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More than 1,000,000 women in the U.S. are currently under supervision of the criminal legal system (CLS). Since 1980, the number of women in prison has increased by over 800%. CLS involvement increases risk of physical and sexual violence, with direct or indirect health and health care effects, which impact families and communities. These risks are consequences of pre-incarceration factors, including poverty, structural racism, and inadequate health care access; limited jail and prison health care; and the health impacts of carceral systems themselves. Furthermore, parenting and reproduction, health care needs as they age, and reentry challenges of WICLS are underrepresented in current policy, research, and clinical contexts. We delineate reproductive health and motherhood, aging in prison, and reentry as critical areas exemplifying women's complex health related needs, which may be best addressed via gender-responsive and trauma-informed care. Bipartisan criminal justice reform legislation, which includes improving the health of WICLS, is gaining support. As a public health community committed to advancing equity, we must evaluate and support legal and legislative reform that seeks to improve health care quality and access for this often overlooked population.
Improving Health Equity for Women Involved in the Criminal
Legal System
Cynthia A. Golembeski, MPH
, Carolyn B. Sufrin, MD, PhD
Brie Williams, MD, MS
, Precious S. Bedell, MA, CHW
, Sherry A. Glied, PhD
Ingrid A. Binswanger, MD, MPH, MS
, Donna Hylton, MA
Tyler N.A. Winkelman, MD, MSc
, Jaimie P. Meyer, MD, MS, FACP
Rutgers University School of Law and School of Public Affairs and Administration, Newark, New Jersey
Johns Hopkins University School of Medicine, Baltimore, Maryland
University of California San Francisco, Division of Geriatrics and Amend at UCSF, Francisco, California
University of Rochester College of Arts, Sciences, and Engineering, Turning Points Resource Center, Rochester, New York
New York University Robert F. Wagner Graduate School of Public Service, New York, New York
Kaiser Permanente Institute for Health Research and Chemical Dependency Treatment Services, University of Colorado School of Medicine,
Denver, Colorado
A Little Piece of Light, New York, New York
General Internal Medicine, Department of Medicine, Hennepin Healthcare. Health, Homelessness, and Criminal Justice Lab, Hennepin
Healthcare Research Institute, Minneapolis, Minnesota
Yale University School of Medicine, New Haven, Connecticut
Article history: Received 16 May 2020; Received in revised form 12 June 2020; Accepted 20 June 2020
More than 1,000,000 women in the United States are
currently under supervision of the criminal legal system (CLS),
with the majority on probation or parole.
Since 1980, the
number of women in prison has increased by more than 800%,
which is twice the rate of growth for men, whose rates are falling
(Bronson & Carson, 2019). Similarly, the male jail population
decreased by 9% from 2008 to 2018, whereas the female jail
population experienced a 15% increase (Zeng, 2020). Women
involved in the CLS (WICLS) have high rates of mental and
physical health conditions, socioeconomic challenges, and
trauma and violence histories (Meyer et al., 2014;McDaniels-
Wilson & Belknap, 2008;Fedock & Covington, 2017;Sufrin,
These high rates are consequences of pre-incarceration
factors, including poverty, structural racism, and inadequate
health care access; limited jail and prison health care; and the
health impacts of carceral systems themselves (Binswanger et al.,
2012;Cloud, Bassett, Graves, Fullilove, & Brinkley-Rubinstein,
2020;Venters, 2019). Broader efforts to address womens
health equity should include WICLS, who are often otherwise
excluded from public health programs, policies, and initiatives.
The health and well-being of WICLS may also be adversely
shaped by intersecting forms of oppression, including racism,
poverty, ageism, ableism, homophobia, and sexism. Social de-
terminants of health and CLS involvement include aspects of the
social environment, such as discrimination and income, the
physical environment, and health services. Furthermore,
parenting and reproduction, health care needs as they age, and
reentry challenges of WICLS are underrepresented in current
policy, research, and clinical contexts (Aday & Forney, 2014;
Fedock & Covington, 2017;Sufrin, 2017). These intersectional
forces bear on women and their families before, during, and after
incarceration and may lead to poor health across the lifespan
Dr. Sufrins efforts were supported by grants from the National Institute on
Drug Abuse (5K23DA045934-02) and the Society for Family Planning Research
Fund (SFPRF11-09). Dr. Williamsefforts were supported by the National Insti-
tute on Aging of the National Institutes of Health under the Aging Research in
Criminal Justice Health Network (grant R24AG065175) and the University of
California, San Francisco Pepper Center (grant P30 AG044281). Dr. Meyers ef-
forts were supported by the Doris Duke Charitable Foundation Clinical Scientist
Development Award (DDCF CSDA).
*Correspondence to: Cynthia A. Golembeski, MPH, Rutgers University School
of Law and School of Public Affairs and Administration, 111 Washington Street,
Newark, NJ 07102. Phone: 347-664-2840.
E-mail address: (C.A. Golembeski).
Jails are typically short-term holding facilities under local jurisdiction for the
newly arrested, those awaiting trial or sentencing, and those serving short sen-
tences. State or federal prisons are institutional facilities where those who are
convicted serve longer sentences.
Women and men involved in the CLS include adults serving sentences in
prisons and jails, awaiting trial or sentencing, and those under community su-
pervision. We try to use person-rst and nonstigmatizing or pejorative language
(Broyles et al., 2014;Baggio et al., 2018).
1049-3867/$ - see front matter Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health.
Women's Health Issues xxx-xx (2020) 17
(Hayes et al., 2020;Meyer, 2019a). CLS involvement increases
risk of physical and sexual violence, with direct or indirect health
and health care effects, which impact families and communities
(Brinkley-Rubinstein, 2013;Hatzenbuehler, Keyes, Hamilton,
Uddin, & Galea, 2015;Kajeepeta et al., 2020;Venters, 2019).
We delineate reproductive health and motherhood, aging in
prison, and reentry as critical areas exemplifying womens
complex health related needs, which may be best addressed via
gender-responsive and trauma-informed care.
WICLS have
different experiences and needs in comparison with men
involved in the CLS as well as other women living in the com-
munity without CLS involvement. These complex medical, psy-
chiatric, and social conditions may require dedicated high-
quality, comprehensive, and evidence-based health care in
prisons and jails, which link women to care and support in the
community on release (Meyer, 2019b;Rich et al. 2013). Patient-
centered care is well-suited to address the heterogeneity of ex-
periences, identities, and health conditions and to support
developing well-tailored, structurally competent interventions
and programs for WICLS (Metzl & Hansen, 2014;Meyer, 2019b).
Paradoxically, some jails and prisons have become spaces where
women can nd health care, which reects the withering health
and social safety net that fails to advance equity in many of our
communities (Sufrin, 2017).
