It was a chilly afternoon in December 2024 when I joined a Zoom call with Pamela Winn. She greeted me with a smile, her voice as gentle as the time I first watched her speak in Atlanta, advocating for pregnant people and women behind bars. It is this work that had led me to Atlanta in 2018, sitting in an audience galvanized by Winn’s words on putting an end to prison births. That December day, she recalled her time serving part of a 78-month federal sentence in a Georgia prison while pregnant.

At six weeks, she was chained around her ankles, hands, and belly, a constraint that led to an accidental fall while stepping into a van for a court date. It wasn’t until 16 weeks of numerous medical requests that prison guards allowed her pregnancy to be evaluated by a medical professional. Unsanitary conditions, lack of air ventilation, unsafe drinking water, expired food, and verbal harassment from guards were things that she and other incarcerated women had no choice but to accept as part of their “punishment.”

Shortly after her medical appointment, Winn started to experience severe cramping and began to bleed. She screamed for hours, and her cellmates banged on the cell door, only to be met with silence. It wasn’t until the early morning that the guards called 911.

At this point in our chat, Winn took a deep breath and recounted, “They shackled me when they found out I was pregnant at intake, and they shackled me again when I went to the hospital.… That’s how I went through the remainder of my miscarriage, shackled to the bed with two male officers refusing to reposition their sight. It was humiliating and dehumanizing.”

The guards reported to the nurses that they had disposed of the remains of her fetus in the trash. Upon her return to prison, Winn was placed in solitary confinement. While her story is not unique, neither is her response to the horrors she endured while incarcerated. 

As a Black woman in the South, Winn was determined to bring the stories of incarcerated women to the center, reflecting the legacy and the labor of love of many Black women activists who have played a significant role in bridging the gaps between reproductive justice and the carceral system. Seven years later, her advocacy has helped lead to key prison reforms, including the First Step Act, which aims to lower federal prison sentences, and the Dignity for Incarcerated Women Act, making shackling and solitary confinement for incarcerated pregnant people and postpartum individuals illegal. “It seems like we’ve made progress,” she said during our Zoom interview, “but nothing really has changed.”

In February 2023, the Senate Subcommittee on Human Rights, led by Georgia Senator Jon Ossoff, launched an investigation into the abuse of pregnant people and women in prisons. The report revealed 200 human rights violations in state prisons and jails. Women who testified to the committee spoke about undergoing obstetrics procedures they did not consent to; spending hours wailing from contractions only to be met with silence; being forced to give birth on cell toilets while male guards watched; being shackled during labor and delivery; being sent straight to solitary confinement just hours after giving birth; and even having had to hear about the death of their babies through a phone. Despite the documented horrors, the hearings were barely covered on national news outlets. 

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One reason for that could be that mass incarceration discourse is heavily male-centered, which often serves to dissipate the existing realities of women and girls behind bars. It not only restricts our collective understanding of how the carceral system serves as a space of re-traumatization, particularly for those who have been subjected to gender-based violence, but also our ability to question the implication of the policies, research, and interventions that have been implemented over the course of five decades. For example, were the constitutional rights protected under Roe ever extended in practice to incarcerated women and pregnant people? Does the Estelle v. Gamble case, which guarantees medical care to all incarcerated people, provide quality medical care? Are there any written policies or guidelines specific to women’s health services like routine STI screenings, gynecological cancer screenings, prenatal care, or abortion care?     

Although women represent just under 10 percent of the 2 million people behind bars, their incarceration rate surpasses that of men. Between 1980 and 2022, the incarceration rate among women and girls increased by 585 percent. Nearly half of these women—44 percent—are in jails. Unlike state- or federally run prisons that hold convicted offenders for one year or longer, jails are county or municipality-run criminal punishment centers where the majority (60 percent) of people are either not convicted of any crime or are awaiting trial.

Over 50 percent of incarcerated women are parents to minor children, and 4 percent are pregnant at the time of incarceration.

In 1994, a group of Black women scholars and activists coined the term “reproductive justice,” which entails (1) the right to have children; (2) the right to not have children; and (3) the right to raise a child in a sustainable and nurturing environment. Mass incarceration violates every pillar of reproductive justice.

It undermines the capacity for women and pregnant people to make decisions about their bodies by limiting or denying access to contraception, abortion services, and pre-and-postnatal care. It also strips incarcerated mothers of their ability to parent and nurture their children by taking newborns away from them—a practice whose roots date to chattel slavery, where enslaved Black and Indigenous women were violently separated from their children as a way to secure the wealth of enslavers.

A setting that was originally designed for men, jails often fail to provide gender-specific services and health care for women. Reports of women in state prison systems suggest that despite the fact that contraception—including emergency contraception—is a frequently requested resource, incarcerated women rarely have access to it. In some states, prisons and jails provided access to permanent contraception, such as sterilization, but not reversible contraception like birth control or condoms. In 2020, 67 clinics across 25 states provided more than 300 abortions to incarcerated people; however, with the Dobbs decision, that number is expected to change. 

