It depends.

• Can incarcerated people be shackled during labor? It depends.
• Can women breastfeed or pump after delivery? Will anyone see to it that their infant receives this milk? It depends.
• Are pregnant people in custody with opiate addiction given medical assistance to detox, or are they left to go cold turkey on their own? It depends.
• Can an incarcerated woman have access to an abortion? It depends.
• Are pregnant, birthing and postpartum people treated with dignity and humanity while behind bars? It depends.
• Do we even know how many pregnant, birthing or postpartum people are behind bars in the U.S.? Actually, that answer is a straightforward No.

Whether incarcerated pregnant people have adequate nutrition, access to obstetric care or even such necessities as maternity clothing depends on what state they’re in, whether they’re in a prison or jail (more on that distinction later), and sometimes simply on the whims of jail staff or local sheriffs and deputies.

According to the , the capriciousness of reproductive care for pregnant, birthing and postpartum pregnant people in custody comes to us via a patchwork of decentralized and overlapping criminal legal systems throughout the U.S. comprising thousands of federal, state, local and tribal systems that together incarcerate more than 2 million people. Around 173,000 of that number are women or girls, primarily people of color, mostly young, and most arrested for non-violent offenses. The U.S. has the highest number of incarcerated people in the world and is second only to Thailand in the number of women behind bars.

Until recently, the pregnancy status of these incarcerated women had not been updated for decades, making it impossible to say with any certainty how many pregnant people were behind bars, how they were being cared for and the outcomes of their pregnancies. The federal First Step Act of 2018 now requires the U.S. Bureau of Justice Statistics to collect data on pregnancy outcomes from federal prisons, but no such requirement is in place for state prisons and jails. Any data at all on the thousands of women in local jails is spotty to nonexistent.

In 2019, Dr. Carolyn Sufrin, a national expert and advocate for reproductive care for incarcerated women, and her multi-sector research team at Johns Hopkins University School of Medicine and School of Public Health published , a significant study that collected data from 2016 to 2017 from 22 state prison systems, the Federal Bureau of Prisons, six jails and three juvenile justice systems, representing 57 percent of females in prison and 5 percent of those in jail. The study found that at any given time, 3 to 4 percent of females were pregnant when they entered U.S. jails and prisons.

An obstetrician-gynecologist with a doctorate in medical anthropology, Sufrin ran a women’s health clinic for six years as an OB-GYN at the San Francisco County Jail before going to Johns Hopkins. She found that the hard data she needed to study maternal health, including pregnancies, miscarriages and abortions behind bars, didn’t exist. She launched the initiative that became the PIPS study, the first-ever systematic study of pregnancy outcomes for women behind bars in the U.S.

“Part of why we know so little is that, as a society, we’ve just ignored these women,” Sufrin says. “We either pretend they don’t exist, or else people believe it’s such a small number of women, ‘Who cares?’ But how do we know it’s a small number unless we study it?

“There’s a saying, ‘Whoever isn’t counted doesn’t count,’ so the lack of data signifies how little we care about pregnant people, especially those at the margins of society.”

As the PIPS project concluded, Sufrin founded the (ARRWIP), which continues to conduct research on reproductive health care issues among incarcerated women. She says she became committed to this specialty as a first-year OB-GYN resident in Pennsylvania when she delivered the baby of a woman from the local jail who was shackled to the hospital bed throughout labor and delivery. Until that moment, she writes in her excellent book, “Jailcare: Finding the Safety Net for Women behind Bars,” like most Americans, she had given little thought to the idea that there were pregnant people behind bars, nor the complicated reality of that fact.

Shackles and Health Care

If the idea of shackling a pregnant woman in active labor seems medieval — or cruel and unusual punishment at the very least — welcome to large swaths of the U.S. Despite well-established medical risks, as of July 2023, only 40 states, the District of Columbia and the federal government have banned restraints in labor and delivery; some have banned the practice at other points in the pregnancy and postpartum period. In Maternal and Child Health Journal, November 2022), authors Camille Kramer et al. report that pregnancy policies and services in prisons and jails vary widely, with little consistency in compliance with anti-shackling legislation even in states where it’s banned. Most facilities station an officer inside the hospital room during labor and delivery, and nearly a third don’t even require that it be a female-identifying officer.