CLS Involvement and Health Among Women
CLS involvement among women closely affects a broad range
of health outcomes. Women have similar or lower prevalence of
chronic conditions compared to men in the general population,
yet rates of chronic illness and comorbid conditions of WICLS are
higher than other women in the community and men involved in
the CLS (Binswanger, Krueger, & Steiner, 2009). An analysis of
Bureau of Justice Statistics data and nationally representative
cross-sectional data from the early 2000s nds nearly 65% of
women in prison and jail reported having a chronic condition, in
comparison to approximately 50% of men in prison and jail
reporting a chronic condition (Harzke & Pruitt, 2018). Womens
pathways to being enmeshed in the CLS are often associated with
their relationships, including substance use in dyads, conscrip-
tion or coercion to engage in illicit activity, and intimate partner
violence exposure (Meyer et al., 2014,2017;Jiwatram-Negr
on &
El-Bassel, 2015).
Substance use, psychiatric disorders, and prior exposure to
violence are prevalent among WICLS. According to the Bureau of
Justice Statistics, 69% of women in state prison and 72% of
women sentenced in jail in 2012 met criteria for severe sub-
stance use disorders, which require specialized approaches to
management (Bronson, Stroop, Zimmer, & Berzofsky, 2017).
Similarly, infectious diseases related to injection drug use and
high-risk sex networks, such as HIV and hepatitis C, were more
prevalent than in the general population (Binswanger et al.,
2010;Williams et al., 2013;Meyer, 2019a). Furthermore,
sexually transmitted infection rates were recorded as 10 to 20
times greater relative to women in the community without CLS
experience and, if left untreated, these infections can negatively
impact womens health (Knittel & Lorvick, 2019;Linder, 2018;
Meyer, 2019b). Thus, the Centers for Disease Control and Pre-
vention issued recommendations to expand sexually transmitted
infection screening and treatment in prisons and jails in 2015
(Centers for Disease Control and Prevention, 2015).
The prevalence of co-occurring psychiatric disorders and
substance use disorders, often associated with trauma,
frequently exceed 75% among WICLS (Meyer et al., 2013;Prins,
2014;Staton-Tindall, Duvall, Leukefeld, & Oser, 2007;
Winkelman, Chang, & Binswanger, 2018). People with severe
psychiatric disorders have high rates of repeated contact with
the CLS, where evidence-based treatment may be lacking,
further contributing to negative psychiatric outcomes
(Baillargeon, Binswanger, Penn, Williams, & Murray, 2009;Glied
& Frank, 2009).
Girls and young women of color are disproportionately
vulnerable to the sexual abuse to prison pipeline(Marquardt,
2020). Girls only constitute 20% to 25% of the juvenile CLS pop-
ulation, yet 50% to 66% of those dually involved in juvenile
criminal legal and child welfare systems are girls (Saar et al.,
2015). WICLS contend with violence and trauma history as
prevalent as 95%, including sexual assault and intimate partner
violence (Meyer et al., 2014;McDaniels-Wilson & Belknap, 2008;
Richie, 2012). Nearly 40% of WICLS meet criteria for post-
traumatic stress disorder, and research shows that untreated
posttraumatic stress contributes to womens distinct incarcera-
tion and recidivism pathways (Baranyi, Cassidy, Fazel, Priebe, &
Mundt, 2018;Fuentes, 2014;Harner, Budescu, Gillihan, Riley, &
Foa, 2015).
Exposure to degradation, body searches, shackles, cell
shakedowns, restraints, and seclusion during incarceration
further compound trauma; in addition, trauma-related symp-
toms may be mistaken for acts of aggression or deance (Center
for Substance Abuse Treatment, 2014;Kramer & Comfort, 2011;
Fedock & Covington, 2017;Kraft-Stolar, Brundige, Kalantry, &
Getgen, 2011). Prison discipline policies punish women more
harshly than men, including disproportionate isolation for mi-
nor, nonviolent infractions (LaChance, 2018;U.S. Commission on
Civil Rights (USCCR), 2020). Disciplinary record, charges, and
punishment can be associated with gendered charges. Women
with psychiatric conditions are overrepresented in segregation
environments (LaChance, 2018). Staff sexual misconduct, lack of
respect, and potential control of womens bodies may be
conducive to a lack of safety, abuse, exploitation, and violence
(Owen, Wells, & Pollock, 2017;Rantala, 2018). Violence targeting
transgender women is particularly perilous, given dispropor-
tionate incarceration and victimization risks (Ba
cak et al., 2018).
People who are incarcerated are the only population in the
United States with a constitutional guarantee to health care,
including protection from serious physical and psychological
harm, yet health care standards and practices widely vary
(Dolovich, 2009;Venters, 2019). Estelle v. Gamble established the
constitutional mandate that institutions of incarceration address
serious medical needs(Dolovich, 2009). However, there are no
mandatory standards as to what services have to be provided or
what conditions count as serious medical needs. Health care
spending, quality, and organizational structures vary across fa-
cilities where services and practices also vary, particularly for
womens health within prison and jail contexts designed pri-
marily for men (Pew Charitable Trusts, 2017). Overall, health
This article focuses primarily on people whose biological sex is female and
who identify as women (also known as cis-gendered women; however, we
recognize transgender individualsdisproportionate contact with the criminal
legal system and that people, who may not identify as women(i.e., trans
men) might have pregnancy and other reproductive health care needs.
Metzl and Hansen (2014) introduce structural competency: 1) recognizing
the structures that shape clinical interactions, 2) developing an extra-clinical
language of structure, 3) rearticulating culturalformulations in structural
terms, 4) observing and imagining structural interventions, and 5) developing
structural humility.
C.A. Golembeski et al. / Women's Health Issues xxx-xx (2020) 172
delivery systems within prisons and jails are associated with
various levels of expertise in evaluation, quality improvement,
evidence-based practice, and implementation science (Pew
Charitable Trusts, 2017).
Reproductive Health and Parenting
Approximately 75% of women in state and federal prisons are
younger than 45, so health care needs must address reproductive
health, including family planning care, comprehensive preg-
nancy, birth, and postpartum care, and abortion access (Carson,
2020). Addressing incarcerated womens health care within a
reproductive justice framework prioritizes health careinequities,
alongside material resourcesdsuch as safe neighborhoods, good
schools, clean water, and just court systemsdneeded to parent
(Hoff et al., 2020;Strickler & Simpson, 2017). Reproductive jus-
tice is an intersectional theory and platform for action that
emerged from and centers the experiences of women of color
and draws on the knowledge of historical legacies in which their
reproduction has been systematically devalued (Strickler &
Simpson, 2017). Three rights are central to achieving reproduc-
tive justice: the right not to have children, the right to have
children, and the right to parent children in dignity and safety.
