"Maybe if we weren't in the pandemic, I would have reconsidered": Experiences of abortion care-seeking during the COVID-19 pandemic in Maryland

OBJECTIVE

To understand the COVID-19 pandemic's impact on abortion care-seeking in Maryland, a state with Medicaid coverage for abortion, high service availability, and laws supporting abortion rights.

METHODS

We conducted semi-structured telephone interviews with 15 women who had an abortion between January 2021 and March 2022 at a hospital-based clinic in a mid-sized Maryland city. We purposively recruited participants with varied pandemic financial impacts. Interview questions prompted participants to reflect on how the pandemic affected their lives, pregnancy decisions, and experiences seeking abortion care. We analyzed our data for themes.

RESULTS

All participants had some insurance coverage for their abortion; over half paid using Medicaid. Many participants experienced pandemic financial hardship, with several reporting job, food, and housing insecurity as circumstances influencing their decision to have an abortion. Most women who self-reported minimal financial hardship caused by the pandemic indicated they sought an abortion for reasons unrelated to COVID-19. In contrast, women with economic hardship viewed their pregnancies as unsupportable due to COVID-19 exacerbating financial instability, even when they desired to continue the pregnancy. All participants expressed that having an abortion was the best decision for their lives. Yet, when making decisions about their pregnancy, the most financially disadvantaged women weighed their desires against the pandemic's constraints on their reproductive self-determination.

CONCLUSIONS

The pandemic changed abortion care-seeking circumstances even in a setting with minimal access barriers. Financial hardship influenced some women to have an abortion for a pregnancy that-while unplanned-they may have preferred to continue.

Development and evaluation of measures to assess self-determination in peripartum contraceptive decision-making

OBJECTIVES

We aimed to adapt and validate person-centered measures to evaluate various contributors to self-determination in perinatal contraceptive decision-making.

STUDY DESIGN

We developed and administered four scales adapted from existing measures in the context of Self-Determination Theory: the Treatment Self-Regulation Questionnaire (TSRQ), Perceived Competence Scale, modified Health Care Climate Questionnaire, and Important Other Climate Questionnaire. The TSRQ consists of three subscales: autonomous motivation, controlled motivation, and amotivation. We recruited a nonprobability convenience sample of 300 hospitalized postpartum patients in Baltimore, MD, between 2015 and 2016 and administered surveys in English and Spanish. We validated the scales with Cronbach's alpha coefficients, confirmatory factor analysis, and invariance analysis. We examined construct validity by testing correlations between the scales and other person-centered measures, such as satisfaction with counseling.

RESULTS

Cronbach's alpha was >0.8 except for the amotivation subscale. Confirmatory factor analysis was adequate for all scales. Autonomous motivation correlated positively and significantly with perceived competence, health care provider autonomy support, important other autonomy support, and other measures of patient satisfaction.

CONCLUSIONS

We found the four scales to be internally consistent and valid except for the amotivation subscale. We recommend using the autonomous motivation subscale in place of the full TSRQ. The autonomous motivation subscale, Perceived Competence Scale, modified Health Care Climate Questionnaire, and Important Other Climate Questionnaire showed adequate internal consistency, construct validity, and adherence to the expected conceptual structure of the scales.

IMPLICATIONS

Autonomous decision-making is central to ethics and quality of care, especially for contraceptive methods that require a provider for initiation or discontinuation and at more vulnerable times, such as postpartum and postabortion. These scales may help tailor person-centered and autonomy-supportive interventions and programs to improve contraceptive counseling and care delivery.

Termination counseling among US perinatal genetic counselors in the setting of second trimester fetal anomalies

Many pregnant people learn of fetal anomalies in the second trimester and subsequently present to prenatal genetic counselors (PGCs) for counseling, including but not limited to a nuanced discussion about whether to continue or terminate pregnancy. In those who choose to terminate, the decision between dilation and evacuation (D&E) or induction is often one of patient preference and as such, is heavily influenced by the quality of counseling received. PGCs are expertly trained to provide values-based counseling, yet little is known about their termination counseling practices, referral practice patterns, and perceived responsibilities in caring for this group of pregnant people. To gain this knowledge, we surveyed a national sample of PGCs in early 2022 and received 70 completed responses. The survey contained open- and closed-ended questions. Data were analyzed using descriptive statistics, and free response data were analyzed using inductive content analysis. Eighty percent (n = 56) of respondents reported that <50% of their patients had previously received termination options counseling. Most strikingly, 15% of respondents provided termination counseling that was beyond their self-identified comfort level. Scenario-based questions assessed respondents' counseling practice patterns in seven real-world situations, presented in order of decreasing severity for the fetus. Respondents were 50% less likely to provide termination options counseling to patients between the most lethal to the least lethal proposed fetal anomaly. The scenario-based analysis revealed two distinct termination counseling approaches: (1) all options counseling with an explicit discussion of options to continue or terminate and (2) discretionary options counseling focused on identifying patient preferences to guide counseling and not explicitly stating all available options. This study highlights the need to ensure PGCs feel well-trained to discuss the general features of second trimester pregnancy termination and, if unable to do so, to practice in systems with timely referral to providers well-versed in the counseling about all methods of termination.

Impact of new abortion restrictions on people in prison: Estimated number of incarcerated people without abortion access and distance to abortion providers

OBJECTIVES

This study aimed to estimate the annual number of incarcerated pregnant people in state and federal prisons needing an abortion.

STUDY DESIGN

We used 2021 Bureau of Justice Statistics data and prior studies' findings to estimate the number of pregnant incarcerated people, then calculated state-specific abortion ratios to determine the number potentially needing an abortion.

RESULTS

Of 638 pregnant people incarcerated in prisons annually, 110 would be expected to need an abortion, including 55 in states where abortion is currently banned or restricted.

