Reproductive Health Care for Incarcerated Women: Promoting Justice Through Research

Reproductive Health Care for Incarcerated Women: Promoting Justice Through Research


>>DENISE: So first, I want to
welcome everyone to the U3 lecture series. The purpose of this series is to educate people
about the health disparities among populations of women who are (1) understudied, (2) underrepresented,
and (3) underreported in biomedical research. So, those three things are where we get
the U3 abbreviation. My name is Denise Stredrick, and I have the pleasure — I get to coordinate
the U3 program and bring really smart people to the NIH to talk to you about various populations. And you know, I have to confess
that there are times when we’ll bring people in to discuss populations that
I didn’t even consciously realize were populations.
Or maybe better wording is that they’re forgotten populations. And that is why I think that this program
is so important. That’s also why I’m excited that you decided to take
time out of your day to hear about one such population. And that’s incarcerated women. So, today we are privileged to have
Dr. Carolyn Sufrin tell us about her work with incarcerated women. Dr. Sufrin is a medical anthropologist and
an obstetrician-gynecologist specializing in family planning at Johns Hopkins University. She’s an assistant professor in the department of gynecology
and obstetrics at the School of Medicine. She’s an assistant professor in the department of health, behavior, and society
at the Bloomberg School of Public Health. And she’s the associate director of the Center
for Medical Humanities and Social Medicine at Johns Hopkins University. She has worked extensively on reproductive
health issues affecting incarcerated women, from providing clinical care in jail to research, policy, and advocacy.
Her work is situated at the intersection of reproductive
justice, health care, and mass incarceration. Dr. Sufrin was a BIRCWH Scholar. And BIRCWH stands for
Building Interdisciplinary Research Careers in Women’s Health.
During that time that she was a Scholar,
she conducted the first prospective study to collect data on pregnancy outcomes
in U.S. prisons. I hope I have given you a small taste of what
you can look forward to over the next hour. Now I’m going to pass the mic over to Dr.
Sufrin. Dr. Sufrin? Are you on mute?>>CAROLYN SUFRIN: Nope.
>>DENISE: Oh, there you are. Can you hear me?>>DENISE: Yes.>>CAROLYN SUFRIN: OK. It might have just taken a moment. Well, I wanted to say thank you so much, Denise,
for that introduction. And thank you to the Office of Research on
Women’s Health for hosting this webinar. I’m very excited to be virtually with all of you today to talk about some of the things I’ve learned over the years in conducting
research with this group that certainly meets the criteria of all three of those U’s. So I’m going to pause for a moment and share
my screen and hope that this has — OK. Slideshow — here we go. Sorry. I can’t get to my icon in the corner here. There we go. OK. OK. Hopefully, everything is up and running for
folks and you can follow along with my slides. If not, hopefully my narration of it will
take you along. So again, thank you very much. And what we’re going to discuss today are,
just at a very basic level, why should we care about research on issues facing incarcerated women,
especially reproductive health issues? So I’ll give some background on our criminal
justice system and reproductive health care and who the people are who are incarcerated.
And then I’m going to highlight some of the research that I and my group, ARRWIP, which
I’ll tell you what that stands for, because it’s an important part of our research
mission. But that’s the name of my research group at
Johns Hopkins. So I’ll share some highlights from our group’s research
and from research that I’ve done in the past. And then I’m going to also spend a lot of
time discussing some of the unique considerations of conducting research with and about incarcerated
women. So, a little bit of background on incarceration
in the United States and why we should recognize its connections
to health and health care. There really are some profound social and health
foundations to thinking about mass incarceration. And “mass incarceration” refers to the phenomenon
of the last four decades in the United States where we have seen an unprecedented and exponential
rise in the number of people behind bars. And that rise has not been proportional and
is differentially distributed across different population groups, as I’ll describe. The phenomenon of mass incarceration is something that we could spend hours,
days, weeks, months talking about. But it is a phenomenon that is deeply rooted
in our country’s history and present of racism and white supremacy. And these come to bear on health
and the health care experiences of people behind bars. Incarceration itself is a social and structural
determinant of health and also has — it has deep roots in people’s pre-incarceration health
but also impacts their health once they leave institutions, as well as while they’re there. And for a variety of reasons, some of which
will become apparent as I go through further the background today, mass incarceration is a public health
epidemic. If we think about the connections that make
us think of a problem as public health and as an epidemic, mass incarceration and the
effects that it’s had on individuals’ bodies and psyches and on the communities really make it a public health issue
and an epidemic. So specifically thinking about women — and
I’m foregrounding this before even getting into more background in incarceration, because oftentimes,
women are neglected, not discussed, forgotten, and so I really want to foreground this. So, in the United States, there are, according
to the latest statistics from the Bureau of Justice Statistics, over 225,000 adult females
in prisons and jails across the country. And those data come from the 2017 census. This represents an increase of 2.6% from the prior year. So we continue to see the number of women behind
bars rising, while overall, we see a decline in the incarcerated population. This represents a substantial increase from
40-plus years ago. And since 1980, there’s been a 750% increase
in the number of women behind bars. And this graphic, from The Sentencing Project,
shows those numbers and distributed by jail, State prison, and Federal prison. So you can see that it continues to rise for
all women. And it’s a pretty substantial exponential
rise since 1980. So, most of these women in the United
States are mothers — and are mothers to young children. And these are people who were the primary
caregivers prior to being incarcerated. So when you think about the incarceration
of females in this country, it’s not only about those individuals; it’s about the impact
that it has on their children, on their families and communities when the primary caregivers
of these children are left behind.

