Abstract
Objectives
Rates of unintended pregnancies in women with a history of incarceration are high and access to contraception before and after arrest can be limited. Individualized counseling can better prepare women for healthy pregnancy or provide an opportunity for contraceptive education and access within correctional facilities. In this study, we assessed the efficacy of motivational interviewing as an individualized intervention to increase the initiation of contraceptive methods while incarcerated and continuation after release in female inmates who wanted to avoid pregnancy for at least one year after release.
Study Design
We performed an RCT in a population of incarcerated women who wanted to avoid pregnancy. Women were randomized to either a computer-assisted motivational interviewing intervention group (n=119) or an educational video with counseling control group. (n=113). The primary outcome was initiation of a method of birth control prior to release from the correctional facility.
Results
Initiation of contraception was higher in the intervention group (56% vs. 42%, p=0.03), but this difference was not significant after controlling for number of male partners within the year prior to incarceration. There was no difference between the groups in the rates of pregnancies or STIs or continuation of contraception after release, which was generally low (21%).
Conclusion
Computer-assisted motivational interviewing did not improve uptake or continuation of contraception in this study.
Keywords: contraception, incarcerated women, sexually transmitted infection, motivational interviewing, unintended pregnancy
1. Introduction:
Unplanned pregnancies can be burdensome for women and costly to the public health system with nationwide public expenditures on unintended pregnancies as high as $21 billion [1]. Rates of unintended pregnancy in the population of women who become involved in the correctional system have been reported to exceed 80% [2]. Notably, these pregnancies can be preventable with access to and use of effective contraceptive methods. Just as inadequate use of contraception can lead to unplanned pregnancies, unsafe sexual practices place women at risk for sexually transmitted infections (STI). Both unintended pregnancy and STI rates are higher among women with a history of incarceration [2–5]. Providing reproductive health services during periods of incarceration could help address these health issues in a population of vulnerable and underserved women and thus serve as a relevant time for interventions to address contraception and STIs.
Risk factors for both unplanned pregnancies and STI are similar and include: poverty, low educational attainment, substance abuse, homelessness, lack of health insurance, history of an abusive environment and the practice of commercial sex work [6]. These characteristics are particularly common in the population of women who have a history of incarceration [7]. Surveys of incarcerated women report that a high proportion of women desire contraception, typically greater than 75% of women at risk for pregnancy report wanting to start a contraceptive method [2,8] and further, a high proportion of these women report that they would be accepting of contraception if offered within the correctional facility [9,10].
Motivational interviewing is an evidence-based approach for facilitating behavior change by enhancing and facilitating an individual’s own internal motivation for change, often used in attempts to reduce risky behaviors such as substance abuse [11]. Brief interventions using motivational interviewing have been suggested as particularly well-suited to incarcerated populations because of their non-confrontational and empathetic approach. Another benefit of motivational interviewing in this population is the focus on an individual’s beliefs and goals, tailoring the discussion to the particular needs of the individual woman [12]. This individualization can also promote autonomy and prevent reproductive coercion in this vulnerable population.
The effectiveness of motivational interviewing in increasing contraceptive use has been shown in previous studies to increase post-abortion contraceptive use in young women and promote long-acting reversible contraceptives (LARC) uptake in postpartum teenagers [13–15]. A randomized controlled trial (RCT) using motivational interviewing to prevent rapid repeat pregnancy in adolescent teen mothers also demonstrated the effectiveness of this intervention in reducing repeat teen pregnancy within 18 months [16]. In a RCT, computer-assisted motivational interviewing was used to assess the potential to reduce condomless sex in adolescents, not only to reduce pregnancy but also risky sexual behavior [17]. This RCT showed promise in reducing condomless sex in female adolescents but was limited by a high attrition rate. Computer-assisted methods may be useful for delivery of motivational interviewing interventions as they can readily incorporate personalized feedback, often an important component of motivational interviewing. Computer-assisted methods may also assist in reducing costs that can be associated with reviewing, scoring, and creating personalized feedback in systems with few resources.
