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. Author manuscript; available in PMC: 2026 Jun 14.
Published in final edited form as: J Obstet Gynecol Neonatal Nurs. 2025 Dec 20;55(3):287–299. doi: 10.1016/j.jogn.2025.12.001

Health Outcomes of Women on Community Supervision in South Central Texas During the Perinatal Period

Allison D Ihle 1, Ariadna Forray 2, Kimberly Hughes 3, Rebecca L Freese 4, Rebecca J Shlafer 5
PMCID: PMC13264111  NIHMSID: NIHMS2181664  PMID: 41435885

Abstract

Objective:

To assess the health outcomes of women on community supervision during the perinatal period and to analyze the associations between length of community supervision and perinatal health outcomes.

Design:

A cross-sectional survey study.

Setting:

Individual telephone interviews in San Antonio, Texas.

Participants:

Women aged 18 to 50 years (N = 60) on community supervision.

Methods:

We developed survey questions to measure participants’ perinatal health outcomes during pregnancy, childbirth, and the postpartum period. We used logistic regression to assess the associations between the length of community supervision and perinatal health outcomes.

Results:

Most participants had an average of 4 arrests (SD = 7) and 5 years of community supervision (SD = 3), gave birth before 38 weeks gestation (n = 43; 71%), and reported feelings of depression (n = 40; 67%) and anxiety (n = 31; 52%) during their most recent pregnancies. Most participants had inadequate social support during childbirth (n = 55; 92%). More than a third of the participants experienced partner violence while on community supervision (n = 21; 35%), and a quarter experienced violence during their most recent pregnancies (n = 15; 25%). For each additional year on community supervision before birth, the odds of experiencing a pregnancy complication were 1.63 (95% confidence interval = [1.08, 2.82]) times higher.

Conclusion:

The criminal legal system, although not designed to provide health care, should dedicate resources to address the perinatal health care needs of women while on community supervision.

Keywords: criminal legal system, maternal child health, perinatal health, probation

Of the 1.2 million women in the United States who experience incarceration (Wainstein, 2023), three fourths are of childbearing age from 18 to 50 years (Hayes et al., 2020). Most (n = 888,000; 74%) are prioritized to be released and placed on community supervision, a form of community-based legal system oversight monitored by officers and court systems that takes the place of jail while awaiting trial and/or formal incarceration in prison (Kajstura & Sawyer, 2024). Community supervision often lasts for a year or more and routinely requires participants to (a) pay restitution, also known as fees, to cover the costs associated with the time they spent in jail, community supervision, court fees, and urine analysis; (b) report to officers in the community; (c) take classes specific to parenting, recovery, or other behavioral issues; and (d) respond to spontaneous drug screens (Phelps, 2020). The frequency and type of requirements may vary depending on the geographic location and/or the severity of the criminal charge (Phelps, 2020).

The financial sanctions or fees and time requirements related to programming in community supervision can be challenging to meet (Diaz et al., 2024), and we speculate that they are especially difficult for those at the intersection of pregnancy, childbirth, and the postpartum period, also known collectively as the perinatal period, because of employment or travel restrictions from bedrest during pregnancy, childbirth, or recovery after birth. As the number of women on community supervision during their childbearing years increases, so does the need to address their perinatal health needs and outcomes (Crawford, Testa, Darilek, et al., 2024). In other words, the health of these women and their children depends, in part, on the ability of health care systems to confront the gaps in care within the criminal legal system that span beyond the confinement of jails and prisons to include community supervision.

Literature Review

Women affected by the criminal legal system were shown to experience disproportionate rates of adverse childhood experiences (DeHart & Lynch, 2021; Lawrence, 2024), sexual (Karlsson & Zielinski, 2020) or domestic violence (Rogers & Lockwood, 2025), and chronic conditions such as hypertension, diabetes, and mood disorders (Sufrin et al., 2019, 2020) before their initial incarceration compared with populations that never experienced involvement with the criminal legal system. Consequently, their children’s health can be negatively affected by elevated risks for premature birth, fetal death, low birth weight, and being small for gestational age (Sufrin et al., 2019, 2020).

