The Contraceptive Needs of Incarcerated Women

Abstract

Objectives:

We assessed the contraceptive needs of women incarcerated in jails in the southeastern United States to determine feasible and effective birth control interventions based on the needs of this population.

Methods:

Participants were recruited from local jails around a medium-sized metro area. Participants completed a survey of demographics, sexual health, contraceptive use, and preferred method of contraception.

Results:

The survey was completed by 188 women in jail. Participants reported high rates of sexually transmitted diseases (STDs) (50.5%), inconsistent use of birth control (36.5%), and use of unreliable and user-dependent methods of birth control. The majority did not desire to become pregnant in the future (61.5%) but intended to have sex after release from jail (76.9%). Women who were able to bear children were more likely to report intentions to use birth control or STD protection after release (77.9%). Additionally, significant racial differences were found. Specifically, nonwhites were more likely to be single and have more STDs and less use of a variety of birth control methods than whites.

Conclusions:

Women in this sample were at high risk for unplanned pregnancies. Therefore, a primary contraceptive need for this population appeared to be education about longer lasting, user-independent forms of contraception. Many of these women would be ideal candidates for such forms of contraception, especially if it was provided prior to release.

Introduction

Unintended pregnancies are an important issue in public health today, as they comprise almost half of all pregnancies.^1

–4 Approximately half of these pregnancies end in abortion, and 13% end in miscarriages.^4,5 Unintended pregnancies are of particular concern because they may affect the health of the newborn through a woman's prepartum and some postpartum behavior and experiences, including greater likelihood of smoking during pregnancy, greater likelihood of insufficient folic acid intake during pregnancy, lower likelihood of breastfeeding after birth, greater likelihood of infant death in the first 28 days of life, and higher likelihood of child abuse and neglect.^6

–10

Women who are sexually active, fertile, not pregnant, and not trying to become pregnant and who come from a medically underserved, low-income background are much more likely to demonstrate contraceptive risk taking or nonuse of contraception while being sexually active compared with the general population of fertile women at all income levels.^5,11 One study found that women who practice contraceptive risk taking had more than three times as many unwanted pregnancies as women who regularly use contraception.¹² African American and Hispanic women, regardless of income status, are at highest risk of unintended pregnancy by not using contraception regularly.^12,13 Finally, a study reported that women from low-income populations who specifically planned on using oral contraceptives or condoms postpartum were less likely to actually use that method of contraception or any contraception than those who chose longer-term contraceptive methods.¹⁴ Previous research has found that oral contraceptive users tend to include women from higher socioeconomic status (SES) and with lower sexually transmitted disease (STD) risks. On the other hand, barrier method users and those who used no form of contraception included women who were younger and at higher risk for contracting an STD.⁶

Incarcerated women are generally considered a low-income and medically underserved population. They tend to be more likely not to use any form of contraception once released from jail or prison, even if pregnancy is undesired, which increases the risk of having an unintended pregnancy.¹⁵ In addition, the large majority of women who are incarcerated consider themselves very likely or extremely likely to have sexual relations with a man within 6 months of release from prison. Very few women report consistent use of birth control, however, and one study found that >80% of incarcerated women reported having had at least one unplanned pregnancy in their lifetime.¹⁶ For many of these women, incarceration may be the only opportunity to receive reproductive healthcare.

This study intended to replicate the findings of Clarke et al.^15,16 by investigating the types of birth control that women in jail had used prior to incarceration and to assess their intentions to use birth control after release. Additionally, this study aimed to extend this body of knowledge by gathering additional information about preferred birth control method after release from jail and exploring racial differences within this population. We are interested in the differences in terms of contraception use between women who are able to bear children and those who are not. Finally, we are interested in determining the birth control methods with the most acceptability and feasibility to provide to a population of incarcerated women prior to their release from jail. We hypothesized that this sample of women would be at high risk for contracting STDs and having unplanned pregnancies, as evidenced by inconsistent use of birth control, intentions to have sex after release from jail, and lack of a healthcare provider, and, therefore, may benefit from education about and access to long-term, user-independent methods of contraception.