The goal of the current study, Contraceptive Awareness and Reproductive Education (CARE), is to conduct an RCT using motivational interviewing to alter contraceptive behaviors and enhance STI prevention among incarcerated women. The primary objective of this RCT is to evaluate the effect of computer-assisted motivational interviewing on the initiation of contraceptives while incarcerated and the post release continuation of contraceptives at 3,6,9,12 months.
2. Materials and Methods
2.1. Study participants and design
We conducted a RCT involving incarcerated women who were at risk of an unplanned pregnancy. We randomly assigned women to motivational interviewing (treatment) or educational videos with counseling (control). While educational videos are not the standard of care, we wanted an attention control group matched in time, content, and assessments. We recruited study participants from the women’s division of a state-run correctional facility from March 2009 through July 2012. This facility is the state’s sole correctional facility and functions as both a jail and prison for women. At the time of this study, the average daily population was 240. Throughout the study period, all incarcerated women between the ages of 18–35 were screened for eligibility. Women were eligible if they had vaginal-penile intercourse at least monthly with men in the three months before incarceration and reported that they did not plan to become pregnant within a year after release. We excluded women if they were unable to give consent or unable to participate in the intervention, pregnant or planning to be pregnant within the next year, sterilized or using a LARC method of birth control, monogamous with a partner who has had a vasectomy, not English speaking, or did not plan to stay in the immediate geographic area after release. The study was approved by a local university IRB and the institutional research advisory committee of the correctional facility.
2.2. Interventions
Computer-assisted motivational interviewing.
Participants randomized to computer-assisted motivational interviewing received two sessions. The first session occurred at the time of randomization and a second session occurred three months after release. Counselors led discussions about pregnancy intentions, STI risk assessments, and Stages of Readiness to Change [18,19]. In accordance with the motivational interviewing approach, the goal setting behavior change was patient-initiated. All motivational interviewing participants received: (1) feedback on personal risk factors for pregnancy and STIs; (2) clear advice to avoid unplanned pregnancy and STIs by either using highly effective contraceptives and condoms consistently and correctly or remaining abstinent; (3) a review of the options that are designed to prevent pregnancy and STIs. Detailed education about contraceptives was provided according to the participant’s needs and requests. The motivational interviewing session ended with the development of a ‘CARE plan’ in which the participant listed her plans for achieving her goals regarding preventing pregnancy and STIs. A second session was conducted three months after release to reinforce any behavior change to reduce STI and unplanned pregnancy, revisit any obstacles to goals, and set new goals if appropriate.
Didactic Educational Video and Counseling.
Participants randomized to the video session watched two didactic videos in the presence of a counselor, each matched in time with the motivational interviewing sessions. Concurrent with the first intervention session, participants in the didactic education groups viewed a video about contraception. At the second session, the video focused on STIs, condom use, and preconception counseling. Women were encouraged to ask questions and engage with the counselor during the educational video sessions.
Intervention Fidelity.
Two counselors with Bachelor’s level training were hired and trained to conduct both motivational interviewing and educational videos with counseling sessions. Counselors received educational training on contraceptive methods, STIs, and condom instruction to enable them to answer questions and provide appropriate information during the sessions. Additional training in brief interventions and motivational interviewing was conducted with the counselors and two Co-Investigators (Co-Is) with extensive experience developing, implementing and evaluating interventions among incarcerated populations and specifically in motivational interviewing. The trainees performed mock computer-assisted motivational interviewing and didactic educational counseling sessions that were audiotaped and reviewed by the Co-Is in a formal manner using the Motivational Interviewing Treatment Integrity (MITI) scale and an adherence checklist for content and processes [20]. Training and evaluation of fidelity was continued via weekly review of recorded counseling sessions over the entire course of the study.
