In the aftermath of the killings of George Floyd, Ahmaud Arbery and Breonna Taylor, the Black Lives Matter movement has once again brought the issues of mass incarceration and prison reform to the forefront of national discourse. The United States does incarcerate its citizen at a comparatively higher rate than other countries: it has the highest incarceration rate of all the OECD countries, and according to the ACLU, while the United States only makes up 5% of the total global population, it has nearly 25% of the world’s prison population. Though the United States has the largest per capita prison population, research has shown that the American prison healthcare is not equipped to adequately address the health needs of inmates. As well, the COVID-19 pandemic has illuminated the health risks posed by current prison conditions and the vulnerability of the prison population, and recent reporting conducted by the Marshall Project has found that 108, 118 prisoners in the United States have tested positive for coronavirus. In the 1976 landmark case of Estelle v. Gamble, the Supreme Court judged that all persons in custody have the right to adequate medical care while incarcerated. While this ruling appears to guarantee protections and services for prisoners, studies have shown that the highly unregulated nature of prison healthcare has led to many incarcerated individuals lacking access to care, enduring neglect and cruelty, and experiencing negative health outcomes. 

We Don’t Have a Lot of Data On Pregnant Prisoners 

Far from being included within the “Healthcare for All” paradigm, prisoners are often an overlooked population in regard to healthcare. Among incarcerated women, there is an even more vulnerable and understudied subgroup: incarcerated pregnant women. Reproductive abuse within the American prison system is rampant, and current estimates of incarcerated pregnant mothers who are denied care are likely lower than the actual numbers due to data collection being limited to cases in the court system or the press. Though there are currently 111,616 pregnant incarcerated women in the United States, data regarding these women’s pregnancies and birth outcomes are scarce.

We Do Know That Pregnant Women Are Mistreated

Though the effect of prison conditions on pregnancy outcomes still warrants further study, the mistreatment of pregnant women within the prison system is well documented. Historically, pregnant women have been shackled to the bed while delivering their child — a practice that the ACLU has described as “inhumane,” as shackling often causes potentially fatal health effects such as blood clots and lack of balance for mothers. To address the health dangers posed by this practice, in December 2018, Congress passed the First Step Act, which prohibits the use of restraints on pregnant prisoners during delivery. However, the bill only applies to women incarcerated in federal facilities, not to women housed in local jails or state prisons, which holds the majority of pregnant women in the nation. Because of this, in many states, the practice is still quite common. 

The inconsistency of laws pertaining to shackling is just one example of the variability in permitted practices and quality of healthcare that exists among American prisons. There are no strict criteria for the provision of healthcare services, and states such as California have recently ended federal oversight of prison healthcare systems. As a result, incarcerated pregnant women in many prisons often do not receive the care that they need. Incarcerated pregnant women have reported that they have been kept in isolation during delivery, been denied medication, and received inadequate or no prenatal care. Moreover, incarcerated women are more likely to have pre-existing health problems that place them at a higher risk for negative birth outcomes. Research has shown that women who have contact with jails are more likely to have experienced physical or sexual abuse, suffer from consistent psycho-social anxiety and other mental health issues, and suffer from chronic health conditions such as diabetes. 

Across the country, public health departments are implementing programs to both prevent and mitigate the effects of these inequities. At Contra Costa Health Services, based in Martinez, California, the Lift Every Voices (LEV) program provides continuous perinatal support to pregnant women detained at West County Detention Facility (WCDF). Since 2005, LEV has operated as a place-based and home visiting program that provides outreach and case management services to incarcerated pregnant women prior to and after release from the county jail; additionally, the program aids those women in accessing prenatal care, psycho-social support services, and other home visiting programs once they are released. Lift Every Voice offers a range of services: helping women access health insurance and specialized care in prison, arranging for temporary guardianship of babies, offering continuous case management following release, partnering with Contra Costa Office of Education to provide educational workshops, and providing counseling and companionship during labor and delivery. 

While this program was founded as a way to achieve birth equity for all incarcerated women, its services also aim to address the racial disparities that comprise this issue. Maxine Larry, the coordinator of the Lift Every Voice program, believes that addressing these issues of racial justice and societal inequality is a central tenet of the program’s strategy. 

“The majority of the women that we work with are African American women,” Larry says. “These women have experienced several types of trauma in their lives, come from communities where there are disadvantaged socioeconomic conditions, and grew up in families where they weren’t able to get a good start in life.”

