A qualitative analysis of formerly incarcerated women’s perspectives on a prison-based perinatal support program

Abstract

Background

People who are pregnant while incarcerated are a high-risk population with complex and often unmet health care needs. Although perinatal support programs are becoming more common in carceral settings, limited research has examined individuals’ interest in and experiences with these programs. This study explored formerly incarcerated perinatal individuals’ knowledge about, participation in, and perceptions of currently existing and potential future components of a perinatal support program in a Mid-southern women’s state prison.

Methods

Semi-structured interviews were conducted with individuals who were incarcerated during pregnancy (N = 15; 100% identified as women; 66.7% white), the majority of whom gave birth while in custody (n = 13; 86.7%). Participants were asked about three existing elements of the program (support group, lactation, childbirth education), and a hypothetical fourth element, doula support. Data was analyzed using a qualitative description approach via MAXQDA.

Results

Most women viewed the program positively and expressed satisfaction with the program. Nearly all women participated in at least one program component; fourteen (93.3%) participated in the support group and two (13.3%) participated in lactation. Most of the thirteen women who did not participate in lactation reported this was due to ineligibility per institutional policies (69.2%), but some indicated non-participation was due to personal choice (23.1%) or not knowing that lactation was offered (7.7%). Seven of the nine women who were ineligible for lactation (77.8%) expressed desire to participate if eligible. While the childbirth education component was ultimately found to be unavailable during incarceration for most women who were interviewed due consequences of the COVID-19 pandemic, the great majority of women (86.7%) indicated they would have participated had it been offered. Nearly all women (93.3%) also reported interest in a hypothetical doula support component to the program should it become available.

Conclusions

Incarcerated perinatal individuals are both interested in and voluntarily participate in prison-based perinatal support programs and view these services as acceptable and beneficial to their needs. Findings highlight the importance of expanding access and addressing institutional barriers to improve perinatal care within these settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-025-07900-w.

Background

From 1980 to 2021, the number of women incarcerated in the United States (U.S.)1 dramatically increased by over 525% and at rates twice as high as incarcerated men [1–3]. This surge in the number of incarcerated women has ushered in a host of gender-specific reproductive healthcare challenges, particularly in relation to pregnancy, childbirth, and postpartum care [4]. Among the broader population of women who become incarcerated in state prisons, three-quarters are of child-bearing age [5]. A recent study of 22 state prisons estimated that nearly 4% of women enter prison while pregnant; however, this figure is likely an underestimate, given the widespread lack of standardized pregnancy testing and inconsistent documentation of reproductive health outcomes across facilities [6, 7].

Compared to the general population, pregnant women who are incarcerated are at increased risk for adverse perinatal and neonatal outcomes, such as preterm birth and infants with low birthweight [8]. Although incarceration alone is a risk factor for adverse perinatal and neonatal outcomes, pregnant women who are incarcerated often experience additional risks for complications due to histories of substance misuse, mental illness, violence and trauma exposure, and chronic disease and infection [9–11]. These health and social vulnerabilities may be exacerbated by the carceral environment, particularly by limited access to both general and specialized health care services [12]. As a result, targeted interventions to support the complex and unique health needs of pregnant and postpartum people who are incarcerated are sorely needed 2.

Perinatal support programming in prisons

Recently, prisons have begun to offer prison-based perinatal support programs for pregnant and postpartum people. Although variable by facility, prison-based perinatal support programs are typically adjunctive to standard medical and obstetric care provided in prisons [15]. Common program components include parenting and childbirth education; support groups; breastfeeding and lactation programs; and doula and birthing support services, with some facilities also having mother-baby units [16–19]. Although 21 states are believed to have attempted or are currently implementing prison-based perinatal support programs [15]these programs are still novel and there is little knowledge regarding pregnant and postpartum people’s participation and perceptions of these programs—a gap our study sought to fill. Here, we retrospectively examine the perspectives of fifteen formerly incarcerated pregnant and postpartum individuals who participated in a prison-based perinatal support program in a Mid-Southern state prison.

Group-based education and support groups

Pregnant and postpartum people who are incarcerated face a multitude of physical, emotional, and psychosocial stressors such as inadequate prenatal care, concerns about preparing for childbirth, lack of access to childbirth education, unknown expectations during pregnancy, labor, delivery, and postpartum, absence of support during pregnancy and delivery, and anxiety surrounding infant separation and caregiver placement [20–22]. Although not well-documented in the literature, some carceral settings have implemented recurring group-based perinatal education and/or support groups for both pregnant and postpartum people [15, 16, 23]. Programs like Pregnancy and Beyond and Mother Inside implemented in Minnesota’s prisons utilize manual-based curricula that focuses on pregnancy, parenting during the child’s first year of life, and parenting roles while incarcerated [15]. Alternatively, some groups, like those in Georgia and Michigan’s prisons, are open-discussion and each session is tailored to needs identified by members of the group [15].

