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Abstract

Background:

Given the historic and contemporary legacy of non-consensual sterilization and concern for coercion among incarcerated populations, routine provision of permanent contraception is discouraged. However, as with non-incarcerated patients, the 58,000 pregnant people who are incarcerated every year have diverse contraceptive goals, including the desire for permanent contraception. Clinicians caring for incarcerated patients must navigate this ethical tension. The perspectives and experiences of obstetricians who perform surgical permanent contraception procedures and who care for incarcerated patients requesting permanent contraception are unknown.

Objective:

To explore the knowledge, beliefs, and experiences of obstetricians who provide care to pregnant patients experiencing incarceration who request postpartum permanent contraception.

Design:

Qualitative study of obstetricians with experience providing care to pregnant people seeking postpartum permanent contraception during incarceration in North Carolina.

Methods:

Semi-structured interviews were conducted via Zoom or phone and transcribed, coded, and analyzed using a Framework Analysis methodology. Interviews explored domains of carceral policy, contraceptive decision-making and counseling, hospital availability of permanent contraception, and the Medicaid sterilization policy.

Results:

Eight obstetricians were interviewed. The major themes identified from the interviews were physician support for patient autonomy, physician desire for certainty, and the implications of incarceration on the universal challenges of providing postpartum permanent contraception. Physicians described striving to honor patient autonomy while working within a system that inherently limits liberties and imparts coercive influence. Physicians highlighted the struggle between treating all patients equally while acknowledging that pregnant people experiencing incarceration are a unique population that necessitates individualized care and considerations.

Conclusions:

Physicians in our sample were supportive of requests for permanent contraception by pregnant people experiencing incarceration, when evidence of long-standing, autonomous decision-making was available, especially given the inherently coercive system in which these decisions are made. Our findings highlight the need for well-developed ethical guidance for physicians approaching the care of pregnant people experiencing incarceration who request permanent contraception.

Plain language summary

Obstetric doctors’ experiences caring for pregnant people in prison who request permanent contraception after delivery

This study focuses on the ethical dilemmas doctors experienced when caring for patients who were pregnant and in prison and asked for permanent contraception.

Why was the study done? Many people choose permanent contraception after they have a baby. This option is discouraged for patients who are in prison because of a history of sterilizations in prisons without consent. At the same time, helping patients get the contraception they want is important. Doctors face ethical dilemmas when they care for pregnant patients in prison, but we don’t know much about how they think or feel about this issue.

What did the researchers do? We interviewed 8 doctors who provided care to pregnant patients in prison who asked for permanent contraception. We focused on their ideas and feelings about the ethical issues involved.

What did the researchers find? Overall, doctors balanced the idea that patients in prison should be allowed to choose permanent contraception and the reality that it is hard to make free choices in prison. The doctors felt better doing the procedure when there was evidence that patients had really thought it through and weren’t pressured.

What do the findings mean? Ethical guidance for doctors should help them to support pregnant people in prison who ask for permanent contraception.

Keywords

permanent contraception postpartum contraception carceral health reproductive health

Introduction

Mass incarceration over the past 40 years has led to an exponential increase in the number of pregnancy-capable people in U.S. prisons and jails. An estimated 58,000 pregnant individuals enter jails and prisons annually, with more than 1000 births in custody each year.^1,2 Postpartum permanent contraception, referring to the occlusion or removal of the fallopian tubes at the time of delivery or in the immediate postpartum period, remains a popular contraceptive method and is requested following approximately 8% of births in the United States.³ Requests for permanent contraception while in custody, however, must be considered in the historical context of the use of non-consensual sterilization to control the procreative abilities of many groups whose reproductive worth has been devalued, including racial and ethnic minorities, non-citizens, those who live on low incomes, and those experiencing incarceration.^4
–6 The umbrella term “permanent contraception” is used here in place of the term sterilization and includes both male (vasectomy) and female tubal surgeries. It connotes a voluntary procedure that is a method of contraception in the continuum of other available methods. We use the term sterilization to refer both to the Medicaid sterilization policy, which requires those who receive income-based public health insurance (i.e., Medicaid recipients), to sign a consent form and endure a 30-day waiting period prior to undergoing the procedure, and also to any procedures that are involuntary or coerced, consistent with the literature.⁷

Through systems of policing, laws, and courts, there is substantial overlap between groups targeted by explicit or implicit eugenic sterilization programs and groups who are both historically and contemporarily overrepresented in the carceral system. This overlap is understood in the context of stratified reproduction, or the disparate value that society places on the fertility and childbearing of people of color and those experiencing material poverty.⁸ It is inherent in policies and cultural practices that promote unequal allocation of resources to enhance the reproductive potential of the privileged, as in the case of fertility treatments, while disempowering the same potential of other groups who may be viewed as less worthy to parent, through the targeted promotion of long-acting or permanent contraception, for example.⁸ Thus, the determination by clinicians of whether and how to fulfill requests for permanent contraception during incarceration is rife with concern for perpetuating this stratification.

