Welcome, Jacob Kang-Brown!

Please welcome our new Senior Researcher, Jacob Kang-Brown!

by Danielle Squillante, May 27, 2025

We’re excited to announce that Jacob Kang-Brown has joined our team as a Senior Researcher. In this role, he’ll research and write briefings and reports, help develop new projects, and provide additional support for the research team’s use of large datasets and quantitative analysis.

Before joining Prison Policy Initiative, Jacob was a Senior Researcher at the Vera Institute of Justice where he specialized in analyzing incarceration trends. His work has appeared in The Lancet Public Health, The New York Review of Books, Contexts, SSM-Population Health, The Atlantic, Dissent, USA Today, and American Jail Magazine, in addition to the Vera Institute of Justice. He holds a PhD in Criminology, Law & Society from the University of California, Irvine and bachelor’s degree from Wheaton College (Ill). Jacob has also worked for Physicians for Social Responsibility-Los Angeles and the L.A. County Commission on Human Relations.

Welcome to the team, Jacob!

Policies for waiving medical copays in prisons are not enough to undo the harm caused by charging incarcerated people for health care access

Our review of copay policies show that exemptions are so limited, ill-defined, and inconsistent that they fail to make the copay system less harmful for incarcerated people.

by Emily Widra and Dr. Emily Lupez, May 15, 2025

In most states, people incarcerated in prisons must pay medical “copays,”¹ which are essentially fees to access health care including physician visits, medications, dental treatment, and other health services. While these fees may seem reasonable at two or five dollars, research shows they actually act as barriers to health care for incarcerated people who typically earn less than a dollar an hour, if they are paid at all. Prison administrators claim these fees deter the “overuse and abuse” of limited health care resources,² and have countered critiques by including waivers and exceptions in their copay policies and insisting that no one is denied care because they can’t afford to pay. However, our review of these policies and evidence from a recent study show that these exemptions are so limited, ill-defined, and inconsistent that they fail to make the copay system fairer and less harmful for incarcerated people. Instead, these exemptions lend a veneer of rationality to prison medical fee policies — which are known to limit access to care — ultimately helping to perpetuate them.

We reviewed each state’s prison copay policy, including any waivers or exemptions, to build upon the initial findings of Dr. Lupez and her colleagues, which indicated that copay waivers are likely not working as intended. They found that, despite two-thirds of states that charge copays having chronic condition waivers, people with chronic conditions in states charging copays were substantially more likely to have never seen a doctor since admission compared to those in states without copays.³ If copay waivers were being applied routinely and consistently, we would expect people without a chronic condition (i.e., people ineligible for a chronic condition waiver) to be more likely to have never seen a doctor since incarceration, but this was not the case, implying that these waivers are not promoting healthcare access for some of the most vulnerable people in prison.

In research published in 2024, Dr. Lupez and her colleagues found that among people incarcerated in state prisons for any amount of time, more unaffordable copays were associated with worse access to the necessary healthcare, like obstetrical examinations for pregnant people and seeing a medical provider for people with chronic medical conditions. For more details, see New research links medical copays to reduced healthcare access in prisons.

To better evaluate how copays and copay exemptions function in prison systems, we analyzed policies from all states charging medical copays and the federal Bureau of Prisons. While we cannot estimate the frequency with which care is actually exempt from copays, our analysis of the various policies reveals that copay waivers are inevitably inconsistently⁴ or retroactively applied,⁵ unclear to incarcerated people,⁶ and frequently left up to the discretion of a single healthcare provider, administrator, or other correctional staff.⁷ This helps explain why incarcerated people may expect to be charged a burdensome fee every time they seek medical care, regardless of potential exemptions, and in turn, how that fee functions as a significant barrier to healthcare access.

Key findings from our study of prison copay policies

Almost all state prison systems charging copays have policies outlining exemptions for some healthcare services for some incarcerated people. Among the 40 prison systems still charging these fees, the exemptions can be based on any number of factors including how the care was requested,⁸ the specific health condition,⁹ the type of medical care required,¹⁰ and the circumstances leading to treatment.¹¹ Ultimately, we find that copay waiver policies frequently rely on the discretion of individual healthcare providers or correctional staff and are far too limited and have far too many caveats to meaningfully counteract the harmful deterrent effect of copays on healthcare access.

Below, we highlight the most striking examples from our analysis that illustrate why waivers or exemptions still fail to ensure appropriate and equitable access to the care people need.