Breastfeeding & lactation

The benefits of breastfeeding for the mother-infant dyad are well-documented [24]; however, few carceral facilities are known to provide opportunities or resources for breastfeeding [25–27]. Breastfeeding can minimize risk of negative maternal outcomes such as emotional distress from infant separation, postpartum depression, and self-harm and suicidal ideation post-delivery [18, 28]. Little is known about the breastfeeding rates of individuals who give birth while incarcerated, both during their hospitalization and upon returning to prison. However, rates are likely low due to existing prison policies that restrict individual’s ability to breastfeed while hospitalized and given that few prisons have programs to support breastfeeding and/or pumping of breastmilk [18, 27, 29].

Wouk and colleagues (2022) concluded in their recent systematic review that perinatal populations receive little, if any, lactation support during incarceration. Consistent with this conclusion, Asiodu and colleagues’ (2021) survey of 22 state prison systems and six county jails in 2016–2017 found that while half allowed for breastfeeding and/or pumping of breastmilk, only seven facilities (25%, all prisons) had a formal written policy related to lactation. In a recent comprehensive review of six state’s perinatal support programs, Wilson and colleagues (2022) reported that four of the states (i.e. Alabama, Arkansas, Minnesota, and Virginia) offered some degree of lactation support, but services provided varied among programs in each state. Services included meeting with a certified lactation consultant, access to private pumping areas with personal pumping supplies, storing and shipping expressed milk, and breastfeeding during visitation hours.

Doula support

Advocacy for doula support services has grown due to recent evidence that highlights its potential to mitigate the negative effects of giving birth while incarcerated [30, 31]. Despite this, doula support for pregnant people who are incarcerated is offered in only a few carceral settings across the U.S. and outcome studies are scarce [12, 15, 19, 29, 31, 32]. Schroeder and Bell (2005) were the first to describe a pilot program that provided 18 women with continuous physical and emotional support by a doula before, during, and following labor and delivery while incarcerated. Shlafer and colleagues (2021) compared the outcomes of mother-infant dyads who received doula support in a prison-based doula program to a historical control group who had received only standard prenatal care. Although there were no differences in the outcomes examined (i.e., vaginal or cesarian birth; birthweight; premature birth; Neonatal Intensive Care Unit [NICU] admission; Appearance, Pulse, Grimace, Activity, Respiration [APGAR] score) between the groups, those who received doula services reported being very satisfied with the support received by their doula and the time spent with their infant post-delivery.

The current study

Although literature documenting perinatal support programs in carceral settings is growing, this literature largely describes perinatal program components (e.g., educational themes, delivery methods, program length, specialized training for program leaders). Less is known about pregnant and postpartum people’s participation in these programs and if they feel these programs meet their needs. In the current study, we sought to describe knowledge about, participation in, and perceptions of existing (support group, lactation, childbirth education3) and potential (doula support) components of prison-based perinatal support programs among pregnant and postpartum people who were formerly incarcerated in a Mid-southern state prison.

Method

The perinatal support program examined in this study is located within a rural Mid-southern women’s state prison– a state with one of the highest rates of women’s incarceration in the U.S. From 2014 to 2019, most people who entered the state’s prison system while pregnant were identified as Caucasian/white (75.3%) or African American/black (15.5%) and non-Hispanic/Latinx (89.0%), similar to recent nationwide U.S. statistics collected on pregnancy prevalence in state and federal institutions [6, 10].

In this state, individuals entering the women’s prison system are initially processed at a centralized intake facility, which is also the largest prison for women in the state. Those who test positive for pregnancy during intake are subsequently transferred to a smaller facility that houses all pregnant and postpartum individuals, regardless of security classification. This facility is located approximately 30 minutes from a partnering academic medical center that is contracted to provide obstetric care, including weekly on-site prenatal visits and hospital-based labor and delivery services, and where many of those involved in the perinatal support program we explored are employed.

In collaboration with the senior author, the state’s Department of Corrections launched the perinatal support program as an adjunct to contracted obstetric care in mid-2019. The program was designed based on a series of listening sessions with individuals who had been or currently were pregnant while incarcerated. The program aimed to include a continuum of voluntary, individual elements including childbirth education classes, a support group, and a lactation program (See Table 1 for a description of each program element). Components of the program were selected based on existing research evidence, models of pregnancy support programs in other states, and feedback from pregnant and postpartum people during focus groups held at the prison in May of 2019. Because the program is relatively new, we assessed the rate of participation and perceptions of acceptability for each existing program element. We also asked about interest in a doula support service and their likelihood of enrollment if the service was available to them.

Table 1.

