Committee Opinion
Number 535, August 2012


Committee on Health Care for Underserved Women
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

PDF Format

Reproductive Health Care for Incarcerated Women and Adolescent Females

ABSTRACT: Increasing numbers of women and adolescent females are incarcerated each year in the United States and they represent an increasing proportion of inmates in the U.S. correctional system. Incarcerated women and adolescent females often come from disadvantaged environments and have high rates of chronic illness, substance abuse, and undetected health problems. Most of these females are of reproductive age and are at high risk of unintended pregnancy and sexually transmitted infections, including human immunodeficiency virus (HIV). Understanding the needs of incarcerated women and adolescent females can help improve the provision of health care in the correctional system.


Background

Between 1990 and 2009, the number of incarcerated women increased 153% (1). Most women in correctional facilities are incarcerated for nonviolent crimes. Drug offenses are the most common felonies committed by women in both federal (72%) and state (34%) prison systems, and are the second most common offense committed by women in local jails (30%) (2). By the middle of 2009, 106,362 women (6.9% of all prison inmates) were incarcerated in federal or state prisons, and by the middle of 2011, 93,300 women (12.7% of all jail inmates) were incarcerated in local jails (3, 4). In 2010, 306,498 females younger than 18 years were arrested, representing 29% of all juvenile arrests (5). Juvenile offenders may be housed in juvenile detention homes or residential correctional facilities or, in some cases, in adult prisons or jails.

Incarcerated women and adolescent females often come from economically, educationally, socially, and emotionally disadvantaged environments; a disproportionate number have acute and chronic illnesses, substance abuse problems, and undetected health issues, including reproductive health needs. In one study, 27% of incarcerated women had chlamydia and 8% had gonorrhea, compared with rates of 0.46% and 0.13% in the general population, respectively (6). In 2008, 2% of women in state and federal prisons were known to be infected with human immunodeficiency virus (HIV) (7). Fifty-six percent of women in federal prisons and 62% of women in state prisons were parents of one or more minor children, and 19% of these children were in the care of someone other than a family member during the mother’s incarceration (8).

Approximately 6–10% of incarcerated women are pregnant, and are mostly incarcerated in local jails (9, 10). There are few studies about birth outcomes for women who continue pregnancies during incarceration. Although a woman retains her legal right to an abortion during incarceration, a woman’s experience in attempting to obtain an abortion varies widely by state, region, and individual prison (11, 12). In a survey of correctional health officials, 68% indicated that women in their prisons were allowed to have an elective abortion, but only 54% helped arrange appointments (11).

Sexually transmitted infections and pregnancies may result from sexual victimization of women during incarceration. In a survey of local jail inmates using audio computer-assisted self-interviews to maximize confidentiality and reliability, 5.1% of female inmates reported sexual victimization (13). Of these, 3.7% of women experienced sexual victimization by another inmate and 2.0% reported sexual victimization by a staff member (13). In a similar survey of state and federal prison inmates, the rate of sexual victimization among men and women was 4.5% (14). Total rates for women were not presented, but rates were as high as 10.8% at some prisons, with sexual victimization by a staff member reported by up to 5.3% of women (14).

Mental health disorders and substance abuse are common among incarcerated women. Sixty-nine percent of women admitted to local jails met the criteria for substance dependence or abuse (not including tobacco use); dependence was diagnosed more commonly among women than among men (15). Rates of mental health problems among women inmates ranged from 61% in federal prisons to 75% in local jails (16). Incarceration is an important risk factor for suicide by adolescent inmates (17). More than 50% of women in jail reported a history of physical or sexual abuse, and this rate is as high as 92% among female juvenile offenders in California (18, 19).

Medical Care Availability and Access

Although most state and federal prisons provide some level of care to prisoners, availability and access to medical care in jails is variable. The short and often unpredictable duration of incarceration in local jails often makes provision and continuity of care difficult. In addition, systems of care vary in state and local prison and jail settings. Services at state prisons and jails may be provided on site by health care providers, by arrangements with local hospitals or clinics either on site or by inmate transport, or by an on-site health care provider contractor. Historically, health care was delivered by way of a “sick call,” where an inmate notified a guard or other designated authority of the need for medical attention. A sick call system does not allow for provision of primary or preventive care and health education. Although many facilities have moved to systems that provide primary care, the increase in the number of inmates makes provision of adequate care difficult. In addition, women are often housed in facilities with predominantly male populations, which limits the availability of health services tailored to women’s needs. Financing of correctional facilities, including health care, depends on legislative appropriations that compete with other priorities. In general, Medicaid funding cannot be used for care for adults and adolescents in secure confinement.

