The American College of
Obstetricians and Gynecologists
WOMEN’S HEALTH CARE PHYSICIANS

COMMITTEE OPINION
Number 535 • August 2012	
Committee on Health Care for Underserved Women
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Reproductive Health Care for Incarcerated Women
and Adolescent Females
ABSTRACT: Increasing numbers of women and adolescent females are incarcerated each year in the United
States and they represent an increasing proportion of inmates in the U.S. correctional system. Incarcerated
women and adolescent females often come from disadvantaged environments and have high rates of chronic illness, substance abuse, and undetected health problems. Most of these females are of reproductive age and are
at high risk of unintended pregnancy and sexually transmitted infections, including human immunodeficiency virus
(HIV). Understanding the needs of incarcerated women and adolescent females can help improve the provision of
health care in the correctional system.

Background
Between 1990 and 2009, the number of incarcerated
women increased 153% (1). Most women in correctional
facilities are incarcerated for nonviolent crimes. Drug
offenses are the most common felonies committed by
women in both federal (72%) and state (34%) prison
systems, and are the second most common offense committed by women in local jails (30%) (2). By the middle of
2009, 106,362 women (6.9% of all prison inmates) were
incarcerated in federal or state prisons, and by the middle
of 2011, 93,300 women (12.7% of all jail inmates) were
incarcerated in local jails (3, 4). In 2010, 306,498 females
younger than 18 years were arrested, representing 29% of
all juvenile arrests (5). Juvenile offenders may be housed
in juvenile detention homes or residential correctional
facilities or, in some cases, in adult prisons or jails.
Incarcerated women and adolescent females often
come from economically, educationally, socially, and emotionally disadvantaged environments; a disproportionate
number have acute and chronic illnesses, substance abuse
problems, and undetected health issues, including reproductive health needs. In one study, 27% of incarcerated
women had chlamydia and 8% had gonorrhea, compared
with rates of 0.46% and 0.13% in the general population,
respectively (6). In 2008, 2% of women in state and federal
prisons were known to be infected with human immunodeficiency virus (HIV) (7). Fifty-six percent of women in
federal prisons and 62% of women in state prisons were

parents of one or more minor children, and 19% of these
children were in the care of someone other than a family
member during the mother’s incarceration (8).
Approximately 6–10% of incarcerated women are
pregnant, and are mostly incarcerated in local jails (9,
10). There are few studies about birth outcomes for
women who continue pregnancies during incarceration.
Although a woman retains her legal right to an abortion
during incarceration, a woman’s experience in attempting to obtain an abortion varies widely by state, region,
and individual prison (11, 12). In a survey of correctional
health officials, 68% indicated that women in their prisons were allowed to have an elective abortion, but only
54% helped arrange appointments (11).
Sexually transmitted infections and pregnancies may
result from sexual victimization of women during incarceration. In a survey of local jail inmates using audio
computer-assisted self-interviews to maximize confidentiality and reliability, 5.1% of female inmates reported
sexual victimization (13). Of these, 3.7% of women experienced sexual victimization by another inmate and 2.0%
reported sexual victimization by a staff member (13). In
a similar survey of state and federal prison inmates, the
rate of sexual victimization among men and women was
4.5% (14). Total rates for women were not presented, but
rates were as high as 10.8% at some prisons, with sexual
victimization by a staff member reported by up to 5.3%
of women (14).

Mental health disorders and substance abuse are
common among incarcerated women. Sixty-nine percent of women admitted to local jails met the criteria for substance dependence or abuse (not including
tobacco use); dependence was diagnosed more commonly among women than among men (15). Rates of
mental health problems among women inmates ranged
from 61% in federal prisons to 75% in local jails (16).
Incarceration is an important risk factor for suicide by
adolescent inmates (17). More than 50% of women in
jail reported a history of physical or sexual abuse, and
this rate is as high as 92% among female juvenile offenders in California (18, 19).

