Abstract
Objective:
To describe the prevalence of requests and frequency of fulfillment for postpartum permanent contraception among patients receiving prenatal care in a state prison system compared to a multi-state, community population.
Methods:
We abstracted contraceptive preferences from electronic prenatal and delivery records among patients accessing prenatal care within the North Carolina Department of Adult Corrections from 2016–2021 and compared to previously abstracted data from a community sample of patients covered by Medicaid who delivered 2018–2019. We chose this comparison group as most incarcerated patients are Medicaid-eligible. Further, incarcerated patients would be excluded from the community sample since Medicaid coverage is suspended or terminated during incarceration. We described demographics, pregnancy and delivery characteristics, prevalence of permanent contraception requests, and fulfillment of requests.
Results:
In the prison clinic and community samples, 15.1% (128/890) and 23.5% (2,307/9,837) had a documented plan for permanent contraception, respectively (p < 0.0001, SMD=0.21). Of prison clinic patients who requested permanent contraception and delivered while incarcerated, 25 of 86 (29.1%) received permanent contraception, compared with 1,096 of 2,076 (52.8%) in the community sample (p < 0.0001, SMD=0.48).
Conclusion:
Patients experiencing incarceration request postpartum permanent contraception at lower frequencies to patients in the community; however, substantially fewer received permanent contraception. Further study is needed to better understand the contraceptive gcoals and experiences of those experiencing incarceration to promote reproductive justice and reduce health disparities.
Precis
Incarcerated postpartum individuals request postpartum permanent contraception at similar frequency to their non-incarcerated counterparts but receive it at lower rates.
Introduction
Permanent contraception requests during perinatal incarceration present complex ethical challenges. The distressingly recent history of systematic and non-consensual sterilization of individuals experiencing incarceration in the United States (US) follows decades of non-consensual sterilization enacted through eugenic and coercive policies and practices.1,2 Given these atrocities as well as the ethical concern for the lack of informed consent in a coercive setting, permanent contraception is often not permitted in the carceral setting.3 However, some pregnant people who are incarcerated express well-formulated, long-standing desires to obtain postpartum permanent contraception.4 Broad policies that do not allow for permanent contraception in the carceral setting foreclose access to desired contraceptive care at a time period that is both highly convenient from a patient perspective and given the high degree of interaction with the healthcare system. This conundrum reflects an ever-present tension due to centuries of racialized reproductive injustice.1,5
Although approximately 58,000 pregnant people experience incarceration each year,6,7 little is known about their requests for postpartum permanent contraception. More clearly understanding these requests is necessary for a more nuanced ethical consideration of the balance between protection from coercion, support of bodily autonomy, and minimizing medical consequences of non-fulfillment.8–13 We describe the prevalence of requests and frequency of fulfillment for postpartum permanent contraception among pregnant people receiving prenatal care in the North Carolina state prison system and to compare rates of request and fulfillment in a multi-center, community population. Given the multiple barriers to contraceptive care in the carceral setting, we hypothesized that rates of request and fulfillment would be lower for the population experiencing incarceration than the community population.
Methods
We conducted a retrospective cohort study of existing medical record data to document requests during pregnancy for and fulfillment of permanent contraception among postpartum patients in the North Carolina prison system from 2016–2021 and among non-incarcerated postpartum patients using Medicaid insurance in a multi-state community sample from 2018–2019. We chose a Medicaid-covered comparison group because most incarcerated patients would be eligible for Medicaid in the community, increasing comparability, but their coverage is suspended or terminated during incarceration, resulting in exclusion of incarcerated patients from the community sample.14 The community sample is also large, representative of the larger U.S. Medicaid-covered population, and collected during the middle years of the prison clinic sample, thus allowing for a contextual comparison. Patients were excluded from both samples if they were under age 21 due to the Medicaid prohibition on permanent contraception for this population, and if they experienced delivery at <20 weeks gestational age.