Though state prison systems hold twice as many individuals as jails, the PIPS study reports that more women are held in jails than in state prisons, a statistic that carries profound consequences for these women and their families. The distinction between prison and jail is that prisons are long-term confinement facilities the federal or state government monitors, often by an entity the government contracts. People in prison typically have been convicted of a felony and sentenced to one or more years. Jails are short-term facilities managed by a local or county government. More than 60 percent of women held in local jails have not been convicted of a crime and are awaiting trial, often because they can’t afford bail. A whopping 80 percent of women incarcerated in the U.S. are mothers, and most are their children’s primary caretakers.

The 1976 Supreme Court ruling in Estelle v. Gamble established health care as a constitutionally protected right for incarcerated people, but it didn’t prescribe mandatory services, standardization or oversight, creating the present system of health care roulette for those behind bars. Providing care for incarcerated women presents multiple unique challenges for any institution; caring for pregnant women in custody significantly raises the stakes. Pregnancies are often unplanned and complicated by a lack of prenatal care, a woman’s neglected health before incarceration, maternal trauma, poor nutrition, substance abuse, mental illness, limited social support and low socioeconomic status — all in a correctional system designed for men.

Post-Dobbs Pregnancy Behind Bars

Before the Supreme Court’s ruling in Dobbs V. Jackson Women’s Health, access to abortion already varied widely from state to state and among prisons. After the Court removed the constitutional right to abortion, the choices for pregnant incarcerated women have become even more precarious. Sufrin’s research found that even in states where abortion was legal, some prisons and jails had either official or unofficial policies that prevented incarcerated women from accessing abortion.

Under Roe v. Wade protections, incarcerated pregnant individuals at least had a constitutional right to abortion just like everyone else in the U.S. Despite this guarantee, abortion was not accessible to many in custody. Post-Dobbs, things are likely to get worse for those who are pregnant behind bars.

“We don’t know yet the full impact of the Dobbs decision because it’s hard to study this population,” Sufrin says. “But abortion access for incarcerated individuals was already constrained. How much this is going to impact abortion access in restrictive states is still to be determined.

“What I’m more concerned about is the ripple effect this is going to have on other aspects of pregnancy care in custody. We’ve already seen in abortion-restrictive states like Texas that non-incarcerated people brought to the hospital for obstetric emergencies like bleeding from a miscarriage or their water breaking early are being turned away from care where an abortion procedure would save their lives. They’re turned away because of how the law is written or because physicians fear what might happen if they misinterpret it. Women are basically being told to come back when they’re at death’s door.

“I’m concerned about the impact on incarcerated pregnant people with complications because they will be sent back to prison, which is ill-equipped to handle obstetrical emergencies. We’re likely going to see more pregnant individuals overall in the United States who are going to be sicker, and that may also be true in custody.

“None of this has been studied, so these are just hypotheses.”

When Jail Means Safety

Though it may not be intuitive, Sufrin says the “thorny reality” is that jail can improve outcomes for incarcerated pregnant people and their infants and can increase their chances for successful reintegration into the community. Jail is the new safety net, she writes in “Jailcare.” Women in jail represent one of the most marginalized and vulnerable groups in society. Indigent, addicted mothers too often can only access prenatal care behind bars. Though not all jails provide an environment that supports these women, those that do offer medical and prenatal care, treatment programs, improved nutrition and the relative stability that they’ve lacked can provide a safer, healthier alternative to the lives these women experienced on the outside.

Make no mistake, Sufrin says. Jail is still a place of punishment. The fact that it’s better behind bars for some people than being in the community isn’t so much an endorsement of jail as it is an indictment of our abandoned and ineffective social systems that have broken down and utterly failed these people relegated to society’s sidelines.

