Reproductive Health Care for Incarcerated People: Advancing Health Equity in Unequitable Settings

Abstract

There are over 150,000 incarcerated females in the U.S. Structural inequities, including racism, adversely affect the reproductive health outcomes, autonomy, and access to care that people in custody face. This article reviews the status of reproductive health and health care among incarcerated women and describes ways that community Ob/Gyn’s can address health inequities by providing comprehensive, compassionate care to incarcerated people, especially when they come to community settings for care while they are in custody. In order to address reproductive health disparities and inequities that adversely affect incarcerated individuals, community providers can implement these recommendations and also engage in advocacy.

“I am a human being”.

I will never forget the day that I was wheeled into the clinic to see a doctor. I was shackled, I was in a prison uniform, and I was escorted by two armed correctional officers. I will live forever with the images of seeing other patients recoil as I was wheeled by – like I [was] someone to be feared. I struggle with the memory of how the medical staff acted as if I was a burden to be dealt with and dismissed as quickly as possible. As if treating me was beneath them. I was, I am a human being – I am deserving of dignity and compassion and not derision and fear. I am home now and yet each time I return to see my providers, I feel the shame and stigma that continues to hang unspoken in the air.

When an incarcerated individual is transported to a community-based provider for care, how we treat and care for them must change. People respond to how they are perceived and treated. Why someone is incarcerated should never enter the treatment space. The same dignity, respect and confidentiality that is afforded to other patients must extend to those who are incarcerated.

Background

These words from co-author and formerly incarcerated woman Kimberly Haven exemplify the connections between health disparities in a broad sense and the everyday, lived health experiences of people affected by them. Since the 1970s, there has been an exponential rise in the number of people behind bars in the U.S. For women, incarceration numbers increased more than 800% from 1980 to 2019 and Black women are imprisoned at twice the rate of white women.¹ This phenomenon of mass incarceration has resulted not from a direct rise in violent crime, but from a constellation of policies grounded in structural racism that have entailed harsher punishment for drug-related crimes; divestment from mental health and social safety net services; over-policing of Black communities; and draconian, prolonged sentencing laws.² Mass incarceration has profound negative health effects on families and communities—it is both an upstream, social determinant of health and a downstream consequence of other social determinants of health, such as poverty, homelessness, and racism.

This trend has played out in distinct ways for women. Around 1.2 million females are arrested annually, and the majority of incarcerated women are of reproductive age, mothers, primary caregivers to young children, and they are incarcerated for nonviolent charges.^1,3,4 Although often overlooked, incarcerated women have distinct reproductive health needs that Ob/Gyn’s should be attuned to. In this article, we review those health needs and highlight what Ob/Gyn’s can do to care for incarcerated patients when they come to community settings, while they are in custody, and when they return to their communities.

Language and Framing

We frame the health inequities experienced by incarcerated women through the lens of reproductive justice, a framework created by and centering the reproductive experiences of Black women and others whose reproduction has been systematically devalued.⁵ Through policies and practices both behind bars and in communities, the U.S. carceral system violates the core tenets of reproductive justice — the right to have children, the right not to have children, and the right to parent with dignity and safety.⁵

It is important to use humanizing language when referring to or interacting with incarcerated individuals and avoiding stigmatizing terms that label this group solely according to their incarceration status (Table 1). Ob/Gyn’s should also be aware of the differences between prison, jail, juvenile detention, immigration detention, and community supervision, as these have different implications for health and health care (Table 1). Most incarcerated women will eventually return to their communities; thus, what happens (or does not happen) to their health behind bars extends into the community. In this article, we use gender inclusive language to acknowledge that not all individuals who are pregnant identify as women; however, when we cite published data that report “women,” we use this terminology. This article does not address transgender health care services for incarcerated people.

Table 1.