No federal or state mandates require correctional health facilities to obtain accreditation, and there is no organization to which all facilities are accountable. Several organizations accredit prisons, but their standards only serve as guidelines and are followed voluntarily. These organizations include The Joint Commission, the National Commission on Correctional Health Care, and the American Correctional Association. Health care standards for jails, prisons, and juvenile facilities have been developed by the National Commission on Correctional Health Care, the American Correctional Association, and the American Public Health Association (20–23).

In general, care for incarcerated women and adolescent females should be provided using the same guidelines as those for women and adolescent females who are not incarcerated, with attention to the increased risk of infectious diseases and mental health problems common to incarcerated populations. Health care for incarcerated women and adolescent females is outlined in Table 1 (23, 24).

Table 1. Recommended Care for Incarcerated Women and Adolescent Females
Type of Care Adult Jail or Prison* Juvenile Facilities

Entering facilities

Ask about any current medical problems and care and safety of minor children at home.

Same as in adults, but also screen for eating disorders

Obtain a medical history—immunization status; sexual activity, contraceptive use, and menstrual cycle to assess the need for a pregnancy test; number of pregnancies and outcomes; history of medical problems, chronic illness, hospitalizations, breast disease, and gynecologic problems; and domestic violence, sexual abuse, and physical abuse Same as in adults
Mental health assessment Same as in adults, bearing in mind that adolescents in correctional facilities are at higher risk of suicide than those in the general population

Physical examination†—pelvic and breast, Pap test, and baseline mammography based on College guidelines

In a jail setting, Pap test and mammography should only be done if there is enough time to obtain results before release.

Same as in adults, except mammography and Pap test are unlikely to be needed. Pap test should be performed on adolescents according to College recommendations.

Laboratory work—STIs, HIV, pregnancy, hepatitis, and tuberculin skin tests based on College guidelines

In a jail setting, tuberculin skin tests should only be done if incarceration is expected to be for at least 48 hours to see if any reaction occurs.

Same as in adults

Pregnancy care Pregnancy counseling, perinatal care, and abortion services should be offered based on College guidelines Same as in adults
Preventive care

Any additional tests, examinations, and care based on College guidelines

Same as in adults

Health education on contraception and pregnancy; tobacco, alcohol, and substance abuse cessation; and parenting

Same as in adults

Comprehensive HIV and STI treatment and prevention programs Same as in adults, bearing in mind that adolescents are at higher risk of STIs than the adult population
Contraceptive services, including emergency contraception, based on medical need or potential risk of pregnancy Same as in adults
Provide immunizations as necessary based on College guidelines, with particular focus on influenza and pneumococcal vaccination Same as in adults, but with particular focus on HPV, meningococcal, and influenza vaccination
Care for older women Hormone therapy, if indicated Not applicable
Screening, treatment, and prevention programs for osteoporosis Osteoporosis prevention programs may be useful
Screening for depression and dementia Screening for depression
Mental health care Medication management, suicide prevention, crisis intervention, substance abuse programs, and linkage to social services and community substance abuse programs upon release Same as in adults, noting that incarceration is a risk factor for suicide among adolescents

Abbreviations: College, American College of Obstetricians and Gynecologists; STIs, sexually transmitted infections; HIV, human immunodeficiency virus; HPV, human papillomavirus.

*If a juvenile is housed in an adult prison or jail, the recommendations under the juvenile facilities column should be followed.

†The request by either a patient or a physician to have a chaperone present during a physical examination should be accommodated regardless of the physician’s sex.