The conditions of incarceration also complicate clinician responses to requests for permanent contraception in custody. Prisons and jails are contexts that explicitly diminish individual autonomy. Thus, any “choice” afforded during incarceration must be contextualized within this coercive system, especially choices that are permanent. Safeguards, like standardized consent forms and waiting periods, are intended to decrease the risk of coercion or non-consensual sterilization. One of these safeguards, the Medicaid sterilization consent policy, was created in the 1970s to guard against coercive sterilization of people receiving public assistance but does not apply to incarcerated individuals because they are currently excluded from Medicaid under the Medicaid Inmate Exclusion Policy.⁵ This lack of protection was demonstrated in 2010, following reports that over 100 women in California were unlawfully sterilized in the state prison system after coercive or no counseling by prison clinicians.⁹ In response, California became the first (and only) state to ban permanent contraception procedures during incarceration through a 2014 law.⁹ While many other state prisons and local jails continue to permit permanent contraception procedures, most do so without formal written policies, ethical guidance, and/or without providing comprehensive reproductive care, including offering reversible contraceptive options.¹⁰ As a result, clinicians are often left to navigate their response to individual requests for permanent contraception without clear legal, ethical, or logistical guidance.

When situated within a reproductive justice framework, the ethical tension clinicians may experience attempting to uphold individual autonomy while safeguarding against irreversible reproductive health decisions made within an inherently coercive system becomes apparent.¹¹ In offering guidance to clinicians, the American College of Obstetricians and Gynecologists discourages against routinely performing permanent contraception procedures for patients experiencing incarceration but acknowledges that denying all requests would prevent patients with a well-formulated, long-standing desire for permanent contraception that predates incarceration from achieving their reproductive goals.¹²

It is unknown how often physicians who care for pregnant persons experiencing incarceration during the delivery hospitalization encounter patients requesting postpartum permanent contraception, how often these requests are fulfilled, and if these physicians understand the applicable carceral policies around permanent contraception. Furthermore, the physicians caring for this population in the hospital often differ from those hired or contracted to provide prenatal care in prison or jail settings, which results in a clinician meeting a patient for the first time upon delivery admission. Yet, in this short window, obstetric physicians—the clinicians most often responsible for performing surgical procedures to achieve permanent contraception—may be asked to perform procedures with irreversible impacts on the reproductive future of patients experiencing incarceration. The perspectives and experiences of these physicians who care for incarcerated patients requesting permanent contraception and who are tasked with navigating these complexities are largely unknown.

Understanding how obstetric physicians interpret and utilize federal, state, and local policies, historical context, and their own values to guide their clinical practice is necessary to develop optimal ethical guidance for postpartum permanent contraception for pregnant people experiencing incarceration. Our goal in this qualitative study was to explore the knowledge, beliefs, and experiences of physicians caring for pregnant and postpartum patients experiencing incarceration who request postpartum permanent contraception, surrounding the logistical and ethical complexities of providing this care.

Methods

Eligibility criteria and recruitment

From September 2023 to February 2024, we recruited obstetric physicians at two large hospitals, one community-based and one academic medical center, that serve as the delivery hospitals for all pregnant people incarcerated in the North Carolina state prison system. Pregnant people in the state prison system receive prenatal care at the facility from clinicians employed by the academic medical center and give birth at one of these two nearby hospitals. At the time the interviews were conducted, postpartum permanent contraceptive procedures and immediate postpartum long-acting reversible contraception (LARC, both subdermal implants and intrauterine devices) were available at both hospitals following either vaginal or cesarean birth. However, permanent contraception procedures for incarcerated patients are permitted at the time of cesarean section only, as the prison does not permit separate procedures following vaginal delivery or after delivery-hospitalization discharge. Reversible contraception, including pills, patches, injections, and LARC (including implants, hormonal and non-hormonal IUDs), was and is available in the prison system for management of menses.

Obstetric physicians, including residents and attending-level clinicians who provided care on labor and delivery at either hospital site, were invited to participate via email. Inclusion criteria to participate in the semi-structured interviews included being an obstetric physician who self-identified as ever having cared for pregnant persons experiencing incarceration during delivery hospitalization who had requested postpartum permanent contraception. There were no exclusions by age, race, gender, or ethnicity. Exclusion criteria included non-physician clinicians, such as midwives and advance practice providers, who, despite often caring for these patients on labor and delivery, do not perform permanent contraception procedures and therefore would likely have sufficiently different experiences as to warrant separate study. We recruited study participants via email and obtained verbal consent to participate, given that interviews were conducted virtually and the study posed no more than minimal risk to participants. Consent was documented in a secure enrollment log, and interviews were conducted by phone or Zoom.