Terminology and Definitions of Incarceration Facilities

Humanizing language
Instead of using…	Use:
Offender, inmate, prisoner, felon, convict, ex-offender, ex-felon	Individual(s)/person/people experiencing incarceration; incarcerated individual(s)/person/people For people leaving prison/jail to return home: returning citizen, returning individual Rationale: Incarceration is a descriptor of a person at a specific moment in time, not a fixed identity
Correctional facility	Carceral facility/institution Rationale: ‘correctional’ implies that incarceration exists to correct the individual. However, incarceration results not simply from an individual’s alleged criminal behavior, but bias and discrimination in systems, systems that themselves need to be corrected
Types of incarceration & criminal legal system involvement
Facility or system	Characteristics
Jail	Houses people who have been arrested, are awaiting trial (i.e., have not been convicted of a crime) and cannot afford bail, are awaiting sentencing for a convicted crime, are serving a sentence for a misdemeanor level crime Under local control, usually the locally elected sheriff Short stays can range from a few hours, days, weeks but usually not more than one year (average is 25 days); can extend to more than one year depending on courts/legal system processing
Prison	Houses people who have been convicted of a felony-level crime and people who have violated the terms of their parole Under state (state department of corrections) or federal (Federal Bureau of Prisons) control May be geographically far from an individual’s home community Sentences typically longer than one year (average is 2.6 years)
Juvenile detention	Houses youth who have been charged with or convicted of certain crimes In some states, minors may serve time in adult jails or prisons Individual facilities may be under state or county jurisdiction
Immigration detention	Confines non-U.S. citizens on the basis of migration, not criminal, related charges Under the jurisdiction of federal Homeland Security Housed in Immigration and Customs Enforcement (ICE) facilities or in local jails
Probation	Court ordered monitoring/reporting for someone convicted of certain crimes, someone who was serving time in jail for a crime Accompanied by behavioral and geographic restrictions and surveillance
Parole	Form of conditional, early release from a prison sentence Accompanied by behavioral and geographic restrictions and surveillance

Health Care Delivery Behind Bars

The availability of reproductive health care for incarcerated people is variable and often limited. While institutions of incarceration are legally and constitutionally required to provide access to health care, no mandatory standards or oversight systems exist. Although the American College of Obstetricians and Gynecologists (ACOG) and other organizations have published recommended guidelines for comprehensive reproductive health care for incarcerated people, there are no requirements for facilities to follow these.⁶ Consequently, each institution determines its own health care policies and services, with some providing comprehensive preventive, acute, and chronic health care and many others providing sparse care.

Medicaid does not cover care for incarcerated individuals and most private insurers suspend coverage; thus, carceral facilities/agencies are responsible for paying for health care costs. Many facilities will contract a private prison health company to administer an agreed-upon set of health care services. Some facilities charge patients a co-pay to access health care services, which deters people from seeking care. What’s more, medical record systems are not standardized, and some facilities use only paper charts, creating care challenges for community providers during and after incarceration.

Service delivery arrangements are also variable. Some facilities have nurses on-site 24/7 with or without on-site physicians/advanced practice clinicians and mental health support at designated times; others transport patients off-site for care; others have no nursing or clinical staff on-site and rely on officers to triage health concerns and act as gatekeepers to healthcare. Furthermore, unlike free-world patients, individuals who are incarcerated do not have the freedom to choose their physician or location of services, nor can they contact their doctor directly for questions, concerns, or follow-up needs related to their condition.

Scope of Reproductive and Other Health Care Needs and Services

Incarcerated women have higher rates of chronic disease, substance use disorder, mental illness, and trauma as compared to the general public.⁷ Various structural barriers before incarceration may inhibit access to regular healthcare, resulting in higher rates of undiagnosed or untreated chronic illness upon prison/jail entry.⁶ Such disparities are amplified by incarceration, as imprisonment inherently exacerbates chronic conditions due to health risks such as stress, violence, sexual assault, injury, communicable diseases, and poor nutrition, sanitation and housing.

Gynecological health

Incarcerated women experience higher rates of irregular menstrual bleeding. Access to menstrual materials is often inconsistent or inadequate.⁶ Sexually transmitted diseases are disproportionately elevated among incarcerated women and may have occurred prior to incarceration or by sexual assault while in custody.⁶ Cervical and breast cancer rates are increased in part due to limited access to preventive health services before and during incarceration.

