Characteristics and Outcomes of Women and Infants Who Received Prenatal Care While Incarcerated in Arkansas State Prison System, 2014-2019

BACKGROUND

Prisons face challenges in meeting the unique health care needs of women, especially those who are pregnant. This retrospective chart review sought to describe the maternal and infant health outcomes of incarcerated women who received prenatal care while in an Arkansas prison.

METHODS

Using a hospital-based electronic medical records (EMR) system, we examined the maternal health history and current pregnancy characteristics of 219 pregnant women who received prenatal care while incarcerated from June 2014 to May 2019. We also examined labor and delivery characteristics and postpartum and infant birth outcomes for the 146 women from this cohort who delivered a living child while still incarcerated.

RESULTS

Most records indicated complex health histories with several chronic illnesses, mental health diagnoses, history of substance use, and lifetime medical complications. Despite comorbid illness, substance use disorder (SUD), trauma-history, and post-traumatic stress disorder (PTSD) prevalence was lower than expected. Previous and current obstetrical complications were common. Although the Neonatal Intensive Care Unit (NICU) admission rate (41%) was high, few infants required extensive treatment intervention. Postpartum complications were rare; however, a small portion of women who gave birth in custody experienced severe complications and were re-admitted to the hospital post-discharge.

CONCLUSIONS

Incarcerated pregnant women and their infants are a marginalized population in great need of health care advocacy. To optimize maternal-infant outcomes, carceral agencies must recognize the health needs of incarcerated pregnant women and provide appropriate prenatal care. Expansion of carceral perinatal care to include screening for SUD and psychiatric symptoms (e.g., PTSD) and referral to appropriate care is highly encouraged. Policies related to NICU admission for non-medical reasons should be further examined.

Justice-Involved, Sexually Victimized Women's Perspectives on the Acceptability of Receiving Trauma-Focused Therapy in Prison

Incarcerated women report high rates of sexual victimization. Interviews with 63 previously incarcerated women survivors of sexual violence explored perceptions toward receiving trauma-focused therapy while incarcerated and postrelease trauma-focused therapy utilization. Nearly all participants (97%) recommended that trauma-focused therapy be available to incarcerated women. Most believed that prisons are acceptable places to receive trauma-focused therapy, without qualification (65%); some reported mixed feelings or indicated acceptability but identified factors that would increase acceptability (33%). Notably, most were currently experiencing trauma-related symptoms, but few had attended trauma-focused therapy following release. Findings indicate that access to prison-based trauma-focused therapy is necessary and acceptable.

State Laws on Substance Use Treatment for Incarcerated Pregnant and Postpartum People

Background

Incarcerated perinatal populations report high rates of substance use in the United States (US). Despite this, substance use disorder (SUD) treatment is not routinely available in carceral settings and state policies related to the provision of substance use screening and treatment are unknown.

Methods

We conducted a systematic search in WestLaw through the end of the 2020 legislative session combining the terms "pregnant" and "postpartum" with terms for incarceration and related terms. The search returned 453 statutes from 43 states. A deductive codebook of various maternal health topics was developed. Legislative texts related to SUD screening and treatment were extracted for textual analysis.

Results

Of the 43 states identified as having at least 1 state statute pertaining to pregnant or postpartum incarcerated people, 7 states had statutes relevant to SUD screening and treatment. Statutes related to substance use screening, education, treatment and diversion programs, program eligibility, aftercare and release planning, and funding appropriations.

Conclusions

The majority of states across the U.S. lack legislation that address SUD screening and treatment among incarcerated perinatal populations. Given the known limited access to SUD treatment for perinatal populations in custody, increasing legislative statutes could increase access to essential care.

