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Abstract

Background:

Pregnancy and substance use disorders (SUD) for incarcerated individuals often overlap, but their management varies greatly between jails. A better understanding of pregnancy management across jails is needed to better guide policy and practice recommendations.

Objectives:

To examine the current state of pregnancy management across North Carolina jails, including current practices, challenges, and gaps in pregnancy management in jails.

Design:

This is a qualitative analysis within a mixed-methods study assessing the scope of perinatal incarceration and the capacity of North Carolina jails to manage perinatal SUD.

Methods:

We conducted in-depth interviews with North Carolina jail staff using a semi-structured interview guide between October 2022 and September 2023. We used the ideal-type analysis approach to systematically compare pregnancy management and SUD management practices across facilities.

Results:

We completed 26 interviews with jail staff. Pregnancy management approaches were unevenly distributed across three ideal types: (1) exclusive use of internal prenatal care resources (n = 2), (2) exclusive use of external prenatal care resources (n = 16), and (3) hybrid use of both internal and external prenatal care resources (n = 8). Within ideal types, SUD management was highly variable.

Conclusion:

The heavy reliance on external resources for prenatal and SUD care highlights the chronic underfunding and staffing challenges faced by these facilities. There is an urgent need for standardized policies governing prenatal care in jail facilities to help reduce disparities in care quality and ensure that all pregnant individuals receive adequate support, regardless of the jail’s resources. Alternatives to incarceration during pregnancy should be prioritized.

Plain language summary

Pregnancy management for incarcerated individuals with substance use disorder in North Carolina jails

Why was the study done? There is an increasing number of pregnant individuals incarcerated in the U.S., and pregnant people who experience incarceration face worse maternal and infant health outcomes. However, management of pregnancy and substance use disorder varies greatly across jails. The research team aimed to fill in the gaps in knowledge surrounding current practices, challenges, and gaps in pregnancy management in North Carolina jails, in order to better guide policies and practices. What did the researchers do? The research team conducted 26 qualitative interviews with North Carolina jail staff between October 2022 and September 2023. The researchers analyzed the transcripts using an ideal-type analysis approach that identified three topics: pregnancy management, SUD management, and policy changes and implementation climate. This analysis focuses on the pregnancy management typology. What did the researchers find? Jails in the sample had three approaches to pregnancy management: (1) exclusive use of internal prenatal care resources, (2) exclusive use of external prenatal care resources, and (3) hybrid use of both internal and external prenatal care resources. The most common approach was exclusive use of external resources, used by 16 jails. What do the findings mean? The findings reveal no standardized prenatal care management across jails and significant variation in the robustness of pregnancy management protocols. The overwhelming reliance on external resources for pregnancy management underscores the resource constraints that many jails face, including insufficient funding, staff shortages, and limited infrastructure to support in-house pregnancy care. The researchers recommend prioritizing alternatives to incarceration during pregnancy to better support both pregnant individuals and under-resourced jails.

Keywords

incarceration pregnancy management prenatal care substance use disorder

Introduction

Perinatal incarceration refers to the incarceration of pregnant and postpartum individuals, a population that faces unique health challenges including perinatal substance use disorders (SUD). Of note, many pregnant and postpartum individuals identify as women and/or as mothers, while others hold a range of non-binary or gender expansive identities. We strive to use gender-inclusive language here, but also to stay consistent with citations of prior work that use other terminology. It is also important to recognize that individuals incarcerated are often assigned sex at intake (i.e., male or female) based on their sex assigned at birth and irrespective of their current gender identity; jail and prison statistics are reported using sex assigned at intake. Most perinatal incarcerations begin in city, county, or regional jails, which house individuals awaiting trial, serving short sentences, or awaiting transfer to other facilities. Jails may lack the financial, staffing, and regulatory resources necessary to provide adequate care for pregnant individuals, leading to potential adverse outcomes.^1,2 In North Carolina, where an estimated 1200–1400 pregnant individuals are incarcerated each year in more than two-thirds of the 97 jails in the state, the challenge of providing perinatal care during incarceration may be compounded by varying policies and practices and differential access to perinatal care resources across different county facilities, creating a patchwork of care standards.^2
–4

The number of female individuals in jails in the United States is growing, with a 9% increase occurring from 2021 to 2022 and a trend toward longer incarcerations over the past 10 years.⁵ Approximately 3% of female individuals are pregnant at the time they enter jail.^3,6,7 Additionally, there is substantial overlap between female incarceration and SUD, with prevalence estimates ranging from 25% to 90% depending on the setting and specific SUD.^8
–11 Nationally, the number of pregnant individuals with SUD and experiencing SUD-related morbidity and mortality is rising.^12,13 For pregnant incarcerated individuals, SUD treatment, including medications for opioid use disorder (MOUD) is ideally integrated within pregnancy care services.¹⁴ Understanding the complexities that exist at the intersection of incarceration, pregnancy, and SUD, improving pregnancy management in jails presents a significant opportunity to improve maternal and infant health outcomes.

