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Abstract

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.

Keywords

incarceration pregnancy substance use

Background

In the United States, women comprise only 10% of the incarcerated population, yet their arrest rates have risen by 25% over the past 35 years and the rate of women’s incarceration has increased by over 750%.¹ Currently, women comprise the fastest growing correctional population, with Black, Latinx, and Native American women being arrested and incarcerated at disproportionate rates.² Recent incarceration data indicate that Black women are incarcerated at nearly double the rate of White women, while Latinx and Native American women are incarcerated at nearly 1.5 times the rate of White women.^2,3 The War on Drugs resulted in increasingly punitive drug enforcement trends that caused a surge in women’s incarceration, specifically among marginalized and minority women.

In general, women are more likely to be imprisoned for drug offenses compared to their male counterparts, as the number of women convicted for drug-related offenses increased nearly 15% since 1986.⁴ When considering racial demographics, American Indian, Latinx, and Black women are more likely than White women to be arrested, convicted, and serve time for drug-related offenses.⁵ In relation to substance use, estimates suggest that nearly 70% of incarcerated women would meet criteria for a substance use disorder (SUD⁴), with up to 90% self-reporting a problem with substance use.⁶ Expansive drug enforcement policies contributed to a significant rise in the number of incarcerated women, while incarceration simultaneously limited access to adequate substance use treatment despite the need.

Of the women who enter prison, approximately 4% are pregnant upon intake.¹ Although the true prevalence of substance use among incarcerated perinatal populations is unknown, we can assume that a substantial portion of women who enter prison pregnant will meet criteria for an SUD given such high prevalence among incarcerated women in general. Incarcerated pregnant women (It is assumed that all incarcerated pregnant people are women in the studies included within this review. Many studies do not adequately assess gender identity; thus, we do not know whether findings extend to trans and non-binary perinatal populations.) have significant health care needs and are disproportionately vulnerable to a multitude of complex health issues. Many of these women have high-risk pregnancies due to economic and social factors, such as unstable housing and homelessness; financial instability; lack of education; limited and/or inadequate health care; and substance use and addiction.⁷ Incarcerated pregnant women and their fetuses are at risk of poor perinatal outcomes including pre-term birth⁸ and low birth-weight,^9,10 which are conditions that are often exacerbated by substance use during pregnancy. Furthermore, neonatal abstinence syndrome (NAS⁹) is of great concern as it is a condition caused by fetal exposure to substances in utero and causes withdrawal symptoms in the infant post-birth.^11,12 Maternal incarceration adds to the complexity of treatment and cost, as it is associated with increases in neonatal intensive care unit (NICU) length of stay for infants born with NAS.¹³

As such, correctional facilities must be prepared to face the challenges of meeting the immense health needs of perinatal populations in relation to substance use and addiction. Incarcerated pregnant women who use substances prior to and/or during pregnancy are at an increased risk of poor perinatal outcomes; however, the extent to which carceral settings provide treatment for substance use is not well understood. In the remainder of this article, we summarize themes among the current state of literature related to the prevalence of substance use among incarcerated pregnant and postpartum populations and the provision of substance use treatment offered in correctional facilities. We also describe considerations, recommendations, and strategies from previous studies to augment the care of incarcerated pregnant and postpartum women, specifically those with concurrent substance use using an integrative literature review approach.

Method

The aim of this integrative literature review is to review, critique, and synthesize literature¹⁴ related to substance use and treatment services provided to incarcerated pregnant and postpartum populations—a topic still in its infancy. We utilized Whittemore and Knafl’s¹⁵ methodology for conducting integrative literature reviews, which has been used previously in similar topic areas.¹⁶ This approach allows for the inclusion of diverse methodologies (e.g. experimental and non-experimental) on a relatively new, emerging topic in efforts to generate new frameworks and perspectives and inform evidence-based practice.¹⁵ Thus, this integrative literature review has the potential to bridge perspectives in the fields of public health and criminal justice to inform research, practice, and policy initiatives¹⁵ in carceral settings that are otherwise lacking in evidence-based healthcare practices,¹⁷ especially for perinatal populations.

Literature search

The selection of articles for the review was driven by three research questions:

What is the prevalence of substance use among incarcerated pregnant and postpartum women?

What are the substance use treatments provided to pregnant and postpartum populations in carceral settings?

What are the considerations, recommendations, and strategies for increasing access to substance use treatment for incarcerated pregnant and postpartum populations?

The authors and a Health Science Information Specialist from the University’s library conducted an extensive, electronic search for peer-reviewed studies limited to papers written in English and that were published between January 2000 and May 2022 to limit the review to the most recent prevalence rates. The following search terms were utilized: (Prisons OR “Correctional Facilities” OR Jails OR incarcerated OR prisoner* OR inmate*) AND ( pregnant OR pregnancy OR “pregnant person” OR “pregnant individual*” OR “pregnant women” OR “pregnant woman” OR postpartum OR “postpartum women” OR postnatal) AND (“substance abuse treatment” OR “Medication for Opioid Use Disorder” OR “Medication-Assisted Treatment”).