Incarceration disrupts core reproductive justice tenets, denying
contraception and abortion access and implementing coercive
contraceptive practices, and providing substandard maternity
and postpartum care; and over-investing in systems to conne
people and under-investing in safety net systems (Hayes et al.,
Menstrual dysfunction is three times higher among incar-
cerated women, of whom 50% lack access to basic menstrual
supplies (Allsworth et al., 2007;Linder, 2018). Only four states
offer free access to menstrual products in prison (Johnson, 2019).
WICLS, in custody and upon release, experience unmet family
planning service needs, including contraceptive access and
counseling (Allsworth et al., 2007;Clarke et al., 2006;Larochelle
et al., 2012). Unlawful sterilization in California prisons as
recently as 2010 runs counter to necessary noncoercive, patient-
centered, reversible contraceptive methods access (Hayes et al.,
2020;Sufrin et al., 2009a). Although incarcerated women
retain their legal right to abortion, many facilities disallow access
(Bronson & Sufrin, 2019;Hayes et al., 2020;Sufrin, Creinin, &
Chang, 2009b).
Nearly 4,000 admissions of pregnant people to prisons and
55,000 to jails occur annually (Bronson & Sufrin, 2019;Sufrin
et al., 2020a). Until 2019, there was limited systematic data
reporting on incarcerated pregnant people and related out-
comes, including births, miscarriages, and abortions. This lack of
data collection and reporting reects a potential disregard for
incarcerated womens gender and reproductive specic needs
and the slow pace at which the growing female jail and prison
populations have been addressed. Shackling women in labor in
federal prisons is banned, yet only 29 states have similar laws for
state prisons, which are frequently violated (Goshin, Sissoko,
Stringer, Sufrin, & Byrnes, 2020;Sufrin, 2019;Kuhlik & Sufrin,
In Press). Pregnant people with opioid use disorder may expe-
rience withdrawal, despite this being contrary to standards of
care (Sufrin et al., 2020b). Prenatal care availability and quality
vary considerably, as do policies promoting breastfeeding and
infant bonding for birth while in custody.
Approximately 60% to 80% of incarcerated women have minor
children and most are single parents (Fedock & Covington, 2017;
De Claire, K., & Dixon, L., 2017). Compared with incarcerated men,
women in prisons and jails are ve times more likely to have
children placed in foster care (Swavola, Riley, & Subramanian,
2016;De Claire, K., & Dixon, L., 2017). More than one-half of
women in prison are more than 100 miles from home and never
receive childrens visits (Women & Justice Project, 2019). Incar-
cerated parentschildren, who may struggle with this separation,
are more than six times more likely to experience incarceration
themselves (Boudin, 2011;Wakeeld & Wildeman, 2013).
Notably, womens removal and return to communities associated
with incarceration can have effects on families and communities
(Boudin, 2011;Fedock & Covington, 2017).
Policy reforms should standardize and expand reproductive
health care scope and quality for incarcerated women, including
comprehensive prenatal, birth, and postpartum care; abortion
and noncoercive contraception access; menstruation manage-
ment; cervical and breast cancer screening, diagnosis, and
management; and pregnancy data collection. Further, training
and oversight will bolster policies in supporting the right to
parent in safety and dignity, alongside alternatives to incarcer-
ation, community health, and economic infrastructure (Hayes
et al., 2020). Lastly, supporting parenting skills along with con-
tact and reunication with loved ones is critical to rehabilitation
and reducing recidivism (De Claire & Dixon, 2017;Fedock &
Covington, 2017;Meyer, 2019b).
Disproportionate incarceration rates and longer sentences
than men for similar offenses often combine with histories of
violence, trauma, and poverty to compromise the health of older
WICLS. Incarcerated older women experience higher rates of
chronic disease and disability, victimization, and mental illness
in comparison with men involved in the CLS and non-
incarcerated women (Aday & Farney, 2014;Barry, Adams, Zaugg,
& Noujaim, 2020). The proportion of aging women in prison is
growing faster in comparison with men, which is associated with
greater health demands and costs largely owing to increased
comorbidity burden and physical and cognitive disabilities
(Skarupski, Gross, Schrack, Deal, & Eber, 2018). In 2018, nearly
25% of women in state and federal prisons were over the age of
45 (Carson, 2020). Between 1993 and 2013, the number of
women in state prisons age 40 and older increased by more than
300% (Carson & Sabol, 2016).
Geriatric syndromes, including cognitive and functional
impairment, dementia, falls, and incontinence, are present at
higher rates and at younger ages in incarcerated populations
than for nonincarcerated women (Bedard, Metzger, & Williams,
2016;Williams et al., 2006). Jail and prisonsenvironmental
conditions designed to restrict the liberty of young people,
poor lighting and ventilation, inadequate climate control, over-
crowding, and service barriers exacerbate older womens phys-
ical challenges (Bedard et al., 2016;Aday & Farney, 2014).
Physically demanding work activities lacking modications for
functional impairments persist and vary across states (Williams
et al., 2006). Additionally, daily living activities while incarcer-
ated are also more challenging for women than men (Skarupski
et al., 2018;Williams et al., 2006). Consequently, many older
women who would be independent in the community are not in
prison (Williams, Goodwin, Baillargeon, Ahalt, & Walter, 2012).
Clinicians working with patients who are incarcerated
oftentimes lack training in palliative care, which is the commu-
nity standard of care for patients with life-limiting or serious
illnesses (Bedard et al., 2016). Additionally, while medical or
C.A. Golembeski et al. / Women's Health Issues xxx-xx (2020) 173
compassionaterelease policies exist to allow people of
advanced age or with serious illness to leave prison before they
die, in practice few are released through these mechanisms
(Mitchell & Williams, 2017;Prost & Williams, 2020). As a result,
ideal medical release candidates frequently lack appropriative
assessments and remain unnecessarily conned (Prost &
Williams, 2020). Many older women also experience dif-
culties and unmet needs around grief and loss as part of traumas
of incarceration, which also include personal, social, and envi-
ronmental deprivations (Aday & Farney, 2014;Aday & Krabill,
Gender-sensitive, trauma-informed, patient-centered, and
evidence-based geriatric and palliative care standards appro-
priate to carceral environments should be designed to minimize
victimization and injury. Relatedly, improving disability trajec-
tories by mitigating environmental risk factors and reducing
avoidable suffering for women with serious and life-limiting
illness while in prison is key if older women must remain incar-
cerated (Rich, Allen, & Williams, 2015). Older women, in com-
parison with older men in prison and women in the community,
are prone to fewer disciplinary infractions and lower recidivism
rates upon release (Bedard et al., 2016).Reentry supports for aging
women should facilitate securing health care continuity, housing,
employment, and social services. WICLS returning to the com-
munity may experience bias and discrimination associated with
their age, gender, class, race, and criminal records.