These perinatal (Sufrin et al., 2019, 2020), sexual violence (Karlsson & Zielinski, 2020), domestic violence (Rogers & Lockwood, 2025), substance use (Phelps et al., 2022), and mood symptoms (Hawks et al., 2020) remain after incarceration as women transition back into their communities while on community supervision, and we speculated that this may influence perinatal outcomes. These increased risks illustrate the need to better understand the needs and improve the perinatal outcomes of women on community supervision following incarceration. Through a literature review, we found only four studies specific to perinatal health among women on community supervision that focused on the severity of postpartum substance use or mood disorder; however, no researchers evaluated these women’s health specific to pregnancy and/or childbirth (Crawford, Testa, Darilek, et al., 2024). Although community supervision is the most extensive form of legal oversight for women of childbearing age (Ghandnoosh, 2023), women’s health during pregnancy and childbirth experiences while on community supervision remain largely understudied (Crawford, Testa, Darilek, et al., 2024). Therefore, the purpose of this study was to assess the health outcomes of women on community supervision during the perinatal period and to analyze the association between length of community supervision and perinatal health outcomes.

The following research questions guided our study regarding women on community supervision: What are their pregnancy and birth outcomes? What is the rate of intimate partner violence during pregnancy? What is the quality of social support during the perinatal period? What are the self-reported postpartum mood disorder outcomes? and How does the length of time on community supervision influence perinatal outcomes in terms of gestational age at birth and mode of birth?

We hypothesized that women on community supervision would report high rates of adverse outcomes and that the length of community supervision would be positively associated with adverse birth outcomes. Said differently, we expected that women with longer community supervision sentences would report more adverse perinatal outcomes. We defined perinatal outcomes as those that occurred during pregnancy (rate of violence, contraception use, hypertension, and diabetes), childbirth (quality of support, spontaneous or medically necessary abortions, ectopic pregnancies, stillbirth infants, bleeding disorders, rate of induction, unplanned cesarean births, and vacuum-assisted births), and the postpartum period (self-reported postpartum mood symptoms, bleeding disorders, hypertension, diabetes, inadequate pain control, rate of violence, and infection) as well as among infants (resuscitation after birth, shoulder dystocia, low birth weight, small for gestational age, and NICU admission).

Methods

Design

Data from our study were drawn from a diversity supplement (3R01HD103634–04S2; principal investigator [PI]: Ihle [formerly Crawford]) from a national R01 that is being conducted across eight different states and prison systems (3R01HD103634–04S1; PI: Shlafer). Following institutional review board (IRB) approval (STUDY00000282), we used a cross-sectional design and the same survey tools from the parent R01 (3R01HD103634–04S1) to assess the perinatal needs and outcomes of women on community supervision.

We used a quantitative approach to ask survey questions in the form of a telephone interview to describe demographic characteristics, birth outcomes, rate of violence during pregnancy, quality of social support during childbirth, and self-reported postpartum mood symptoms during the most recent pregnancy while on community supervision.

Participants

We purposively sampled 60 women from a large metropolitan community supervision department in South-Central Texas. In this community supervision department, an average of 21,885 people are on community supervision per month. Most (n = 14,620; 67%) identify as Hispanic and are 22 to 50 years of age (n = 17,787; 81%), and about one quarter are women (n = 4,624; 26%) (Anderson, 2022). Women were eligible to participate if they identified as female, were 18 to 50 years old, resided in Texas, and experienced their most recent pregnancies, childbirths, and postpartum recoveries on court-mandated community supervision within the past 5 years.

With the help of research partners at the community supervision department, we sent batch emails with the study flyer to their clients. We invited participants to call the first author (A.D.I.) so they could be screened for inclusion, a process that took approximately 10 min. During this time, participants read an information sheet and had opportunities to ask questions about the study.

After the consent process, a member of the research team contacted women to enroll them in the study, a process that took approximately 5 to 10 min. After enrollment in the study, women received mailed copies of the information sheet and university-approved debit cards with a $0 balance. Once they confirmed receipt of the debit cards, their telephone interviews for the survey data collection with the PI were scheduled. After initial enrollment and verbal informed consent, we were unable to recontact 11 women to conduct data collection; therefore, we obtained IRB approval to consent more women until we had our target sample size of 60. A total of 71 women were consented, and 60 completed data collection. Following data collection, the study team paid participants $60 electronically through their debit cards for their participation.