A focus on pregnancy care in jails is warranted because there are more incarcerated female individuals in jails than in prisons, whereas the reverse is true for men.^15,16 As of 2023, 52% of incarcerated female individuals—95,100 individuals—in the United States were held in jails, compared to 85,900 in prisons.^15,16 Jails and prisons are different carceral settings with implications for pregnancy management. The longer sentences typical of prisons make it more practical to establish regular healthcare for pregnant people, unlike the transient nature of jail stays.³ Jail sentences are often shorter, with an average stay in U.S. jails of 32 days for men and women in 2023; thus, many pregnant individuals will still be pregnant upon release.^7,15 Furthermore, the operation of jails under local jurisdictions means that healthcare generally—and perinatal care specifically—in jails vary significantly from facility to facility, depending on county-level resources and other factors.^2,17 The shorter duration jail stays and the localized nature of care, establishing perinatal care for pregnant individuals in jail is particularly important because it has the potential for continuity of care in the community.

Unfortunately, as few as 17% of jails provide comprehensive prenatal care, with pregnancy services in many jails limited or non-existent due to financial and structural barriers.^1,2 There are myriad documented inadequacies of prenatal care in U.S. jail facilities, including failures to consistently provide prenatal vitamins,¹ ultrasound examinations,¹⁸ standard-of-care vaccinations,¹⁹ and birth and lactation support.²⁰ When perinatal SUD care that meets the community standard-of-care is included in the definition of comprehensive prenatal care, even fewer jails are able to provide this care. Most jails lack any behavioral health services (i.e., self-help groups, peer counseling, substance use education, or professional SUD counseling)⁹ and provision of MOUD is often severely limited.^{8,10,21
–24}

It is important to recognize that the operational challenges within jails that directly result in poor pregnancy and SUD care management are just one end result of broader social structures. To understand the scarcity of pregnancy and SUD care management in jails, perinatal incarceration must be viewed as a public health crisis birthed from racism and the lingering and long-lasting implications of racism. The differential and intersectional impacts of racist, classist, and sexist systems of drug policing and enforcement, incarceration, family surveillance, and reproductive injustice that lead to massive overrepresentation and harsh sentencing of Black women in jails^5,15,25 and separation of Black families^26,27 also reinforce racist, classist, and sexist differential societal values place on pregnancy and childbearing structurally and systemically within (incarcerated) and outside the walls of jails and prisons (reentry).^{5,15,25,26,28} The impact of disparate incarceration is further amplified through the collateral consequences of incarceration, enacted through stigma and discrimination, that have led to limited access to safe housing, employment opportunities, and education for individuals returning to the community after incarceration.^29
–32

The concentration of pregnancy health needs and exacerbation of existing pregnancy health disparities that occur in jails suggest that increasing pregnancy care services in jail might serve as a buffer to adverse perinatal outcomes.³ Indeed, individuals exposed to the limited pregnancy care management available in jails often experience similar challenges to access to care in the community after incarceration and have higher risks of adverse pregnancy and delivery outcomes, such as low-birth weight, preterm birth, pre-eclampsia, and spontaneous abortions.^7,18 Inadequate perinatal SUD treatment further increases the risk of adverse pregnancy and delivery outcomes as well as the risk of exposure of the fetus to substances and the risk of overdose and death for the pregnant person.^12,33,34 Jails represent a convergence of multiple, systemic public health issues, and addressing pregnancy management within carceral systems is a critical step in reducing health inequities, particularly in maternal health.

This study seeks to illuminate the current state of pregnancy management among incarcerated individuals in North Carolina jails to improve practices and policies. This research addresses gaps in knowledge surrounding current pregnancy practices, challenges, and gaps in management in jails, offering insights that can drive more effective prenatal care policies within carceral settings.

Methods

Study design

This study was conducted as part of a larger project assessing the scope of perinatal incarceration and the capacity of North Carolina jails to manage perinatal SUD.³⁵ The parent study design included an initial quantitative survey focused on the prevalence of perinatal incarceration followed by the semi-structured qualitative interviews described here exploring approaches to pregnancy and SUD management in jail. For the qualitative interviews, we recruited a subset of the 77 North Carolina jails that completed the surveyed as part of the parent project, with 39 jails contacted and 26 jails participating between October 2022 and September 2023. We recruited jail staff by email and phone using a qualitative sampling matrix that targeted representation from at least five each of small, medium, and large capacity facilities, at least one facility from each of nine geographically diverse regions across North Carolina, and at least five each of facilities that did and did not previously make a referral to our institution for perinatal behavioral health services. Eligible participants were either custody or medical staff deemed knowledgeable about the management of pregnant individuals in the facility. Non-participation was recorded, as 13 jails were unable to participate due to scheduling constraints.