CONCLUSIONS

Under Dobbs, many incarcerated pregnant people will be forced to continue unwanted pregnancies to term.

Incarceration Status Among Individuals Obtaining Abortion in the United States, 2020

Objectives. To examine the abortion frequency among incarcerated people before Dobbs v Jackson Women's Health Organization was decided. Methods. We used data from the 2020 Abortion Provider Census to examine the number and distribution of facilities that provided abortions to incarcerated patients. Results. Sixty-seven clinics across 25 states and the District of Columbia provided more than 300 abortions to incarcerated patients in 2020. Eleven of these clinics are in states that now have total or near-total abortion bans. Public Health Implications. People in jails and prisons face many structural barriers when seeking an abortion, especially with increased state abortion restrictions and an inability to travel out of state. If they cannot obtain desired care, people may be forced to continue pregnancies in harsh conditions. To address abortion access inequities, policy and research must consider incarcerated individuals. (Am J Public Health. 2023;113(12):1352-1355. https://doi.org/10.2105/AJPH.2023.307411).

Patient-Led Approaches to a Vaginal Birth After Cesarean Delivery Calculator

OBJECTIVE

To describe patient approaches to navigating their probability of a vaginal birth after cesarean (VBAC) within the context of prediction scores generated from the original Maternal-Fetal Medicine Units' VBAC calculator, which incorporated race and ethnicity as one of six risk factors.

METHODS

We invited a diverse group of participants with a history of prior cesarean delivery to participate in interviews and have their prenatal visits recorded. Using an open-ended iterative interview guide, we queried and observed these individuals' mode-of-birth decisions in the context of their VBAC calculator scores. We used a critical and feminist approach to analyze thematic data gleaned from interview and visit transcripts.

RESULTS

Among the 31 participants who enrolled, their self-identified racial and ethnic categories included: Asian or South Asian (2); Black (4); Hispanic (12); Indigenous (1); White (8); and mixed-Black, -Hispanic, or -Asian background (4). Predicted VBAC success probabilities ranged from 12% to 95%. Participants completed 64 interviews, and 14 prenatal visits were recorded. We identified four themes that demonstrated a range of patient-led approaches to interpreting the probability generated by the VBAC calculator: 1) rejecting the role of race and ethnicity; 2) reframing failure, finding success; 3) factoring the physical experience of labor; and 4) modifying the probability for VBAC.

CONCLUSION

Our findings demonstrate that a numeric probability for VBAC may not be highly valued or important to all patients, especially those who have strong intentions for VBAC. Black and Hispanic participants challenged the VBAC calculator's incorporation of race and ethnicity as a risk factor and resisted the implication it produced, especially that their bodies were less capable of achieving a vaginal birth. Our findings suggest that patient-led approaches to assessing and interpreting VBAC probability may be an untapped resource for achieving a more person-centered, equitable approach to counseling.

State Laws on Substance Use Treatment for Incarcerated Pregnant and Postpartum People

Background

Incarcerated perinatal populations report high rates of substance use in the United States (US). Despite this, substance use disorder (SUD) treatment is not routinely available in carceral settings and state policies related to the provision of substance use screening and treatment are unknown.

Methods

We conducted a systematic search in WestLaw through the end of the 2020 legislative session combining the terms "pregnant" and "postpartum" with terms for incarceration and related terms. The search returned 453 statutes from 43 states. A deductive codebook of various maternal health topics was developed. Legislative texts related to SUD screening and treatment were extracted for textual analysis.

Results

Of the 43 states identified as having at least 1 state statute pertaining to pregnant or postpartum incarcerated people, 7 states had statutes relevant to SUD screening and treatment. Statutes related to substance use screening, education, treatment and diversion programs, program eligibility, aftercare and release planning, and funding appropriations.

Conclusions

The majority of states across the U.S. lack legislation that address SUD screening and treatment among incarcerated perinatal populations. Given the known limited access to SUD treatment for perinatal populations in custody, increasing legislative statutes could increase access to essential care.

COVID-19 Restrictions In Jails And Prisons: Perspectives From Carceral Leaders

COVID-19 has been an unprecedented challenge in carceral facilities. As COVID-19 outbreaks spread in the US in early 2020, many jails, prisons, juvenile detention centers, and other carceral facilities undertook infection control measures such as increased quarantine and reduced outside visitation. However, the implementation of these decisions varied widely across facilities and jurisdictions. We explored how carceral decision makers grappled with ethically fraught public health challenges during the pandemic. We conducted semistructured interviews during May-October 2021 with thirty-two medical and security leaders from a diverse array of US jails and prisons. Although some facilities had existing detailed outbreak plans, most plans were inadequate for a rapidly evolving pandemic such as COVID-19. Frequently, this caused facilities to enact improvised containment plans. Quarantine and isolation were rapidly adopted across facilities in response to COVID-19, but in an inconsistent manner. Decision makers generally approached quarantine and isolation protocols as a logistical challenge, rather than an ethical one. Although they recognized the hardships imposed on incarcerated people, they generally saw the measures as justified. Comprehensive outbreak control guidelines for pandemic diseases in carceral facilities are urgently needed to ensure that future responses are more equitable and effective.

Reproductive Health Care for Incarcerated People: Advancing Health Equity in Unequitable Settings

There are over 150,000 incarcerated females in the United States. Structural inequities, including racism, adversely affect the reproductive health outcomes, autonomy, and access to care that people in custody face. This article reviews the status of reproductive health and health care among incarcerated women and describes ways that community OB/GYNs can address health inequities by providing comprehensive, compassionate care to incarcerated people, especially when they come to community settings for care while they are in custody. To address reproductive health disparities and inequities that adversely affect incarcerated individuals, community providers can implement these recommendations and also engage in advocacy.

