In 2007, Contra Costa County had an estimated population of 1,042,804 which represented an increase of 9.9% since 2002. During the last fifteen years, the number of incarcerated women has doubled. As a result of criminal justice policy changes on sentencing non-violent crimes and increasing poverty, women are the fasted growing population of incarcerated individuals. As these women serve time, their children suffer. The majority of incarcerated women are of reproductive age and an increasing number are pregnant. Nearly two-thirds of incarcerated women have at least one child. 80% were primary caregivers for their child(ren) before incarceration. Babies born to incarcerated women have the highest risk of going into foster care.
Contra Costa Health Services
Lift Every Voice (LEV) Program
In 2007, Contra Costa County had an estimated population of 1,042,804 which represented an increase of 9.9% since 2002. During the last fifteen years, the number of incarcerated women has doubled. As a result of criminal justice policy changes on sentencing non-violent crimes and increasing poverty, women are the fasted growing population of incarcerated individuals. As these women serve time, their children suffer. The majority of incarcerated women are of reproductive age and an increasing number are pregnant. Nearly two-thirds of incarcerated women have at least one child. 80% were primary caregivers for their child(ren) before incarceration. Babies born to incarcerated women have the highest risk of going into foster care. Additionally, incarcerated women are at risk of having adverse birth outcomes.
They have multifaceted risk factors including:
Alcohol and other drugs addiction
Mental health issues
Physical/sexual abuse which are pervasive among incarcerated women.
Lift Every Voice (LEV) offers services to all incarcerated pregnant women detained at the West County Detention Facility (WCDF). Services are provided prior to women’s release from WCDF. Every woman arrested in Contra Costa is initially detained at the Martinez Detention Facility (MDF) and receives a pregnancy test. Women, assessed as ‘functionally mentally unbalanced’, having ‘other high risk behaviors’, or deemed ‘high security’ are maintained at MDF. The rest are transported to WCDF. These pregnant women are interviewed by LEV during the week (Monday – Friday), except for those who are released during the weekend. Contra Costa Office of the Sheriff (Sheriff) offer pregnant women the opportunity to obtain or decline LEV services.
LEV represents a Health Equity and Life Course Perspective. LEV addresses health inequities associated with race, poverty, gender and social determinants of health. Life is an integrated continuum and health outcomes are not isolated events; they are interchanges of both protective and risk factors over the person’s life. Family, Maternal and Child Health Programs (FMCH), in partnership with First 5 Contra Costa (First 5), FMCH’s Prenatal Care Guidance (PCG), other county programs, and community organizations, had been working together to streamline our system of care and improve linkages and services among perinatal programs. These efforts included a funding request to First 5 to address the poorest perinatal outcomes - pregnant incarcerated women and teens.
LEV activities started in October 2004, which included:
Securing 50% funding from First 5 for a full time employee and some overhead costs;
Meeting and getting buy-in from jails;
Hiring a social worker;
Developing LEV’s model, forms, charts, data collection, policies, and procedures;
Creating linkages with other home visiting programs like PCG, Black Infant Health(BIH); and
Changing the LEV model from outreach to case management.
LEV goals included:
Improve the health and well-being of incarcerated pregnant women by creating a Mom and Baby Care Plan so that the mothers and other caregivers feel supported;
Decrease the number of newborns of incarcerated women in foster care where 90% of newborns get placed with their mother or relative caregiver;
Decrease recidivism rates by avoiding re-incarceration for six months after discharge; and
Improve mother/child relationships by ensuring that 90% of the women have a Mom and Baby Care Plan created with them, and receive mother/child supportive services.
Practice outcomes included:
Women’s increased knowledge
Women’s increased self-sufficiency
An advocate for women’s judicial issues
Mothers and caregivers felt supported
Women’s empowerment in the creation and development of the Mom and Baby Care Plan
Avoiding re-incarceration six months after discharge
LEV’s successful accomplishments were due to:
Exemplary skills, knowledge, experience and commitment of the LEV team;
LEV’s theoretical framework, vision, and comprehensive and holistic approach; and
Continued efforts to evolve as ‘best and promising practices’.
Throughout implementation, LEV learned that:
Many women in jail have been misdiagnosed, not diagnosed or treated for mental health issues;
Case management needs to be linked with family members;
Staff psychosocial support and consultation get built-in when reviewing cases;
Aftercare is needed after the post partum period ends;
Shackling of pregnant women needs to be addressed;
Incarcerated women require timely access to early abortions;
Improved collaboration and partnerships are needed with organizations serving children 0-5;
Fathers of the babies need supportive interventions; and
An expansion of LEV services are needed to support enrolling women in alcohol and other drugs treatment, outreach, housing and workforce development.