Staff-initiated versus patient-requested care. In most states (33), incarcerated people are expected to pay a fee if they request their own medical care, but medical care requested or initiated by healthcare staff, correctional staff, or facility administrators is exempt from fees.¹² In some cases, this reflects standardized or systems-based visits like mandatory tuberculosis testing, which is more aligned with the priorities of the carceral system (i.e., infection control) than patient needs. Staff-initiated visits force incarcerated people to rely on the prison medical system to monitor when preventative care or chronic health condition follow-ups are due, a process likely hindered by staffing shortages and the absence of sufficient medical record systems.¹³ Exemptions for care initiated by correctional staff — such as a request for a mental health evaluation — require incarcerated people to depend on correctional staff to access healthcare services, compromising patient privacy — when medical information has to be shared with non-medical staff — and establishing a system where staff exert control over who gets seen by medical providers, undermining patient autonomy.

Medical emergencies. Only 27 prison systems include an explicit exemption for emergency treatment, and in most of those states, the emergency is defined by either healthcare providers¹⁴ or departmental staff,¹⁵ not the person actually experiencing the medical emergency.¹⁶ In seven states with medical fees, incarcerated people are required to pay the fee for emergency medical care if the injury or illness is determined — by medical staff, correctional staff, or in a disciplinary hearing¹⁷ — to be self-inflicted.¹⁸ An additional two states specify that care provided for self-inflicted injuries are subject to copays (although do not specifically mention emergency medical care). At least one state (Michigan) requires the incarcerated person to pay all costs associated with the treatment of injuries and illnesses determined to be self-inflicted, which is inevitably above and beyond the initial fee for health services; essentially, such policies use medical fees as additional punishment for accidents, self-harm, and mental illness.¹⁹ In our survey of state policies, we only found two states with policies specifying that people with serious mental illness could be exempt from the fees associated with medical care for self-harm²⁰ and only one other state (Texas) that exempts medical treatment for all self-inflicted injuries from medical fees. Policies charging fees for medical care needed for self-inflicted injuries are particularly cruel given the mental health harms caused by incarceration itself. In states that punish self-harm this way, incarcerated people not only have to suffer these injuries — they must also financially pay for them.

Work-related injuries. Almost half of prison systems that charge copays (17) have some exemption for medical care associated with work-related injuries. In some prison systems, only the initial medical treatment for a work-related injury is exempt,²¹ and in others, the treatment for work-related injuries is exempt from the medical fee only if it is a medical emergency.²² In some prison systems, the treatment for work-related injuries is only exempt if it was reported at the time of the injury and is verified by an incident report (filed by correctional staff).²³ Like the exemption for emergency care, this exemption relies entirely on the accuracy and timeliness of staff reporting workplace incidents. It’s also worth noting that incarcerated workers generally do not have the workplace health and safety protections that people do outside of prisons (such as those enforced by the Occupational Safety and Health Administration or similar state programs). They are also often exposed to dangerous work conditions. So it’s remarkable that when incarcerated people are injured under work conditions controlled by the prison system itself, they are often still assessed medical fees and experience lost wages, given the lack of standard labor protections like sick leave.

Chronic health conditions. While most states (26) have exemptions related to care for chronic health conditions like cardiovascular disease, diabetes, HIV, or mental illness, many (17) of these exemptions only apply if the appointment is scheduled by a health care provider or as a part of a recurring “clinic,” not if the individual seeks additional care outside of previously scheduled appointments.²⁴ Someone who meets the exemption criteria may also need to pay copays for the initial two or three nursing sick call visits before clinicians identify them as someone who should be exempt from copays.²⁵ In Alaska, for example, people with chronic conditions are charged a $5.00 fee for their initial provider visit and $5.00 every year “for ongoing treatment of the chronic condition.” At least three states (Georgia, Indiana, and Oklahoma) mention an exemption for fees associated with prescriptions for chronic conditions, but do not exempt chronic condition-related provider visits or other treatments from the fee.²⁶ People in state prisons suffer disproportionately from chronic health conditions when compared to the total U.S. population, and financial barriers to treatment will only exacerbate the poor health outcomes of incarceration.²⁷

Pregnancy-related care. In 18 prison systems, some or all of the care related to pregnancy is exempt from copays. In some states, like Arizona and New Hampshire, they are only exempt from copays for pregnancy-related medical care (i.e., they would not be exempt from copays for treatment for a non-pregnancy-related illness or injury).²⁸ Five states and the federal Bureau of Prisons only exempt prenatal care (care while pregnant) with no mention of delivery-related care or postpartum medical care.²⁹ At least three states explicitly exempt postpartum medical care from copays.³⁰ About 4% of people (or 3,500) in women’s prisons in 2016 — disproportionately women of color — were pregnant at admission, and many of them did not received the basic prenatal care you would expect, like an obstetric exam, medication, special diets, testing, or pregnancy education. Given that many prison systems seem to have limited or no policies exempting pregnant people from medical copays, many may not seek care during their pregnancy. Combined with a lack of robust healthcare resources in prison to identify people in need of care, it’s no wonder many pregnant people are not receiving necessary medical care.

