Health Problem Addressed by the Case

The number of women incarcerated in the United States has increased by more than 600% over the past three decades. By 2009, more than 198,000 women were incarcerated in US prisons and jails, with the highest rate among individuals with racial and ethnic minority backgrounds [Reference Glaze and Maruschak12]. Most of the women are of reproductive age, and thousands are either pregnant when they enter prison or have recently given birth [Reference Sufrin, Beal, Clarke, Jones and Mosher2,Reference Sufrin, Jones, Mosher and Beal13]. By 2019, 80% of the 231,000 incarcerated women were mothers, and most of them were the main caregivers of their children [Reference Kajstura14].

Physical (e.g., chronic conditions and infectious diseases) and mental health problems (e.g., depression and substance abuse) are more common among people in prison than in the general population [Reference Fazel and Baillargeon15]. In most states, incarcerated women typically give birth in a local hospital and are returned to the prison, while their babies are taken in by relatives or the state’s foster care system.

Research studies of health disparities in prisons were rare at the time of the featured research’s planning and implementation. In a systematic review of perinatal health care services for incarcerated pregnant women, researchers identified only six studies published in the international literature between 1980–2014 that described practices aimed at improving conditions of care: doulas (birth companions) supporting pregnant prisoners before, during, and after birth; enhanced prenatal care provided for all pregnant prisoners; and outreach workers identifying incarcerated women at risk of giving birth to an HIV-positive or substance-exposed infant and linking these women to prenatal care [Reference Bard, Knight and Plugge16]. A more recent systematic review found only five studies published since 2014 that examined incarcerated pregnant women’s needs, including quality prenatal care, education on pregnancy, childbirth and parenting, nutrition, and substance abuse management [Reference Alirezaei and Latifnejad Roudsari17].

Key People and Partnerships Engaged in the Research

From August 2011 to January 2013, Dr. Rebecca Shlafer (at that time an assistant professor in the University of Minnesota Department of Pediatrics) and Erica Gerrity (co-founder of the local non-profit Everyday Miracles) conducted a pilot research project funded by the UMN Clinical and Translational Science Institute (“Health Disparities in the Context of a Parenting and Pregnancy Support Program for Incarcerated Mothers Project”) [Reference Shlafer and Gerrity18]. This community-university collaboration was formed out of a serendipitous meeting between UMN researchers and practitioners at the Everyday Miracles’ Isis Rising (currently the Minnesota Prison Doula Project, MnPDP), a prison-based parenting, pregnancy, and birth program for women serving time at the Minnesota Correctional Facility-Shakopee. Isis Rising provided the expertise to implement the program within the prison, while the academic researchers provided skills needed to empirically investigate health needs of the participants. Key project staff included Dr. Rebecca Shlafer (co-PI) and one graduate research assistant from the University of Minnesota; Erica Gerrity, MSW (co-PI), two Isis Rising project coordinators and five group facilitators. Prior to the research, Dr. Shlafer was a UMN postdoctoral fellow in the Department of Pediatrics, with Ph.D. in child psychology and experience of working with children of incarcerated parents. The community group was led by the other co-PI, Erica Gerrity, an experienced clinical social worker working with mothers and children.

Research Aims, Methodology, and Results

The pilot project was intended to document physical and mental health needs of women in the Shakopee Prison and evaluate impact and health outcomes of the MnPDP program – providing scientific evidence informing future programming and policies affecting incarcerated women in Minnesota [Reference Shlafer and Gerrity18]. The first program component, a 12-week New Moms Group, was available to women who were pregnant, had given birth recently, or were parenting children under 5 years of age. Weekly, two-hour group sessions were facilitated by a doula (a trained, experienced, nonmedical professional who provides physical, emotional, and informational support to the mother before, during, and just after birth). In the second component, the Doula Program, pregnant women could meet with a doula individually to discuss prenatal education and birth planning. The doula met a laboring woman at the local hospital and stayed with her throughout the labor, birth, and postpartum.