Implementation of group cognitive processing therapy in correction centers: Anticipated determinants from formative evaluation

Nearly all people in prison have experienced trauma, and many meet the criteria for posttraumatic stress disorder (PTSD). Untreated PTSD increases the risk of substance use problems after release, contributing to a well-documented cycle of trauma, addiction, and incarceration. However, evidence-based, trauma-focused therapy for PTSD is rarely offered in prisons, and there is little research that can guide implementation efforts. In preparation for an effectiveness-implementation hybrid II pilot trial examining group-delivered cognitive processing therapy (CPT) in prisons, we conducted a formative evaluation using interviews structured according to the consolidated framework for implementation research (i.e., CFIR). Participants were correction center leadership, treatment staff, health care staff, and security staff (n = 22) and incarcerated persons (n = 14; 57.1% female). We found that CPT was highly compatible with residents' needs and the centers' available resources, culture, existing programs, and current workflow. CPT was also acceptable to all stakeholders. Potential barriers were the lower relative priority for CPT compared with programs that are reinforced at the system level, limited staff time to deliver CPT, limited staff knowledge about PTSD, and center features that could distract from CPT groups and/or training or be countertherapeutic. Taken together, CPT is a promising trauma-focused therapy for corrections, but these findings underscore the importance of identifying and matching potential barriers to effective implementation strategies a priori and work in the policy arena to promote sustainability.

An integrative literature review of substance use treatment service need and provision to pregnant and postpartum populations in carceral settings

Pregnancy is a critical time to provide access to substance use treatment; this is especially true among incarcerated populations, who are known to be at particularly high risk of poor health outcomes. In this integrated literature review, we (1) report what is known about the prevalence of substance use among incarcerated pregnant and postpartum populations; (2) describe substance use treatment programs and current care practices of pregnant and postpartum populations in carceral settings; and (3) explore recommendations and strategies for increasing access to substance use treatment for incarcerated pregnant and postpartum populations. A comprehensive search of seven electronic databases yielded in the retrieval of 139 articles that were assessed for inclusion. Of the retrieved articles, 33 articles met criteria for inclusion in this review. A review of the literature revealed that the understanding of substance use prevalence among pregnant incarcerated women is limited. We also found that treatment of substance use disorders among pregnant and postpartum populations is not routinely available, enhanced perinatal services are sorely needed, and substance use treatment programs are feasible with the help of community partnerships. More research is required to understand current substance use treatment initiatives and outcomes for pregnant women in prison. In addition, strategies for integrating evidence-based, substance use treatment in carceral settings is also needed. Future directions are discussed.

A participant-randomized pilot hybrid II trial of group cognitive processing therapy for incarcerated persons with posttraumatic stress and substance use disorder symptoms: study protocol and rationale

BACKGROUND

Trauma exposure and drug addiction go hand-in-hand for the 2.17 million people who are incarcerated in US prisons; prevalence of both exceed 80% among this population. This manuscript describes the rationale and methods for a participant-randomized effectiveness-implementation hybrid type II pilot trial designed to: 1) examine the effectiveness of Cognitive Processing Therapy group (CPT), an evidence-based psychotherapy for posttraumatic stress disorder (PTSD), for reducing post-release drug use and PTSD symptoms when adapted for and delivered in prisons; and 2) provide data on implementation outcomes associated with the use of implementation facilitation as a strategy for supporting uptake of CPT in prisons.

METHOD

Participants in the effectiveness portion of the trial (N = 120) will be incarcerated men and women who are randomly assigned to one of two group therapies: CPT or a control condition (PTSD coping skills group; PCS). Participants will complete assessment measures three times: pre-treatment, post-treatment, and 3 months following release from incarceration. CPT groups will be led by prison counselors who are receiving implementation facilitation to support their efforts. PCS groups will be led by trained clinicians on the research team. Implementation outcomes will include acceptability, appropriateness, adoption, feasibility, fidelity, and sustainability. After enrollment ends, the research team will monitor CPT sustainment and recidivism outcomes of study participants for one year.

DISCUSSION

This study will lay the groundwork for a larger study of interventions for co-occurring PTSD and SUD in prisons and, critically, inform the development of strategies (such as implementation facilitation) for supporting their uptake in routine practice.

TRIAL REGISTRATION

NCT04007666 , clinicaltrials.gov, 24 June 2019, 02 September 2021.