Menstrual health. Only one state’s copay exemption policy makes any mention of menstrual health: in Arizona, people “who require additional feminine hygiene products due to medical issues” can complete a form and submit it to Health Services, and the copay is waived for the subsequent medical appointment. Only half of state prison systems (25) are required by law to provide menstrual products, and only 18 of those systems are obligated to provide those products for free.³¹ Not only do many women have to pay for their menstrual products, but they also must pay for any healthcare related to problems caused by inadequate access to menstrual products. For the more than 85,000 women in prison in 2023, inadequate access to period products and reproductive healthcare can have serious health consequences, and almost every single prison copay policy fails to even address menstrual health.

Substance use. Only eight states and the federal Bureau of Prisons explicitly exempt substance use related healthcare from medical copays. Even when healthcare providers refer people to substance use treatment, incarcerated patients are frequently charged for their initial request for an appointment with the provider, and many incarcerated people may not know how to access treatment without being charged copays and fees. Any perceived barrier to accessing substance use treatment behind bars has serious consequences for the more than half-million people in prison who reported a substance use disorder in the year before their admission.³²

Vaccinations. About one-quarter of prison systems with copays (13) waive them for vaccinations explicitly. Even when vaccinations are exempt from copays, there are often additional caveats: in West Virginia, the waiver only applies to vaccinations and preventative care “provided or made available to all inmates.” While these exemptions may clearly apply to the distribution of the COVID-19 vaccine in 2021, it is unclear how this may play out when an incarcerated person requests a specific vaccine that may not be offered to the entire facility population, like the HPV vaccine,³³ the pneumococcal vaccine,³⁴ or Hepatitis B vaccine.³⁵

In addition to these highlighted findings, we have categorized the state copay policies we found according to the conditions or types of medical care that are exempt (and under what circumstances) and compiled this information in our appendix table.

Conclusion

“Copay” fees for medical care in prison are unaffordable at prison wages. They deter necessary care for an incarcerated population that faces many medical conditions — often at higher rates than national averages — and that routinely receives inadequate health services behind bars. The copay waiver policies ostensibly meant to “fix” this problem of copays deterring necessary care are, in many states, extremely limited with only a handful of care types or medical conditions exempted. Oftentimes, the exemptions are so ill-defined and inconsistent that it is hard to imagine any fair, consistent implementation of these policies. Many incarcerated people may be unaware that such waivers exist at all; even if they are aware, the complexity of the waiver criteria makes it nearly impossible for them to determine whether, when, or how a waiver might apply to their care.

Ultimately, we conclude that these copay exemption policies fail to make the copay system any less harmful for incarcerated people, especially the large number of incarcerated people with chronic medical needs. Instead, these exemptions simply give cover to prison systems that limit access to care and prioritize their bottom lines by imposing medical fees on a largely poor, medically vulnerable population with no other options.³⁶ Rather than tinkering with the edges of these policies through waivers and exemptions, prison systems should drop copays altogether.

WEBINAR: Fighting Jail Expansion: Lessons from the Front Lines

Learn how advocates are responding to shifting arguments for new jail construction.

by Emmett Sanders, May 14, 2025

For decades, calls for new jail construction were largely accompanied by “Tough on Crime” rhetoric that ignored the fact that jails often house the most precariously situated members of our society. While these dehumanizing narratives persist, in many places jail construction has taken a carceral humanist turn that depicts cages as places of care and compassion and the jail as a service provider for those with mental health or substance use support needs.

This is just one of the ways in which arguments for new jail construction have evolved over time, leading communities to spend millions and sometimes even billions of dollars on new jail construction, even as public safety initiatives are being viciously defunded. Fortunately, those on the frontlines who oppose new jail construction have evolved their own arguments and have developed new strategies to push back.

On June 11, 2025, Prison Policy Initiative brought together a panel of activists who have pushed back against jail expansion in communities from Atlanta, Georgia, to Sacramento, California, all the way to Oahu, Hawai’i. We discussed how arguments for new jail construction have shifted over time, went over some useful strategies and tools for responding to these arguments, and talked about how our advocacy department can help support efforts to challenge new jail construction in your area.

Panelists included:

• Carrie Ann Shirota: Policy Director, ACLU-HI with the Reimagining Public Safety in Hawai’i Coalition
• Liz Blum-Gutierrez: Co-founder Decarcerate Sacramento
• Michael Collins: Senior Director of Government Affairs, Color of Change with the Communities Over Cages Coalition

Watch the full webinar:

Webinar Resources

• Webinar Slides

Additional Resources

• Does our county really need a bigger jail? – contains important questions to ask when jail construction is being discussed in your area
• Jail expansion toolkit – offers useful tips for opposing jail construction, including advice on reading jail needs assessments
• If They Build It: Organizing lessons and strategies against carceral infrastructure – lessons learned and recommendations for opposing carceral infrastructure from Community Justice Exchange

Gov. Abbott’s bail proposals would make communities less safe, drain taxpayer dollars, and worsen racial disparities

The proposals before the Texas legislature would dramatically increase the state's already bloated jail populations.

by Sarah Staudt, May 14, 2025

This week in Texas, Governor Greg Abbott and conservative lawmakers are trying to change the state constitution to enshrine the worst features of the current bail system. These proposals, if passed and then approved by voters, would cause a rise in Texas’ already bloated jail populations. As a result, more people will be detained in private prisons out of state, taxpayers will be saddled with huge expenditures, and public safety and public health will get worse.