To address the research aims, both qualitative and quantitative assessments were done before, during, and after program participation. All participants were asked to complete pre- and post-surveys about their current physical and mental health, the type and quality of prenatal care they received, and their satisfaction with the labor and delivery process. Doulas shared case notes, information collected at group sessions, a birth inventory that documented the mother and baby’s health status and interventions used. Doulas also completed a post-birth survey about their perspectives of the birth experience.

Out of the 40 participants in the New Moms Group, 11 (age ranging 21–40) were pregnant and matched with a doula in the Doula Program. Participants commonly reported mental and physical health concerns. In evaluation surveys, they reported a decrease in depressive symptoms, more confidence as a parent, receiving more support from other women and from prison staff at the end of the program than they did on the initial survey. The analysis of the participant surveys and doulas’ written reports of the mothers’ birth stories identified four key themes: care and emotional support, empowerment, collaborations with corrections staff, and normalizing and validating the birth [Reference Shlafer and Gerrity19]. The project results suggested that providing doula care might improve birth weight and maternal mental health outcomes, lower rates of cesarean delivery and complications, and save taxpayer dollars [20].

Table 1 outlines a summary of the case study elements and their characteristics that are further described in different sections of this manuscript.

Research Impact Contributions to Health Care, Policy, Research, and Social Justice

Impacts of the case align with the following TSBM and other areas and indicators (presented in italics), including demonstrated benefits (those that have been observed and are verifiable) and potential benefits (those logically expected with moderate to high confidence).

Community and public health translational benefits included improved health care characteristics (health care accessibility, health care delivery, and quality) and health promotion (quality of life). Incarcerated women reported higher levels of support from program staff, more parenting confidence, more support from other inmates, and more support from prison staff after their participation in the weekly support group. All doulas reported that they were able to establish a trusting relationship, normalize the delivery, empower, and provide physical, emotional, and informational support to the women during their labor, delivery, and recovery [Reference Shlafer, Gerrity and Duwe21]. Fitting the benefit category of health activities and products (community health services and health education resources), the researchers translated their research into resources and activities, such as a Pregnancy Resource Guide for Incarcerated Mothers, a webinar about how to create a prison doula program, and trainings with the Department of Corrections (DOC) in MN and other states [22]. The research also influenced programmatic activities of the MnPDP, which developed the Prison Birth Storytelling Project featuring online booklets, video series, and podcast series highlighting diverse experiences of women who give birth while incarcerated [Reference Terrill23].

Bolstered by the research, by 2016 the MnPDP served women in eight county jails and one prison for women. For the state prison alone, between November 2010 and December 2020, there were 160 births supported by doulas (Rae Baker, e-mail communication, December 2022). The interviewees observed a substantial shift in policy, practice, and shared knowledge within Minnesota and beyond, with other states using such experiences to inform their own legislation and practices around doula care, lactation, and anti-shackling. Using the MnPDP as a successful model, Alabama launched its own Prison Birth Project in 2016. At that time, Minnesota was contacted by 10 other states interested in implementing similar interventions [Reference Quinn24]. The researchers helped inform programming in Alabama, Arkansas, Georgia, Michigan, and Virginia. The federal prison system is currently considering implementing lactation and doula care for every qualified person in federal custody [Reference Shlafer, Gerrity, Norris, Freeman-Cook and Sufrin25].

Economic translational benefits are expected and indicated in the financial savings & benefits (cost effectiveness and reduced social & financial cost of illness). According to health equity advocates, better conditions promoting healthy pregnancies and births ultimately improve the health of mother and child, benefit society by saving money for taxpayers, and build a strong foundation for babies [Reference Sawyer26]. A DOCs official suggested that “…there does appear to be a correlation between a reduction in the number of cesarean procedures connected to the education that the doulas provide… coaching the mom and supporting them in making some of those decisions. Our department pays for all medical expenses for a woman in our care, and if we can eliminate a surgical procedure, shorten her stay, better health outcomes, all of that is so beneficial. The ongoing postpartum support offered by the doulas has decreased some of our mental health demands.”