Materials and Methods

Procedures

Participants were recruited from five local jails around a medium-sized metro area in the southeast. IRB approval was obtained by Virginia Commonwealth University, and each of the participating jails granted approval for this study. A brief announcement explaining the survey was conducted in the common areas of the jails, and potential participants were free to ask questions after the announcement or in private with the research staff. All women who were present to hear the announcement received a self-stamped envelope to use to mail a letter to family or friends, regardless of their completion of the survey. Women who agreed to participate took a survey and completed it on their own in private (e.g., in their cells). Participants were told to not write their name or any other identifying information on the survey. Surveys were returned directly to a member of the research team. The number of incarcerated women eligible to be interviewed (across five jails) was 299. Of the 299 women, 188 completed the survey. This is a response percentage of about 63%.

Measures

The Sexual Health Survey, developed for the study, consisted of questions including demographic information, history of pregnancies, sexual health (e.g., history of STDs and other gynecological infections, number of sexual partners), forms of contraceptives used in the past, intention to engage in sexual intercourse on release from prison, intention to become pregnant after release from prison, and intention to use contraceptives on release from prison, including preferred contraceptive method. Participants were also asked about their potential release date and any method of sterilization (anything that would render them unable to bear children, e.g., tubal ligation or menopause). This survey took about 10–15 minutes to complete. According to Microsoft Word 2003 readability statistics, the survey scored at a fourth to fifth grade reading level. Almost all inmates were able to complete the survey on their own, but if they could not read or their reading level was not sufficient, the research assistant administered the survey to them.

Results

Participants were predominantly nonwhite (61.7%), single (82.5%) women of childbearing age (mean = 36.8 years, SD = 8.8). A little over half of the women reported completing high school or GED (51.6%), most planned to work full-time after being released from jail (74.3%), and few planned to attend school after release (Table 1). Over half of the participants were due to be released from jail within 6 months of participation in the study.

Table 1.

Demographic Characteristics a

	Able to bear children (n = 108)	Unable to bear children (sterile) (n = 80)	p value
Age, mean (SD)	33.6 (8.0)	40.9 (8.1)	0.001 ***
Race, %			0.63
White	36.8	40.2
Black	58.5	54.9
Other	4.7	4.9
Marital status, %			0.03 *
Single	72.3	53.7
Married/partnered	13.9	22.0
Divorced	13.9	24.4
Education, %			0.01 **
No HSDb or GED	33.0	25.6
HSD or GED	56.6	45.1
Technical/associate's degree	9.4	25.6
Bachelor's degree or greater	0.9	3.7
Plan to attend school after leaving jail, %			0.02 *
Full-time	6.7	3.7
Part-time	20.0	8.8
Do not plan to attend school	73.3	87.4

13 participants did not answer questions about intentions to use condoms after release and were not included in the present analysis.

^* p < 0.05; ^*** p < 0.001.

HSD, high school diploma.

Bold indicates statistical significance.

Sexual and reproductive histories

Women reported an average of 3.2 (SD 2.2) pregnancies that resulted in 2.2 (SD 1.5) live births (Table 2). Although 63.6% of women reported access to a healthcare provider prior to jail, only 25.5% reported access to an obstetrician/gynecologist, and only 57.5% believed that they would have a healthcare provider after release from jail. About half of women reported a history of an STD, the most common of which were trichomoniasis (27.7% of total sample), Chlamydia infection (26.1%), and gonorrhea (20.7%). Nonwhite women reported a greater history of STDs (57.9%) than white women (38.6%) (chi-square (1) = 6.478, p < 0.01). Over half of all the women reported a history of a gynecological infection, the most common of which was vaginal candidiasis (yeast infection).

Table 2.

Gynecological Characteristics

	Able to bear children (n = 108)	Unable to bear children (sterile) (n = 80)	p value
Number of pregnancies, mean (SD)	2.7 (2.4)	3.9 (1.8)	0.001 ***
Number of live births, mean (SD)	1.7 (1.6)	2.8 (1.2)	0.001 ***
Access to healthcare provider prior to jail, %	64.1	63.0	0.88
Will have healthcare provider after jail, %	63.2	51.2	0.14
Ever had an STD/STI,a %	48.6	53.2	0.54
Abnormal Pap smear, %	33.0	50.0	0.02 *
History of PID/pelvic infection	19.0	18.5	0.93
Ever had a gynecological infection, %	58.7	45.7	0.56

^* p < 0.05; ^*** p < 0.001.

STD, Sexually transmitted disease; STI, sexually transmitted infection.

Bold indicates statistical significance.