Data Collection

We collected and managed data with Research Electronic Data Capture (REDCap; Harris et al., 2010), an electronic data capture tool that is hosted at the University of Texas at San Antonio’s School of Nursing. REDCap is a secure, web-based software platform that is designed to support data capture for research studies and to provide an intuitive interface for validated data capture, audit trails for tracking data manipulation, and automated export procedures for downloads to common statistical packages (Harris et al., 2010). The first author (A.D.I.) collected data during the telephone interview without video. The first author read the survey questions to each participant, which took approximately 45 min to 1 hour.

Measures

Participants were asked about their demographic characteristics and retrospective survey questions about their outcomes during pregnancy (rate of violence, contraception use, hypertension, and diabetes), childbirth (quality of support, spontaneous or medically necessary abortions, ectopic pregnancies, stillbirth infants, bleeding disorders, rate of induction, unplanned cesarean births, and vacuum-assisted births), and the postpartum period (self-reported postpartum mood and anxiety symptoms, bleeding disorders, hypertension, diabetes, inadequate pain control, rate of violence, and infection) as well as among infants (resuscitation after birth, shoulder dystocia, low birth weight, small for gestational age, and NICU admission) during their most recent pregnancies while on community supervision. We selected measures and created variables for our analysis based on the existing evidence of the factors that influence incarceration (Aslim et al., 2022; Bell et al., 2020; Dodge & Pogrebin, 2001) and adverse health outcomes during the perinatal period (Dyer et al., 2019; Liu et al., 2023; Sufrin et al., 2019, 2020).

Self-Report Demographic and Pregnancy History Survey.

We used a survey created by the research team that conducted the R01 to ask participants questions regarding age (18–25, 26–34, 35–44, or 45–50 years), education (eighth grade or less; some high school; high school diploma or GED; some college/postsecondary; associate degree; trade apprenticeship, licensure, or other certification program; or bachelor’s, master’s, or doctorate degree), marital status (married, single, divorced, separated, open relationship, or living with partner), incarceration history (What date did you get put on probation? When do you expect to be done with probation? How many times have you been put on probation in your lifetime?), and obstetric history (Was this pregnancy planned? Have you experienced prior pregnancies? What kind of pregnancy, childbirth, or postpartum complication did you experience with the most recent pregnancy while on community supervision?) (Table 1).

Table 1:

Participant Characteristics (N = 60)

Characteristic n %
Age, years
 18–25 16 27
 26–34 32 53
 35–44 11 18
 45–50 1 2
Race
 Black or African American 3 5
 Multiple 3 5
 Other 1 2
 White 53 88
 Hispanic/Latino 41 68
Employment
 Not employed 28 46
 Full-time 15 25
 Part-time 16 27
 Contract 1 2
Place of residence
 Home 25 42
 Apartment 26 43
 Group home 1 2
 Recovery center 2 3
 Homeless 6 10
Highest education level
 Eighth grade or less 3 5
 Some high school 9 15
 High school diploma/GED 23 38
 Some college/Postsecondary 14 23
 Associate degree 3 5
 Trade apprenticeship, licensure, or other certification program 6 10
 Bachelor’s, master’s, or doctorate degree 2 3
Relationship status
 Married 6 10
 Single 32 53
 Divorced 2 3
 Separated 3 5
 Open relationship 1 2
 Living with partner 16 27
M SD
Prior times arrested 4 7
Estimated time on community supervision, years 5 3
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Patient Health Questionnaire and Generalized Anxiety Disorder.

The two-item Patient Health Questionnaire (PHQ-2) and two-item Generalized Anxiety Disorder (GAD-2) tools (Villarreal-Zegarra et al., 2023) are valid and reliable tools used to measure depressed mood, anhedonia, and anxiety symptom frequency and severity within the past 2 weeks (Table 1). We chose to use these modified and shortened tools because of familiarity and to decrease participant burden. We summed responses separately for the PHQ-2 and GAD-2 to yield a total score with clinically defined cut-points (e.g., cut-off scores >3 were considered clinically elevated; Staples et al., 2019). The PHQ-2 (α = .83; ω = .80) and the GAD-2 (α = .74; ω = .70) showed internal consistency scores and good reliability (Staples et al., 2019; Villarreal-Zegarra et al., 2023).