Data from Anno BJ. Correctional health care: guidelines for the management of an adequate delivery system. Chicago (IL): National Commission on Correctional Health Care; 2001. Available at: http://static.nicic.gov/Library/017521.pdf. Retrieved April 16, 2012; American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007; American College of Obstetricians and Gynecologists. Guidelines for adolescent health care. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011; American College of Obstetricians and Gynecologists. Guidelines for women’s health care: a resource manual. 3rd ed. Washington, DC: ACOG; 2007; American College of Obstetricians and Gynecologists. Well-woman care: assessments and recommendations. Washington, DC: American College of Obstetricians and Gynecologists; 2012. Available at: www.acog.org/http://www.acog.org/-/media/Departments/Annual Womens Health Care/PrimaryAndPreventiveCare.pdf. Retrieved April 19, 2012; American Public Health Association. Standards for health services in correctional institutions. 3rd ed. Washington, DC: APHA; 2003; Cervical cancer in adolescents: screening, evaluation, and management. Committee Opinion No. 463. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:469–72; Health care for pregnant and postpartum incarcerated women and adolescent females. Committee Opinion No. 511. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:1198–1202; National Commission on Correctional Health Care. Standards for health services in jails. Chicago (IL): NCCHC; 2008; National Commission on Correctional Health Care. Standards for health services in juvenile detention and confinement facilities. Chicago (IL): NCCHC; 2004; National Commission on Correctional Health Care. Standards for health services in prisons. Chicago (IL): NCCHC; 2008; and Health care for youth in the juvenile justice system. Policy Statement. American Academy of Pediatrics. Pediatrics 2011;128:1219–35.

Recommendations

  • Obstetrician–gynecologists should support efforts to improve the health care of incarcerated women and adolescent females at the local, state, and national levels. Activities may include the following:
    — Gaining representation on the boards of correctional health organizations.
    — Working in correctional facilities to provide services to incarcerated women and adolescent females and continuing care after the woman’s release, when feasible.
    — Undertaking efforts to ensure that medical needs of incarcerated women and adolescent females are being addressed appropriately, such as by providing training or consultation to health care providers and correctional officers in prison settings.
    — Advocating at the local, state, and federal levels for increased funding to provide access to necessary health care for incarcerated women and to restrict shackling of women and adolescents during pregnancy and the postpartum period (10).
     
  • Facilitate care provision by health care providers to incarcerated women and adolescent females (eg, allowing incarcerated women and adolescent females to enter through alternate entrances to avoid stigmatization in the waiting room or to be seen during off-hours).
     
  • Ensure that adolescents only be detained or incarcerated in facilities with developmentally appropriate programs and staff trained to deal with their unique needs. If they must be housed in adult correctional facilities, they should be separated from the adult population into an environment that is able to address their specific developmental needs (24).
     
  • Ensure that adolescents with serious mental disorders are not placed in detention when they do not face criminal charges. The placement of adolescents with mental disorders who have been charged with crimes and are able to be released from incarceration into a community mental health facility should be completed in a timely fashion.
     
  • Facilitate collaboration between medical schools and other health care professional schools and correctional facilities to improve care to inmates.
     
  • Obtain and support funding for research on the health needs of incarcerated women and adolescent females, the services they receive, the qualifications of the health care provider, the location of the service, and the outcomes of these services.
     
  • Support state and federal funding that increases access to necessary health care that includes not only disease-specific treatment, but also preventive services and access to qualified health care providers for incarcerated women and adolescent females.

Specific medical recommendations include the following:

  • Correctional facilities should be adequately funded to provide a continuum of care model providing female inmates with initial screenings, in-house services or referrals for preventive and curative care, including Pap tests and appropriate follow-up, health education, and adequate planning before release from correctional facilities.
     
  • Health care providers and other correctional facilities staff should receive appropriate training to provide care for female inmates, including the care of pregnant women (10).
     
  • Incarcerated women of all ages should receive reproductive health care, including access to adequate contraception, prenatal care, and abortion services (9, 10).
     
  • Appropriate and adequate care should be provided for pregnant women and adolescents, including opioid dependence treatment, avoiding the use of restraints, and promoting breastfeeding (10).
     
  • If hospitalization or other off-site health care occurs, prescribed treatments, such as medications, must continue once the patient returns to the correctional facility.
     
  • Incarcerated women and adolescents’ mental health needs should be addressed.
     
  • Incarcerated women and adolescents should be protected from sexual abuse. If sexual abuse occurs, the guilty party should be punished to the full extent of the law.