Elements of the perinatal support program

Program Element	Description
Support Group	The mental health support group launched in June 2019. This group is delivered in an unstructured, group-based format and facilitated by a licensed counselor who provided psychoeducation to help process emotions related to being pregnant or postpartum while incarcerated. Session topics were to be decided by group consensus prior to the start of each individual session and have ranged from mental health, substance use, emotional well-being, coping with stress, postpartum recovery, parenting, and re-entry concerns.
Lactation Program	The lactation program launched in June 2019 and designated a private, sanitary place for postpartum women to pump breastmilk to be stored and picked up weekly by the infant’s caregiver. Women in the lactation program are also able to breastfeed their infant during visitation if they chose.
Childbirth Education	The childbirth education element of the program launched in January 2020. Childbirth education was volunteer-led classes using a structured curriculum that provided basic information about pregnancy, such as physical changes during each trimester of pregnancy, warning signs of problems (e.g., premature labor), relaxation techniques and positions of comfort during labor, and expectations during labor and delivery. This class was tailored to women who were currently pregnant but also open to those who were postpartum. The childbirth education element of the program first convened just weeks before the prison implemented visitation restrictions during the COVID-19 pandemic. Only two sessions were offered prior to facility closure and classes have not resumed post-closure.
Proposed Doula Support	Doulas are “trained professions who provide continuous physical, emotional, and informational support to their client before, during, and after childbirth to help them achieve the healthiest, most satisfying experience possible” 33. Doulas are not medical professionals but compliment the broader health care team by providing pregnancy education, giving physical and emotional support during childbirth, and supporting the mother-infant dyad post-delivery (e.g., encourage skin-to-skin, breastfeeding). Women would meet with their doula three times: (1) prior to childbirth to develop a birth plan, discuss what to expect when giving birth, and choices that women can make or might need to make while in labor, (2) labor and delivery to provide continuous physical and emotional support during childbirth as well as at hospital discharge during separation, and (3) after delivery to process the birth experience, give emotional support, and answer any questions related to recovery.

Participants

Participants were purposely sampled based on their pregnancy status. To be included in the study, potential participants were required to be (1) previously incarcerated in the women’s state prison while pregnant, (2) at least 18 years of age, (3) able to understand and speak English, and (4) give informed consent.

During much of our study enrollment period, facility restrictions due to the COVID-19 pandemic prevented study staff from entering the prison to conduct participant interviews. As a result, all interviews were completed in the community after being released from prison. All pregnant and postpartum individuals were initially approached about their interest in the study during a routine prenatal visit by the Advanced Practice Registered Nurse (APRN) who was employed by the contracted hospital system to provide obstetric care. During this visit, the APRN provided written information about the current study and asked individuals to check yes/no to express interest in hearing more about the study. A statement was included on this form to advise individuals that their decision to express interest or disinterest in the study would not affect the prenatal care they received. Individuals who expressed interest in meeting with study staff to learn more about the study upon their release completed an additional form that requested several potential methods of contact including personal, family, friends, social media, and probation and parole officer information. The APRN then notified the study personnel of potential participants and forwarded the completed forms. None of the documents or information provided by potential participants was shared with prison staff, and prison staff had no role in recruiting individuals for the study.

In total, 33 individuals consented to be contacted about possible study participation upon release from prison; one individual declined. Study enrollment began in November 2021 and concluded in December 2023. Of the 33 individuals who consented to be contacted, 15 individuals (45.5%) ultimately agreed to participate, five (15.2%) declined, two (6%) were unreachable, and 11 (33.3%) still remained incarcerated in the state prison by the end of the study period and were unable to participate. All participants (N = 15) identified as cisgender women (See Table 2 for demographics).

Table 2.

Participant demographics

	M (SD; RANGE)	% (n)
Age	30.33 (3.39; 23–35 years)	-
Race
Caucasian/White	-	66.7% (10)
African American/Black	-	33.3% (5)
Education
8th Grade or higher, no diploma	-	26.7% (4)
High school diploma/General Education Equivalent (GED)	-	53.3% (8)
Some college credits, no degree	-	13.3% (2)
College graduate	-	6.7% (1)

Procedure

All study visits occurred after release from the state prison and in a modality that was feasible for the participant (e.g., in-person [jail, research staff office], virtually, by phone). Study staff met with interested participants and verbally reviewed consent forms prior to study enrollment and participation. At this time, individuals were informed that their participation in the study would have no impact on their legal status. Informed consent was obtained from all study participants prior to the interview. On average, the semi-structured interview lasted 41-minutes (Range: 13–70 min) and queried women’s interest and participation in the perinatal support program elements, their perspectives about potential additions to the program, and their thoughts about other perinatal service needs. The interview also asked women about their birthing experiences, current healthcare access, and community healthcare needs. One participant declined to be recorded; all other interviews were audio-recorded and transcribed verbatim. All participants were compensated for their participation in the study. All study procedures were approved by the University of Arkansas for Medical Science's Institutional Review Board.