The North Carolina Correctional Institution for Women houses all pregnant patients sentenced to prison within the North Carolina Department of Adult Corrections as well as patients incarcerated in county jails that lack the capacity to provide comprehensive prenatal care.15,16 Prenatal clinicians from the University of North Carolina at Chapel Hill (UNC) provide prenatal care onsite at the prison and births during incarceration occur at either UNC or a community hospital nearby. Counseling regarding postpartum contraceptive options for patients at the prison is provided during routine prenatal visits by UNC clinicians and by hospital clinicians at the time of delivery. For incarcerated patients during the study period, permanent contraception was available at both hospitals at the time of cesarean section, but not after vaginal birth per carceral policy. Immediate postpartum LARC, both subdermal implants and intrauterine devices, were available after 2018 at UNC only. The study period included the beginning of the COVID-19 pandemic and although fulfillment of requested permanent contraception after vaginal birth would have been decreased at that time, the effect on permanent contraception at the time of cesarean section was minimal. A limited number of reversible contraceptive options were available postpartum at the prison during the study period, including, depot medroxyprogesterone acetate (DMPA) and combined and progestin-only oral contraceptive pills; levonorgestrel intrauterine devices were available in more limited circumstances for individuals with abnormal uterine bleeding.
The prison clinic sample included all pregnant patients in the state prison system aged 21 years or older who accessed prenatal care at the prison between January 1, 2016, and December 31, 2021. We abstracted data directly from prenatal records from the prison electronic health record (EHR) as well as any hospitalization records such as discharge summaries scanned into the EHR due to hospitalizations occurring while the patient was incarcerated. Not all patients delivered while still in custody. We ascertained the type(s) of contraception requested at each trimester by reviewing the text of all prenatal visit notes. For patients whose deliveries occurred in custody, we also ascertained their contraception plan at the time of delivery by reviewing the text of the delivery hospitalization documentation. As data were only abstracted from the prison EHR, delivery or contraception outcomes that may have occurred outside of the incarceration were not captured.
As a comparison, the community sample utilized records from a multi-state, community sample dataset of 21,154 individuals focused on postpartum permanent contraception abstracted from linked inpatient and outpatient EHR. Full study methodology has been previously published for this dataset.17 This sample consisted of patients aged 21 years or more who delivered at or beyond 20 weeks of gestation between January 1, 2018, and December 31, 2019, at four geographically diverse hospitals in the United States: University of California San Francisco in San Francisco, California; Northwestern Memorial Hospital in Chicago, Illinois; MetroHealth Medical System in Cleveland, Ohio; and University of Alabama at Birmingham in Birmingham, Alabama. As the study dataset did not include individual level data for all patients who did not request permanent contraception, we have noted below where the analysis was adjusted accordingly.
Our first primary outcome was request of permanent contraception during prenatal care (at any visit). For this analysis, we categorized requests as requesting permanent contraception only, permanent contraception and another type of contraception, another type of contraception, or no contraceptive plan. Our second primary outcome was fulfillment of requested permanent contraception by delivery hospitalization discharge for the subsample within the prison clinic sample who delivered while incarcerated. For the prison clinic sample, we also measured documentation of any contraception plan in each trimester of pregnancy, documentation of permanent contraception request in each trimester, and requests for multiple or alternate methods of postpartum contraception along with permanent contraception. For the prison clinic sample who delivered, we also measured fulfillment of another, reversible contraceptive method by six weeks postpartum for those patients who did not receive their requested permanent contraception.
We used standard measures of parity, maternal age, gestational age at delivery, delivery method, marital status, and body mass index (BMI). In the community sample, maternal race was self-reported. In the prison clinic sample, maternal race was abstracted from the EHR, which imports demographic data from the state criminal legal databases. It is uncertain the extent to which this reflects self-reported race and at what point in time. We chose to report descriptive data with this variable given the well-documented racial inequities in the criminal legal system and acknowledge that it is a limited reflection of race as a social, rather than biological, construct. Adequacy of prenatal care was assessed as a marker of patient-clinician contact and thus patient opportunities to receive counseling and to express preferences about postpartum contraception. We used Kotelchuck’s two-factor Adequacy of Prenatal Care Utilization Index to assign adequacy based on timing of care initiation and the actual as a proportion of expected prenatal care visits via the Index SAS Macro,18,19 modified to designate whether adequacy could not be established given prenatal care may have occurred outside of the carceral setting.