Policy and legislation translational benefits included advisory activities with the researchers’ committee participation in Minnesota’s Legislative Advisory Committee on the Care and Treatment for Incarcerated Women developing a report to the Minnesota legislature in January 2015 with recommendations for jails and prisons to follow “community standards of care” [Reference Anderson and Benning27]. Expert testimony was key to the Healthy Start Act passing as the researchers provided testimony supporting the bill at the state legislature [Reference McCabe28]. The research data on the physical and mental health effects on separated mothers and babies were directly used to inform the proposed legislation [29]. The scientific research reports indicator was evident in the “Legislative Advisory Committee on the Care of Pregnant Incarcerated Women (SF2423/HF2833) Committee Report” in January 2015 [30]. Demonstrating powerful, long-term impact, the research collaboration’s results and advocacy efforts contributed to policies and legislation: the 2014 MN Anti-Shackling Law [31] to outlaw the use of restraints during and just after childbirth and to guarantee incarcerated people access to doulas, and the 2021 Healthy Start Act, the first legislation of its kind in the nation, to keep incarcerated mothers and their newborn babies together [29,32].

Clinical and medical benefits included research contributions to the development of guidelines, that is, formal recommendations or principles to assist with patient care for specific clinical circumstances. Under the guidelines of the 2021 Healthy Start Act, the Commissioner of Corrections can place women who are pregnant or have just given birth into community alternatives such as halfway houses or substance abuse rehabilitation centers, supervise the women and their newborn children, and provide them post-birth treatment for up to one year [Reference McCabe28,Reference Bierschbach33]. Doulas play an additional role now – a navigator for women in the community. They transport released women to the halfway house, help them get supplies for babies, take them to the doctor, and find resources for parenting education.

Catalyzing research categories identified may fit the Scientific Outputs and Outcomes domain of the TSBM Logic Model [Reference Luke, Sarli and Suiter34]. The initial research pilot created nuanced questions about the target population and led to consequent health research studies/activities over the following decade; it “planted the seed that has grown over time… that led to other pilot grants, to larger grants, to continue programming and services” [29]. For example, research participants shared concerns about being unable to eat enough during their pregnancies and not knowing what they should eat in the first place. This became the focus of the “Nutritional Status and Unmet Needs among Incarcerated Women of Reproductive Age” research project in 2013, funded by the CTSI Pre-K Discovery Scholars Program [35]. In 2014, the “Incarcerated Parents in Minnesota and their Minor Children” research, funded by the CTSI KL2 Scholars Career Development Program [36], investigated the prevalence of parental incarceration and the number of affected children to guide the development of evidence-informed efforts for this population and provided financial support to continue implementing and evaluating the prison doula program [22,Reference Shlafer, Duwe and Hindt37,Reference Shlafer and Saunders38].

Two more grants were awarded in 2018 for research conducted by Dr. Shlafer and her collaborators: “Identifying and Addressing Disparities in the Criminal Justice and Health Care Systems” (a multidisciplinary research project funded through the UMN Grand Challenges Research Initiative; $572,525 in direct costs; nine manuscripts published with a few more under review) and “Efficacy and Cost Effectiveness of Doula Care for Incarcerated Women” (funded by the NIH National Institute of Child Health and Human Development; $154,000 in direct costs; one publication [Reference Shlafer, Saunders, Boraas, Kozhimannil, Mazumder and Freese39]). Finally, in 2021, NIH/NICHD funded their research grant titled “Pregnancy and Postpartum Support Programs for Women in Prison: Maternal and Neonatal Outcomes” [40].