States continue to grapple with how to handle the aging
prison population growth. The Centers for Medicare and
Medicaid Services funds a privately owned nursing home facility
contracted by the state of Connecticut, which houses ailing
people in custody. Experts urge repeal of mandatory minimum,
habitual offender,and truth-in-sentencing laws and support
interim reform efforts, such as conditional release for aging men
and women in custody who pose little security risk, compas-
sionate release, parole board transparency, and federal aging
prisoner release reauthorization (Mitchell & Williams, 2017;
Williams et al., 2012). Moreover, further research in this area is
needed to improve survey methods, tools, and research to opti-
mally assess the health of older WICLS (Barry et al., 2020;Bedard
et al., 2016;Skarupski et al., 2018;Williams et al., 2012).
Nearly 95% of those incarcerated will return to communities
(Hughes & Wilson, 2002). This reentry period is associated with
numerous health challenges, including increased mortality,
psychiatric symptoms, and victimization (Binswanger et al.,
2007,2011;2013,2016;Meyer et al., 2014). During reentry,
womens high rates of co-occurring conditions can be exacer-
bated by care discontinuities, medication disruption, and inad-
equate insurance (Binswanger et al., 2011;Johnson et al., 2015;
Woods et al., 2019). Common health care barriers include
experienced or anticipated stigma and discrimination, low
health literacy, and difculties navigating health care systems
(Johnson et al., 2015;Kramer & Comfort, 2011;Winkelman et al.,
2016). Many women return to under-resourced neighborhoods
amidst prevalent poverty, violence, and substance use (Fedock &
Covington, 2017;Golembeski & Fullilove, 2008). Womens
reentry challenges include greater parental responsibilities, in-
come disparities, housing insecurity, and dependency on part-
ners for subsistence needs (Fedock & Covington, 2017;Johnson
et al., 2015;Western, 2018).
Custody revocation laws and child welfare oversight may
compromise family reunication (Sufrin, 2017). Reentry-related
stressors may lead women to deploy survival strategies,
including transactional sex, associated with recidivism (Kramer
& Comfort, 2011;Richie, 2012). Difculties securing housing
and employment, plus exposure to potential violence, drug use,
and high-risk survival behavior, can compound trauma
(Binswanger et al., 2014;Jiwatram-Negr
on & El-Bassel, 2015;
Meyer et al., 2014). Women often shoulder greater nancial
burdens and family responsibilities than men (Hersch & Meyers,
2018;Richie, 2012). Plus, collateral consequences of incarcera-
tion for women involving health, employment, housing, debt,
civic involvement, families, and communities can reduce op-
portunities to sustain healthy relationships and nancial security
(Fedock & Covington, 2017;Hersch & Meyers, 2018;Kirk &
Wakeeld, 2018).
Transitions to care outside of jails or prisons have improved
through the establishment of community-based clinics
providing transitional care, including primary care and case
management, as well as peer patient navigators (Binswanger
et al., 2015;Fox et al., 2014;Wang et al., 2010). For instance,
New Yorks Womens Initiative Supporting Health-Transitions
Clinic involves peer health workers in providing treatment and
support to recently released women (Bedell, Wilson, White, &
Morse, 2015;Morse et al., 2017). Cross-agency collaboration,
which incorporates psychological and emotional components
that women need to heal and recover, can facilitate and sustain
integrative continuity of care models that address structural
racism, poverty and trauma histories, and mental and physical
health conditions.
Adverse life events are prevalent among WICLS, who contend
with structural barriers that compromise health and well-being
and facilitate contact with the CLS. Disproportionate health
burdens and barriers to care are associated with syndemic effects
of substance use disorders, plus chronic medical and psychiatric
conditions within the context of racism and gender inequities
(Meyer et al., 2013;Williams et al., 2013). Sexual and physical
violence within the CLS is a serious concern (McDaniels-Wilson
& Belknap, 2008;Venters, 2019). Relatedly, the forced migra-
tion, also known as coercive mobility, of incarceration disrupts
social, family, and sexual networks with secondary effects on
communities (Binswanger et al., 2012;Hatzenbuehler et al.,
Most national health surveys exclude WICLS, so much is un-
known to researchers and providers about their gender and
reproductive health specic needs. This problem can be reme-
died: experts have developed ethical data collection for public
health surveillance in jails, prisons, and under community su-
pervision (Ahalt, Haney, Kinner, & Williams, 2018;Binswanger
et al., 2019;Sufrin et al., 2019b;Wang, Macmadu, & Rich,
Additional research, clinical, and policy efforts to
address intimate partner violence, trauma, and comorbid health
conditions are needed to improve health equity for WICLS
(Bowen & Murshid, 2016).
The transformative role of WICLS in peer support, research,
service delivery, and policy addressing inequities associated with
Data collection purposes include surveillance, health promotion and disease
prevention, healthcare performance and patient value, policy relevance, health
equity, and human rights and legal considerations (Binswanger et al., 2019).
C.A. Golembeski et al. / Women's Health Issues xxx-xx (2020) 174
the CLS is widely acknowledged (Bedell et al., 2015;Binswanger
et al., 2015;Epperson & Pettus-Davis, 2017;Kraft-Stolar et al.,
2011;Sturm & Tae, 2017). Moreover, the Share Project, a health
justice initiative, trains patients with incarceration histories,
community health workers, policymakers, and researchers in
participatory research involving a data-sharing platform (Elumn
Madera et al., 2019). Health care providers are uniquely qualied
to improve the health of WICLS via care that is patient-centered,
structurally competent, and sensitive to the complex interplay of
trauma, violence, and co-occurring mental and physical health
conditions (Goshin et al., 2019;Hayes et al., 2020;Metzl &
Hansen, 2014;Morse et al., 2017;Sufrin, 2017).
Decarceration, drug policy reform, and alternatives to incar-
ceration are necessary criminal justice reform efforts, which may
improve health outcomes further upstream and aid women in
addressing underlying challenges while maintaining and
strengthening positive ties to families and communities. From a
systems perspective, it is less costly and disruptive to avoid
incarceration altogether and deliver continuous care in the
community for chronic health conditions including substance use
and psychiatric disorders (Meyer, 2019b). Women have strengths,
needs, risks, and pathways into the justice system that often differ
from mens(Binswanger et al., 2013;Richie, 2012;Machtinger,
Cuca, Khanna, Rose, & Kimberg, 2015). Gender-responsive,
trauma-informed, strength-based care supports womens rein-
tegration and recovery. Relevant clinical training, capacity
building, material resources and structural support in commu-
nities are also necessary to sustain such efforts (Machtinger et al.,
2015;Meyer et al., 2017;Binswanger et al., 2014).