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In addition, relatedly, the majority of these
women are between the ages of 18 and 44, or what we commonly think of as reproductive age. Most of these women are arrested for property,
drug, or other minor charges. And while some women also are arrested, convicted,
and serving sentences for violent charges, it’s important that while this may help us
think about some of the reasons why some people are incarcerated, that in no way means they
deserve less health care or less-quality health care than people who are convicted of other charges. But it is important to think about this when
thinking about the overlaps between the social determinants of health that characterize many people’s lives and also the pathways to incarceration. We know that women have been disproportionately
affected by what has commonly been called the war on drugs, which is a very broad term
but refers generally to a series of policies and laws and judicial enforcements that have
resulted in, for one, in people with drug addiction being managed in prisons and jails
disproportionately rather than with drug treatment in the community. So these trends and longer sentencing for
drug-related charges, these have disproportionately affected women. And one way you can see this is by the rates
of increase in incarceration, but we also see this in how women continue to rise. And if we compare rates of incarceration between
2005 and 2017, we’ve actually seen a pretty substantial drop in the male population of
people in jail — a 12% drop — but a mirrored increase in the number of women
who are in jail. And so women remain the fastest-growing subsection
of the incarcerated population in the U.S. As I alluded to, and it’s something that I can’t
emphasize enough, the profound racial disparities and inequities in our system of incarceration
are true for females, as well as the overall population, and Black women are incarcerated at about
twice the rate of White women. Now, while every individual woman who is incarcerated
is different, there are certainly some trends. And we know that among incarcerated women, research has shown
that they have a high prevalence of sexually transmitted infections,
and that’s often related to the high rates of being engaged in sex work
and not having access to adequate sexually transmitted infection treatment, prevention education,
and screening. So we see very high rates of STIs and also very high rates of mental illness and prior histories of trauma. And these are higher when compared to nonincarcerated
women, as well as incarcerated men. And I really want to emphasize the mental
health and trauma issues and just how high those rates are. And I would say in my own clinical experience
when I was providing health care in a jail, I would say that more than 90% of my patients had
histories of prior physical or sexual abuse. So even higher than what some of the literature
shows. And that’s really important when thinking
about research questions, providing clinical care, or other services is recognizing the
trauma, the potential post-traumatic stress disorder that women experience but also the
re-traumatization that many of them may experience while being incarcerated. So now, stepping back again to talk
more broadly about the United States and our context, so we have the largest and most
expensive prison system in the world. And this graphic represents rates of incarceration. So, although we certainly don’t have the largest
population of any country in the world, we have the highest incarceration rate — higher than other countries which we may think
of as being extremely punitive. But we have the highest incarceration rate. And that reflects the ways that our society
has come to rely on incarceration for a variety of things — for managing social and health problems, in
many ways. Certainly, that is not the express purpose
of it, but by default and by policies that have been implemented, this has contributed to
this phenomenon of mass incarceration and our high incarceration rates. There are many, many things that characterize
our system, and there have been hundreds and hundreds of books written about it. We read about it all the time in the news
media. And so it’s really hard to boil down our system
to one or two or three or four key characteristics. But for the purposes of the ways that I think about
research questions and reproductive health and reproduction in this setting, there are
four key themes that I think emerge and are important to ground this in. One is that our system is characterized by
high cost and, actually, profit. So, it’s estimated that our country spends
at least $80 billion a year on prisons. And there are actually several corporations
that profit off of incarceration from privately running prisons, from privately running health care
services, and from other activities, as well. It is characterized, as I have already mentioned,
disproportionately by people of color. It is characterized by high recidivism rates, meaning that when people get released from prison or
jail, they’re extremely likely to be rearrested and come back to prison or jail. And if part of the purpose of our system, which
some argue would be a failed purpose, but a part of the purpose is to help reform people,
if they are, indeed have been convicted of something, we are doing a very bad job of
preparing them for reentry and helping them reintegrate into society. And our system is also characterized by its
mass proportion. This graphic, you don’t need to worry about
the exact numbers. Just look at the shape of that curve from 1980
until now. Just the steepness of that rise in incarceration
rates and the number of people behind bars in the United States. And it’s estimated now there are about 2.2
million adults behind bars on any given day, compared to about 500,000 in 1979. And that exponential rise, again, relates
to a complex set of social, political, and economic phenomena. So, related back now to the racial inequities
in incarceration, the legal scholar Michelle Alexander has written a very often-cited and well-read book
called “The New Jim Crow,” which details the ways in which our current incarceration system is a legacy of Jim Crow segregation. And if you haven’t read it and you’re interested,
it’s a very good and important read, and it really outlines the racial differences and inequities in incarceration rates in a very easy-to-understand and well-researched way. From a health care perspective, one way to
think about it, too, is about addiction and drug use. We know that people who are — Black individuals
and White individuals in this country have equal rates of drug use. But Black individuals are 13 times more likely
to be in prison for drug-related crimes. And although they comprise about 14% of the U.S.
population, they represent nearly half of the incarcerated population. These disparities are true for females, as
well as males. Another important distinction to understand
in our country is the difference between prison and jail. And I’ll be honest, before I started working
as a physician in a jail about 13-14 years ago, I had no idea what the difference was. But there are a lot of differences that have
implications for research and for health care. So, prisons are generally under State and Federal jurisdiction. People are in prisons because they’re serving
a sentence if they’ve been convicted of a felony-level charge. In addition, if they are on parole and they
have violations of their parole, they will often serve their sentence in prison. People in prisons are generally serving sentences
that are longer than a year. And geographically, prisons are often located far
from people’s communities. Someone goes to a particular prison based
on their classification level on their crime, on other things related to their custody, not because of where they were arrested or
where their family is. And many prisons in some States are
located in rural areas. So that has implications, especially, for
mothers who are incarcerated. They may be very far from their children. Jails, on the other hand, are typically under city
and county jurisdiction. They hold people who are detained pretrial,
where people who have been convicted of a crime that are awaiting sentencing or awaiting transfer to
prison. People who are serving a sentence in jail
are typically serving a short sentence. And they’re typically more minor crimes, more
minor charges that people are in jails for. And so jails are very high-turnover places. There’s a lot of transition. Sometimes people have unpredictable release
dates. They may be there for a few hours, 24 hours,
a week, a few months. Depending on where you are, the median time
length of stay in a jail might be 1 month or 4 months. But they’re very high-turnover places. Jails are located within communities, within
the places where people live. Someone gets arrested and generally goes to
the nearest — the jail that’s closest to where they get arrested. So that also has implications when thinking
about continuity of health care upon release and connections with people’s families. So now, very briefly, just a little bit about health care for incarcerated
people. There are lots of ways to think about it. And one of them is a public health perspective. We know that people who are incarcerated and
who are cycling through the criminal legal system, they generally have poor status
pre-incarceration. And that’s often related to various social determinants
of health that characterize their lives and often that they’ve had limited access to health care. So, when they become incarcerated, they have
access to health care, although it’s highly variable what that looks like. And so it often becomes an opportunity for new
diagnoses. As an OB-GYN and reproductive health provider, one of those is pregnancy.
And many people first learn about a pregnancy when they get their screening in prison or jail. It’s also a moment for people to access preventative health care,
as well as maintaining care for chronic health care. But prisons and jails can actually, in addition
to providing health care to people who may not have had access, can be health hazards
for people, depending on the environment that people are in — the chronic stress that people experience
while inside, the violence they may be exposed to. In addition, you may note that I put the word “opportunity” in quotes. People often refer to this, you know, as an opportunity
to provide health care. But that perspective needs to be placed in
the broader context of the fact that it may appear that way because in the community,
many people who are incarcerated may have had limited access to health care. But prisons and jails are not health care providers. They are places of confinement and punishment. And so thinking of it as an opportunity really
misses the mark of diagnosing the deficiencies of our broader systems in the community.