African American women are disproportionately represented in the American prison system, and studies have shown that they are three times as likely as Latinas to be imprisoned and six times more likely than White women to be imprisoned. This is compounded by the fact that there are vast racial and ethnic disparities in pregnancy-related outcomes in the general U.S. population. For example, African American women are three to four times as likely to die from pregnancy related causes than non-Hispanic white women. Though the data is quite limited, it is likely that the racial and ethnic disparities in pregnancy outcomes among the general U.S. population are equivalent in the incarcerated population. 

Incarcerated pregnant women often have harrowing personal histories. Because of this, Suzzette Johnson, the Public Health Program Manager of Family, Maternal, and Child Health programs at Contra Costa Health Services, requires that her staff use a trauma-informed approach when working with their clients. According to Trauma Informed Oregon, a collaborative that provides resources and information for individuals seeking to implement a trauma informed approach, trauma informed care is a framework that includes “an awareness of the prevalence of trauma, an understanding of the impact of trauma on physical, emotional, and mental health as well as on behaviors and engagement to services; and an understanding that current service systems can retraumatize individuals.” 

“Instead of asking the question, ‘What did you do?’, we ask, ‘What has happened to you?’” Johnson says.

As part of the California Second Chance Act, thousands of formerly incarcerated people have been released back into their communities. However for many individuals, the transition back into society can be difficult. Many inmates are from marginalized communities that, due to various socioeconomic burdens, are unable to provide sufficient resources for their successful reintegration. To address this, the LEV program provides a bridge between formerly incarcerated women and their communities through facilitating communication between the family and the justice system, offering information for resources such as parenting workshops and employment skills classes, and providing constant communication to their clients about the reunification plan for the mother and child.

While the LEV program was initially founded to address the disparities regarding maternal health and birth outcomes of incarcerated individuals, the program’s approach is also guided by a more long term framework: the life course theory. This public health intervention framework, largely popularized by the Dean of the UC Berkeley School of Public Health Dr. Michael Lu, posits that the circumstances of one’s early life are extremely influential to  the state of an individual’s health later in their life. 

Informed by the life course theory, the LEV program prioritizes the unification of 90% of newborns with their mother or a close relative rather than being placed into the foster care system, which can pose lasting mental and physical health risks for the foster children. Studies have shown that nearly 50% of children in the foster care system suffer from chronic health conditions as a result of neglect or under-treatment, and these conditions are frequently exacerbated as they grow older. The Juvenile Law Center reports that children in the foster care system have a much higher risk of being incarcerated within their lifetime, with youth who are placed in group homes are 2.5 times as likely to be involved with the justice system than their counterparts. As well, other studies have shown children in the foster care system often have limited educational opportunities, experience unstable housing circumstances, and lack strong emotional support systems.  Research has shown that placing children with their families, also known as ‘kinship care’, leads to increased placement stability, lower rates of behavioral problems, and helps children maintain connections with their extended family and preserve their cultural identity.

Research has shown that the practice of placing children with members of their families, known as “kinship care,” results in children who are less likely to experience behavioral issues, psychiatric disorders, and emotional distress; kinship care also increases the likelihood that a child has a long term stable placement than a child placed into a foster care family. Itika Greene, Founding Manager of the LEV program, considers the rate of placing children with family as a sentinel indicator of the program’s success. “If a child ends up in foster care, out of their community and away from their family, this can cause numerous issues for their development and well-being,” Greene says.  

With regards to the future, Johnson is hopeful that the program can increase its staffing and take a more long term approach to its services. “It’s always been a part of our vision that the program coordinator would be able to see the women not only in jail, but also to follow her outside of the jail. In the current scope of our services, we do provide a warm handoff to other programs after being released; however, being able to follow women after they leave jail would be ideal,” Johnson says. 

While the program currently offers a wide variety of services to clients and is engaged in many community collaboration initiatives, increased future funding could serve to increase the availability and quality of resources provided by the Lift Every Voice program. 

Ultimately, in order to effect positive and equitable change regarding access to healthcare, vulnerable communities, such as formerly incarcerated women, must be included in the discussion. For this reason, Johnson believes engaging in advocacy is just as crucial as the provision of services. 

“We strive to lift the voices of women who have lost their voices,” Johnson says. “We must advocate for them to make sure that they are receiving the healthcare they need and to ensure their safety.”