Bipartisan criminal justice reform legislation, which includes
improving the health of WICLS, is gaining support. The Second
Chance Act, the Fair Sentencing Act, and the First Step Act of 2018
have been enacted. The Dignity for Incarcerated Women Act,
which focuses on health, visitation, programming, oversight, and
telecommunications, was reintroduced by Senators Elizabeth
Warren and Cory Booker in April 2019. The First Step Act, which
only applies to federal contexts, contains some of the Dignity
Acts clauses: menstrual product provision, shackling bans, and
incarceration closer to home. Moreover, the proposed 2018
Pregnant Women in Custody Act supports data collection and
reporting on pregnant women, prohibiting restrictive housing
and restraints, and addressing health care needs in federal
prisons. Relatedly, Senators Ann McLane Kuster and Bookers
proposed Humane Correctional Health Care Act seeks to improve
health care delivery and treatment behind bars (Kuster & Booker,
2019). As a public health community committed to advancing
equity, we must evaluate and support legal and legislative reform
that seeks to improve health care quality and access for this often
overlooked population.
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Author Descriptions
Cynthia A. Golembeski, MPH, is a Rutgers University JD/PhD student who teaches
undergraduate courses in prison with NJ-STEP. She, is a Robert Wood Johnson
Foundation Health Policy Research Scholar. Research interests include criminal
justice/health policy and management, equity, ethics, nonprot management and
philanthropy, and citizen-state relations.
Carolyn B. Sufrin, MD, PhD, is an obstetrician-gynecologist and medical anthropol-
ogist at Johns Hopkins University. Her work is situated at the intersection of repro-
ductive justice, health care, and mass incarceration, which she examines in her
book, Jailcare: Finding the Safety Net for Women Behind Bars.
Brie Williams, MD, MS, is a professor of medicine at the University of California San
Francisco in the Division of Geriatrics, who integrates a healthcare perspective into
criminal justice reform. She founded Amend at UCSF which draws on public health
to transform prison and jail culture. She also co-directs the Aging Research in
Criminal Justice Health (ARCH) Network funded by the National Institute on Aging.
Precious S. Bedell, MA, CHW, University of Rochester Department of Arts, Sciences
and Engineering and Turning Points Resource Center. Her research interests are
health issues for women in prison, formerly incarcerated individuals, their family
members, and community-based participatory research.
Sherry A. Glied, PhD, New York University Robert F. Wagner Graduate School of
Public Service, is an economist focusing on health care policy and mental health
policy. She has served as Assistant Secretary for Planning and Evaluation in the
Department of Health and Human Services.
Ingrid A. Binswanger, MD, MPH, MS, Senior Investigator, Kaiser Permanente Colo-
rado Institute for Health Research and a physician with the Colorado Permanente
Medical Group, conducts research designed to prevent overdose and improve the
health of populations that interact with the criminal legal system.
Donna Hylton, MA, wrote A Little Piece of Light. she is founder and president of A
Little Piece of Light, Inc., which works to end the criminalization of women and
Tyler N.A. Winkelman MD, MSc, is Co-Director of the Hennepin Healthcare
Research Institutes Health, Homelessness, and Criminal Just ice Lab; Associate Di-
rector, Virtual Data Warehouse; a physician with Hennepin Healthcare; and Assis-
tant Professor, Departments of Internal Medicine and Pediatrics at the University of
Jaimie Meyer, MD, MS, FACP, is Assistant Professor, Yale AIDS Program, and Clinical
Assistant Professor of Nursing. She is a board-certied physician in Medicine, Infec-
tious Diseases, and Addiction Medicine. Her lab studies HIV interventions for
women in criminal legal systems.
C.A. Golembeski et al. / Women's Health Issues xxx-xx (2020) 177
... Estimates of mental illness among older adults who are incarcerated range from 16% (Maschi et al., 2011a) to more than 40% (Di Lorito et al., 2018;Fazel et al., 2001a). Such disparities are shaped by disproportionate traumatic experiences throughout the life course, economic deprivation, service barriers and deficient preventive and primary care and carceral-specific factors including isolation, overcrowding, violence and victimization and environmental stressors related to lighting, ventilation and temperature (Bailey et al., 2017;Ford et al., 2019;Golembeski et al., 2020Golembeski et al., , 2021Stojkovic, 2007). ...
... Persons of color also endure disproportionate rates of arrest, detention, solitary confinement and injury, illness and death while incarcerated (Golembeski et al., 2021;Massoglia, 2008). Institutional and interpersonal discrimination and oppression including microaggressions, limited structural competency and race-related violence no doubt contribute to poor mental health outcomes among specific subsets of older adults and thus, to health inequities (Metzl and Hansen, 2014;Williams et al., 2020). ...
... The incarceration rate for women has continued to climb and compared to men, aging women face distinct burdens. These include longer sentences, pronounced histories of poverty, violence and trauma, elevated levels of chronic health problems, exacerbated menstrual and menopausal symptoms and unmet needs regarding grief and loss (Bronson and Berzofsky, 2017;Handtke et al., 2015;Jaffe et al., 2021;Golembeski et al., 2020). Substantial challenges are also likely present for older gender and sexual minorities, though too little research has been completed with these persons (Maschi and Morgen, 2020;Ba cak et al., 2018). ...
Full-text available
The targeted use of standardized outcome measures (SOMs) of mental health in research with older adults who are incarcerated promotes a common language that enables interdisciplinary dialogue, contributes to the identification of disparities and supports data harmonization and subsequent synthesis. This paper aims to provide researchers with rationale for using "gold-standard" measures used in research with community-dwelling older adults, reporting associated study sample psychometric indexes, and detailing alterations in the approach or measure. Keywords: Incarceration; Measurement; Mental health; Older adults; Outcomes; Standardized measures.
... About 40% of the increase in female rates of incarceration in state prisons between 1993 and 2013 was owing to increases in the incarceration of females over age 55 (Carson & Sabol, 2016). The shifting age and gender demographics of those incarcerated or serving sentences in community corrections have led to concerns about the capacity of carceral and probationary systems safely to accommodate their needs (Aday & Farney, 2014;Golembeski et al., 2020). Our goal in this analysis was to contribute to what is known about the health risks, health conditions, and health services access and use of older adult women (age 50 and older, hereafter 50+) who have a history of criminal-legal system (CLS) involvement. ...
... Recent position papers and narrative reviews have usefully organized what work there is and have called for more study (Bedard et al., 2016;Golembeski et al., 2020). Yet the paucity of empirical research is evident in reviews like Skarupski et al. (2018) where just two of 20 studies was focused on older adult women's health needs, or that of Loeb and AbuDagga (2006), who did not even report the gender of samples as a characteristic of the studies in their review, noting only one comparative result (men and women) in one study from 1990. ...
... Although older and younger women with a history of CLS involvement in our study shared many aspects of structural and behavioral risk, health conditions, and health services access and use, this study showed that they also diverged from one another in important respects that could inform areas of emphasis for future research and health intervention. Based on the differences we found, there is particular need for programs or processes that offer wraparound services for older adult women who manage chronic illness-especially multimorbidity (Golembeski et al., 2020). Women as they age may also require more intensive services when they leave incarceration, including long-term care services, which can be especially difficult for persons with CLS involvement to coordinate and afford (Boucher et al., 2021). ...