Prisons and jails should not be thought of as health care providers, although they do have an obligation to provide
health care. And then, of course, most people are ultimately
released into society. And there’s a lot that needs to be done at
that vulnerable and important moment of release when it comes to continuity of health care,
recognizing the competing priorities that people may have. And reflecting what a vulnerable and important
time this is, a landmark study out of the State of Washington
found that in the first 2 weeks from release from State prison, people had a nearly 13
times greater odds of dying in those first two weeks when compared to community-matched
controls. One of the leading causes of death
was overdose. But this is a very vulnerable time, and so
a lot of research can and should focus on that release care. Now, there’s also a legal perspective on health care
for incarcerated people. They actually have a constitutional right
to health care. Prisons and jails are constitutionally mandated to provide health care. And that relates to the Eighth Amendment’s prohibition on
cruel and unusual punishment and a Supreme Court case from 1976 in which
the Supreme Court affirmed that prisons and jails are required to provide health care and not
to do so would be cruel and unusual punishment. But what’s important is, the wording from this
Supreme Court decision is somewhat vague. Justice Marshall said that the deliberate
indifference to serious medical needs of prisoners is cruel and unusual punishment. But there is no official definition of what
health care services count as a serious medical need. And that ability to decide, that discretionary
open power, leads to a lot of variability. So when we think about what health services delivery
looks like on the ground for incarcerated people, it really depends. So there is no mandatory standardization. Now, there are several voluntary accreditation
programs that exist that advance voluntary standards. There is a variability in terms of what
health care services are routine, versus what can be requested, what’s available on-site, versus off-site,
versus just not available at all. At some places, they require incarcerated
people to pay in order to see a health care provider in prison or jail. And these are people who already have limited
resources. So that’s a barrier that can impair access
to health care for people. There are some prisons and jails that have
chosen to contract out their services to private corporations. And so that also has implications in terms
of the variability and accountability and, in some cases, the profit motives for providing health care. So, when anyone asks me what health care looks
like for pregnant incarcerated people or what are the standards or how often are pregnancy
tests done, all I can say is it depends. And that presents a challenge but also a lot
of opportunities when it comes to research. Now, when it comes to thinking about women’s
health in the setting of health care in incarcerated settings, women’s health has really received
limited attention. Because they represent a smaller proportion
of the incarcerated population, there has often been neglect. And in addition, people sort of assume that they are the same or interchangeable with male incarcerated people. And they presume female — they neglect, rather,
women’s gender-specific health care needs. It sends the message that males are the default
prisoner. And we see this highlighted really notably
when we have conversations — whether it’s research or advocacy here or legislative, in the media —
about issues like shackling pregnant women in labor or the ability of incarcerated people to have
access to menstrual hygiene products. Women are still shackled in labor. There are only 29 States that have laws prohibiting it,
and even in States that have laws, it still happens. The fact that we have to have a conversation
about a practice that is dangerous and that is a human rights violation signals again
that women are often an afterthought. The same is true with needing to pass laws,
which only a few States have, but ensuring adequate access to menstrual hygiene products. So, again, these deficiencies and the neglect
and the variability, it means that there are a lot of gaps and a lot of — a potential large impact
that research can have. And understanding these things, this is a
matter of health equity and health justice when we think about the people who are behind
bars and how forgotten they are and also how vulnerable the situation of
incarceration is in the power dynamics. So research really has the potential to promote
real policy change and have a real impact on people’s lives to support alternatives to incarceration and also to ensure that until that time comes,
women get the health care that they need while they’re in custody. So now, with that background in mind, I want
to share just some examples of recent and some past research from our group at Johns Hopkins. Some research that my colleagues have conducted
at other institutions and since I’ve been at Hopkins has focused largely on family
planning. And what these research studies have found is
that there’s an unmet need for family planning in incarcerated settings. And some people may be scratching their heads, thinking,
“Family planning, huh? Contraception — do women need access to contraception?” And the short answer is yes. These are women who are predominantly women of reproductive
age. Some of them enter correctional facilities on birth control methods, and they should be allowed to continue those as they would any chronic medication they’re on.
And also, ultimately these women are going to be released into society. And so this is part of their comprehensive
health care. And so some of the research that we’ve conducted
that supports that include various needs assessments that we’ve conducted with women who are just
entering jails. And have found that most of these women have been
pregnant before. And most of them have been sexually active
with men in the either weeks or months, depending on which study, prior to their arrest. A landmark study by my colleague in Rhode
Island, Jennifer Clarke, has found that most of these women planned to be sexually active
with men upon release. And research that we’ve conducted has also shown
that on admission to prison or jail, most women were not using a reliable method of contraception. And most women did not have positive attitudes about pregnancy. So you can see, this is depicting a picture of women who we
know are of reproductive age, who are heterosexually active, not using birth control, and don’t want to be pregnant, so there is a need for family planning. And in addition, about 60% said that they wanted
to access contraception while they were in custody. Now, I do want to also highlight that although one
of these studies found that 77% did not have positive pregnancy attitudes, there are women
who do have positive pregnancy attitudes and want to be pregnant upon release. And so it is also a moment for truly family planning and preconception counseling and helping them think about next steps when they get out. So although there is a need for accessing
contraception for people who are incarcerated, contraception is infrequently available for either continuation or initiation. And one study of health care providers in prisons and jails that we
conducted found that only 38% had birth control available on-site. And only about half of providers who were
surveyed said that women could continue their pre-incarceration methods. So that also presents some challenges when they
get released from prison or jail. They are not on a method of birth control that they had
been using before, and they’re at risk for an undesired pregnancy. We’ve also found, when we look at the need for emergency contraception, that
nearly one-third of women entering an urban jail, at the San Francisco jail where we conducted this, had had unprotected sex within the last 5 days before arrest and
wanted to get emergency contraception. In our survey of services, we found that abortion
services were inconsistently available, even though we know that incarcerated women retain their
legal right to abortion while they’re incarcerated. And we’ve also highlighted programs and shown ways that it
actually is feasible to provide contraception in prison and jails. Now, as I’ve already highlighted, a majority
