1. Incarcerated Women and Reproductive Health: A Survey of Contraception Services in Correctional Health Facilities
Carolyn B. Sufrin, MD, MA
Judy C. Chang, MD, MPH; Mitchell D. Creinin, MD
University of Pittsburgh
APHA Annual Meeting 2007
Women Prisoners: Dignity, Advocacy, and Health
November 06, 2007

2. Background 3.2 million women arrested annually Median age 32
Relevance of reproductive health care
7% of inmates in 2005 were women
These are women of repro age for whom contraception is impconjugal visits, rape, pre-release. The moment of release from jail or prison is a transitional one. For many women, an unplanned pregnancy might interfere with this process and disempower them as they reconstitute their lives.
Because women represent small minority of prison population, their specific health needs have often been ignored.
Prison as a source of control/power
History of forced sterilization/eugenics on prisoners
Potential for reform and window of opportunity for health care of people who are typically marginalized (stats on prisoners) and without insurance. Great window for contraception, esp as women are about to be released.
Disparities in rates of unintendedness of pregnancy and contracetpion use; when control for access to care, this disparity exist, and those who are in jail mirror those disparities.
6% of women entering prison are pregnant
4.4% in PA
Mostly non-violent crimes (71.8%)
These women are of reproductive age and thus have particular health concerns/needs that pertain to them. 70% of incarcerated women have a child at home younger than 18.
Greenfeld L, Snell T. Women Offenders. US DOJ 1999:1-14.

3. Background Unique public health opportunity
Population w/ limited health care access
Pre-release health care
Minimal attention to gender-specific health needs
Eighth amendment- against cruel and unusual punishment has been interpreted to guarantee their health care

4. Background National Commission on Correctional Health Care (NCCHC)
Some guidelines, few requirements
Prenatal care vs. contraception
Guidelines do exist and in order to become accredited, a facility has to meet 100% of essential clinical standard services. Prenatal care is one of those essential services, but contraception counseling is not.
Despite this accreditation, guidelines are loosely interpreted.
Comprehensive services for women’s unique health problems should be provided
Counseling on parenting
STI screening
‘should receive a pregnancy test on admission’
Mental health, substance abuse
No mention of contraception!!!
Standards: suggest inquiry into current gyn problems, pregnancy for females and adolescents; recommends pelvic exam and pap smears, but not mandated except in prisons. Comprehensive counseling given to pregnant inmates in keeping with their desires in planning children or abortion or adoption. Theyu should implement intake procedures that include histories on menstruation, pregnancy, gyn problems.
Comprehensive services for women’s unique health problems should be provided: Pap and MMX as indicated by ACOG; consider high levels of DV/victimization; parenting sisues; high rates of substance abuse and depression. Intake should include breast exam, pap smear, MMX if indicated. STI screening should be provided. Females should receive a pregnancy test on admission.

5. Background
27% of sexually active women using contraception upon incarceration1
67% likely to be sexually active upon release1
Women more likely to initiate contraception if accessible in facility (OR=14.6) 2
27% of women are using a consistent form of birth control in 3 months prior to incarceration. The remainder either inconsistently use birth control or use none
1)Clarke JG, et al Am J Public Health 2006;96(5):834-9
2)Clarke JG, et al Am J Public Health 2006;96(5):840-5

6. Objective
To describe current contraceptive services provided to female inmates in the US
Hypothesis: Contraception services are not fully addressed in correctional facilities

7. Methods Cross-sectional survey Correctional health providers
Self-administered
Written
Mailed

8. Survey design 29 questions Pretesting: Demographics
Screening practices
Birth control methods (BCM)
Abortion
Open-ended (3)
Pretesting:
Piloted to 10 physicians & 5 nurses in correctional health
Questions were designed to measure key behaviors and variables.
Pretesting was done with 10 physicians and 5 nurses in corr health. Comments were then incorporated and revisions made accordingly.

9. Sampling Inclusion: Exclusion:
Members of Academy of Correctional
Health Providers (ACHP)
Exclusion:
Dentists, detention officers and wardens, pharmacists, attorneys, administrators

10. Data analysis Descriptive statistics Chi-squared test
Multivariate logistic regression
Qualitative extraction of key themes
Measures of association were performed using bivariate analysis via chi squared test.
Open ended questions were interpreted to extract key themes

11. Response Response rate 44% 286 Surveys analyzed Mailing #1 950
Ineligible 61
Surveys returned
219
No response
664
Mailing #2
664
Male only 29
Surveys analyzed
190
Ineligible 33
Surveys Returned
156
No response
469
Overall response: 391 (45%)
104/391 responses excluded
89 male facilities
15 non-clinical
287 (72%) for analysis
Response rate 44%
286 Surveys analyzed
Surveys analyzed 96
Male only 60

12. Demographics Age 45 (29-75) Gender Female Male 73% 27% AA White 8% 85%
Race/Ethnicity AA
White 8%
85%
Hispanic 5%
Training RN
MD/DO NP
57%
22%
11%
Type of facility
Jail
State
Federal
Juvenile
64%
22% 1% 9%
Time in practice
5-10 yrs
>10 yrs
19%
65%
Certified Corr. health (CH)
68%
No statistically significant differences between males and females and other demographics other than profession: 66% of the doctors were male, and 34% of doctors were female. Similarly, 80% of the women were NP or RN, as opposed to 36% of the men having a nursing degree.