We pilot tested the interview guide with our first two interviewees to ensure clarity and effectiveness in eliciting detailed responses; only very minor changes were made and these interviews were included in the analysis. For the interview guide, see Supplemental Material 1. Two female team members (JJ and ZS) with training in qualitative research conducted phone interviews using the interview guide and probing questions that addressed local resources and programs for pregnant incarcerated individuals, treatment of SUD in cases of perinatal incarceration, the capacity to identify and implement alternatives to incarceration, screening policies for pregnancy and SUD within the jail, organizational structure, barriers and facilitators to SUD treatment in the jail, prior program and policy changes implemented, and key decision-makers around perinatal incarceration and perinatal SUD interventions. The interviews took 30–45 min and were recorded, de-identified, and transcribed, except for four interviews during which another team member (IF) took notes because the interviewees did not want to be recorded. The transcripts were reviewed for accuracy as the research team familiarized themselves with the data to prepare for analysis. Our team is experienced in providing care for pregnant individuals in the North Carolina carceral system and partnering with jail staff to find alternatives to incarceration.

The research was reviewed by the Institutional Review Board at the University of North Carolina at Chapel Hill (IRB#22-1508) and was determined to be non-human subjects research. All participants provided verbal informed consent to participate after disclosure of the name of the program/research team conducting the interview, the goal and topics of questions that would be asked, and the study funder. We used a verbal consent since all interviews were conducted remotely and the research posed no more than minimal risk to the participants. Verbal consent was recorded in the recruitment log by the research team member obtaining consent. We offered participants a $50 gift card after completion of the interview.

Three main topics were drawn from this mixed-methods data for analysis: pregnancy management, SUD management, and policy changes and implementation climate. This article will focus on the analysis of pregnancy management from the qualitative data, including pregnancy screening and resource utilization for management.

Qualitative analysis

We utilized the ideal-type analysis approach to analyze the qualitative interviews conducted with North Carolina jail staff and followed the analytic steps outlined by Stapley et al.³⁶ The ideal-type analysis method involves grouping sources of qualitative data, usually individual interviewees, into ideal types, which are simplified models that capture the essential features of a particular characteristic of the participants; in this case, we grouped jail facilities into types describing their pregnancy management practices. These ideal types are constructed from recurring patterns and themes in the data, allowing for systematic comparison of pregnancy management across different facilities. This method helps to streamline complex data into meaningful categories, and focuses on comparative observations within and between categories rather than thematic analysis.³⁶

We constructed two typologies for this study: (1) pregnancy management, categorized by pregnancy screening and resource utilization for management; and (2) perinatal SUD management, categorized by SUD screening and resource utilization for management. We used Microsoft Word and Excel to facilitate the ideal type analysis, and did not utilize other qualitative software.³⁷

Three members of the research team (IF, AA, and ZS) wrote short summaries of the resources used for pregnancy and SUD management for each jail. To create ideal types, we first systematically compared each of the pregnancy management approaches by identifying prominent patterns and shared characteristics across the case reconstructions. We grouped similar jail summaries into distinct pregnancy management ideal types with the goal of clear distinctions between them and strong similarities within them. For each pregnancy management ideal type, we identified an optimal case, or one jail that most clearly exemplified the defining characteristics, and assigned the other jails to a single ideal type to maintain the clarity and distinctiveness of each group. Two team members (IF and ZS) independently reviewed and assigned the cases and then met to compare selections. In instances where their choices differed, they discussed their reasoning and reached a consensus on the most representative case. We used a credibility check process with a fourth researcher (JJ) unfamiliar with the analysis who independently sorted the case reconstructions into the established ideal types. We discussed discrepancies among the four team members and reached consensus.

This process produced three ideal types for pregnancy management: (1) exclusive use of internal prenatal care resources; (2) exclusive use of external prenatal care resources; and (3) a combination of both internal and external prenatal care resources. One unique external resource in North Carolina is “safekeeping,” a legal procedure that allows jails to obtain a judicial order to transfer a person to prison custody in order to meet medical or security needs beyond what the jail can provide.³⁸ We wrote detailed descriptions of each ideal type to capture the essence of the typical practices and characteristics for pregnancy management.

Lastly, we compared each ideal type to the others to analyze the differences and similarities between types. We also compared cases within each ideal type to understand the variations and commonalities in practices across the jails. These comparisons were conducted by repeated review of the interview transcripts and discussion as a team to identify key comparative observations. Notably, this is different from a thematic analysis as ideal type analysis is focused solely on generating the typology and comparisons between and within types. These observations are primarily hypothesis-generating and do not rely on data saturation or thematic saturation.^36,39

We repeated the ideal type analysis process for perinatal SUD management, resulting in four ideal types: (1) management using only internal SUD resources; (2) management using only external SUD resources, including safekeeping; (3) management using a mix of internal and external resources, including safekeeping; and (4) exclusive use of safekeeping for all pregnant people with SUD. Finally, we nested the SUD ideal types into the pregnancy management categories. The reporting of this study conforms to the COREQ guidelines (see Supplemental Material 2).