of these women in prisons and jails in the U.S. are of reproductive age and have not been
using contraception before they enter into institutions. And so some of them are going to be pregnant. So, how many? Well, previously in my research and my background
sections, I would cite some statistics like this: 6 to 10% of incarcerated women are pregnant. Or 3 to 5%. There are about 1,400 births per year. But as I started citing these statistics
over and over, I really started to question where they came from. And I realize that they’re incredibly outdated
and not systematic in what they report. And so my group conducted a study that reflects
this notion that, you know, the lack of data signals women who don’t count don’t get counted. And the women who don’t get counted, well,
they don’t count when it comes to — if we don’t have the data, how can we inform policies
that will change things and improve conditions for them? And so to address this gap in knowledge,
we conducted the Pregnancy In Prison Statistics (PIPS) project. And this was my BIRCWH project, so I want to acknowledge the Office of Research on Women’s Health for this
and also funding from the Society of Family Planning. So, the PIPS study was an epidemiologic surveillance
study in which we collected data on a monthly basis from participating prisons — mostly prisons — and jails across the country to
report certain pregnancy outcomes. And this was a voluntary study, but we
were able to recruit 22 State departments of corrections, getting State-level data. We also got participation from the Federal
Bureau of Prisons. And because there are over 3,000 jails in
this country, we knew that we were not going to be equipped to collect data systematically
from jails. So we decided to focus on the five largest
jails in this country. We also used snowball sampling, and through
our recruitment, one small jail just asked if they could participate, and then three juvenile detention
facilities also participated. But primarily, PIPS was focused on prison-
level data. And although we don’t have all 50 States,
our data do represent information from — that represent 57% of women in prison in the
United States. Now, from a research perspective, I really
want to emphasize that being able to get this level of recruitment really relied on my collaborative networks
that I’ve established over the years with other academic researchers but also with
Government agencies and nonprofit advocacy organizations. So the National Institute of Corrections and
the National Resource Center on Justice Involved Women were really very helpful in promoting
recruitment for the study through their materials. And I was able to indicate in my recruitment
materials that they supported that. In order to get the Bureau of Prisons to participate,
I did have to get a letter from several representatives of Congress, and that’s what convinced DOJ
to agree to participation. So it was a long process, but ultimately,
they did agree to participate. So, I’m really excited to share with you some
of the results from our study. And these were published in March online in
the American Journal of Public Health. These data are open-access. So if you are interested, you can freely download
the publication. But the key findings from the study — and it’s
just from our prisons; we haven’t published the jail data yet. But there were approximately 1,400 pregnant
people who were admitted to these sites in one year. There were about 750 live births, 46 miscarriages, 11 abortions, 4 stillbirths, 3 newborn deaths, 2 ectopic pregnancies, and no maternal deaths. Of all the pregnancies that happened in the study,
6% were preterm, which is actually lower than the national preterm birth rate of about
10%. And the cesarean delivery rate was 30%, which is
pretty close to average. Now, one of the most striking findings of the
PIPS study is actually the variability from State to State. So, the highest preterm birth rate from one
State was 16%, which is significantly higher. And the highest C-section rate from any given
State was 58%, which is significantly higher. So it’s important to think about the disaggregation
of these data by State. I am eager to get out the many other results
we have to share from the PIPS study. So, we have to share our — publish our results on the pregnancy
outcomes in jails and our three juvenile detention systems. We collected data on opioid use disorder in pregnancy, both
in policies and on outcomes. And I should mention that in addition to collecting
the monthly outcomes data that people reported to our study database, we also, at baseline,
collected information about various policies related to pregnancy care and services — so some of those policies related to how they
treated pregnant women with opioid use disorder. Did they go through withdrawal? Did they have
access to methadone or morphine? So we are excited to publish those results soon. And in fact, these PIPS data, as an example
of how — they certainly fill in some gaps, but they also create other research questions. And so I am now funded by a K23 from NIDA to further investigate opioid use
disorder in pregnancy management in our Nation’s jails. We are also going to be publishing more
detailed information about abortion and contraception policies from our PIPS sites; other pregnancy policies and services, parenting
programs, and policies around the use of restraints; other medical and mental health comorbidities, like diabetes, hypertensive disorders, mental health conditions, other substance use disorders. We’ll be publishing information on tubal
sterilization occurrence and policies and information on breastfeeding and what happens to the infants after they are released.
So I’m going to be busy. Our team is going to be busy, and we have a
lot of information to share and get out there. An important limitation of the PIPS study
is that we collected aggregate de-identified data. So each reporter designated at our participating
sites, they just reported a number each month. There were 20 pregnant women admitted to our prison this month. But we didn’t have any information on the demographics
of these women. They were all de-identified. And while that was important, an intentional
design of our study, a limitation is not only that we don’t have detailed demographics
about people but also each number represents a real lived experience for a person who experiences
pregnancy behind bars. And those experiences are profoundly different
for everyone and can be extremely isolating and stressful, among other things. And so our team is also conducting a qualitative
study on people’s lived experiences of pregnancy and incarceration and how the experience of
being incarcerated impacts their pregnancy- related decision-making. In addition, I have also conducted ethnographic
research. This was actually my Ph.D. dissertation. My Ph.D. is in medical anthropology. And for my dissertation research, I conducted ethnographic research
of the San Francisco jail on pregnancy care and other health care among women and also spent time
with them and jail workers, both in and out of jail, and published these findings as a book, published
by University of California Press. There’s a lot of findings from this research,
but one of the key findings and the argument that I make in the book is that jail has unwittingly
and unfortunately become an integral part of the medical and social safety net for many
women who are on the margins of society. And although many women only were able
to access health care in jail, that doesn’t mean that we should think of jails as good
places or that we should try to make jails more harsh to discourage people from being
in jails. It really, again, diagnoses the failings of
our broader society if their lives are so chaotic and in such disarray that jail is
the only place where they can find care. So now, after highlighting just a little bit
of our group’s research, I want to move on to talk now about some unique research considerations
for conducting research in this setting, and especially on reproductive health and health care
issues. One of the things that I certainly didn’t think about my language very intentionally when I started this research over a decade ago, but it’s something I’m much more critically thoughtful
about now, and I feel like it’s constantly evolving. So, for instance, I do reproductive health care research.