An exploratory study of COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia

OBJECTIVES

This exploratory study aimed to assess COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia.

DESIGN

Data came from a convenience sample of eight abortion clinics in this region. We implemented a cross-sectional survey and collected retrospective aggregate monthly abortion data overall and by facility type, abortion type, and patient characteristics for March 2019-August 2020. We evaluated changes in the distribution of the total number of patients for March-August in 2019 compared to March-August 2020. We also conducted segmented regression analyses and produced scatter plots of monthly abortion patients overall and by facility type, abortion type, and patient characteristics, with separate fitted regression lines from the segmented regression models for the pre- and during-COVID-19 periods.

RESULTS

Five clinics reported a reduced number of appointments early in the pandemic while four reported increased call volume. There were declines in the monthly abortion trend at hospital-based clinics at the outset of the pandemic. Monthly number of medication abortions increased from March 2020 through August 2020 compared to pre-COVID-19 trends while instrumentation abortions 11 up to 19 weeks decreased. The share of abortions to Black individuals increased during the early phase of the pandemic, as did the monthly trend in abortions among this group. We also saw changes in payment type, with declines in patients paying out-of-pocket.

CONCLUSIONS

Results revealed differences in abortion services, numbers, and types during the early stages of the COVID-19 pandemic in Washington, DC, Maryland, and Virginia.

Jail Provision of Pregnancy and Sexual Health Services in Four Midwestern States

OBJECTIVE

Women incarcerated in local jails have pregnancy and sexual health needs, yet little information is available about what services are provided and how jail administrators prioritize this care. Our objective was to document jails' provision of pregnancy and sexual health services in four states in the Midwest.

METHODS

We invited all jail administrators (N = 347) in Kansas, Missouri, Iowa, and Nebraska to participate in a web-based survey conducted from November 2017 to October 2018. We asked administrators which pregnancy and sexual health services they offered and to rate the importance of offering services. Results were analyzed using descriptive statistics and logistic regression.

RESULTS

The survey response rate was 55% (192/347). Jails most often provided pregnancy testing (n = 116 [60%]) and distribution of prenatal vitamins (n = 85 [44%]). Sexually transmitted infection treatment was offered at 23% of jails (n = 45). Larger, accredited jails located in urban areas and with high numbers of clinical providers on staff were more likely to provide sexual health services. Jails with privately contracted health care were more likely to provide pregnancy services compared with other entities providing medical care. The most prioritized sexual health service was sexually transmitted infection testing, with 39% of administrators believing it was important. Only 6% of administrators responded that contraception was important.

CONCLUSIONS

Local jails in the Midwest do not meet the basic reproductive and sexual health needs of women. Provision of these services is not a priority for jail administrators. Appropriate partnerships could engage administrators and increase the availability of services to meet the needs of women in jail.

Complicity Consciousness: The Dual Practice of Ethnography and Clinical Caregiving in Carceral Settings

Anthropologist-clinicians who engage in both ethnographic inquiry and clinical practice confront methodological, ethical, and epistemological predicaments that can challenge and enhance the moral practice and ethics of care inherent both to healing and to ethnography. Clinician-ethnographers often find themselves practicing within harmful systems that they also critique, such as hospitals or carceral institutions. This paper analyzes the dual practice of obstetrical care and ethnography in a county jail and a county hospital. These intertwined roles involve wrestling with sometimes conflicting vocational and ethical obligations to heal, to protect privacy, to address bodily consequences of systemic oppressions, and to critique the systems that mete human suffering. Developing a consciousness of clinical-ethnographers' complicity, rather than disavowing it, can be aligned with approaches of abolition medicine to reimagine more just forms of healing.

COVID-19 impacts on abortion care-seeking experiences in the Washington, DC, Maryland, and Virginia regions of the United States

CONTEXT

Many people wanted to avoid or delay childbearing during the COVID-19 pandemic. This study sought to examine the extent COVID-19 influenced abortion care-seeking in a region that did not enact policy restricting abortion due to the pandemic, has high service availability, and few abortion-restrictive policies.

METHODOLOGY

We conducted telephone surveys with adults (n=72) requesting abortion appointments between September 2020 and March 2021 at five clinics in Washington, DC, Maryland, and Virginia. We used χ² tests to compare sociodemographic, reproductive history, service delivery characteristics, and pandemic-related life changes by whether COVID-19 influenced abortion care-seeking.

RESULTS

Most respondents (93%) had an abortion at the time of the survey, 4% were awaiting their scheduled appointment, and 3% did not have an appointment scheduled. Nearly 40% of people reported COVID-19 influenced their decision to have an abortion. These individuals were significantly more likely to report "not financially prepared" (44% vs. 16%) as a reason for termination compared to people reporting no influence of COVID-19. They were also more likely to have lost or changed their health insurance due to pandemic-related employment changes (15% vs. 2%), report substantial money difficulties due to COVID-19 (59% vs. 33%), and report that paying for their abortion was "very difficult" (25% vs. 2%).

CONCLUSION

COVID-19 influenced many people to have an abortion, particularly those financially disadvantaged by the pandemic. Expansion of Medicaid abortion coverage in Washington, DC and Virginia could reduce financial barriers to care and help people to better meet their reproductive needs amid future crises.

Availability of Medications for the Treatment of Opioid Use Disorder Among Pregnant and Postpartum Individuals in US Jails

Importance

Thousands of pregnant people with opioid use disorder (OUD) enter US jails annually, yet their access to medications for OUD (MOUD) that meet the standard of care (methadone and/or buprenorphine) is unknown.

Objective

To assess the availability of MOUD for the treatment of pregnant individuals with OUD in US jails.

