Postpartum contraception plans among a cohort of pregnant incarcerated individuals

Abstract

Objective:

Our objective was to describe patterns of postpartum contraception plan documentation and fulfillment among patients receiving prenatal care in a state prison system.

Study Design:

This is a retrospective chart review of patients over age 21 who accessed prenatal care in a state prison clinic between January 1, 2016 and December 31, 2021. We described demographic characteristics, contraception plans documented during prenatal care, and fulfillment of contraception method by hospital discharge for patients who delivered while incarcerated. For patients who had prenatal care for two or more trimesters, we also assessed the consistency of documented contraception plans.

Results:

Of the total 890 patients, only 44.2% of all patients had documentation of a postpartum contraception plan while incarcerated. Overall, long-acting reversible contraception (9.1%) and permanent contraception (8.9%) were the most commonly documented plans. Of the 74 patients with a contraceptive plan documented in two or three trimesters, 64.9% consistently had one plan documented at all visits. Over half, 472 (53.0%), delivered while incarcerated and the most common type of contraception method provided at delivery was depot medroxyprogesterone acetate (13.1%) despite only 2.8% of patients having documentation of this method as their contraception plan during prenatal care visits while incarcerated.

Conclusions:

Less than half of the patients in the study sample had documentation of their desired goal for postpartum contraception. Patterns of documentation and fulfillment were likely a byproduct of a combination of individual preferences, anticipated length of incarceration, clinician practice patterns, and facility policies.

1. Introduction

Of the nearly 2 million people incarcerated in state or federal prisons or local jails each year, an estimated 56,100 will have been pregnant at the time of admission and nearly 1,000 will have given birth in the past year [1–3]. The early postpartum period, defined as the first six weeks after birth, is a common time to consider contraceptive methods relative to individual goals for family building and preferences. People who are incarcerated during pregnancy may desire counseling and provision of postpartum contraception, but documented barriers to this contraception care include distrust in carceral health services, uncertainty about community follow-up, inadequate carceral clinical staff training, limited contraception formularies, and a highly variable national contraceptive carceral policy landscape [2–9].

There are multiple opportunities for contraception care during incarceration that address historical and contemporary contraceptive coercion in carceral settings and promote shared decision-making around postpartum contraception plans. However, the extent to which clinicians in outpatient carceral health services, community clinics, and in the hospital provide contraception care while in custody is unknown. Additionally, very little is known about the postpartum contraception plans of pregnant and postpartum people in carceral settings.

To better understand postpartum contraception counseling access and postpartum contraception plans among people who receive prenatal care while incarcerated, we undertook a retrospective study of patients receiving prenatal care in a state prison system over a five-year period. Our goals were two-fold. First, we sought to understand patterns of documentation surrounding postpartum contraception, including both no documentation and specifics regarding method desired, during outpatient prenatal care in the carceral clinic. Second, we desired to understand fulfillment rates for postpartum contraception among women who deliver while incarcerated.

2. Materials and Methods

The study population included all patients, 21 years or older, who accessed prenatal care at North Carolina Correctional Institution for Women (“the prison”) between January 1, 2016 and December 31, 2021. All patients were included in this analysis excluding one participant who underwent an unplanned postpartum hysterectomy (Figure 1). Pregnant people are housed at the prison if they are sentenced to prison within the North Carolina Department of Adult Corrections or are transferred to the prison through a legal process called “safekeeping” if the county jail they enter lacks the capacity to provide comprehensive prenatal care [10, 11]. Clinicians from the University of North Carolina at Chapel Hill (UNC) provide prenatal care – including contraceptive counseling – onsite at the prison. These clinicians and their partners provide inpatient obstetric care for births during incarceration at UNC’s North Carolina Women’s Hospital (Hospital A). If a laboring patient cannot make it to UNC hospital, they are routed to a single community hospital near the prison (Hospital B). Patients who gave birth in custody were subject to the hospital postpartum contraception policies in place at those facilities as well as the prison policies (Table 1). Notably, patients who were incarcerated were not able to access permanent contraception after vaginal delivery at either hospital nor outpatient LARC at the prison unless they had a diagnosis of abnormal uterine bleeding prior to pregnancy.

Figure 1.

Flow diagram of the analysis sample of patients who received prenatal care while incarcerated in the North Carolina State Prison System, 2016–2021.

NCCIW = North Carolina Correctional Institution for Women

Table 1.

Postpartum contraception options by hospital and prison policy, North Carolina, 2016–2021.

