A total of 25 articles were selected for this review, ranging in date of publication from 1975 to 2019. Articles that addressed more than one key question were included in each category and were not considered exclusively to address a single question. A summary of the different types of publications included in this review can be found in Table 2, with scientific research comprising almost half of all articles. These studies included both qualitative and quantitative analyses in the form of cross-sectional survey data, semi-structured interviews, and retrospective analyses.

Table 2 Article types included in review Full size table

Key question 1: what is the contraceptive need among incarcerated women?

The seven articles identified addressing the contraceptive need among incarcerated women can be found summarized in Table 3. Three articles (43%) reported information on jails only, in contrast to the remaining four that reported data from an integrated jail and prison correctional system. The articles reporting jail data only are noted as such.

Table 3 Summary describing the contraceptive need in American women’s carceral system (key question 1) Full size table

Clarke et al. in 2006 determined that among women in the Rhode Island Adult Correctional Institute, 84% previously experienced an unplanned pregnancy and 35% had a history of at least one abortion [7]. This is considerably higher than nationally reported data, where 45% of US pregnancies were unintended [12] and 24% of US women had had an abortion [13]. Of women within the study who were at risk for pregnancy, only 28% consistently used birth control during the 3 months prior to incarceration and only 20% consistently used a condom, thus increasing the risk of unintended pregnancy at the time of carceral entry. Eighty-five percent of these women at-risk for pregnancy reported that it would be likely for them to have intercourse with a man within 6 months of release.

Clarke and colleagues collected survey data in 2006 on a similar Rhode Island population of prisoners as above [8]. They discovered that 50% of inmates had negative attitudes towards pregnancy (i.e., they did not want to become pregnant). Another 41% of respondents acknowledged ambivalent pregnancy attitudes. Among the women with negative pregnancy attitudes, 91% experienced a prior unintended pregnancy and 40% had a history of abortion. Overall, 55% of the population surveyed reported wanting to start a birth control method immediately, with a greater proportion of those with negative pregnancy attitudes desiring initiation. Preincarceration contraception use was similar to Clarke’s prior study described above, and 42% of respondents perceived some chance of becoming pregnant in the next 6 months. Clarke et al., 2006 demonstrated in another study that almost 80% of incarcerated women desired to initiate contraception while within the correctional facility [9]. They also discovered that women were more likely to initiate contraception if it was provided while in jail or prison (discussed in further detail under key question 3). In this study, 64% of women experienced a prior unintended pregnancy and 34% a prior abortion.

Hale and colleagues recruited respondents from five local jails in the southeast U.S in 2009 [14]. In this study, 62% of reproductively capable women used contraception almost all the time, and 76% planned to have sex after release from jail and were at risk of unintended pregnancy. Of these reproductively capable women, 64% reported access to a provider prior to arrest, with a similar proportion reporting access to a health care provider after jail release. It is important to note that only 25.5% of respondents reported having access to an OB/GYN, which has important implications for the types of contraceptive options that may be offered to them and continued surveillance of their chosen contraceptive method.

In a San Francisco jail population in 2012, LaRochelle et al. found that 54% of respondents had a history of abortion; overall 45% of all women sampled wanted to use contraception post-release and 60% would accept it if it were offered from jail health services [15]. An average of 28% reported finding a provider or clinic as a barrier to contraception use, with 52% of women who reported not using contraception prior to incarceration noting this as a barrier. Cannon and colleagues in 2018, in contrast, found that 42% of respondents from Cook County jail had a history of at least one prior abortion and 72% desired contraception that would be offered from the jail health service [16].

Taken together, these studies demonstrate that incarcerated women are at higher risk for unintended pregnancy and abortion and will remain at increased risk for pregnancy post-release due to no or inconsistent contraception use preincarceration and poor access to health care providers. The overwhelming majority desired to use contraception. These findings effectively demonstrate the need for contraception in this population.

Key question 2: can incarcerated women access contraceptive and abortion services?

Fourteen publications addressing this question were identified. They are listed and summarized in Table 4. This section contains the greatest variation of publication types, including at least one article from each of the six article types listed in Table 2. Except for one article which will be specifically noted, all publications comment on jails and prisons collectively.