Data collection

We adapted the interview guide (Supplemental Material A) from prior qualitative studies regarding physicians’ attitudes, beliefs, and experiences surrounding permanent contraception, which addressed domains of contraceptive decision-making, contraceptive counseling, hospital availability of permanent contraception, and Medicaid sterilization policy.¹³ We incorporated an additional domain of carceral policy and included specific questions aimed at eliciting obstetric clinicians’ experience of personal and societal bias related to permanent contraception and incarceration. The Medicaid sterilization form is commonly used to document consent for permanent contraception for populations beyond those with Medicaid insurance, including uninsured patients who receive hospital-based financial assistance to pay for care and incarcerated patients. This form is routinely used at one of the two delivery hospitals. In this context, the portion of the prior interview guide focused on the Medicaid sterilization policy was retained. The questions were modified to capture how obstetric physicians understood this application of the Medicaid sterilization policy to incarcerated patients. The wording and specific framing of the questions were guided in large part by the clinical experience of the authors in providing hospital-based obstetric care to pregnant people experiencing incarceration. Following the first interview, the study team reviewed the transcript and identified several additional probes that the interviewer could use but did not substantially revise the interview guide. Two members of the research team (JJ and IF) conducted the interviews. JJ has qualitative research and semi-structured interviewing experience and is a doula and research professional but not a clinician. IF was trained in semi-structured interviewing for the purposes of this study. She was a public health graduate student research assistant at the time of the study with an interest in maternal and child health. Interviews were conducted privately with only the interviewer and participant present, lasted between 30 and 60 min, and were audio recorded, transcribed verbatim, and deidentified. This project and the mode of consent were approved by the Institutional Review Board at the University of North Carolina at Chapel Hill School of Medicine (#22-2250). The reporting of this study conforms to the COREQ statement.¹⁴

Data analysis

We used the rigorous and accelerated data reduction (RADaR) technique described by Watkins to rapidly distill transcripts into a condensed and concise summary of textual data.¹⁵ This technique entails first removing text from the transcripts that are not relevant to the research question, followed by coding the remaining excerpts and using the data reduction process to identify illustrative quotes. We used a Framework Analysis methodology to code and analyze the data, starting with a set of themes from previous research and adding topics common in participant responses, which were then subdivided based on re-occurring ideas and concepts.¹⁶ The creation of sub-topics allowed for a more in-depth analysis and complex interpretation of each one. We classified and compiled the codes and sub-codes in a codebook with clear descriptors. Next, three coders (JJ, IF, and SU) evaluated the first two interviews independently. The study team compared results and discussed any transcript segments that did not have full consensus. Once a qualitatively high degree of reliability was established between the three coders, two coders (IF and SU) coded the remaining six interviews. In the final steps of the analysis, we created code summaries by synthesizing all quotes for each code. The entire research team reviewed the code summaries to identify key themes and subthemes which endured rounds of revision until a consensus was met. The sub-codes were subsequently organized into levels based on the social-ecological model—societal/structural, system, and interpersonal—to facilitate the incorporation of the results into future ethical guidance aimed at structural, health system, and clinician-level factors.

We were limited in the number of interviews that could be conducted based on a small pool of potential respondents. While our research team did note that some of the same comments and ideas recurred in multiple subsequent interviews (i.e., data saturation may have been reached, even with our small sample), we primarily focused on what has been described as inductive thematic saturation in our analysis of the interviews, where saturation reflects the quality of the analysis (rather than achievement of a particular sample size) and indicates that no new codes or themes are identified with analysis of subsequent transcripts.¹⁷

Results

We interviewed eight obstetric physicians who had provided care to pregnant persons experiencing incarceration requesting permanent contraception. All were obstetrician-gynecologists, one participant also described their experience providing care to patients within the state prison prenatal clinic, and one participant mentioned having seen patients from the prison for outpatient ultrasound visits or consultations. We identified three key themes across the interviews: physician recognition of restrictions to patient autonomy during incarceration, physicians’ desire for certainty around performing permanent contraception procedures for pregnant persons experiencing incarceration, and the additive implications of incarceration on the universal challenges of providing permanent contraception. Within these themes, we identified several subthemes that were organized into levels based on the social-ecological model—societal/structural, system, and interpersonal—shown in Figure 1. The societal and structural level refers to historic and contemporary socio-political influence on the themes, the system level refers to carceral systems and healthcare systems, and the interpersonal level refers to interactions between physicians and patients, patients and their families or community, or individual physician behaviors. A framework with themes, levels, subthemes, and illustrative quotes is summarized in Table 1. The outline framework with associated codes is outlined in Supplemental Material B. We reached inductive thematic saturation in our analysis; in that, no new codes or themes were identified once the codebook had been finalized.