I’m an OB-GYN, and most of the people I take care of and do research
with are women. However, there are transgendered individuals
who are incarcerated and people with female anatomy but may not
identify as women, and they can be pregnant, as well. And so in order to be trans-inclusive, I
often use “person” or “individual.” But sometimes I do use “woman” or “female,” especially
when the person herself identifies as female gender. I also do this when I’m referring to statistics
from other studies or from publicly available information that refer to them as
women or female. The term “inmate” is one that is very commonly
used and commonly understood to refer to someone who’s incarcerated. And I’ll break that down in a second, but
I would encourage people never to use the word “offender,” although that is used among
people, administrators who are on the custody side of things who work in prisons or jails. It’s a very pejorative term, and it’s not person-centered at all. Similarly, “felon,” “convict,” “criminal” — these are all very loaded
terms and very discriminatory. I have started veering away even from using the
term “inmate” and instead just describing the person as who they are — incarcerated person, incarcerated
individual. This is person-first language. It also makes incarceration an adjective,
a temporary state. It’s not the noun of who they are. In addition, “correctional” is commonly
used — correctional facilities, correctional health care. And that is, you know, that comes from the
context of thinking that prisons or jails or the tradition of prisons and jails being
places where rehabilitation happens, that we can somehow correct people’s behaviors. But I’ve found that that word, “correctional,” is loaded. It has a specific history to it. And in addition, it implies that the problem
with incarceration is with the individual’s behavior that needs to be corrected rather
than recognizing that incarceration is a complex political, social, racial phenomenon. And then I think relatedly, “correctional facility”
and even “facility” is just sanitizing. And so I prefer to be direct. Instead
of using “correctional,” I say “carceral.” That includes the root form of “incarceration.” And then for “correctional facility,” I just call
it what it is. If I’m talking about a prison or a jail or
a detention center or if it becomes too wordy to list all of them, then I say “institutions of incarceration.” In addition, “guard” or “CO,” or “correctional officer,” that
also can be variable. And although I personally have not explored
how people who work in prisons and jails feel about the terminology, just anecdotally, some of them do not prefer this language. And so a common term instead is “custody administration” or “custody
staff.” So that’s just a little bit on language. And I think it matters in how we communicate in our publications
and in our instruments and with research subjects. I also want to talk about the fact that when
studying incarcerated people, we need to think about their perspectives. And the organization the National Council
for Incarcerated and Formerly Incarcerated Women and Girls taught me this phrase. I don’t know if they coined it, but it’s something
they use a lot. “Nothing about us without us,” meaning if you’re going to do research that will impact
us, you need to involve directly impacted folks. And that means everything from designing your
research questions and making sure there are things that matter and that will have an impact, hopefully a positive
one, on the directly affected people, making sure that the methodology that you’re proposing
is appropriate and ethical, and even getting input from directly impacted
people on what the best methodology is — qualitative, survey, epidemiologic surveillance methodology — also, at the very least, getting input on survey instruments and interview guides. And we do this in our group. We have a network of people whom I’ve collaborated with
who are previously incarcerated who are willing to look at and provide input. But we always provide them with compensation for their time, recognizing their expertise. And I believe that ethically, that is important. Relatedly, from a methods perspective — and this comes strongly from my anthropological training — recognizing the researchers’ own positionality. And as feminist scholar Donna Haraway once wrote, “there is no view from nowhere,”
so we always have to recognize where we are coming from in our methodology
and how we’re asking questions and that our own identities — my
identity as a white physician at an academic university, that shapes how people perceive
me and how I ask questions, what I might be missing, the degrees that I have, the institution
I’m with, my lack of personal experience of being incarcerated —
all of these things matter, as do the power dynamics that are inherent to the researcher
and research subject. Now, there are a lot of ways and a lot of
potential sources of data on research in this area, in addition to research with incarcerated subjects. The Bureau of Justice Statistics is congressionally
mandated to collect certain demographic data every year from jails and prisons across the
country. And their data is free and downloadable if you just go to their website, and I use it
all the time. I can’t tell you how many times a week I go
to their website. They don’t typically collect robust health care
data, and every several years, they do publish some
information on medical issues. But unfortunately, the information they have on health care is limited. And so if you want to do database research
or policies, you have to go to individual State and county websites or the Federal
Bureau of Prisons. But there is a lot of information that is publicly
available. There is a lot that is not,
which speaks to the broader issue at the beginning of the neglect of focus on this population and just how opaque these institutions can be. Probation and parole offices and officers can be a source
of information and also a place to recruit subjects who are previously incarcerated, especially that it can take time to get approval and recruit incarcerated subjects. Freedom of Information Act requests can certainly be sent to prisons and jails to collect information. And then, you know, some people, myself included, want
to collect information on policies at jails. I mentioned there are over 3,000 jails
at least in this country, and so really trying to understand what’s happening, there must be some comprehensive list of jails
that are available, right, just, like, you know, all 50 States so we could somehow
contact their DOCs? Well, no. There actually is no comprehensive list
of jails that you can look at. So trying to do any systematic research on jail policies is very challenging. There are a lot of things to talk about
when thinking about having incarcerated people as research subjects. I think we’re all aware that there is a long and unfortunate,
really shameful history of coercion and exploitation
on incarcerated subjects from pharmaceutical trials that harmed people. And as a result, there are a lot of safeguards
in place, appropriately so. And it does raise the question, Are they able to consent? These are people who give up most of their rights.
They are in an inherently coercive environment. And I think ultimately, they can consent, but you have to be cautious
and careful in how you go about doing that. And some ways to do that that I’ve learned
from my IRBs in the past are to think about additional safeguards. Sometimes we’ve had waiting periods for consent in between when a research assistant tells them about the study and then returning a few days or a
week later to see if they’re interested in participating. You have to be careful about confidentiality
and their decision to participate and make sure that their nonparticipation will
not impact their receipt of health care, their legal proceedings, how they’re treated in
custody and keep that confidential and that there are are no consequences for them. There are a lot of regulatory considerations,
and I’m actually not going to spend much time on this, because there’s a lot of publicly available
information. And I’m sure everyone’s IRB has information
about this, as well. But there are Federal regulations on doing
research when incarcerated people are research subjects. They’re classified as a vulnerable population
or vulnerable research subject. Each IRB has to have a prisoner representative
on the committee when reviewing your research application. There are also regulatory considerations, in
terms of getting approval from Department of Corrections or jails. If you actually want to go in and recruit incarcerated
subjects, you absolutely need approval from those sites to get access, and they need to
know about your study and approve it. Sometimes that also — it’s also good to have
a backup document that’s an MOU or data transfer agreements. But beyond those regulatory considerations, there are
also a lot of logistical considerations that you might not have thought of. You have to get security clearance to enter a site, and that often requires
fingerprinting, a background check. There are very strict dress codes, and they vary from prison to prison and jail
to jail. There are a lot of things you cannot bring —
phones, of course, but some research things, like audio recorders, pens, research tablets. These are things you have to get approval
for, and often you have to get a special clear bag that you bring everything in. You can’t go whenever you want. You have to follow their routines, their schedules,
and work that out ahead of time as to what times you’re able to go. Are you allowed to give people copies of their
consent form? Can they have staples in them? And if not, then no staples. You should have a phone number on the consent
form so that people can contact you or the IRB, but it needs to be a phone number they
can reach and one that can accept collect phone calls. Compensating research subjects — that’s a complex set of ethical discussions. And some people do worry that it’s coercive. But I believe that if a research subject is giving
their time, then they should be compensated, and so my studies always provide some level of compensation. But we often have to conform it to the prison or jail
where people are. Are you going to have private space in which to conduct research — if you’re doing interviews or surveys, for instance? So, with all of these logistics, my research
group has developed an approach and a template form where we discuss certain operational logistics with custody and health care administrators at the start of each study so we can be on the same page, know when our
team can go, etc., etc. Follow-up with incarcerated subjects can be challenging. If they’re still in custody, it’s quite easy, but if they’re out of custody, you have to follow
a lot of different leads. And there has been some research published on what
strategies are successful. If collecting this information from research subjects
ahead of time so that if they get released during the study, you have a way to follow up with
them. Doing research in this setting requires
a lot of patience and flexibility, a lot of waiting. You may be waiting in the prison waiting room
for an hour or two before you’re allowed to get in. And then you might be waiting in the housing
unit or the clinic for another hour for them to bring the patient or the research subjects
to you. Unexpected things, like lockdowns or if the
person has a court appearance — these can all interfere with things, and you might spend 6 hours visiting a prison
hoping to get one subject, only to find that on that day, you don’t get anyone. So now, in the final few minutes, before we switch to the discussion, I want to talk about
advocacy and then why it’s important and how we’ve used research that we’ve collected in order
to have an impact, either directly or indirectly. And I’ve already, you know, at the beginning, painted
the picture of how there are tremendous inequities in our system of incarceration.
