Motivational interviewing of women leaving prison on contraception

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Computer-assisted motivational interviewing is no more helpful than an educational video for convincing female inmates scheduled for release to use contraception, according to a randomized controlled trial conducted in Rhode Island.

The authors of the study in the journal Contraception noted there are high rates of unintended pregnancies in women with a history of incarceration and that 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,” the authors wrote.

Methods
Study participants were recruited from the women’s division of a state-run correctional facility, which functions as both a jail and prison for women, between May 2009 and July 2012. During the study period, the average daily population of the facility was 240. All incarcerated women aged 18 to 35 were screened for eligibility, which was vaginal-penile intercourse with men at least monthly in the 3 months prior to incarceration and a desire not to become pregnant within 1 year of release. 

Women were randomized to either a computer-assisted motivational interviewing intervention group (n=119) or an educational video with counseling control group (n=113). Those randomized to computer-assisted motivational interviewing completed two sessions: the first at the time of randomization and the second 3 months after release. 

During the first session, counselors led discussions about pregnancy intentions, sexually transmitted infection (STI) risk assessments and Stages of Readiness to Change, with goal-setting behavior patient-initiated.

“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,” the authors wrote. The second session reinforced any behavior change to reduce STI and unplanned pregnancy, as well as revisiting obstacles to goals and setting new goals.

Participants randomized to the two video sessions, which were spaced the same as the motivational interviews, watched one didactic video at each session: the first was devoted to contraception and the second was on STIs, condom use and preconception counseling. The women were encouraged to ask questions and engage with the counselor during both video sessions.

Findings
The primary outcome of the study was initiation of a method of birth control prior to release from the correctional facility. Initiation of contraception was higher in the intervention group: 56% vs. 42% in the placebo group (P = 0.03). However, this difference was not significant, after accounting for more than four male partners within 1 year prior to incarceration. There was also no difference between the two groups in the rates of pregnancies, STIs or continuation of contraception after release, which was generally low anyway (21%).

Conclusions
Motivational interviewing may be ineffective “in addressing a behavior change associated with an outcome that is not universally ‘bad’ such as pregnancy,” the authors wrote. They support comprehensive family planning services; however, they stressed that use of the services must be completely voluntary and that informed consent has to be obtained for any contraceptive plan.

Furthermore, women newly released from incarceration may prefer oral and injectable contraceptives, the study results that their compliance is poor. Therefore, long-acting reversible contraception (LARC) may be a better choice for this population.