Disturbingly, proponents of these measures are calling them “bail reform” when in fact they are the exact opposite. “Bail reform” generally refers to the effective policies enacted around the country to make bail processes fairer and to reduce pretrial jail populations. A system of wealth-based detention that determines who should be in jail based on how much money they have in their bank accounts is an illogical and ineffective policy. Efforts to change or eliminate these money bail systems in Illinois, New Jersey, and elsewhere have been highly successful, have not led to rises in crime, and have saved communities countless millions of dollars in bail payments.

Texas conservatives are proposing to do the opposite. The proposals would make it mandatory in many cases for judges to hold people until their trials without bail, and in other cases would require the use of monetary bail in situations where people are currently being released without needing to pay any money. It is vital that Texas legislators and voters oppose these regressive policies, and that activists around the country understand the negative impacts of these kinds of changes to bail systems.

Overusing pretrial jailing undermines fairness and harms public safety and public health

Decades of research shows that growing the pretrial jail population is a mistake that will harm the justice system, public safety, and public health. There is ample evidence that lower jail populations do not harm public safety. Moreover, the overuse of pretrial jailing destabilizes both the individuals who are incarcerated and their communities, stoking the root causes of crime and harming public safety in the long run.

Individuals in custody are affected in a variety of negative ways by pretrial jailing. People incarcerated pretrial are more likely to:

• lose their jobs and experience housing instability;
• commit suicide, and are more likely to overdose after release;
• become re-involved in the criminal legal system in the future, as measured by long-term re-arrest rates;
• fail to appear in court;
• be convicted and be sentenced to longer jail and prison terms, worsening prison overcrowding and mass incarceration as a whole.

Overuse of pretrial jailing also harms the fairness of the criminal legal system as a whole by worsening racial disparities and disproportionately impacting women. People in poverty and Black and brown people are less likely to be able to afford bail, and bails are set at higher rates for Black and Latino people. Women are also less likely to be able to afford monetary bail when it is set (even though bail is set at lower amounts for them). Black people are less likely to be released on their own recognizance and more likely to be detained without bail. Texas already imprisons Black people in jails at disproportionate rates, and expanding pretrial jailing is likely to worsen that problem.

A deeper dive into the regressive bail package

The package of regressive measures being pushed in the Texas legislature consists of three parts (known as SJR 5, SB 9 and HB 75, and SJR 1). The exact language of these measures has been changing daily, but the core problems of each provision remain the same.

SJR 5 expands no-bail jailing without due process

SJR 5 would change the Texas constitution to allow detention without monetary bail for a wide variety of charges. The United States Supreme Court has been clear for decades that detention before trial, particularly without bail, should be a “carefully limited exception.” The federal government and states that have reduced or eliminated monetary bail, like Illinois and New Jersey, have tried to ensure that no-bail detention is “carefully limited” by restricting the charges for which it can be used and enshrining important due process protections in the law. However, Texas’ recent proposals would expand jailing without these careful limitations.

Although the exact provisions of SJR 5 are changing almost daily, many of the drafts have lacked key due process protections. It is vital that any version of SJR 5 that advances includes basic provisions that ensure that detention decisions are fairly made and that jail is only used as a last resort. Some of those key provisions would include:

• Limiting the availability of no-bail detention only to serious, violent cases, rather than allowing it in broader categories of charges;
• Ensuring that everyone who may be jailed without bail has access to counsel.
• Ensuring that prosecutors be held to a high standard of proof that a person will pose a danger to others — “clear and convincing” evidence, rather than simply a “preponderance” of evidence.
• Requiring that detention based solely on risk of fleeing the jurisdiction hinges on whether someone is likely to willfully flee prosecution. If no-bail detention is allowed based solely on whether someone is likely not to appear in court through no fault of their own, it will increase the unnecessary detention of poor and unhoused people, who sometimes struggle to find transportation and other resources necessary to appear for their court dates.
• Requiring that jail only be used if there is no less restrictive set of conditions that could protect the public. No-bail jailing should always be a last resort, and should only be used if there are no other alternatives.

Without these key due process protections, increasing no-bail detention is likely to lead to more people being held in jail longer, increasing jail populations without improving public safety.