	Non-LARC Methods	LARC Methods	Permanent Methods
Hospital A (inpatient)	Available for all patients: • depot medroxyprogesterone acetate (DMPA) • oral contraceptive pills (progestin-only)	Before 2018, not available After 2018, available for all patients: • subdermal implants • hormonal and non-hormonal intrauterine devices	Available: • during a cesarean delivery for all patients • after vaginal delivery for non-incarcerated patients
Hospital B (inpatient)	Available for all patients: • depot medroxyprogesterone acetate (DMPA) • oral contraceptive pills (progestin-only)	Not available	Available: • during a cesarean delivery for all patients
The Prison (outpatient)	Available for all patients: • depot medroxyprogesterone acetate (DMPA) • oral contraceptive pills (combined and progestin-only)	Available for patients with abnormal uterine bleeding prior to pregnancy: • subdermal implants • hormonal intrauterine devices	Not available

This study was approved by the University of North Carolina Institutional Review Board (#22–2250) and the North Carolina Department of Adult Corrections (#HS2212–01) with a waiver of informed consent for analysis of existing data. We abstracted data from the North Carolina Department of Adult Corrections electronic health records system, which included electronic pre- and postnatal records as well as hospital delivery records. Contraceptive counseling and patient preference in method desired, if any, is documented as free text in both the outpatient and inpatient documentation. Not all patients in the sample were incarcerated during their entire pregnancy, and data collection was limited to visits and hospital encounters that occurred while the patient was incarcerated.

We described clinical and demographic characteristics of the sample including parity, number of living children, age, race, legal status, and gestational age at first prenatal care visit while incarcerated and at delivery or at release. We used SAS 9.4 software for analyses [12].

Our primary outcomes were planned postpartum contraceptive method(s) documented during prenatal care visits for all patients. Among patients who delivered while incarcerated, we report planned contraceptive method at delivery admission and fulfillment of contraception method by delivery. If no contraception was received during delivery, we also report patient’s contraception plan by six weeks postpartum. The type of contraceptive methods documented are categorized as “permanent method” (including tubal occlusion and complete or partial removal of the fallopian tubes), “LARC method” (hormonal or non-hormonal IUD or subdermal implant), “non-LARC method” (condoms, combined oral contraceptive pills, progestin-only pill, DMPA, or vaginal ring), and “no method” (documented plan for no method or planned on abstinence/anticipated prolonged incarceration). For participants who had a prenatal care visit in at least 2 trimesters, we describe if there were a documented contraception plan and the consistency of method plan as measured by documentation of only one method (i.e., no documented alternate plan) over time and by documentation of the same method over time.

3. Results

We abstracted data from 891 patients. One patient was excluded from further analyses due to undergoing an unplanned hysterectomy. The majority of patients were White (74.5%) or Black (21.7%) and the median age at the time of incarceration was 28 years. Most patients (74.0%) were sentenced to prison. The median gestational age at incarceration was 20.9 weeks and the median gestational age at first prenatal care visit while incarcerated was 22.7 weeks. Only 393 (44.2%) of all patients in the sample had any contraception plan documented in at least one prenatal visit during their incarceration. The most common type of documented contraceptive plans during prenatal care were for permanent contraception (79/890, 8.9%) and for LARC (80/890, 9.1%) (Table 2). Among the 64 patients with more than one method documented as their contraceptive plan during one or more prenatal care visit(s), the most common methods documented were permanent contraception (n=43), a subdermal implant (n=41), DMPA (n=24) and a hormonal or non-hormonal IUD (n=24).

Table 2.

Contraceptive type plans documented for patients who received prenatal care in the North Carolina State Prison System, 2016–2021 (n = 890).

	Overall (n = 890) n (%)
No method	22 (2.4)
Abstinence/prolonged incarceration	3 (0.3)
None (e.g. declines or planning immediate subsequent pregnancy)	19 (2.1)
Non-LARC Method *	38 (4.2)
Condoms	2 (0.2)
Progestin-only pill	7 (0.8)
Combined contraceptive pill	6 (0.7)
DMPA†	19 (2.1)
Vaginal ring	4 (0.4)
LARC Method ‡	80 (9.1)
IUD (hormonal or non-hormonal) ‖	26 (3.0)
Subdermal implant	54 (6.1)
Permanent Method	79 (8.9)
More than one method	64 (7.2)
No plan documented	607 (68.2)