Figure 1.

Physician perspectives on permanent contraception for pregnant people experiencing incarceration: The three key themes identified across the interviews are shown above (purple box). Several subthemes were identified within each theme and are organized into levels—societal/structural, system, and interpersonal—based on the social-ecological model.

Table 1.

Selected key quotes by theme, level, and subtheme identified through coded interviews of physicians discussing providing care for pregnant people experiencing incarceration who requested permanent contraception.

Theme	Levels	Subthemes	Key quotes
Physician recognition of restrictions to patient autonomy during incarceration	Societal/structural	Societal bias	I could imagine there are some, you know, ways that people are made to feel—I’m trying to think of the right way to say this—you know, probably made to feel poorly about themselves, you know, as an individual, as their ability to parent, and maybe are told, you know, certain things by people that makes them feel pressured to not get pregnant, not be a parent again in the future.
	Societal/structural	Potential for coercion	And in the context of incarceration, I think there’s this other piece where you—like, we know prisoners are a vulnerable population because they could be coerced in so many different ways. And so I think there’s another level there where you’re just trying to be extra certain that there’s no coercion involved or that they’re not making a decision that they don’t want Somebody’s in a time in their life that they don’t have a lot of control, and it’s a very unique time. And so, you know, you wonder, like, are they just making this decision cause they’re incarcerated? Like, would they make the same decision if they weren’t incarcerated?
	System	Carceral policy	We were just flat-out told contraception, IUD, Nexplanon, sterilization, you can’t do. The patient can ask for it, can beg for it, can be their fifth kid in seven years, and they’re, like, I have to say, “I’m not allowed to do that because the state considers it to be elective, and I can’t do it.” And it made me feel like a complete asshole, basically.
	Interpersonal	Family and community pressure for permanent contraception	I’ve seen it most with, like, family members or their own perception of what their family members think. So let’s just say someone’s incarcerated. Their mother has custody of their other kids. They’re gonna have this baby that’s gonna be separated from them and given in custody to their mom, and they may even feel this own internal pressure to be sterilized because they know they’ve had unplanned pregnancies, and, like, they don’t wanna put more burden on their mother and their other children.
	Interpersonal	Targeted counseling	There could be real benefits to having detailed contraception options counseling with our patients. And making sure that our patients receive similar counseling regardless of their status with insurance or incarceration, or any other social determinant of health that could affect their decisions.
Physician desire for certainty in performing postpartum permanent contraception procedures	Societal/structural	Historic legacy of forced sterilization	I think that autonomy is just important for everyone in general regardless of if they’re incarcerated or not. And hopefully people don’t use the history of forced sterilizations as a barrier to care for patients that really want this done.
	System	Adequate documentation	We often get very incomplete records. So sometimes it’s hard to see if there has been a discussion for a plan in place, if, you know, just really any of that counseling, and this applies to LARC and also for sterilization, really any of it. So records can be a barrier. I think also, you know, knowing what the patient’s intentions were prior to incarceration can be a barrier.
	Interpersonal	Short-term physician-patient relationship	So probably because I was the person who ultimately was performing the surgery but not the person who counseled her initially regarding her options or her wishes. I feel like that conversation was fairly quick The most recent patient I provided postpartum sterilization for, I just took care of her on the day of her surgery.
		Physician bias	I worry sometimes about even if we as providers are not sort of playing a role in the reproductive coercion There are definitely issues related to chronic health conditions, like people who have insulin-dependent diabetes, for example, they have future pregnancies, they’re gonna have a lot of medical involvement. And I think that there are times when people get some pressure, sort of—either explicit or implicit from, medical folks.
		Physician confidence	Like, I wanna do this. I think it’s the right thing. I truly feel the patient wants it, but I don’t have the support or the documentation to make me sure that she’s been not coerced. And that was always a uncomfortable time. Um, but if it’s what she wanted, to me, then it was her call. My biggest concern is, like, is it truly what she wanted, or is she just taking “the best option” of potentially crappy options that she’s been dealt? And I do think there’s this overarching concern among providers, myself included, that this is a patient population in which we want to take a special care not to coerce patients into permanent sterilization. At the same time, I don’t think it’s fair or ethical to flatly deny any patient who’s experiencing incarceration permanent sterilization just because they’re experiencing incarceration.
Implications of incarceration on the universal challenges of providing permanent contraception	Societal/structural	Systemic racism	So I think, like, our whole system is biased against certain people conceiving. But there’s a lot of intersectionality ‘cause the same goes for race, and, you know, Black women are disproportionately incarcerated, and then there’s a lot of stigma substance use disorder, and there’s a lot of people who are incarcerated due to substance use disorder. And so, like, all of those biases are, you know, in society and in most of us, even if we don’t realize it, are, like, they shouldn’t have more kids ‘cause of X, Y, or Z.
		Intersectional oppression
		Medicaid sterilization policy	What protects them from coercion is having conversations and being aware of their options and educating them about alternatives and what sterilization actually is.But it’s, kind of, you know, funny because in a way, like, they could be coerced to sign the form, and, you know, still be in coercion even though they sign it, and then—so it is an imperfect process, and I’m honest about that.
	System	Institutional barriers to permanent contraception completion	When patients have a vaginal delivery, it can be a lot more dependent on what else is happening in the OR. Whether we have nursing and scrub tech availability. Um, what the rest of the day looks like. And, of course, that’s true for all patients not just patients experiencing incarceration.
	Interpersonal	Striving for equality	I try as hard as I can to arrange for all patient’s sterilizations if that’s what they ultimately desire.I don’t think that there should be a different standard for them just because they are incarcerated—or certainly not for their medical care.I don’t think that there’s much of a difference of any patient who expresses a strong desire for contraception or for sterilization. I think the only cases not related to incarceration where I would be a little bit more hesitant is if a patient was, like, very young.I do think it’s a population that might at the same time both very disadvantaged or at risk of exploitation. And at the other hand it’s a population in which my care of them is, you know—as it should be—prone to a fair amount of scrutiny. And I don’t think that just because patients are experiencing incarceration they should no longer have dominion over their own bodies in terms of deciding their own treatment decisions including the decision to achieve permanent sterilization.