Contraception

The majority of females entering incarceration have been sexually active with men and are not using regular contraception; most plan to be heterosexually active and most (though not all) would like to avoid pregnancy upon returning to their communities.⁶ Yet, access to reversible contraceptive methods in prisons and jails is inconsistent and many facilities will not even permit women to continue their pre-incarceration method of contraception.⁸ Studies have found that the majority of incarcerated women would like to access contraception in custody.⁸ However, the diminished autonomy that is inherently part of incarceration can lead to overt and subtle contraceptive coercion. Women have reported pressure from prison and hospital personnel to obtain contraception, including rewards for those who agree to long-acting reversible contraceptives (LARC) or sterilization, and punishment for those who do not.⁹ From 2006–2010, over 100 women in California prisons were unlawfully sterilized. The history of coercive or forced contraception has disproportionately affected women of color. ACOG guidelines state that sterilization generally should not be performed on incarcerated people.⁹ Thus, while carceral facilities should provide access to contraception, it must be done in ways that mitigate the potential for coercion, such as providing access to the full range of U.S. Federal Drug Administration (FDA)-approved reversible methods, centering counseling on patients’ reproductive goals, and separate counseling visits prior to LARC placements.

Pregnancy and postpartum care

Nearly 58,000 admissions of pregnant people to prisons and jails occur each year.^10,11 Many of these pregnancies will end in custody, mostly live births, and some people will leave incarceration while still pregnant. The only prospective study of pregnancy outcomes in custody, the Pregnancy in Prison Statistics (PIPS) study, documented that, at six jails, 22 state prisons, and all federal prisons, there were nearly 900 live births, 87 miscarriages, and 44 abortions in a one year period.^10,11

Before the Supreme Court overturned Roe v. Wade in 2022, incarcerated individuals in all states had a constitutional right to abortion. Even under those legal protections, however, abortion was not consistently available, whether due to prohibitive facility policies or other barriers such as self-pay requirements.¹² With the protections of Roe no longer in place, incarcerated individuals will experience even more disparities in abortion access, as those in states where abortion is illegal cannot travel out of state for abortion.

The prison/jail environment exacerbates pregnant people’s underlying risk factors for adverse outcomes through stress, inadequate nutrition, lack of exercise, and violence. A 2022 study found that incarceration was associated with greater odds of preterm birth, abruption, and antepartum hemorrhage.¹³ Access to healthy nutrition and appropriate physical activity during pregnancy are variable for incarcerated people; and pregnant people can only access food at scheduled mealtimes and do not have choices in what they eat. Although prenatal care is required under the Eighth Amendment, no detailed federal standards ensure the provision of the standard of care.

People who give birth in custody must rely on officers as gatekeepers to triage their labor symptoms and contact medical personnel. This has meant that, though rare, some women have given birth in jail cells. Some prisons and jails partner with doulas who may provide support during pregnancy, labor and birth, postpartum and with lactation; however, these programs are not universal and are underfunded.¹⁴ Furthermore, as discussed in greater detail below, pregnant people may be shackled during pregnancy, transport, labor, birth, and the postpartum period, despite established medical risks, human rights violations, and laws.⁶

After birth, mothers are usually separated from their infant, either at hospital discharge or in the immediate postpartum period. This division inhibits bonding with the newborn and the initiation of breastfeeding. A qualitative systematic review of pregnancy and childbirth during incarceration found that incarcerated women’s most significant and devastating mental health concern was the traumatic separation from their newborn after birth.¹⁵ These women have reported reluctance to initiate breastfeeding due to fear of emotional attachment to the infant or feeling uncomfortable in the presence of officers.¹⁵ Upon return to the carceral facility, lactation is further limited and dependent on institutional policies. Only seven of 22 prisons and two of six jails in the PIPS study had written policies on lactation, mostly just allowing milk expression to maintain supply but not to be stored and delivered to infants.¹⁶ Programs called “nursery programs,” where infants reside with mothers in the prison, may make it easier to bond with their newborn or breastfeed, but they carry limitations, such as restrictive criteria to participate and the over-emphasis on incarceration instead of community alternatives.

Mental health, trauma, and substance use

Seventy percent of incarcerated women have a mental health condition, and up to 80% have report prior histories of trauma.¹⁷ Prevalence of substance use disorder among incarcerated women is estimated to be 70%, and the PIPS study found that 26% of pregnant women in prison had opioid use disorder (OUD).^18,19 Despite the established standard that pregnant people with OUD should be on medications for opioid use disorder (MOUD) with methadone or buprenorphine, the majority of prisons and jails do not provide full access to MOUD in pregnancy, which means thousands of pregnant people with OUD will endure withdrawal in custody, with increased maternal and fetal risks.^19,20 Even facilities that provide MOUD during pregnancy, most discontinue treatment after birth.¹⁹ Stopping medication postpartum is particularly dangerous given high rates of both postpartum and post-release overdose.