Qualitative interview guide

We used a semi-structured interview guide to query participants about elements of the perinatal program (i.e., childbirth education, support group, lactation program; see Appendix I). Questions were divided into three different sections; this allowed us to ask questions as they related to participants’ participation and experiences. Questions were sectioned by (1) participants who participated in the element of the program, (2) participants who remembered hearing about the element of the program but did not participate, and (3) participants who did not hear about the element of the program and did not participate. All participants were asked about their opinions on the potential addition of doula support to the program.

Analytical approach

All interviews were coded and analyzed with the aid of MAXQDA, a qualitative data analysis software [33]. The first author, who is an expert in qualitative methods, and the second author utilized a qualitative description approach to gain a better understanding of pregnant and postpartum people’s participation, experiences, and acceptability of prison-based perinatal support programs [34]. The qualitative description approach is appropriate for studies characterizing health care phenomena and utilizing participant experiences to refine interventions [35]. When using qualitative description, content analysis is commonly used to quantify and qualitatively analyze interview data [36]. The first and the second author reviewed and coded each of the interviews together by program element using both deductive (i.e., codes that derived from the interview guide questions) and inductive codes (i.e., codes that emerged from participant responses). First, the semi-structured interview questions were used to guide deductive coding. Next, each individual interview transcript was inductively coded whereby meaningful segments of text were assigned with an ‘in vivo’ code, which are codes that use specific words, language, or concepts as stated by participants. Disagreements during the coding process were discussed among the pair and resolved through consensus to reach a shared understanding. Using a constant comparative approach, codes were assigned to data with common characteristics in each subsequent interview to explore participants’ perceptions of program elements and identify emerging themes. Finally, the senior author, who is also an expert in qualitative methods, reviewed the interpretations for accuracy, clarity, and consistency.

Results

Results revealed that fourteen of the fifteen women interviewed for the current study reported engaging in at least one of the active elements (i.e., support group or lactation) of the perinatal support program, and the majority expressed positive perceptions and satisfaction with their experience. Although childbirth education was ultimately found not to be available during the study period due to consequences of the COVID-19 pandemic, 13 women expressed being interested in participating if it were available to them during their incarceration. Lastly, 14 women reported they would have been interested in doula support services if it were available and would support its addition to the existing program.

Perception of services currently offered

Support group

Among the women interviewed, 14 reported participating in at least one session of the support group. The remaining participant reported that she did not remember hearing about the group and did not participate. Those who did participate provided primarily relational reasons for attending, including having a safe place to share thoughts and feelings, having a similar experience with others in the group, feeling comfortable with the group facilitator, and meeting their needs for support. One participant reported attending to receive parenting education and coping skill development. Most women reported attending the group after being encouraged by another person, usually an incarcerated peer, though some were motivated to attend by a group leader or a relative.

Of those who participated, most reported positive experiences, felt highly satisfied, and would recommend the group to other pregnant and postpartum people who are incarcerated. Largely, women found the support group to be a safe place to speak openly among peers with a shared experience. One woman described, “I was in prison, I really didn’t have anyone to talk to about it…it was good, supportive, and nice to be surrounded by women who was probably going through the same thing I was” (30-year-old, African American). Another said, “it’s a safe place for girls that are pregnant to talk amongst people that encountered [pregnancy and incarceration]” (33-year-old, White). Others spoke specifically about how the support group provided an outlet for women to openly share their feelings and frustrations without repercussion. Women described the support group as a place to “be open, say how you feel and be a crybaby and it’d be okay” and stressed the importance of having “open discussion outside the barracks” and “being able to be open and not worry what could come of it.” Two women mentioned the support received from the facilitator influenced their decision to attend. One described the group facilitator as “amazing” and “very helpful,” while the other elaborated, “[The teacher], whenever I came back here from having my baby, just showing that she cared just enough to come back and check on me, that helped a lot” (26-year-old, African American).

Two women felt neither satisfied nor dissatisfied with their experiences in the support group. One of these women shared similar positive views about the support group facilitator but also expressed that the topics of conversation in group were misaligned with her current needs. She stated the support group facilitator was, “down to earth…genuine, not judgmental” but added,

“I’ve been clean before I went to prison…all they [members of the group] wanted to talk about was their drug use and they were scared to get out and use again. I felt like that was one of the main and only topics we talked about, just since there’s so many people that were still talking about getting high again and that didn’t help me at all…” (30-year-old, White).

The other woman also expressed mixed feelings about the group and stated that her favorite part was the opportunity to, “talk to other inmates going through the same thing” but also added that, “no one really talked” (33-year-old, White), leaving her feeling neither satisfied nor dissatisfied.