Objectives: We profiled the health and health services needs of a sample of older adult women (age 50+) with criminal–legal system (CLS) involvement and compared them with younger women (age 18–49), also CLS-involved. Methods: Using survey data collected from January to June 2020 from adult women with CLS involvement in three US cities, we profiled and compared the older adult women with younger women on behavioral and structural risk factors, health conditions, and health services access and use. Results: One-third (157/510) were age 50+. We found significant differences ( p < .05) in health conditions and health services use: older women had more chronic conditions (e.g., hypertension and stroke) and more multimorbidity and reported more use of personalized care (e.g., private doctor, medical home, and health insurance). Discussion: Although older women with CLS involvement reported good access to health services compared with younger women, their chronic health conditions, multimorbidity, and functional declines merit attention.
... Seminal works analyze discrimination and the political and sociohistorical antecedents of hyperincarceration, including the Black Codes, as a social determinant of health (Acker et al., 2019;Alexander, 2012;Davis, 2020;Fullilove, 1993;Hinton, 2016;Muhammad, 2010). Hyperincarceration and negative individual and populationlevel public health effects, along with structural violence at its core, have been well documented (Golembeski & Fullilove, 2008;Golembeski et al., 2020b;Gottschalk, 2015;Patterson, 2013;Venters, 2019;Wacquant, 2009). Paradoxically, there is evidence that some jails or prisons may provide quality care and healing, which underscores the withering health and social safety nets in lesser-resourced communities (Massoglia & Remster, 2019;Sufrin, 2017). ...
... People involved with the criminal legal system disproportionately face significant health challenges during periods of time before, during, and after incarceration (Acker et al., 2019;Cloud, Bassett, Graves, Fullilove, & Brinkley-Rubinstein, 2020;Wildeman & Wang, 2017). Substandard health care within jails and prisons, unhealthy environmental factors, and the health impacts of carceral systems have been well documented (Golembeski et al., 2020b;Massoglia & Remster, 2019;Venters, 2019). A high prevalence of comorbid chronic medical and mental health conditions exists among incarcerated individuals, who are often from underserved communities (Binswanger, Redmond, Steiner, and Hicks, 2012). ...
... Moreover, Massoglia found individuals with a history of incarceration are consistently more likely to develop illnesses associated with stress (Massoglia, 2008). Understanding and addressing the health challenges of people involved in the criminal legal system is critical to achieving the triple aim of improving patient experience of care and population health while limiting costs (Binswanger, Maruschak, Mueller, Stern, & Kinner, 2019;Golembeski et al., 2020b;Mery, Majumder, Brown, & Dobrow, 2017). Ultimately, Venters and colleagues conceptualize the triple aim of correctional health as patient safety, population health, and human rights (MacDonald et al., 2013). ...
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The United States has approximately 5 percent of the world's population but incarcerates nearly 25 percent of the world's incarcerated population and produces nearly 25 percent of global carbon dioxide emissions to date. Climate change and hyperincarceration are causes and consequences of structural racism and economic deprivation, which disproportionately affect structurally disenfranchised citizens, including lower‐income communities, communities of color, and people with disabilities. Empirical evidence exists regarding the adverse health effects of climate change and mass incarceration, which occur in cascading and overlapping categories and include preventable death, illness, and injury. Researchers underscore the medical vulnerability of incarcerated populations, who are increasingly susceptible to climate‐driven exposure pathways and mental and physical health outcomes involving extreme temperatures, natural disasters, infectious diseases, and displacement. Intersectional structural drivers, such as anthropogenic climate change and hyperincarceration, undermine social and political determinants of health equity. Policymakers and health professionals can advance understanding and mitigate present and anticipated public health threats by increasing transparency, accountability, and human rights protections with an emphasis on decarceration and decarbonization.
... Reducing carceral contact via decarceration and other legal reforms (e.g., drug policy) can prevent disruptions to community-based HIV care, thus improving individual health benefits for PWH and community-level health benefits by reducing transmission in high-risk communities [70,71]. ...
... Despite the increased vulnerability and unique risk profiles experienced by transgender and cisgender women, these two groups have not received sufficient attention to improve HIV outcomes, an area that necessitates increased attention, funding, and research. In addition to incorporating known efficacious intervention components (e.g., navigation, substance use treatment), interventions for these groups may be strengthened by addressing gender-based power imbalances, intersectional stigma (e.g., based on an individual's genderidentity, HIV serostatus, carceral history, race/ethnicity), risk for and exposure to interpersonal violence, and other barriers to healthcare unique to each of these groups [71,81,82]. ...
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Purpose of Review To describe existing evidence and identify future directions for intervention research related to improving HIV care outcomes for persons with HIV involved in the carceral system in the USA, a population with high unmet HIV care needs. Recent Findings Few recent intervention studies focus on improving HIV care outcomes for this population. Successful strategies to improve care outcomes include patient navigation, substance use treatment, and incentivizing HIV care outcomes. Technology-supported interventions are underutilized in this population. Notable gaps in the existing literature include intervention research addressing HIV care needs for cisgender and transgender women and those under carceral supervision in the community. Summary Future research should address existing gaps in the literature and respond to emergent needs including understanding how the changing HIV care delivery environment resulting from the COVID-19 pandemic and the approval of new injectable ART formulation shape HIV care outcomes in this population.
... Biological sex modifies the effect of age on the health of incarcerated people (Golembeski et al., 2020). Women who are incarcerated present with aging health concerns earlier than males and at higher costs (Aday and Farney, 2014;Krabill and Aday, 2005;Aday and Krabill, 2006;Lane et al., 2020;Rikard and Rosenberg, 2007;Williams and Rikard, 2004). ...
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Purpose: Older adults who are or have been incarcerated constitute a growing population in the USA. The complex health needs of this group are often inadequately addressed during incarceration and equally so when transitioning back to the community. The purpose of this paper is to discuss the literature on challenges older adults (age 50 and over) face in maintaining health and accessing social services to support health after an incarceration and to outline recommendations to address the most urgent of these needs. Design/methodology/approach: This study conducted a narrative literature review to identify the complex health conditions and health services needs of incarcerated older adults in the USA and outline three primary barriers they face in accessing health care and social services during reentry. Findings: Challenges to healthy reentry of older adults include continuity of health care; housing availability; and access to health insurance, disability and other support. The authors recommend policy changes to improve uniformity of care, development of support networks and increased funding to ensure that older adults reentering communities have access to resources necessary to safeguard their health and safety. Originality/value: This review presents a broad perspective of the current literature on barriers to healthy reentry for older adults in the USA and offers valuable system, program and policy recommendations to address those barriers.