Menopause

Women aged 55 years and older are among the fastest-growing age group in prisons, and emerging data show that their health care needs are not adequately addressed. Women may experience vasomotor symptoms including hot flashes and night sweats, without access to symptom alleviating measures like ice, fans, and changes of clothes. Changes in hormone levels also contribute to mental health disorders, as well as weight gain and osteoporosis, further exacerbated by poor diet, low exercise, and lack of vitamin D (due to low sun exposure) in prisons and jails. Data suggest that women are ignored by prison staff if they complain of menopausal symptoms and may not receive basic supplies for perimenopausal symptoms like heavy bleeding.^21,22

Caring for Incarcerated Patients in the Community

When patients present for care at a community site — clinic or hospital — they are accompanied by one or more armed officers. Thus, incarcerated individuals may experience public rejection, re-victimization, and negative self-perception while seeking and receiving off-site medical care. As such, it is all the more important that the care patients receive outside of carceral facilities is provided in ways that uphold an individual’s dignity and humanity. Medical professionals should work to mitigate further trauma within a clinic or hospital through policy and practice (Table 2).

Table 2.

Hospital Policy and Procedural Measures that can Advance Equitable Ob/Gyn Care for Incarcerated Patients

Privacy	Maintain privacy and confidentiality of protected health information Maintain patient privacy through use of headphones and by positioning officers behind drapes or outside of examination rooms, especially during pelvic and breast exams and during birth Consider opportunities to use alternative spaces to maintain privacy and dignity when transport and movement within the hospital (including prescribed ambulation) include access to spaces shared by other patients and visitors
Restraints/Shackling	Prohibit the routine use of nonmedical restraints on pregnant, birthing, and postpartum individuals and other medically vulnerable patients Implement standards for assessment, documentation and channels of reporting when restraints have been utilized Ensure that hospital policies are aligned with state law Collaborate with staff at nearby jail/prison to ensure policies and procedures are aligned
Equitable labor, birth, and postpartum practices	Promote use of doulas and partner with organizations that offer services Create hospital visitation policies, with permission of jail/prison, that allow a support person to be present during labor and birth Maintain uninhibited contact between birthing person and newborn and full support of the parent-infant dyad during hospitalization Provide breastfeeding/lactation support, if desired Allow visitation and access to newborn, including the NICU which may be shared with other parents and newborns
Surgical procedures, including cesarean birth	Assure operating room policies are consistent with policies for non-incarcerated patients and maintain safety of staff without compromising patient dignity, privacy, and safety
Hospital security and custody alignment	Implement collaborative meetings and policies that outline the responsibilities of custody officers and hospital security personnel and contact information/chain of command

Restraints/shackles in the hospital

Shackling refers to the use of nonmedical restraints on a person for purposes of security and restriction of movement; this is distinct from medical restraints. The risks of shackling an individual during pregnancy, labor and childbirth are numerous and obstetricians understand the interplay between patient comfort, labor progression, and the safety of both the pregnant patient and fetus (see Box 1); enduring shackling during childbirth is traumatic and can have long-term adverse mental health consequences. Numerous major professional associations, including ACOG, have condemned the use of shackles in pregnancy on medical safety and ethical grounds.⁶ As of July 2022, 40 states and the federal government have legislation restricting the use of shackles in labor and pregnancy, though the scope of these laws varies greatly.²³ Nonetheless, even in places where legislation exists, the practice continues.²⁴ Hospital perinatal providers may contribute to such violations of care, due to lack of awareness of laws and professional standards, and due to stigmatizing attitudes toward this population.²⁴

Box 1. Potential Health Consequences of Restraints.