Results

We generated ideal types for pregnancy management and perinatal SUD management across interview transcripts with 1 staff member from each of 26 jail facilities (n = 26). The majority of staff were interviewed during the typical workday and two were interviewed at 5 pm at the conclusion of a shift. There were five staff participants who declined the gift card. The perinatal SUD management ideal types nested in the pregnancy management ideal types are shown in Figure 1.

Figure 1.

Ideal case typologies for pregnancy and SUD care in a qualitative sample of North Carolina jails (n = 26), 2022–2023.

We report descriptively on the size and urbanicity of the jails represented in our qualitative sample (Table 1). Due to the sample size, cross-tabulations or reporting subgroup totals by ideal types would increase unduly the risk of deductive disclosure by county, so we have not reported those. Since individual participants were reporting on facility policies and practices, rather than on their personal experiences or opinions, we did not collect individual demographic data.

Table 1.

Characteristics of North Carolina jails (n = 26) in the sample.

Characteristic	Total (n = 26), n (%)
Size of jail^a
Small (<100)	8 (30.8)
Medium (100–999)	14 (53.8)
Large (>1000)	4 (15.4)
Urbanicity^b
Urban	5 (19.2)
Suburban	3 (11.5)
Rural	18 (69.2)

Small: <100 individuals; medium: 100–1000 individuals; large: >1000 individuals.

Drawn from the NC Rural Center database, www.ncruralcenter.org/county-data/. Urban: ⩾750 people per square mile; suburban: >250 to <750 people per square mile; rural: ⩽250 people per square mile.

We grouped jails into three ideal types based on how prenatal care was managed: (1) exclusive use of internal prenatal care resources (2 jails); (2) exclusive use of external prenatal care resources (16 jails); and (3) a combination of both internal and external prenatal care resources (8 jails). In all of the interviews, pregnancy testing, prenatal vitamins, and dietary needs were provided by the facility, and interviewees focused on prenatal healthcare, such as nursing and clinician encounters, when they described the management approaches of each facility. We grouped jails into four ideal types based on how SUD care was managed: (1) exclusive use of internal SUD management resources (5 jails); (2) exclusive use of external SUD management resources (7 jails); (3) a combination of both internal and external SUD management resources (10 jails); and (4) exclusive use of safekeeping (4 jails).

Typology

Type 1: internal prenatal care resources (n = 2)

This category included jails that exclusively used prenatal care resources within their facility. Instead of referring pregnant individuals to external resources, like a local health clinic, these jails relied on in-house health providers, such as registered nurses (RNs), licensed practical nurses (LPNs), and obstetricians/gynecologists (OB-GYNs). These providers may be jail facility staff or external providers who visit the jail regularly. Jail B served as the optimal case for this category; the staff member noted that they did not “tap into any [outside] resources” and further clarified that their health staff were in-house, stating that “Once they come in and they are pregnant, they see a provider, get vitamins, and we schedule them for their first visit. . . We have a staff of RNs and LPNs.”

Jails categorized as using only internal prenatal care shared the key feature of conducting appointments on-site, though the specifics of how they achieved this varied. Jail B did not address the hiring structure of on-site staff, while Jail C specifically described contracting its healthcare personnel. Jail B primarily described their on-site nurses—“we have a staff of RNs and LPNs” while only briefly mentioning on-site clinicians who would see patients—whereas Jail C described their broader healthcare team: “We have a medical provider with multiple mental health professionals, discharge units, and a psychiatrist on-call. We also have a nurse practitioner four days a week, ten hours a day.” Jail C even described a special care unit for high-risk pregnancies, which was unique among the jails interviewed.

Within this type, where pregnancy care is managed entirely with internal resources, there were meaningful differences in how jails approached SUD treatment. Jail B relied exclusively on internal, jail-based resources for SUD management, mirroring their approach to pregnancy care. Staff emphasized continuity of care, noting that they verify whatever medication or therapy a pregnant individual was receiving in the community and continue it in custody. As one staff member explained, “If they’re on [medication as therapy (MAT)] outside, we continue that in-house. We verify it and keep it going. We don’t want a pregnant mom to go through withdrawals.”

In contrast, Jail C used a hybrid model that incorporated both internal and external resources. Historically, and still currently, they ensure that pregnant individuals maintain their community MOUD program while incarcerated. At the same time, Jail C is in the process of developing its own internal MOUD pathway that would allow individuals to begin treatment in custody and transition into a structured program after release. As one staff member described, “We’re building a modified MAT program where they can start it here and then move through the process with probation, parole, and the court.” Neither jail in this category described additional behavioral health services, only MOUD access.

Type 2: external prenatal care resources (n = 16)

Jails in this category exclusively relied on external prenatal care resources following the initial pregnancy screening. External prenatal care resources consisted of appointments for prenatal visits, ultrasounds, laboratory testing, and other components of routine care at facilities outside the jail, such as hospitals, local private obstetric clinics, or local health departments. Some of the jails in this category also used safekeeping to send patients whose needs exceeded the capacity of their local external resources. Jail D was the optimal case of this category. The facility depended entirely on the health department for all aspects of prenatal care, transporting pregnant individuals to the local public health department clinic. The interviewee highlighted their county’s limited resources. When asked if they had any other local programs, the interviewee responded, “No, I can’t think of any. We don’t have a lot of resources in our county.”