Among state prison systems that allow abortions, 68 percent require individuals to pay for their own abortion care. This is not surprising.  One of the testimonies at the Subcommittee hearing was that of Jessica “Drew” Umberger. Umberger was not only subjected to having a cesarean section without her consent but also forced to pay for the procedure.

Incarcerated and formerly incarcerated people in the US have long been excluded from accessing public services and resources, including healthcare. Under the provision of the Medicaid Inmate Exclusion Policy (MIEP), which was passed in part of the 1965 Social Security Amendments, the use of federal Medicaid funds are not allowed to be disbursed for the care of an “inmate of a public institution”—this includes local jails, state prisons, and federal prisons and jails.

Many states have interpreted the exclusion as terminating Medicaid eligibility during incarceration, rather than a change in payment status. As a result, most incarcerated people pay co-pays for medications, medical visits, and other health services, even though women living in poverty represent the majority of the women’s prison population. For example, Pennsylvania pays private vendors $2 billion annually for its carceral system and receives about $400,000 in co-pays from incarcerated people. Moreover, some states charge incarcerated people an average of $5 co-payments for medical care in prisons or jails.

Other barriers from the MIEP include the lack of written policies and guidelines for health services, especially services around women’s health. Numerous incarcerated women and pregnant people have reported feeling dismissed and neglected by their gynecologists. Some have also expressed concern that many providers in prisons are not well trained to provide care. (“They’re like…people who just go out of med school or like people who’s been doing internships. They’re not highly trained…or know a lot of information,” a woman incarcerated at Rikers Island told the American Journal of Public Health in 2015.) Gynecological experiences can retraumatize incarcerated women, since a large percentage of them are survivors of sexual assault outside and inside detention centers, often at the hands of correctional staff. Incarcerated women do not have a choice over the gender of their gynecologist.

Comprehensive written policies on pregnancy and postpartum care vary across states as well as carceral facilities. For example, about 57 percent of New York State jails have policies addressing prenatal care, and none have any policy on labor and delivery. The failure to provide proper care to pregnant people, coupled with prison conditions of insufficient food and confinement, can delay medical care, which in turn causes poor maternal and infant health outcomes.

Such was the case of Tiana Hill, a Black pregnant woman who was detained at Georgia’s Clayton County Jail. At the Senate hearings, she recounted: “Instead of taking me to the doctor, they held me in the jail. I had to lay on a hard metal bed while going through labor pains.… My baby was born premature, in my panties.” Shortly after giving birth, Hill was separated from her baby and taken to solitary confinement. It wasn’t until almost a week later that she got an update that her baby had passed away. The parallels between Hill and Pamela Winn’s experiences are stark, despite their occurring decades apart.

The practice of shackling was also noted in the July report. Today, at least 37 states have some kind of law limiting the shackling of pregnant incarcerated people, a practice that has been repeatedly identified as a violation of human rights and scientifically proven to cause physical and mental health complications, like increased risk of falling, pulmonary embolism, and psychological trauma. Shackling during labor and delivery is also a practice that is highly racialized. With Black birthing people being incarcerated at higher rates compared to their white counterparts, shackling becomes a practice that reflects the historical degradation and “un-mattering” of Black women from chattel slavery to Jim Crow laws to the present Black maternal health crisis. Among developing nations, the US ranks worst on maternal care despite spending the most in healthcare. The significant racial disparities in maternal and infant health make this public health crisis even more alarming.

Sexual health and other gender-specific health services continue to be limited, a shocking revelation when we consider how jails and prisons became an epicenter of the HIV epidemic in the 80s and 90s. State prison data on HIV testing practices during intake in 2021 showed that only 16 states perform mandatory HIV testing. The lack of medications such as pre-and post-exposure prophylaxis (PrEP and PEP), antiretroviral therapy (ART), and contraception in correctional facilities creates a cycle where interrupted care leads to the clinical progression of HIV and viral rebound.

While listening to the testimonies of incarcerated women and pregnant people may be a step forward, it’s as important to understand the historical landscape that has led to the incarceration of so many women and girls in the United States. The link between the criminal punishment system and reproductive coercion and abuse traces its roots to American chattel slavery. In fact, the survival of chattel slavery relied heavily on the reproductive abilities of enslaved Black women and girls.

Legal doctrines such as partus sequitur ventrem, which transferred the enslaved status from mother to child, or the exclusion of Black women in rape statutes are some of the ways the legal system illustrated the US’s dependence on the reproduction of the Black body. Under such legal regimes, white enslavers could sexually assault, impregnate, and victimize enslaved women without any kind of repercussions. In Are Prisons Obsolete?, Angela Davis describes that slave punishment was gendered, where Black enslaved pregnant women were required to lie on the ground with their stomachs positioned in a hole as a way to safeguard the fetus while they were whipped.