The search was conducted in seven databases: PubMed, CINAHL, PsychInfo, PsychArticles, SocINDEX, Embase, and Google Scholar. Overall, the database search yielded 125 articles: 71 results from PubMed, 22 results from PsychInfo, 14 results from CINAHL, 10 results from SocINDEX, and 8 results from Embase. A search of Google Scholar using similar search terms was conducted to determine the existence of any additional publications that could meet inclusion criteria. Fourteen additional articles were retrieved from Google Scholar, which were not included within the larger search. The selection of final papers for analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart (see Figure 1). Combined search results yielded 139 articles. Duplicates were removed and the abstracts of all 139 articles were read to assess relevance and were examined for inclusion. Of the abstracts, 124 were retained for evaluation. Full texts were downloaded or requested for further analysis. Each full manuscript was assessed for content and relevance. The final analysis included 33 texts.

Figure 1.

PRISMA chart.

Inclusion criteria

The flexibility of the methodology allowed for a wide range of publications and methodologies to be included to reflect the exploratory nature of this review. To be included, the study sample or content of the publications must relate to pregnant and postpartum incarcerated women and substance use. Empirical studies must have provided substance use data relevant to a portion (i.e. comparison studies) of women who were incarcerated and pregnant or postpartum. Articles were excluded if the text was not in English, could not be obtained, or did not include incarcerated women within the sample. Table 1 summarizes the publications examined within the review.

Table 1.

Data summary table.