LARC: long-acting reversible contraception.

Physician recognition of restrictions to patient autonomy during incarceration

Overall, physicians expressed a strong desire to support patient autonomy in choosing permanent contraception during incarceration; however, physicians also acknowledged how patient autonomy was severely limited as a condition of incarceration. This sentiment expressed by one physician was echoed throughout the interviews: “I know it’s never gonna be a perfect situation because when you take away people’s free will on 99.9 percent of their body, it’s kind of a joke to say that they really have free will about that 0.1 percent.” Within the societal/structural level, nearly all physicians considered how a societal bias that devalues the reproductive worth of pregnant people experiencing incarceration would make their reproductive health choices vulnerable to coercive influence, including through internalized ideas about stratified reproduction. One physician stated, “There may be some societal systemic reproductive coercion occurring either by patients being made to feel they shouldn’t parent, shouldn’t reproduce, shouldn’t be pregnant again.”

At the systems level, physicians noted how carceral policy, including the lack of privacy during counseling sessions and limited alternative contraceptive options, reduce contraceptive autonomy. One physician recalled their experience providing contraceptive counseling in the outpatient setting in the presence of a custody officer which created an environment where they, as a physician, felt limited in what they could say or offer, stating, “We always had a guard in the room. So counseling someone about their personal reproductive health is a little bit difficult when you’ve got someone who’s job is to make sure you toe the line—it’s difficult.” Others noted awareness of restrictions on the contraceptive options available in the prison, but simultaneously some expressed uncertainty regarding what those limitations were. One physician recalled telling a patient, “Hey, these are options, but I don’t think they’re an option for you because of the incarceration or prison.” Another physician speculated that based on the current policy of reimbursement by the prison system, mode of delivery can be the deciding factor in whether a patient receives their requested postpartum permanent contraception procedure during incarceration. “You can have one at the time of cesarean birth but not at the time of vaginal birth. That, like, physiologically doesn’t make sense, whatsoever. They’re both births.”

At the interpersonal level, the physicians identified targeted contraceptive counseling and family and community pressure for permanent contraception as two areas that may contribute to diminished autonomy in contraceptive choice. One participant noted that pregnant persons experiencing incarceration may have their options artificially limited by physician counseling that emphasizes highly effective methods, stating, “I think they may have heard a little bit more bias toward permanent and highly effective methods versus ones that might be perceived as less effective, and I think that’s unfair.” Another physician considered how pressure from family or a provider may also narrow the range of options and prompt a patient to request permanent contraception, stating, “It’s more of what they think their family wants, or what their family has told them they want, or maybe what a provider has told them they should do, versus what they really, really want for them.” Despite a collective support for patient autonomy in decision-making around permanent contraception among the physicians interviewed, physicians generally recognized the impact of their own implicit or explicit biases toward stratified reproduction to limit autonomy.