To explore perspectives on sexuality, sexual health, and sexual health care of older adult women with a history of criminal legal system involvement, we conducted phone interviews with women aged 50 years or older who were living in the community but had a history of jail and/or prison incarceration. Interview questions and initial analysis were guided by the sexual health framework for public health and Mitchell's sexual wellness model. Data analysis followed a framework method. Nine women, aged 53-66, participated in phone interviews between December 2020 and December 2021. Slightly over half the participants were Black; none were Hispanic. Most were single. We formulated a sex-in-aging (SAGE) framework comprising three categories and two overarching themes. Women with a history of criminal-legal system involvement have heterogeneous views on sex and sexual health and describe a range of desire and sexual activity as they age, including shifting ideas about what they expect from partners, how they keep themselves safe in sexual and intimate relationships, and how life circumstances that are often associated with criminal legal system involvement (substance use, trauma) impact their interest in sex as they age. The SAGE framework integrates these categories and themes and offers a starting point for further research and intervention development.
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As the prison population grays, so too does the people leaving prison. In New Jersey and New York, 35% and 26% of people on parole are over the age of 50 respectively. While older persons have lower recidivism rates compared to younger persons, there are physical, mental, and societal challenges that come with advancing age that can make reentry and reintegration a particularly difficult experience compared to younger persons. The aim of this dissertation is to explore the experiences of older adults on parole and the parole officers that assist them in their reentry and reintegration. This study is unique in that it is the first known study that looks at differences in redeemability and reintegration based on age. Additionally, this study uses sociological perspectives that are under-utilized when studying the correctional, but more specifically, the paroled population. Maruna (2001) and O’Sullivan’s (2018) Belief in Redeemability, and Braithwaite’s (1989) Reintegrative Shaming and Wolff and Draine (2004), Smith & Hattery (2011) and Lin’s (2000) social capital theories will be used to address the following four research questions addressing persons on parole: (1) Do the needs of people leaving prison differ based on age? (2) Are there age-related differences in concerns regarding reintegration for people leaving prison? (3) Are there age-related differences in concerns regarding stigmatization for people leaving prison? (4) Are there age-related differences in finding meaning in life post incarceration? To understand parole officer perceptions of counseling older persons on parole Helfgott’s (1997) theory on social distance as well as parole officer decision-making theories will be used to answer the following two research questions: (1) Are parole officers’ experiences working with older persons on parole different than younger persons? (2) How do parole officers manage counseling and supervision of older persons on parole compared to younger persons? This dissertation is, as far as the author knows, the first mixed methods examination of life on parole for older persons, and how their experiences differ from their younger cohorts. This mixed methods study will use qualitative and quantitative methods of analysis to understand the experiences of older person on parole from multiple angles including thematic and quantitative content analysis, descriptive analyses and chi-square analyses where appropriate. This study defines older person on parole as someone over the age of 50, and a younger person on parole as someone between the ages of 18-49 under parole supervision. This proposal investigates whether older persons on parole believe they can be successfully reintegrated into the community, considering their age, time served and health conditions that typically accompany older persons who have been impacted by the criminal justice system as it compares to younger persons on parole. Furthermore, this study aims to understand how older persons on parole find life satisfaction after prison and parole. Finally, this dissertation aims to understand how parole officers view older persons on parole and seeks to understand their perceptions of managing and counseling older persons on parole.
Purpose Previously incarcerated women have specific gender and physiologic needs that are poorly addressed on community re-entry. The objective of this study is to evaluate the relationship between contraception use and perceived healthcare quality post-incarceration. Additionally, we examine the association between social determinants of health and contraception use post-incarceration. Methods A secondary analysis of a cross-sectional study of reproductive-aged women with a history of criminal-justice involvement in three cities (n = 383) was performed. Questions related to demographics, social determinants of health, sexual and reproductive health practices, health services use, and healthcare quality were analyzed. Bivariate analysis and logistic regression examined associations between these variables and contraception utilization among persons recently incarcerated. Results 35% of the participants used a method to prevent pregnancy. There were no significant differences noted between contraceptive users and non-users in perceived healthcare quality. Participants who were not using a contraceptive method were more likely to lack health insurance and experience food insecurity when compared to contraceptive users. Conclusions Although there was no difference in perceived healthcare quality between contraceptive users and non-users, significant barriers to contraceptive access on community re-entry exist. More studies are warranted to explore the sexual and reproductive health of previously incarcerated women.
Purpose: The USA outpaces most other countries in the world in the rates at which it incarcerates its citizens. The one million women held in US jails and prisons on any day in the USA face many physical health challenges, yet interventional work to address physical health in carceral settings is rare. This study's purpose was to summarize the literature on programs and interventions implemented with women in US carceral settings (jail or prison) that primarily addressed a physical health issue or need. Design/methodology/approach: A scoping review was conducted. The authors searched databases, reference lists, individual journals and websites for physical health program descriptions/evaluations and research studies, 2000-2020, that included women and were set in the USA. Findings: The authors identified 19 articles and a range of problem areas, designs, settings and samples, interventions/programs, outcomes and uses of theory. The authors identified two cross-cutting themes: the carceral setting as opportunity and challenges of ethics and logistics. Research limitations/implications: Much potential remains for researchers to have an impact on health disparities by addressing physical health needs of women during incarceration. Originality/value: Interventional and programmatic work to address physical health needs of women during incarceration is sparse and diversely focused. This review uniquely summarizes the existing work in a small and overlooked but important area of research and usefully highlights gaps in that literature.
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As the number of women under correctional supervision continues to increase in the United States, attention to gender within correctional programming is crucial as women offenders present with different concerns than their male counterparts. Gender differences exist in a range of criminal justice factors, including pathways to involvement in the criminal justice system, frequencies in types of offenses, treatment needs, and facilitating factors for treatment engagement and positive outcomes. Thus, this chapter highlights the importance of gender in terms of correctional program design and delivery. Gender-responsive programming for women involved in the criminal justice system is guided mainly by the feminist pathways theory of women's criminality, as well as additional theories. This framework considers the interconnected roles of trauma and victimization histories, substance abuse, economic and social marginalization, and the gendered effects of criminal justice policies and practices. For gender-responsive programming, elements that should be considered in women's treatment and services in correctional settings include: program environment or culture or both, staff competence, theoretical foundations, treatment modalities, reentry issues, and collaboration. In addition, principles of trauma-informed care are crucial elements needed in systems and services for women involved in the criminal justice system. These two frameworks of gender-responsive programming and trauma-informed care offer specific principles that can be applied across correctional settings for women to shape policies, programming design, program delivery, and daily practices. Likewise, these frameworks encourage community-based responses to women's involvement in criminal behaviors. Gender is a crucial element for correctional programming in multiple ways.