Another translational science outcome category was significant research dissemination, influence, and public awareness. The research became a model for research and programs in other states, for example, mental health and depression research in Arkansas, the Alabama Prison Birth Project, and the “Mother’s Milk Initiative” at a prison in Alabama [41]. The researchers collaborated on the national (11 States: MN, MA, MI, OH, VA, CT, IL, CA, TN, WI, NE) and international (South America, Chile) levels [42]. Bibliometric research impact analysis revealed that by 2021, the research was promoted and referenced: in 207 different policy and news media resources from 149 organizations; in 124 documents by 91 groups such as the Centers for Disease Control and Prevention, the Interagency Working Group on Youth Programs, Organization for Economic Cooperation and Development, Danish Institute for Human Rights, and the American Medical Association; 83 times in 58 popular media channels, including newspapers, websites, and news outlets; and syndicated news stories have been republished 84 times [Reference Bakker, Chew, McBurney, Aho and Reardon7].

The impact could be also seen in cultivating the translational science workforce, as Dr. Shlafer mentored many junior scholars and engaged in CTSI education programs. Michelle Lamere, the Assistant Director of Education Programs at UMN CTSI, appreciated “having somebody who really showed us what it looked like to translate into policy and practice and in the community. Being able to show the other scholars a kind of the depth and breadth of how translational research can play out was important. This health equity story is one that captures people’s imagination and especially inspires younger people to get them involved.”

Social and institutional change (a category that is not captured by the TSBM) was acknowledged by multiple data sources. Erica Gerrity emphasized the importance of pursuing social change efforts in the community, where “we had to take our data and translate it in different ways.” The social change process includes creating new policies and practices for the corrections system and working in the legislature to craft legislation grounded in research demonstrating the disparity and need for policies that could improve health.

There was a sizable institutional change within the prison that hosted the research program, reflected in new practices with increased responsiveness towards the needs of incarcerated women to support their health, wellbeing, and reproductive health literacy. A DOC representative shared that it “was really helpful that there was a lot of contact with the research subjects – with the pregnant women or women who had delivered – and I don’t think their voices had been heard before.” Another tangible research outcome mentioned was raising the standards of record management by medical and other prison staff: “No one had looked at the information like this. I think it helped give us greater focus about what was important to know. Prior to that, there was no paper trail of who was having babies. I think just the attention improved our ability to be able to look back at data and much easier to identify these women and guide us in terms of what’s important.”

The research contributed to health equity advocacy. The research work and results have been used by equity advocates [Reference Bakker, Chew, McBurney, Aho and Reardon7,Reference Terrill23,Reference Muza43]. Additionally, according to an interviewee: “We have former participants who are now doulas for the program, who come and present, who are deeply committed to… sharing their story for the goal of something bigger.”

Timeline of Key Events and Benefits

Figure 1 provides a graphical depiction of the key events in the development, implementation, translation, dissemination, and influence of the incarcerated pregnant women research. These events are linked to the translational benefits we identified in our analysis.

Figure 1.

The timeline of the key events, outcomes, and benefits of the incarcerated pregnant women research.

Challenges for Research Implementation and Translation

Table 2 outlines challenges and mitigating strategies for successful research implementation and translation.

Table 2.

Challenges and mitigation strategies for research implementation and translation

There were barriers on an institutional system level with access to research participants and data. The researchers pointed out the cultural differences between proactive public health and prevention research and the DOCs as a reactive, disciplinary system:

“I was met with ‘Why do you care about this? …So few women are pregnant in prison. This isn’t a priority for us’. If we couldn’t do the prison doula work, …we’d have had no access to research. We were always doing this delicate dance with how much we push back on a system… and maintain access to the system.”

A DOC official confirmed that there was an initial lack of trust and tremendous resistance to sharing information: “I think that our facility was very suspicious, concerned about confidentiality. We do not partner well with community agencies, because we are a prison, and there is an attitude that what happens here is not the business of a community agency or entity. …There was just a lot of concern that this is going to somehow come back to reflect poorly on our department… that the Doulas themselves would interfere with security. So, the researchers were really blazing a new trail.” Their professional, respectful attitude, and positive program outcomes helped overcome the formidable challenges related to the lack of trust and made it much easier for future research efforts.