Lastly, the one woman who did not participate in the support group expressed that she would have been interested in the group and would have attended had she heard about it. Her interest in the support group mirrored those who did participate. When asked why she would be interested in attending, she stated, “I was unprepared. It would’ve been nice to get other mothers’ opinions and stuff like that. Which, I did do that, but I had to do it on my own by going around and asking women who had kids” (28-year-old, White).

Lactation program

Two women reported participation in the lactation element of the program. Twelve women remembered hearing about lactation but did not participate and one woman did not remember hearing about it and did not participate. Of the two women that participated, one woman reported being highly satisfied with the experience, while the other expressed ambivalence and gave several suggestions to improve the program. Both participants expressed that they would recommend the lactation element of the program to other postpartum people who are incarcerated and gave similar reasons for participation. Both chose to participate because they knew they wanted to breastfeed their infant and felt that breastmilk was best for their baby. One stated, “I thought it would probably be a good idea…I thought it was the best way to feed my baby breastmilk” (32-year-old, African American). The other enrolled in the lactation program for, “support while being locked up and so my baby would be able to breastfeed” (30-year-old, White).

Although both women gave similar reasons for being interested in the lactation element of the program, the two women shared very different experiences. One described feeling very satisfied with her experience and did not offer suggestions to improve the program. She expressed,

“The [guards] didn’t give me any problems pumping…they did what they was supposed to. We had to go every three hours…my pump broke and the [hospital] was good, they came and brought a [new] pump right over. It was very, really helpful” (32-year-old, African American).

In comparison, the other woman who participated reported a less positive experience and expressed several concerns with the pumping schedule, access to the pumping room and supplies to clean the pump, and logistical barriers experienced by the caregiver picking up the milk. She explained,

“[Pumping] is something you have to do on a schedule, and sometimes it is hard to get out of there [barracks]…breastfeeding is on a schedule like every four hours type deal…it was an issue trying to get out of the barracks, getting the guards attention when it came time to go breastfeed, to pump” (30-year-old, White).

Although she believed that being provided with a pump and pumping supplies was beneficial, she did express a need for more consistent stocking of supplies in the lactation room. She stated that at times,

"We were out of stuff, we didn’t know who to tell…like we needed more soap to wash bottles with…but when I ran out, I didn’t know who to get in contact with, or request to get more of what I needed."

She also urged that caregivers should be able to pick up milk more than once a week, which was the limit per facility policy, and felt that it would be beneficial both for the mother and the infant. She emphasized:

“When the baby runs out, it really hurts her stomach to have to switch back and forth [between breastmilk and formula], so it would prevent the baby running out if they could let the people coming to pick up the milk pick it up more than just one time…” (30-year-old, White).

Of the 12 women who remembered hearing about the lactation element of the program but did not participate, seven wished to participate but were ineligible per institutional policies, three were eligible to participate but declined, and two were ineligible and did not want to participate. Institutional policies that prevented participation in the lactation element of the program included Department of Human Service (DHS) involvement in infant placement following birth (n = 5), infant placement for adoption (n = 1), infant placement with a caregiver who lived out of state (n = 1), and COVID-19 restrictions (n = 1). Similar experiences were echoed by all women who were interested in lactation but unable to participate due to DHS involvement. One woman informed us, “I wanted to [participate], but the rules are if your family member gets your baby, then you can participate in lactation. But if DHS get your baby, they don’t let you participate” (26-year-old, African American). Similarly, another woman described being denied the opportunity to participate in lactation due to DHS involvement despite obtaining a relative as an approved caregiver. She proclaimed,

“The bad thing about the way the contract is written or whatever, it says if DHS is involved, they just don’t participate [in lactation]. My aunt spoke with DHS and had everything already lined up and pre-approved so there was no reason why I should have been denied an application. She [my aunt] picked him up from the hospital. He never went into [DHS] custody or anything” (35-year-old, White).

The three eligible women who chose not to participate due to their personal choice to formula feed. One participant explained that she knew she wanted to formula feed out of concern for her emotional-wellbeing post-separation. She expressed,

“I knew I was going to have to leave her, it’s just, more depressing knowing if I started breastfeeding her and then not being able to continue breastfeeding her. I decided to bottle feed for that reason because I did not want to get more attached knowing I was going to have to leave her” (33-year-old, White).

Perception of services not currently offered

Childbirth education

Thirteen of the fifteen women interviewed expressed interest in attending childbirth education if it were available to them at the time of their incarceration. Most reported being interested in childbirth education to learn more about maternal, fetal, and infant health and well-being, with some noting particular interest in learning how to manage and cope with stress, prepare for childbirth, or access emotional support. One woman stated, “it would have been helpful for me to know things that I could do just to help with stress and overall health of myself and my baby while incarcerated” (28-year-old, White).