Physician desire for certainty in performing postpartum permanent contraception procedures

Each physician interviewed identified considerations that give them pause when performing postpartum permanent contraception procedures for pregnant persons experiencing incarceration. At the societal level, acknowledgment of historical and contemporary reproductive coercion and forced sterilization in the carceral system weighed on many physicians. One participant stated, “Our health system, our profession, our state, and old white dudes who look like me have a really crappy track record of just sterilizing women because we feel we need to or should or have the right to. And so I was always kind of nervous.” Physicians described this history as motivating them to be very certain of a patient’s desire for permanent contraception before providing the procedure.

At the systems level, all the physicians expressed the importance of adequate documentation to inform their decision to fulfill postpartum permanent contraception requests. They noted the challenges to feeling certain with regard to difficulties obtaining a patient’s prenatal records from the prison, having documentation of patient contraceptive choice and prior counseling, and accessing signed Medicaid consents. One participant mentioned, “It’s not easy for us to access records or we’re unable to access records. We may not have been able to see that she had consistently expressed interest in permanent contraception prior to her incarceration.” Another physician stated they “would probably think twice about performing permanent sterilization on a patient experiencing incarceration unless [all of the documentation] was in tip-top perfect shape.” One participant stated, “I acknowledge that it could be my error in understanding, but we’ve always been sort of told when the patients are incarcerated, they are not covered under Medicaid. But again, I think that we try to be thoughtful and consider that there are some similarities in the fact that they’re a vulnerable patient population and considering some time period of documented decision-making or some consideration so that it’s not that the patient has just made the decision hours before they undergo the surgical procedure.” These quotes suggest that physicians rely on outside documentation, including the Medicaid sterilization consent form, to confirm that a patient has expressed desire for permanent contraception longitudinally, despite incarcerated patients not being eligible for Medicaid. Without that evidence, they expressed hesitation to proceed with a permanent contraception procedure for an incarcerated patient.

A short-term physician/patient relationship, physician bias, and physician confidence were all subthemes at the interpersonal-level subthemes that contributed to physicians’ desire for certainly in providing postpartum permanent contraception procedures during incarceration. Because most physicians interviewed had not met the patient until the delivery hospitalization, they described the challenges of a short-term physician/patient relationship, including their ability to establish trust and certainty of informed consent. One physician expressed this sentiment stating, “I’m trying to negotiate with a patient who I don’t have a relationship with, trying to advocate for them, but also, not having it in the context of anyone having a prior conversation, prior consent.” Many participants described how their own implicit bias influenced their need for certainty about patients’ reproductive decision-making. One physician explained, “I mean, that’s, like, very societal, and, in many of us, it’s there without us even realizing it. And some of it comes to us in our training and when we’re taking care of patients, and we’re like, ‘Oh, they’re pregnant again.’” Similar to what was described in the theme of limited autonomy and targeted counseling, other physicians explained how awareness of individual and societal attitudes and biases stemming from ideas of stratified reproduction increased their sense of a need for certainty and documentation of the consent process.

Implications of incarceration on universal challenges to permanent contraception

Throughout the interviews, the physicians considered how the constraints of incarceration exacerbate the universal challenges they experience providing permanent contraception. At the societal level, participants described incarceration as one in a litany of social structures, including systemic racism and intersectional oppression that differentially devalue the fertility and childbearing of certain groups. Intersectional oppression, a framework that considers how overlapping social identities including race, class, and gender create unique and compounded forms of oppression and discrimination,¹⁸ contributes to stratified reproduction as illustrated in this physician’s explanation, “You probably could make a scale of like, how seriously someone’s reproductive choices will be constrained or people would wish they could constrain them. And it’s not strictly black/white. Incarceration is up there—up there with drug addiction, serious mental illness, in that corner. And then race and immigration status and money.”

In the context of institutional practices leveraging the Medicaid sterilization consent form for patients not covered by Medicaid, it is unclear whether all participants were aware that the Medicaid form does not legally apply to incarcerated patients. One physician expressed, “On the other hand, given that this is a population that is, you know, at risk of exploitation or coercion, it would definitely give me pause if somebody’s papers weren’t completely in order.” This statement suggests this physician would consider not performing a permanent contraception procedure for any individual from any group at risk of coercion, including an incarcerated patient, without a properly completed and mature Medicaid consent.

