Multi-Level Factors Impacting Postpartum Contraception During Incarceration

This ongoing project is a supplement to the primary R01.

Abstract

Pregnant or postpartum people experiencing incarceration (PPEI) are a critical U3 population with overrepresentation of NIH-designated health disparities populations. Yet, PPEI are understudied due to barriers inherent to research in carceral institutions, underrepresented due to the standard exclusion of institutionalized individuals from research, and underreported because they comprise a minority within incarcerated people. There are multiple bioethical and logistical hurdles to their inclusion in sterilization research. Tragically, many PPEI have been sterilized without consent, and many others have faced myriad barriers to sterilization despite well-formulated, long-standing desire to receive this procedure that predated their incarceration. Many policies and laws do not permit PPEI to undergo sterilization given the ethical complexities of obtaining truly informed consent, potential for coercion, and the risk of regret if reproductive goals change post-incarceration.^9-11 In our clinic, approximately 20% of PPEI request postpartum sterilization, suggesting that annually, 11,000 of the 55,000 PPEI nationally may face this issue. Therefore, nuanced consideration is required to balance protection from coercion and continuing health disparities. The overall objective of this supplement is to better understand the goals, experiences, and health outcomes of PPEI desiring postpartum sterilization and their obstetricians.

Specific Aims

Our central hypothesis is that nuanced, patient-centered ethical guidelines are needed to ensure equitable postpartum sterilization fulfillment for PPEI. Aligned with the scope & strategy of the parent grant, we will test our central hypothesis via three specific aims:

1. Longitudinally assess the contraceptive goals of PPEI. Using medical record data, we will retrospectively abstract the reproductive goals and contraceptive preferences at intake and throughout pregnancy care during incarceration from 2016-2021 (n=850). These data will allow for comparison with the parent grant. We hypothesize that the incarcerated population will mirror the general population in terms of goals for postpartum sterilization, despite external limitations on sterilization due to carceral policy.
2. Identify the attitudes, beliefs, and practices of PPEI and their obstetricians regarding postpartum sterilization. We will prospectively collect and analyze qualitative data from semi-structured interviews of PPEI requesting postpartum sterilization (n=15) and their delivering obstetrician (total 30 interviews). Exploring the experiences of incarcerated patients, perspectives of their hospital provider, and specific reasons for fulfillment or non-fulfillment of sterilization will provide detailed understanding regarding sterilization decision-making on the part of both patients and obstetricians.
3. Develop clinical guidance for ethical postpartum sterilization for PPEI. Combining both theoretical and bioethics considerations with quantitative and qualitative findings from Aims 1 and 2, we will conduct a robust ethical analysis using a patient-centered and health-equity lens. We aim to develop ethically-sound, clinically-based recommendations for incorporation by the prison system to reduce disparities in ethical postpartum sterilization, mindful of the complexities of consent and the potential for patient coercion and regret.

This project is funded through the National Institute of Health’s NICHD R01 HD098127 as a supplement through the U3 mechanism of the Office of Research on Women’s Health (ORWH).