SB 9 and HB 75 entrench the use of monetary bail

While SJR 5 seeks to increase the number of people held without bail, SB 9 and HB 75 seek to use monetary bail even more often than it’s currently being used. These bills would undo progress that has been made in reducing the use of monetary bail in Texas localities like Harris County.

SB 9 and HB 75 would require the use of money bail in many cases, including misdemeanors. Currently, people are often released on these charges without having to pay money. A particularly disturbing set of cases included in SB 9 and HB 75 are so-called “terroristic threat” cases. Although these charges sound very serious, they actually include any threat to people or property that causes an official or volunteer emergency agency to respond. This can include misdemeanors that often are charged against school-aged children because of social media posts. Including these non-violent charges in the set of charges where money bail will be required will do nothing to improve public safety — but it will ensure that poorer accused people are stuck in jail more often.

These bills also create procedural barriers that will prevent people from being released pretrial in a timely fashion. As we have noted, even one day in jail can lead to a range of negative outcomes. First, the proposals restrict the ability of magistrates and law hearing officers to set bail, and these kinds of decision makers play a key role in how large municipalities make bail decisions quickly. Second, it allows prosecutors to unilaterally prolong detention even when a judge intended to set an affordable bail. Prosecutors would be allowed to appeal these decisions, claiming that bail was set too low, and strand people in custody while the appeal is pending.

SJR 1 targets immigrants with mandatory jailing

The last provision in this regressive bail package combines the harms of the immigration system with the harms of the criminal legal system, requiring no bail detention for a group of people the proposal refers to as “illegal aliens.” The definition of “illegal aliens” has changed in various drafts of the proposal, but includes DACA recipients (so-called “dreamers” who entered the United States as children) and asylum seekers. Because criminal legal system statistics are not broken up by immigration status, it is impossible to estimate how many people this will affect, but it will certainly have a disproportionate impact on Texas’ Latino residents.

Because the proposal requires detention even in non-violent cases, judges will be barred from considering individual facts and circumstances. As a result, they will end up detaining people who do not pose a threat to anyone or who are charged with weak cases that are unlikely to lead to a conviction. Even when a judge decides that a person can be safely released to await trial in the community, the law will overrule that judgment and require them to send the accused person to jail. In other words, the measure ties the hands of the very people who are entrusted with the responsibility of ensuring that the criminal legal system is administered fairly. Judges hearing individual cases — not legislators in Austin — should make these decisions.

SJR 1 would also unnecessarily burden Texas taxpayers and local governments with the cost of incarcerating undocumented people who, under current law, would instead be detained by the federal government. Under federal law, many undocumented people charged with a wide variety of crimes are already required to be held in immigration detention. By requiring no-bail detention in their criminal cases as well, SJR 1 shifts the burdens and costs of incarcerating those people from the federal government to local jails — all without providing any additional funding to localities to absorb these costs.

Regressive bail policies will worsen Texas’ already out-of-control pretrial jailing crisis

Texas cannot afford to adopt these regressive policies. The state is already well above the national average for incarceration rates overall, and its pretrial jail population has been rising steadily for decades. This creates a serious overcrowding problem in Texas jails; 41% of Texas counties already send incarcerated people to other counties or states while awaiting trial. Harris County alone spends more than $50 million per year on out-of-state jail contracts. These expensive arrangements are often made with private prison companies, costing Texas taxpayers more money while enriching private corporations. To be clear, this problem cannot be solved by building bigger jail facilities — in most cases, it is a lack of staff, not a lack of bed space, that leads counties to outsource pretrial incarceration.

Expanding pretrial jailing will also cost lives. Deaths in jails are on the rise across Texas, and the situation is worsened when people are sent out of state, since those facilities do not have to follow standards set by the Texas Commission on Jail Standards, nor do they have to follow death reporting and investigation rules.

Lawmakers are voting on these proposals in the next few days, and there are real opportunities to stop them from moving forward, or to push for important revisions that strengthen due process protections. There will also be an opportunity for Texans to voice their opposition to SJR 5 and SJR 1 at the polls if they do advance past the legislature. Texas deserves true reform measures that seek to reduce harmful pretrial jailing, rather than so-called “tough-on-crime,” anti-immigrant measures masquerading as “bail reform”.

New data on pregnancy prevalence, outcomes, and programs in prisons are welcome additions, but raise new questions

The Bureau of Justice Statistics published 2023 data on pregnancy prevalence and outcomes in prisons, as well as the prison systems that offer relevant prenatal and postnatal accommodations, supports, and programming.

by Emily Widra and Emmett Sanders, May 7, 2025

A new Bureau of Justice Statistics report offers updated data on pregnancy among people in state and federal prisons. This important new dataset includes the prevalence of pregnancy among incarcerated people, pregnancy outcomes, and some limited data on the types of services, medical care, and support offered to incarcerated pregnant people. The findings from Maternal Healthcare and Pregnancy Prevalence and Outcomes in Prisons, 2023 are based on data collected for the first time in 2024 as a supplement to the annual National Prisoner Statistics survey. While this report is a welcome contribution to a shamefully understudied experience during incarceration, the data it provides raises almost as many questions as it answers.