The most common methods of birth control used by these women in the past were the male condom (74.1%), birth control pills (66.5%), withdrawal (38.9%), or Depo-Provera (Upjohn Pharmaceuticals, Kalamazoo, MI) injection (24.3%), but only 63.5% reported using birth control “almost all the time” during sexual intercourse, and 7% reported no previous use of birth control. Most birth control methods (birth control pills, spermicide, birth control patch, rhythm method, sponge, withdrawal, and vasectomy of partner) were used less by nonwhite women than white women. Nonwhite women (10.5%) were also more likely than white women (1.4%) to report not using any method of birth control in the past (chi-square (1) = 5.57, p < 0.05). Although most women (76.9%) intended to have sex with a man within 6 months after release from jail, only 38.5% planned on becoming pregnant in the future. As shown in Table 3, most women intended to use the male condom (58.3%), birth control pill (9.7%), or withdrawal (8.6%) as their primary birth control method after jail, but only 72.4% intended to use birth control during every instance of sexual intercourse.

Table 3.

Contraceptive Use

	Able to bear children (n = 108) %	Unable to bear children (n = 80) %	p value
Number of sexual partners			0.63
None	2.0	1.3
1	6.9	7.6
2–10	31.7	39.2
11–20	20.8	13.9
More than 20	38.6	38.0
Birth control used prior to jail
Male condom	73.1	75.3	0.73
Birth control pill	65.4	67.9	0.72
Withdrawal	45.2	30.9	0.05 *
Injection	29.8	17.3	0.05 *
No previous use of BC	9.6	3.7	0.12
How often used BC			0.72
Almost all the time	62.4	65.0
Sometimes	21.8	16.2
Rarely	3.0	7.5
Almost never	4.0	7.5
Plan to have sex after jail	76.0	78.0	0.57
Plan to use other birth control after jail
Male condom	69.1	44.9	0.001 ***
Birth control pill	15.5	2.6	0.004 **
Withdrawal	10.3	6.4	0.36
Injection	6.2	3.8	0.49
How often use BC after jail	77.9	65.8	0.08†
Almost all the time
Birth control plan to use if money/availability did not matter			0.001 ***
Male condom	29.2	36.4
Tubal ligation	4.7	29.9
Injection	15.1	3.9
Birth control pill	16.0	0.0
Desire to become pregnant after jail	56.4	15.4	0.001 ***
How soon become pregnant			0.001 ***
Within 2 years	34.7	10.0
3 or more years	19.8	5.0
No kids in future	45.5	85.0

†

p < 0.10; ^* p < 0.05; ^** p < 0.01; ^*** p < 0.001.

Bold indicates statistical significance.

Sexual health history and contraceptive use by ability to bear children

Because high rates of unintended pregnancy were identified in previous studies, those participants who were unable to bear children (sterile) were separated from those who were able to bear children. Of the women who were unable to bear children (n = 80), 77.5% reported having been sterilized, 41% had begun menopause, 53.8% had a tubal ligation, and 17.5% had a hysterectomy. These numbers do not total to 100% because some participants reported more than one method of sterilization (e.g., they had begun menopause and also had a tubal ligation). Participants who were able to bear children were younger, had lower levels of education, and were more likely to report intention to attend school after release from jail (all p < 0.05). They also reported fewer pregnancies, live births, and abnormal Pap smears than participants unable to bear children (all p < 0.05). When asked about contraceptive use, women who were able to bear children were significantly more likely to have used Depo-Provera injection and withdrawal methods prior to jail, to report intentions not to use the male condom or any other form of birth control after release from jail, to report intentions not to use birth control “almost all the time” after release from jail, and to report more desire to have children in the future (all p < 0.05).

Discussion

Similar to previous studies of incarcerated women,^13,15,16 the current study revealed high rates of STDs, inconsistent use of birth control, and lack of a healthcare provider (especially after release). Most women intended to have sex after release, but only about half intended to use birth control. Therefore, as hypothesized, the women in this study were found to be at high risk for unplanned pregnancies. Additionally, the nonwhite participants reported they are significantly less likely to use any form of birth control most of the time. Over half of the women were due to be released within 6 months; in combination with the other findings, this indicates a great need for provision of user-independent, long-lasting but reversible contraception prior to release for childbearing women as a protective measure against unintended pregnancy.

Because a relatively high number of participants (43%) reported at least one method of potential sterilization (onset of menopause, tubal ligation, or hysterectomy), analyses were run separately for the two groups (women with childbearing potential and those who reported being sterile). The women who were able to bear children were younger and had lower levels of education. Their use of Depo-Provera injections and withdrawal methods was higher than that among sterile women. However, like the total sample, male condoms were the most commonly used method of contraception for women able to bear children, and nearly 10% of these women reported no use of birth control prior to incarceration. High rates of unreliable or user-dependent birth control methods put these young, sexually active, fertile women at risk for unintended pregnancy.

