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Elizabeth Feldman, MD Kathleen Talamayan, MD, MPH

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

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, bags intranasal heroin/d Urine HCG negative I JUST SHORTENED THE TEXT

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) 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 MEN


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 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) Research in own institution one way of effecting change in policies and procedures

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 - These will be answered by objective #4:advocacy for policy change How many need/would accept EC on entry to jail How best to provide contraception information How to offer contraceptive services to women being released into the community

10 Methodology Design: Cross-sectional
Participants: newly incarcerated women, 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 DATA COLLECTED FROM COOK COUNTY JAIL DATA COMPAREDWITH COOK COUNTY JAIL CENSUS

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 HS grad >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.

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 Two or more 112 41 58% 21% Think I am pregnant 14 7% Actually pregnant (by uHCG) 9 5%

13 Results: Pregnancy ‘Intention’
Of total (194) % Of those at risk (146) Desires pregnancy 31/194 16 28/146 19 Does not desire pregnancy 83/194 43 81/146 56 Undecided 28/194 14 27/146 No answer 52/194 27 10/146 7

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% Excluding the 57 who either were already pregnant, had a hysterectomy or TL, were postmenopausal, or had an IUD or an Implant

15 Results: Knowledge, Attitude and Practices of Women Regarding EC
Category # of Participants Percent distribution % Knowledge Think a women can prevent pregnancy a few days after unprotected sex 141/194 72.7% Have heard of EC 156/193 80.8% Think EC is safe to use 53/158 33.5% Think EC is good in preventing pregnancy 64/158 40.5% Thinks EC can cause abortion 65/158 41.1% Attitude Will accept free EC if offered today 135/194 69.6% Will accept free EC at release from jail 158/194 81.4% Interested in learning more about EC 120/194 61.9% Practice Have used EC 42/194 21.6% Knowledge about EC was obtained from those who reported having heard of emergency contraception

16 Knowledge about how to prevent pregnancy after sex
Yes No/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 I don’t 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 ABORTION

17 Barriers to Use of EC Reasons for Refusal of EC # of participants
Brings up religious concerns 7 Do not mind being pregnant 30 Do not like medication 9 Worried about safety/side effects 22 Want to talk to provider first 16 Other (won’t take in jail (3), think can’t get pregnant (3)) 12 Just wouldn’t take it (2) Don’t believe in abortion (2) Don’t’ know enough about it (1) would be having sex with regular partner (1)

18 Results: Attitudes and Practices regarding Contraception
Wanted birth control in past year 44% 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% Of entire sample

19 Birth Control Method Use
Type of Birth Control Current Use Within past year Surgical 34 Not asked IUD 7 9 Subdermal implant 2 Long-acting progestin (The Shot) 12 32 Combined pill, patch or vaginal ring Spermicide None 138 123 We did not ask about condoms in these questions!

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 11,229 women admitted in our 14 mo period. Equals 9625 annually SO this means that 1982 may have had unprotected sex 70% of those would accept EC - =

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” Discussion of OUR sample At risk Want free contraception Knowledge very limited – based on our specific results

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

28 References Devine, K. S. (2012). The underutilization of emergency contraception. American Journal of Nursing, 112(4), 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), 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), 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), Prine, L. (2007) Emergency contraception, myths and facts. Obstetrics and Gynecology Clinics of North America, 37(1),

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


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