External prenatal care resources varied across jails of this type. For instance, Jail E uniquely outsourced to an OB-GYN affiliated with a local hospital—“Once we determine they’re pregnant, if they’re going to be here a while, we set up an appointment with [hospital omitted] OB-GYN.” Most other jails in this category relied at least partially on their public health departments. For example, as mentioned above, Jail D utilized their local health department exclusively. However, Jail F used two local resources depending on availability—“We get them an appointment with [clinic omitted] or our health department, whichever can see them sooner.” The reliance on public health departments and clinics was common, while only Jail E used a hospital-affiliated clinic for prenatal care. Some jails varied which clinic they sent patients to, based on pregnancy risk level. Jail G, for example, used the local health department for most cases but referred high-risk pregnancies to a specialized clinic. Having to rely solely on outside prenatal care did raise issues for some jails more than others, based on how far they had to travel to reach external sources of care. For example, Jail F noted that they struggled more to keep up with prenatal care due to fewer resources and being more geographically isolated “because we don’t have a lot of resources here, and it will be a lot of traveling, taking back and forth to appointments and that kind of thing.”

Half of the jails that relied on external prenatal care resources also relied exclusively on external resources for supporting pregnant individuals with SUD (n = 5) or even sent all pregnant individuals with SUD for safekeeping (n = 3). External resources included local community-based treatment programs, drug courts (i.e., treatment-oriented, court-supervised diversion programs), and safekeeping. Jail D noted that limited internal capacity forces them to look outward for SUD care as well as pregnancy management. “We would send people to social services because they are the ones that would be able to tell that person what they need to do and what’s available.” They reported that, per policy, they send individuals to safekeeping after 6 months gestation so they can receive care at the better-equipped, central facility. Jail E, for example, also reported actively trying to move pregnant individuals with SUD out of the jail through different external mechanisms, either through drug court or through a local SUD recovery center. Staff emphasized that their social worker plays a central role in this process, working to connect individuals with “whatever program they qualify for,” and “trying hard to get them admitted” to supports outside the jail. Jail F also partners with a local nonprofit organization with an addiction medicine arm, sending most pregnant individuals with SUD to this program. This nonprofit is the same organization the jail relies on for general pregnancy management.

The other half of jails that used exclusively external resources for prenatal care reported using either a mix of internal and external SUD resources (n = 5) or exclusively internal SUD resources (n = 3). Internal resources included MOUD available within the facility and designated monitoring. For example, Jail G used a hybrid model that incorporated both internal and external resources. The facility reported, “We don’t have really no MAT program right now. We do use resources like the detox program,. . .counseling, [and] try to set up stuff with them on the outside.” They also rely on local hospitals for individuals who are experiencing acute withdrawal, noting that it is too risky to manage severe detox within their jail. Jail J identified their in-house MOUD program as their sole internal resource for managing perinatal SUD, stating “Yeah, we do that here ourselves. . .If you have someone that comes in that’s on Suboxone or something like that while they’re pregnant, we don’t detox them off of that.” They clarified that they did not have access to external resources, stating “This is a small county jail.”

Type 3: hybrid approach (both internal and external prenatal care resources; n = 8)

This category included jails that provided both internal and external prenatal care following an initial internal pregnancy screening. In these jails, some prenatal care was available within the jail, but external services (including from a local health department or clinic) were also used when needed. Jail A was the optimal case with well-defined internal and external resources: “So we are contracted medical care here. We can do prenatal visits here. We then use our scheduler to help us schedule any prenatal exams with an outpatient provider, so they get connected with an obstetrician, and then we end up kind of doing simultaneous visits with them.”

The combination of internal and external resources varied. Jail A provided in-house medical and psychiatric services during pregnancy but relied on external OB-GYNs and hospitals for specialized care. Jail H split its regular prenatal care between an in-house physician assistant and the local health department, turning to an external provider as needed: “We start with our physician assistant, who connects us with the health department. If they can’t handle it, we use an outside provider.” Jail I worked with a private medical company for in-house prenatal care for low-risk pregnancies, outsourcing to the health department for high-risk cases.

In terms of SUD management, most jails that used a mix of internal and external prenatal care resources also used a hybrid approach, combining internal and external resources, for pregnant individuals with SUD. For example, Jail I operates an in-house MOUD program with buprenorphine only for individuals with opioid use disorder. Those who enter the jail already on methadone are transported to a local clinic daily to continue their treatment. Jail H also described a mix of resources. They use their in-house MOUD program and keep individuals in the jail for the first two trimesters of pregnancy. For the third trimester, however, they either transfer individuals via safekeeping to better-equipped facilities or “find a way to adjudicate the case one way or another,” implying efforts to move the case through the legal system to facilitate release.