Abuse Assessment Screening.

The Abuse Assessment Screening tool (AAS; McFarlane, 1992) is a five-item measure that is used to total and average incidents of abuse perpetrated against childbearing women (Table 1). The screening tool has been tested with pregnant women specific to abuse throughout their lives and during pregnancy and was used to ask the participants in our sample the following questions: Have you ever been emotionally or physically abused by a partner or someone important to you? and Within the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? The AAS has a sensitivity of 93% to 94% and a specificity of 55% to 99% (McFarlane, 1992). We added this measure to this study to observe violence that may take place in the community setting (Crawford et al., 2022; Karlsson & Zielinski, 2020; Rogers & Lockwood, 2025).

Social Support and Post-Birth Survey.

The research team that conducted the R01 created and used the Social Support and Post-Birth Survey to ask participants about their experiences of social support while giving birth when they were on community supervision (On a scale of very poor, poor, acceptable, good, to very good, how would you rate the care you received from your support person? On a scale of strongly disagree, disagree, neutral, agree, to strongly agree, did your support person advocate for you when you needed it?) (Table 1). Therefore, we used the same measure in our supplement study to evaluate any differences in outcomes between women on community supervision and those who are currently incarcerated within prison systems.

Analysis

The research team summarized participant demographics and obstetric and health history with mean (and standard deviation) for continuous variables and count (%) for categorical variables (Tables 1 and 2). We conducted separate logistic regression models by outcome to observe the length of time on community supervision and its influence on perinatal outcomes, violence during pregnancy, limited social support during labor, and postpartum mood and anxiety symptoms.

Table 2:

Regression Results of Criminal Legal System Involvement and Its Association on Perinatal Outcomes

Outcome Predictor of Interest Estimate OR 95% CI LL UL Wald Chi-square p Value
Perinatal complication(s) Time on probation prior to birth 0.49 1.63 1.08 2.82 4.12 .04
Prior times in jail −0.04 0.96 0.85 1.04 0.77 .38
Patient Health Questionnaire (PHQ, 2 items) Expected time on probation, years −0.09 0.92 0.74 1.12 0.69 .40
Prior times in jail −0.05 0.95 0.79 1.04 0.69 .45
Generalized Anxiety Disorder (GAD, 2 items) Expected time on probation, years 0.10 1.10 0.91 1.34 0.99 .32
Prior times in jail 0.09 1.09 098 1.31 0.99 .26
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Note. OR = odds ratio; CI = confidence interval; LL = lower level; UL = upper level. Perinatal complications from most recent pregnancy while on community supervision to include the following: during pregnancy (rate of violence, contraception use, hypertension, and diabetes), childbirth (quality of support, spontaneous or medically necessary abortions, ectopic pregnancies, stillbirth infants, bleeding disorders, rate of induction, unplanned cesarean births, and vacuum-assisted delivery), and the postpartum period (self-reported postpartum mood and anxiety symptoms, bleeding disorders, hypertension, diabetes, inadequate pain control, rate of violence, and infection) as well as with infants (resuscitation after birth, shoulder dystocia, low birth weight, small for gestational age, and NICU admission).

All models were adjusted for age, relationship status, and employment status.

We adjusted for possible confounders such as age, marital status, employment status, education status, and participant’s living situation. These variables may influence a person’s financial stability, social support, and access to socioeconomic resources, which are protective factors to rearrest, also known as recidivism. For example, the older a person is, the more likely the person may have obtained higher education, which positively influences housing stability and reduces the likelihood of incarceration (Bell et al., 2020; Yukhnenko et al., 2020). The p values were two-sided and are considered at the .05 level for statistical significance. We completed all analyses in R Version 4.4.1 (R Core Team, 2024).

Results

Participant demographics and perinatal outcomes are outlined in Table 1. Participants were arrested on average 4 times (SD = 7) and spent an average of 5 years (SD = 3) on community supervision.