^*Non-LARC: non-long-acting reversible contraception

^†DMPA: Depot medroxyprogesterone acetate

^‡LARC: long-acting reversible contraception

^‖IUD: intrauterine device

Among the 505 patients who were incarcerated and received prenatal care in two or three trimesters, 321 (63.6%) had no contraceptive plan recorded at all, 110 (21.8%) had a contraceptive plan recorded in only one trimester, and 74 (14.7%) had a contraceptive plan recorded in two or three trimesters. Overall, plans were recorded more often in the second or third trimester. Among the 110 with a contraceptive plan documented in only one trimester, 15.5% were recorded in the second trimester and 79.1% were recorded in the third trimester; and among the 74 with more than one trimester with plans recorded, 13.5% were in the second and 86.5% were in the third. There was a high degree of consistency in documented contraceptive plan across trimesters . Of the 74 patients with a contraceptive plan documented in two or three trimesters, 48 (64.9%) had one method at all visits without an alternative plan; 16 (21.6%) had a non-LARC method, 14 (18.9%) had a LARC method, and 18 (24.3%) had a permanent method. Among the 74 patients with a contraceptive plan documented in two or three trimesters, 16/24 (66.7%) of those who ever had a documented plan for non-LARC had a non-LARC plan in every trimester. Similarly, 14/32 (43.8%) maintained their plan for a LARC method, and 18/35 (51.4%) maintained their plan for a permanent method.

Of the 890 patients, 472 (53.0%) delivered while incarcerated. For this group, the most common plans at delivery admission were LARC methods (70, 14.8%) and non-LARC (67, 14.2%) (Table 3). By far, the most common type of contraception method received at delivery was DMPA (62, 13.1%); 13 (2.8%) patients had a documented plan for this method during prenatal care visits while incarcerated. There were also 37 (7.8%) patients who received a subdermal implant at delivery; 30 (6.4%) patients had a documented plan for the method during prenatal care visits (Table 3). Ten patients had a documented plan for contraception by six weeks postpartum.

Table 3.

Contraceptive plans documented and fulfilled among those who delivered while incarcerated (n = 472), for patients who received prenatal care in the North Carolina State Prison System, 2016–2021.

	Prenatal care contraception plan type (n = 472)	Delivery admit contraception plan type (n = 472)	Contraception type received (n = 472)	Postpartum contraception plan type* (n = 472)
	n (%)	n (%)	n (%)	n (%)
No method	14 (3.0)	39 (8.2)	12 (2.5)	1 (0.2)
Abstinence/prolonged incarceration	1 (0.2)	2 (0.4)	3 (0.6)	1 (0.2)
None (e.g. declines or planning immediate subsequent pregnancy)	13 (2.8)	37 (7.8)	9 (1.9)	0 (0.0)
Non-LARC Method †	21 (4.4)	67 (14.2)	85 (17.9)	3 (0.6)
Condoms	1 (0.2)	1 (0.2)	0 (0.0)	1 (0.2)
Progestin-only pill	3 (0.6)	7 (1.5)	12 (2.5)	0 (0.0)
Combined contraceptive pill	3 (0.6)	11 (2.3)	10 (2.1)	0 (0.0)
DMPA ‡	13 (2.8)	48 (10.2)	62 (13.1)	2 (0.4)
Vaginal ring	1 (0.2)	0 (0.0)	1 (0.2)	0 (0.0)
LARC Method §	43 (9.1)	70 (14.8)	45 (9.5)	3 (0.6)
IUD (hormonal or non-hormonal) ‖	13 (2.7)	22 (4.6)	8 (1.7)	2 (0.4)
Subdermal implant	30 (6.4)	48 (10.2)	37 (7.8)	1 (0.2)
Permanent method	47 (10.0)	35 (7.4)	25 (5.3)	1 (0.2)
More than one selected	48 (10.2)	18 (3.8)	0 (0.0)	2 (0.4)
No plan documented	299 (63.3)	243 (51.5)	305 (64.6)	462 (97.9)

^*This was documented only when no method was documented as initiated at the postpartum visit.

^†Non-LARC: non-long-acting reversible contraception

^‡DMPA: Depot medroxyprogesterone acetate

^§LARC: long-acting reversible contraception

^‖IUD: intrauterine device

4. Discussion

In this cohort of patients receiving prenatal care in a state prison system over a five-year period, fewer than half had documentation in their prenatal record of a plan for postpartum contraceptive method. The most common documented plans were for DMPA, a subdermal implant, or permanent contraception. The most commonly provided postpartum contraceptive method was DMPA. Among patients with plans documented during multiple trimesters, there was a high degree of consistency in contraceptive plans.

