The study is significant because incarcerated women who are released into the community are at high risk for unplanned pregnancies, as well as medical complications to the mother and baby from alcohol and drug use.
"Women are accessing birth control services when they're made available in correctional institutions, and we should be making those services available throughout the country," says lead author Jennifer G. Clarke, MD, MPH, an internist at Rhode Island Hospital and the Rhode Island Department of Corrections (RI DOC), and an assistant professor of medicine at Brown Medical School. "If we want to help empower women in their recovery from drugs and alcohol, for example, we need to give them the tools so they can plan their pregnancy during a time when they're more stable."
The study found that women overall were 14 times more likely to start using birth control when it was offered in prison. Thirty-nine percent of incarcerated women started birth control when it was offered before their release, while only 4 percent took advantage of free birth control offered at a community health center after their release.
When researchers looked at women with similar background, education and sexual history, they found that women in the second group were 20 times more likely to use contraceptives offered in prison.
There are a number of barriers that may prevent women from seeking birth control once they are released. Previous research has shown that being Hispanic, married and homeless were associated with decreased contraceptive use. This study found that women who were monogamous and lived with their partner were less likely to use contraceptives.
"Simply making contraceptive services freely available in the community … was insufficient to engage large numbers of women in contraceptive services," the authors say, citing that women are faced with other priorities, such as housing, food and families when released from prison.
The study looked at women ages 18 to 35 who were at risk for an unplanned pregnancy and serving time or awaiting trial at the RI DOC. In phase 1 of the study, 119 women participated before contraceptive services were available on site. Phase 2 included 105 women who were evaluated after contraceptive services were made available at the correctional facility. Contraceptive services were made available through a joint effort of Title X funds, the Rhode Island Department of Health and the RI DOC.
Participants were surveyed about their desire to use birth control, as well as history of sexual activity and sexually transmitted diseases, number of pregnancies, previous birth control use, sexual abuse and drug use – along with demographic factors.
The majority of women had no health insurance, a history of unplanned pregnancies, negative attitudes toward pregnancy, and expressed a desire to start or continue using birth control. Of the women surveyed, the majority had experienced an unplanned pregnancy, and 32 percent of women had had at least one abortion.
All women in the study received family planning and reproductive health services. A nurse educator worked at both the prison and the health center, providing a link to services in the community. At the time of their release, women in both groups were offered a follow-up appointment at the health center, as well as free transportation to the appointment. However, women in the second group were also offered free birth control in prison, "thus requiring little organization or effort by the client," the authors write.
"This approach also allows women to make a contraceptive choice free of the influence of drugs or alcohol and, in some cases, independent of an abusive partner," the paper states.
Contrary to previous research, this study found that homeless women were more likely to start using birth control, possibly because "the structural barriers to reproductive health services that are insurmountable outside of prison have been removed."
Women were considered to initiate birth control if they were given Depo-Provera, had an intrauterine device inserted, or were prescribed an oral or transdermal hormonal contraceptive. Condom use was not considered reliable birth control, as it is not consistently documented in medical charts.
Although nearly 80 percent of the women in the second group expressed a desire to start using birth control, only 47 percent did so. The authors surmise that some women were released from prison before seeing a physician, while others may not have expected to be sexually active for several months while in jail, but were released sooner than expected.
One solution is to provide nurse and physician assessments more immediately to women interested in contraceptives. The authors say they plan to work with the courts and rehabilitative centers to ensure that women who want contraceptives can receive them.
"There are many women incarcerated in this country, and the population is growing," Clarke says. "The majority of women in the study wanted to start a birth control method. Making birth control convenient for women and empowering women to make reproductive choices is very important if we want to prevent high-risk, unplanned pregnancies."
The study was conducted by researchers from Rhode Island Hospital and Brown Medical School, both in Providence, RI. The research was supported by the National Institute of Child Health and Human Development and the U.S. Department of Health and Human Services.
Founded in 1863, Rhode Island Hospital (www.rhodeislandhospital.org) is a private, not-for-profit hospital and is the largest teaching hospital of Brown Medical School. A major trauma center for southeastern New England, the hospital is dedicated to being on the cutting edge of medicine and research. Rhode Island Hospital ranks 13th among independent hospitals who receive funding from the National Institutes of Health, with research awards of more than $27 million annually. Many of its physicians are recognized as leaders in their respective fields of oncology, cardiology, orthopedics and minimally invasive surgery. The hospital's pediatrics wing, Hasbro Children's Hospital, has pioneered numerous procedures and is at the forefront of fetal surgery, orthopedics and pediatric neurosurgery. Rhode Island Hospital is a founding member of the Lifespan health system.
Journal
American Journal of Public Health