Pregnancy Outcomes

Most participants (n = 47; 79%) stated that their most recent pregnancies while on community supervision were not planned. More than half of the sample (n = 31; 51%) became pregnant by choosing to not use the contraception they had on hand, whereas others (n = 16; 26%) became pregnant by not having access to contraception because they lacked money or the contraception was defective such as a ripped condom (n = 4; 6%). Several pregnancies were the results of rape (n = 7; 11%) or not having access to abortion health care (n = 2; 4%). Participants had on average 3 prior pregnancies (range = 1–10, M = 3, SD = 2) that resulted in vaginal (n = 48; 80%; SD = 2) or caesarean (n = 25; 42%; SD = 1) births. Most participants (n = 45; 75%) experienced pregnancy complications in the past before their most recent pregnancies while on community supervision, which included outcomes such as spontaneous or medically necessary abortions, ectopic pregnancies, and stillbirth.

Childbirth and Postpartum Outcomes

Childbirth outcomes included participants’ perceptions of the quality of their support during their most recent births while on community supervision. Most participants (n = 49; 82%) had support in the hospital during birth from their partners (n = 28; 47%), parents (n = 9; 15%), friends (n = 7; 11%), or siblings (n = 3; 5%). Many participants (n = 38; 63%) noted that they could not ask questions, but others (n = 44; 73%) noted that they were not advocated for during childbirth. Most participants (n = 55; 92%) stated that they would have liked additional support such as a doula.

Many participants (n = 37; 61%) had complications that affected childbirth. More than half of the participants (n = 32; 54%) were induced during their most recent pregnancies while on community supervision, and some (n = 5; 8%) stated that induction was medically indicated because of complications such as diabetes and hypertension. Most participants (n = 55; 92%) had live births, whereas the rest had complications such as miscarriage (n = 3; 5%), infant loss (n = 1; 2%), and stillbirth (n = 1; 2%). Others (n = 10; 16%) had bleeding that required blood transfusion, unplanned cesarean births (n = 3; 5%), and vacuum-assisted births (n = 3; 5%).

Postpartum outcomes included bleeding issues that required blood transfusion after childbirth (n = 9; 15%), preeclampsia (n = 7; 12%), inadequate pain control (n = 5; 8%), and postpartum infection (n = 3; 5%). Some participants experienced partner violence during their most recent pregnancies (n = 21; 35%) and within the past year (n = 15; 25%).

Regarding mental health conditions, most participants (n = 45; 75%) had formal psychiatric diagnoses, including depression (n = 40; 67%), anxiety (n = 31; 52%), posttraumatic stress disorder (n = 1; 22%), and bipolar disorder (n = 13; 22%). Most participants (n = 55; 92%) stated that they did not receive mental health care services before their last arrests and pregnancies while on community supervision.

Furthermore, during the most recent pregnancies while on community supervision, 33% of participants (n = 20) had cut-off scores >3 for the PHQ-2, which indicated probable major depressive disorder. Major depressive disorder is a common and serious mental health condition characterized by a persistently low mood or loss of interest or pleasure in most activities that lasts for at least 2 weeks and causes significant impairment in daily functioning (Marx et al., 2023). In addition, most participants (n = 34; 57%) had cut-off scores >3 for the GAD-2, which indicated symptoms consistent with generalized anxiety disorder, a common disorder characterized by excessive, persistent, and uncontrollable worry about a variety of events and activities.

Infant Outcomes

The outcomes of infants whose mothers were on community supervision included resuscitation after birth (n = 11; 18%) and shoulder dystocia (n = 2; 3%). Infant birth weight averaged 7 pounds (SD = 1). Some participants (n = 23; 39%) disclosed complications after birth that affected their infants such as the need to be admitted to the NICU (n = 11; 18%).