Only a few jails in this category reported using exclusively internal or exclusively external resources for SUD management, including one facility that sends all pregnant individuals with SUD for safekeeping. In contrast, Jail A reported using internal resources only, prescribing buprenorphine within the facility and then “[giving] them resources to follow up for that treatment in case they were to get out.”

Comparing within and across ideal types

The 26 jails included in this analysis were unevenly distributed across 3 ideal types, reflecting differential access and approaches to pregnancy management and prenatal care. The comparisons within and across types resulted in several key comparative observations.

Comparative observation 1: geography and access

Our comparisons identified the relative privilege of using exclusively internal resources in larger, urban counties, the reliance on external resources by more rural facilities, and the pragmatism of a hybrid approach for many facilities.

The first ideal type, characterized by reliance solely on internal prenatal care resources either with staff or contracted nurses and clinicians, was the least common, with only two jails describing this approach in our sample. The scarcity of this model among the jails we identified is consistent with the significant resource and logistical challenges that might present for smaller or rural jails. The two jails of this type, Jail B and Jail C, were large jails in urban counties with access to a more comprehensive healthcare infrastructure, including private clinics, hospitals, and universities. The large size and urban setting likely provided an advantage in hiring and retaining jail-based healthcare teams. Jail C highlighted the inclusion of mental healthcare as part of their pregnancy management, stating that they have “mental health professionals along with a psychiatrist.” This notable focus on mental health, paired with their urban and more affluent county context, underscores the broader availability of resources for both pregnancy and SUD management in such settings compared to rural counterparts.

In contrast, the second ideal type, which relied exclusively on external prenatal care resources, was the most prevalent, with 16 jails following this model. These jails outsourced prenatal care to local health departments, hospitals, and clinics, a strategy that allowed smaller facilities with limited funding to access specialized care, especially for high-risk pregnancies. This model also presented some challenges for jails, including logistical hurdles such as coordinating appointments and transportation to external facilities. Smaller jails (capacity <100) and medium-sized jails (capacity 100–1000) were more likely to depend solely on external resources in our sample, often relying on county health clinics as their only viable option. For instance, an interviewee from Jail J explained, “We utilize the [county name omitted] County Health Department. We will contact them when we need to do any type of prenatal appointments.” Of the four large jails (capacity >1000) interviewed, only one fell into this category. This supports the idea that larger facilities, often located in areas with more resources, may find internal or hybrid care models more practical or sustainable, while small, rural facilities lack the option. Only half of the jails in this category were able to leverage some internal resources for SUD, likely reflecting the simultaneous push for jails to offer at least some form of MOUD during incarceration and the limited access to community-based resources for perinatal SUD care in many rural areas.^40,41

The third ideal type, in which facilities blended internal and external prenatal care resources, was employed by eight jails. This model generally combined in-house care for routine prenatal needs and SUD care with external providers for specialized, high-risk, and complex services. Jails adopting this model cited its flexibility in addressing the diverse needs of pregnant individuals. By integrating both internal and external resources, these facilities could minimize the logistics and transportation challenges inherent to using external resources while meeting specialized demands they might encounter less frequently.

Comparative observation 2: unique conditions of confinement in pregnancy

During the interviews, many jail staff noted mandated practices related to the care of pregnant individuals, including those concerning diet and safety. For instance, Jail L (type 2) emphasized dietary adjustments and supplements: “We make sure they get two trays at every meal and prenatal pills.” Jail M (type 2) noted similar practices, including increased protein intake: “We typically just increase their protein. . . like milk and peanut butter. We also ensure they get prenatal vitamins.” Jail M (type 2) also maintained a detailed flow sheet to document monthly vitals and lab work. Two jails mentioned housing pregnant individuals separately as a way to “ensure safety,” although it is unclear whether this was due to increased supervision in this area or some other rationale for separate housing. Jail N (type 2) explained, “We have an area where we house our pregnant females,” while Jail O (type 2) noted, “We make sure they’re safe in a cell by themselves.” To the extent that these special housing arrangements are conditions of solitary confinement or quarantine, they could actually increase negative emotional and mental health consequences of incarceration in pregnancy.

Comparative observation 3: limited experience and expedited release

Across both external only (type 2) and hybrid care (type 3) facilities, multiple jails reported challenges related to staffing, funding, and lack of experience implementing their standardized protocols. For instance, an interviewee from Jail G (type 2) stated, “I don’t really know. We use the health department,” suggesting a lack of experience with the guidelines, perhaps due to admitting only a small number of pregnant individuals to the facility. Jail K (type 3) self-described as a “one-nurse site,” also explained, “I haven’t actually come into contact with a pregnant inmate yet. . . we send them to a local gynecologist.” North Carolina has 100 counties with nearly as many jails, which may mean that many small facilities admit pregnant individuals only very rarely and may be even less prepared than their established policies might suggest.