2.3. Procedures.
We recruited women from the housing units at the Department of Corrections (DOC). Special attention was placed on ensuring that inmates were aware that participation was completely voluntary and would not affect their parole status or any other privileges. We reviewed eligibility criteria for all women who were interested, and if eligible and willing, we completed the informed consent. Prior to the first treatment session, participants completed a 45–60-minute computer-assisted background questionnaire. This questionnaire included measures such as: demographics, obstetric and gynecologic history, length of stay in prison, medical insurance, primary care provider or clinic, relationship violence, adverse childhood events, addiction and depression history. After the completion of this questionnaire, the research assistant administered computer-assisted motivational interviewing or didactic educational video and counseling according to randomization. Self-collected vaginal samples for Trichomoniasis vaginalis, C. trachomatis, and N. gonorrhoeae, as well as a urine pregnancy test were also obtained at this time. Follow-up interviews were attempted at 3,6,9, and 12 months after release to assess pregnancy and STIs. Chart reviews and STI samples were also collected at the follow-up times. Persons conducting assessments were blinded to intervention status.
2.4. Sample and Randomization.
Urn randomization was used to balance groups on age (25 years or younger vs. older than 25), race/ethnicity (non-Hispanic White vs other), and pregnancy intentions (doesn’t want any future pregnancies vs wants future pregnancy). [21] We proposed a sample size of 400 women (200 subjects in each arm). A previous study conducted in the RI correctional system determined that after reproductive education alone, 38% of women initiated a contraceptive method. [8] Projecting that the intervention would have a moderate effect on contraceptive initiation increasing initiation by 20%, a sample of 400 participants would provide 95% power with a two-sided alpha of 0.05.
2.5. Measures
The primary outcome was initiation of hormonal contraception prior to release from the correctional facility defined as documentation in the medical chart as receipt of a contraceptive injection, pill, patch, or ring. These were the types of birth control that were available within the correctional facility during the period of the study. Subdermal implants and intrauterine devices were not available within the facility during this study. This primary outcome was measured again at 3-,6-,9-, and 12-month follow-ups to determine continued use of effective birth control. During the post-release follow up, intrauterine devices and subdermal implants were also available at some clinics. The secondary outcomes of pregnancy or STI were determined by a urine pregnancy and STI test at each follow-up visit. An incident STI was defined as a positive test for Trichomoniasis vaginalis, C. trachomatis, or N. gonorrhoeae occurring after a negative baseline test or after a documented successful treatment if positive at baseline.
2.6. Data Analysis
We analyzed data using SAS 9.4. We tabulated and compared descriptive statistics between the groups with Chi-square and Wilcoxon tests as appropriate. Although the individual covariates were equally distributed among the groups, we conducted regressions on each of the four outcomes both for crude odds ratios and adjusting for potential covariate in turn, in order to confirm the robustness of the findings.
3. Results
Over a 41-month period, 805 women were approached about the study and 778 were screened. Three hundred thirty-one women were eligible, and the final valid sample consisted of 232 (Figure 1), with 119 randomized to the computer-assisted motivational interviewing group and 113 randomized to didactic educational videos with counseling. All participants were analyzed in their originally assigned group. The only significant difference in baseline characteristics between intervention and control groups (Table 1), was reported number of male partners within the previous year. Thirty-two percent (n=35) of the intervention group stated that they had four or more male partners in the past year compared to 15% (n=17) of the educational video group. Almost 80% of participants had at least one follow-up encounter (n=185). Participants in the control group were more likely than the intervention group to attend any follow up (86% compared to 74%, p=0.02).
Figure 1.
Participant Flowchart
Table 1.