Authors	Population	Design methods	Findings/comments
Quantitative studies
1. Testa et al.¹⁸	Survey of 17,551 pregnant women included in the Pregnancy Risk Assessment Monitoring Survey (PRAMS)	Survey, birth certificate records, vital statistics	Incarcerated exposed women were 2.9 times more likely to use opioids during pregnancy when compared to non-incarcerated exposed women
2. Drago et al.¹³	166 infants with neonatal abstinence syndrome (NAS)	Retrospective cohort study—medical records	Infants born to incarcerated women had longer length of hospital stays and exposure to alcohol and benzodiazepines in addition to opiates when compared to non-incarcerated opiate users
3. Knittel et al.¹⁹	279 incarcerated pregnant women	Retrospective cohort study—administrative records	Custody level, estimated due date, pre-incarceration heroin use, and pre-incarceration MOUD were significant predictors of MOUD receipt while in prison; less than one-third of women were referred to a community MOUD provider upon release
4. Sufrin et al.²⁰	2,885 US jails	Survey	Sixty percent of jails offered MOUD during pregnancy, 32% initiated and continued MOUD during pregnancy, 28% continued but did not initiate, and 22% percent of pregnant women were managed by only withdrawal.
5. Shadowen et al.²¹	9 pregnant women using injectable buprenorphine 1 year postpartum	Retrospective chart review—medical records	One-third of the women initiated the injectable buprenorphine while in jail. All who initiated in jail continued post-release for 1 year postpartum
6. Schiff et al.²²	2,314 women who were receiving MOUD at delivery	Retrospective cohort study—administrative records	Incarceration was most strongly associated with the discontinuation of MOUD postpartum
7. Knittel et al.²³	179 incarcerated pregnant women with opioid use disorder (OUD)	Retrospective chart review	The majority of women only received MOUD while incarcerated if they received it pre-incarceration. Forty-seven percent received no MOUD, while 11.7% of pregnant women received buprenorphine, 17.8% received methadone, and 22.8% received oxycodone. Those who received buprenorphine and methadone were more likely to be referred to a community MOUD provider upon release
8. Rose and LeBel²⁴	27 incarcerated pregnant women in a large, midwestern county jail	Survey	More than half (55.6%) met criteria for substance dependence, but only 44% reported substance use disorder (SUD) treatment during their lifetime and even fewer (18.5%) reported receiving treatment in the previous year
9. Sufrin et al.²⁵	22 state prison systems; 6 county jails	Cross-sectional survey	Twenty-six percent of pregnant women admitted to the prisons and 14% admitted to the jails had OUD. One-third were managed through withdrawal and were only likely to receive MOUD if they were receiving treatment pre-incarceration. Only four prisons and two jails initiated MOUD in custody
10. Kelsey et al.²⁶	53 jails across 40 states	Survey	Almost half of the jails reported women were managed through withdrawal without the use of symptom alleviators (e.g. suboxone) after intake. One-third allowed pregnant women to remain on MOUD if they were receiving treatment prior to incarceration. Twenty-one percent of facilities report initiating MOUD
11. Tanner et al.²⁷	Birth outcomes of 200 pregnancies in a women’s prison	Administrative correctional data	Substance use is common in incarcerated women’s pregnancies. Only 17 women reported no history of drug use. The most commonly abused substances were tobacco, alcohol, cocaine, methamphetamine, marijuana, and opiates
12. Rich et al.²⁸	Medical directors of federal prison systems in all 39 states	Survey	Thirteen respondents indicated their prisons provided MOUD to opiate-dependent pregnant women; however, they were significantly less likely to refer to a community provider upon release for continued treatment
13. Bell et al.⁸	496 births to incarcerated women compared to 4960 Medicaid-recipient births from the community	Retrospective cohort study	In general, substance use rates were much higher among incarcerated pregnant women. Incidents of alcohol use during pregnancy were significantly higher among incarcerated women at 36.5% compared to 28.1% in the Medcaid-recipient births
14. Eliason and Arndt²⁹	Comparison of demographics and substance use histories of 53 pregnant inmates and 1160 non-pregnant inmates	Cross-sectional administrative correctional data	Eighty-five percent of pregnant women reported problems with substance use. Twenty-four percent of pregnant women reported only abusing one substance. Most problematic substances reported by pregnant women included alcohol (20%), cocaine/crack (27%), marijuana (24%), and methamphetamine (29%). Nearly 30% reported IV drug use history
15. Barkauskas et al.³⁰	90 incarcerated pregnant women with histories of substance use	Retrospective chart review	Women who were diverted to a community-based, residential substance use treatment program had low occurrences of positive drug screens and received adequate prenatal care and case management which improved maternal and infant health outcomes
16. Kyei-Aboagye et al.³¹	149 women who delivered at Boston Medical Center full-term—31 were incarcerated, 47 enrolled in methadone maintenance program, 71 were in randomly chosen control group	Retrospective cohort study	Women who were incarcerated (76%) or in the methadone maintenance program (96%) were more likely smoking cigarettes during pregnancy when compared to the control group. Sixty-two percent of incarcerated women reported alcohol use
Qualitative studies
17. King et al.³²	16 OTP	Phone interviews	Only nine OTPs reported having an arrangement with a carceral settings to provide care for pregnant people with OUD. Many will experience barriers to care when transiting into the community after release. Lack of access to childcare, preparing for the baby, feeling unwell, transportation, inadequate housing, and financial stability were all cited as barriers to continuity of care post-release
18. Gray et al.³³	Incarcerated pregnant woman with OUD who gave birth in custody	Case study	A 28-year-old women with a history of severe OUD following a polysubstance overdose while on methadone treatment. While incarcerated, she gave birth to a healthy baby at 37 weeks’ gestation. An obstetric team within the jail advocated for continuing MOUD postpartum. After release, she continued methadone, reported no illicit opioid use, attended group therapy and counseling regularly, and obtained custody of her child
19. Clarke and Adashi¹¹	25-year-old woman who was in jail while pregnant	Interview	Herself and others she met in prison were addicted to drugs. She mentions that prison is a time where women experience a stable living environment conducive to recovery. Communication between clinicians and patients would be greatly beneficial if receiving care from a single site
20. Fogel and Belyea³⁴	63 incarcerated pregnant women in their third trimester	Interviews	Half reported using alcohol or drugs during their current pregnancy. The majority reported histories of family violence prior to the age of 18; however, those who reported substance during pregnancy were more likely to have experienced physical and/or sexual abuse during childhood. Seventy percent reported depressive symptoms meeting the criteria for clinical depression
Systematic review
21. Mukherjee et al.³⁵	11 studies of pregnant women in correctional facilities that addressed at least one mental illness, including substance use disorder	Systematic review	Substance use is common among pregnant populations. Tobacco and alcohol use were commonly reported. Range for tobacco use included 50%–84%, while 36% of inmates reported illicit substance use
Protocol
22. O’Connor and Bowling³⁶	N/A	N/A	Creation of a multidisciplinary work group at a rural hospital in Maine inclusive of medical/nursing staff, social work, hospital administration, and law enforcement to assist staff at jail facilities in the initial management of incarcerated women with OUD who are pregnant
23. Lorenzen and Bracey³⁷	N/A	N/A	Creation of a public health case management program offered to substance-using pregnant women, including those who are incarcerated. Program encourages prenatal care and substance use treatment by a multidisciplinary team
24. Wiewel & Mosley³⁸	N/A	N/A	Family Foundation Program (FFP) is an alternative sentencing program for women in prison who are non-violent and have histories of substance use. The program is administered through a community-based, non-profit substance use treatment provider. Women are sentenced to a 12-month, highly structured, residential treatment program where their children are allowed to stay with them.
25. Siefert and Pimlott³⁹	N/A	N/A	Women and Infants at Risk (WIAR) is a residential treatment program for incarcerated, pregnant, substance-using women that increases the availability of substance use treatment, reduces the effect and severity of drug exposure to fetuses, reduces recidivism, promotes community awareness of incarcerated pregnant and postpartum women to improve services, and facilitates coordination among relevant agencies to meet the complex needs of these women
Policy or research brief
26. Jones, Hairston, Alexander, et al⁴⁰	N/A	N/A	Pregnant people who use substances face significant challenges that are exacerbated by incarceration. Integrated prenatal services, substance use disorder treatment, and transitional care upon release in carceral settings are needed
27. Poehlmann⁴¹	Interviews with 60 incarcerated pregnant women in a Wisconsin prison	Interviews	Sixty percent of children born to incarcerated mothers from 60 Wisconsin families reported that 60% of children were exposed to illicit substances in utero, 45% experience complications at birth, and 20% were pre-term
Commentary
28. Ahlbach et al.⁴²	N/A	N/A	Outlines legal and ethical obligations of carceral settings, specifically related to OUD treatment and pregnancy and recommendations to consider when providing MOUD to pregnant, incarcerated populations
29. Williams⁴³			Argues that incarcerated pregnant women have a constitutional right to MOUD during incarceration
Recommendation
30. National Commission on Correctional Healthcare⁴⁴	N/A	N/A	All incarcerated pregnant women should have timely access to MOUD to avoid withdrawal due to maternal and fetal risks. Treatment should be administered by experienced clinicians in both MOUD and pregnancy
31. Peeler et al.⁴⁵	N/A	N/A	MAT is an evidence-based treatment for OUD and buprenorphine and methadone are effective treatments for pregnant populations. Correctional facilities that house pregnant and postpartum women should be prepared to provide MAT and invest in multifaceted programs including support groups, Cognitive Behavioral Therapy (CBT), or contingency management for substance use treatment
32. Sutter et al.⁴⁶	N/A	N/A	Recognition and treatment of incarcerated pregnant, opioid-dependent women are essential to increase the likelihood of entering treatment upon release and avoid the risk of withdrawal and neonatal complications. Programs that incorporate full spectrum of care show improved outcomes, including increased rates of retention and completion and sustained recovery post-release
33. American College of Obstetricians and Gynecologists⁴⁷	N/A	N/A	Offers various best practices to caring for pregnant women with histories of OUD including universal screening with validated tools, brief intervention, and referral to treatment which should be integrated into routine prenatal care. Pharmacotherapy is a recommended alternative to supervised withdrawal because of the maternal and infant health risks. Adequate postpartum support should be provided including MOUD and relapse prevention programs

