Reproductive Health in Newly Incarcerated Women

Elizabeth Feldman, MDKathleen Talamayan, MD, MPHCermak Health Services of Cook CountyLinda Forst, MD, MPHUniversity of Illinois at Chicago

Reproductive Health Issues in Newly Incarcerated Women at Cook County JailAcknowledgmentsAdina Goldberger, MS2, Miranda Hart, MD, and Rose Kiken, BSN served as research assistants

Carolyn Sufrin, MD for her 2010 NCCHC presentation and willingness to permit us to adapt her survey instrument

Cook County Department of CorrectionsCase37 yo G4P2002 c/o opioid withdrawal

Multiple arrests for retail theft, PCS, prostitution

Unprotected vaginal intercourse in previous 5 days

Never used hormonal contraception

+GC dx last incarceration

+ regular tobacco use, + 3-4 bags intranasal heroin/d

Urine HCG negative

I JUST SHORTENED THE TEXT4BackgroundWomen represent the fastest growing prison population (Greenfield and Snell,1999, Staton et al, 2003)

Incarcerated women are underserved and socioeconomically disadvantaged (Covington,2007)

This population has reduced access to and utilization of family planning services (US DHHS)BASED ON STUDY BY GREENFIELD, THE NUMBER OF WOMEN INVOLVED IN THE US CRIMINAL JUSTICE SYSTEM AHS GROWN 48% SINCE 1990 COMPARED TO A 27% INCREASE IN MEN5

BackgroundIn the US, 39m women are at risk for unplanned pregnancy (Clark et al, 2006a)

Of those women at risk for unplanned pregnancy, 67% report inconsistent use of birth control (Clark et al, 2006a)

Despite OTC availability, emergency contraception (EC) is underutilized (Devine,2012)

Only 4% of women ages 15-44 who have ever had sexual intercourse have used EC (CDC, 2005)

Public Health OpportunityJail setting is a unique access point for high risk women

Opportunity to provide reproductive health education and services including contraception

Provision of EC at entry may impact unintended pregnancies in incarcerated women

Offering birth control services pre-release improves likelihood of initiating contraceptive use after release (Clarke, 2006b)

Research in own institution one way of effecting change in policies and procedures8ObjectivesExplore reproductive health needs among newly incarcerated urban women

Describe the knowledge, attitudes and practices related to long term and emergency contraception

Discuss barriers to utilization of contraception

Advocate for policy change within Cook County Jail to provide EC at entry and contraception prior to release- These will be answered by objective #4:advocacy for policy changeHow many need/would accept EC on entry to jailHow best to provide contraception informationHow to offer contraceptive services to women being released into the community

9MethodologyDesign: Cross-sectionalParticipants: newly incarcerated women, 18-50 yoRecruitment: convenient nights, 33 occasions over 14 month periodSurvey: 41 items, face to face interviewData: frequency analysisHuman Subjects: CCBHCS IRB protocol for research on incarcerated subjectsDATA COLLECTED FROM 2011-2012COOK COUNTY JAILDATA COMPAREDWITH COOK COUNTY JAIL CENSUS10Results: DemographicsNewly incarcerated women, 18-50 yearsJune 2011-August 2012Study n=194Jail, Overalln=11,229Age Average Median30.8 8.7 yo29 yo32.1 9.4yo31 yoRace/ethnicity African American White, non-Hispanic Hispanic +Other 121 (62.4%) 54 (27.8%) 36 (18.6%)67.2%19.8%12.8%Education HS 50 (25.8%)125 (64.4%) 19 ( 9.8%)We do not have average age or educational attainment in this group. I suggest doing no statistical comparison, and simply stating that demographics are a little different in your sample compared to all women who have been incarcerated during this time.11Results: Pregnancy History (n=194)Number of live births:NoneOneTwoThreeFour or more534030244727%20%15%12%24%Number of abortionsNoneOneTwo or more112414158%21%21%Think I am pregnant147%Actually pregnant (by uHCG) 95%Results: Pregnancy IntentionOf total (194)%Of those at risk (146)%Desires pregnancy

