Two speakers at the workshop focused specifically on the issue of women’s health in jails and prisons. Marjie Mogul, senior director of research at Maternity Care Coalition (MCC), spoke about MCC’s programming inside Riverside Correctional Facility, which is Philadelphia’s county jail for women. Charmaine Smith Wright, who specializes in internal medicine and pediatrics at the Christiana Care Health System in Wilmington, Delaware, discussed some of the special health care needs of women who have been incarcerated. Both made the point that services
provided to women in jails and prisons can improve their health while they are incarcerated and increase the odds of successful reentry, which can benefit not only the women involved, but their children as well.
WOMEN IN JAIL
Of the 219,000 women experiencing incarceration in the United States, nearly half (44 percent) are held in local jails, Mogul pointed out. Wright added that women represented 8.8 percent of the incarcerated population in 2013, and no country incarcerates more women than the United States. Nearly 80 percent of these women are mothers and the primary caregivers of their minor children. Approximately 10 million children have experienced parental incarceration at some point in their lives, and approximately 50 percent of children with parents experiencing incarceration are under 10 years old. These children experience a major disruption in mother–child bonding, Mogul observed.
Women experiencing incarceration have some of the poorest health indicators of any population group, noted Wright (see Figure 4-1). The women who are incarcerated in Philadelphia tend to be poor and mostly African American. They are disproportionately single, unemployed, and undereducated. Almost 40 percent are obese before they come into prison, 73 percent already had a mental health diagnosis, and 84 percent had a minor child living with them prior to incarceration. “Overwhelmingly, women in prison are mothers, and we have to think about that as part of their identity,” said Wright.
Parental incarceration is an adverse childhood experience, Mogul explained, which is to be expected, given the major brain developments that occur from ages 0 to 3. This brain development has a critical influence on future behavior, including the development of executive functioning leading to impulse control.
Wright made the same point, noting that even events occurring in utero can affect health for a person’s entire life. She has done research on the molecular pathways that link maternal and child health, and specifically on the DNA methylation that can repress gene activity.1 Stress, toxins, nutrition, and other factors, providing a mechanism by which parental experiences can have biological effects in children, affect this methylation. “Genetic predispositions [are] being read and sealed into the DNA during that period,” she said.
1 Methylation is a biochemical process that leads to the epigenetic modification of DNA.
A TWO-GENERATION APPROACH
MCC is a maternal–child health and early care and education nonprofit organization serving pregnant women and families with young children in southeastern Pennsylvania.2 Its programming is based on the idea that health is a result of where people live, learn, work, and play, Mogul said. “When people leave the hospital or the clinic, that’s where the social determinants happen, and that’s where the real work happens,” she added.
MCC works to improve the health and well-being of pregnant women and parenting families, and to enhance school readiness for infants and young toddlers ages 0 to 3. It achieves this goal through direct service, advocacy, and research in collaboration with individuals, families, providers, and communities. It provides a number of evidence-based services, including center- and home-based programs like Early Head Start and Healthy Families America; MCC also employs a community health worker to make home visits. MCC uses relatively simple interventions such as baby carriers and pedometers, as well as motivational health texting, where women receive texts every day with tips and encouragement. These interventions in the community have been successful in stabilizing women’s weight in the postpartum period, Wright pointed out, increasing their self-efficacy for healthy behaviors and reducing depression at 6 months, though this latter measure did not persist at 1 year.
One MCC program involves what it calls the MOMobile, which is a community-based home visiting program that provides free support and education to help families with the changes and challenges that come with pregnancy and parenting. As part of this work, the MOMobile provides parenting, doula, and lactation support to pregnant and postpartum women inside Riverside Correctional Facility. Four staff members are located inside the jail and work alongside the social workers, “although they don’t do the same work,” Mogul said. “They are distinctly focused on pregnant women and mothers.”