MOUD: medication for opioid use disorder; OTP: opioid treatment providers; NA: not applicable; MAT: medication-assisted therapy; IV: intravenous.

Results

The articles that met criteria for inclusion in our review (N = 33) included secondary data analysis studies using medical records or administrative data (n = 11), perspective papers (n = 6), quantitative survey studies (n = 5), protocol papers (n = 4), qualitative studies (n = 2), case studies (n = 2), policy briefs (n = 2), and a systematic review (n = 1). Overall, we found that research that focused on incarcerated pregnant populations and substance use was sparse until the mid-2000s. Also, most publications had a primary focus on opiate use and/or treatment and were published during the height of the on-going opioid pandemic. We present key findings relevant to each of our literature review aims in the sections below.

Prevalence of substance use among incarcerated pregnant and postpartum populations

Ten of the 33 articles that met inclusion criteria for this review reported data relevant to the prevalence of substance use among incarcerated pregnant and postpartum populations^{8,13,18,23–25,27,29,35,41} (see Table 2). However, the degree to which assessing the prevalence of substance use was a central aim of the article varied as did the methodology and breadth of substances assessed. Six of the articles presented provided rates of use for multiple substances, two reported findings related to one substance, and the remaining two articles focused exclusively on opiate use.

Table 2.

Prevalence rates of substance use among incarcerated pregnant women by study.

Authors	Population	Prevalence rates of substance use by substance(s) assessed	Prevalence of substance use disorders or self-identified problem (if assessed)
1. Poehlmann⁴¹	Interviews with 60 incarcerated pregnant women in a Wisconsin prison	Unspecified illicit substances (60%)	NA
2. Bell et al.⁸	Comparison of 496 incarcerated women’s births and 4960 Medicaid-recipient births from the community	Unspecified illicit substance use (56%)Tobacco (54%)Alcohol (37%)	NA
3. Eliason and Arndt²⁹	Comparison of 53 pregnant inmates to 1160 non-pregnant female inmates on demographic and substance use and abuse	Methamphetamine (29%)Unspecified IV use (29%)Cocaine or crack (27%)Marijuana (24%)Alcohol (20%)	Self-reported substance abuse problem (84.91%)Self-report illegal drug problem (91.11%)
4. Tanner²⁷	Outcomes of 200 pregnant women in an Indiana prison	Tobacco (81%)Alcohol (50%)Cocaine (40%)Marijuana (33%)Opiates (11%)Methamphetamine (10%)Barbiturates (0.8%)Benzodiazepines (0.5%)	NA
5. Mukherjee et al.³⁵	Systematic review of mental health issues among incarcerated women.	Unspecified illicit substance use (60%–90%)Tobacco (50%–84%)Alcohol (15%–62%)	NA
6. Knittel et al.²³	Chart review of 179 incarcerated women with OUD	Opiates (86%)Tobacco (74%)Marijuana (30%)Cocaine or crack (30%)Alcohol (27%)Amphetamines (24%)Heroin (16%)	NA
7. Rose and LeBel²⁴	Self-report assessments with 27 incarcerated pregnant women in a large, midwestern county jail	Alcohol (55%)	Self-reported substance use problems (33.3%)Positive substance use disorder screen (55%)
8. Sufrin et al.²⁵	Cross-sectional survey and 6-month epidemiological survey of US state prisons and county jails participating in the Pregnancy in Prison Statistics (PIPS) study	NA	OUD among women entering prison (26%)OUD among women entering jail (14%)
9. Drago et al.¹³	Chart review of opioid-exposed infants born to 28 incarcerated women and compared to 138 non-incarcerated women’s opioid-exposed infants	Unspecified illicit substance use (39%)Benzodiazepine (21%)Alcohol (14%)	NA
10. Testa et al.¹⁸	Comparison of opiate use by (non)incarceration exposure among 17,551 pregnant women included in the Pregnancy Risk Assessment Monitoring Survey (PRAMS). Of the 17,551 women, 5850 reported incarceration exposure	Hydrocodone (8%)Oxycodone (7%)Codeine (6%)Morphine (3%)Tramadol (3%)Fentanyl (3%)Hydromorphone/Meperidine (2%)Oxymorphone (0.9%)	NA

NA: not applicable; OUD: opioid use disorder; IV: intravenous.

