Almost half of all pregnancies in the United States are unplanned, a higher percentage than in several other industrialized countries
[1, 2]. Seventy percent of women between 18 and 29 years of age are at risk of unplanned pregnancy
, a higher proportion than any other age group
. The social and financial costs of unplanned pregnancies are staggering. In 2006, 64% of births in the Unites States resulting from unintended pregnancies were publicly funded, compared with 48% of all births and 35% of births resulting from intended pregnancies. Of the 2 million publicly funded births, 51% resulted from unintended pregnancies, accounting for $11.1 billion in costs
. Unplanned pregnancies have been associated with negative antenatal behaviors and birth outcomes
Sexually transmitted infections (STIs) are some of the most commonly reported diseases in the United States with approximately 19 million cases occurring annually
. STIs can cause serious and even life-threatening sequelae including cancer, ectopic pregnancy, infertility, chronic pelvic pain, spontaneous abortion, stillbirth, low birth weight, prematurity, congenital and perinatal infections, neurological damage, and death. More recent data indicate that many STIs increase the risk of HIV transmission at least three- to five-fold
. The economic cost of STIs is staggering. Women, minority populations, and adolescents are disproportionately affected by STIs. The incidence of STIs and their sequelae are consistently higher among African Americans and Hispanic Americans than among Caucasians
. In addition, two-thirds of all STIs occur in people younger than 25 years of age
Previous research indicates that both unplanned pregnancies and STIs disproportionately affect poor and medically underserved women, especially the incarcerated population
. Among incarcerated women, risk factors for unplanned pregnancies are very high (low educational attainment, poverty, homelessness, and substance abuse)
 and over 80% of incarcerated women at risk for an unplanned pregnancy report a history of an unplanned pregnancy. Many women with incarceration histories lose custody of their children either because of substance abuse, lack of resources, or re-incarceration. Approximately half of women in prison and jail are between the ages of 18 and 34 years. Over three-quarters of women in jail at risk for an unplanned pregnancy report they want to start a contraceptive method
. Furthermore, national statistics of STIs among incarcerated women reveal rates of chlamydia and gonorrhea at 7.2% and 1.6%, respectively
. STI rates vary by state but are 12 to 16 times higher in prisons and jails than in the general population
Women comprise approximately 3.2 million arrests annually and many pass through prisons and jails. With so many women at high risk for unplanned pregnancies and STIs passing through United States jails annually, improving contraceptive service utilization and STI prevention services in this non-traditional setting has the potential to reach the women in the greatest need of services. We will conduct a randomized controlled trial (RCT) of an innovative intervention based on motivational interviewing aimed at enhancing contraceptive initiation and maintenance among incarcerated women who do not want a pregnancy within the next year and who are anticipated to be released back to the community.
Motivational Interviewing (MI) to decrease unplanned pregnancies and STIs
MI provides an empirically supported style for matching counseling to an individual’s readiness to change. Based on the principles of motivational psychology, client-centered therapy, and the Transtheoretical Model (TTM),
[18, 19] MI represents a general and practical approach for facilitating behavior change by enhancing and eliciting a client’s own internal motivation for change.
 Responsibility for changing a behavior is assumed to lie within the individual, and ambivalence is recognized as a natural part of this change process. MI is designed to assist clients in working through ambivalence and in moving toward change. Their ambivalence may reflect a desire for a pregnancy in which case the MI counselor changes focus to having a healthy pregnancy. Utilizing MI techniques, the counselor helps the participant identify barriers to using birth control and methods for overcoming those barriers. MI targets increasing interest and confidence in accessing and using condoms and other forms of birth control and use of family planning professionals. Elements of the protocol are tailored to a woman’s specific needs including holding off on pregnancy until she is ready (for example, is financially stable or has a steady partner); it focuses on good and not-so-good ways regarding how to effectively negotiate use of contraceptives with partners (not so good would be to carry a knife to dissuade aggressive partners), decreasing use of alcohol and other drugs during sex (which may make it harder to use birth control and condoms), increasing use of referrals to family planning clinics, and identifying barriers specific to women and generating possible solutions. The MI counselor utilizes techniques including providing personalized feedback, reflective listening, exploring pros and cons of change, giving affirmations, supporting client autonomy and self-efficacy, eliciting ‘self-motivational statements’ (problem recognition, intention to change, optimism about change), and generating solutions to potential barriers to change. Of critical importance, MI emphasizes client’s personal choice regarding change, de-emphasizes labeling the client and her behaviors, and avoids arguing with or confronting the client with the need to change.