One of the first things MCC discovered when it started working in Riverside was that women were routinely being shackled during labor and delivery and during transport to the hospital and back. MCC was part of a statewide effort to ban shackling in Pennsylvania, so the state is now one of just a handful that have banned the practice. In addition, no family members or anyone else who could offer support were allowed in the delivery room. Trained birth assistants or doulas now accompany every pregnant woman at Riverside into childbirth, Mogul reported.
To help women transition successfully to parenthood during and after incarceration, MCC provides parenting, childbirth, and breastfeeding education, and “almost all the women do engage in breastfeeding in the hospital,” Mogul said. In addition, MCC provides breast pumps in the jail, and advocates deliver the milk to the caregiver of the baby.
In addition to its parenting and childbirth programs, MCC offers a program called Fit Beginnings for Mom, which facilitates healthy choices in eating and physical activity. Individualized health and wellness plans are based on a woman’s self-identified goals and needs, though these plans inevitably face obstacles at Riverside. “Getting pedometers into the prison was a challenge, but we did it,” said Mogul.
IMPROVING NUTRITION IN JAILS AND PRISONS
Because of diets high in processed foods, carbohydrates, fat, and sodium, limited opportunities for exercise, and the effects of psychotropic medications, women gain an average of 17 pounds during their first year of incarceration, noted Wright. Typical meals contain very little fresh fruits and vegetables, and food systems are institutionally managed catering services. Yet, women still seek to maintain some control over their eating while incarcerated. For example, they often learn how to make meals for themselves using items on commissary menus, such as Cheetos prepared with processed cheese and cut-up bologna. “There are issues of control, love, and autonomy” in prison food, said Wright. “Identity gets wrapped up in food in prisons, and it’s hard to disentangle.”
MCC has worked to provide women with low-calorie and healthy meals snacks. For example, the Fit Beginnings program has identified red light, green light, and yellow light food choice options on commissary menus, which are filled with unhealthy options. Some prisons have self-cook facilities, which is a way of giving some control back to the people in those prisons, Wright noted. Some have gardens or farms, though those unfortunately tend to be disproportionately at jails and prisons that serve men rather than women. Wright also pointed out that, based on data gathered largely in male prisons and jails, fewer outbursts and disciplinary incidents occur when nutrition is improved. “They started giving vitamins in one prison because they realized that they saw a good effect,” she said. Preventing diabetes among people who are incarcerated also cuts down on health care costs during and after incarceration.
As a healthy alternative, Wright offered the example of a prison in Denmark where meals are self-cooked and shared. More broadly, international organizations like the World Health Organization have been supporting health-promoting prisons, and a humanitarian principle was established that individuals detained in prison must have the benefit of
care equivalent to that available to the general public, said Wright. Well-coordinated health-promoting interventions in jails and prisons have the potential to address the health needs of those who are the most marginalized in society, and because people in prison often serve multiple and relatively short-term sentences, their health and the public’s health are intertwined.
SUPPORT UPON REENTRY
The women served by the MOMobile average 60 to 90 days in jail, and most are charged with lower-level property- and drug-related offenses. Mogul stated that most of the women will be released soon and will have a relationship with their child upon reentry. Some give birth in the jail and give up their babies, but they are reunited with them after leaving jail. Most of these women were the victims of trauma when they were growing up and developed mental health issues that manifested in substance use, said Mogul.
Mother–child bonding may serve a protective function for mothers during the reentry period, Mogul observed. The research is less clear cut on this point, but reunification with their children is a major issue for women in prison. They want to be good mothers and serve as good role models, Mogul explained. The women say “Yes, I did something wrong. I don’t want my child to follow my path. I love them. I want to be a good parent.” Mogul concluded, “These are women who are very smart and could be really productive if they were given the opportunity.” Providing mothers with the support to care for their children may keep them out of jail, Mogul said.
As with men, employment, education, and housing are important for women after they leave prison, noted Wright. But women who have been incarcerated have other needs. Relationships are important for women when they return to the community, along with a holistic perspective on maternal health, access to health insurance, and access to identification and documentation, Wright added.