Table 4 Summary of articles surrounding reproductive service availability in American carceral system (key question 2) Full size table

Fiedler and Tyler in 1975 describe a pilot family planning program to provide education and services to incarcerated women in New York City [17]. The program was limited to education and counseling conducted during the week prior to a woman’s release from prison only. Contraceptive initiation was not allowed due to concern for complications and lack of follow-up. For many New York prisons, contraception provision is still not allowed today. Although this article describes an important movement to provide carceral contraceptive options in this area, the authors pejoratively generalize about the women they serve, stating that they “lack interest in their own health”, and “suffer from self-neglect”.

Kasdan addresses a woman’s right to abortion while incarcerated [18]. While the right to an abortion is not lost as a result of incarceration, certain carceral policies, such as only allowing inmate transport for medically necessary procedures, may delay care and make an abortion increasingly difficult to obtain when it is deemed elective.

Sufrin and colleagues published two studies in 2009a and 2009b exploring correctional care provider responses about contraception services and abortion provision [10, 11]. Thirty-eight percent of respondents reported that birth control and emergency contraception were provided at their facility and while 70% of providers state that some degree of contraception counseling was performed, only 11% of responders provided routine counseling prior to release. As mentioned above, incarceration does not legally restrict a woman’s right to abortion, however in their second study, only 68% of providers surveyed stated that incarcerated women could obtain an abortion. Eighty-eight percent of responders stated that the facility provided transportation, but only 54% of providers stated that they assisted with arranging appointments. This is evidence for additional logistical barriers beyond the legal right to abortion. Many states require mandatory waiting periods varying from 24 to 72 h, mandated abortion counseling content, and restrictions on using public funding for abortion, all of which can delay a woman’s access to abortion care in any context [19]. Based on location, women in carceral systems are subject to these same state restrictions in addition to limitations of their personal liberties such as using the phone or internet to schedule an appointment or calling a clinic for information about a procedure. This may make seeking an abortion from behind bars incredibly difficult and may result in lengthy delays in care.

Roth’s 2011 commentary piece details policies regarding access to abortion care and pregnancy options counseling [20]. She states that one-third of states have policies mandating prison staff to inform women of all their pregnancy options, including abortion. Another one-third of states use conditional wording to provide options counseling only in the event that the woman mentions abortion herself. Some states require that women inmates bear the burden of additional costs to obtain an abortion, such as gas, toll, and wages of the officers that are required when they travel off site. At least eight states have no written policy on abortion, a situation that leaves important decisions in the hands of prison officials. Sufrin joins Roth and Kolbi-Molinas in 2015 to extend this discussion and describe how prison and jail officials who deny incarcerated women access to abortion punish women by forcing them to continue their pregnancies [21].

In a 2013 bioethics review, Kouros discusses the unapproved sterilization of 148 California inmates between 2006 and 2010 [22]. Some women later reported feeling pressured into sterilization. According to the American College of Obstetricians and Gynecologists, incarcerated women should undergo sterilization very rarely, and only after access to LARC methods have been available and excellent documentation of prior (pre-incarceration) request for sterilization is available. These additional safeguards are needed because of the likelihood that the coercive environment of prison hampers true informed consent [23]. The College also states that policies denying all sterilization may encroach upon some women’s genuine desire to be sterilized and should be reconsidered, especially because many women may not have access to sterilization outside of the prison system. Roth and Ainsworth in 2015 completed a law review exploring the history of sterilization of incarcerated women that led to the adoption of federal regulations against the practice [24].

In her detailed report from 2015 on the state of the New York prison system, Kraft-Stolar describes how the carceral system prohibits its providers from prescribing contraceptives with very few exceptions [25]. Women participating in the Family Reunion Program, being released from the prison, or undergoing treatment for hepatitis C (because of the teratogenic nature of antiviral medications) can be provided with condoms only. No other contraception is permitted. This may be particularly problematic for women in the Family Reunion Program and are concerned about asking their partners to use a condom. There was a short period from 2009 to 2013 when the carceral system contracted with Planned Parenthood to offer contraception to women at certain prisons that were within 2 weeks of their release date. However, the funding was cut, and the initiative subsequently ended. The opportunity to participate in a two-hour class about family planning and general health prior to release also ended with the expiration of the program.

