Jail as a Point of Contraceptive Care Access: Needs and Preferences Among Women in an Urban Jail.

Utah is an uncommon site of carceral research and Utah’s jail population is also unique compared to other places in the United States. For instance, racially, it is a majority white state with a majority white prison population. 15 However, similar to many other states, until 2021 (with the passing of new legislation in March), there was no pathway for women to continue their contraceptive care while incarcerated. The jail under investigation is located in one of the most populous counties in Utah and has a higher proportion of women who are incarcerated (17%) compared to the national average (14%). 16 , 17 Unlike prison, which is typically where individuals are held while serving longer sentences, jails are short-term holding facilities housing those who have been recently arrested and/or are awaiting trial or sentencing. This study focuses on a jail due to the short-term nature of most stays: those leaving jail and immediately re-entering their communities can find themselves at increased chance of pregnancy if their methods are disrupted in jail. The survey consisted of 55 questions pertaining to demographic information, current and past incarcerations, sexual and reproductive history, pregnancy intentions, contraceptive use prior to their time in jail, contraceptive needs and preferences, and sterilization attitudes. The survey was part of a larger study that also included focus groups covering women’s opinions on sterilization as well as one-on-one phone interviews with providers at different jails. 18 The study was approved by the University of Utah Institutional Review Board and supported by the county sheriff’s office. In this report we focus on survey results. The research team adapted survey questions from previous studies that have explored the family planning needs of women who are incarcerated. 2 , 7 The survey aimed to primarily assess women’s opinions around their contraceptive needs and preferences while in jail. In addition to questions about contraception, surveys asked a series of questions related to pregnancy intentions, including: “Do you want to get pregnant within one year after you are released from jail;” a Likert scale measurement (1-5) of agreement or disagreement with the statement, “I would be very upset if I were pregnant right now;” and responses to the question, “If you are pregnant now, what are your plans for the pregnancy” (abortion, adoption, parenting, or uncertainty). The research team also collected contraceptive needs and preferences by asking participants: whether they planned to use contraception after they were released; generally speaking, which methods they were interested in (including the pill, patch, ring, injectable, implant, emergency contraception pill, condoms, diaphragms, copper IUD, hormonal IUD, tubal ligation, and fertility awareness methods); where they would want to get contraception and how they would pay for it; if they had problems with their partner wanting to use contraception; if they believed they knew enough about contraception in the past; and if they would like to initiate contraception in jail prior to release. The survey also provided two blank pages for participants to write in more about their family planning history or goals ( Supporting Information Appendix S1 ). Although the study was completed in 2015, the results of these surveys have not been published previously. Note that the survey did not ask about gender identity, so it is possible that some of the participants did not personally identify as women but instead, as a person of another gender identity (such as trans or nonbinary) who could become pregnant. The researchers were unable to pilot test the survey among the target population (women who are incarcerated). However, volunteers tested the survey for duration and readability software assessed the reading level. The survey scored at a fourth to fifth grade reading level and took 15-20 minutes to complete. In the interest of space, some questions that would be important for future research, such as those related to the use of contraception primarily for health reasons rather than concerns around preventing pregnancy, did not appear on surveys. Survey administration occurred in the jail on two consecutive Saturdays in February, 2015. Individuals were eligible for the study if they were in minimum- to medium-level security female housing units at the jail, were between 18 and 48 years of age, and spoke English or Spanish. Approximately 398 people were eligible and invited to complete the survey on the day it was administered. Since the research team focused on those incarcerated on a few select study days, the sample was one of convenience, although the team aimed to recruit at least 200 participants (a response rate of around 50%). In the week prior to survey administration, flyers in English and Spanish advertised the study in the common areas of the female housing units (or pods ). On subsequent study days, a research team of four worked in pairs to administer surveys in two of the seven pods (which housed 30 to 50 women) simultaneously. The team broke into pairs with one English-speaking and one Spanish-speaking researcher, who explained the survey in both English and Spanish. Women who agreed to participate received a consent cover letter, a survey, a golf pencil and rubber pencil-topping eraser. Women did not receive monetary compensation for completing the survey in an effort to minimize coercion but were able to keep the pencil and eraser. Though the paper administration of the survey might have been more difficult than provision through digital means (such as through using a tablet, for example), it also seemed more equitable as the researchers were asking a population without much access to technology to give their time to participate in the study. Digital survey administration would also likely have proven difficult, since the research team needed a time-efficient way to administer the survey with multiple participants at once so as not to compete with meals, visiting hours, and other jail programs. In each housing unit, a member of the research team read aloud the consent cover letter, informed participants that they could discontinue their participation at any time, and stated that taking the survey had no impact on their sentences or the care they received in the jail. The research team emphasized that the survey was voluntary and anonymous. Though the research team offered a Spanish option, all participants requested surveys in English. Before completing the survey, but after agreeing to participate in the study, all participants watched a 12-minute informational contraceptive education video, “Which contraception method is right for you?” This video was created by the CHOICE Project at Washington University School of Medicine 19 and covered the following methods: intrauterine devices (IUDs), contraceptive implant, contraceptive injection, oral contraceptives, contraceptive ring, contraceptive patch, condoms, and emergency contraception. Women watched the video for educational purposes to ensure that they were informed regarding different contraceptive options. The CHOICE video did present different methods in order of efficacy. However, at