Design, Setting, and Participants

In this cross-sectional study, electronic and paper surveys were sent to all 2885 identifiable US jails verified in the National Jails Compendium between August 19 and November 7, 2019. Respondents were medical and custody leaders within the jails.

Main Outcomes and Measures

The primary outcome was the availability of MOUD (methadone and/or buprenorphine) for the treatment of pregnant people with OUD in US jails. Availability of MOUD was assessed based on (1) continuation of MOUD for pregnant incarcerated individuals (if the individual was receiving MOUD before incarceration), with or without initiation of MOUD; (2) both initiation and continuation of MOUD for pregnant individuals; (3) only continuation of MOUD for pregnant individuals; and (4) management of opioid withdrawal for pregnant individuals. Secondary outcomes included MOUD availability during the postpartum period and logistical factors associated with the provision of MOUD. Multivariate logistic regression analysis was used to assess factors associated with MOUD availability during pregnancy.

Results

Among 2885 total surveys sent, 1139 (39.5%) were returned; of those, 836 surveys (73.4%; 29.0% of all surveys sent) could be analyzed, with similar proportions from metropolitan (399 jails [47.7%]) and rural (381 jails [45.6%]) settings. Overall, 504 jails (60.3%) reported that MOUD was available for medication continuation, with or without medication initiation, during pregnancy. Of those, 267 jails (53.0%; 31.9% of surveys included in the analysis) both initiated and continued MOUD, and 237 jails (47.0%; 28.3% of surveys included in the analysis) only continued MOUD; 190 of 577 jails (32.9%; 22.7% of surveys included in the analysis) reported opioid withdrawal as the only management for pregnant people with OUD. Among the 504 medication-providing jails, only 120 (23.8%) continued to provide MOUD during the postpartum period. Methadone was more commonly available at jails that only continued MOUD (84 of 123 jails [68.3%]), whereas buprenorphine was more commonly available at jails that both initiated and continued MOUD (73 of 119 jails [61.3%]). In an adjusted model, jails with higher odds of MOUD availability were located in the Northeast (odds ratio [OR], 10.72; 95% CI, 2.43-47.36) or metropolitan areas (OR, 1.92; 95% CI, 1.31-2.83), had private health care contracts (OR, 1.49; 95% CI, 1.03-2.14) and a higher number of women (≥70) reported in the female census (OR, 1.69; 95% CI, 1.02-2.80), and provided pregnancy testing within 2 weeks of arrival at the jail (OR, 2.66; 95% CI, 1.69-4.17).

Conclusions and Relevance

In this cross-sectional study, a substantial proportion of US jails did not provide access to MOUD to pregnant people with OUD. Although most jails reported continuing to provide MOUD to individuals who were receiving medication before incarceration, few jails initiated MOUD, and most medication-providing jails discontinued MOUD during the postpartum period. These results suggest that many pregnant and postpartum people with OUD in US jails do not receive medication that is the standard of care and are required to endure opioid withdrawal, signaling an opportunity for intervention to improve care for pregnant people who are incarcerated.

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.

Seeking recognition through carceral health care bureaucracy: Analysis of medical care request forms in a County Jail

People experiencing incarceration in the U.S. have a constitutional right to have access to health care. Yet actualizing this right is constrained by the everyday reality of an environment designed to punish and limit autonomy. The principal means for accessing health care in a carceral facility is for an individual to submit a written request, which then gets handled through the jail's bureaucratic processes. In this paper, we provide quantitative and qualitative analyses of the content and circulation of one month of these written requests-called "medical care request" (MCR) forms-at an urban, U.S. jail to understand the meanings of health and health care for a group of individuals who are systematically marginalized. In one month in 2012 at this jail housing 140 individuals, 527 MCRs were submitted. We coded requests into categories: medications, amelioration of living conditions, specific symptoms, and requests for a specific health care service. The most common request was for pain medication. In qualitative analysis, four key themes emerged: reliance on the clinic to mediate the needs of daily life; deservingness of health care; hyperawareness of bodily and psychic discomfort; and temporal techniques for asserting control over individuals' time and bodies in jail. We show that MCRs are a key mechanism through which incarcerated individuals seek recognition of their physical and psychic suffering, and more broadly, of their very existences. When considered in the broader context of controlling carceral regimes and health inequities that characterize U.S. society, MCRs become dynamic terrain through which jail health care providers and incarcerated people negotiate the tensions of deservingness of care.

Breastfeeding in Incarcerated Settings in the United States: A National Survey of Frequency and Policies

Objectives: To assess the existence of prison and jail policies and practices that allow incarcerated women to breastfeed while in custody, and prevalence of women in custody who pumped human milk for their infants. Methods: We surveyed 22 state prison systems and 6 county jails from 2016 to 2017 about policies related to breastfeeding and other programs for pregnant and parenting women in custody. In addition, 11 prisons and 5 jails reported 6 months of monthly, prospective data on the number of women pumping human milk, as well as information on placement of infants born to women in custody. Results: Eleven prisons and five jails had policies that supported the practice of expressed milk, either through pumping or breastfeeding. Over 6 months at these sites that allowed lactation, there were 207 women who gave birth in the prisons and an average of 8 women/month who pumped human milk; at the jails, there were 67 women who gave birth and an average of 6 women/month who pumped human milk. Most infants born to women in custody were placed in the care of a family member. Conclusions: Breastfeeding and the provision of human milk are critical public health issues. Our data show inconsistent implementation of policies and practices supportive of breastfeeding in prisons and jails. However, there are institutions in the United States that are supportive of incarcerated women's breastfeeding and lactation needs. Further research is needed to identify the barriers and facilitators associated with implementing supportive breastfeeding policies and practices in the carceral system.

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.