Perhaps the most important implications drawn from this research are those regarding the feasibility of providing reliable contraceptive methods before women are released from jail. Overall, this sample reported high rates of STDs, high numbers of sexual partners, inconsistent use of contraceptives, intentions to have sex after release from jail, and low desire to have children in the future, rendering them at high risk for unplanned pregnancies. The nonwhite participants in this group reported even less use of most birth control methods, higher STD rates, and lower intentions to use birth control methods regularly after release from jail than white participants. In addition, three of the most commonly used forms of contraceptives among this entire sample based on past use and intentions to use in the future (condoms, birth control pills, and withdrawal) are user or partner dependent or very unreliable. Condoms, although extremely important for protection against STDs, are dependent on a partner's willingness to wear them, rely on consistent and correct use, and generally have a higher failure rate than other forms of birth control.^17
–19 The effectiveness of oral contraceptives, such as the birth control pill, is highly dependent on the user's ability to remember to take them everyday, and many women miss pills and are noncompliant with this method.²⁰ Finally, withdrawal is very unreliable and also dependent on a partner's willingness to comply with the method.²¹ Previous research has found that longer-term methods of contraception have been shown to be acceptable and satisfying methods and are often the preferred methods of birth control over shorter-term methods when tested in low-income populations.²²

Women leaving jail or prison appear to be an ideal population for user-independent, long-term yet reversible birth control. In a previous study,¹⁶ women who were offered user-independent contraceptives, such as the Depo-Provera injection, within a correctional setting were much more likely to initiate using these contraceptives than women who were connected to free reproductive healthcare in the community postrelease. In the current sample, one of the four most commonly used methods of contraception was the injection (Depo-Provera), indicating that these women are interested in using a user-independent method of birth control. The injection method for birth control was a preferred birth control option among nonwhite participants if cost and availability were not an issue. The only birth control option preferred above the injection within the nonwhite population was the male condom. However, the IUD, another user-independent form of birth control had not been used by any of the women in our sample and represents a low-cost option for birth control. Initiation of such methods prior to release has a number of advantages compared with a passive referral to obtain birth control after the women are released.

Many women may be uncertain as to how to obtain contraceptives or how to use them; having a nurse educator explain the basics of contraceptive options and instructions as to how to use them correctly could greatly benefit such women. In addition, many women must immediately deal with other issues after release, such as housing, employment, child care, and drug and alcohol treatment, rendering them unable to allot energy toward reproductive healthcare even if they are provided with free resources from which to obtain it. Providing user-independent contraception prior to release from jail also allows women to make choices about birth control without pressure from their partner²³ and ensures protection against pregnancy from the moment they walk out the door.

It is also important to note, however, that only 57.5% of participants believed they would have a healthcare provider after release from jail. Even user-independent forms of contraception, such as the IUD and Depo-Provera, require some form of ongoing care from a healthcare professional. If women are provided with such forms of contraception prior to release from prison, they will require at least minimal access to a physician or nurse practitioner and should also be provided with information about free or low-cost family planning clinics in the community. In addition, educators should strongly stress the importance of using condoms to protect against STDs, even if women will be using user-independent forms of contraception to prevent pregnancy. Although the majority of women reported they intended to have sex after release from jail, only 58% reported intentions to use condoms in the future, suggesting the need for education about safe sex and protection against STDs among this population as well.

There are several limitations to the current study. First, only adult women were enrolled in the study. Therefore, it is unclear if these results can be generalized to juvenile offenders. Previous studies have documented low rates of consistent contraceptive use among adolescents, and these rates are somewhat comparable to the low rates seen among minority and disadvantaged women in general.^21,24 In addition, this study was conducted in local jails where the majority of participants were due to be released in less than 6 months. It is not clear if these results would apply to longer-term institutions, such as prisons, or less restrictive correctional environments, such as community corrections. However, previous studies on this topic have revealed similar findings for women in prisons.^13,15,16 Further investigation is needed to determine the applicability of the results to all incarcerated women.

This study replicates findings from previous studies indicating the need for user-independent, long-term, reversible, and reliable forms of contraception among a sample of women incarcerated at local jails. Data from the current study add additional knowledge about racial differences as well as differences between women who are able to bear children vs. those who are sterile. Information about preferred birth control method after release from jail if cost and availability were not an issue helped to provide insight into the birth control options this population may be interested in using. In addition, the study has important implications for prisoner officials, policymakers, and healthcare providers in terms of providing contraception to incarcerated women. It appears that these women would greatly benefit from such services.