Women of reproductive age are the fastest growing population of incarcerated individuals and an increasing number are pregnant. Nearly two-thirds have one child. 80% were the primary caregiver before incarceration. When a mother is in jail or prison, it causes deterioration in children’s living situation, developmental milestones, and ability to bond and form stable relationships, in addition to disrupting their ability to learn in school. Incarcerated women are at risk of having the poorest birth outcomes. They have a complexity of risk factors including alcohol and other drugs addiction, PTSD, depression and anxiety, and other mental issues, family/domestic violence, and physical/sexual abuse. Many pregnancies result in miscarriage, preterm delivery, low birth weight infants, fetal and neonatal deaths, and other complications. Postpartum care is almost non-existent.
The lack of prenatal screening, biopsychosocial assessment and treatment leaves incarcerated women and their babies at risk for lifelong health problems. Babies born to incarcerated women have the highest risk of going into foster care. Most health care systems automatically separate the mother from her newborn. Depending on the family, an infant can go home with their father or extended family member (i.e. grandmother, aunt, or cousin). African American women are disproportionately represented among incarcerated women. They are four times more likely than Latinas and eight times more likely than White women to be imprisoned. In Contra Costa, African Americans are less likely to receive first trimester prenatal care; experience infant loss at a rate of 9.7 (three times higher than the County rate); and have the highest rate of low birth weight infants, fetal, and infant deaths. Root causes for these adverse birth outcomes consist of a complex interplay of biological, psychological, social, and economic factors. County data risk factors associated with poor birth outcomes include: being African American, obese, partner abuse, isolation, substance abuse, unintended pregnancy, pre-term labor, pre-existing medical conditions, previous poor birth outcomes, and unstable housing.
FMCH looked at Contra Costa Community Assessments data for late and no-entry into care. We analyzed data on the small population that had a higher risk of babies going into NICU. We were aware of the decade of data collected from our Fetal Infant Mortality Review (FIMR) Program indicating the risk factors of premature labor, domestic violence, unstable housing, alcohol and other drugs use, and severe and persistent mental illness, and being African American which impact perinatal outcomes. Data indicated that domestic violence, alcohol and other drugs, and mental health were the highest risks for the worst perinatal outcomes. We researched and became aware of the activities and programs that served pregnant incarcerated women in California and nationally. It was through this analysis and Contra Costa Health Services (CCHS) lack of response to the needs of pregnant incarcerated women that determined the relevance of this model. Incarcerated pregnant and reproductive age women are often a transient population with high recidivism rates who utilize the County hospital- Contra Costa Regional Medical Center (CCRMC) - to deliver their newborns while in jail. They utilize county clinics when they seek prenatal care, and county emergency room and pediatric care for their children when not incarcerated. Incarcerated pregnant and reproductive age women are county residents that represent an underserved and otherwise invisible population. Finally, literature supports common knowledge that African American women are disproportionately represented in the jails and prison system. In addition, African American women experience the worst birth outcomes in Contra Costa.
LEV is a public health approach that addresses an often overlooked and neglected population of women. LEV clients are at high risk for adverse birth outcomes. This hard-to-reach and difficult to serve population requires a complex array of services and strategies to ensure that they are successful parents and make healthy and positive choices. Through educating women and supplying them with essential information and support, they can make informed decisions about their reproductive choices. LEV’s approach is comprehensive and holistic. Services are offered with cultural humility and are strength-based, gender-specific, trauma informed, and relational. LEV negotiates with detention facility, health services, and support services staff about women’s mental and medical care to help staff understand the biopsychosocial issues that have contributed to their incarceration. LEV’s work with the system of care facilitates provider awareness and knowledge about the issues of pregnant incarcerated women in Contra Costa. LEV provides case management, home visiting, outreach, advocacy, resource assessments, motivational interviewing, and case conferences with Children and Family Services (CFS), other home visiting programs like PCG and BIH, probation, parole, and family members. LEV participates in county Team Decision Making and larger county reentry initiatives. In Contra Costa, CFS is known as Child Protective Services. When LEV visits a woman in WCDF, a trusting relationship is established while the woman is detained and/or after she is released. LEV and the client work closely together in the development of a Mom and Baby Care Plan prior to the birth of her baby. Women are linked to prenatal care, psychosocial support services, and other home visiting programs. LEV engages and retains women until they deliver their babies.