These results constitute the largest study to date of postpartum contraception plans and fulfillment from a carceral setting. Our finding that most patients lacked a documented contraceptive plan is consistent with prior literature demonstrating that contraception is often deprioritized within carceral health systems [13]. National surveys of correctional health clinicians and correctional facilities have identified substantial variability in contraceptive counseling and availability, with many facilities reporting limited provision of contraceptive care [14]. While the documentation rate for a LARC method, for example, mirrors request rates reported in other studies of incarcerated women [8], the relatively frequent documentation of permanent and long-acting reversible contraceptive methods may reflect clinician attention to methods that required advance planning and could only be obtained in limited clinical settings. This finding could also indicate a tendency toward counseling and fulfillment that prioritizes the most effective methods of contraception during incarceration, similar to well-documented emphasis on tiered-effectiveness and LARC-first counseling for other groups that experience stigma and discrimination [15].

The discrepancies observed between documented contraceptive plans and methods ultimately received likely have multiple explanations. Irrespective of carceral status, patient contraceptive preferences evolve over the course of pregnancy and the postpartum period and gaps exist between desired and received contraception. Our findings show a somewhat higher degree of consistency in contraceptive plans over time than has been documented for non-incarcerated patients (approximately half versus one-third), albeit with methodological differences [16]. While direct comparisons are challenging because few studies report prenatal documentation of postpartum contraceptive plans, discrepancies between contraceptive preferences and contraceptive receipt have also been described in non-incarcerated populations with public insurance and others facing barriers to postpartum care [16, 17]. These discrepancies, particularly for permanent contraception, are often due to health-system, logistical, and policy barriers rather than changes in patient preference. Our findings suggest that incarcerated individuals may experience many of these same challenges, potentially compounded by additional institutional restrictions and limitations on contraceptive availability. For example, the predominance of DMPA among methods provided may reflect patient preference, use as a bridge method to a desired future contraceptive option (e.g., that may be more available outside the carceral system), or constraints on access to other methods due to formulary-related misalignment.

These findings should be interpreted within the broader context of reproductive justice, which emphasizes patient autonomy, informed decision-making, and equitable access to reproductive health care. Outside of incarceration, three quarters (78%) of pregnant and postpartum women reported receiving contraceptive counseling during prenatal care [18]. Our findings of limited documentation of contraceptive plans and discordance between documented plans and methods received suggest opportunities to strengthen patient-centered contraceptive counseling and access during and after incarceration. Such efforts may include improving documentation practices, expanding access to the full range of contraceptive methods, and ensuring that counseling acknowledges both the constraints of the carceral environment and patients’ reproductive goals. Recognizing that the carceral system is fundamentally antithetical to reproductive justice, our data nonetheless shine a light on feasible changes in the carceral setting to improve care [19].

The analysis was subject to the limitations of medical record abstraction and therefore relied on incomplete medical documentation and inconsistent data quality for patient characteristics. Additionally, a patient’s incarceration status is dynamic over the course of pregnancy, meaning that a complete record for every participant’s entire pregnancy does not exist within the prison’s medical record system. Patients’ contraceptive goals may have been documented in prenatal and postnatal care notes that existed outside of the carceral system. This fact limited our ability to ascertain the contraceptive goals with certainty and to know if and what final contraception method was provided beyond what was documented in the prison system’s electronic health record. This analysis also relies on clinician’s documentation rather than direct data collected from the patient, meaning we cannot know their true contraceptive preferences and motivations nor determine whether patients discussed additional contraceptive preferences that were not recorded in the medical record. Despite these limitations, the strengths of this study include the collection and analysis of a large and novel data source on postpartum contraception in a population that is understudied and vulnerable to contraceptive coercion.

This study suggests that there may be a disconnect between what incarcerated patients desire as a postpartum contraception method and what is discussed, documented, or provided while incarcerated. Notably, the largest finding in this study was not the predominance of any specific contraceptive method, but rather the absence of documented contraceptive plans for most patients. It is likely that the patterns of documentation and fulfillment were a byproduct of individual preferences, clinician practice patterns, and facility policies. More research is needed to understand the contraception preferences of postpartum patients while they are incarcerated. Further, interventions at the federal, state, and facility policy levels as well as clinician training and values clarification are likely needed to support patient autonomy and access to contraceptive care as a component of essential health care services.

Implications.

There may be misalignment between patient preferences for postpartum contraception method and what is discussed, documented, or provided during incarceration.