Length of Time on Community Supervision and Association With Perinatal Outcomes

Finally, we considered how the length of time on community supervision was associated with perinatal outcomes (Table 2). We found that for every 1-year increase in time on community supervision, the odds of ever having outcomes during pregnancy (increased rate of violence, limited contraception use, hypertension, and diabetes), childbirth (quality of support, spontaneous or medically necessary abortions, ectopic pregnancies, stillbirth infants, bleeding disorders, rate of induction, unplanned cesarean births, and vacuum-assisted birth), and the postpartum period (self-reported postpartum mood and anxiety symptoms, bleeding disorders, hypertension, diabetes, inadequate pain control, rate of violence, and infection) as well as with infants (resuscitation after birth, shoulder dystocia, low birth weight, small for gestational age, and NICU admission) were 1.63 times higher (95% confidence interval = [1.08, 2.82], p = .042) when accounting for age, relationship status, and employment status. Evaluating outcomes during childbirth, we found that most participants (n = 43; 71%) gave birth prior to 38 weeks gestation (M = 37; SD = 6) and that only a few (n = 3; 5%) stated that their inductions were medically necessary. We did not find an association between time on community supervision and gestational age.

Discussion

Although community supervision is considered less disruptive than incarceration in jail or prison (Ghandnoosh, 2023; Phelps, 2020), participants reported barriers that inhibited access to appropriate perinatal health care services such as limited economic stability, preventative obstetric and mental health care, and social support, findings that aligned with those of prior researchers (Hawks et al., 2020; Phelps, 2020; Phelps et al., 2022). The perinatal outcomes of the participants in our study were similar to those of populations in jail and prison settings, including high rates of unplanned pregnancy, complications such as preterm birth, high induction rates (Sufrin et al., 2019, 2020), experiences of violence (Karlsson & Zielinski, 2020; Rogers & Lockwood, 2025), mood symptoms (Hawks et al., 2020; Phelps et al., 2022), and limited social support (Kozhimannil et al., 2013; Longmate et al., 2021). These complications during pregnancy place risks on the overall health of these women, their children, and any offspring they may have in subsequent pregnancies. The criminal legal system is not designed to provide health care and lacks a formal process to assess or respond to the perinatal health care needs and health status of women on community supervision. However, increasing evidence points to the essential need to address health and well-being with community-based oversight to prevent maternal morbidity and mortality (Crawford, Testa, Darilek, et al., 2024) and rearrest or recidivism (Aslim et al., 2022; Bell et al., 2020; Yukhnenko et al., 2020).

In addition, health self-efficacy and access to health care are protective factors for recidivism (Aslim et al., 2022; Syasyila et al., 2025). We found that most participants reported limited access to mental health care services before their most recent arrests and unplanned pregnancies while on community supervision. Likewise, more than half of the participants in our sample had self-reported symptoms of depression and anxiety and instances of recidivism during the perinatal period while on community superivision. Hence, recidivism may have been reduced if they had access to preventative mental health services. The recidivism rate in women during their childbearing years is high (Bell et al., 2020), and as the rate increases, so does adjacent harm to these individuals and their families such as separation of children from their caregivers (Austin et al., 2022; Shlafer et al., 2019), trauma (DeHart & Lynch, 2021), perinatal morbidity and mortality (Hessami et al., 2023; Sufrin et al., 2019, 2020, 2023), and negative socioeconomic implications (Bryan, 2023; Yukhnenko et al., 2020). In other adult populations, researchers noted that the health of those on community supervision, such as those with substance use or mood disorders, must be considered in program implementation and sustainment to achieve health equity and successful reintegration into society (Hawks et al., 2020; Phelps et al., 2022) and to address chronic conditions such as asthma, cardiovascular disease, and cancer (Puglisi & Shavit, 2020). This notion may also apply to women during the perinatal and postpartum periods in community supervision spaces; therefore, preventative measures to lower adverse outcomes must be considered in future program implementation and sustainment.

Limitations

We did not formally calculate sample size for this exploratory study. In addition, the sample was drawn exclusively from South-Central Texas, a predominantly Hispanic region of the state, so the generalizability of our findings is limited. The size and location of the sample were related to funding constraints, the exploratory nature of this study, and reliance on community partners such as the local community supervision department to gain access to this hard-to-reach population. Despite these limitations, the characteristics of the sample add to the literature by providing context for the perinatal health outcomes of a racial/ethnic minority group (i.e., women who identify as Hispanic) that has been historically limited in past research (Dreyfus et al., 2023; Laguna-Torres et al., 2023).

Our study was further limited by using cross-sectional, self-reported, retrospective data, which limited the reliability of the results and our ability to make causal claims. Studies using a longitudinal design that capture data in real time may address this limitation, and this is a valuable area for future research.