Another, who was still pregnant with her first child at the time of her release, explained that her current pregnancy was unexpected, and she felt unprepared for childbirth. She said, “I didn’t find out I was pregnant until six and half months, doctors told me I could never have kids, I feel totally unprepared for this baby…I don’t know what to expect during birth” (28 years-old, White). She added that she was due in eight days and knew very little about signs of labor and how the body prepares for childbirth. However, even women with multiple pregnancies reported interest in childbirth education, a sentiment exemplified by another woman who explained, “even though it was my fourth child, it felt like having a new baby every time…every labor is different, and you’ll experience something different with every single one of them, so the more you know, the better” (35 years-old, White).

Two women denied interest in the childbirth education component by expressing low perceived compatibility—not with the content, but rather with practical elements of an educational group. For example, one woman explained, “I was really really bad at waking up in the morning and while I was in prison, I’d sleep all day and at night I’d read a book” (23-year-old, White). Another described that she, “doesn’t normally do support groups” (33-year-old, White).

Doula support

Fourteen participants indicated that if they were still incarcerated and would be giving birth in custody, they would be interested in the hypothetical doula support service component of the program and having a doula attending their birth. All participants were asked to rate the likelihood of enrolling in doula support services if it were available to them. Most women (n = 13) responded they would have almost certainly enrolled, one woman’s response was neutral towards the doula service, and another woman’s response indicated she would have been unlikely to use this service.

Nine of the 13 women felt they would have enrolled because of the physical and emotional support the doula would provide during childbirth. One woman expressed, “there’s nobody in the room with you but the guard…they’re not emotional or supportive, no one’s gonna be there to hold my hand” (26-year-old, African American). Another woman detailed how family members could not attend their delivery and the opportunity to have a trusted emotional support person would have contributed to a better birth experience. She stated,

“Because you can’t really have your family there with you, so that would help to have somebody that was there before [childbirth], and then if they were there with you, you kind of feel close to them. Even though you can’t have family and support there, that would make a big difference” (33-year-old, White).

Others shared similar views and made statements like, “…you need that kind of support going into labor…cause you don’t have your family” (23 year-old, White) or “our husbands can’t be there for the birth, our families can’t be there for the birth, so having somebody there, other than a police officer or uniformed guard, would be nice” (28 year-old, White).

Eight of these 13 women highlighted the importance of receiving mental health and emotional support from the doula during the pregnancy and into the postpartum period. One woman explained,

“I feel like the [Department of Corrections] does not give pregnant or postpartum women the mental help that they really need…I think that having somebody there that you trust would help tremendously with the birthing process and the postpartum afterwards. I feel like that’s a really big issue in the program…” (28-year-old, White).

Another woman gave similar sentiments, “…just to have someone there for mental support. You know what I’m saying? Because you don’t have that in there. They don’t have steady mental health” (33-year-old, White). One woman equated postpartum emotions to a nightmare and expressed the need for someone, such as a doula, to assist with emotional processing following childbirth, “it is such a hard experience, to have someone there would be helpful, that’s a really emotional rollercoaster…whole thing is like a nightmare” (35-year-old, White).

Two women expressed feeling neutral about the doula service or unlikely to enroll. Among them, one woman felt uncertain about the doula being a ‘stranger,’ but felt that having a support person during childbirth was needed. She stated.

“I would be a little hesitant about it…you need that kind of support going into labor transition cause you don’t have your family…I guess they wouldn’t really be a stranger after meeting with her so many times, but I don’t know” (23-year-old, White).

The other woman felt highly unlikely to enroll in the doula service and would not be interested in having a doula attend their childbirth. Although she agreed that incarcerated birthing people could benefit from doula support and services, she was personally not interested in doula support because, “I’d rather be my own support” (33-year-old, White).

Program needs and recommendations

Nearly all women emphasized the need for additional support and advocated for a component within the program to provide continued mental and emotional support throughout the postpartum period, particularly after being separated from their newborns and the subsequent readjustment to the prison environment. One woman described,

“I would say better help with the postpartum after you come back…they don’t really help you with that in there [in prison]…you’ll have days where you’ll be okay and then you’ll have days where every little thing makes you cry and they sent me to mental health to talk to them and when I went down there, she didn’t really talk to me. She just gave me a packet and sent me back to the barracks” (26-year-old, African American).

One woman shared her thoughts about having more frequent access to program staff throughout the week,

“I think just having somebody to come in and help you deal with the postpartum depression or any concerns of the postpartum period would be a really big help to have available to us…I just feel like if you’re having a really hard day…you should be able to go off and talk to somebody right then instead of having to wait a whole week for somebody to come in and be able to talk about it” (28-year-old, White).