“That the system of incarceration has become an integral part of the country’s social and medical safety net is peculiar to the U.S.,” she writes, “and represents one of its greatest tragedies, the whittling away of public services for the poor coupled with an escalation in the number of jails and prisons with custody of that same population.”

“It’s still jail,” she says.

More than four years after she and her father created an app designed to connect incarcerated parents with their children, teenage coder “Jay Jay” Patton — the subject of a recent short —has not slowed down.

When she was a toddler, Jay Jay’s father Antoine went to prison for more than seven years, leaving her and her teenage mother. Because of her personal experience with her father, Jay Jay understood the consequences and struggles of staying in communication and bonding with an incarcerated parent.

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After her father’s release, they grew close through coding and created Photo Patch, an app that allows children to communicate with incarcerated parents through photos and letters.

Now 16, Jay Jay continues to build a strong community for those who have parents and loved ones in prison.

In 2018, Jay Jay became the youth leader of Unlock Academy, an online coding school created by her father to make coding more accessible to marginalized communities such as young people of color.

The interview was edited for length and clarity.

ĂŰĚŇÓ°ĘÓ: Going back to the beginning, when you and your father were separated, what incentivized you to go into coding and to work with your father to help others? 

I knew firsthand, the struggles and how hard it was to be able to communicate with my father… So when he had this idea, it just made sense for me to help because I just knew how it felt. And I wanted to be the person who can help other kids instead of just sitting back and just watching.

What is the most important thing you’d like to come out of Photopatch?

The best thing is being able to reach across the 2.7 million kids who have an incarcerated parent and be able to bridge that gap of communication and keep that bond intact. When a parent goes to prison and they’re not with their child, it disfigures this bond they might have once had, the parents missing out on stuff, and the kid is just sad. I see this a lot with family and friends who have an incarcerated parent. It’s hard to keep that same bond. And I look at how me and my dad were able to even though he was away, we were able to still have a strong bond.

And when you and your father were not together, was there anyone else who helped you pave the way? 

I had my mom most of it. She was a single mom trying to figure it out, but she just always wanted the best for me my whole entire life. She got pregnant at 16, and had me at 17. So she was trying to pave the way for me to be a great kid. She didn’t grow up with such a great childhood. So my mom was always my best friend, and I was always her best friend, because she was young. And I was the only person she kind of had, and she was so independent. And I got a lot of those independent tendencies from her, wanting to do things on my own and wanting to flourish.

If you could go deeper into how you got into coding, not just how you were introduced but how you continued it as well?

I actually learned coding from my dad because this was something he was passionate about. And he was coming up with all these cool ideas. This is what he wanted to do, after being in prison. While in prison, he taught himself how to code. Being able to still connect with my dad and build that bond with my dad….So he was really excited that I wanted to get into this and he’s thought why not teach my own daughter these skills I know. He was always giving me little activities to do and just being a great teacher.

Did school ever foster that passion for coding? Or was it something you had to pursue out of classes and school?

… in school, there was no technology or coding classes, which drove me to want to learn more, and be somebody who can teach….other women of color, and girls, and people who don’t have the opportunity to be able to learn this skill. It was just strictly learning from my dad, we didn’t have that in school. When I was in middle school one of my teachers knew what me and my dad were doing, and she thought it was really cool, and she had a group of kids who were doing technology. And they wanted to do coding also so my dad actually came to our school and did like a whole class for coding after school. We’d have a lot of different kids, and you just never knew these kids had interest in this and, if it would have been like a whole regular class, who knows where these kids would go with it?

Could you give me updates on Unlock Academy? How’s that going and updates on that as well, and what do you hope people get out of it? 

We’ve been doing really great. We’ve been getting a lot of new students. Since the whole pandemic has come, it’s been actually better because more people are at home. And they are trying to find something to do… It’s a really big effort for me to try to get women of color and women in general and kids and people who feel marginalized into the tech space so that they feel like they can do anything. The tech space is not as diverse as it can be and as it should be. So that’s really our mission for Unlock Academy, to get people who really feel like they want to do it, or that they can’t do it, and put them into this world…Don’t psych yourself out, don’t let other people kind of steer you away from it. We want to be able to be the people that are able to stem their career and get them into this world.

