraception Quality Improvement Initiative with Detained Young Women: Counseling, Initiation, and Utilization

STUDY OBJECTIVE

To assess the effect of providing standardized counseling to improve the rates of contraception initiation and utilization among detained young women. This was a quality improvement (QI) project conducted at a large urban juvenile short-term detention center. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The intervention included educating all staff and care providers, counseling detained young women on various contraceptive options, and offering contraception initiation with oral contraceptive pills or depot medroxyprogesterone acetate injection. Retrospective chart review before February 2012 established baseline contraception initiation and utilization rates. The QI intervention began in February 2012 and continued for 6 months followed by chart review. Outcomes measured included number of patients counseled about contraception, started contraception, and overall contraception utilization.

RESULTS

We reviewed 120 and 186 charts before and after intervention, respectively. Compared with baseline data, the intervention group had statistically significant (P < .05) higher proportions of patients counseled (10% [10/120] baseline vs 84% [156/186] intervention) and who started contraception (7% [8/120] baseline vs 52% [97/186] intervention).

CONCLUSION

This contraception QI intervention showed significant improvement in the rates of contraception counseling, contraception initiation, and utilization among detained young women. Most of youths' guardians were supportive and approved contraception initiation. This project showed it is feasible for health care providers to include contraception services for all intake assessments at juvenile detention facilities.