We used SAS 9.4 (SAS Institute, Cary, NC) software to describe key sample characteristics for the prison clinic sample and community sample. The analytic samples for each part of the analysis are shown in Figure 1. We reported frequency and proportion for categorical variables and median and interquartile range for continuous variables since they were not normally distributed. We conducted a descriptive comparison of the variables and outcomes using Pearson χ2, Fisher’s Exact, and Welche’s T-Test with a significance level of α = 0.05. Because of the large variability in sample sizes, we also examined standardized mean differences to aid with interpretation of the p-values. For the fulfillment analysis, we excluded one patient from the prison sample who had an unplanned hysterectomy at the time of delivery. We used R Studio software to illustrate the timing and flow of permanent contraception request among those who requested permanent contraception and delivered while incarcerated.20,21
Figure 1.
Samples used in analysis for postpartum permanent contraception requests and fulfillment among individuals experiencing incarceration and individuals in the community, 2016–2021. NNCIW, North Carolina Correctional Institution for Women.
This project was reviewed and approved by the University of North Carolina at Chapel Hill Institutional Review Board (IRB #22–2250) and was reviewed and approved by the North Carolina Department of Adult Corrections Research Authorization Panel (HSRC #HS2212–01). Written consent was waived by the IRB due to minimal risk to participants [45 CFR 46.116].
Results
Demographic characteristics of the prison clinic sample (n=845) and comparisons to the community sample (n=9,837) are shown in Table 1. The prison clinic sample had a higher parity and a higher frequency of inadequate prenatal care. The prison clinic sample also had a smaller proportion of Black patients and a larger proportion of White patients.
Table 1.
Demographic and Clinical Characteristics and Requests for Permanent Contraception in the Overall Prison Clinic Sample (n=890, 2016–2021) and Overall Community Sample Contributing Individual Level Data (n=9,837, 2018–2019)
| Prison Clinic | Community | p-value* | SMD | |
|---|---|---|---|---|
| N = 845 | N = 9,837 | |||
| Maternal age at delivery (years) | 28.0 (25.0, 31.0) | 27.0 (22.4, 31.4) | <0.0001 | 0.02 |
| Parity less than 2 at hospital admission (%) | 76 (9.0) | 5,511 (56.0) | <0.0001 | 1.01 |
| Gestational age at delivery (weeks)† | 39.0 (37.9, 39.4) | 39.0 (37.0, 39.4) | <0.0001 | 0.26 |
| Adequacy of prenatal care (%) | <0.0001 | |||
| Inadequate | 244 (28.9) | 573 (5.8) | 0.61 | |
| Inadequate but received care prior to incarceration | 127 (15.0) | -- | ||
| Intermediate | 0 (0.0) | 264 (2.7) | −0.23 | |
| Adequate | 1 (0.1) | 601 (6.1) | −0.34 | |
| Adequate plus | 61 (7.2) | 454 (4.6) | 0.11 | |
| Unable to calculate (didn’t deliver) | 412 (48.8) | -- | ||
| Missing | 0 (0.0) | 7,945 (80.8) | −0.61 | |
| Delivery type (%) | 0.0037 | 0.01 | ||
| Caesarean section | 126 (14.9) | 2,872 (29.2) | ||
| Vaginal delivery | 297 (35.1) | 6,920 (70.3) | ||
| Not applicable | ||||
| Did not deliver while incarcerated | 412 (48.8) | -- | ||
| Miscarriage/abortion | 4 (0.5) | -- | ||
| Missing | 6 (0.7) | 45 (0.5) | ||
| Maternal race (%) | <0.0001 | |||
| Another race | 21 (2.5) | 2,135 (21.7) | 0.22 | |
| Black | 181 (21.4) | 4,966 (50.5) | −0.61 | |
| White | 631 (74.7) | 2,736 (27.8) | 1.54 | |
| Declined or unknown | 12 (1.4) | -- | 0.17 | |
| Married (%) | <0.0001 | 0.45 | ||
| Married | 57 (6.7) | 1,880 (19.1) | ||
| Not married | 87 (10.3) | 7,863 (79.9) | ||
| Missing | 301 (83.0) | 94 (1.0) | ||
| BMI (kg/m2) | 27.6 (24.4, 31.5) | 32.6 (28.4, 38.2) | <0.0001 | −0.08 |
| Requested permanent contraception | 128 (15.1) | 2,307 (23.5) |
Presented as n (%) or median (Q1, Q3)