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We describe how mass incarceration directly undermines the core values of reproductive justice and how this affects incarcerated and nonincarcerated women. Mass incarceration, by its very nature, compromises and undermines bodily autonomy and the capacity for incarcerated people to make decisions about their reproductive well-being and bodies; this is done through institutionalized racism and is disproportionately done to the bodies of women of color. This violates the most basic tenets of reproductive justice—the right to have a child, not to have a child, and to parent the children you have with dignity and in safety. By undermining motherhood and safe pregnancy care, denying access to abortion and contraception, and preventing people from parenting their children at all and by doing so in overpoliced, unsafe environments, mass incarceration has become a driver of forms of reproductive oppression for people in prison and jails and in the community.
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Objectives. To examine relationships among actionable drivers and facilitators of stigma and nurses' intentions to provide the standard of maternal care recommended by the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) for incarcerated women.Methods. We conducted a Web-based survey of perinatal nurses in the United States (n = 665; participation rate 98.0%; completion rate 95.3%) in July through September 2017. We used multivariable logistic regression to predict higher than median intentions to provide the standard of care.Results. Lower stigmatizing individual attitudes and institutional norms and higher perceived autonomy when caring for an incarcerated woman were significantly associated with higher care intentions. Knowledge of the AWHONN position statement on the standard of care or their own state's shackling laws was not associated with higher care intentions.Conclusions. We documented significant associations among actionable drivers and facilitators of stigma and the intentions of a key health care provider group to deliver the standard of maternal care to incarcerated women. Individual- and institutional-level stigma-reduction interventions may increase the quality of maternal care and improve perinatal outcomes for women who give birth while incarcerated.
Background: Women involved in criminal justice systems (WICJ) are affected by multilevel biological and sociocultural factors that result in adverse health outcomes and health disparities. Criminal justice systems (CJS) must be appropriately resourced to address these issues. Materials and Methods: We developed a systematic review to understand the intentions and needs for pregnancy prevention and planning among WICJ to inform future reproductive health services. We conducted a systematic literature review of epidemiologic and interventional studies that addressed the pregnancy prevention and planning needs of U.S. WICJ (2000-2019). An initial screen identified 7061 articles and 3 independent reviewers determined that 28 articles (16 descriptive studies in adults, 7 descriptive studies in adolescents, and 5 interventional studies) met inclusion criteria. Results: The literature review identified high rates of contraception underutilization and negative attitudes toward pregnancy among WICJ in a wide variety of settings. WICJ described minimal access to reproductive health services, including evidence-based contraception, and experienced high rates of unplanned and undesired pregnancies. Results were interpreted in the context of the reproductive justice (RJ) framework. Conclusions: The CJS, although not designed to provide health care, should dedicate resources to address the multilevel barriers to care experienced by women. WICJ require targeted, gender-responsive, trauma-informed pregnancy prevention and planning interventions that acknowledge the history of reproductive coercion in this population and address key aspects of RJ, including the right to and to not have a child.
Objective: To describe the number of admissions of pregnant people to U.S. jails and the outcomes of pregnancies that end in custody. Methods: We prospectively collected pregnancy data from six U.S. jails, including the five largest jails, on a monthly basis for 12 months. Jails reported de-identified, aggregate numbers of pregnant people admitted, births, preterm births, cesarean deliveries, miscarriages, induced abortions, ectopic pregnancies, and maternal and newborn deaths. Results: There were 1,622 admissions of pregnant people in 12 months in the selected jails. The highest 1-day count of pregnant people at a single jail was 65. The majority of these admissions involved the release of a pregnant person. Of the 224 pregnancies that ended in jail, 144 (64%) were live births, 41 (18%) were miscarriages, 33 (15%) were induced abortions, and four were ectopic (1.8%). One third of the births were cesarean deliveries and 8% were preterm. There were two stillbirths, one newborn death, and no maternal deaths. Conclusion: About 3% of admissions of females to U.S. jails are of pregnant people; extrapolating study results to national female jail admission rates suggests nearly 55,000 pregnancy admissions in 1 year. It is feasible to track pregnancy statistics about this overlooked group.
Background and aims: Established standard care in pregnancy is medication for opioid use disorder (MOUD); however, many institutions of incarceration do not have MOUD available. We aimed to describe the number of incarcerated pregnant people with opioid use disorder (OUD) in the U.S. and jails' and prisons' MOUD in pregnancy policies. Design: Epidemiologic surveillance study of 6 months of outcomes of pregnant, incarcerated people with OUD and cross-sectional survey of institutional policies. Setting: USA PARTICIPANTS: Twenty-two state prison systems and six county jails MEASUREMENTS: Number of pregnant people with OUD admitted and treated with methadone, buprenorphine, or withdrawal; policies on provision of MOUD and withdrawal in pregnancy. Findings: Twenty-six percent of pregnant people admitted to prisons and 14% to jails had OUD. One-third were managed through withdrawal. The majority who were prescribed MOUD were on methadone (78%, prisons; 81%, jails), not buprenorphine. While most sites (n=18 prisons, n=4 jails) continued pre-incarceration MOUD in pregnancy, very few initiated in custody (n=4 prisons; n=2 jails). Two-thirds of prisons and 3/4 of jails providing MOUD in pregnancy discontinued it postpartum. Conclusions: In this sample of US prisons and jails, one-third required pregnant people with opioid use disorder go through withdrawal, contrary to medical guidelines. More people were prescribed methadone than buprenorphine, despite the fewer regulatory barriers on prescribing buprenorphine. Most sites stopped medication for OUD postpartum, signaling prioritization of the fetus, not the mother. Pregnant incarcerated people with OUD in the US frequently appear to be denied essential medications and receive substandard medical care.
Objectives. To evaluate the relationship between changes in county jail incarceration rates and subsequent county mortality rates across the United States. Methods. We analyzed county jail incarceration rates from the Bureau of Justice Statistics from 1987 to 2016 for 1884 counties and mortality rates from the National Vital Statistics System. We fit 1-year-lagged quasi-Poisson 2-way fixed-effects models, controlling for unmeasured stable county characteristics, and measured time-varying confounders, including county poverty and crime rates. Results. A within-county increase in jail incarceration rates from the first to second quartile was associated with a 2.5% increase in mortality rates, adjusting for confounders (risk ratio [RR] = 1.03; 95% confidence interval [CI] = 1.02, 1.03). This association followed a dose–response relationship and was stronger for mortality among those aged 15 to 34 years (RR = 1.07; 95% CI = 1.06, 1.09). Conclusions. Within-county increases in jail incarceration rates are associated with increases in subsequent mortality rates after adjusting for important confounders. Public Health Implications. Our findings add to the growing body of empirical evidence of the harms of mass incarceration. The criminal justice reform and decarceration movements can use these findings as they develop strategies to end mass incarceration.