COVID-19 vaccine prioritization of incarcerated people relative to other vulnerable groups: An analysis of state plans

BACKGROUND

Carceral facilities are epicenters of the COVID-19 pandemic, placing incarcerated people at an elevated risk of COVID-19 infection. Due to the initial limited availability of COVID-19 vaccines in the United States, all states have developed allocation plans that outline a phased distribution. This study uses document analysis to compare the relative prioritization of incarcerated people, correctional staff, and other groups at increased risk of COVID-19 infection and morbidity.

METHODS AND FINDINGS

We conducted a document analysis of the vaccine dissemination plans of all 50 US states and the District of Columbia using a triple-coding method. Documents included state COVID-19 vaccination plans and supplemental materials on vaccine prioritization from state health department websites as of December 31, 2020. We found that 22% of states prioritized incarcerated people in Phase 1, 29% of states in Phase 2, and 2% in Phase 3, while 47% of states did not explicitly specify in which phase people who are incarcerated will be eligible for vaccination. Incarcerated people were consistently not prioritized in Phase 1, while other vulnerable groups who shared similar environmental risk received this early prioritization. States' plans prioritized in Phase 1: prison and jail workers (49%), law enforcement (63%), seniors (65+ years, 59%), and long-term care facility residents (100%).

CONCLUSIONS

This study demonstrates that states' COVID-19 vaccine allocation plans do not prioritize incarcerated people and provide little to no guidance on vaccination protocols if they fall under other high-risk categories that receive earlier priority. Deprioritizing incarcerated people for vaccination misses a crucial opportunity for COVID-19 mitigation. It also raises ethical and equity concerns. As states move forward with their vaccine distribution, further work must be done to prioritize ethical allocation and distribution of COVID-19 vaccines to incarcerated people.

The Compendium of U.S. jails: creating and conducting research with the first comprehensive contact database of U.S. jails

BACKGROUND

Millions of people pass through U.S. jails annually. Conducting research about these public institutions is critical to understanding on-the-ground policies and practices, especially health care services, affecting millions of people. However, there is no existing database of the number, location, or contact information of jails. We created the National Jails Compendium to address this gap. In this paper, we detail our comprehensive methodology for identifying jail locations and contact information. We then describe the first research project to use the Compendium, a survey assessing jails' treatment practices for incarcerated pregnant people with opioid use disorder.

RESULTS

This study sent surveys electronically or in paper form to all 2986 jails in the Compendium, with 1139 surveys returned. We outline the process for using the Compendium, highlighting challenges in reaching contacts through case examples, cataloging responses and non-responses, and defining what counts as a jail.

CONCLUSION

We aim to provide tools for future researchers to use the Compendium as well as a pathway for keeping it current. The Compendium provides transparency that aids in understanding jail policies and practices. Such information may help devise interventions to ensure humane, evidence-based treatment of incarcerated people.

Society of Family Planning clinical recommendations: Management of individuals with bleeding or thrombotic disorders undergoing abortion

Individuals who have bleeding disorders, thrombophilias, a history of venous thromboembolism (VTE), or who are taking anticoagulation medication for other reasons may present for abortion. Clinicians should be aware of risk factors and histories concerning for excessive bleeding and thrombotic disorders around the time of abortion. This document will focus on how to approach abortion planning in these individuals. For first-trimester abortion, procedural abortion (sometimes called surgical abortion) is generally preferred over medical management for individuals with bleeding disorders or who are on anticoagulation. First-trimester procedural abortion in an individual on anticoagulation can generally be done without interruption of anticoagulation. The decision to interrupt anticoagulation for a second-trimester procedure should be individualized. Individuals at high risk for VTE can be offered anticoagulation post-procedure. Individuals with bleeding disorders or who are anticoagulated can safely be offered progestin intrauterine devices. Future research is needed to better assess quantitative blood loss and complications rates with abortion in these populations.

Access to treatment for pregnant incarcerated people with opioid use disorder: Perspectives from community opioid treatment providers

BACKGROUND AND AIMS

Many jail facilities provide limited access to medications for opioid use disorder (MOUD) for pregnant people with opioid use disorder (OUD), despite it being the standard of care. We aim to explore the perspectives of opioid treatment providers (OTPs) on access to MOUD for pregnant people while incarcerated and postincarceration.

METHODS

We conducted 16 semistructured phone interviews with providers and administrators representing 16 unique OTPs in various U.S. states with high maternal opioid use rates. We developed the interview guide using the Consolidated Framework for Implementation Research, and we analyzed interview transcripts using a direct content analysis.

RESULTS

Nine participants reported having an arrangement with a carceral facility to provide care for pregnant people with OUD; however, others described how their local jail offered no OUD treatment for incarcerated pregnant people. Even if participants' clinics had arrangements to provide MOUD in a jail, most participants described significant barriers to continuity of care between jails and community providers as patients transition between jails and community settings. OTPs described their belief of how postincarceration, pregnant people experience barriers to OUD care such as lack of access to childcare, preparing for the baby, feeling unwell, in addition to the barriers that nonpregnant patients experience, such as transportation, housing, and financing.

CONCLUSIONS

OTPs perceive that pregnant people with OUD experience significant barriers to accessing treatment while incarcerated and in community settings due to discrimination, difficulties in continuity of care, and lack of treatment access while incarcerated. The implementation of evidence-based MOUD treatment for pregnant people in jail and continuation of treatment upon release is crucial to reduce health disparities.

Health Care in the Age of Mass Incarceration: A Selective Course for Medical Students in Their Preclinical Years

INTRODUCTION

While medical school curricula increasingly address health disparities, content regarding health care for persons impacted by incarceration is a persistent and notable gap. There is a high burden of disease among incarcerated populations, and health care challenges continue postincarceration. We developed a course to introduce medical students to the current landscape of mass incarceration in the US and implications for health and health care delivery to people impacted by this system.