the time of the study, the research team felt it was the best option for relaying information about different contraceptives and provide comprehensive education around the various options available. Following the video, participants then completed the survey in the common area or multipurpose room and returned it to a member of the research team. Researchers were available to answer any questions participants had during survey administration. The survey team collected 99 surveys from four pods on the first Saturday. On the second Saturday, the team collected 103 additional surveys from three more pods and an auxiliary facility where women were on laundry service. We entered data from the paper surveys into a spreadsheet, which was then transferred to a data analysis program (Stata V16.0, StataCorp LLC, College Station TX). for analysis. First, we tabulated descriptive variables and assessed participants’ contraceptive histories and interest in different methods. Second, we used chi-square analysis to examine associations between demographic characteristics and desires for contraceptive care while incarcerated (specifically, desires to initiate or access methods free of cost while in jail). Lastly, we used logistic regression to conduct a separate assessment examining whether interest in specific contraceptive methods predicted desire to access contraceptive care while incarcerated. We included for the present analysis the responses of those who clearly stated their views on contraceptive provision in jail (ie, did not skip questions on the survey related to contraceptive provision in jail) and those who had the presumed ability to become pregnant based on age (< 49). Data from participants who reported a previous hysterectomy or tubal ligation were excluded from this analysis since their personal views on contraception in jail might be skewed by their inability to become pregnant. We also excluded fertility awareness-based methods from our analyses since they do not require access to medication or device use. We did include women reporting a current pregnancy because at the time of the survey, they had the potential for additional future pregnancies. Further, though surveys asked about copper and hormonal IUD interest separately, they are combined here as an indicator of interest in any IUD (regardless of type). In addition, we conducted a review of the open-ended survey responses in order to explore whether our statistical results matched participants’ qualitative comments. While we did not conduct a formal qualitative analysis of the comments, we used the comments to provide insight into what women were thinking about with regard to the survey and the issue of contraceptive care in jail. Though the survey asked specific open-ended questions (see Appendix S1 ), many women also used the space provided to share their general thoughts on contraceptive care in jail.

Two hundred and two women agreed to participate and returned a survey (response rate 51%). We excluded 54 surveys from the present analysis for reported age 49 or older (n=8), history of tubal ligation or hysterectomy (n=30), and missing responses on contraceptive interests and/or whether contraception should be provided in jail (n=16). As a result, the analytic sample comprises 148 responses. Participants had a diverse age distribution and range of educational backgrounds (see Table 1 ). Racial and ethnic distribution was unique for our sample compared to the population of women incarcerated across the United States. For example, the sample included no non-Hispanic Black participants, whereas Black Americans are overrepresented in the US prison population as a whole. 9 In our sample, only six participants (all also Hispanic) identified as Black. It is possible there were some Black women present on the days of the survey, but that they did not opt in to taking the survey. Overall, 73% of the sample wanted access to contraceptive provision while in jail. Half of the participants (n=75) reported being uninsured before their current incarceration, and 77% of women reported that they would like help signing up for post-release health insurance. Regarding pregnancy history, 85% of the women (n=125) reported a previous pregnancy, and 44 participants reported being pregnant while incarcerated (either currently or previously). Only 25% of women reported that they would like to be pregnant within a year, whereas the remainder of women reported that they did not want to be pregnant in the next year or reported that they were unsure or ambivalent. When asked about prior use of contraceptive methods, women reported most frequent use of condoms, IUDs, and contraceptive pills. Participants expressed interest in starting a variety of methods, although condoms and IUDs garnered the most attention ( Figure 1 ). We did not identify any significant associations between demographic characteristics and women’s desire to access contraceptive services in general while in jail with the exception of a desire for pregnancy within one year (see Table 1 ). We also explored relationships between women’s interest in different specific contraceptive methods and their desire to access contraceptive services while in jail (see Table 2 ). We excluded diaphragm from the regression analysis due to low numbers of both current interest and prior use. Ultimately, we found general interest in the subdermal contraceptive implant (odds ratio [OR], 8.44; 95% confidence interval [CI], 1.70-41.99) and intrauterine devices (OR, 10.04; 95%CI, 3.46-29.20) to have statistically significant associations with desire to access contraceptive services in jail. We also found a statistically significant relationship between interest in injectable contraception and desire to access contraceptive services in jail (OR, 4.75; 95%CI, 1.03-21.94). Thus, those participants interested in the implant, IUDs, and injectable contraception in general were also more likely to answer in the affirmative when asked if they would be interested in receiving cost-free contraceptive care before their release. However, given our large confidence intervals, our test of association should be interpreted as largely exploratory and a springboard for future research. At the same time, our assessment of the qualitative, open-ended comments from the surveys confirmed our statistical analyses. The open-ended comments we reviewed generally fell into two groups: women sharing more details about their own individual sexual and reproductive health lives or their opinions on contraceptive provision and care in jail (or lack thereof). Regarding the latter, most women who commented voiced a desire for more contraceptive and prenatal care while incarcerated. Only two women wrote specifically about distrusting the idea of expanding contraceptive services due to concerns about reproductive coercion. For instance, one participant wrote, “I DO NOT TRUST the medical history or staff or system that serves incarcerated people. Look at the history! Nothing permanent should ever be done while incarcerated, although the option could be discussed [and] set up [it should] not [be] performed.” This illustrates that although increased contraceptive care is something many women in Utah jails desire, these services should always be optional and never compulsory or coerced.