Profile of study population
| Computer-assisted motivational interviewing (n=119) |
Didactic education with counseling (n=113) |
p value* | |
|---|---|---|---|
| Demographics | |||
| Age | |||
| 18–24 | 50 (42.4%) | 50 (44.3%) | 0.62 |
| 25–29 | 39 (33.1%) | 31 (27.4%) | |
| 30+ | 29 (24.6%) | 32 (28.3%) | |
| Race/ethnicity | 0.37 | ||
| Hispanic/Latina | 12 (10.1%) | 18 (15.9%) | |
| Black (non-Hispanic) | 10 (8.4%) | 9 (8.0%) | |
| White (non-Hispanic) | 77 (64.7%) | 74 (65.5%) | |
| All other identities | 20 (16.8%) | 12 (10.6%) | |
| Education | 0.28 | ||
| No high school degree | 58 (50.0%) | 45 (40.2%) | |
| High school graduate/GED | 20 (17.2%) | 20 (17.9%) | |
| Post-secondary education | 38 (32.8%) | 47 (42.0%) | |
| Married or living with boyfriend/partner | 51 (42.9%) | 56 (49.6%) | 0.31 |
| Living children | 68 (57.1%) | 69 (61.1%) | 0.54 |
| Uninsured | 60 (50.4%) | 53 (46.9%) | 0.86 |
| Physical or sexual abuse | 71 (60.7%) | 61 (54.5%) | 0.34 |
| Reproductive history | |||
| Number of pregnancies | 0.86 | ||
| 0 | 22 (18.6%) | 24 (21.2%) | |
| 1–2 | 48 (40.7%) | 46 (40.7%) | |
| 3 | 48 (40.7%) | 43 (38.1%) | |
| Number of unplanned pregnancies | 0.78 | ||
| No pregnancies | 22 (18.8%) | 24 (21.4%) | |
| 0–1 unplanned | 37 (31.6%) | 34 (30.4%) | |
| 2 unplanned | 24 (20.5%) | 27 (24.1%) | |
| 3+ unplanned | 34 (29.1%) | 27 (24.1%) | |
| Abortions | 0.75 | ||
| No pregnancies | 22 (18.8%) | 24 (21.6%) | |
| No abortions | 43 (36.8%) | 43 (38.7%) | |
| 1 abortion | 29 (24.8%) | 21 (18.9%) | |
| 2+ abortions | 23 (19.7%) | 23 (20.7%) | |
| Next pregnancy wanted | 0.16 | ||
| Never | 31 (27.0%) | 20 (18.5%) | |
| >1 year | 75 (65.2%) | 73 (67.6%) | |
| within 1 year | 9 (7.8%) | 15 (13.9%) | |
| Interested in starting birth control pre-release | 74 (63.3%) | 74 (66.7%) | 0.59 |
| Risk factors | |||
| Transactional sex (lifetime) | 35 (29.4%) | 27 (23.9%) | 0.34 |
| >= 4 male partners in past year | 35 (31.6%) | 17 (15.2%) | 0.004 |
| Any hard drugs | 77 (65.8%) | 68 (61.3%) | 0.48 |
| Unstably housed prior to incarceration | 60 (50.4%) | 43 (40.6%) | 0.14 |
| Positive STI lab test at baseline | 19 (16.0%) | 29 (25.7%) | 0.07 |
| Any follow-up encounter | 88 (74.0%) | 97 (85.8%) | 0.02 |
Wilcoxon
GED=General Education Development, STI=Sexually transmitted infection, Hard drugs= heroin, methamphetamine, cocaine, hallucinogens, inhalants, and non-prescribed opiates, barbiturates, benzodiazepines, amphetamines
The initiation of birth control within the correctional facility was significantly higher among the motivational interviewing participants compared to participants that received the educational videos with counseling (56% vs. 42%, p=0.03). However, after controlling for having more than four male partners, this difference was no longer significant. There was no significant difference between intervention groups in the continuation of contraception after release (Table 2). The outcomes of pregnancy and new STI did not differ between the two groups during follow-up (Table 2). These patterns were maintained in regression models, where only pre-release birth control initiation was statistically significant (OR 1.74) [95%CI 1.04–2.96]. The most common contraceptive methods initiated by all women were oral contraceptives and medroxyprogesterone intramuscular injection. (Table 3)
Table 2.
Outcomes by study arm
| CAMI (n=119) |
DEC (n=113) |
p value | |
|---|---|---|---|
| Birth control* initiated prior to release | 66 (55.9%) | 47 (42.0%) | 0.03 |
| Birth control initiated prior to release and maintained postrelease | 25 (21.6%) | 23 (20.9%) | 0.91 |
| Pregnancy at any followup | 19 (16.0%) | 15 (13.3%) | 0.06 |
| New STI at any followup | 16 (13.5%) | 21 (18.6%) | 0.07 |
CAMI=Computer-assisted motivational interviewing, DEC=Didactic education with counseling, STI=Sexually transmitted infection
birth control includes oral contraceptives, intravaginal ring, hormonal patch, or medroxyprogesterone injection
Table 3.