13. BCM assessment 71% ask about BCM at some point
44% at intake only
1% release only
8% intake and release
20% some other time
55% do not allow inmates to continue BCM
What’s striking is that although 71% ask about contraception at some point, very few providers do so immediately before release
Most providers who permit women to continue BCM do so for ‘medical reason’
20-40% routine screening for STIs

14. BCM counseling Formal policy on contraception counseling = 30%
Provision of counseling = 70%
19% on intake
11% immediately prior to release
40% upon request only
Remainder of counseling occurs when requested (65% when requested) or at other points during incarceration

15. Methods of contraception
38% provide BCM %
Very few provide counseling/provision of other hormonal methods
Provision of OCPs (either/both)=34%
Provision condoms =10%
Provision Depo (either/both)=25%
Patch counseling: 40%
Ring counseling: 35%
Depo Counseling: 49%
IUD counseling: 33%
Tubal counseling 36%
Condoms counseling: 59%
Abstinence counseling=53%

16. BCM Counseling & Provision Bivariate Analysis
(%) p
Provide
Jail
179 64
177 31
State Prison 60 82 52
Fed prison 3 33 2
Juvenile 25 96 24 63
Female
204 73
.036 41 NS
Male 75 74 30
Continue BCM
125 76
124 57
<.001
BCM counseling --
194 45
.001
Practice>10yrs
181 71 44
.039
Ab. Not allowed 88 61
.041 89 19
Democrat
113
112 53
Republican 69 67 26
.007
.001
These data show that the type of facility correlates to whether or not providers counsel women on birth control. Female gender also does.
NS: type of provider, age, certified in correctional health NS
<.001

17. BCM Counseling and Provision: Screening practices
Test
Screen
& BCM Counsel (%)
No screen & BCM Counsel (%) p
Screen & BCM Provided (%)
No Screen
& BCM Provided
(%) GC 73 39
.001 40 22 NS CT 44
.003 24
HIV 93 54
.052 19
.043
RPR 95 32
<.001 17
.016
Hep B 87 45 41 25
.026
Hep C 76 48 42 20
Pap 77 33 15
PPD 71
.033
*This slide shows that there is a strong correlation between screening practices and counseling on contraception
Providers who screen for STIs, cervical cancer
and TB are more likely to counsel on BCM than those
who don’t screen, but no more likely to provide.
Only 3.5% do not do a PPD.
Otherwise, most screening tests are done by 90% of providers, either routine or by request. Pap is not done by 24%.
Totals who are screened:
GC (254)
CT (251)
HIV (251)
RPR (246)
Hep B (218)
Hep C (219)
Pap (209)
PPD (269)
Totals who are not screened:
No screen
(23)
(25)
(26)
(28)
(55)
(54)
(67)
(10)

18. Counseling BCM: multivariate analysisOR p
95% CI
Ask about BCM
1.8
.001
Desire BCM education materials
3.0
.013
Syphilis screening
16.5
3.1-90
In multivariate logistic regression, facility and gender are no longer significantly associated with counseling.
However, people who ask women about contraception are more likely to counsel them on it. Those who are interested in additional educational materials are also more likely to counsel women.
Additionally, syphillis screening was also associated with counseling.

19. Provision BCM: multivariate analysisOR p
95% CI
Ask about BCM
1.1
.046
Allowed to continue BCM
5.4
<.001
Abortion allowed
2.6
.018
Pap screening
4.2
.017
In multivariate logistic regression, facility and gender are no longer significantly associated with counseling.
However, people who ask women about contraception are more likely to counsel them on it. Those who are interested in additional educational materials are also more likely to counsel women.
Additionally, syphillis screening was also associated with counseling.

20. Text responses: themes
Continue BCM for ‘medical reasons’
Perceive that women not interested
Facilities not interested
Competing priorities
Transient populations, high turnover
Not enough time or staff
Not enough money
Some people gave suggestions for getting around things or felt it was important:
“We can reach this audience while they’re incarcerated”
“We need a class prior to release regarding contraception”
“we also post signs advising the women to start on birth control two months prior to release”

21. Limitations Selection Bias Self-reporting bias
Convenience sampling
Non-responses
Self-reporting bias
Not trackable to facility to verify actual practices
Not powered to show SS differences
Not prospective so not designed to have power to detect differences ie b/t state and county
Eliminated people who listed ‘mental health as their interest/specialty area
I didn’t ask about religion
Questions don’t address men

22. Conclusions
Contraception is addressed, but is inconsistently counseled and prescribed.
Minimal counseling & provision occur pre-release.
Providers who ask about BCM and screen for STIs are more likely to counsel incarcerated women on BCM.
Providers who counsel women on BCM and who report that women can continue BCM or obtain an abortion are more likely to provide women w/ BCM.
People who are more committed to preventitive reproductive health concerns are more likely to counsel women on BCM
There are no formal policies which presents a loophole for people to introduce a policy.
In our current political climate, the fact that no formal national or local policy exists presents an opening for a political rather than a public-health. minded policy to be created. As an example, I was not surprised that abstinence was commonly counseled

23. Future Directions Inmates’ perspectives Program development
Ethnography
Program development
Cost analysis

24. Incarcerated Women and Reproductive Health: A Survey of Contraception Services in Correctional Health Facilities
Carolyn B. Sufrin, MD, MA
Judy C. Chang, MD, MPH; Mitchell D. Creinin, MD
University of Pittsburgh
*supported by the Irene McLenahan Young Investigator Research Fund Award from the Magee-Womens Health Foundation*

25. Extras. . .

27. Abortion permitted: Bivariate
(%) p
Jail
179 66
State Prison 59 73
Fed prison 2 50
Juvenile 24 75
Female
202 69
.519
Male 74 62
Continue BCM 90
.077
BCM counseling
191 71
.176
.853
NS: Years in practice, profession, certified in corr. Health

28. n=88
n=116
n=69 p
Abortion allowed
49%
79%
72%
<.001
Arrange appt
40%
63%
50%
.040
Provide transport
96%
87%
.010