This comes to bear on people’s health and unequal health outcomes, and especially with reproductive health and reproductive health care. And so it’s important to our group that we conduct
research that can improve things and that is meaningful. And that is reflected even in our research
group’s name. And I want to acknowledge my former research
coordinator Lauren Beal, who — together, she and I brainstormed this name: Advocacy and Research on Reproductive Wellness
of Incarcerated People. And we thought about each and every word. We thought research, that was pretty much a
given, since we’re at an academic center and research is what we do. But we also do advocacy and try to make our research meaningful
for change. We thought about reproductive wellness, as
opposed to just reproductive health, recognizing that it’s not only about health but many other aspects of
people’s lives and families. We even thought about the preposition
“of” and what would be appropriate and not cumbersome. And then incarcerated “people,” not “women.” So, with our group, some examples of how we’ve
incorporated advocacy, well, one project that we conducted in collaboration
with colleagues at the Baltimore City Health Department, we did a reproductive health needs assessment
at the Baltimore jail and found that there were needs for family planning services, among
other things. We summarized this and made recommendations to the State and local jail
system. And they saw this, and they said, “OK, we need to make some changes.” But earlier, in our interactions with them, before
we had done this research project, they didn’t really — we had presented the national data
that existed, but they wanted to know what was happening in
Baltimore. It wasn’t enough to know what a study in Rhode
Island or San Francisco showed. It was having local data that then led them
to change their policies. And so that’s really important when thinking
about things you could do locally. In terms of the PIPS study, from the start, advocacy was important. And so we implemented that as our main results were
being published. And we promoted our results widely on social media, in the media,
with interviews, and other things. We have a study website that we promote. So we definitely promote the research. We wanted our research publication to be open-
access so that people could see the full publication. We also presented the raw data by States. So the tables in our study break all the
raw numbers down by State so that people in their individual State
can use the data and do what they want with them. Some examples of what some of the participating sites in
PIPS have done, so Cook County jail, they used the data that they were reporting to the PIPS study to make a case for not incarcerating pregnant women who were in their third trimester if they were arrested on nonviolent charges. So now Cook County doesn’t incarcerate pregnant people in
their third trimester unless they are arrested for violent charges. So really, a policy change in terms of decarceration. The State of California declined participation
in the PIPS study. And I noted that in the methods section of the academic publication,
and somebody in the California legislative system and the Department of Corrections and Rehabilitations saw this and contacted me to find out what happened
with that, why did California decline participation, and then came to me and said, “Well, based on these
data that you found in other States, what recommendations do you have? Can you help us so that we can start to collect
these data?” So this was really exciting for us to see
that even nonparticipation effected some policy movement. In addition, there is a House resolution,
the Pregnant Women in Custody Act, that has a provision in it that is basically the PIPS study, meaning that it requires institutions of incarceration
to collect pregnancy data. This is still on the floor, and I’m not sure where it will go, but it’s great to see it in legislation. So, before we open it up to questions, I just
want to summarize a few key points, recognizing that mass incarceration has really deeply racialized roots. And this has implications for health care and for research. Incarceration and reproductive health are deeply intertwined with each
other, and therefore, there’s a tremendous role in the value of research. And it’s an overlooked area of research, but
conducting thoughtful research in this area is absolutely essential to improving health care, promoting equity,
and advancing health justice for everybody. So with that, I want to thank everybody, and I think we will open it up to discussion.>>DENISE: Dr. Sufrin, thank you. That was a wonderful
talk. And we already have questions. So, everyone can start sending your questions, but I’m
going to give you the first question we have. Can you discuss home visiting programs in
prison, specifically Family Spirit, because it is culturally sensitive to American Indians. They make up over 50% of South Dakota’s State prison population but only 8%
of the State population. That’s the question they asked.>>CAROLYN SUFRIN: OK, great. Well, thank you for sharing that. It’s important for everyone to understand
that every State also has different demographic profiles of who’s incarcerated. But I think what unites it is that marginalized communities
that are discriminated against in many ways are often the ones disproportionately incarcerated. So although I didn’t talk about Native populations, obviously
that is true in South Dakota and other States. So if I heard the question correctly, you were
talking about the Family Spirit program. If that’s a formal program, I’m not familiar
specifically with that one. In terms of visiting programs for mothers
or parents who are in prisons or jails, it is highly variable whether those exist at
all and what they look like. We do know more generally that maintaining
parental-child bonds when people are incarcerated is really important for the children and that there are profound intergenerational
effects on children of having a parent who is incarcerated and that visiting programs do not get rid
of those problems but they’re one way to address and ameliorate some of those issues and maintain connections. However, the data on those programs are limited
and variable. And it really depends on the kind of programs. There are some prisons that have really robust
visitation policies with frequency and the kind of contact that’s allowed. But there are other places where visits only
happen by video. And when you think about the fact — when
I mentioned that many prisons are in rural places and it can be really hard for children and
family members to travel to these places, but they might. They might travel hours and hours, get to
a prison, and then all they get is a video visit, a video conference visit, in the prison. Or if they’re allowed a person-to-person visit,
they’re not allowed contact. And then some places don’t even have contact
visits at all. There’s a lot to be said about visits with
newborns for people who give birth while in custody, and there’s, again, a lot of variability in
that. And there are some programs that do allow
women who have given birth in custody to bring their children back to the prison or jail with
them. But there are only a handful of State prisons and I’m
only aware of one or two jails that do this. While there is some research to suggest that these — they’re often called prison nursery programs —
have benefits for the mothers in terms of reduced recidivism rates in the future, you know, it’s questionable whether those are women
who already were at lower risk for recidivism and that perhaps we should be investing in community-based
alternatives to really strengthen the bonds and connections between parents and children. So, in summary, I can’t speak specifically
to the program that the questioner was asking about, but I can tell you that there’s certainly
opportunity for more research on this. Speaking again to the variability and the
opacity of information, there are probably some good visiting programs
out there, but there just isn’t any centralized clearinghouse of information. So we just don’t know what best practices
are and what they might look like.>>DENISE: OK. That’s perfect. And you answered another question that we just received
about commenting on mother-baby programs. So that was good. Another question is, How dangerous is it for
someone who has a prolapsed uterus, and what can we do to help an individual with
this issue?>>CAROLYN SUFRIN: So, uterine prolapse is
a condition that happens usually to people who’ve had births before, and it’s more common
in postmenopausal women, though it can happen in premenopausal women. It is a benign gynecologic condition, meaning it’s not cancerous, there’s no risk for cancer. And so it is a condition that can be very
uncomfortable and that can be embarrassing, and people can
feel a lot of stigma over it. And in some cases, it can put people at increased risk
for urinary infections and other related gynecologic issues, as well. So, in terms of its danger, it’s not something