References

  1. Glaze LE. Correctional populations in the United States, 2009. Bureau of Justice Statistics Bulletin. Washington, DC: U.S. Department of Justice; 2010. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/cpus09.pdf. Retrieved
    April 16, 2012.
  2. Greenfeld LA, Snell TL. Women offenders. Bureau of Justice Statistics Special Report. Washington, DC: U.S. Department of Justice; 2000. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/wo.pdf. Retrieved April 16, 2012.
  3. West HC. Prison inmates at midyear 2009 - statistical tables. Washington, DC: U.S. Department of Justice; 2010. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/pim09st.pdf. Retrieved April 16, 2012.
  4. Minton TD. Jail inmates at midyear 2011 - statistical tables. Bureau of Justice Statistics. Washington, DC: U.S. Department of Justice; 2012. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/jim11st.pdf. Retrieved May 2, 2012.
  5. Federal Bureau of Investigation. Crime in the United States, 2010. Washington, DC: FBI; 2011. Available at: http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-in-the-u.s.-2010. Retrieved April 16, 2012.
  6. High prevalence of chlamydial and gonococcal infection in women entering jails and juvenile detention centers—Chicago, Birmingham, and San Francisco, 1998. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 1999;48:793–6. [PubMed] [Full Text]
  7. Maruschak LM. HIV in prisons, 2007–08. Bureau of Justice Statistics Bulletin. Washington, DC: U.S. Department of Justice; 2010. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/hivp08.pdf. Retrieved April 16, 2012.
  8. Glaze LE, Maruschak LM. Parents in prison and their minor children. Bureau of Justice Statistics Special Report. Washington, DC: U.S. Department of Justice; 2010. Available at: http://www.bjs.gov/content/pub/pdf/pptmc.pdf. Retrieved April 16, 2012.
  9. Clarke JG, Hebert MR, Rosengard C, Rose JS, DaSilva KM, Stein MD. Reproductive health care and family planning needs among incarcerated women. Am J Public Health 2006;96:834–9. [PubMed] [Full Text]
  10. Health care for pregnant and postpartum incarcerated women and adolescent females. Committee Opinion No. 511. American College Obstetricians and Gynecologists. Obstet Gynecol 2011;118:1198–202. [PubMed] [Obstetrics & Gynecology]
  11. Sufrin CB, Creinin MD, Chang JC. Incarcerated women and abortion provision: a survey of correctional health providers. Perspect Sex Reprod Health 2009;41:6–11. [PubMed] [Full Text]
  12. Kasdan D. Abortion access for incarcerated women: are correctional health practices in conflict with constitutional standards. Perspect Sex Reprod Health 2009;41:59–62. [PubMed] [Full Text]
  13. Beck AJ, Harrison PM. Sexual victimization in local jails reported by inmates, 2007. Bureau of Justice Statistics Special Report. Washington, DC: U.S. Department of Justice; 2011. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/svljri07.pdf. Retrieved April 16, 2012.
  14. Beck AJ, Harrison PM. Sexual victimization in state and federal prisons reported by inmates, 2007. Bureau of Justice Statistics Special Report. Washington, DC: U.S. Department of Justice; 2008. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/svsfpri07.pdf. Retrieved April 16, 2012.
  15. Karberg JC, James DJ. Substance dependence, abuse, and treatment of jail inmates, 2002. Bureau of Justice Statistics Special Report. Washington, DC: U.S. Department of Justice; 2005. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/sdatji02.pdf. Retrieved July 12, 2011.
  16. James DJ, Glaze LE. Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report. Washington, DC: U.S. Department of Justice; 2006. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/mhppji.pdf. Retrieved April 16, 2012.
  17. Hayes LM. Juvenile suicide in confinement: a national survey. Mansfield (MA): National Center on Institutions and Alternatives; 2004. Available at: https://www.ncjrs.gov/pdffiles1/ojjdp/grants/206354.pdf. Retrieved April 19, 2012.
  18. Harlow CW. Prior abuse reported by inmates and probationers. Bureau of Justice Statistics Selected Findings. Washington, DC: U.S. Department of Justice; 1999. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/parip.
    pdf. Retrieved April 18, 2012.
  19. Acoca L, Dedel K. No place to hide: understanding and meeting the needs of girls in the California juvenile justice system. San Francisco (CA): National Council on Crime and Delinquency; 1998.
  20. National Commission on Correctional Health Care. Standards for health services in jails. Chicago (IL): NCCHC; 2008.
  21. National Commission on Correctional Health Care. Standards for health services in juvenile detention and confinement facilities. Chicago (IL): NCCHC; 2004.
  22. National Commission on Correctional Health Care. Standards for health services in prisons. Chicago (IL): NCCHC; 2008.
  23. American Public Health Association. Standards for health services in correctional institutions. Washington, DC: APHA; 2003.
  24. Health care for youth in the juvenile justice system. Policy Statement. American Academy of Pediatrics. Pediatrics 2011;128:1219–35. [PubMed] [Full Text]

Copyright August 2012 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photocopies should be directed to: Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400.

ISSN 1074-861X

Reproductive health care for incarcerated women and adolescent females. Committee Opinion No. 535. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:425–9.