P-values from unadjusted Pearson, Fisher’s Exact, and Welch’s T-Tests (Satterthwaite) for descriptive purposes only
SMD = standardized mean difference
Gestational age at delivery only includes only deliveries after 20 weeks of gestation and is only reported for those in the prison clinic who delivered while incarcerated (n=472)
Of the 845 patients in the prison clinic sample, 128 (15,1%) requested permanent contraception during a prenatal visit while in custody compared to 2,307 (23.5%) within the community sample (p < 0.0001, SMD = 0.21, Table 1). As shown in Figure 2, for the prison clinic sample, documentation of contraceptive plans increased over the duration of pregnancy and was more frequent among prison clinic patients who delivered while incarcerated. Of those incarcerated during their first trimester, 11.4% (21/2184) of all prison clinic patients and 5.4% (3/56) of prison clinic patients who delivered had any documented contraceptive plan. This grew to 33.8% (231/683) among all those incarcerated during their third trimester and 38.4% (163/424) had any documented contraceptive plan among those who delivered during incarceration.
Figure 2.
Contraception type requested at each pregnancy trimester among participants who requested permanent contraception and delivered while incarcerated (n=86), 2016–2021. LARC, long-acting reversible contraception.
Compared with the community sample who requested permanent contraception (n=2,076), the prison clinic patients requesting permanent contraception who delivered during incarceration (n=86) were similar in gestational age at delivery, of higher parity, and had a smaller proportion of Black patients (Table 2). More prison clinic patients had inadequate prenatal care (n=48, 55.8%) compared with community patients (n=533, 25.7%, p-value < 0.0001, SMD = 0.61). The prison delivery sample who requested permanent contraception underwent cesarean delivery in 47.7% (n=41) of births and in 41.6% (n=863) of births in the community delivery sample who made permanent contraception requests (p=0.26, SMD = 0.12).
Table 2.
Demographic and Clinical Characteristics for Patients who Requested Postpartum Permanent Contraception and Delivered, From a State Prison Clinic Sample (2016–20121) and a Community Sample (2018–2019)
| Prison Delivery Sample | Community Delivery Sample | p-value* | SMD | |
|---|---|---|---|---|
| n = 86 | n = 2,076 | |||
| Maternal age at delivery (years) | 29.5 (27.0, 33.0) | 31.0 (27.0, 35.0) | 0.06 | −0.19 |
| Parity less than 2 at hospital admission (%) | 0 (0.0) | 402 (19.4) | <0.0001 | 0.65 |
| Weeks of gestation at delivery † | 39.0 (38.0, 39.3) | 38.5 (37.0, 39.1) | <0.0001 | 0.42 |
| Adequacy of prenatal care (%) | <0.0001 | |||
| Inadequate | 48 (55.8) | 533 (25.7) | 0.61 | |
| Inadequate but received care prior to incarceration | 14 (16,3) | -- | ||
| Intermediate | 0 (0.0) | 244 (11.8) | −0.50 | |
| Adequate | 0 (0.0) | 567 (27.3) | −0.80 | |
| Adequate plus | 24 (27.9) | 436 (21.0) | 0.16 | |
| Missing | 0 (0.0) | 296 (14.3) | −0.55 | |
| Delivery type (%) | 0.26 | 0.12 | ||
| Caesarean section | 41 (47.7) | 863 (41.6) | ||
| Vaginal delivery | 45 (52.3) | 1,213 (58.4) | ||
| Miscarriage/abortion | 2 (2.3) | -- | ||
| Maternal race (%) | <0.0001 | |||
| Asian | -- | 19 (0.9) | −0.14 | |
| Black | 17 (19.8) | 991 (47.7) | −0.59 | |
| White | 64 (74.4) | 594 (28.6) | 0.91 | |
| Another race | 4 (4.7) | 159 (7.7) | −0.13 | |
| Declined or unknown | 1 (1.2) | 313 (15.1) | −0.51 | |
| Married (%) | 0.33 | 0.23 | ||
| Married | 5 (5.8) | 474 (22.8) | ||
| Not married | 10 (11.6) | 1602 (77.2) | ||
| Missing | 71 (82.6) | -- | ||
| BMI (kg/m2) | 28.1 (24.7, 32.0) | 34.4 (29.8, 40.0) | <0.0001 | −0.77 |
Presented as n (%) or median (IQR)
P-values from unadjusted Pearson, Fisher’s Exact, and Welch’s (Satterthwaite) T-Tests for descriptive purposes only.