Kraft-Stolar continues to outline how contraception is not offered for women in work release programs within the New York prison system, although they spend time in the community and may have sexual partners there. As if the implication of an unintended pregnancy were not significant enough, women who become pregnant may be terminated from their work release program. Many women also reported that they were denied contraception for reasons unrelated to pregnancy prevention (menstrual regulation, dysmenorrhea, etc.) even when prescribed by an outside provider. There were conflicting reports about whether emergency contraception was provided, although review of the prisons noted that emergency contraception was not dispensed within the last decade. The report also states that there is no central written policy on abortion, which as described elsewhere in this paper can be problematic for several reasons. Some women noted standard policies such as those that served disciplinary action to women who made a medical appointment and canceled it, discouraging women from making appointments.

Sufrin, Baird, Clarke, and Feldman’s 2017 publication did list four model programs offering carceral family planning services, one of which is Rikers Island jail in New York [26]. Rikers jail complex stands in contrast to the New York prison facilities described in other publications above, in that there is a policy on contraception provision and all contraceptive options and emergency contraception are available. However, in 2019 New York City lawmakers voted to close the jail, which is scheduled to be shuttered by 2026 with distribution to smaller more “modern” jails located closer to the city’s main courthouses [27]. Other exceptional carceral reproductive care models include Cook County Jail, Rhode Island Department of Corrections, and San Francisco County Jail. Sufrin and colleagues’ retrospective study from 2015 on LARC provision feasibility is the only publication in this section that focused exclusively on a local jail population and found LARC to be a safe and feasible option in this setting [28].

In sum, access to contraception varies across facility types, geography, and programs (e.g. work release, public-private partnerships, etc.), and is limited by concerns about coercion, cost, and a lack of consistent policies. We noted that multiple articles refer to “timely” access to abortion services without specification of a time frame. Similarly, none of the included articles discussed what constituted a reasonable length of time to access a health care provider for a concern or problem visit. Despite this, there is evidence for feasibility of model programs providing the full range of contraceptive options within a carceral setting.

Key question 3: what contraceptive services do incarcerated women want?

A summary of five articles addressing the question of what contraceptive services do incarcerated women want (key question number three) can be found in Table 5. All articles except the Clarke et al., 2006 [9] publication focus on specific jail populations in Chicago, San Francisco, and New York. Clarke’s paper included women from both jail and prison populations, making the results potentially more generalizable to women in various divisions of the carceral system.

Table 5 Summary of contraceptive services women in the American carceral system want (key question 3) Full size table

Clarke examined whether contraceptive availability within the carceral system would increase birth control initiation among women who are incarcerated [9]. This study found that almost 80% of respondents reported a desire to initiate contraception during incarceration and that women who were housed in facilities offering contraception were over 14 times more likely to initiate a contraceptive method compared to those who were not. Half of the women chose to use oral contraceptive pills, 48% chose depo medroxyprogesterone acetate injectable, and 2% opted for intrauterine devices. Even when connected with a free clinic post-release for contraceptive provision, only 4.4% of women who reported interest in contraceptive initiation started a method if it was not offered to them while in jail/prison. This suggests that contraceptive provision in the carceral system would be welcomed and well-utilized by women who are incarcerated.

In a 2010 publication, Sufrin and colleagues addressed emergency contraception provision in the jail population [29]. Based on a 63-item survey, they discovered that 29% of women being booked into a San Francisco jail were eligible were emergency contraception services, and half of these women would accept emergency contraception if offered. Over 70% of women who were eligible for emergency contraception had either a negative pregnancy attitude or were ambivalent towards a new pregnancy. Over 40% of these women had experienced a prior abortion. Finally, 71% of all women surveyed stated that they would accept an advance supply of emergency contraception upon release from jail. These findings suggest that newly arrested women are at high-risk for unplanned and unintended pregnancy and emergency contraception provision is not only desired among this population but may have important implications to increase reproductive service access among this traditionally marginalized population and decrease their risk of unintended pregnancy. Larochelle et al., in 2012 found that 60% of all women surveyed in San Francisco desired contraception be available through the jail health services and would accept its use if offered [15]. Additionally, 88% of women who did not access contraception in the year prior to the study but wanted to, stated that they would accept birth control if offered in jail.