In this study, a majority of those surveyed (73%) report a desire to access contraceptives while incarcerated, which is consistent with previous studies done in other carceral settings. 5 , 6 This research also finds that the women surveyed express interest in a wider range of methods than they had used in the past. The relationship between IUD interest and desire to access contraceptive care in jail is particularly strong. Our results suggest a few points. First, our participants express interest in methods beyond what they have used previously, suggesting a potential access issue, possibly due to cost. The fact that half of the individuals in our sample reported no health insurance at the time of their arrest supports this point. That cost-prohibitive methods, such as the IUD and implant, relate to interest in cost-free contraceptive care before release also supports this point. Second, jail could serve as a point of access for contraceptive care, especially for those interested in methods, such as the injectable, implant, or IUD, that require a provider to do a procedure in order to initiate or, in the case of IUDs and implants, to discontinue the method. Even among the 37 participants who stated a desire for pregnancy in the next year, more than half reported they would be interested in initiating contraception of some kind in jail prior to release. The need to address women’s lack of access to reproductive health care while incarcerated is serious. 20 , 21 Addressing this need could greatly improve women’s health outcomes, although making changes will also require careful thought. For example, many women who are incarcerated have had traumatic experiences related to structural racism, poverty, substance use and dependence, pregnancy, parenthood, domestic violence, and sexual experiences that must be taken into account when considering their reproductive life goals and contraceptive needs. 22 - 24 These experiences must be acknowledged and it is critical that medical professionals who provide contraceptive counseling and care have an understanding of clinical best practices when discussing contraception. Providers must also be aware of trauma triggers that can occur (eg, during an IUD insertion) with individuals who have experienced sexual violence. The coercive environment of jail itself must also be taken into consideration, as well as the historical legacies of coercive contraception imposed on marginalized groups. 13 The unlawful sterilization of women incarcerated in California as recently as 2010 23 and of women held at a Georgia Immigration and Customs Enforcement Detention facility in 2020 25 are just two examples illustrating that care must be taken when implementing any kind of contraceptive programs in carceral settings. It is also critical to consider structural racism in the interpretation of our results. For example, our participants are majority non-Hispanic white. Since non-Hispanic Black women are incarcerated at a rate disproportionate to their population numbers across the United States, our case is unique in terms of demographics. 26 Other states with different carceral histories and demographic populations might find different results if conducting a similar study on women’s contraceptive preferences and needs in jail settings. In particular, there may be more apprehension around IUD and possibly implant provision in studies that include more women of color who are incarcerated, since historical (and as the aforementioned cases show, ongoing) practices of reproductive coercion are a concern for these groups especially. 27 - 29 Women’s desire for contraception while in custody must be approached carefully, with safeguards in place and ideally with external oversight in order to avoid coercion. This study has several limitations. First, because the survey was self-administered, women who are illiterate might have excluded themselves from participating and the sample’s education distribution could be skewed towards higher levels of education. Further, because the survey was conducted in a common area, women could have been reluctant to ask the researchers for help or clarification. This could explain why some women had missing answers when it came to their contraceptive preferences. Third, the timeline and consistency of a woman’s contraceptive use in the year prior was undistinguishable in this study. Women may have used two methods of contraception at once, or had gaps in their use of reported contraceptive methods. Fourth, given our sample size, these results are largely descriptive. Although a larger sample size would result in more precise estimates, typically jail populations are small; thus, we would recommend that future work continue to investigate what individuals who are incarcerated say they want, and to advocate for access based on those findings. Fifth, the original survey did not ask for participants’ gender identity. Although the participants were housed in pods designated for female inmates, it is unconfirmed that all participants identified as women. Future work should be sure to ask participants’ gender identities, since some groups, such as transgender women, experience higher incarceration rates and unique health challenges compared to cisgender women. 30 It would be helpful to ask more questions about individuals’ capacity to become pregnant as well. Lastly, the task of assessing pregnancy desires and intentions itself is complex and is dependent on a range of factors, which makes pregnancy intentions difficult to measure in survey research. 