Medical Care Availability and Access
Although most state and federal prisons provide some
level of care to prisoners, availability and access to medical care in jails is variable. The short and often unpredictable duration of incarceration in local jails often makes
provision and continuity of care difficult. In addition,
systems of care vary in state and local prison and jail
settings. Services at state prisons and jails may be provided on site by health care providers, by arrangements
with local hospitals or clinics either on site or by inmate
transport, or by an on-site health care provider contractor. Historically, health care was delivered by way of a
“sick call,” where an inmate notified a guard or other
designated authority of the need for medical attention. A
sick call system does not allow for provision of primary
or preventive care and health education. Although many

facilities have moved to systems that provide primary
care, the increase in the number of inmates makes provision of adequate care difficult. In addition, women are
often housed in facilities with predominantly male populations, which limits the availability of health services
tailored to women’s needs. Financing of correctional
facilities, including health care, depends on legislative
appropriations that compete with other priorities. In general, Medicaid funding cannot be used for care for adults
and adolescents in secure confinement.
No federal or state mandates require correctional
health facilities to obtain accreditation, and there is
no organization to which all facilities are accountable.
Several organizations accredit prisons, but their standards
only serve as guidelines and are followed voluntarily.
These organizations include The Joint Commission, the
National Commission on Correctional Health Care, and
the American Correctional Association. Health care standards for jails, prisons, and juvenile facilities have been
developed by the National Commission on Correctional
Health Care, the American Correctional Association, and
the American Public Health Association (20–23).
In general, care for incarcerated women and adolescent females should be provided using the same guidelines as those for women and adolescent females who
are not incarcerated, with attention to the increased
risk of infectious diseases and mental health problems
common to incarcerated populations. Health care for
incarcerated women and adolescent females is outlined
in Table 1 (23, 24).

Table 1. Recommended Care for Incarcerated Women and Adolescent Females
Type of Care	

Adult Jail or Prison*	

Entering facilities	
Ask about any current medical problems and care and 	
	
safety of minor children at home.
	
Obtain a medical history—immunization status; sexual 	
	
activity, contraceptive use, and menstrual cycle to assess 	
	
the need for a pregnancy test; number of pregnancies and 	
	
outcomes; history of medical problems, chronic illness, 	
	
hospitalizations, breast disease, and gynecologic problems; 	
	
and domestic violence, sexual abuse, and physical abuse	
	
Mental health assessment	
		
		
	
Physical examination†—pelvic and breast, Pap test, and 	
	
baseline mammography based on College guidelines	
	
In a jail setting, Pap test and mammography should 	
	
only be done if there is enough time to obtain results 	
	
before release. 	
	
Laboratory work—STIs, HIV, pregnancy, hepatitis, and 	
	
tuberculin skin tests based on College guidelines
	
In a jail setting, tuberculin skin tests should only be done
	
if incarceration is expected to be for at least 48 hours	
	
to see if any reaction occurs. 	

Juvenile Facilities
Same as in adults, but also screen for eating disorders
Same as in adults

Same as in adults, bearing in mind that adolescents
in correctional facilities are at higher risk of suicide
than those in the general population
Same as in adults, except mammography and Pap
test are unlikely to be needed. Pap test should be
performed on adolescents according to College
recommendations.
Same as in adults

(continued)
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Committee Opinion No. 535

Table 1. Recommended Care for Incarcerated Women and Adolescent Females (continued)
Type of Care	

Adult Jail or Prison*	

Juvenile Facilities

Pregnancy care	
	

Pregnancy counseling, perinatal care, and abortion services 	 Same as in adults
should be offered based on College guidelines 	

Preventive care	
	

Any additional tests, examinations, and care based on	
College guidelines

	
	

Health education on contraception and pregnancy; tobacco, 	 Same as in adults
alcohol, and substance abuse cessation; and parenting

	
	

Comprehensive HIV and STI treatment and prevention	
programs	

	
	

Contraceptive services, including emergency contraception, 	 Same as in adults
based on medical need or potential risk of pregnancy

	
	
	

Provide immunizations as necessary based on College 	
guidelines, with particular focus on influenza and 	
pneumococcal vaccination