Women’s incarceration has grown at twice the pace of men’s incarceration in recent decades but there is often too little data to explain this growth or to elaborate the specific effects incarceration has on women and their health, including their experience of pregnancy.¹ Previously, the most recent national data on pregnancy in prisons from the Bureau of Justice Statistics was collected in the Survey of Prison Inmates in 2016 and was published in 2021. Since then, researchers from Johns Hopkins University collected detailed data on pregnancy outcomes in a smaller set of 22 state prison systems and the federal Bureau of Prisons from 2016 to 2017 as part of the Pregnancy in Prison Statistics (PIPS) study. Even though the PIPS study covered only about half of state prison systems surveyed by the Bureau of Justice Statistics, the findings offered a closer look at pregnancy outcomes in prison than were available from the Survey of Prison Inmates. In this new publication, the Bureau of Justice Statistics surveyed 50 state departments of corrections and the federal Bureau of Prisons regarding:

1. the number of pregnancy tests provided and found positive upon admission to prison,
2. the number of pregnant people in prison at year-end,
3. the outcomes of the more than 700 pregnancies that ended in prison in 2023, and
4. the availability of specific kinds of pre- and post-natal support across jurisdictions.

Yet the data raises a series of new questions. There are unexplained differences in the prevalence of pregnancy behind bars compared to the PIPS report, as well as a lack of basic data on the outcomes of live births, and a failure to report how often pregnancy-related services and accommodations are actually used. The report also helpfully touches on services like prison nursery programs; however, crucial details about their implementation are left out — a gap we attempt to fill in this briefing using our own research. This new report is a step in the right direction, but much more work needs to be done to provide an accurate and useful portrait of pregnancy in prison.

Fewer people in prison report being pregnant when entering prison

The prevalence of pregnancy in prisons is measured in two ways: the number of pregnant people admitted to prison over the course of the year and the number of pregnant people in prison on a single day. The Bureau of Justice Statistics reports that 2% of women tested upon admission were pregnant in 2023.² This is surprisingly low compared to findings from previous data collection. In 2016, twice as many women (4%) admitted to prison each month were pregnant, according to the Pregnancy in Prison Statistics (PIPS) study. Past surveys from the Bureau of Justice Statistics that asked incarcerated women whether they were pregnant at admission (regardless of what year they were admitted) also found higher rates, from 6% in 1991 to about 4% in 2016. While the PIPS project surveyed only 22 state prison systems, it seems unlikely that this difference in the sample would explain the inconsistency in the data.³

We see this same issue in the point-in-time count of incarcerated pregnant people. According to the Bureau of Justice Statistics, on a single day in 2023 , there were 328 pregnant people in state (0.5%) and federal (0.3%) prisons, representing a total of 0.5% of all women in prison. This is much lower than we would expect based on the 2016 Pregnancy in Prison Statistics (PIPS) data, which found there were 350 pregnant people in just the smaller group of state (0.7%) and federal (0.3%) prisons they surveyed, for a total of 0.6% of the combined prison population. In other words, the actual number of pregnant incarcerated people was higher in the PIPS report that covered half as many state prison systems (22 states) as the Bureau of Justice Statistics report. It’s unclear what accounts for this substantial difference in the datasets.

The new Bureau of Justice Statistics report also offers new data on the race and ethnicity of pregnant people in prison on a single day. Compared to the overall population of women in prison,⁴ white, Black, American Indian and Alaska Native, and Asian women are overrepresented in the population of pregnant people in 2023. Meanwhile, Hispanic and “other” women were underrepresented.

Certainly, some decline in the number of pregnant people in prison could be expected, given that the national pregnancy rate in the United States has been steadily falling over the past two decades.⁵ However, this trend does not explain the dramatic reduction in the number of pregnant women in prison between the PIPS 2016 study and the Bureau of Justice Statistics’ 2023 report. Given the limited data available, we do not have any clear understanding of why there are so many fewer pregnant people reported in this Bureau of Justice Statistics publication.

First national data on pregnancy outcomes in prisons

This Bureau of Justice Statistics report is significant in that it offers the first national data on pregnancy outcomes in prisons — a welcome if overdue development. More than 700 pregnancies ended while the mother was in custody in 2023, and almost all of these were live births (91.5%),⁶ with 6.5% ending in miscarriage and 2.1% ending in abortion.⁷ Additionally, there were four stillbirths and ectopic pregnancies. These percentages are largely consistent with the outcomes of pregnancies reported in the Pregnancy in Prison Statistics (PIPS) study from 2016, however the counts are once again surprisingly low: in 2016, PIPS found 816 pregnancies ended in 22 state prison systems and the federal Bureau of Prisons, but in 2023, the Bureau of Justice Statistics reported 89 fewer pregnancies ending in prison (727 total) across the federal system and 48 state departments of correction.