SMD = standardized mean difference
Gestational age at delivery only includes deliveries after 20 weeks of gestation
Of the subsample who requested permanent contraception at any time and delivered during incarceration, requests for permanent contraception were documented during first trimester prenatal visits (n=2/86, 2.3%), second trimester visits (n=17/86 19.8%), and third trimester visits (n=71/86, 82.6%). At the delivery hospitalization, 35 patients (40.7%, 35/86 had a documented contraceptive plan for permanent contraception only; two (2.3%, 2/86) had documented plans for both permanent contraception and another, reversible contraception type; and 22 (25.6%, 22/86) had a documented plan for another, reversible type of contraception only (Figure 2).
In the prison delivery sample, 25 of the 86 patients (29.1%) who had requested permanent contraception during prison clinic visits and delivered while incarcerated underwent permanent contraception procedures at delivery hospitalization while incarcerated. In comparison, 52.8% (1,096/2076) of the total cohort sample that used Medicaid and requested permanent contraception had it fulfilled during delivery hospitalization (χ2 p-value < 0.0001, SMD = 0.48). For the prison clinic patients who requested permanent contraception, just over a quarter (26.7% 23/86) received a reversible form of contraception at delivery or at a postpartum visit, including 12 (14.0, 12/86) who received DMPA and 11 (12.8%, 11/86) who received an intrauterine device or subdermal implant; there were no documented prescriptions of oral contraceptive pills. The remaining 38 (44.2%, 38/86) of the prison clinic patients who requested permanent contraception received no documented method of contraception at delivery.
Discussion
This study represents a novel quantitative examination of patient requests for permanent contraception during incarceration. We found that one-in-seven people receiving prenatal care in one state prison requested permanent contraception at some point during their incarceration, somewhat lower than our comparison community sample, but similar to rates of request in other community samples, including in North Carolina (i.e., 7–15%).17,22 Of those incarcerated who requested permanent contraception, the majority were consistent in their requests and did not identify an alternative that was desirable to them for postpartum contraception. A smaller proportion of postpartum patients who were incarcerated received requested postpartum permanent contraception than their community counterparts. Nearly two-thirds of patients with unfulfilled permanent contraception requests at the time of birth during incarceration had no documented alternative contraceptive plan at hospital discharge or at a subsequent postpartum visit. While comparable to the community sample, this signals a continued need to focus on desired postpartum contraception for all individuals.
Ethically, respect for autonomy entails provision of a patient’s requested method of contraception while minimizing the potential for regret should circumstances (such as incarceration status) change.4 In terms of age, the most consistent predictor of permanent contraception regret, the patients in the prison and community samples were similar.23 Additionally, while having permanent contraception performed at the time of a pregnancy is a risk factor for regret, postpartum status also did not differ between our samples.24 The documentation of first-trimester requests suggests that some patients’ requests for permanent contraception may have been formulated in the community, prior to incarceration. If these patient characteristics and documentation patterns are interpreted as indicating incarcerated and community patients are similarly situated, lack of fulfillment of permanent contraception requests could represent a violation of bodily autonomy in both populations.