31/1941628/14619Does not desire pregnancy83/1944381/14656Undecided28/1941427/14619No answer52/1942710/146713Results: At risk for pregnancy(137) :Had sex in last 5 days (n=61) 44.5% Did not use any contraception (n=40/61) 65.6% Used condoms every time (n=15/61) 24.6% Subject to rape, forced or survival sex (n=11/61) 18.0% Drunk or high while having sex (n=25/61) 41.0%Excluding the 57 who either were already pregnant, had a hysterectomy or TL, were postmenopausal, or had an IUD or an Implant14

Results: Knowledge, Attitude and Practices of Women Regarding ECCategory# of ParticipantsPercent distribution %KnowledgeThink a women can prevent pregnancy a few days after unprotected sex141/19472.7%Have heard of EC156/19380.8%Think EC is safe to use 53/15833.5%Think EC is good in preventing pregnancy 64/15840.5%Thinks EC can cause abortion 65/15841.1%AttitudeWill accept free EC if offered today

135/19469.6%Will accept free EC at release from jail

158/19481.4%Interested in learning more about EC120/19461.9%PracticeHave used EC 42/19421.6%Knowledge about EC was obtained from those who reported having heard of emergency contraception15Knowledge about how to prevent pregnancy after sex

YesNo/Dont KnowCan a woman prevent pregnancy a few days after unprotected sex?141 (72.7%)53 (27.3%) How?Take a pillHome remedyAbortion127/141 (90.1%) 7/141 (5.0%) 28/141 (19.9%) Listed other ways: take pill, hot bath, douche, pee, go to doctor, get shot, squeeze out, patch

I dont know how long you can use MAP after sex, either (LF)MAP OR PLAN B OR LEVONORGESTREL IS SAFE AND IT CAN BE USED UP TO 72HRS POST COITAL. IT PREVENTS PREGNANCY FOR WOMEN WHO ARE NOT PREGNANT YET AND DOES NOT CAUSE ABORTION16Barriers to Use of ECReasons for Refusal of EC# of participantsBrings up religious concerns 7Do not mind being pregnant30Do not like medication 9Worried about safety/side effects22Want to talk to provider first16Other (wont take in jail (3), think cant get pregnant (3)) 12Just wouldnt take it (2)Dont believe in abortion (2)Dont know enough about it (1)would be having sex with regular partner (1)17Results: Attitudes and Practices regarding ContraceptionWanted birth control in past year44%Saw provider in past year about birth control39%Did not use any reversible method in past year63%Currently using hormonal method (shot, OC, patch, ring)11%Will accept free birth control upon release80% Of entire sample

Birth Control Method UseType of Birth ControlCurrent UseWithin past yearSurgical34Not askedIUD79Subdermal implant22Long-acting progestin (The Shot)1232Combined pill, patch or vaginal ring734Spermicide00None138123We did not ask about condoms in these questions!

19Discussion: EC at Intake66% of those who had had recent sex reported it was unprotected

21% of our sample had unprotected sex within previous 5 days70% of our sample would take EC if offered

As many as 1982 women annually may be eligible for EC at entry to Cook County jail

As many as 1387 doses may be dispensed

11,229 women admitted in our 14 mo period. Equals 9625 annuallySO this means that 1982 may have had unprotected sex70% of those would accept EC - =20Discussion: Birth Control ServicesMajority of women did not wish to become pregnantMajority wanted to use birth controlOnly about 1/3 had used any birth control in the past year, and a much smaller number were currently using hormonal contraceptionMost women would accept free birth control prior to release from jail

DiscussionNewly incarcerated women are at high risk for unintended pregnancy

Knowledge about EC and ability to access birth control services are both significantly limited

Other studies show that interventions during incarceration work (Clarke, et al)

During incarceration there is an opportunity to provide sex education - teachable moment

Discussion of OUR sampleAt riskWant free contraceptionKnowledge very limited based on our specific results22Recommendations: IntakeIntake screening to identify women at risk for unintended pregnancy during previous three to five days

Intake providers educated about use and provision of emergency contraception

Emergency contraception immediately available during Intake to jail for those women who desire it

Recommendations: Birth ControlImplement reproductive health education for incarcerated women

Provide opportunity to meet with health care provider to discuss contraceptive choices for those who desire

Offer birth control services prior to releaseLimitations of the StudyStudy based on convenience sample may not be representative of all incarcerated women