Although most of these studies are now dated, the prevalence of substance use among the studies included within our review ranged from 30% to 96% of pregnant women who enter prison report using substances during their pregnancy, which is much higher than the rates found in community samples^{8,23,27,29,35,41} For example, Bell et al.⁸ examined the prevalence of illicit drug use, alcohol use, and tobacco use among incarcerated pregnant women and compared their use to pregnant Medicaid recipients. They found higher rates of drug and alcohol use among incarcerated women (57% and 37%, respectively, compared to 55% and 28%, respectively, among Medicaid recipients). Half of the women (54%) in both groups reported tobacco use.

Of the 10 studies, 4 of the more recent articles examined the prevalence of opioid use disorder (OUD) among incarcerated pregnant women as a primary focus.^13,23,25,18 The most robust study of OUD among incarcerated women was conducted by Sufrin et al.²⁵ In this large study of monthly pregnancy data from 22 state and federal prison systems and six of the largest county jails, Sufrin et al.²⁵ found that a quarter of pregnant women entering prison have an OUD (26% of women admitted to state prisons and 14% of women admitted to jails, respectively). In a statewide study of pregnant women entering North Carolina’s prison system, the prevalence of OUD was found to be significantly higher. Knittel et al.²³ reported that 179 pregnant women with OUD entered prison over 2 years, which accounted for half of the entire pregnant population. Although the prevalence of OUD was the primary focus of this study, they also examined pre-incarceration substance use history. Among those with OUD, pregnant women also reported pre-incarceration use of tobacco (74%), marijuana (30%), cocaine/crack (32%), alcohol (27%), methamphetamines (24%), and heroin (16%).

Although the American College of Obstetricians and Gynecologists (ACOG; 2017) recommends universal screening of SUDs among pregnant populations, no articles assessed the degree to which this practice is occurring in carceral settings or reported on administrative data from routine screenings. Rose and LeBel²⁴ utilized the Alcohol Use Disorder Identification Test (AUDIT-12) screening tool to determine the prevalence of alcohol use disorders in a sample of 27 pregnant women admitted to a large mid-western jail; however, the screening was administered by the research team and is not a routine practice within the facility.

Overall, prevalence studies tend to be small, single-site, and cross-sectional. Most are also now dated. Furthermore, most data were sourced from electronic medical records extracted by research teams from academic medical centers or college universities. Most studies were dedicated to the determination of prevalence of substance use during only the current pregnancy, which largely neglects those who continue or resume using in the postpartum period. Notably, no studies examined racial or income disparities. Collectively, the existing prevalence data vary widely; however; this culmination of research indicates that an overwhelming majority of incarcerated perinatal women report illicit substance use during pregnancy.

SUD treatment in carceral settings for perinatal populations

A significant portion of the literature on SUD treatment for incarcerated pregnant and postpartum women is dedicated to the treatment of OUD; 18 of the 33 publications examined or provided perspectives on OUD and medication for opioid use disorder (MOUD) treatment in carceral settings.^{13,18–26,28,33,36,42,43,45,46,48–50} Of those 18 publications, 12 discussed the provision and accessibility of substance use treatment in carceral settings. Although MOUD is the recommended standard of care for OUD treatment,^20,39,48,51 articles included within the review show that only some carceral facilities provide MOUD to pregnant and postpartum women. Taken together, these studies show that access is limited and significant gaps exist in the initiation, retention, and referral to community MOUD providers upon release. Overall, a notable portion of facilities report offering MOUD, but only provide it to those who were already receiving treatment in the community prior to their incarceration or discontinue treatment immediately following delivery. Even fewer facilities provide perinatal individuals with referrals to community MOUD providers upon release to either initiate or continue treatment.

Despite the existence of carceral facilities that do provide MOUD, medically supervised withdrawal is the most common treatment utilized in prisons and jails,^20,52 and access to MOUD when offered is limited. In a recent large-scale, national survey to determine the availability of MOUD treatment of pregnant individuals in 836 US jails, Sufrin et al.²⁰ found that 60% of jails reported offering MOUD during pregnancy; however, only 32% initiate MOUD upon intake. Most jails that offered MOUD only continued treatment for pregnant women who were receiving treatment immediately prior to incarceration. Moreover, only 23% of facilities continued MOUD treatment during the immediate postpartum period²⁰ despite being when women are at their highest risk for relapse and overdose.⁵³ The forced withdrawal during the postpartum period is largely attributed to administration’s desire for a “drug free” treatment, despite being inconsistent with clinical recommendations.⁵⁴

Also, researchers expressed that the initiation of MOUD for pregnant women and continuation postpartum while incarcerated is shown to increase engagement and retention in community-based treatment, increase likelihood of abstinence during re-entry, and decrease risk of overdose death.^21,30 Although a small sample size, one study found that pregnant women who initiated a once-monthly injectable buprenorphine treatment while in jail continued postpartum and upon release in the community.²¹ Despite the increased benefit of continuation upon release, estimates indicate that only 19%–30% of pregnant and postpartum women will receive referral for MOUD in the community upon release.^19,23 Ultimately, articles in this review indicate that few incarcerated pregnant and postpartum women will have the opportunity to access the standard of care for OUD, thus underscoring the importance of interventions to improve care and promote maternal and infant health,²⁰ such as mechanisms to enhance perinatal care.

