Dear Dr Novick,
We were troubled by the publication “Expanding Contraceptive Access for Women With Substance Use Disorders: Partnerships Between Public Health Departments and County Jails.”1 While the title suggests an important goal—improving family planning service availability for a group of people with constrained access—the program's goal to reduce neonatal abstinence syndrome (NAS) and practice of not offering the full range of reversible birth control methods raises serious concerns for ethical, equitable, and just health care and public health practice.2 The authors describe a state health department program providing family planning education and limited clinical services, accompanied by information about NAS, to women incarcerated in 15 rural Tennessee jails. The authors not only promote this intervention as increasing access to contraception but also justify it as reducing the financial burden to the state from babies born to people with opioid use disorder (OUD). This premise is deeply problematic.
First, the premise devalues the reproduction of people with OUD and sends the message that they should not be having babies, in historical continuity with eugenics campaigns that suppressed the reproduction of “undesirable” social groups.3 Linking contraception and NAS education sends the message that some people should not reproduce. If people with OUD desire pregnancy, this should not be discouraged, even subtly, and particularly by a state agency from which they may obtain future care. All this in a state that has enacted legislation to criminalize drug use in pregnancy.4
Second, if a person with OUD wants to avoid pregnancy, ensuring access to noncoercively provided contraception is essential. The authors are clearly aware of the potential for coercion, as they detail a thoughtful approach to avoid coercion. However, the power dynamics of incarceration are such that unhindered, unmonitored, self-determined bodily autonomy is unachievable. The authors' emphasis on transparent consent should not be confused with commitment to the human rights of individuals living behind bars. Furthermore, person-centered methods such as oral contraceptives were not available. The justification for this is specious. Other family planning programs have creatively navigated similar jail-imposed restrictions.5 Only offering limited contraception—particularly long-acting reversible contraceptives—is, according to the American College of Obstetricians and Gynecologists, inherently coercive.2 Withholding birth control methods that are woman-controlled impedes incarcerated people's human rights, which includes their sexual and reproductive rights.
In this program in Appalachia, nearly every incarcerated person was white. Nationally, though, our system of mass incarceration is shaped by the white supremacist legacies of slavery and Jim Crow, and disproportionately incarcerates people of color—people who have also had their reproduction controlled and suppressed by targeted contraception campaigns.6
Third, addiction treatment is not mentioned by the authors. “Medications for opioid use disorder” (MOUD) is the evidence-based standard of care but is absent from both jail educational sessions and clinical services described. The emphasis on NAS prevention via contraception, rather than treatment, clearly deprioritizes the health of an actual adult whose chronic disease management benefits not just the individual but also her family and community. As the authors note, NAS does not have long-term health consequences. Thus, while NAS is an expected and treatable possible outcome of MOUD in pregnancy, the evidence and all professional society guidelines support MOUD due to improved prenatal care and addiction treatment adherence, decreased HIV/HCV infection, and decreased overdose and overdose death.7 The authors acknowledge the limitations of Medicaid and access to treatment in Tennessee, but given that this program was state-sponsored, it is unsettling that it could not invest in improving the treatment shortcomings. Withholding MOUD from incarcerated individuals has recently been ruled in violation of the Americans with Disabilities Act.8 To provide birth control without providing access to comprehensive reproductive and sexual health education, and to discuss NAS but not provide treatment for OUD, both miss the mark of providing care in line with reproductive justice—the human rights to have children, not to have children, a quality of life before and beyond the ability to give birth or parent, and the ability to parent with safety and dignity.9
Fourth, the authors argued that their program was a cost-saving strategy. The authors likely overestimated their cost savings by about half a million dollars as they assumed that all pregnancies result in births, when, in fact, about 40% of pregnancies end in miscarriage or abortion.10–12 More importantly, making an economic argument—of reducing NAS costs—for suppressing incarcerated women's reproduction is discriminatory and reduces the complexities of reproduction to a monetary value—but only for some.
We hope that the state of Tennessee works to expand access to OUD treatment as well as quality family planning care for all people, including incarcerated women and other women of reproductive age. A reproductive justice, person-centered, and family-centered approach would not prioritize the short-term goal of NAS reduction, but instead treatment and supporting all people's reproductive goals, whether they want to avoid pregnancy or parent.
—Carolyn Sufrin, MD, PhD
Johns Hopkins University
—Mishka Terplan, MD, MPH
Virginia Commonwealth University
Founder and CEO
—Sarah Roberts, DrPH
University of California, San Francisco
San Francisco, California
1. McNeely CA, Hutson S, Sturdivant TL, Jabson JM, Isabell BS. Expanding contraceptive access for women with substance use disorders: partnerships between public health departments and county jails. J Public Health Manag Pract. 2019;25(3):229–237.
3. Roberts D. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York, NY: Pantheon Books; 1997.
5. Sufrin C, Baird S, Clarke J, Feldman E. Family planning services for incarcerated women: models for filling an unmet need. Int J Prison Health. 2017;13(1):10–18.
6. Alexander M. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York, NY: New Press; 2010.
7. Terplan M, Laird HJ, Hand DJ, et al Opioid detoxification during pregnancy: a systematic review. Obstet Gynecol. 2018;131(5):803–814.
10. Finer L, Zolna M. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med. 2016;374(9):843–852.
11. Jones RK, Jerman J. Abortion incidence and service availability in the United States, 2011. Perspect Sex Reprod Health. 2014;46(1):3–14.
12. Martin JA, Hamilton BE, Ventura SJ, Osterman MJK, Mathews TJ. Births: final data for 2011. Natl Vital Stat Rep. 2013;62(1):1–69, 72.