At the systems level, physicians also expressed that the challenges they experienced completing any postpartum permanent contraception, such as the availability of hospital resources, healthcare team motivation, and scheduling, became more important in the context of incarceration. As one physician stated, “a general lack of access to outside medical care and carceral policy prevents patients from returning for interval procedures.” When discussing the general process of scheduling a postpartum permanent contraception procedure, one physician stated, “I don’t think people drag their feet more for incarcerated patients. I just think they had a tendency to drag their feet all the time for postpartum tubals.” Physicians expressed frustration at these challenges and noted that they could be exacerbated in the context of incarceration.

Overall, despite acknowledging the vulnerability and power imbalance faced by incarcerated patients there was an inherent desire by physicians to treat all patients in the same manner: “In general, whether or not patients are incarcerated I would be supportive if they’re very, very certain that they truly do not want any more kids.” Some participants shared their distress that they could not help but care for pregnant persons experiencing incarceration differently: “I really struggle with treating this population differently from other patient populations.” At the interpersonal level, physicians grappled with their own desires for equality, as well as equity, when facing patients whose care was complicated by not only the universal barriers they struggled to overcome in the provision of permanent contraception procedures but also the structural, societal, and interpersonal barriers to equitable care posed by the carceral system.

Discussion

In this qualitative analysis of physician perspectives on providing care to pregnant people experiencing incarceration who request postpartum permanent contraception, physicians were overall supportive of patient requests, when long-standing intent free of coercion could be confirmed. Yet, as physicians considered the multi-level factors that contribute to a patient’s decision-making, they seemed to recognize and acknowledge that truly autonomous decisions could not be made within the context of the coercive carceral system. They also expressed a sincere desire to treat all patients the same, providing equal as well as equitable care to patients during incarceration.

Our findings of physician support for patient autonomy align with prior research that found that, overall, physicians support patients’ desires for permanent contraception when they can ensure patient certainty in their decision-making.^19
–21 The physicians in our study discussed several mechanisms they use to confirm and document longitudinal decision-making certainty despite limited counseling opportunities. Despite the Medicaid policy not applying to patients experiencing incarceration, physicians described how they operationalize the consent form, using it as evidence of long-standing intent by patients to have a permanent contraception procedure performed. While many physicians expressed that the Medicaid form was not a substitute for comprehensive counseling and shared decision-making, the presence of a mature form provided additional assurance of a well-formulated choice and provided guidance for counseling. On the other hand, such reliance on paperwork designed to place the onus on clinicians to document consent nonetheless results in an unpleasant collateral consequence—without documentation, patient preferences may not otherwise be believed. A critique of the Medicaid sterilization policy in general, the requirement that patients receiving public insurance must provide written and mature evidence of an informed choice while others with private insurance are not required to do so, raises important ethical questions about new problems created by this initially well-intentioned policy.²²

The physicians we interviewed seemed motivated to fulfill patients’ autonomous permanent contraception requests despite the deeply coercive system in which patients are making reproductive decisions, in part because they acknowledged the desire to treat patients experiencing incarceration as they would other patients. Yet, it is important to consider individual autonomy within intersecting oppressive systems impacting fertility, sexuality, and parenting.¹¹ Mass incarceration violates the tenets of reproductive justice on several levels, not only through substandard reproductive health care, impeding parent-child relationships, and reducing fecundity, but by making it impossible for patients to make irreversible decisions about their reproductive futures during incarceration that are free of fear, coercion, or violence.⁴ Some scholars argue that support for sterilization under the guise of reproductive justice and individual autonomy is deceitful,⁵ although in the case of other irreversible reproductive health decisions, such as abortion, most advocates and scholars agree that these decisions can and should be permitted in custody. Thus, for physicians to be champions of reproductive justice for patients experiencing incarceration, they must be committed to acknowledging and working to address their own implicit biases, providing patient-centered counseling including counseling on reversible contraceptive methods, ensuring longitudinal decision-making for permanent contraception, and understanding carceral policies surrounding permanent contraception and disseminating this knowledge to other obstetric clinicians.

Limitations

While our study was limited to interviews with a small number of obstetricians from two secular hospitals in the southeastern United States which may limit the generalizability of the findings, we are unaware of any prior studies that explored the experiences and perspectives of physicians providing postpartum contraceptive care to incarcerated patients. The small sample size also precluded reaching saturation on a larger number of themes as we did not have the textual data to support further separation of the themes. Another limitation is that, to prevent deductive disclosure across our small sample, we did not collect or report on demographic or employment characteristics. Other limitations of this study include the risk of self-selection bias among participants whose views differ from the majority of physicians tasked with caring for pregnant people experiencing incarceration who request permanent contraception.