Five publications included within the review expressed that incarcerated perinatal populations with SUDs require comprehensive and intensive care to make a successful recovery.^{18,24,36,45,46} These publications stressed that in order to improve both maternal and infant outcomes, incarcerated pregnant women require coordinated and collaborative enhanced prenatal care that addresses mental health and trauma sequelae in tandem with substance use and addiction. Incarcerated pregnant women who use substances are likely to have also experienced trauma and have comorbid mental health disorders such as depression, anxiety, and posttraumatic stress disorder.^24,34 In qualitative interviews with 63 pregnant incarcerated women in their third trimester, Fogel and Belyea³⁴ found that almost half of the women reported using alcohol or drugs during their current pregnancy. The majority reported histories of family violence prior to the age of 18 years; however, those who reported substance use during pregnancy were more likely to have experienced physical and/or sexual abuse during childhood. Moreover, 70% reported depressive symptoms meeting the criteria for clinical depression. Indeed, Sutter et al.⁴⁶ suggested that programs that incorporate a full spectrum of care in addition to substance use treatment (e.g. perinatal care, trauma-informed care) show improved outcomes in retention, completion, and sustained recovery post-release and lead to an overall reduction in stigma surrounding substance use and pregnancy.

Recommendations and strategies to increase SUD treatment

Although it is understood that correctional facilities will experience barriers to provide the recommended standard of care for pregnant and postpartum women with SUDs,⁵⁵ scholars provided recommendations and strategies for integrating substance use treatment into standard of correctional care. Themes among recommendations and strategies discussing the integration of evidence-based substance use treatment within the broader literature are summarized below. Fourteen publications referenced the importance of community partnerships to integrate evidence-based substance use treatments into carceral settings and the feasibility of such programs.

Community partnerships can help facilitate the uptake of evidence-based practices

Fourteen publications specifically stressed the importance of partnerships with community organizations and providers to overcome barriers. Most of these articles focused on the provision of MOUD in carceral settings, but all recognized that carceral settings will experience significant barriers³² in integrating treatment into their current system or providing referrals upon release. For example, not all prisons can meet the Drug Enforcement Administration’s (DEA) licensing requirements for dispensing MOUD. According to regulations outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Commission for Correctional Health Care (NCCHC), methadone can only be administered by DEA-licensed opioid treatment programs (OTPs), while buprenorphine may only be administered by trained and waived medical practitioners.⁵⁶ However, if prisons and jails are not DEA-licensed or have staff eligible for waiver, they can partner with community-based OTPs or medical providers.

Recommendations by both NCCHC and ACOG, two large proponents of the expansion of healthcare services in prisons, specifically stress the importance of community partnerships in facilitating integration of evidence-based practices into correctional settings. The NCCHC (2005) encouraged ongoing collaborations between public health, community, public assistance, and correctional agencies to meet the gender-specific healthcare needs of incarcerated women, specifically in relation to pregnancy and substance use. Thus, stakeholder partnerships can and should be leveraged to increase capacity within these settings to create long-term, sustainable systems to optimize maternal and child health.²⁰

Three articles discussed barriers correctional facilities, especially jails, might face when providing someone with a referral to a community substance use treatment program.^11,20,37 Some of the greatest barriers mentioned are the uncertainty of release dates, where treatment will be arranged and received upon release, and ensuring insurance coverage at the time of release.^11,37 To overcome such barriers and ensure women receive care when transitioning into the community, Lorenzen and Bracey³⁷ suggest that connections with knowledgeable public health and community healthcare providers are paramount. Upon release, referral to community clinical care must be available, which stresses the importance of community relationships. Sufrin et al.²⁰ mention that continued communication and mutual support between correctional administration, community organizations, and healthcare professionals can help encourage women to continue treatment upon release and can lead to an increase in post-release service utilization for women re-entering the community.