METHODS

We developed a 3.5-hour elective course taken by 19 first-year medical students in its first year and 20 students in its second. The course utilized lecture, case-based discussion, and guest speaker modalities to introduce students to the history of mass incarceration, health care delivery within the carceral system, and challenges in accessing care during and following incarceration.

RESULTS

Students received two surveys after completing the course. In the first, 100% of respondents reported outstanding, excellent, or good levels of satisfaction with various elective components, including organization, learning activities, and student discussion. The second found significant increases in knowledge about mass incarceration and incarceration health issues, in addition to significant increases in interest in advocating or providing health care for incarcerated populations.

DISCUSSION

Given current mass incarceration practices, students will encounter patients impacted by this system. This elective course sought to better prepare students to effectively care for these patients. We were limited by time availability, and future directions include incorporating a standardized patient exercise, trauma-informed care principles, and providers working within the carceral system.

Opioid use disorder incidence and treatment among incarcerated pregnant women in the United States: results from a national surveillance study

BACKGROUND AND AIMS

The established standard care in pregnancy is medication for opioid use disorder (MOUD); however, many institutions of incarceration do not have MOUD available. We aimed to describe the number of incarcerated pregnant women with opioid use disorder (OUD) in the United States and jails' and prisons' MOUD in pregnancy policies.

DESIGN

Epidemiological surveillance study of 6 months of outcomes of pregnant, incarcerated women with OUD and cross-sectional survey of institutional policies.

SETTING

United States.

PARTICIPANTS

Twenty-two state prison systems and six county jails.

MEASUREMENTS

The number of pregnant women with OUD admitted and treated with methadone, buprenorphine or withdrawal; policies on provision of MOUD and withdrawal in pregnancy.

FINDINGS

Twenty-six per cent of pregnant women admitted to prisons and 14% to jails had OUD. One-third were managed through withdrawal. The majority who were prescribed MOUD were on methadone (78%, prisons; 81%, jails), not buprenorphine. While most sites (n = 18 prisons, n = four jails) continued pre-incarceration MOUD in pregnancy, very few initiated in custody (n = four prisons; n = two jails). Two-thirds of prisons and three-quarters of jails providing MOUD in pregnancy discontinued it postpartum.

CONCLUSIONS

In this sample of US prisons and jails, one-third required pregnant women with opioid use disorder to go through withdrawal, contrary to medical guidelines. More women were prescribed methadone than buprenorphine, despite the fewer regulatory barriers on prescribing buprenorphine. Most sites stopped medication for opioid use disorder postpartum, signaling prioritization of the fetus, not the mother. Pregnant incarcerated women with opioid use disorder in the United States frequently appear to be denied essential medications and receive substandard medical care.

Tough Choices: Exploring Decision-Making for Pregnancy Intentions and Prevention Among Girls in the Justice System

Despite California's declining teen pregnancy rate, teens in the juvenile justice system have higher rates than their nonincarcerated counterparts. This study explored domains that may shape decision-making for pregnancy prevention in this group. Twenty purposively selected female teens with a recent incarceration participated in hour-long semistructured interviews about their future plans, social networks, access to reproductive health services, and sexual behavior. Transcripts revealed that, contrary to literature, desire for unconditional love and lack of access to family planning services did not mediate decision-making. Lack of future planning, poor social support, and limited social mobility shaped youths' decisions to use contraceptives. Understanding this group's social location and the domains that inform decision-making for pregnancy intentions and prevention provides clues to help programs predict and serve this population's needs.

Stigma and US Nurses' Intentions to Provide the Standard of Maternal Care to Incarcerated Women, 2017

Objectives. To examine relationships among actionable drivers and facilitators of stigma and nurses' intentions to provide the standard of maternal care recommended by the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) for incarcerated women.Methods. We conducted a Web-based survey of perinatal nurses in the United States (n = 665; participation rate 98.0%; completion rate 95.3%) in July through September 2017. We used multivariable logistic regression to predict higher than median intentions to provide the standard of care.Results. Lower stigmatizing individual attitudes and institutional norms and higher perceived autonomy when caring for an incarcerated woman were significantly associated with higher care intentions. Knowledge of the AWHONN position statement on the standard of care or their own state's shackling laws was not associated with higher care intentions.Conclusions. We documented significant associations among actionable drivers and facilitators of stigma and the intentions of a key health care provider group to deliver the standard of maternal care to incarcerated women. Individual- and institutional-level stigma-reduction interventions may increase the quality of maternal care and improve perinatal outcomes for women who give birth while incarcerated.

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.

Reproductive Justice Disrupted: Mass Incarceration as a Driver of Reproductive Oppression

We describe how mass incarceration directly undermines the core values of reproductive justice and how this affects incarcerated and nonincarcerated women.Mass incarceration, by its very nature, compromises and undermines bodily autonomy and the capacity for incarcerated people to make decisions about their reproductive well-being and bodies; this is done through institutionalized racism and is disproportionately done to the bodies of women of color. This violates the most basic tenets of reproductive justice-the right to have a child, not to have a child, and to parent the children you have with dignity and in safety.By undermining motherhood and safe pregnancy care, denying access to abortion and contraception, and preventing people from parenting their children at all and by doing so in overpoliced, unsafe environments, mass incarceration has become a driver of forms of reproductive oppression for people in prison and jails and in the community.

Patient perceptions of immediate postpartum long-acting reversible contraception: A qualitative study

OBJECTIVES

The objective of this study was to explore perceptions and experiences of immediate postpartum long-acting reversible contraception (LARC) counseling and decision-making, with a focus on reproductive autonomy. We aimed to assess the potential for reproductive coercion.