Nationally, data on pregnancy outcomes regularly includes information about the outcomes of live births, including if they were preterm, early term, C-sections, or low birthweight, as well as if there was neonatal death (within 28 days) or maternal death following the birth. Although the U.S. Centers for Disease Control and Prevention regularly collects and publishes these data for non-incarcerated people, the Bureau of Justice Statistics survey did not request this information from correctional authorities, despite our recommendation during the public comment period. Basic national statistics on pregnancy in prison can and should include these outcomes. Elevated rates of chronic and infectious diseases – as well as substance use disorders – and limited access to necessary healthcare among incarcerated people make more detailed data about live births critical to understanding the experience of pregnancy in prison. Such data can also inform the interventions and medical treatments required to promote health before, during, and after birth for this population.

Some prisons fail to provide even the most basic prenatal and postnatal care

Pregnancy poses a number of short-term and long-term risks to health. Globally, the United States has one of the highest rates of pregnancy-related complications among developed nations,⁸ with a disproportionate burden falling upon women of color and low-income women.⁹ Addressing such risks is particularly important in prisons, where women already face higher rates of chronic health conditions, substance use disorders, and mental health conditions, as well as a history of poor healthcare access. Decarceration is the most important tool we have to address these risks, however as long as our society incarcerates pregnant people, prisons must be prepared and equipped to provide them with adequate healthcare and support before, during, and after delivery.

Most prison systems reported they train staff to care for pregnant people (88%) and have an onsite infirmary (96%) or 24/7 or on-call medical care (98%). The majority of prison systems also reported that they provide medical appointments to pregnant people within two weeks of a positive test (96%), routinely throughout the pregnancy (100%), and within three weeks of delivery (96%). Prison systems claimed that these services are available, however there is no information in the report about their actual utilization. Does every pregnant person have an appointment within two weeks of a positive pregnancy test and within three weeks of delivery? Do all staff receive training regarding pregnancy, or only healthcare staff? These questions are arguably more important than whether these services and practices technically exist.

It is particularly troubling that six state prison systems (Alaska, Hawaii, Iowa, Maine, Nevada, and Washington) reported that they do not provide any staff training regarding pregnant people in prison. No state prison system is immune from admitting a pregnant person, and these six states accounted for around 5% of the almost 50,000 women admitted to prison in 2021.¹⁰ At the very least, corrections and healthcare staff should receive training regarding emergency responses that may be required with a pregnancy.

Postpartum depression is another serious risk facing pregnant people. Nationally, postpartum depression diagnosis rates have been climbing: across all racial and ethnic groups, the rate of diagnosis increased from 9% in 2010 to 19% in 2021. Undoubtedly, this trend persists behind bars, where women face a number of risk-factors for postpartum depression. This includes previous mental illness diagnosis,¹¹ a lack of social support, poor prenatal and perinatal healthcare, separation from the newborn, and experiencing partner violence. In one study of 58 people who gave birth while in prison, researchers found that more than one-third of participants met the diagnostic criteria for moderate to severe depression during pregnancy or postpartum. Yet four state prison systems (Alabama, Iowa, Massachusetts, and Washington) said they do not provide depression screenings during pregnancy or postpartum. Not screening for depression at all during pregnancy and the postpartum period is a failure to meet the most basic standards of pregnancy-related care.

The Bureau of Justice Statistics report also provides information about which state prison systems provide certain accommodations and support services to people before and after delivery. Prison systems universally reported furnishing at least two accommodations for pregnant people: lower bunk placement¹² and prenatal vitamins.¹³ Most (but not all) prison systems offer a special diet during pregnancy (86%) and consultation with social workers (92%) or psychologists (88%). Prenatal diets require increased calories and a particular balance of nutrients that are likely not met by the typical prison diet. Accessible, appropriate mental health services for pregnant people behind bars are also vitally important, and most standards for pregnancy-related health care in correctional settings emphasize the need for counseling and psychosocial support.