Same as in adults, but with particular focus on HPV,
meningococcal, and influenza vaccination

Care for older women	

Hormone therapy, if indicated 	

Not applicable

	
	

Screening, treatment, and prevention programs for 	
osteoporosis

Osteoporosis prevention programs may be useful

	

Screening for depression and dementia 	

Screening for depression

Mental health care	
	
	
	

Medication management, suicide prevention, crisis 	
intervention, substance abuse programs, and linkage to 	
social services and community substance abuse programs 	
upon release	

Same as in adults, noting that incarceration is a risk
factor for suicide among adolescents

Same as in adults

Same as in adults, bearing in mind that adolescents
are at higher risk of STIs than the adult population

Abbreviations: College, American College of Obstetricians and Gynecologists; STIs, sexually transmitted infections; HIV, human immunodeficiency virus; HPV, human papillomavirus.
*If a juvenile is housed in an adult prison or jail, the recommendations under the juvenile facilities column should be followed.
The request by either a patient or a physician to have a chaperone present during a physical examination should be accommodated regardless of the physician’s sex.

†

Data from Anno BJ. Correctional health care: guidelines for the management of an adequate delivery system. Chicago (IL): National Commission on Correctional Health Care;
2001. Available at: http://static.nicic.gov/Library/017521.pdf. Retrieved April 16, 2012; American Academy of Pediatrics, American College of Obstetricians and Gynecologists.
Guidelines for perinatal care. 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007; American College of Obstetricians and Gynecologists. Guidelines for adolescent
health care. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011; American College of Obstetricians and Gynecologists. Guidelines for women’s
health care: a resource manual. 3rd ed. Washington, DC: ACOG; 2007; American College of Obstetricians and Gynecologists. Well-woman care: assessments and recommendations. Washington, DC: American College of Obstetricians and Gynecologists; 2012. Available at: http://www.acog.org/~/media/Departments/Annual%20Womens%20
Health%20Care/PrimaryAndPreventiveCare.pdf?dmc=1&ts=20120419T1033428879. Retrieved April 19, 2012; American Public Health Association. Standards for health services
in correctional institutions. 3rd ed. Washington, DC: APHA; 2003; Cervical cancer in adolescents: screening, evaluation, and management. Committee Opinion No. 463. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:469–72; Health care for pregnant and postpartum incarcerated women and adolescent females. Committee
Opinion No. 511. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:1198–1202; National Commission on Correctional Health Care. Standards for
health services in jails. Chicago (IL): NCCHC; 2008; National Commission on Correctional Health Care. Standards for health services in juvenile detention and confinement facilities. Chicago (IL): NCCHC; 2004; National Commission on Correctional Health Care. Standards for health services in prisons. Chicago (IL): NCCHC; 2008; and Health care for youth
in the juvenile justice system. Policy Statement. American Academy of Pediatrics. Pediatrics 2011;128:1219–35.

Recommendations
	 •	 Obstetrician–gynecologists should support efforts to
improve the health care of incarcerated women and
adolescent females at the local, state, and national
levels. Activities may include the following:
	 —	Gaining representation on the boards of correctional health organizations.
	 —	Working in correctional facilities to provide services to incarcerated women and adolescent
females and continuing care after the woman’s
release, when feasible.
	 —	Undertaking efforts to ensure that medical needs
of incarcerated women and adolescent females are

Committee Opinion No. 535	

being addressed appropriately, such as by providing training or consultation to health care providers and correctional officers in prison settings.
	

—	Advocating at the local, state, and federal levels for
increased funding to provide access to necessary
health care for incarcerated women and to restrict
shackling of women and adolescents during pregnancy and the postpartum period (10).