On the other hand, incarceration is, by design, intended to restrict liberty and autonomy as part of the punishment, with coercion part of everyday prison routines.25 Despite clinicians’ attempts to isolate prison medical care from such coercive regimes, patients often nonetheless experience health care while in custody as part of the coercive apparatus.26 Thus, some advocate for non-fulfillment of all permanent contraception requests while individuals are incarcerated.1 Our data showing non-fulfillment therefore could also be interpreted as demonstrating that some safeguards may be in place to avoid performing some permanent contraception procedures during incarceration. The ethical balance of respecting autonomy while minimizing coercion and regret is inherently personal, and aggregate data as presented in this study cannot ensure this balance has been met. Qualitative study of perspectives of people with lived experience is essential for understanding how best to approach availability of postpartum permanent and other contraception in this population.
The tension between ensuring access to care and avoiding the perils of coercive sterilization is reflected in ACOG’s statement on ethics of permanent contraception. They state first that “although women are not wholly without decisional agency to make medical-care choices while incarcerated, in the setting of historical and contemporary abuses, irreversible procedures such as permanent contraception should not be performed routinely there.” And subsequently advise, “At the same time, some incarcerated patients may genuinely desire permanent contraception, may have requested it previously, and may not have access to health care outside of the prison system. A policy of denying all requests for permanent contraception in prison may impinge on some patients’ authentic desire to control their fertility permanently.”
Strengths of this study include the analysis of an understudied, underreported, and underrepresented population with a large multi-center community population as a comparison. Limitations include the lack of ability to assess contraceptive goals outside of what was documented in the electronic health record. The quality of counseling for those who underwent permanent contraception while incarcerated also could not be explored. Additionally, potential loss to follow-up to institutions outside of the community cohort or upon release from incarceration affects our outcome of permanent contraception fulfillment. However, given barriers with accessing healthcare upon reentry into the community for those no longer experiencing incarceration, this likely would also result in lower permanent contraception fulfillment frequencies in the interval postpartum period for those who were previously incarcerated compared to the community sample.
Finally, the community sample is not a perfect comparator. It does not include patients from North Carolina, as these data are not available. This may introduce differences due to geographical patterns of care and hospital policies potentially reflecting differences unrelated to patient preferences. Although we do not have data on the incarceration status of the community sample, Medicaid is either suspended or terminated during incarceration and so incarcerated individuals would have been excluded from the community sample.14 The inclusion of a community sample for comparison, even an imperfect one, does enhance the interpretability of the results by providing a community sample benchmark with that has been calculated using the same methods and with direct descriptive comparisons of the samples (i.e., rather than more oblique comparisons with published estimates).
Patients experiencing incarceration request postpartum permanent contraception at similar frequencies to those in the community but few actually undergo the procedure. While it is critical to ensure that contraceptive choice is not a result of coercion, it is also imperative to remove barriers to desired care. Further study is needed to better understand the contraceptive goals and experiences of those experiencing incarceration and those counseling them on contraceptive options to promote reproductive justice and reduce health disparities.
Acknowledgements:
The authors wish to thank Arzice Chua, Rosylen Quinny, and Tiffany Lee for assistance with chart abstraction, and Kristen Berg for assistance with data curation.
Funding Source:
This project was funded by R01HD098127 (PI – Arora) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) branch of the National Institutes of Health (NIH). Andrea Knittel is a faculty scholar supported by the UNC Women’s Reproductive Health Research (WRHR) Program funded by the National Institute of Child Health and Human Development (NICHD) (K12HD103085, PI Neal-Perry). This manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Financial Disclosure:
Mary Carmody receives support from the CPC NICHD-NRSA Population Research Training: T32 HD007168 and an infrastructure grant for population research (P2C HD050924) to the Carolina Population Center at the University of North Carolina at Chapel Hill.
Footnotes
The other authors did not report any potential conflicts of interest.
Peer Review History
Peer reviews and author correspondence are available at http://links.lww.com/xxx.
Meeting Presentation: A preliminary version of the findings was presented at the Academic Consortium on Criminal Justice Health, March 16-18, 2025, Austin, TX.
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