Our findings highlight several areas of opportunity to improve the reproductive health care provided to the increasing number of pregnant-capable people experiencing incarceration. Physicians described the challenges posed when they were unsure of the reversible contraception options available in the prison or of the facility policy on permanent contraception. Thus, educating medical trainees and others on the care patients receive in their local carceral institutions is needed to provide optimal patient-centered care in the hospital setting. Furthermore, physicians must understand the federal and local carceral policies surrounding permanent contraception, including the Medicaid Inmate Exclusion Policy, and in what circumstances, if any, are permanent procedures permissible during incarceration.

Our findings do support some concrete recommendations. Carceral institutions that permit permanent contraception procedures should have clear, written policies in place and ensure that both patients and clinicians understand the policies. If institutions permit permanent contraception procedures, they must also expand their formularies and clinical capacity to provide the full spectrum of reversible methods of contraception for patients. Research shows that patients experiencing incarceration support access to all forms of contraception in carceral settings.^23
–26 The aim of eliminating the potential for patients to request permanent contraception simply due to the absence of other options should be balanced with the reality that among women who had experienced incarceration and also chosen permanent contraception, many did so because alternative methods had failed them.²⁷ Additionally, there is a clear need to increase access to trusted clinicians, educate clinicians on patient-centered contraceptive counseling tailored to acknowledge the circumstances of incarceration, and improve continuity of contraceptive care from the carceral setting into the community, particularly for LARC removal.

Conclusion

In conclusion, the obstetricians we interviewed supported completing requests for permanent contraception for pregnant people experiencing incarceration, when evidence of long-standing autonomous patient decision-making was available given the inherently coercive system in which these decisions are made. Expanded access to reversible contraception in the carceral system as well as focused training for physicians and trainees regarding local carceral policies and contraceptive care for patients experiencing incarceration is needed. Our findings, along with the perspectives of those with lived experience—including those who requested permanent contraception during custody and did or did not receive the procedure, as well as those who did not request the procedure but were sterilized—can be used to inform nuanced, patient-centered ethical guidance for physicians approaching the care of pregnant people experiencing incarceration who request permanent contraception.

Supplemental Material

sj-pdf-1-whe-10.1177_17455057261428101 – Supplemental material for Obstetricians’ experiences caring for pregnant people experiencing incarceration who request permanent contraception

Supplemental material, sj-pdf-1-whe-10.1177_17455057261428101 for Obstetricians’ experiences caring for pregnant people experiencing incarceration who request permanent contraception by Grace A. Trompeter, Jamie Jackson, Isabelle Falk, Suzanna Larkin, Sreya Upputuri, Carolyn B. Sufrin, Kavita Shah Arora and Andrea K. Knittel in Women’s Health

Supplemental Material

sj-pdf-2-whe-10.1177_17455057261428101 – Supplemental material for Obstetricians’ experiences caring for pregnant people experiencing incarceration who request permanent contraception

Supplemental material, sj-pdf-2-whe-10.1177_17455057261428101 for Obstetricians’ experiences caring for pregnant people experiencing incarceration who request permanent contraception by Grace A. Trompeter, Jamie Jackson, Isabelle Falk, Suzanna Larkin, Sreya Upputuri, Carolyn B. Sufrin, Kavita Shah Arora and Andrea K. Knittel in Women’s Health

Footnotes

Acknowledgements

None.

ORCID iDs

Grace A. Trompeter

Andrea K. Knittel

Ethical considerations

This study received ethical approval from the Institutional Review Board at the University of North Carolina at Chapel Hill School of Medicine (#22-2250) on December 14, 2022.

Consent to participate

Participants provided verbal consent to participate. Study data will not be shared with third parties.

Consent for publication

Not applicable.

Author contributions

Grace A. Trompeter: Formal analysis; Writing – original draft.

Jamie Jackson: Investigation; Writing – review & editing; Data curation; Formal analysis; Project administration.

Isabelle Falk: Writing – review & editing; Data curation; Formal analysis.

Suzanna Larkin: Formal analysis; Writing – review & editing.

Sreya Upputuri: Writing – review & editing; Formal analysis.

Carolyn B. Sufrin: Supervision; Conceptualization; Writing – review & editing.

Kavita Shah Arora: Conceptualization; Funding acquisition; Writing – review & editing; Supervision.

Andrea K. Knittel: Conceptualization; Funding acquisition; Supervision; Writing – review & editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by R01HD098127 (PI: Arora) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) branch of the National Institutes of Health (NIH). Andrea Knittel is a faculty scholar supported by the UNC Women’s Reproductive Health Research (WRHR) Program funded by the National Institute of Child Health and Human Development (NICHD; K12HD103085, PI: Neal-Perry). This article is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Our regulatory approvals do not permit our data to be made publicly available. Researchers who are interested in viewing the data can contact the University of North Carolina at Chapel Hill School of Medicine Institutional Review Board.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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