In 2015, Schonberg and colleagues published a qualitative study that explored what incarcerated women desired in contraceptive services offered in jail [30]. This was the only qualitative study included in our review. Nearly 100% of women interviewed believed that contraception should be available as a basic health service while in jail. While most felt that all forms of contraception should be available while in jail, a few thought it would be better suited to include in discharge planning- either at the jail or by referral to a local community clinic. One woman explained that she would like to have contraception offered in jail in case it “takes longer than planned to get on [her] feet”. She wanted to ensure that she was protected against pregnancy as she took steps to improve and enhance her life. Other desires that respondents expressed were sexual education classes, counseling, and printed materials.

Cannon and colleagues explored contraceptive desires among women housed at Cook County jail in Chicago [16]. They determined that 73% of respondents were interested in contraceptive supplied if provided free of charge just prior to release and 82% of women were interested in receiving a free supply of emergency contraception.

Across studies, the respondents also explained their apprehensions about utilizing contraception from the jail health care system. The most prevalent concern was about lack of follow-up once released. This was especially true regarding long-acting reversible contraception, which requires provider assistance for discontinuation. Another concern was potential stigma associated with contraceptive use. As explained by respondents, a woman on birth control in a single-sex jail raised suspicions regarding the woman in question having sexual relations with male jail staff. Other concerns included feeling that the products they received would be lesser quality or experimental when compared to care sought outside the carceral system, or that providers were either very early in their training, lacked knowledge, or were too forceful about prescribing birth control methods without taking to time to review side effects or the inmates’ concerns. These concerns may be valuable for those providing carceral health care, jail/prison administrators who make decisions about the type of services offered, and public health officials with an interest in this population.

None of the articles mentioned women’s desires surrounding pregnancy options counseling or abortion care while incarcerated. Although majority of prison pregnancies end in a live birth [3], this population is at high-risk for unintended pregnancy and alternatives to parenting such as adoption services and referrals for abortion should remain available.

All told, women who are incarcerated report a desire to initiate contraceptive methods during incarceration or receive their initial prescription at the time of release, provided that their concerns about provider training, stigma, and community follow-up are addressed.

Key question 4: what reproductive and contraceptive plans do women who are incarcerated have after release from correctional facilities?

Table 6 summarizes the findings from the three articles addressing women’s plans to become pregnant or use contraception post-release, all of which focus specifically on local jail populations. Hale et al. in 2009 found that 45% of reproductively capable women did not desire to ever have children in the future, and an additional 19% did not desire to become pregnant in the first 2 years post-release [14]. Among the 72.4% of respondents who reported intentions to use birth control with every act of intercourse post-release, 69.1% planned on using the male condom, 15.5% the oral contraceptive pill, 10.3% withdrawal, and 6.2% contraceptive injection. Respondents were also asked about their contraceptive choices if money and availability did not matter, and 4.7% reported that they would pursue tubal ligation and a larger proportion opted for the contraceptive injection. As discussed under key question 1, only 25% of reproductively capable women had access to an OB/GYN prior to incarceration, and only 57% of individuals believed that they would still have access to health care after release.

Table 6 Summary of postrelease reproductive and contraception plans (key question 4) Full size table

In another population, Oswalt et al. in 2010 found only 38.5% of women desired to become pregnant after release from jail [31]. Among the 62.4% respondents who reported intentions to use birth control with every act of intercourse postrelease, the preference for contraceptive method was similar to the results of the Hale et al. (2009) study. Women who planned on using the male condom made up 69.1% of the respondents, 15.5% planned to use oral contraceptive pills, 10.3% planned to use the withdrawal method, and 6.2% planned on using the contraceptive injection. Non-White women were less likely to use contraception after release vs. White women (67% vs. 80.9%, p < 0.05). Furthermore, the study found that only 63.2% of respondents reported that they would have access to a health care provider after release.

Neither the Hale nor Oswalt publications included long-acting reversible contraceptive (LARC) options in their surveys, because their population was drawn from five local jails in the southeast United States that did not provide LARCs at baseline [14, 31]. Therefore, these studies did not identify women who were planning on using LARC methods after jail release. Similar to the Sufrin et al. publication on emergency contraception [29], LaRochelle et al. found that 78% of incarcerated women reported either a negative or ambivalent attitude towards pregnancy, and that 45% of women wanted to use contraception after their release from jail, although they did not include the specific method desired [15].

Taken together, these studies show that women desire a range of contraceptive options after they return to the community, but face barriers related to cost and access to providers for follow-up.