What do you think of the racial gender and inequity in the tech world? Why does it exist and how do you think we should fix it? 

I think it’s there because these people are not given the resources. There’s just nowhere really for them to easily obtain it…you can go to college and take classes, but it’s a lot of money…they don’t have all this kind of money to be going to take the big classes for these courses. Or even if they do, it’s just not marketed to them in a way that they can do it. There’s a stereotype around coding that it’s this crazy thing, and you have to be a genius or a mathematician….Like when you see it in movies, it looks like the matrix… When I first saw my dad doing it, I thought the same thing too at 10 years old…but when you actually get into it, it’s really not as crazy. Because my dad and I both came into the coding world, unknowingly, we understand why it seems crazy….we thought the same thing…I definitely think that’s why there’s a barrier because it’s just not marketed to our people in a way they can do it. And that’s how we plan to help is to give it to them in an affordable way, but also in a way they feel like they can do it.

Was there a moment where you realize this is really making a difference? Any moment of gratification that you can think of?

When stories started to come out, and brought a lot of awareness to us, and more people were in my DM’s or comments, people were telling me like, how much of an inspiration I am. And for me, I’m a very humble person… It’s kind of surreal for me, because I’m actually making a difference.

Between 1980 and 2016, the number of women incarcerated in the United States increased by more than 700 percent, rising from a total of 26,378 in 1980 to 213,722 in 2016. More than 60% of women in state prisons have children under age 18, according to , and the reports that roughly half of incarcerated mothers were single parents at the time of their arrest. The statistics add up to more children than ever suffering negative consequences of having a mother behind bars, children who themselves become at risk of school problems, economic hardship and criminal activity, according to the .

But statistics are not an absolute predictor of future catastrophe. Research shows that a strong parent-child bond and well-functioning social support system play significant roles in the child’s ability to surmount these challenges and thrive.

Mindful of these facts, developmental behavioral pediatrician Sherri Alderman, president of the Oregon Infant Mental Health Association, has designed a program that can not only strengthen the parent-child bond, but provides a research-based way for parents to reset their approach to interacting with their children.

In 2017, she created a pilot project called Nurturing Healthy Attachments for the Coffee Creek Correctional Facility, Oregon’s only prison for women (it also houses a smaller population of men). The program’s three-pronged approach combined components Alderman knew from her research and experience over decades of working with vulnerable families could interrupt negative, hand-me-down parenting patterns and knit families closer together: Circle of Security, Vroom and the CDC’s Act Early program.

Together, they help mothers understand their child’s behavior and their own reactions, then provide a structure to practice new ways of interacting.

Coffee Creek already had a Head Start program for incarcerated mothers with children aged birth to five who attend two half days a week with their children in the classroom. Alderman designed Nurturing Healthy Attachments to dovetail with and enhance the excellent program already in place.

Triad of Support

Circle of Security is a Spokane, Washington-based organization that provides training and workshops worldwide using the science of attachment research to create a guided process of self-discovery into how a parent’s personal history affects the way they relate to their child. For the two and a half months of the Nurturing Healthy Attachments program, the mothers attended a weekly, two-hour Circle of Security session, in addition to their Head Start program. They delved into their life experiences to develop insights that helped them transform their automatic reactions into behaviors more aligned with the child’s needs.

“Having a struggling parent is difficult enough for a child,” says Deidre Quinlan, Circle of Security’s Project and Professional Development director. “Abuse, neglect, mental illness, homelessness and addiction all stress the developing child. Then the [judicial/correctional] system removes the parent from the child, which adds another layer of trauma to the developing person.”

Through working with the adults in a child’s life, Circle of Security works to ensure children have strong, kind, committed adults who are there for them, who provide a secure base when the child is out exploring and a safe haven when they return.

“Without this knowledge, the child cannot learn well. This ‘felt safety’ comes from repeated events, thousands of times in the earliest days of the life of the baby and sets the template for how the child will come to understand what it means to be a person in relationship as they move forward in life.”