Small sample size

Self report data introduces some bias

Utilized frequency analysis

Case, continuedPt urine + chlamydiaPAP showed ASCUS, cannot r/o HGSILcolpo with LGSIL, cryo performedEducated about contraceptive choices by PCP, chose to start depo-ProveraProvider ordered first depo shot to be administered day before next court date (expected release date)Pt received depo, but was not released until 6 weeks later, with info about Family Planning Clinic walk-in options at Stroger Outpatient ReferencesBaldwin, K., & Jones, J. (2000). Health issues specific to incarcerated women: Information for state maternal and child health programs. Retrieved from http://www.jhsph.edu/research/centers-and-institutes/womens-and-childrens-health-policy-center/publications/prison.pdf

Center for Disease Control and Prevention. (2005). Fertility, family planning, and reproductive health of US. women: Data from the 2002 national survey of family growth. Vital and Health Statistics, 23(25), 1-180.

Clarke, J. G., Hebert, M. R., Rosengard, C., Rose, J. S., DaSilva, K. M., & Stein, M. D. (2006a). Reproductive health care and family planning needs among incarcerated women. American Journal of Public Health, 96(5), 834-839.

Clarke, J. G., Phillips. M., Tong, I., Rose, J., & Gold, Melanie, G. (2010). Timing of conception for pregnant women returning to jail. Journal of Correctional Health Care, 16(2), 133-138.

Clarke, J. G., Rosengard, C., Rose, J. S., Hebert, M. R., Peipert, J., & Stein, M. D. (2006b). Improving birth control service utilization by offering services prerelease vs postincarceration. American Journal of Public Health, 96(5), 840-845.

Clarke, J. G., Rosengard, C., Rose, J., Hebert, M. R., Phipps, M. G., & Stein, M. D. (2008). Pregnancy attitudes and contraceptive plans among women entering jail. Women & Health, 43(2), 111-130.

Covington, S. (2007). Women and the criminal justice system. Women's Health Issues, 17(4), 180-82.

Crandall, L. A., Metsch, L. R., McCoy, C. B., Chitwood, D. D., & Tobias, H. (2003). Chronic drug use and reproductive health care among low-income women in Miami, Florida: A comparative study of access, need, and utilization. Journal of Behavioral Health Sciences Research, 30(3), 312-331.

ReferencesDevine, K. S. (2012). The underutilization of emergency contraception. American Journal of Nursing, 112(4), 44-50.

Department of Health and Human Services. (2012, Sept. 6). Family Planning. Retreived from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=13

Greenfeld, L.A., & Snell, T. L. (1999). Women Offenders. Washington, D.C.: Bureau of Justice Statistics.

Hale, G. J., Oswalt, K. L., Cropsey, K. L., Villalobos, G. C., Ivey, S. E., & Matthews, C. A. (2009). The contraceptive needs of incarcerated women. Journal of Women's Health, 18(8), 1221-226.

LaRochelle, F., Castro, C., Goldenson, J., Tulsky, J. P., Cohan, D. L., Blumenthal, P. D., & Sufrin, C.B. (2012). Contraceptive use and barriers to access among newly arrested women. Journal of Corrective Health Care, 18(2), 111-119.

Oswalt, K., Hale, G. J., Cropsey, K. L., Villalobos, G. C., Ivey, S. E., & Matthews, C. A. (2010). The contraceptive needs for STD protection among women in jail. Health Education & Behavior, 37(4), 568-579.

Prine, L. (2007) Emergency contraception, myths and facts. Obstetrics and Gynecology Clinics of North America, 37(1), 127-36.

ReferencesStaton, M., Leukefeld, C., & Webster, J. M. (2003). Substance use, health, and mental health: problems and service utilization among incarcerated women. International Journal of Offender Therapy and Comparative Criminology, 47(2), 224-239.

Sufrin, C. B., Creinin, M. D., & Chang, J. C. (2009). Contraception services for incarcerated women: A national survey of correctional health providers. Contraception, 80, 561-565.

Sufrin, C. B., Tulsky, J. P., Goldenson, J., Winter, K. S., & Cohan, D.L. (2010). Emergency contraception for newly arrested women: Evidence for an unrecognized public health opportunity. Journal of Urban Health, 87(2), 244-53.

THANK YOU30