It is important for individuals to have the ability to break their falls. Shackling increases the risk of falls and decreases the individual’s ability to protect oneself and the fetus if a fall occurs. If a person has abdominal pain during pregnancy, a number of tests and examinations to evaluate for serious conditions will be impaired while an individual is shackled. Prompt and uninhibited assessment for vaginal bleeding during pregnancy is important. Shackling can delay diagnosis, which may pose a threat to the health of the pregnant person or the fetus. Hypertensive disease occurs in approximately 2–8% of pregnancies and is directly responsible for 16% of maternal deaths in high-income countries.* Preeclampsia can result in seizures, which may not be safely treated in a shackled patient. People are at increased risk of venous thrombosis during pregnancy and the postpartum period.† Limited mobility caused by shackling may increase this risk and may compromise the health of the pregnant person and fetus. Adding the discomfort of restraints to an individual already suffering from common symptoms in pregnancy such as nausea and vomiting is cruel and inhumane. Pregnant people may develop swelling in their extremities. Restraints may be applied too tightly, causing pain and skin damage. Shackling interferes with normal labor and delivery: The ability to ambulate during labor increases the likelihood for adequate pain management, successful cervical dilation, and a successful vaginal delivery. Pregnant people need to be able to move or be moved in preparation for emergencies of labor and delivery, including shoulder dystocia, hemorrhage, or abnormalities of the fetal heart rate requiring intervention, including urgent cesarean delivery. After delivery, a healthy baby should remain with the parent to facilitate infant bonding. Restraints may prevent or inhibit this bonding and interfere with the person’s safe handling of the infant, including the ability to breastfeed.

^*Gestational hypertension and preeclampsia. ACOG Practice Bulletin No. 222. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;135:e237-60.

^†Thromboembolism in pregnancy. ACOG Practice Bulletin No. 196. American College of Obstetricians and Gynecologists [published erratum appears in Obstet Gynecol 2018;132:1068]. Obstet Gynecol 2018;132:e1–17.

Recognizing that many of the same risks and harms of shackling in pregnancy apply to nonpregnant patients, the call for the healthcare community to critically evaluate the indiscriminate use of nonmedical restraints has been extended to incarcerated patients in other settings, such as intensive care units, operating rooms, and for those receiving palliative care—all places where patients may also experience the overlapping harms of shackling, including increased risks of thromboembolism, falls, skin trauma, effects on mental health, pain, and impedance of medical care.²⁵

Custody restraints are never medically necessary and should not be thought of in the same way as medical restraints, for instance, as with patients with acute psychiatric conditions. Clinicians should request removal of custody restraints when they are impeding clinical care. Surgeons should discuss their institutional protocols with patients when obtaining informed consent. They may also work with custody staff to remove shackles when a patient is fully anesthetized. In both outpatient and acute care settings, alternative and nonphysical interventions should be the default practice, with shackles used only in extreme cases where all other measures have failed.^25,26 If nonmedical restraints are used, documentation and assessments by healthcare professionals should align with internal policies for the use of restraints on non-incarcerated patients as outlined by the Centers for Medicare and Medicaid Services (CMS). The justification and authorization for use, the type and duration of restraints, and alternative and nonphysical interventions, as well as the patient’s physical condition, emotional state, and response to restraints, should be recorded.

Ob/Gyn’s should be familiar with existing state legislation regarding shackling of incarcerated individuals. Health care facilities should evaluate their internal policies, which should align with state laws and evidence-based recommendations from national organizations like ACOG, to ensure patient dignity and safety.⁶

Patient privacy/HIPAA

Discussions with patients often occur with custody officers present; and within the carceral system, an incarcerated person’s health information may reside in many locations. The original HIPAA proposal excluded incarcerated people; they were later added to the final regulation due to concerns that health information could lead to discrimination of individuals with certain stigmatized conditions within carceral facilities. Knowledge of sensitive health information could be misused, trigger assaults within the incarceration facility, or impair reintegration into society. Strategies to promote patient privacy include asking officers to move out of the hearing range of the conversation — ideally out of the room — and/or use headphones.

Privacy during surgical procedures presents unique challenges among incarcerated individuals. Officers may be present during anesthesia, in the operating rooms, and the patient may remain shackled to the operating table. Not only does this risk the safety of the patient, but it limits trust between surgeon and patient. Officers may witness extremely sensitive parts of the patient’s body and reveal private information during the procedure.