Implications

The community supervision setting may be an effective context in which to target preventative health intervention programs such as specialty courts specific to the needs of women during the perinatal period. Specialty courts are programs that work in tandem with jail, court, and community supervision departments to give special considerations to individuals while they are on community-based criminal legal oversight (Morgan et al., 2016). For example, specialty courts may provide housing, medication assistance therapy, classes, or child care services so that individuals with issues can transition more effectively into the community while on community supervision (Morgan et al., 2016).

Populations in which specialty courts show promising results include adolescents (Godoy et al., 2023) and those experiencing substance use (Easter et al., 2021), homelessness (Dodson, 2018), and prostitution (Blakey et al., 2017). Likewise, women who are under community supervision during their childbearing years may benefit from targeted health care solutions and tailored interventions in a specialty court model that supports their health during the perinatal and postpartum periods and the health of their children.

Because program implementation in community supervision spaces is limited (Van Deinse et al., 2023), especially specific to women’s health during the perinatal period (Crawford, Testa, Darilek, et al., 2024; Crawford et al., 2025), we use the Exploration Phase of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework (Aarons et al., 2011) to report the implications of our findings. The tenants of the EPIS framework include outer, inner, bridging, and innovative factors between systems that can be used to inform next steps. According to a systematic review (Moullin et al., 2019), the EPIS framework has been extensively applied in health and social sciences, particularly in the public sector to inform programming implementation and sustainment (Leavy et al., 2017; Patterson et al., 2012; Peltzer et al., 2016; Willging et al., 2016).

Outer level factors.

Outer level factors include leadership qualities outside of community supervision and health care spaces that serve the needs of this population, funding, policies, interdisciplinary networks, participant advocacy, and the characteristics of participants (Moullin et al., 2019). Regional, state, and federal leaders must consider the perinatal needs and rights of women and their children while on community supervision. Although attempts have been made to address maternal morbidly and mortality across sectors within the criminal legal system, policies that mandate standard, evidence-based, perinatal health care to those on community supervision are limited (Crawford, Testa, Corbett, et al., 2024; Unlu et al., 2020). Furthermore, criminal legal system reforms such as allowing those with felony convictions to vote, access housing, and work have been suggested to implement among adult populations (Lattimore, 2022) and may significantly reduce barriers.

Inner level factors.

Inner level factors include elements within institutions and departments (Moullin et al., 2019). For example, inner factors may be the leadership qualities, programming and protocols, quality monitoring and support, staffing processes, and individual characteristics within people working within community supervision and health care departments that provide care for women during the perinatal period (e.g., the individual perceptions of health care staff or officers within community supervision; Moullin et al., 2019). The economic and time requirements of community supervision for individuals in Texas (Reichstein, 2015) create additional barriers to care for women during the perinatal and postpartum periods. Most of our participants were unemployed or underemployed because of the physical and time constraints of pregnancy, childbirth, postpartum recovery, and/or felony criminal records. Similarly, other researchers found that most jobs that allow those with felonies to apply are often dangerous for those who are pregnant or recovering from childbirth (Corchero-Falcón et al., 2023).

In addition, safe housing is difficult to find for individuals with felony charges (Bryan, 2023; Russell et al., 2021) like most of our sample. These barriers put the safety of childbearing women at risk while on community supervision by increasing the chances of violence and raising recidivism rates related to rearrest for technical violations, not finding employment, or defaulting on payments. Thus, we recommend measures for community supervision departments to consider while serving the needs of women during the perinatal period (Table 3).

Table 3:

Community Supervision Programming to Address the Needs of Women

Policy Solution Rationale
Delay or waive employment requirements until later than 1 year after birth It is difficult for women to find employment that is safe and flexible during the perinatal and postpartum periods that accommodate their health status and/or schedules with young children or doctor’s appointments.
Implement a process to delay or waive community service hour requirements or give alternatives to community service such as payment options Community service opportunities are often located in places that require manual labor and are unsafe during the perinatal and postpartum periods. This population also lacks financial stability, which makes paying for community service hours difficult.
Implement a process to delay or waive restitution payments during pregnancy, birth, and the first year after birth Restitution, or fees that are required to be paid throughout the duration of community supervision, average more than $60 per month. These fees make it difficult for women to support their families and manage their health. In addition, the barriers to employment make successful payment difficult.
Provide programming and economic support for child care for those with children under the age of 12 years Transportation and child care factors make community supervision difficult for caregivers of young children or for those recovering from childbirth.
Prioritize virtual visits for caregivers on community supervision with young children Caregivers should be prioritized for virtual visits, especially if they are pregnant, on bedrest, recovering from pregnancy (within the first year), and/or have young children under the age of 12 years.
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Bridging factors.

