The Davidson County jail for females: a modern-day crisis center.
DCSO's correctional health services are provided by Nashville's public health department through a contract with Correct Care Solutions, a for-profit correctional health care management company. Of particular challenge to CDFs correctional health providers are gynecological and obstetrical health issues. Women in this population have sex in high-risk circumstances, compounded by a background of mental health problems, substance abuse and inadequate health care. The results include higher rates of unplanned pregnancy, sexually transmitted diseases and children born with significant health problems into broken families.
A 27-year-old black female inmate recently came to the jail and reported that she was 10 weeks pregnant. She admitted that this was her 11th pregnancy and that she had her first child at age 13. Without facial expression or emotion in her voice, she said: "If I lose this one, I have seven others so I'll be fine." Four of her children had already died either before birth or shortly thereafter, and she does not have custody of her seven living children. She has been in and out of the adult system since 2004. Sadly, many women in custody can tell a similar story.
According to research conducted in 2007 at CDF, of the inmates who had been pregnant at least once, 86 percent had at least one unplanned pregnancy--some had as many as nine. On average, 68 percent of female inmates' pregnancies were unplanned, which is significantly higher than the national average of 49 percent. (1) Furthermore, the majority--54 percent--of female inmates stated that all of their pregnancies had been unplanned.
The effects of unprotected sex are tremendous, and the risks may be even greater for female inmates, who are often charged with drug-related offenses. (2) These women are more likely to have had multiple sexual partners in exchange for drugs and to have had unprotected intercourse while under the influence of drugs and/or alcohol. Of greatest concern for the women and for society are sexually transmitted diseases, especially HIV/AIDS, and unplanned pregnancies.
According to the Centers for Disease Control and Prevention, correctional facilities consistently report higher rates of HIV, chlamydia, gonorrhea and syphilis than the general population. (3) In fact, more than 20 percent of HIV-infected people in the U.S. passed through a correctional facility in 1997. (4) HIV/AIDS is of particular concern because it is chronic, life threatening and costly to treat. A 1996 study done in a San Diego jail found that the average daily cost of care for an HIV-infected, injection-drug-using inmate was $51.40, whereas care for a noninfected, noninjection-drug-using inmate cost only $4.10 per day. (5) Black women, who are disproportionately represented in correctional populations, (6) constituted 72 percent of newly reported cases of HIV infection.
Another potentially negative effect of unprotected sex is unintended pregnancies, which can pose significant risks to both the neonate and the mother, especially when they occur under the high-risk circumstance of substance abuse. These risks include higher infant mortality, higher rates of preterm deliveries, lower birth weight, fetal alcohol syndrome, birth defects and pre-eclampsia, which is a life-threatening condition for the mother (7)
Unintended pregnancies among this population also threaten the lives of the children once they are born and the stability of society in general. In a 1999 survey, 2.1 percent of minor children in the U.S. had a parent in prison. This amounts to 1.5 million children with an incarcerated parent--a 50 percent increase from 1991, when a previous survey was conducted. The increase is attributed to the increase in the number of female offenders, a number that has been rising steadily. (8)
Data is not available for parents incarcerated in jails, but these numbers likely compare, as jails and prisons house a similar population of individuals. Based on an informal survey at the CDF, most women report that their children are staying with a relative or are in the custody of the Department of Children's Services. A few have children who stay with the child's father.
Children can be negatively affected by their parent's incarceration. Boys who were separated from a parent due to the parent's incarceration were found to exhibit more anti-social behavior and delinquency in adulthood than their peers, registering greater incidences of criminal convictions, substance use, self-reported delinquency and problems in interpersonal relationships. These negative impacts can be partially attributed to the stigma of having an incarcerated parent, as boys who were separated from their parents for other reasons exhibited less anti-social and delinquent behavior than those who were separated due to parental incarceration. (9)
The challenges of unplanned pregnancies and STDs among female inmates have a direct economic impact on correctional institutions, governments and, ultimately, society. The pregnant inmate discussed earlier experienced pregnancy complications that required a five-day stay in the hospital. She lost the baby and a dilation and curettage had to be performed to remove the contents of her uterus. Prenatal care was financed by the county health department, while her in-hospital care and procedure were provided at Nashville's public hospital--meaning that her care, like that of most other pregnant inmates, was financed by Davidson County taxpayers.
The Correctional Population and Contraception
CDF's 2007 study (10) " identified some major reasons that women in the correctional population do not use contraception. The three most common reasons offered by women indicate a lack of education. Fifty out of 96 women (52 percent) reported that they did not use a method of contraception because they had a consistent partner or they were in love. Women must be educated that there is a place for using contraception, including condoms, even within monogamous and loving relationships, in order to prevent unplanned pregnancies and STD transmission. Concern regarding side effects was a reason given by 39 percent of female inmates surveyed for not using contraception in the past. Finally, 20 percent became pregnant at a time when they did not think pregnancy was possible. Thus, women require more education regarding the low incidence of negative side effects among people who use contraceptives and more individual counseling regarding their personal risks for pregnancy.
There was also a significant correlation between women who responded that they were "very likely" or "somewhat likely" to have unprotected sex within three months of release from jail and women who responded that they "felt sex would be less exciting if birth control was used" and "felt that using birth control would make sex unnatural" as reasons why they had not used birth control in the past. (11) These perceptions must be addressed when educating women about birth control.