Vroom, the second component in the project, is a free science-based program and with downloadable resources, including a mobile app and SMS-text platform, that turns the latest research on early learning brain development into playful, actionable tips and activities parents can enjoy with their children ages 0-5. Activities turn routine shared moments — mealtimes, bathing, taking a bus — into brain-building moments. Each tip also provides the “Brainy Background” of how that activity helps develop the child’s brain.

“This is where Vroom really picks up,” Alderman says. “Vroom provides concrete suggestions of activities, so that the women can come back and say, ‘I tried Vroom, and this is how it went,’ when they go to their next Circle of Security session.”

Nurturing Healthy Attachments’ third component incorporates the Centers for Disease Control and Prevention’s “Learn the Signs. Act Early.” program. After a baby’s birth, mothers don’t automatically know what happens next and their inexperience in understanding their child’s development can have dire consequences. Unrealistic expectations of a child’s behavior relative to their developmental age is a major risk factor for child abuse, Alderman says.

The Act Early program provides parents and caregivers science-based information on what behavior to expect from a child from age 2 months to 5 years, so a parent can see, for example, that a wailing toddler is not “being a brat,” but needs something and doesn’t have the language to communicate it.

Listening for Sharks

The work of Circle of Security, Quinlan says, is to bring the unconscious to the level where it can be perceived. “When stressed, the amygdala triggers a fight-or-flight response, and in the Circle of Security, we call that ‘Shark Music.’ We use that metaphor as a way to recognize the non-verbal signals in the body and bring our thinking brain (the prefrontal cortex) online by naming it. As (psychologist and best-selling author) Dan Siegel says, ‘You have to name it to tame it.’”

The three components that comprise Nurturing Healthy Attachments each approach a fundamental issue at the heart of attachment: fear. Fear from the mother’s upbringing, fear of not knowing what she is doing, fear of getting it wrong, fear of being disrespected, even fear of her own child. In learning to recognize the shark when it rears its unhelpful head, the women learn to be in the present and to respond to their child in real time.

Vrooming Old School

Because the incarcerated moms are not allowed to use smartphones, Alderman “reverse engineered” the Vroom app and printed out hard copies of the activities with their explanations of brain-building moments.

The adaptation worked great, says Coffee Creek’s Head Start teacher Carmen Slothower. Alderman posted 8 ½ x 11-inch copies of the tip printouts throughout the classroom. Then she created Vroom “tickets” to give the moms, 4 x 6-inch slips of paper that had the name, description of the activity and the brain-building moment on them.

“The mother could pick what she wanted to do,” Slothower says, “and on the back of the tickets there was space for her to write her anecdotes of engaging in the activity together with her child and her reactions and feelings about that.

“The mothers also could send the tickets home with the child’s caregiver, sharing that they had ‘Vroomed’ with their child in class. It was a wonderful way for mothers to share a positive experience of what they did with their child that day.”

The tickets also provided a bit of themselves that the mother could give to the caregiver, which could spark a conversation with the child about the activity and how the morning went. This interaction reinforced the activity and helped smooth the child’s transition between mother and caregiver.

Next Steps

The pilot project’s success has inspired Alderman to move forward in looking for ways to replicate it in other arenas. “We know that the model works, and I would love to see it disseminated widely so that as many people as possible can benefit from it,” she says. “There are some facilities where the child actually stays with the mom while she is in residential treatment for substance abuse and the program would work well there.”

She is continuing to work with Oregon’s Women’s Services agency on the state level, where Nurturing Healthy Attachments was well-received, to explore possibilities for expanding the program’s reach. A recent development is that Department of Corrections staff has expressed interest in implementing the adapted Vroom activities in the Coffee Creek facility itself to provide access for mothers during child visits, Alderman says.

Meanwhile, Community Action Organization of Washington County, Coffee Creek’s parent organization, has sent one of its supervisors to the Circle of Security training and is sending two more supervisors, as well as its 15 home-based program’s home visitors this month.