SUD treatment is feasible through community partnerships

Literature surrounding the integration of evidence-based substance use treatment specific to perinatal populations into carceral settings is sparse; however, four studies provided overviews of existing models and suggest that substance use treatment for pregnant and postpartum populations is feasible and sustainable with the assistance from community health organizations. One example described in the literature was the Women and Infants at Risk (WIAR) residential treatment program for incarcerated, pregnant, substance-using women in the Michigan state adult correction system. WIAR reportedly works to increase the availability of substance use treatment, reduce the effect and severity of drug exposure to fetuses, reduce recidivism, promote community awareness of incarcerated pregnant and postpartum women to improve services, and facilitate coordination among relevant agencies to meet the complex needs of these women.³⁹

Women are eligible if they have a history of drug and/or alcohol dependence, a non-violent offense, and a sentence of less than 2 years. Women agree to actively parent their infant and remain in the program for at least 4 months after the infant’s birth. Women remain incarcerated until they reach their third trimester. Once women have reached their third trimester of pregnancy, they are transported to WIAR’s community-based residential facility, roomed, assessed for other needs (e.g. nutrition and clothing), and provided with education materials regarding pregnancy, prenatal care, and breastfeeding. Program staff assist with scheduling prenatal care and applying for Medicaid. Women are then matched with a multidisciplinary team including a nurse, social worker, and nutritionist. In addition to intensive prenatal care, women are provided with individual counseling sessions, group therapy, and didactic sessions for substance use. Unfortunately, “truth in sentencing laws” enacted to reform judicial sentencing ultimately led to the demise of the program despite 10 years of operation and successful, measurable outcomes.³⁰

In another example, Public Health-Seattle and King County Correctional Facility partnered to create MOMS Plus (Maternal Opiate Medical Supports Plus), which is a case management program that serves incarcerated pregnant women who use substances.³⁷ MOMS Plus connects incarcerated, pregnant substance-using women to prenatal care and supportive services inclusive of housing, counseling, and substance use treatment in an effort to improve maternal health and reduce infant mortality. This collaborative model of care involves public health agencies, county corrections, community medical providers, substance use treatment centers, and drug and mental health courts. Referrals are provided by the inmates themselves, correctional officers, medical providers, courts, and state and community corrections staff. Because incarcerated women’s needs are complex and multifaceted, MOMS Plus case management works to connect incarcerated pregnant women to services that are most likely to impact prenatal outcomes, such as prenatal care, substance use treatment, housing programs, behavioral healthcare, and food programs.

Discussion

Taken together, results of this integrative review show significant gaps in research and provision of substance use treatment for incarcerated perinatal women. Findings from the publications included within in this review suggest that our understanding of substance use prevalence among incarcerated pregnant and postpartum populations is limited. Despite the lack of recent, national estimates inclusive of a wide range of substances, the prevalence among the studies included within our review ranged from 30% to 96% of pregnant women who enter prison report using one or more illicit substances during their pregnancy.^{8,23,27,29,35,41} Given that the highest estimate is 96%, we should anticipate that many women who enter prison pregnant will have used substances over their lifetime, during their current pregnancy, and/or meet diagnostic criteria for an SUD.

Furthermore, this extensive review indicated that substance use treatment for pregnant and postpartum women is not routinely accessible. For MOUD, carceral settings report providing MOUD treatment to pregnant populations; however, only a small portion of these settings initiate such treatment or continue MOUD treatment post-delivery despite being constitutionally mandated to provide healthcare and treat incarcerated persons with “serious medical need” (Estelle v. Gamble, 1976). Although Estelle did not classify “serious medical need,” forced withdrawal is the most widely used method of treatment, which can be dangerous for both the mother and the fetus. For pregnant women, medically supervised withdrawal does not contribute to lower rates of neonatal abstinence syndrome and increases risk of relapse, overdose, and death upon release.⁵⁷ Generally, this method of treatment is not recommended for pregnant and postpartum populations because of withdrawal symptoms that can lead to maternal and infant health complications during pregnancy and birth and high risk of maternal relapse postpartum. Instead incarcerated pregnant women should be offered medications for OUD.⁴² Carceral settings have a moral, ethical, and medical responsibility to provide life-saving medication treatment to incarcerated pregnant and postpartum persons.⁴²

A large majority of this literature focuses on the treatment of OUD; while needed and insightful, there is an overall neglect of substance use treatment practices and outcomes for pregnant and postpartum populations in carceral settings more broadly. Specifically, studies included within this review show that polysubstance use is prevalent among incarcerated women^13,58 and is salient for pregnant and postpartum populations;²³ however, few correctional interventions are tailored to treat polysubstance use in perinatal populations.

The current state of the literature regarding substance use and treatment provided to incarcerated pregnant and postpartum women is ripe with implications. In the future, greater emphasis should be placed on policy development surrounding the creation and use of existing diversion programs for women with substance use and addiction who are convicted of non-violent offenses to encourage service utilization. In recent years, several state legislatures have passed increasingly punitive laws or extended existing child endangerment laws to prosecute women who use substances while pregnant.⁵⁹

Current retaliatory laws and policies targeting pregnant women who use illicit drugs are counter-productive and disproportionately enforced, and in turn discourage women from seeking care for both pregnancy and substance use treatment.⁶⁰ Pregnant women who use substances are more likely to avoid prenatal care in fear of being reported to law enforcement and child protective agencies.^60,61 For pregnant women who are justice-involved, community treatment while under alternative forms of supervision, such as drug court, expedited parole, or suspended sentencing, should be considered rather than solely relying on correctional intuitions to provide adequate, integrative treatment.