Resource constraints were occasionally reported to lead to efforts to expedite the release of pregnant individuals, and some jails described attempts at expedited release to benefit the pregnant individual. Jail F (type 2) stated, “Once we confirm pregnancy, we get their bond unsecured, and they get out. We don’t have the staff or funding to manage transportation and appointments.” Jail A, representing type 3, described the release of pregnant individuals as being part of a supportive policy, stating, “We work with our patients to avoid staying in custody through their pregnancy.” They also described efforts to connect individuals with community-based services to support ongoing healthcare and community reintegration after release. These services can help individuals with their transition back to the community by facilitating their attendance at prenatal and postnatal appointments, their access to transportation, their access to food assistance programs, stable housing, and educational or job-readiness programs. However, Jail A identified a primary challenge to offering these transition-related resources: the mistrust many incarcerated individuals felt toward jail-provided resources: “We honestly haven’t had anyone successfully follow up. . . as my understanding. But we’re at least distributing the information. I think, unfortunately, our patients are highly suspicious when we give them that information.”

Discussion

We identified 3 distinct ideal types of jails managing prenatal care across our sample of 26 North Carolina jails. Among these, reliance on external prenatal care resources was the most common model, followed by a hybrid approach and reliance on internal resources. Accessible and affordable community health centers were frequently utilized. The predominance of external resources only highlights the resource constraints faced by many jails, including insufficient funding, staff shortages, and limited infrastructure to support in-house pregnancy care. Additionally, geographical factors may influence reliance on external providers, as rural jails often lack proximity to private OB-GYN clinics, hospitals, or specialized nonprofit resources. Within these ideal types, we also identified four distinct ideal types of jail management perinatal SUD care. While it was most common for jails to use the same balance of internal and external resources for perinatal SUD management as for pregnancy management generally, even some small facilities talked about recent implementation of in-house MOUD programs offering buprenorphine during pregnancy.

Our findings align with existing literature describing the wide variability in pregnancy management protocols among jails and the corresponding pregnancy preparedness levels.^1,2,40,42,43 This inconsistency among pregnancy care management policies across facilities—documented here and elsewhere—reflects the absence of regulatory or clinical standards for perinatal care in carceral facilities, resulting in care practices that are heavily dependent on local jurisdictional resources and priorities. Additionally, like findings in the literature, this study revealed no standardized prenatal care management across jails and significant variation in the robustness of pregnancy management protocols. For instance, some jails maintained detailed procedures, while others had limited formalized policies or had no prior experience in implementing pregnancy care management policies. The chronic underfunding and staffing challenges described by jail facilities, particularly related to healthcare, are one factor contributing to variation in pregnancy care management services, while the need to travel long distances to reach healthcare facilities is another. Several interviewees explicitly noted that inadequate funding, staffing shortages, and increasing numbers of incarcerated individuals within their jails hinder their ability to develop or implement comprehensive pregnancy management protocols; this is consistent with reports of increasing jail healthcare costs, including in North Carolina.^44
–46 Despite these challenges in providing prenatal care, jail staff did see the need for alternative placement solutions for pregnancy and SUD care management. While few facilities did mention transfer to prison as an alternative to local care resources, the near universality of challenges in managing pregnancy and SUD suggests that many jails may prefer an alternative to incarceration altogether if it were available.

The high degree of variability in SUD care observed across our qualitative sample also echoes other research demonstrating uneven access to MOUD and exceedingly limited access to non-medication behavioral health services in U.S. jails, including during pregnancy.^23,40 Our findings are also consistent with previously demonstrated geographic disparities in community-based SUD care, with rural jails having fewer resources upon which to draw when providing SUD care within their facilities.^24,40 It is notable that several of the jails in our sample that identified themselves as small, rural, and under-resourced had nonetheless recently implemented in-house buprenorphine programs. This is additional evidence of a trend toward policies allowing for jail-based initiation of MOUD with buprenorphine in pregnancy, rather than simply continuity of pre-incarceration MOUD with either methadone or buprenorphine.^8,23

Our study underscores the need for improved perinatal care practices in North Carolina jails and highlights the ultimate necessity of reducing incarceration for this population. Training jail staff to recognize and respond to the unique needs of pregnant individuals, including perinatal SUD, maternal warning signs and mental health urgencies and emergencies, is essential. When individuals must be incarcerated during pregnancy, our findings suggest that a hybrid model, blending internal and external care, may offer the most practical solution for many facilities, balancing consistency and flexibility to address the diverse and complex pregnancy needs. Ultimately, diversion from incarceration across the entire spectrum of criminal legal system involvement—from pre-arrest to sentencing—is likely necessary to minimize criminal legal system contact for pregnant individuals.^47,48

Standardization of policies governing prenatal care in jails could help reduce disparities in care quality and ensure that all pregnant individuals receive adequate support, regardless of the jail’s resources. Where states have intervened in mandating a specific standard of care, such as MOUD, gaps in care have been successfully closed.⁴⁹ Our analyses of these interviews suggest the following specific policy recommendations:

Prioritization of alternatives to incarceration during pregnancy: Identification of existing programs tailored to the needs of pregnant individuals to reduce rates of incarceration. These programs should incorporate access to prenatal care, SUD treatment, MOUD, mental health services, and parenting support.