STUDY DESIGN

This was a qualitative study using semi-structured interviews with Spanish and English speaking women who received an intrauterine device or contraceptive subdermal implant immediately postpartum. They were recruited before discharge from two hospitals in Baltimore, MD. We analyzed interviews using directed content analysis.

RESULTS

We interviewed a diverse group of 17 women. Participants praised the convenience of LARC and the ease of immediate postpartum placement. Some women reported feeling pushed by providers during counseling and were critical of their experiences. Women expressed a desire for comprehensive, objective information early and often during antepartum contraceptive counseling, and some valued counseling from multiple providers. They wanted autonomy in their contraceptive decision-making and described making internally motivated decisions based on their life goals and individual priorities.

CONCLUSIONS

Some women felt pressured to choose immediate postpartum LARC, while others expressed enthusiasm for immediate postpartum LARC. Our data suggest that providers should start contraceptive counseling early in prenatal care and readdress it at multiple visits. Patients may benefit from speaking with multiple providers.

IMPLICATIONS

Our study supports immediate postpartum LARC as a favorable contraceptive option for some women when discussed during prenatal care. Providers should take care to avoid coercion during counseling and focus on delivering comprehensive, objective information about all contraceptive methods, including side effects and removal options.

Perspectives on Patient-Centered Family Planning Care from Incarcerated Girls: A Qualitative Study

STUDY OBJECTIVE

We applied a patient-centered care (PCC) framework to explore incarcerated girls' experiences of and preferences for family planning (FP) care.

DESIGN

We conducted qualitative semistructured interviews with incarcerated girls to explore domains of PCC: access to care, patient preferences, information and education, emotional support, family and friends, physical comfort, coordination of care, and continuity and transition.

SETTING

A juvenile detention center (JDC) in an urban California county.

PARTICIPANTS

Girls incarcerated during the study period.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Transcripts were analyzed using directed content analysis to identify themes related to PCC and additional overarching themes.

RESULTS

Twenty-two participants completed interviews. Overarching themes of stigma and autonomy emerged as influential in girls' experiences and preferences for FP care. Participants described stigma related to incarceration, sexual activity, and lack of contraception use. Participants' desire for autonomy contributed to concerns around FP care. Despite this, most desired access to FP care while incarcerated. Many valued relationships they had with JDC providers, reporting more trust and familiarity with JDC providers than those in the community. Constraints of incarceration decreased availability of emotional supports and decreased involvement of family in health-related decision-making, which worsened girls' experiences with FP care and enhanced their sense of autonomy. Difficulties with care coordination and transitions between the JDC and community often resulted in fragmented care.

CONCLUSION

Providing patient-centered FP care in JDCs is desirable but complex, and requires prioritizing patient preferences while recognizing the strengths and limitations of providing FP care within JDCs.

Pregnancy Outcomes in US Prisons, 2016-2017

OBJECTIVES

To collect national data on pregnancy frequencies and outcomes among women in US state and federal prisons.

METHODS

From 2016 to 2017, we prospectively collected 12 months of pregnancy statistics from a geographically diverse sample of 22 state prison systems and the Federal Bureau of Prisons. Prisons reported numbers of pregnant women, births, miscarriages, abortions, and other outcomes.

RESULTS

Overall, 1396 pregnant women were admitted to prisons; 3.8% of newly admitted women and 0.6% of all women were pregnant in December 2016. There were 753 live births (92% of outcomes), 46 miscarriages (6%), 11 abortions (1%), 4 stillbirths (0.5%), 3 newborn deaths, and no maternal deaths. Six percent of live births were preterm and 30% were cesarean deliveries. Distributions of outcomes varied by state.

CONCLUSIONS

Our study showed that the majority of prison pregnancies ended in live births or miscarriages. Our findings can enable policymakers, researchers, and public health practitioners to optimize health outcomes for incarcerated pregnant women and their newborns, whose health has broad sociopolitical implications.

Best Practices for Pregnant Incarcerated Women With Opioid Use Disorder

Pregnant women represent a unique population for correctional facilities to care for. The incarcerated pregnant population is at an increased risk of concurrent opioid use disorder (OUD) that requires specialized care. The evidence-based best practice and standard of care for pregnant women with OUD is medication-assisted treatment (MAT) with methadone or buprenorphine pharmacotherapy. Correctional facilities that house women must be prepared to provide this care in a timely manner upon intake in order to address the serious medical needs of the pregnant woman and her fetus. Providing MAT in the incarceration setting has distinctive logistics that must be considered. This article recommends strategies to optimize the care of pregnant incarcerated women with OUD, emphasizing the importance of appropriate counseling and treatment with opioid agonist pharmacotherapy.

Perinatal Nurses' Experiences With and Knowledge of the Care of Incarcerated Women During Pregnancy and the Postpartum Period

OBJECTIVE

To describe perinatal nurses' experiences of caring for incarcerated women during pregnancy and the postpartum period; to assess their knowledge of the 2011 position statement Shackling Incarcerated Pregnant Women published by the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN); and to assess their knowledge of their states' laws regulating nonmedical restraint use, or shackling, of incarcerated women.

DESIGN

Cross-sectional survey.

SETTING

Online across the United States.

PARTICIPANTS

AWHONN members who self-identified as antepartum, intrapartum, postpartum, or mother-baby nurses (N = 923, 8.2% response rate).

METHODS

A link to an investigator-developed survey was e-mailed to eligible AWHONN members (N = 11,274) between July and September 2017.

