“My worst day in jail is better than my best day on the streets.” Kima, a spunky woman in her early 30s, told me this several times as we sat together in jail while she was pregnant. At the time, in 2012, I was working as an ob/gyn, and conducting research on the experiences of pregnant women and their caregivers in jail. Every time I heard Kima say this, my heart sank. It was troubling to think of how hard this expectant mother’s life on the streets must be if jail was better. Kima was not a violent criminal; she suffered abuse, neglectful parents, unstable housing, poverty, and poor education opportunities, all of which contributed to her struggles with drug addiction. She was in jail three different times during her pregnancy — all for non-violent, petty offenses, including shoplifting some soap from a CVS — and jail was the only place she was able to access prenatal care. “I didn’t want to mess up this baby,” she told me one day.



Because of a 1976 Supreme Court case, prisons and jails are constitutionally mandated to provide health care to incarcerated persons. For some people like Kima, jail and prisons are one of the few places they can reliably access health care, including prenatal care. Levels of care vary widely because there are no standards — some jails and prisons provide routine prenatal visits, ultrasounds and blood tests, and prenatal vitamins, while others provide base-level checkups without adequate nutrition and force women addicted to opiates to detox (despite the known risks to the pregnancy). One report found that 38 states had nonexistent or insufficient prenatal care protocols.

Still, any health care is better than none when you’re pregnant. I got to know another woman, Evelyn, during her pregnancy in and out of jail, who told me that at one point of desperation in her third trimester, she turned herself in to the cops on the street corner. “I just wanted to be in jail,” she said. “I knew that I could eat, I could sleep, and that even if it’s not the best of medical care, I was going to get some type of care.” I spoke with nearly 20 pregnant women in jail while researching my forthcoming book, and for more than half of them, jail was the only place they got prenatal care.

The Affordable Care Act (ACA) seeks to change that. The ACA has expanded health-care coverage for over 20 million people and has had especially positive implications for incarcerated people. Before the ACA, many people struggling with poverty or unemployment — including those just released from prison or jail — did not have health insurance but also did not meet eligibility for Medicaid. The ACA's expansion of Medicaid (at least in some states) "provides an historic opportunity to improve health insurance coverage for correctional populations postrelease, to improve access to needed medical and behavioral treatment, and potentially to reduce costly recidivism," according to the National Commission on Correctional Healthcare. Some prisons and jails have even implemented programs to get people signed up for ACA-subsidized health exchanges while they are in custody, so their insurance goes into effect soon after they are released, and fewer people have to rely on prison or jail as their sole source of medical care. The ACA also ruled out pregnancy as a pre-existing condition, which helps low-income pregnant women get insurance coverage for prenatal care so they can get it outside of jail. And women like Kima and Evelyn also have access to affordable contraception at community clinics after their release, so they can choose when or if they want to be pregnant again, thanks to the ACA’s contraceptive mandate.

But of course all this is poised to change with the Trump administration's effort to repeal the ACA with no replacement plan, let alone one that would try to address racial, economic, and gender inequalities. Their recklessness threatens the health of millions of people, but especially our most vulnerable populations: poor women, young women, incarcerated women. Women without health-care coverage are more likely to have unintended pregnancies, and, when they are pregnant, are less likely to get prenatal care with resulting higher rates of preterm birth, stillbirths, and other complications.

Evelyn and Kima did not want to be in jail. They wanted have healthy pregnancies with good prenatal care, a place to live, and food to eat so they could deliver and raise healthy babies. And post-incarceration health-care coverage offers such opportunities. But if the help they and their babies receive from the ACA disappears, jail will likely, again, become the main place where they are able to access health care — and it may become the place their children grow up to go as well. We cannot let this cycle persist. We can do better for Kima, Evelyn, their children, and all people in this country.

Carolyn Sufrin, MD, PhD, is an obstetrician-gynecologist and medical anthropologist at Johns Hopkins University, and a fellow with Physicians for Reproductive Health. You can read more about Kima, Evelyn, and other women like them in her forthcoming book with University of California Press, Jailcare: Finding the Safety Net for Women Behind Bars.

Raakhee Mirchandani Raakhee Mirchandani is a writer, editor and hairspray enthusiast.

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