Funding support: Mechanisms to support jail funding specific to improving infrastructure and healthcare staff for in-house prenatal care.

Mandatory protocols: Standardization of protocols or establishing an accrediting body for pregnancy management, including detailed guidelines for mental health support and SUD care.

Expanding partnerships: Incentivizing partnerships between jails, community health centers, and community-based organizations to enhance access to prenatal care services.

Monitoring and accountability: Creating mechanisms to monitor compliance with prenatal care standards and hold facilities accountable for lapses in care.

By addressing these gaps, North Carolina can take meaningful steps toward minimizing the potential harms of perinatal incarceration and ensuring that all pregnant individuals have access to the care they need.

Limitations

There are a few limitations to note. First, not all interviews contained the same level of detail regarding pregnancy management in the jail, depending on how interviewees interpreted questions, and the extent to which they provided more information with additional probing. Some interviewees were concerned about confidentiality, which limited what they were willing to share about their facilities. Second, the study involved a small qualitative sample of 26 jails of the 97 jail facilities, which may not have captured all practices and policies of pregnancy management utilized by North Carolina jails. Lastly, the data were self-reported and dependent on the memory and biases of participants, which may have influenced the accuracy and reliability of the data. These factors may mean that some facilities were miscategorized. However, the distribution of facilities across ideal types suggests that our findings are likely robust to occasional miscategorizations in a qualitative sample.

Conclusion

Our study highlights the different ways that North Carolina jails approach prenatal care management, driven by disparities in resources, staffing constraints, and limited standardized protocols. A hybrid model that integrates both internal and external resources may offer a more sustainable solution; however, progress will require increased funding, stronger collaborations with community health providers, integrated care for individuals with SUD, and policy reforms, including state-level guidelines. Ultimately, decreasing incarceration for pregnant individuals is likely to benefit resource-strapped jails and pregnant individuals alike.

Supplemental Material

sj-docx-1-whe-10.1177_17455057261437261 – Supplemental material for Pregnancy management for incarcerated individuals with substance use disorder: Insights from North Carolina jails

Supplemental material, sj-docx-1-whe-10.1177_17455057261437261 for Pregnancy management for incarcerated individuals with substance use disorder: Insights from North Carolina jails by Isabelle Falk, Armani Anderson, Jamie Jackson, Zakiya Stewart, Natalie Satterfield, Essence Hairston, Suzanna Larkin and Andrea K. Knittel in Women's Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057261437261 – Supplemental material for Pregnancy management for incarcerated individuals with substance use disorder: Insights from North Carolina jails

Supplemental material, sj-docx-2-whe-10.1177_17455057261437261 for Pregnancy management for incarcerated individuals with substance use disorder: Insights from North Carolina jails by Isabelle Falk, Armani Anderson, Jamie Jackson, Zakiya Stewart, Natalie Satterfield, Essence Hairston, Suzanna Larkin and Andrea K. Knittel in Women's Health

Footnotes

Acknowledgements

The authors would like to thank Sreya Upputuri, Amaya Wallace, and Olivia Neely for their contributions to the project. Without the generous participation of jail staff across North Carolina, this work would not have been possible.

ORCID iDs

Isabelle Falk

Jamie Jackson

Suzanna Larkin

Andrea K. Knittel

Ethical Considerations

The study was reviewed and approved with a determination on non-human subject research by the Institutional Review Board at the University of North Carolina at Chapel Hill (#22-1508).

Consent to participate

All participants provided verbal informed consent to participate.

Consent for publication

Not applicable.

Author contributions

Isabelle Falk: Data curation; Formal analysis; Writing – original draft; Writing – review & editing.

Armani Anderson: Data curation; Formal analysis; Writing – review & editing.

Jamie Jackson: Project administration; Data curation; Formal analysis; Writing – review & editing.

Zakiya Stewart: Data curation; Formal analysis; Writing – review & editing.

Natalie Satterfield: Writing – review & editing; Data curation.

Essence Hairston: Writing – review & editing; Data curation.

Suzanna Larkin: Writing – original draft; Writing – review & editing.

Andrea Knittel: Conceptualization; Methodology; Formal analysis; Writing – review & editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by a Clinician Scientist Development Award from the Doris Duke Foundation (PI Knittel) and Dr. Knittel’s time was additionally supported by the National Institute of Child Health and Human Development (NICHD) under the University of North Carolina at Chapel Hill Women’s Reproductive Health Research Career Development Program (K12 HD103085, PI Neal Perry).

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Knittel receives travel reimbursement as the American College of Obstetricians and Gynecologists representative to the National Commission on Correctional Health Care Board of Representatives. The other authors have no conflicts to declare.

Data availability statement

The datasets generated and/or analyzed during the current study are not publicly available due to privacy concerns surrounding the richness of qualitative data but are available from the corresponding author upon reasonable request.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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