One woman, who did not give birth during her incarceration, expressed similar thoughts given her peers’ experiences,

“While I was incarcerated, three of the girls gave birth to their babies and had to go back to prison and no support whatsoever, other than hoping and praying that whoever has their baby will send them pictures. They have no support or nobody to talk to about what it’s like to have to leave your baby and be sent back to incarceration” (28-year-old; White).

Discussion

In carceral settings, staff or outside agencies often implement interventions without sufficient understanding of incarcerated peoples’ needs, receptivity to services, and barriers to participation [37, 38]. Arguably, for prison-based programs to be beneficial and effective, potential recipients should be interested and willing to participate and recent studies show that incarcerated individuals’ views of program acceptability are positively associated with their participation [39, 40]. This study, which is one of a small handful of studies specifically focused on perinatal populations and their perceptions of prison-based perinatal support programs, demonstrates that pregnant and postpartum people who are incarcerated are interested in, desire, and voluntarily participate in these programs despite significant barriers and challenges to participation.

Participants’ experiences gleaned from this study can help inform programmatic adjustments to better meet the needs of future recipients and potentially increase overall engagement as well as guide other programs in shaping their service availability. This is evident in that while participants in our sample viewed the perinatal support program positively, they also felt the existing program elements addressed only some of their needs while also identifying barriers that hindered, and in some cases, prevented participation despite interest. For example, women who felt unlikely to attend childbirth education sessions were not disinterested in the content but disliked that the pregnancy-focused programs began in the early morning or were held in a group-modality, both of which are common means of program delivery in carceral facilities [15]. Several participants expressed interest and desire to join the lactation program but were ineligible due to narrow facility policies and circumstances outside their control.

Participants also identified gaps in programming, felt additional resources were needed, and provided suggestions to improve existing program elements. Participants in this study agreed that pregnant and postpartum people do not receive adequate mental health care, education, support and resources while incarcerated. A clear need for education and additional support, particularly during the postpartum period, remains. Education, especially in childbirth planning and expectations for giving birth while in custody, was an area of need across participant responses. The childbirth education curriculum includes content on planning for childbirth and managing expectations for giving birth while in custody; however, this element of the program was not currently offered. All participants believed childbirth education would be beneficial and helpful and advocated for its reinstatement, emphasizing its necessity within prison settings. Many described feeling unprepared for childbirth, both generally and in the specific context of giving birth while in custody, thus corroborating findings in previous literature that highlight the distinct mental and emotional distress that accompanies pregnancy and childbirth while incarcerated [20, 21, 41].

Participants also emphasized the need for physical and emotional support throughout labor, childbirth, and postpartum period due to the well documented distress associated with separation from their newborns [20, 42–44] and when re-acclimating to prison following their birth. Although certain support group topics addressed aspects of separation and postpartum recovery, many participants expressed a desire for a more structured element of the program dedicated to postpartum support.

Potential solutions

To our knowledge, there are no studies that have examined the effectiveness of childbirth education on pregnancy outcomes among women who are incarcerated specifically; however, we may deduce from research about childbirth education among pregnant people in community-based samples. These studies indicate that childbirth classes positively impact pregnancy outcomes. Specifically, childbirth education classes that address concerns relevant to labor processes, pain and emotion management, and postpartum mental health, contribute to better outcomes including increased preparedness for childbirth, greater likelihood for vaginal delivery, reductions in fear and anxiety regarding labor and childbirth, and decreased occurrences of postpartum depression [45–47].

Relatedly, weekly sessions for group-based elements of the program are held in the morning; however, pregnancy and postpartum often bring physical challenges such as sleep disruptions, fatigue, pain, and morning sickness that can make early-morning participation difficult. Thus, it may be beneficial to consider pregnancy as a special case and offer tailored programming that accommodates these unique needs to increase program accessibility and participation given that participants were not disinterested in program content, but preferred sessions to be scheduled later in the day or desired more individualized support.

A potentially acceptable and feasible way to supplement existing program elements, offer more tailored and individualized services, and provide valuable postpartum support may be through the actualization of the program’s initial intent to offer doula services [19, 31, 32]especially given participants’ strong interest and support for its addition to the current program. Active and future programs in other states would benefit from incorporating this component as well. Doula support is linked to improved birth outcomes, including reduced premature birth, increased rates of spontaneous vaginal births, shorter labor, and greater satisfaction with the birth experience [48–50] and, in turn, may help mitigate the adverse effects of health disparities among underserved and high-risk pregnant populations.

Although still a relatively recent initiative, doula programs implemented in carceral settings show promise; pregnant people who have received doula support while incarcerated report feeling empowered during the birthing process and emotionally supported during the separation from their newborns [19, 32]. Additionally, prison-based doulas are known to play a vital role in promoting breastfeeding among women who give birth while incarcerated [15, 29]. Shlafer and colleagues (2018) found that pregnant individuals who discussed breastfeeding with their doulas were more likely to initiate breastfeeding at delivery compared to those who did not. For women who did initiate, breastfeeding was believed to be important to fostering an emotional bond with their newborn before being separated. In regards to continuation of lactation upon returning to prison, multiple states with prison-based lactation programs have successfully packaged and shipped breastmilk to caregivers, including infants with foster family placements, which could be an alternative to denying participation in lactation programming [15, 51].