Bridging factors include community and academic partnerships (Moullin et al., 2019). Interdisciplinary partnership among community supervision (including jail, prison, and health care delivery systems), recovery programs, and other community-based programs (such as schools, employment agencies, and foster care) may enhance the community’s ability to address the gaps in care and target barriers to achieving optimal perinatal health for women. Collaboration between systems and departments may also broaden funding opportunities and improve mechanisms to deliver adequate health care and support to patients (Van Deinse et al., 2023) especially during pregnancy, birth, and the postpartum period.

Innovation factors.

Innovation factors include the application of evidence-based practice (Moullin et al., 2019). We recommend applying evidence-based practice to the care of child-bearing women inside and outside of community supervision because of the high rates of morbidity and mortality experienced by this population (Dyer et al., 2019; Sufrin et al., 2019, 2020). In Table 4, we suggest strategies for those who provide health care to women during the perinatal period while on community supervision.

Table 4:

Evidence-Based Practice Strategies for Health Care Providers

Strategy Rationale
Education Comprehensive education about the pathways to women’s incarceration and reasons why delaying induction and shared decision-making may help to improve quality of care and rapport and lower biases (Zhao et al., 2020).
Community health workers or doulas Use of CHWs or doulas in community spaces can bridge access to care and provide timely, culturally tailored, and nonjudgmental support. These services during nonacute times between standard medical care appointments may offset worsening symptoms and unnecessary visits to local emergency rooms (Haiman et al., 2024; Perry et al., 2021; Steel et al., 2015).
Universal screening for mood disorder and substance use disorder The increased risk of preterm birth is greater among women experiencing posttraumatic stress disorder and mood disorder (Yonkers et al., 2014). Therefore, implementation of standardized screening without criminal legal system repercussions should be considered.
Trauma-informed approach to substance and mood disorder treatment Applying the six principles of trauma-informed care can enhance effectiveness, engagement, and sustained abstinence (Allen et al., 2024).
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Note. CHW = community health worker.

Conclusion

We applied the EPIS framework to inform future programming that addresses the perinatal outcomes of women on community supervision during the perinatal and postpartum periods and their children in South-Central Texas. The criminal legal system, although not designed to provide health care, should dedicate resources to address the perinatal needs of women while on community supervision. We suggest targeted, gender-responsive, trauma-informed interventions across departments and organizations inside and outside of community supervision and health care spaces that acknowledge the unique outcomes and needs of childbearing women.

ACKNOWLEDGMENT

The research presented here uses data collected from a large, urban Community Supervision & Corrections Department, Bexar County, in the southwestern state of Texas. The views expressed here are those of the authors and do not necessarily represent those of the jurisdiction or other data contributors. Any errors are attributable to the authors.

FUNDING

Supported by the Eunice Kennedy Shriver National Institute of Health and Human Development, National Institutes of Health (R01HD103634), and the National Center for Advancing Translational Sciences, National Institutes of Health (UM1TR 004405). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

CONFLICT OF INTEREST

The authors report no conflicts of interest or relevant financial relationships.

Contributor Information

Allison D. Ihle, assistant professor, School of Nursing, The University of Texas at San Antonio, San Antonio, TX.

Ariadna Forray, Associate Dean and Director, Office for Women in Medicine and Science, Yale University, New Haven CT..

Kimberly Hughes, assistant professor, School of Nursing, The University of Texas at San Antonio, San Antonio, TX..

Rebecca L. Freese, senior biostatistician, Clinical and Translational Science Institute, University of Minnesota Biostatistical Design and Analysis Center, Minneapolis, MN.

Rebecca J. Shlafer, associate professor, Department of Pediatrics, University of Minnesota, Minneapolis, MN.

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