In response to widespread and ongoing sexual assault within institutions of incarceration, the Prison Rape Elimination Act (PREA) was passed in 2003 to protect incarcerated individuals. Among other provisions, this legislation allows bodily privacy without opposite-gender officers viewing their breasts, buttocks, or genitalia, except in exigent circumstances. Although PREA does not legally extend to off-site medical care, the same principles regarding privacy should apply. The default should be that custody officers are not present in rooms when discussions or exams are occurring, and especially for pelvic and breast exams and childbirth. Care should be taken to ensure that patients’ breasts and genitals are not exposed to officers. If an officer’s presence is required during sensitive exams or operations, they should be in locations where they are unable to directly visualize parts of the patient or procedure.

Criminal records are often accessible to the public. Nonetheless, health care providers should not search patients’ criminal records. Such curiosity has no clinical relevance, violates patient privacy, and can elicit moral judgment from the provider. Limited studies have found an association between awareness of a patient’s crime and reduced quality of care, even when physicians believe such knowledge will not affect care.²⁷ Despite individual challenges and a pervasive culture that devalues the privacy of incarcerated individuals, Ob/Gyn’s should work to uphold the confidentiality of all patients.

Emotional needs/support during birth and hospitalization

Experiences of trauma and interpersonal violence before incarceration and ongoing structural violence experienced during incarceration may lead to heightened fear of illness and mistrust of the health providers. Body cavity searches by custody staff are common, amplifying the potential for pelvic exams to be traumatizing for incarcerated people. Ob/Gyn’s should be trained in trauma-informed care, with particular attention to avoiding triggering situations, including inquiries that may lead to the disclosure of sensitive personal information and unnecessary pelvic exams.⁶

The vast majority of pregnant incarcerated patients will go through labor, birth, and the immediate postpartum period accompanied only by medical staff and armed officers. Laboring individuals may experience intense pain, emotion, and increased vulnerability. Given the well-established benefits of having a support person during labor and birth, no patient should be forced to give birth alone. While some officers may attempt to provide emotional support during this time, the carceral system by design controls bodies, limits freedom, and exerts power over those incarcerated; officers should neither be expected nor relied upon to assume the role of a friend, birth coach, or doula. To support the dignity and human rights of birthing people, patients should be allowed to have a loved one or doula accompany them. Programs that provide doulas for pregnant individuals experiencing incarceration have been implemented successfully in several places, and some states have also allowed a designated family member, partner, or friend to be present at the hospital for the birth.¹⁴

Comprehensive care of the mother-infant dyad should follow the same recommended practices for free-world patients, including skin-to-skin during the “golden hours” after birth, uninterrupted contact, rooming-in, and upholding parental preferences for infant feeding. Many mothers experiencing incarceration may desire to initiate breastfeeding while in the hospital regardless of their ability to maintain lactation after discharge, and supportive nursing staff can be instrumental in helping individuals achieve success.^16,28 Hospital staff should familiarize themselves with local jail/prison policies, be mindful of the incarceration-imposed challenges to sustained lactation, and avoid undue pressure on patients regarding their preferences for infant feeding. Hospital social workers may help birthing people navigate the complexities of infant placement and provide additional emotional support as people experience the immense emotional grievance of this separation.

Discharge planning

Providers may not disclose discharge plans to incarcerated patients due to concerns related to security breaches, and putting law enforcement and transporting paramedics at risk. This situation creates tension between the ethical obligation to uphold patient autonomy through informed discharge planning and dual loyalty to the public and officers. Incarcerated patients experience longer delays when returning to the hospital in the event of a complication or readmission, given the many layers of approval/authorization and coordination of transportation required for off-site medical care. Consequently, if a woman is in the early stages of labor, it may be prudent to keep her at the hospital. Likewise, resources needed for post-operative care may be scarce inside incarceration facilities and similar barriers apply to return to the hospital. Women have also reported discrimination by hospital staff and prior trauma in hospitals and may be more reluctant to return for care.¹⁵ Given these many barriers, patient education regarding signs and symptoms of when to seek care is especially important in this population.