There was this ever-present challenge in terms of the politics of using and translating the research to policy change: policymaking is always complex, taking diverse variables and values into consideration. Translational success depends on gathering research data, collaborating with policy stakeholders, and sharing convincing evidence with policymakers. There were also challenges implementing community-engaged research at the fundamental science level, for example, teaching the doulas the importance of data collection, helping them collect and share data in a timely fashion, as well as maintaining their databases. A community research partner shared some frustration regarding the power, privilege, and opportunity dynamic conditioned by academic credentialing in our society, including such perceptions as to who is usually considered a “real expert” in research collaborations and the widespread “unspoken assumption” that the university folks always know more than their community counterparts.

The researchers lamented about their struggles around getting enough financial resources for program delivery services. It is a serious challenge for interventional research when it needs to happen in the program context where the people offering the intervention to reduce the health disparity are also the co-researchers trying to do the high-quality job.

According to one of the researchers, there were judgmental perspectives coming from a couple of colleagues who made her question whether her research was “real science” by saying “That’s not science; that’s social justice.” To some degree, that made this emerging researcher doubt her research capacity and whether this was valuable work: “If I think back, maybe, my own passion was coming through in this work in a way that they felt like it wasn’t rigorous science. One of the things that I learned was the power of reframing. I learned that this person could be anybody else to review my grants, and I’d need to convince a person like this. I guess in hindsight that was a benefit to me, even though it felt really hard at the time.”

The case study identified multiple challenges to the successful implementation and translation of research. Overcoming these challenges required the ability to effectively collaborate, properly frame, and communicate the meaning and value of your research to stakeholders, impartial learning from criticism and failures, and tenacity to deal with barriers, doubts, and frustrations along the way.

Facilitators of Translation

The case study identified translational facilitators (Table 3) that clinical research practitioners and translational scientists could use. Such facilitators contribute to what we would call “translational scaffolding”: a system of processes, structures, and conditions for developing and consolidating vital opportunities and supports for impactful research implementation and translation. To be successful, this system requires collaborative engagement of academia, community, industry, government, and other stakeholders. Interacting with the earlier described mitigation strategies, the scaffolding facilitators helped research collaborators stay focused on their goals and avoid getting lost in the complexity of the translational process. Some of these facilitators overlap with the Resources and Scientific Activities categories within the TSBM logic model [Reference Luke, Sarli and Suiter34].

Table 3.

Facilitators of research translation

Current Status of the Research/Translation

The programs providing support to incarcerated mothers have undergone transformation. In 2019, the MnPDP and the Alabama Prison Birth Project merged into the Ostara Initiative [41,49]. With the Healthy Start Act signed into law in 2021, the researchers are now investigating different aspects of program implementation and exploring the realization of similar models in other states. Specifically, researchers are trying to better understand the facilitators and barriers to implementing similar programs in other states. In addition, the researchers seek to understand program impacts on maternal and child health, including rates of adverse birth outcomes, breastfeeding initiation and duration, maternal nutrition, maternal depression and anxiety, maternal satisfaction of doula support, and infant health in the first year of life. An ongoing multi-site, mixed-methods research grant funded by NIH/NICHD in 2021 [40] is taking the next step in exploring the issues examined in the original 2011 research: assessing maternal and neonatal outcomes (e.g., birth outcomes, breastfeeding initiation, maternal mental health) among participants in prison-based support programs in six states and exploring how to scale this up across the country.

A DOC partner lamented the lack of data about the wellbeing of incarcerated parents’ children: “We don’t have a good understanding of what happens with these babies, where they go, and how they are cared for. Are there things we could be doing that could help them have better outcomes?”

According to Ms. Gerrity, one of the future directions for the research and its translation into health equity and social justice include getting more qualitative data – for example mothers’ perceptions of and satisfaction with their pregnancy and birth experiences – and making a case for the fact that some of the egregious treatment of incarcerated people is not anomalous, but rather an extensive pattern that exists throughout the country.