Types of birth control initiated
| Birth control type | Total | Prior to release | In the community |
|---|---|---|---|
| Oral contraceptives | 53 | 47 | 6 |
| DepoProvera | 47 | 43 | 4 |
| Intravaginal ring | 10 | 9 | 1 |
| Hormonal Patch | 14 | 14 | 0 |
| Unknown* | 5 | 0 | 5 |
| Intrauterine device | 1 | 0 | 1 |
Medical record indicates birth control given but doesn’t specify type
4. Discussion
This RCT compared computer-assisted motivational interviewing to educational videos with counseling and examined outcomes of birth control initiation, pregnancy and STI. There was higher initiation of contraception in the motivational interviewing group compared to educational video, but after controlling for number of sexual partners that difference was no longer significant. There was no difference between the two groups for continuation of contraception. This is similar to a study by Wilson and colleagues that found, following a motivational interviewing intervention, contraceptive use is not sustained beyond 3–4 months [22]. It may be that motivational interviewing is not effective in addressing a behavior change associated with an outcome that is not universally “bad” such as pregnancy.
This increase of contraceptive initiation prior to release from the jail/prison might be more beneficial if the contraceptive of choice is a LARC device. In one study, women who received a LARC device in jail reported continued use after release of approximately one full year for intrauterine devices and more than a year for subdermal implants [23]. LARC was unavailable at the facility during the study period. However, LARC is not universally available in prisons and jails and many incarcerated women do not choose this method when it is available. Therefore, the evaluation of use of oral contraceptives, medroxyprogesterone injection, contraceptive patch and ring in this study is still relevant to correctional health today.
It is possible that participants were motivated to initiate birth control when immediately available but did not engage in health care in the community post-release and thus exhausted the birth control pill supply or medroxyprogesterone injection efficacy. This assumption underscores the importance of access to health care in the community post-release. Future studies should include qualitative analyses at follow-up to explore further the reasons for discontinuation of the methods of birth control.
There are several limitations in our study. We did not achieve our intended study sample of 400 women. Similar to national statistics, the number of incarcerations decreased rather drastically over the study period, negatively affecting recruitment. This may have led to the failed randomization with respect to number of partners and future studies may wish to randomize based on this consideration. LARC devices were unavailable within the correctional facility at the time of this study. However, LARC remains unavailable in many correctional facilities and formal policies on provision of contraception remains limited in most facilities [23]. It is important to recognize that provision of LARC can be interpreted as coercive when offered to an underserved population of women during periods of incarceration. While the authors support the provision of comprehensive family planning services (including LARC placement and removal) it is imperative that services be completely voluntary and informed consent be obtained for any contraceptive plans. Another limitation is that there were differential follow-up rates between the two groups. Follow-up rates were lower for the motivational interviewing group as compared to control, and this was also found in a prior study employing a very similar intervention. [17] Should motivational interviewing be used in future related work, modification is needed to enhance receptivity to the intervention.
Computer-assisted motivational interviewing assisted women to initiate use of contraception, but we do not know why group differences were not maintained over time. While it is possible that women were trying to become pregnant after release, this is inconsistent with baseline data documenting that almost 90% of women did not want a pregnancy within the next year.
After controlling for significant treatment group differences, motivational interviewing does not increase contraceptive initiation, nor did it decrease pregnancies or decrease STIs. We suggest future studies focus not only on provision of contraception prior to release but also on access to contraception in the community. While oral and injectable contraceptives may be appealing (due to lower cost, greater availability), results of this study indicate their use after release is poor, and addition of LARC may enhance results.
Implications:
Periods of incarceration provide an opportunity to offer contraceptive services to women who want to avoid a pregnancy. Motivational interviewing may not be an effective method to affect contraceptive behaviors in this population. Future research should explore the family planning values and preferences of women who become involved with the correctional system.
Acknowledgments
Funding: This work was supported by a grant from the National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development 5R01HD054890 and the National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development Women’s Reproductive Health Research Program K12HD050108.
Footnotes
Clinical Trials: NCT 01132950
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