Footnotes

Disclosure Statement

The authors have no conflicts of interests to report.

References

Beck

, Johnson

, Morrow

et al. PRAMS 1999 surveillance report. Atlanta, GA: Centers for Disease Control and Prevention, 2003.

Colley Gilbert

, Brantley

, Larson

. Family planning practices and pregnancy intention, 1997. Atlanta, GA: Centers for Disease Control and Prevention, 2000.

Finer

, Henshaw

. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health, 2006; 38:90–96.

Jones

, Zolna

, Henshaw

, Finer

. Abortion in the United States: Incidence and access to services, 2005. Perspect Sex Reprod Health, 2008; 40:6–16.

Macaluso

, Cheng

, Akers

. Birth control method choice and use of barrier methods for sexually transmitted disease prevention among low-income African-American women. Contraception, 2000; 62:5–13.

Kost

, Landry

, Darroch

. Predicting maternal behaviors during pregnancy: Does intention status matter? Fam Plann Perspect, 1998; 30:79–88.

Hellerstedt

, Pirie

, Lando

et al. Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies. Am J Public Health, 1998; 88:663–666.

Locksmith

, Duff

. Preventing neural tube defects: The importance of periconceptional folic acid supplements. Obstet Gynecol, 1998; 91:1027–1034.

Dye

, Wojtowycz , Aubry

, Quade

, Kilburn

. Unintended pregnancy and breast-feeding behavior. Am J Public Health, 1997; 87:1709–1711.

10.

Bustan

, Coker

. Maternal attitude toward pregnancy and the risk of neonatal death. Am J Public Health, 1994; 84:411–414.

11.

Radecki

, Beckman

. Contraceptive risk-taking in a medically underserved, low-income population. Soc Biol, 1993; 40:248–259.

12.

Radecki

, Bernstein

. An assessment of contraceptive need in the inner city. Fam Plann Perspect, 1990; 22:122–127144.

13.

Willers

, Peipert

, Allsworth

, Stein

, Rose

, Clarke

. Prevalence and predictors of sexually transmitted infection among newly incarcerated females. Sex Transm Dis, 2008; 35:68–72.

14.

Miller

, Laken

, Ager

, Essenmacher

. Contraceptive decision-making among Medicaid-eligible women. J Community Health, 2000; 25:473–480.

15.

Clarke

, Rosengard

, Rose

, Hebert

, Phipps

, Stein

. Pregnancy attitudes and contraceptive plans among women entering jail. Women Health, 2006; 43:111–130.

16.

Clarke

, Hebert

, Rosengard

, Rose

, DaSilva

, Stein

. Reproductive health care and family planning needs among incarcerated women. Am J Public Health, 2006; 96:834–839.

17.

Steiner

, Cates

, Warner

. The real problem with male condoms is nonuse. Sex Transm Dis, 1999; 26:459–462.

18.

Walsh

, Frezieres

, Peacock

et al. Effectiveness of the male latex condom: Combined results for three popular condom brands used as controls in randomized clinical trials. Contraception, 2004; 70:407–413.

19.

Lete

, Doval

, Perez-Campos

et al. Self-described impact of noncompliance among users of a combined hormonal contraceptive method. Contraception, 2008; 77:276–282.

20.

Centers for Disease Control, Prevention. 2002 PRAMS surveillance report: Multistate exhibits unintended pregnancy and contraceptive use. Atlanta, GA: U.S. Department of Health and Human Services, 2006.

21.

Raine

, Harper

, Paukuu

, Darney

. Race, adolescent contraceptive choice, and pregnancy at presentation to a family planning clinic. Obstet Gynecol, 2002; 99:241–247.

22.

Clarke

, Schmitt

, Bono

, Steele

, Miller

. Norplant selection and satisfaction among low-income women. Am J Public Health, 1998; 88:1175–1181.

23.

Campbell

, Cropsey

, Matthews

. Intrauterine device use in a high-risk population: Experience from an urban university clinic. Am J Obstet Gynecol, 2007; 193:e1–6.

24.

Heavey

, Moysich

, Hyland

, Druschel

, Sill

. Differences in contraceptive choice among female adolescents at a state-funded family planning clinic. J Midwifery Womens Health, 2008; 53:45–52.