	 •	 Facilitate care provision by health care providers
to incarcerated women and adolescent females (eg,
allowing incarcerated women and adolescent females
to enter through alternate entrances to avoid stig-

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	 •	

	 •	

	 •	

	 •	

	 •	

matization in the waiting room or to be seen during
off-hours).
Ensure that adolescents only be detained or incarcerated in facilities with developmentally appropriate
programs and staff trained to deal with their unique
needs. If they must be housed in adult correctional
facilities, they should be separated from the adult
population into an environment that is able to
address their specific developmental needs (24).
Ensure that adolescents with serious mental disorders are not placed in detention when they do not
face criminal charges. The placement of adolescents
with mental disorders who have been charged with
crimes and are able to be released from incarceration
into a community mental health facility should be
completed in a timely fashion.
Facilitate collaboration between medical schools and
other health care professional schools and correctional facilities to improve care to inmates.
Obtain and support funding for research on the
health needs of incarcerated women and adolescent
females, the services they receive, the qualifications
of the health care provider, the location of the service, and the outcomes of these services.
Support state and federal funding that increases
access to necessary health care that includes not only
disease-specific treatment, but also preventive services and access to qualified health care providers for
incarcerated women and adolescent females.

Specific medical recommendations include the following:
	 •	 Correctional facilities should be adequately funded
to provide a continuum of care model providing
female inmates with initial screenings, in-house
services or referrals for preventive and curative
care, including Pap tests and appropriate followup, health education, and adequate planning before
release from correctional facilities.
	 •	 Health care providers and other correctional facilities staff should receive appropriate training to provide care for female inmates, including the care of
pregnant women (10).
	 •	 Incarcerated women of all ages should receive reproductive health care, including access to adequate contraception, prenatal care, and abortion services (9, 10).
	 •	 Appropriate and adequate care should be provided
for pregnant women and adolescents, including
opioid dependence treatment, avoiding the use of
restraints, and promoting breastfeeding (10).
	 •	 If hospitalization or other off-site health care occurs,
prescribed treatments, such as medications, must
continue once the patient returns to the correctional
facility.

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	 •	 Incarcerated women and adolescents’ mental health
needs should be addressed.
	 •	 Incarcerated women and adolescents should be protected from sexual abuse. If sexual abuse occurs, the
guilty party should be punished to the full extent of
the law.

References
	 1.	Glaze LE. Correctional populations in the United States,
2009. Bureau of Justice Statistics Bulletin. Washington,
DC: U.S. Department of Justice; 2010. Available at: http://
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April 16, 2012. ^
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fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-inthe-u.s.-2010. Retrieved April 16, 2012. ^
	 6.	High prevalence of chlamydial and gonococcal infection
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providers. Perspect Sex Reprod Health 2009;41:6–11.
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Committee Opinion No. 535

	12.	Kasdan D. Abortion access for incarcerated women: are
correctional health practices in conflict with constitutional
standards. Perspect Sex Reprod Health 2009;41:59–62.
[PubMed] [Full Text] ^
	13.	Beck AJ, Harrison PM. Sexual victimization in local jails
reported by inmates, 2007. Bureau of Justice Statistics
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	15.	Karberg JC, James DJ. Substance dependence, abuse, and
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Committee Opinion No. 535	

	19.	Acoca L, Dedel K. No place to hide: understanding and
meeting the needs of girls in the California juvenile justice
system. San Francisco (CA): National Council on Crime
and Delinquency; 1998. ^
	20.	National Commission on Correctional Health Care.
Standards for health services in jails. Chicago (IL): NCCHC;
2008. ^
	21.	National Commission on Correctional Health Care.
Standards for health services in juvenile detention and confinement facilities. Chicago (IL): NCCHC; 2004. ^
	22.	National Commission on Correctional Health Care.
Standards for health services in prisons. Chicago (IL):
NCCHC; 2008. ^
	23.	 American Public Health Association. Standards for health
services in correctional institutions. Washington, DC:
APHA; 2003. ^
	24.	 Health care for youth in the juvenile justice system. Policy
Statement. American Academy of Pediatrics. Pediatrics
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Copyright August 2012 by the American College of Obstetricians and
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Reproductive health care for incarcerated women and adolescent
females. Committee Opinion No. 535. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:425–9.

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