Despite the importance of perinatal programs under current carceral practices in the U.S., it is important to note carceral environments are restrictive in nature and the practice of incarcerating pregnant people has significant health consequences due to limiting pregnant and postpartum people’s access to comprehensive perinatal care, support, and opportunities for health-promoting activities for mother-infant dyads. Thus, we must also advocate for state and federal policymakers to prioritize legislation that supports community-based alternatives to incarceration for pregnant and postpartum people. Supervised community-based programs allow women to continue to receive access to necessary services, such as quality, stable prenatal care, education and employment opportunities, individual and family counseling, housing, and substance use and mental health treatment, while continuing to reside with their children. Such programs could be a viable and cost-effective alternative to incarceration by improving maternal and child health, fostering mother-infant bonding, mitigating the negative effects of separation, and decreasing the need for child welfare intervention and foster care placements. Importantly, these programs maintain community safety while alleviating the physical, financial, and emotional burden often carried by kinship caregivers and foster families [52, 53]. Moreover, supervised community-based programs demonstrate positive, long-term impacts for pregnant and postpartum people with co-occurring difficulties including substance misuse and recidivism [54–56]further supporting the value of community based supervision programs for them, their families, and their communities.

Limitations

There are several limitations to note in the current study. First, our sample size was small and limited. Due to the COVID-19 pandemic, our study team was unable to conduct interviews with participants during their incarceration. As a result, all interviews were completed post-release, which narrowed our study sample by three quarters. Further, re-entry into the community post-incarceration is a challenging and vulnerable period and, for our population, may be compounded by postpartum stress which also may have influenced individuals’ decisions about participation. Another limitation was that all perinatal program support elements were not available to all participants due to the COVID-19 pandemic; therefore, it was difficult to ascertain the full scope of participant experiences. Finally, only two women participated in the lactation program; thus, our ability to capture a fuller range of participants’ experiences with this program element was limited. Despite the limitations, we believe that findings from the current study add to the existing knowledge of prison-based perinatal services, specifically regarding interest, perceived service needs, and acceptability.

Future directions

Although perinatal programs are becoming more prevalent in carceral settings, they remain limited in availability despite the distinct medical, emotional, and social needs of incarcerated pregnant and postpartum people. Prison-based perinatal programs addressing childbirth, lactation, and general mental health as well as the emotional needs specific to pregnant and postpartum people have the potential to enhance the quality of obstetric care provided in prisons. Moreover, these programs have the potential to improve maternal, fetal, and infant health outcomes. Continued research is needed to identify barriers and facilitators to program implementation and sustainment, as well as develop and evaluate strategies to address structural and institutional obstacles faced by program participants. Future studies should also examine how participation in prison-based perinatal programs influences pregnancy, childbirth, and postpartum experiences and outcomes over time.

Conclusion

Pregnant and postpartum people who are incarcerated have complex health care needs that are rarely met during incarceration. Our study provides insight into pregnant and postpartum peoples’ participation in a prison-based perinatal program in a Mid-southern women’s state prison. In general, most participants expressed interest in existing and proposed elements of the perinatal support program. Moreover, those who participated in one or more elements of the program viewed the elements positively and felt the elements were needed for improved well-being among pregnant and postpartum people who are incarcerated. As more carceral facilities look to implement new or expand existing perinatal support programs, it is imperative to consult with the pregnant and postpartum people to ensure services are adequate and effectively meet their needs.

Authors' contributions

MZ conceptualized the study. MZ and MKSS designed the study and collected data. MKSS and JH analyzed the data, drafted the initial manuscript, and iteratively revised the manuscript. MC and MZ provided revisions to the manuscript and all authors approved the final version prior to submission.

Funding

Execution of this study was supported by NCATS grant PTC2020-02 (PI: Zielinski), awarded by UAMS’ Translational Research Institute which is funded through the National Center for Advancing Translational Sciences (UM1 TR004909; PI: James). Manuscript preparation was also supported by K23DA048162 (PI: Zielinski), T32DA022981 (PIs: Zielinski & Fantegrossi), and K12TR004924 (PI: Steely Smith), which provided salary support for the first and last authors.

Data availability

The qualitative data generated and analyzed in the current study are not publicly available due to the sensitive nature of the data. The data that support the findings of the current study can be made available by the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The current project was reviewed and approved through the University of Arkansas for Medical Science’s Institutional Review Board. Informed consent was obtained from all study participants. Study methods were conducted in accordance with the Belmont Report and Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.