that is an acute problem usually, but it is something that has some health consequences
and some important psychological consequences that can affect people’s quality of life and
functioning. In terms of the treatment of this for women who are in incarcerated settings, I would say
although the majority of incarcerated females are of reproductive age, there are a lot of women
who are older and who are postmenopausal, and we’re seeing more and more of that
than ever before because of policies like mandatory minimum sentences, life sentences without the possibility
of parole. So the prisoner population for females is also
aging. And so probably, health care providers in
prisons are going to be seeing — are seeing more of this. And so treatment involves referral to a
gynecologist or a urogynecologist, who can assist either with pessary management or with surgical management.>>DENISE: OK. Can you speak more to strategies
for connecting with formerly incarcerated individuals to get their input or consultation
on the details of one’s research study or methodology?>>CAROLYN SUFRIN: Great question. And it’s one that I’m actively working on. I don’t have a perfect recipe yet, and actually, it probably will always be
“yet” because I’m not sure that there — you know, there’s always room for improvement. But some strategies include finding an advocacy
organization in your community that works on reentry issues or works with or employs
previously incarcerated people or, in some cases, places that work on substance — support
people with substance use disorder, because many of them have been incarcerated before. But finding the community-based organizations
that might directly service previously incarcerated folks or employ or be
led by them. So first it’s just identifying organizations that you
can partner with and then working with them, explaining to
them, you know, why research is important, you know, saying, “We want to do research that will
help you and people in your position.” So being clear at the outset that you have
the humility to know your limits. And then details like figuring out who ideal
people would be, what the outlining — what is the time commitment? Are you going to develop a community advisory
board that meets on a regular basis or an ad hoc basis? What kind of a place are you going to meet at? Are you going to be able to provide child care? These are some of the nitty-gritty details
that are important to provide. And then one that is also very important is compensation — again, recognizing people’s time is valuable
and their expertise. Also — this is partially related
to getting input on research development — but also when people incarcerated or formerly
incarcerated people are research subjects, recognizing that sharing — them telling
you about their experiences, or what you might call “sharing their stories” — you know, it’s not their stories —
their lived experience, but, you know, when they share their experiences, it can be traumatizing for them. I have some colleagues who are formerly incarcerated
and who are very outspoken and are leaders in the policy realm and have had real impact
on passing legislation — for instance, in Georgia and other States on
anti-shackling laws — and they have had to tell their stories over and
over and over and over again about being shackled in labor to lawmakers, to the media. And so as myself as a researcher, when people
talk to us about their experiences, I acknowledge that at the outset and express gratitude for
their being willing to disclose those experiences and their information. And I think the same is true when you seek
input from formerly incarcerated people on research protocols and development.>>DENISE: OK, so along those lines, can
you speak — let me see here. Can you comment on the role of the physical
environment in the prison on the health of incarcerated women — for example, the presence of lead paint or temperature or ventilation,
etc.?>>CAROLYN SUFRIN: So, I can’t comment in great detail about that,
other than to note, as your question brings up, that the
physical space of incarceration facilities can be dangerous for people’s health, as the questioner already alluded
to, with the paint, the ventilation problems. Water is an issue. And, you know, even if the water might meet chemical
standards of safety, sometimes it looks awful. I shouldn’t say “sometimes.” We don’t know how
often, but I have certainly heard from people who have been incarcerated at facilities,
read media reports of this. And it can taste — it can have a really bad
taste. And it could be room temperature and warm. It makes it really hard to stay hydrated, especially
if you’re a pregnant person. There’s also the physical conditions of crowding
and the impact that could have on transmission of infectious diseases and other conditions. And, you know, this is a brief story about
a study that involved focus groups that I conducted at the San Francisco jail. And in one of the open-ended questions we asked
about, you know, what their thoughts are on health care services in the jail. A lot of
people, when they heard that question, and what they answered it with was describing
what they perceived as unhygienic conditions or the dirty carpeting or how the toilets were dirty or, you know, the physical environment. So it is also, you know, something that people living
in those conditions notice. And then, related, it’s not the physical
environment but the stress of being incarcerated and the way that people are talked to, the
separation, the trauma that it can involve, just being in that environment and not having
any choice as to what or when you eat, having to ask permission to go to the bathroom — those psychological stressors can also have an
impact on people’s health. There is some research being conducted — and I don’t
know the data myself, I just know that the research is being conducted and is out there —
on the environment and impact on obesity and that obesity rates are rising especially in prisons. And that has, you know, connections to nutrition
and access to exercise and those sorts of things. So it’s an excellent question. I’m not deeply knowledgeable
about it, but I know that there is some research about it.>>DENISE: OK. From a public health perspective, how much
energy do you think we should dedicate to institution-level interventions, such as providing
family planning services, versus efforts to reshape the justice system in the United States
on a macro level?>>CAROLYN SUFRIN: That is the question I ask
myself almost every day. And that is a guiding question and balance
that I think about with our group’s research, and so I don’t have a proportion or percent. Instead, the way that I reconcile this is
that I think we need to do both at the same time. I do not have formal training in public policy
or law or political science. And so I’m not the best person to be developing
strategies and working on strategies to reduce our country’s overreliance on incarceration. But I know enough that from a public health
and a health and a human rights perspective to know that we need to do that. And I speak about that. I try to emphasize that when framing my research,
and I support efforts that focus on that. While that is happening and until the day
comes when we are a society that has de-carcerated, we cannot forget about people who are there right now,
and we cannot forget about the fact that that they have a constitutional right to health care and, frankly, a human right to health care and that in order to ensure that they are
safe and they get the health care they need and deserve, we need to do research to make sure that
it is optimal and safe and addresses their needs. And, you know, the abysmal state of health care in some prison
and jail systems is exemplified by the fact that there is a very long multiyear lawsuit
brought against the California Department of Corrections and Rehabilitation because
of a large number of deaths that happen in custody. And it was determined that this excess of deaths in custody — I mean,
there shouldn’t be any deaths while people are in custody, but, you know, if you have people there serving a life sentence, you know, someone who’s in their 90s, that’s, you know, potentially —
but an excess of expected deaths in the California system, and they determined that it was related
to the overcrowding and to the inadequate medical care, that they couldn’t match — the medical
services didn’t match the need. And that made it, like I said, to the Supreme Court. And they required the State of California to
depopulate their prisons by about 30% as a way to respond to this medical malfeasance. So, it’s just to speak to the fact that we can and we
should work on both. We cannot forget about the fact that if we don’t try to improve health care conditions
right now and try to understand them better and try to also improve things so that when people get released,
we can help them with reentry in this very vulnerable time, if we forget about that, then we’re putting
