In this cohort of newly arrested, reproductive-aged women, nearly one third had unprotected sex within the 5 days before coming to jail, and half of them would take EC if it were offered to them during the jail medical intake. The strongest predictor of willingness to take EC among women who were eligible was not having a misperception about the medication’s efficacy, safety, or it being an abortifacient. These findings indicate that a substantial proportion of women entering jail could benefit from being screened for EC eligibility, receiving education about its risks and benefits, and being offered EC.
At any given time, an estimated 6–10% of incarcerated women are pregnant in the USA.7
The timing of when they became pregnant is not known, but many women first discover they are pregnant when they are in jail or prison; it is possible that some of these pregnancies resulted from sexual activity in the days before arrest. The prevalence of abortion while women are in jail or prison is also not known, but Clarke et al.7
have reported that incarcerated women have a high rate of prior unintended pregnancies. While previous research has shown that correctional facilities can improve women’s access to and utilization of contraception, particularly in preparation for release,14
our study addresses how jail could address the more immediate, pre-arrest days. Jail is the first point of contact for women in the criminal justice system and thus represents an ideal site for screening and offering public health measures. Our results suggest that an assessment of sexual activity, pregnancy risk, and pregnancy intention when a woman first enters jail could mitigate the possibility of an undesired pregnancy if emergency contraception were available. This stance is supported by the American Public Health Association whose standards for health care in correctional settings explicitly state that incarcerated women should have access to EC.15
The American College of Obstetricians and Gynecologists also agrees that EC should be available to incarcerated women.16
Nonetheless, only 4% of correctional health providers who responded to a national survey said that EC is available at their facilities.17
While most of our sample had heard of EC before and one third had taken it, more than two thirds of women had misunderstandings about EC’s safety, efficacy, or mechanism. This is not surprising since EC misinformation is common in non-incarcerated populations.11
A substantial proportion of women in our study also indicated their willingness to accept advance provision of EC upon release, which could benefit them as they are transitioning back into mainstream society.
Interestingly, pregnancy attitudes, as they were assessed in this study, did not correlate with a woman’s willingness to take EC. There was also no association between willingness to accept EC and a woman thinking that she could have gotten pregnant from unprotected sex in the last 5 days, nor was having children or having had an abortion predictive of willingness to take EC. These findings are in contrast to studies of non-incarcerated women in which women who took EC were more likely to state that they wanted to avoid pregnancy and to have had an abortion in the past.18,19
It is possible that the circumstance of recent incarceration may add another dimension to a woman’s decision to take EC, in addition to considerations of pregnancy intention. For instance, a woman may desire to be pregnant when she is in the community, but once she becomes housed in jail, she may feel differently. One could also imagine another scenario where a woman may not desire to be pregnant until she gets arrested and has access to prenatal care while in jail. These complicated issues of pregnancy desires and intentions have not been explored in this context, but merit further investigation through qualitative research.
Our data suggest that counseling incarcerated women about EC should not be guided solely by women’s pregnancy history or simply stated pregnancy attitudes. Rather, their desire to take EC should be explored on an individual basis. This is especially important given incarcerated women’s potential vulnerability and the historical context of coercive contraception and sterilization provision among incarcerated populations.20
Making EC available in jails could have important implications for an individual woman while also potentially being cost-saving for the jails which care for these women. One dose of Plan B, the only dedicated EC product in the US, costs $48, which is substantially less expensive than prenatal or abortion care. If 29% of all 2.6 million women arrested in this country were eligible for EC at the time of their arrest, then 750,000 women each year could potentially benefit from EC at jail intake. Without EC, an estimated 8% of these 750,000 women,21
or 60,000, could become pregnant from having unprotected intercourse pre-arrest. EC can reduce the chances of pregnancy after unprotected sex from 8% to 1%,9,21
which could translate into an estimated 52,500 pregnancies prevented annually in the USA.
The demographic characteristics of our sample are similar to the larger population of incarcerated women in the USA who are, in general, of reproductive age, poorly educated, and from racial and ethnic minorities. Likewise, the reproductive health and contraceptive characteristics of these women are similar to the incarcerated women studied in Rhode Island by Clarke et al.7
Given the representativeness of our sample, our results are likely widely applicable to newly arrested women in similar urban centers across the USA.
A few limitations should be addressed. Because of limitations designed to protect prisoners as research subjects, we were unable to ascertain information about non-participants other than there being no trend in the time of day when non-participants were arrested. We thus cannot determine if non-participants had a different need for EC than those who agreed to be in the study. Second, because women self-reported their sexual behaviors, there was potential for social acceptability bias in their responses, and some women may have underreported the frequency of unprotected sex. If this bias were present, our results would be an underestimate, and more women would have qualified for EC. In addition, we used ACASI which has been shown to improve the accuracy of information on sensitive topics like sexual behaviors. While we emphasized to subjects that their participation would not affect their processing through the jail system, it is possible that some women may have perceived their participation in other ways, which could have affected their approach to the survey. Another potential source of sampling bias was the exclusion of women arrested solely for sex work. This restriction could have biased our estimates of EC eligibility in either direction. Some studies have shown that sex workers have a high frequency of unprotected sex,22
while others have shown these women to be fastidious users of condoms.23
Not including these women may limit the ability to generalize our findings to all women who are arrested. This population would benefit from future research investigating the role of EC in their unique context.
In the days immediately before being arrested, many women engage in sexual behaviors which put them at risk for unintended pregnancies. Their initial medical screen in jail thus presents a public health opportunity for women who have had recent unprotected sex and who want to avoid pregnancy. As part of the comprehensive health care that women have access to in correctional facilities, they should be screened for, educated and counseled about, and offered emergency contraception. By addressing the reproductive health needs of this marginalized, high-risk population, the provision of EC to incarcerated women could help contribute to the larger goal of reducing health disparities in the USA.