Published studies include successful MI interventions with individuals who smoke tobacco
, those who are addicted to heroin on methadone
, psychiatric inpatients with and without co-morbid substance use disorders
, and obese women with non-insulin dependent diabetes
. MI is especially effective with individuals who are ‘resistant’
, or not ready to change because the therapeutic process includes recognition and resolution of ambivalence about change. Brief interventions using MI have been postulated to be particularly well-suited to incarcerated populations
, because of their brief duration, non-confrontational, and empathic therapist style, emphasis on facilitating the individual’s consideration of the effects of their behavior on other life areas, and allowance for multiple options for change.
There are currently few published studies evaluating the use of brief interventions to alter overall contraceptive behavior. Belcher and colleagues evaluated the effectiveness of a motivational skill-based intervention to decrease sexual risk behavior in adult women as compared to a standard educational intervention
. Women randomized to MI reported significantly higher rates of condom use and had significantly fewer reports of unprotected intercourse as compared to controls. Reported condom use for women in the MI group rose from 22% to 66% as compared to an increase of 27% to only 43% among controls at 3 months post-intervention (P <0.02).
A Centers for Disease Control study entitled ‘Project CHOICES’ evaluated the impact and acceptability of a four-session MI intervention (n = 190) designed to reduce alcohol-exposed pregnancies among high-risk women by targeting both contraception use and drinking
. Among women who completed the 6-month follow-up, 68.5% were no longer at risk of having an alcohol-exposed pregnancy; 12.6% reduced drinking alone; 23.1% used effective contraception alone; and 32.9% reported both behaviors.
A total of three RCTs assess the impact of MI on women’s contraceptive behaviors in the context of reducing alcohol-exposed pregnancy (AEP). Ingersoll et al. reported their preliminary findings from a RCT of a single-session MI-based intervention to reduce AEP risk among college women (18 to 24 years)
. Significantly fewer women in the control group (48%) reported using effective contraception at 1-month follow-up as compared to those in the MI group (64%), P <0.03. Significantly more participants in the MI group (74%) were no longer at risk for AEP at 1 month compared to control participants (54%), P <0.005. This study demonstrated the potential of MI to alter contraceptive risk-taking behaviors among young women in college.
Peterson et al. conducted a RCT of a two-session MI-based intervention to reduce the risk of unintended pregnancy and STIs among women aged 16 to 44 years
. No significant differences were found between the intervention and control groups between baseline and 12 months. They concluded that additional MI sessions may be necessary to improve contraceptive decision-making and to reduce the risk of unintended pregnancies and STIs
. Barnet et al. investigated the effectiveness of a computer-assisted motivational intervention in preventing rapid subsequent birth to adolescent mothers. They randomly assigned participants (pregnant teenagers, aged 18 years and older who were at more than 24 weeks’ gestation) into three groups. The first group received a multicomponent home-based intervention, the second received a single-component home-based intervention, and the third received usual standard perinatal care. Results indicated that completion of two of more computer-assisted motivational intervention sessions, either alone or within a multicomponent home-based intervention, reduced the risk of rapid subsequent birth
. A review of theory-based interventions for contraception further supports MI as an intervention to prevent STIs
These studies point to the potential effectiveness of an MI intervention to increase contraceptive use, reduce unintended pregnancies, and decrease STI incidence. We are the first to conduct a RCT using the MI intervention to alter contraceptive behaviors among incarcerated women, to assess its impact on contraceptive use other than condoms, and to separate pregnancy from STI prevention. Project CARE (Contraceptive Awareness and Reproductive Education) is designed to evaluate an innovative intervention, Motivational Interviewing with Computer Assistance (MICA), aimed at enhancing contraceptive initiation and maintenance among incarcerated women who do not want a pregnancy within the next year and who are anticipated to be released back to the community.