White physicians also played a big role in exploiting Black women’s autonomy—from experimenting with medical procedures on their bodies without consent or anesthesia to advocating for the criminalization of abortion and the sterilization of Black women during Jim Crow.

The late 1970s to the early 1990s mark some of the most pivotal turning points in the US penal system, especially for women. President Richard Nixon’s declaration of a “War on Drugs” led to harsher sentencing for minor drug offenses and prioritization of drug arrests across many states. The War on Drugs had a significant impact on women, but especially Black and Hispanic women. Between 1982 and 1991, the sentencing of drug offenders accounted for 55 percent of the increased incarceration rate among women. During this time, the number of Black and Hispanic female drug offenders increased by 828 percent and 328 percent, respectively—a rate much higher than that of white women, 241 percent.

The racial dimension of the War on Drugs, fueled by the media, vilified Black mothers by labeling them as addicts, neglectful, and responsible for a generation of “crack babies” that were portrayed to become “dangerous” in the future. These harmful stereotypes led to differential criminalization and prosecution of Black mothers.      

Punitive drug policies reflect the deep wounds of racialized capitalism, an ideology woven into the fabric of our country for the past 400 years. The lionization of Wall Street’s greedy practices that marked the 1980s was tightly connected to the neoliberal foundation that was laid by Reagan and solidified by Clinton in the 1990s. Neoliberal policies in the 1980s that deregulated unions, reduced the tax rate for the country’s wealthiest families, and destroyed the safety nets created by the New Deal led to severe disinvestment in communities of color. Despite the economic expansion of the 1980s, little of that economic gain “trickled down” to those at the margins of society. 

Economic deprivation is also a major factor among women who engage in sex work. The criminalization of sex work has resulted in arrests of women, who are often victims of sex rings, and not of their abusers. While laws like the Violence Against Women Act created programs to assist victims of harassment, domestic violence, and sexual assault, they also inflicted more violence on survivors by making criminalization the standard response.

The abuse-to-prison pipeline takes multiple forms, such as punishing survivors for self-defense, or taking away their children due to to intimate-partner violence or their engaging in illicit drug use or simply being a sex worker or an immigrant. Overlapping structures of oppression, which are produced and reproduced by sexist, classist, and racist policies, place women, especially women of color, at the nexus of inequities.

The medical mistreatment of women and pregnant people in correctional facilities is a clear example of how the carceral state functions to harm people, not rehabilitate them. Protecting reproductive rights and extending reproductive justice to women and pregnant people involved with the criminal justice system is an issue that will continue to expand along with the carceral state. Cases of abortion-related imprisonment in Texas have already been reported after the state passed one of its “trigger laws” that criminalizes abortion from the point of fertilization.

The dramatically increased use of technology to surveil people’s bodies, especially those under the carceral system, is also alarming. Women on house arrest or parole are subject to being tracked by law enforcement through GPS and audio tracking features of ankle monitors. These surveillance methods, which have been used by the criminal punishment system for decades, can now be used to prosecute people over new “criminal acts,” such as the attempt or the performance of illegal abortions. 

Better laws will help, but, as Winn pointed out, “Data is missing. So, because of that, even though we passed bills like the anti-shackling bill, implementation is horrible.” An investigation by the Prison Policy Initiative shows that while the Bureau of Justice continues monitoring the health of incarcerated people, it either delays its reports or does not publish them. When data is missing, any kind of informed policy is almost impossible. Rigorous research is required on prison healthcare governance in order to fully understand the complexities of how medical care is provided to incarcerated people. How can we implement effective policies if we fail to hold prison governance accountable for their violation of human rights? 

During the time I spoke with Winn, Senator Jon Ossoff introduced the Births in Custody Reporting Act to protect incarcerated pregnant women. The bill encourages states to report data on pregnancy care and birth outcomes for individuals behind bars and those awaiting trial. If states fail to report, they will be penalized by having their federal funding cut. While the bill is promising, it does fail to include concrete solutions. Most concerningly, the bill also fails to amplify the voices of incarcerated or formerly incarcerated people.

Continuing to downplay the concerns of incarcerated women will result in continued patterns of silencing and creating solutions that are neither effective nor equitable. As policymakers, we are often faced with the question, “How do we make prisons better for pregnant people?” However, making prisons better should not be our end goal. Our end goal should be to eliminate the possibility that pregnant people end up in prisons. An abolitionist framework helps us recognize that carceral solutions only bring more targeted carceral tactics to bear on poor communities, Black and brown communities, and immigrants without providing any services or resources that ensure safety.

Abolition provides a broader view of issues we’re concerned with, centering the very people that bear the brunt of the carcerality even when they do not fit the “perfect victim” script, and that they too are deserving of compassion, safety, respect, dignity, and freedom. Instead of relying on neoliberal promises of building better communities, abolition calls us to commit to building and sustaining a collective where we build creative ideas of what care looks like and to whom it should be extended and prioritized. And while no solution is perfect, we must do better in showing up and showing out for incarcerated women and pregnant people.