people — we’re perpetuating their risks of deaths. And then, you know, related to the question about visiting
programs and my comment about how we don’t know, I want to be clear that although there is tremendous
variability in health care, quality and quantity, and there are some places where it is downright
dangerous and harmful, there are also some prisons and jails that provide excellent care
and have innovative programs. And yes, they are in prisons and jails and we should still be having these conversations
about alternatives and the need to be investing in our communities, but it is also important that we try to find
these places that are implementing best practices — for instance, allowing postpartum people
to breastfeed or provide breast milk for their babies. So that was a great question, and I’m so glad that person brought that up, because
that balance is one I think about all the time. And I think that both efforts need to be researched
and advocated for in parallel.>>DENISE: OK. Do you know of any research into how incarceration
impacts individuals’ ability to construct their desired family size — for instance, people who hope to have multiple
children who are incarcerated during their final years of their reproductive window?>>CAROLYN SUFRIN: Yeah, great question. So, in terms of systematically asking that question
about how incarceration is impacting their family size, I don’t know of any studies
that have had that, you know, sort of primary focus on that. In my ethnographic research, it is definitely
something that came up. Not so much with the hypothesized situation
or — not hypothesized, real situation that the questioner just asked. But some of the people in my ethnographic research
study, they are women — and they all identified as women — who have been in
and out of jail their whole adult lives and many of them their adolescent lives in juvenile detention systems, and when they’re not in jail, most of them have the involvement
of child protective services in their parental relationships and have not had custody of their children. And so some of the women in my study talked
about how they felt that being pregnant in jail, getting prenatal care, getting some
parenting classes, even if they gave birth they would be giving birth sober, they felt that this gave them a chance to focus
on their pregnancies and their motherhood in ways they hadn’t had outside of jail and hoped that it would give them a chance to get custody
of their children, ironically, even though they gave birth, at least for the short term, in jail. And that is deeply problematic, the way that they’ve become
conditioned to expect the involvement of child protective services in their reproduction. So some of my ethnographic research that emerged in that
study and then the qualitative research that the ARRWIP group is conducting now is focused on how the experience of incarceration impacts their pregnancy-
related decision-making. And also, to some degree, we do follow up or attempt to follow up with women after they’ve given birth, and we try to get a sense of how incarceration has impacted their thoughts
about family size. So it’s a really great question, and it’s not one that I think
has been systematically studied as the primary outcome. But I think it’s really interesting and compelling,
especially when thinking about the ways that many of these women are just used to institutions,
whether it’s prison or jail or child protective services, have been deeply involved in
their reproduction.>>DENISE: OK. Can you discuss a mother’s health
postpartum over the life course, such as depression, infections, etc., and whether it is adequately
addressed for individuals in prison?>>CAROLYN SUFRIN: We don’t know. That is again a fantastic question. So, if we know little about pregnancy in prison
and jails, we know even less about the postpartum time period. And I can tell you that in the PIPS study,
one of the outcomes we assessed in our supplementary surveys — so for the PIPS study, each month every site
had to report the number of pregnant people who were admitted, how many
gave births, had miscarriages, abortions, preterm births, C-section, newborn deaths, and maternal
deaths, and then we had two supplemental sections that they could choose to answer or not for 6 months. And most of them did complete that supplemental
section. And so one of those supplemental sections asked about postpartum depression. And we haven’t fully looked at these data. I’ve just had a cursory look at it. So please don’t cite this, because I can’t, you know, I haven’t finalized
the analysis. But about 6% of women who gave birth
in custody were reported as having postpartum depression. That is significantly lower than the national
rates, and it is significantly lower than I would expect. I would expect incarcerated women to have higher
rates of postpartum depression, because at baseline, these are women who have higher rates of mental illness, to begin with,
and secondly, the trauma that I can imagine is involved in being separated from your child immediately after birth likely has
a profound impact on their risk for depression. So I suspect that there is under-screening and that postpartum issues are not adequately
addressed in this setting. Now, I should also acknowledge that on a national
level, in just community perinatal health care, including efforts from the American College
of OB-GYNs, there’s really a growing recognition that we need to rethink the entire postpartum period and the intersections with health care systems and really revamp
how we approach that. So I think that we don’t know a lot about
the postpartum period for incarcerated people. But I have a lot of hypotheses that it is
a potentially psychologically troubling time, isolating time, and that there are higher rates of
postpartum depression than we think. In terms of infections, that’s something that I
haven’t seen studied and I’m not familiar with. You know, if someone has any medical concerns after
delivery, I would hope that they would be able to access health care in the prison or jail
and then, if needed, be referred to an OB-GYN or a midwife outside of the prison or jail if
needed. But we don’t know how all those systems happen. And there can often be barriers to people
accessing health care systems in prisons and jails.>>DENISE: OK. This is our final question. Given that there are high re-incarceration rates,
is it of interest to treat and empower both the incarcerated person and nonincarcerated
family members as a unit?>>CAROLYN SUFRIN: I think that’s a really
great perspective. And I think there’s a lot of potential in
that. Part of it is — and I would encourage research
efforts that focus on maintaining linkages between families and individuals from that
perspective of empowerment to support their reentry, to try to reduce recidivism and re-incarceration
rates, but I would also add the broader context that recidivism and re-incarceration is not solely an individual problem. And it is not necessarily an issue with an individual’s behavior. It is a broader structural problem with how
we process and deal with people who are enmeshed in the criminal legal system and the ways that they’re set up or not set up
on release for housing, for reinstating their Medicaid benefits. One of the things I didn’t have time to discuss
is that people get — if they have Medicaid or Medicare in the community, that gets suspended when they’re incarcerated. And then, when you get out, you have to reinstate
your benefits. And people might lose their access to supportive housing that they may have been living in before incarceration. And so there are a lot of structural factors,
as well, that can contribute to re-incarceration. And so while I absolutely think that empowering
the family and the individual as a unit is important and can potentially have a profound
impact, it also has to come with the recognition that we need more structural and systemic changes,
as well.>>DENISE: So, thank you so much. Dr. Sufrin, thank you. What a wonderful presentation. And as a matter of fact, one of the comments that we got from the listeners —
someone said, “Amazing presentation from an exceptional speaker.” And I have to say that we agree 100%.>>CAROLYN SUFRIN: Aw, well, thank you so much. I really appreciate everyone’s participation. And I just, for the last moment, shared our
contact information. If anyone is interested further, this is how you can find us. And I hope that some of you will go on to
conduct research in this way. And even if you don’t work with incarcerated
people on a research or advocacy or health care perspective, I hope that these issues we’ve brought up
will be of relevance for any underserved group that you conduct research with.>>DENISE: Wonderful. Thank you so much. And we hope to have this presentation on the
Office of Research on Women’s Health website as soon as possible. But thank you again. We really appreciate it.>>CAROLYN SUFRIN: Thank you.>>DENISE: All right, take care. Bye-bye.

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