KEEPING MOTHERS OUT OF JAIL AND REDUCING THE NUMBER OF WOMEN WHO ARE INCARCERATED
Mogul concluded her presentation by pointing out that models exist across the country, such as house arrest or rehabilitative programs that focus on keeping pregnant women and mothers out of jail. “These aren’t women who need to be punished,” she said. “These are women who need to be given treatment. It’s the best thing for the babies and their future. Philadelphia has been very innovative and open minded about these
types of issues,” said Mogul. “We could be the first big city to take the lead on something like this.”
The major topic of discussion during the question-and-answer session was why the number of women who are incarcerated in the United States is so high, and how this number can be lowered. Kathleen Brown of the University of Pennsylvania (whose presentation at the workshop is summarized in Chapter 3) observed that one answer is to dissuade judges from sending women to jail, especially women who are pregnant. “Philadelphia in particular has had a lot of success with that. As I watch over the years, there are fewer and fewer pregnant women in jail,” she said, a trend she attributed to a campaign to convince judges that sending pregnant women to jail is bad policy. The next step, Brown continued, is to change judges’ minds about what the incarceration of women does to families. “Some judges are coming along, and some judges, not as much.” Brown recounted a story in which a woman delivered a baby in the Philadelphia prison—fortunately, on a day when the ob-gyn physician was there:
Why would you send a woman into prison when she was only going to be there for a few days? The reason was that she had a lot of parking tickets. Isn’t that amazing, that a judge felt comfortable sending a woman that was close to term to jail because she didn’t pay her parking tickets? That has to change. Why are we sending these women to jail, women who have mental health issues, women who have addiction issues? Many of the women I meet end up in jail because they’re placed on parole when they leave, and they can’t follow all the rules for parole … and they end up violating parole and coming back in. It’s a cycle of coming in and going out.
Mogul added that in the past, judges sent pregnant women to prison in an attempt to help them get off drugs before they had their babies. “There was this thought that since that was the place to go to get treatment, and they weren’t accessing it in the community, that would clean them up for when the babies were born,” she said.
The incarceration of women has also been part of the war on drugs and criminalization of poverty. Mogul pointed out, for example, that some states have considered legislation that would criminalize women who are pregnant and using drugs, or legislation that would ban lifetime benefits for anyone convicted of a crime. “It’s part of the larger process of criminalization rather than rehabilitation or support,” she noted.
Brown added that many of the people making policy do not seem to have any understanding of the disparities between their lives and the lives of people who are incarcerated. She also expressed (what she labeled as her opinion) that many policy makers seem to be more interested in their next elections than they are in solving problems. They may talk about a
problem, but they do not have the knowledge base or motivation to act on a problem. Brown also noted that local officials such as judges, prosecutors, and district attorneys have a large amount of discretion about who does and does not go to jail. (The presentation of Philadelphia’s district attorney is summarized in Chapter 7.)
Mogul added that policy makers need to get information from experts, including the people attending and presenting at the workshop. MCC representatives, for example, meet with legislators, “and not necessarily the ones who already support us—those too, but all of them—and we educate them very objectively.” She encouraged people to contact their federal and especially state representatives and senators. “Know your stuff, have a fact sheet, that’s how they learn—and they’ll listen to you,” Mogul said.
Wright pointed to the advantages of diversifying stakeholders. Many people at lower-level positions, like parole officers, have direct contact with people who have been in prison, and these people could help turn the tide. “Think creatively about people we have on the inside who are stakeholders,” she suggested.
In response to a question about whether communities have contributed to mass incarceration because of a perceived lack of safety, Brown noted that it depends on the community:
Many people want to be tough on crime because they’re afraid of it. But their level of understanding about crime is low. They’ve watched different television shows, and they know that this one thing happened because that made for an interesting show…. In the neighborhoods where crime is happening, they understand it. Someone in their family is incarcerated, they understand it, and they are looking for a change in the system.
Wright added that the spread of the opioid epidemic is changing the conversation. As more people become victims of opioid addiction, opportunities arise to discuss the policies of mass incarceration that are fundamentally misguided and harmful.