RESULTS

A total of 74% (n = 690) of participants reported that they cared for incarcerated women during pregnancy or the postpartum period in hospital perinatal units. Of these, most (82.9%, n = 566) reported that their incarcerated patients were shackled sometimes to all of the time; only 9.7% reported ever feeling unsafe with incarcerated women who were pregnant. "Rule or protocol" was the most commonly endorsed reason for shackling. Only 17.0% (n = 157) of all participants knew about the AWHONN position statement, and 3% (n = 28) correctly identified the conditions under which shackling may ethically take place (risk of flight, harm to self, or harm to others). Only 7.4% (n = 68) of participants correctly identified whether their states had shackling laws.

CONCLUSION

Our results suggest critical gaps in nurses' knowledge of professional standards and protective laws regarding the care of incarcerated women during pregnancy. Our findings underscore an urgent need for primary and continuing nursing education in this area.

Making mothers in jail: carceral reproduction of normative motherhood

The over-reliance on incarceration in the USA is a racialized phenomenon which has affected millions of families - disproportionately people of colour - reconfiguring kinship around the criminal legal system. Mass incarceration, then, disrupts conventional modes of reproduction and threatens reproductive justice, separates families and funnels children into foster care, diverts funds from social services into prisons, restricts women's access to abortion and adequate pregnancy care, shackles women in childbirth, and incarcerates people during their prime reproductive years. Beyond these obvious disruptions to reproduction, incarceration also cultivates certain ways of being a parent. Much of the critical literature on mass incarceration focuses on men, largely because of fewer women and masculinist assumptions of the carceral system. This paper looks specifically at how women's reproduction is experienced and managed by carceral institutions, and how mass incarceration itself is a reproductive technology. Based on ethnographic fieldwork at a women's jail, I explore pregnancy and motherhood behind bars. Certain types of mothering are foreclosed, while an idealized version of maternal identity is simultaneously promoted. For many incarcerated women, jail is the only place where they can experience this form of motherhood, as forces of structural violence outside of jail often limit their ability to parent, such as involvement of child welfare institutions, addiction and homelessness. The myriad ways in which incarcerated women's reproduction is suppressed and enabled is a critical lens through which to understand how institutions and forces of racial oppression reinforce idealized notions of motherhood while making them categorically unattainable.

History of Sex Exchange in Women with a History of Incarceration

Sex exchange among incarcerated women is not well-described in the literature. Sex exchange can lead to numerous adverse health outcomes, especially when combined with individual factors (e.g., depression and homelessness) and larger systemic inequalities. The purpose of this study was to explore factors associated with having a history of sex exchange among a sample of incarcerated women. Of 257 women surveyed in this study, 68 women (26.5%) reported a history of sex exchange. In multivariate logistic regression analysis, physical abuse history (p=.05, OR 2.20), history of two or more sexually transmitted infections (p=.01, OR 2.90), injection drug use (p=.04, OR 2.46) and crack-cocaine use (p&lt;.01, OR 3.42) were associated with prior sex exchange. This is one of only two studies to examine factors associated with prior sex exchange among incarcerated women. Our study has important implications for corrections providers to provide more comprehensive care, directly addressing the unique needs of this population.

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

Purpose Incarcerated women around the globe are predominantly of reproductive age. Most of these women have been pregnant before, and many want to be sexually active and avoid pregnancy upon release. Yet few of these women are on a regular method of contraception. Providing contraceptive services for women in custody benefits individual and public health goals of reducing unintended pregnancy. This policy briefing reviews evidence for an unmet need for family planning in the correctional setting, and policy implications for expanding services. The paper aims to discuss these issues. Design/methodology/approach The authors describe four model programs in the USA with established contraceptive services on site, highlighting practical steps other facilities can implement. Findings Correctional facilities health administrators, providers, advocates, and legislators should advance policies which should counsel women on family planning and should make a range of contraceptive methods available before release, while remaining sensitive to the potential pressure these women may feel to use birth control in this unique environment. Practical implications Family planning services for incarcerated women benefits individuals, facilities, and the community. Social implications Policies which enable correctional facilities to provide comprehensive family planning to incarcerated women - including reproductive life goals counseling and contraceptive method provision - promote equity in access to critical reproductive health services and also provide broad scale population level benefits in preventing unintended pregnancy or enabling counseling for healthy pregnancies for a group of women who often have limited access to such services. Originality/value This policy briefing highlights an area of health care in prisons and jails which gets little attention in research and in policy circles: family planning services for incarcerated women. In addition to reviewing the importance of such services for this population, the authors also highlight model family planning programs in correctional facilities. These provide actionable insights for other administrators and providers.

Long-Acting Reversible Contraceptives for Incarcerated Women: Feasibility and Safety of On-Site Provision

CONTEXT

Many incarcerated women have an unmet need for contraception. Providing access to long-acting reversible contraceptive (LARC) methods--IUDs and implants--before release is one strategy to meet this need and potentially prepare them for reentry to the community, but the safety and feasibility of providing these methods in this setting have not been described.

METHODS

A retrospective descriptive study of all LARC insertions at the San Francisco County Jail in 2009-2014 was conducted. Data from community clinic and jail clinic databases were assessed to examine baseline characteristics of LARC initiators, complications from insertion, method continuation, and pregnancy and reincarceration rates. Correlates of method discontinuation were assessed in multivariate logistic regression analyses.

RESULTS

Eighty-seven LARC devices were inserted during the study period--53 IUDs and 34 implants. There were no cases of pelvic inflammatory disease or other insertion complications in IUD users and no serious complications in implant users. Median duration of known use was 11.4 months for IUDs and 12.9 months for implants. Women who discontinued a LARC method most commonly cited a desire to get pregnant (32%). Black women were more likely than whites to discontinue use (odds ratio, 4.4).

CONCLUSIONS

It is safe and feasible to provide LARC methods to incarcerated women. Correctional facilities should consider increasing access to all available contraceptives, including LARC methods, in a noncoercive manner as a strategy to reduce reproductive health disparities among marginalized women at high risk of unplanned pregnancies.