Another major factor in the pregnancies and STDs with which female inmates present is substance use. In 40 percent of the 221 unplanned pregnancies characterized in the 2007 study at CDF, women reported that they were high on drugs at conception. In 27 percent of the unplanned pregnancies, women reported being drunk at conception. (12) This makes sense, given the high rates of substance use among incarcerated women. Arrests of women account for 18 percent of total (men and women) drug-related arrests. Almost one in three women incarcerated in state prisons report that they committed the offense for which they are incarcerated "in order to obtain money to support their need for drugs."(13)
Mental illness is another factor that may initiate or complicate the course of substance addiction and may also independently affect women's decisions regarding contraception and prophylaxis. According to Jeff Blum, mental health coordinator for DCSO, about 25 percent of female inmates are being treated for a mental illness with psychotropic medication. Almost all of these women also have a substance use disorder.
Although women did not report this information during the 2007 survey, some staff members at CDF speculate that another major reason that women fail to protect themselves is that they have sex in desperate situations. They deal with the "here and now" and address basic needs as they arise--by any means necessary. If they are hungry, they steal to eat. If they need to feel close to another person or express love, they will have sex with that person. If they need money for drugs, they will have sex. It is really black and white, with very little gray. For many, sex is a means to an end. HIV, pregnancy and STDs are issues that they will deal with if and when they arise.
Educating CDF Women
How can a correctional institution combat these significant physical, mental and psychological barriers to female health and mindful conceptions with better lifelong outcomes? Based on the previously mentioned data and observations, potential solutions include education, satisfaction of women's physical needs, and empowerment of female inmates to set and work toward goals for the future, including preventing unplanned pregnancies and contraction of STDs. Correctional institutions can serve a critical role in arming inmates with these much-needed resources and tools.
Methods of intervention include offering general medical and mental health treatment and rehabilitation for substance abusers; facilitating beneficial relationships between inmates and community-based service providers; and educating women about STDs, pregnancy and contraception. A network of programs at CDF, in collaboration with community organizations, aims to provide these essential resources.
To address the significant problem of substance addiction, CDF offers "New Avenues - Healing Journey," an alcohol and drug treatment program that is supported by a four-year grant from the Edward Byrne Memorial State and Local Law Enforcement Assistance Grant Program. The program was the first licensed alcohol and drug treatment program for women in jail in Tennessee, and women have eagerly participated.
To address educational needs and physical needs like food and shelter, the county health department employs a correctional health services liaison who links inmates with community clinics and other health care resources that may be used upon release. Women receive this information in multiple settings--in groups during informational presentations, one-on-one during release planning sessions and in their release packets. The liaison also coordinates numerous educational presentations by members of community organizations on topics such as contraceptive services, HIV/AIDS support services, cancers that commonly affect women and application processes for health insurance programs. These educational sessions take place within the women's housing areas so that the information is accessible to all women present.
Beyond offering assistance with "here and now" needs, CDF offers an array of programs aimed at empowering women to plan for the future and to make future-oriented decisions. Women voluntarily participate in GED preparation courses, faith-based initiatives and classes on personal hygiene, self-esteem, culinary arts and parenting skills. Recognizing that women with mental illness are particularly vulnerable, DCSO offers "Mind, Body, Spirit," a holistic educational program for women in the special needs pod that addresses issues of physical, mental and spiritual health.
Two significant lessons have been learned from this research and these initiatives. First, many stakeholders are involved in improving these complex reproductive health problems, from the women themselves to the correctional facilities, government funders in the criminal justice and health sectors, and all members of society who support these institutions with their tax money. Second, correctional institutions cannot single-handedly address these issues. The ongoing growth of collaborations with outside agencies is critical to CDF's efforts to bridge the many gaps in resources and services, ensuring that women leave jail better equipped to handle future crises.
(1) Finer, L.B and S.K, Henshaw. 2006. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 38(2):90-96.
(2) Greenfeld, L.A. and T.L. Snell. 1999. Women offenders. Washington, D.C.: U.S. Department of Justice, Bureau of .Justice Statistics.
(3) Centers for Disease Control and Prevention. 2006. STD surveiltance 2005: Persons entering corrections facilities. Available at www.cdc.gov/std/stats05/corrections.htm.
Maruschak, L.M. 2007. HIV in prisons, 2005. Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics.
CDCP. 2006. Trends in reportable sexually transmitted diseases in the United States, 2005. Atlanta: CDC.
CDCP. 2007. HIV/AIDS surveillance report, 2005 edition, vol. 17. Atlanta: CDC.
(4) Hammett, T.M., M.P. Harmon and W. Rhodes. 2002. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. American Journal of Public Health, 92(11): 1789-1795.
(5) Ray, R., K. Stafford, M. Hewett, R. Hernandez and N. Williams. 1996. Medical care costs associated with jail incarceration of people with HIV/AIDS. Paper presented at the International Conference on AIDS, 7-12 July in Vancouver, British Columbia.
(6) Greenfeld, L.A. and T.L. Snell. 1999.
(7) Clarke, J.G., C. Rosengard, J. Rose, M.R. Hebert, M.G. Phipps and M.D. Stein. 2006. Pregnancy attitudes and contraceptive plans among women entering jail. Women and Health, 43(2): 111-130.
(8) Greenfeld, L.A. and T.L. Snell. 1999.
(9) Murray, J. and D.P. Farrington. 2005. Parental imprisonment; Effects on boys' antisocial behaviour and delinquency through the life-course. Journal of Child Psychology and Psychiatry, 46(12):1269-1278.
(10) Kummerow, K.L. 2008. Circumstances of pregnancy among women at an urban jail. Poster presented at the Annual Convention of the American Medical Student Association, 14 March in Houston.
(13) Mumola, C.J. 2000. Incarcerated parents and their children. Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics.
Kristy Kummerow is a second-year medical student at Vanderbilt Medical School. Ruby Joyner, MSSW, is an administrator at the Davidson County Sheriff's Office Correctional Development Center - Female.