In some circumstances, incarceration of a pregnant woman cannot be avoided. For these occurrences, facilities should implement substance use screening procedures with a validated tool to determine the presence of an SUD.^42,55 Early substance use treatment intervention leads to better pregnancy, birth, and postpartum outcomes, as well as the likelihood of treatment continuation upon release.^18,37 Although for most, incarceration can interrupt care, when adequate, evidence-based substance use treatment is initiated during incarceration, and the likelihood of continuity and retention upon release increases.⁴² In one study, Knittel et al.²³ found that pre-incarceration receipt of MOUD predicted continued receipt during incarceration in facilities that offered MOUD treatment, which suggests that the prison can serve as a viable site of retention. In addition, given the high prevalence of trauma exposure among incarcerated populations, trauma-informed care for incarcerated perinatal populations is paramount to successfully address and treat SUDs.⁴⁶ Trauma-informed care practices recognize the role of violence and exposure to trauma in the development of SUDs among women.⁶²

However, it is understood that some correctional facilities do not have the capacity to treat SUDs, including OUD. To effectively integrate substance use treatment services into carceral settings that are tailored to the needs of pregnant women, criminal justice and public health agencies cannot continue working in isolation and should focus on the development of partnerships. Carceral settings can benefit from relationships with community-based providers to administer SUD treatment, specifically MOUD. The incorporation of correctional facilities into a system of care allows for incarcerated individuals to initiate, continue treatment during incarceration, and connect to resources through referral to a provider upon release. In addition, colleges, universities, and medical school personnel can serve as a tremendous resource for the location SUD specialists and champion the integration of evidence-based practices.⁵⁶ Researchers should consider guidance from international models as well.

It should be noted that this population is marginalized and extremely vulnerable—incarcerated and pregnant; thus, some women have felt coerced into substance use treatment, specifically for OUD.^42,63 Providers should be careful in their recommendations regarding treatment to avoid coercion.⁶⁴ Furthermore, while this review includes programming in both prisons and jails, it should be noted that these facilities are characteristically and fundamentally different, which affects the healthcare they are able to provide.⁴²

Jails are operated by city or county jurisdiction, house individuals for sentences less than 1 year, and release dates can be unpredictable. Because each jurisdiction has the freedom to create their own healthcare policies with little regulation, the care available varies. This stresses the importance of community partnership and involvement, especially when determining the medical or mental healthcare needed among pregnant and postpartum populations. Furthermore, because jail facilities typically house those with short-term sentences, community-based and/or residential diversion programs should be considered for pregnant women as alternatives to incarceration. Some jails offer diversion programs designed to connect individuals with pre-existing mental health and substance use problems to treatment services and often reduce jail time in return.⁶⁵ Although pilot programs created specifically for pregnant, incarcerated women have been difficult to sustain due to political climate and available resources,³⁰ diversion programs should be used more frequently for incarcerated pregnant women as they could potentially benefit both maternal and infant health⁶⁶ by facilitating the connection to resources such as mental, physical, and perinatal care.

Alternatively, prisons are operated at the state or federal level and required to adhere to a minimal standard of care. Despite prisons housing individuals for sentences longer than 1 year and more predictable release dates, there is no mandatory standard of healthcare defining what is considered to be minimal care and the services that must be provided.⁴⁹ Nonetheless, healthcare spending in jails and prisons, quality of care, medical expertise, and organization structure vary widely across facilities and services provided to women.

Limitations

A few limitations should be acknowledged. First, it is possible our review is limited by key phrases and search terms used for our database search, databases we could access, and the method of the literature search. It is possible that additional studies exist and were not included within our original search. Also, our review was limited to only studies conducted within the United States and published in English. Second, our conclusions were limited by the existing data. We were unable to assess for income and racial disparities that exist between incarcerated perinatal populations; however, we recommend that future studies examine such differences. Finally, the articles included within our review spanned nearly two decades. As a result, the socioeconomic and political climate are likely to have varied among the studies.

Conclusion

Incarceration could present an opportunity to provide pregnant women with access to critical healthcare services that might otherwise be inaccessible,³⁷ in turn increasing the possibility of continued healthcare utilization post-release.⁶⁷ An overwhelming majority of incarcerated pregnant and postpartum women report illicit substance use both prior to and during pregnancy, yet carceral systems are deficient in providing treatment for addiction among this population. Despite the abundance of evidence of long-term effectiveness of SUD treatment programs for pregnant women in the community,^37,67 the scarcity of empirical data and research of incarcerated pregnant women suggests there might be an unmet need of pregnancy-focused SUD treatment for these women. Incarcerated pregnant women and their infants possess significant health care need. Initiation of SUD treatment and aftercare planning through community-based organizations in all carceral settings upon intake and release can help facilitate a smooth transition back into the community and engender lasting benefits for both maternal and infant health.

Footnotes

Acknowledgements

The authors would like to thank Stefani Gafford, our Health Science Informationist with the University of Arkansas for Medical Sciences, for her assistance with our literature search.

Declarations

ORCID iD

Mollee K Steely Smith

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

Abstract

Keywords

Background

Method

Literature search

Inclusion criteria

Results

Prevalence of substance use among incarcerated pregnant and postpartum populations

SUD treatment in carceral settings for perinatal populations

Recommendations and strategies to increase SUD treatment

Community partnerships can help facilitate the uptake of evidence-based practices

SUD treatment is feasible through community partnerships

Discussion

Limitations

Conclusion

Footnotes

Acknowledgements

Declarations

ORCID iD

References