31 Other next steps for research building on our findings include more investigation into contraceptive coercion (using recently-developed scales) and the use of contraception for non-reproductive health benefits among individuals who are incarcerated. Yet despite any limitations, our study speaks to an urgent health need and adds insight into an understudied context. In general, women who are incarcerated often struggle to access family planning care due to a lack of trained family planning providers, institutional concerns about contraceptive costs, and the idea that contraception is unnecessary in sex-segregated jails. 10 , 32 - 34 Like many jails across the country, at the time of data collection in 2015, no contraceptive services were available at the jail under study (whether for the purposes of pregnancy prevention or other health concerns). Thus, women could not continue their pre-existing, patient-controlled methods of contraception or initiate a new method while incarcerated. While the jail profiled here offered some medical services, the jail had no policy on the provision of contraception and it was not classified as an urgent medical need. Between 2015 and early 2021, access to contraception in the jail profiled in this report remained unchanged. Recently, however, the findings of this research helped inspire a 2021 bill (H.B. 102) 35 passed in the Utah state legislature that allows for the provision of some hormonal methods (including oral and injectable contraceptives) to individuals who are incarcerated based on the argument that contraception is a healthcare need that can be covered by state funding. This new bill thus speaks to the need for contraceptive access for both pregnancy prevention and other health concerns, for example, the use of hormonal methods to help treat conditions such as endometriosis. 35 , 36 However, the new bill only allows for the continuation of some (but not all) methods, and women on methods not covered would have to switch their method in order to access contraception covered by the bill. Nationally, although recommendations exist, including the provision of contraceptive methods for postpartum women who are incarcerated, 37 jails and prisons are not required to address reproductive health concerns. As a result, jails and prisons often deprioritize or ignore the sexual and reproductive health issues of women. 21 , 38 However, our findings show that women in custody at an urban Utah jail clearly prefer that jails offer some contraceptive services. Jails have an opportunity to help improve women’s reproductive health outcomes, although care must be taken in order to address the traumas and vulnerabilities faced by women who are incarcerated. If the unique environment of jails, including the historical legacies of racism and reproductive coercion, as well as the high preponderance of trauma history in this population, can be addressed, the introduction of more contraceptive care in jail settings has the potential to improve reproductive health outcomes for women as they return to their communities after release.

The majority of women who are incarcerated in the United States are of reproductive age. 1 These women are also sexually active with men before and after incarceration, 2 and research has found that most of these women report not wanting to become pregnant immediately upon returning to the community. 3 Yet compared to women without an arrest history, contraceptive use is lower and unintended pregnancy rates are higher among women incarcerated in the United States, a group that has grown by 645% since 1980. 2 , 4 - 8 Contraceptive use patterns for individuals who are incarcerated are determined in part by their pre-arrest access to contraception and also by individual jail policies around contraception, without any national standardization. Although the average jail stay in the United States is only 25 days, 9 even a short-term disruption in method use (which is common) can increase the chances of unplanned pregnancy for individuals sexually active immediately before arrest or who plan to be upon release. The number of women incarcerated in the United States has grown, 9 and it is imperative to investigate how to best meet their family planning and reproductive health needs. Previous studies have found that although as few as one in five women who are newly incarcerated are using contraception at the time of their arrest, 6 60-79% of women would accept contraception if it was offered to them in jail or soon after release. 5 , 6 Further, research has found that intrauterine device (IUD) and implant provision in jail is safe and feasible. 10 However, less is known about the desirability of IUDs and implants among women who are incarcerated, and few studies have focused more generally on the contraceptive method preferences of these women. 11 - 13 Identifying the contraceptive preferences of women who are incarcerated can contribute to improving their reproductive autonomy and health outcomes and can also help both jail administrators and clinicians make evidence-based decisions when attempting to address the reproductive health care needs of this group. 14 Further, it is important that information on the contraceptive preferences of women who are incarcerated comes from women themselves, and that the demographic contexts of particular jail populations are considered, so that women’s preferences and needs are represented as accurately as possible. In order to assess the contraceptive needs and preferences of one group of incarcerated women, we conducted a cross-sectional survey of individuals at an urban jail in the state of Utah. The purpose of this study is to investigate individuals’ sexual and reproductive health histories and goals in an under-explored carceral context and to understand how their contraceptive needs might be best addressed while they are incarcerated.