Other extremely basic accommodations are less common in prison systems. These include a special postpartum diet (60%), doula support (35%),¹⁴ extra pillows during pregnancy (69%), and breast pumps (78%). These relatively simple interventions can have a tremendous impact during pregnancy and postpartum. For instance, the recommended postpartum diet is associated with fewer symptoms of postpartum depression and can positively impact infant health. People in prison are regularly issued only one pillow, but pregnant people may require more to be comfortable and avoid sleep deprivation, which has been associated with longer labor, elevated perception of pain and discomfort during labor, higher cesarean rates, preterm labor, and other adverse outcomes. While policies may be in place for breast pumping accommodations in most prison systems, the actual accessibility and utilization of breast pumps may be a different story. Some prison systems operate lactation programs that allow incarcerated people to pump breast milk for their babies. However, these programs often have onerous requirements for the incarcerated person’s friends and family, who have to apply for approval to visit and collect the milk. In Florida, for example, incarcerated people are only eligible for this program if there is an approved guardian for the child and the child is not placed in state custody. Reports suggest that when there is no lactation or pumping program, incarcerated people are sometimes not allowed to breastfeed after giving birth,¹⁵ and are not provided with anything to help manage an unused milk supply or information about what to expect.

It’s undoubtedly helpful to know which jurisdictions offer these services, but there is once again no information regarding their actual utilization. In 2016, self-reported data from incarcerated people revealed that half of people pregnant upon admission had not received prenatal care in the form of special testing, dietary changes, or childcare instruction. It’s great that prison systems have policies in place to provide these necessary services, but it is not clear at all how they are being implemented and how many pregnant people actually receive them.

Only 11 states and the federal system operate prison nursery programs where newborns can reside with their parents in custody

The Bureau of Justice Statistics reported that ten states and the federal Bureau of Prisons run prison nursery programs, which are residential programs where people can live with their newborns. Although reducing the incarceration of pregnant people is the best approach to this issue, prison nurseries can be another option that allows incarcerated mothers to avoid separation, and to be with and care for their newborn children. Since the data collection period ended for this report, an eleventh state — Missouri — opened their prison nursery program. Even though there were 665 live births in prisons across the U.S. in 2023, only 86 people were participating in prison nursery programs at the end of the year. In Nebraska and West Virginia, there were no nursery program participants at the end of the year.

There are a number of details about these prison nursery programs lacking in the Bureau of Justice Statistics report. For example, how many people participate in the programs each year and for how long? What programming is available to the participants while in the nursery program? How is eligibility determined for participating in these programs? Again, while data on the number of nurseries is helpful, it’s arguably more important to know how they are being used. So, to better understand how prison nursery programs actually work, we looked at the eligibility requirements and restrictions for prison nursery programs in 11 states and the federal Bureau of Prisons.

We found that in all but one of the prison nursery programs, participation requires release dates within 12 to 36 months of the expected delivery date.¹⁶ A number of factors can influence eligibility, including offense types, prison disciplinary history, medical or mental health status, prior Child Protective Services involvement, and prison security designation or classification. In Illinois, for example, any child that requires “more than normal well child health care” or any parent requiring “more than normal” prenatal or postnatal care can be excluded from the program. In California, Illinois, Indiana, Ohio, and West Virginia, the incarcerated mother must have sole legal custody of the child. To our knowledge, there are no data available about how often a child born to an incarcerated parent remains in their custody, but there is historical evidence to suggest that this is likely rare, or at the very least, complicated.

Eligibility requirements and considerations for prison nursery programs

Unfortunately, because the Bureau of Justice Statistics report does not include information on the sentence length, offense type, prior convictions, or classification status of pregnant people in prison, it is difficult to estimate how many pregnant people in prison would be eligible for these programs. These potentially beneficial programs are a vast improvement over the common practice of simply removing newborn children from their parent at birth.¹⁷ However, access to nurseries is still seriously limited, and ultimately, the best option would be to implement caregiver mitigation and diversion laws and prevent the incarceration of pregnant people.

Conclusion

This Bureau of Justice Statistics maternal healthcare report marks an important step toward filling the huge data gap regarding the incarceration of pregnant people in prisons. Given their particular healthcare needs and the challenges to a healthy pregnancy imposed by the prison environment, these data can help inform interventions that lead to better outcomes for incarcerated pregnant people. Although the data answer some of our initial questions about how many pregnant people enter prison and what jurisdictions have policies offering specific supports, significant questions remain. In addition to getting to the bottom of why the findings in the Pregnancy in Prison Statistics study differ so substantially from the Bureau of Justice Statistics survey, future researchers can make important contributions by answering questions such as:

1. What are the trends in pregnancy in prison over time? Why are these estimates of the prevalence of pregnancy in prison lower than prior estimates?
2. How many people actually receive the services that these jurisdictions report offering?
3. What barriers do prison systems face in providing the most basic prenatal and postnatal care, like depression screenings?
4. Why are so many pregnant people incarcerated (i.e, for what offenses) and for how long (i.e., sentence length)?
5. What are the outcomes of the live births counted in this report (i.e., preterm, early term, C-sections, low birthweight)? What are the rates of neonatal death and maternal death among this population?

Data on maternal healthcare and pregnancy outcomes should continue to be collected and published on a regular basis by the Bureau of Justice Statistics. Doing so — especially in greater detail — would shed light on an important and understudied healthcare experience in prison.