Transitions of Care Upon Release

Based on legal case processing, incarcerated people may move from jail to prison, or to a facility in another county or state. Such transitions may hinder the continuity of health care, as providers and policies differ from one facility to another, and medical records do not always accompany people to their new facility. Facility medical records are often difficult for community providers to obtain, which can pose challenges. For instance, when a pregnant, incarcerated person is admitted for labor and their prenatal records from prison are not available to hospital providers. Furthermore, when an incarcerated patient is discharged from the hospital, the process of ensuring that discharge instructions and medication orders are conveyed and followed through by facility staff is often opaque. Community Ob/Gyns can make direct connections with facility health care staff to ensure appropriate continuing care.

Returning to the community

Leaving prison or jail to return to one’s community can be a vulnerable and challenging time, and even a dangerous one, with the two weeks after return being associated with 12-fold odds of dying compared to community controls.¹⁴ Prison release dates are usually known months ahead of time, enabling some measure of discharge planning for continuity of medical care. However, release from jail is often not known in advance and can come without warning, which makes linking people to community care and filling or writing medication prescriptions challenging. In addition, release times from jail can come at any time of day or night, even at 2:00 am, which not only impairs care continuity but also is not safe for people with no housing. For many women, their priorities for return focus on reunifying with their children and finding stable housing. Yet, people with felony convictions are often ineligible for public housing. They are also excluded from a variety of other public benefits, such as Supplemental Nutrition Assistance Program. Returning individuals should leave prison or jail with a copy of their medical records, but this is not routinely done.

Implicit bias and stigma

Healthcare providers should be vigilant to ensure the stigma of incarceration does not influence care, as studies have shown that stigma towards incarcerated patients can lead to sub-standard care.²⁹ Providers should examine their own implicit biases and assumptions in order to provide the same standard of care for all patients. Mutual trust and shared decision-making are critical to ensure the dignity and right to health care of the incarcerated person.

Advocacy

Medical personnel are critical players in changing how we treat and provide care to incarcerated individuals. By adopting policies and training staff on the issues raised in this article, patient care is greatly enhanced and the shame and stigmatization of individuals is lessened. Carceral and medical staff must come together and agree to standardized treatment protocols; the importance of the role of advocates in the development of protocols cannot be overstated. Working with community-based organizations can help hospitals and staff keep abreast of the changing legislative landscape and also can provide interventions with custody officials when their biases are in contrast to medical best practices.

Examples of successful advocacy efforts, often led by previously incarcerated individuals, include state anti-shackling legislation and California laws to require access to reversible contraception and policies to support breastfeeding in incarcerated settings. Another example comes from Maryland where, in 2017, Reproductive Justice Inside conducted an evaluation of the conditions of confinement for pregnant incarcerated individuals. This assessment identified the need for all carceral facilities to have written pregnancy care policies for incarcerated people—which became law. Creating the first in the nation Model Pregnancy Policy Manual, the goal is to provide guidance to facilities about the best practices, written policies and regulations for pregnant people in custody.

Maryland’s Pregnant Incarcerated Continuity of Care Act would help to ensure coordination provided between public safety institutions and community-based providers by creating clear referral of care pathways to community Ob/Gyn providers upon release. This legislation aims to address the high risk time of transitioning from incarceration back to the community, aiming to improve pregnancy health outcomes through facilitated continuity of care. Additionally, the legislation requires that incarcerated pregnant individuals who present with a substance use disorder be provided comprehensive assessment medications for opioid use disorder as well as be offered mental health evaluations and care prior to release. Many such advocacy efforts to improve reproductive health care for incarcerated people have resulted from partnerships between with community organizations and Ob/Gyn’s.

While it is paramount to know local and state legislation, as well as the state-specific department of corrections policies, it is equally important to understand that correctional policies may be in direct opposition to existing legislation. Hospital policies should continue to uphold the ethical principles of medicine, including beneficence, non-maleficence, autonomy, and justice for all patients. Hospital policies should be comprehensive, explicit, and balance patient dignity and well-being with the safety of others.

At the individual patient level, community providers caring for incarcerated patients can be advocates by providing non-judgmental, compassionate, trauma-responsive care. This attention can include acknowledging with them the difficulties of health care experiences, such as birthing while in custody. Having strong communication channels with a nearby carceral facility that brings patients to hospitals is essential, to facilitate transitions of care and to ensure mutual compliance with state laws. Providers should also develop partnerships with community organizations that can not only help provide support, but also lead advocacy efforts to change conditions for incarcerated people.