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Elizabeth Feldman, MD Kathleen Talamayan, MD, MPH Cermak Health Services of Cook County Linda Forst, MD, MPH University of Illinois at Chicago Reproductive.

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Presentation on theme: "Elizabeth Feldman, MD Kathleen Talamayan, MD, MPH Cermak Health Services of Cook County Linda Forst, MD, MPH University of Illinois at Chicago Reproductive."— Presentation transcript:

1 Elizabeth Feldman, MD Kathleen Talamayan, MD, MPH Cermak Health Services of Cook County Linda Forst, MD, MPH University of Illinois at Chicago Reproductive Health Issues in Newly Incarcerated Women at Cook County Jail

2 Acknowledgments Adina 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

3 Cook County Department of Corrections

4 Case 37 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

5 Background Women 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)


7 Background In 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)

8 Public Health Opportunity Jail 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)

9 Objectives Explore 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

10 Methodology Design: Cross-sectional Participants: newly incarcerated women, 18-50 yo Recruitment: convenient nights, 33 occasions over 14 month period Survey: 41 items, face to face interview Data: frequency analysis Human Subjects: CCBHCS IRB protocol for research on incarcerated subjects

11 Results: Demographics Newly incarcerated women, 18-50 years June 2011-August 2012 Study n=194 Jail, Overall n=11,229 Age Average Median 30.8 ± 8.7 yo 29 yo 32.1± 9.4yo 31 yo Race/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%)

12 Results: Pregnancy History (n=194) Number of live births: None One Two Three Four or more 53 40 30 24 47 27% 20% 15% 12% 24% Number of abortions None One Two or more 112 41 58% 21% Think I am pregnant147% Actually pregnant (by uHCG) 95%

13 Results: Pregnancy ‘Intention’ Of total (194) %Of those at risk (146) % Desires pregnancy 31/1941628/14619 Does not desire pregnancy 83/1944381/14656 Undecided28/1941427/14619 No answer52/1942710/1467

14 Results: 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%

15 Results: Knowledge, Attitude and Practices of Women Regarding EC Category# of Participa nts Percent distributio n % KnowledgeThink a women can prevent pregnancy a few days after unprotected sex 141/19472.7% 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 today135/19469.6% Will accept free EC at release from jail158/19481.4% Interested in learning more about EC120/19461.9% PracticeHave used EC 42/19421.6%

16 Knowledge about how to prevent pregnancy after sex YesNo/Don’t Know Can a woman prevent pregnancy a few days after unprotected sex? 141 (72.7%)53 (27.3%) How? Take a pill Home remedy Abortion 127/141 (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

17 Barriers to Use of EC Reasons for Refusal of EC# of participants Brings up religious concerns 7 Do not mind being pregnant30 Do not like medication 9 Worried about safety/side effects 22 Want to talk to provider first16 Other (won’t take in jail (3), think can’t get pregnant (3)) 12

18 Results: Attitudes and Practices regarding Contraception Wanted birth control in past year44% Saw provider in past year about birth control 39% Did not use any reversible method in past year 63% Currently using hormonal method (shot, OC, patch, ring) 11% Will accept free birth control upon release 80%

19 Birth Control Method Use Type of Birth Control Current UseWithin past year Surgical34Not asked IUD79 Subdermal implant22 Long-acting progestin (The Shot) 1232 Combined pill, patch or vaginal ring 734 Spermicide00 None138123

20 Discussion: EC at Intake 66% of those who had had recent sex reported it was unprotected 21% of our sample had unprotected sex within previous 5 days 70% 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

21 Discussion: Birth Control Services Majority of women did not wish to become pregnant Majority wanted to use birth control Only about 1/3 had used any birth control in the past year, and a much smaller number were currently using hormonal contraception Most women would accept free birth control prior to release from jail

22 Discussion Newly 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”

23 Recommendations: Intake Intake 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

24 Recommendations: Birth Control Implement 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 release

25 Limitations of the Study Study based on convenience sample may not be representative of all incarcerated women Small sample size Self report data introduces some bias Utilized frequency analysis

26 Case, continued Pt urine + chlamydia PAP showed ASCUS, cannot r/o HGSIL colpo with LGSIL, cryo performed Educated about contraceptive choices by PCP, chose to start depo-Provera Provider 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

27 References Baldwin, K., & Jones, J. (2000). Health issues specific to incarcerated women: Information for state maternal and child health programs. Retrieved from 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.

28 References Devine, 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 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.

29 References Staton, 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.


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