FMCH was aware of the lack of attention to this population. We also determined there were no health or public health program approaches or initiatives that focused on pregnant incarcerated women within the state or nationally. A number of studies validated that the programs that did exist resided within the prison system, with no program citations on a similar public health approach. We learned about the MOMS Program (Maximizing Opportunities for Mothers to Succeed) in Alameda County. In the San Francisco County jail, an OB/GYN and a women’s health nurse practitioner conducts a weekly clinic for incarcerated pregnant and reproductive age women. In a few other California counties, public health nurses see women in jail, and a perinatal placement specialist (Alcohol and Other Drugs) works with pregnant women before they are incarcerated and links them with treatment services.
LEV is different because our theoretical framework proposes a health equity and life course perspective to address the issues of this population. This practice recognizes that prenatal care alone is not sufficient to address adverse perinatal outcomes. LEV addresses social determinants of health and poverty by specifically addressing the issues of racism represented by African American and Latinas and the issues of poverty that are inequitable among pregnant women in jails and prisons. Social determinants of health associated with perinatal substance abuse, perinatal depression and anxiety, and other mental issues are also addressed. Furthermore, ‘best practices’ California Interconception care guidelines are offered and made available to both the clients and health care providers to utilize. LEV is a public health approach within the criminal justice system. LEV has formed partnerships with traditional and non-traditional providers to assure that pregnant incarcerated women are consistently and comprehensively served. These partnerships include: the Sheriff, CCHS Detention Health Services, County Office of Education, Healthy Start Martinez, CCRMC Labor and Delivery staff, Probation, Parole, Public Defender, Judges, Mental Health, Alcohol and Other Drugs, CFS, perinatal home visiting programs, Legal Services for Prisoners with Children, county reentry Initiatives, and the African American Health Initiative. An opportunity to optimize education and dialogue among the providers and clients both separately and collectively addresses stigma, discrimination, bias, and internalized oppression. Optimal opportunities for health and well-being and advocacy are being created to address the health issues of this often overlooked and ‘difficult to serve’ population.
Detention Health Services
Office of the Sheriff
Role of Stakeholders/Partners
FMCH and First 5 were responsible for and developed the practice’s units of service, milestone and quarterly reports, and evaluation processes and outcomes. FMCH and the Sheriff planned LEV program implementation. The Sheriff approved FMCH security clearances. The Sheriff also promoted the practice and encouraged relationships with Detention Health Services. They offered FMCH essential WCDF orientation and safety regulations to assure compliance within WCDF and with other ‘Inmate Program and Services’, i.e., County Office of Education, In-Custody Drug Treatment and Friends Outside. FMCH, the Sheriff, and Detention Health Services developed program policy and procedures to set up LEV within WCDF. These procedures included when to enter WCDF, where to operate, access to medical records, and pregnant women’s access to LEV. Mechanisms to communicate about practice updates, problems and feedback were established between the Sheriff, Detention Health Services, and LEV. LEV has been institutionalized within WCDF. The Sheriff continues to provide a supportive atmosphere in order for LEV to intervene with pregnant women (and often women of reproductive age). LEV and Detention Health Services operate as a multidisciplinary team in providing comprehensive health care interventions. LEV regularly attends Detention Health Services staff meetings to assure cooperative communication, receive feedback on what is and/or is not working, problem solve, and educate staff about this population in the context of health equity and the life course perspective. FMCH also meets with the Sheriff to guarantee safety and regulatory compliance to receive feedback and/or problem solve. It is also an opportunity for LEV to educate the Sheriff about health equity and the life course perspective in relationship to the health of pregnant incarcerated women. LEV has initiated regular case conferencing among Detention Health Services and Healthy Start Martinez which is a Comprehensive Perinatal Services Program (CPSP). LEV’s efforts have successfully facilitated communication among Detention Health Services and Healthy Start Martinez regarding the care of LEV clients who are patients in the same system of care. Recently, members of Detention Health Services invited LEV to present the model at the November 4, 2011 California-Nevada Chapter, American Correctional Health Services Association Conference in Sacramento, CA.
FMCH is the organization that is responsible for the planning, implementation, sustainability, promotion, development of collaborations, and the evaluation of LEV. CCHS has promoted the importance of FMCH, First 5, the Sheriff, and Detention Health Services working together to address the issues of incarcerated pregnant and women of reproductive age and their children and families. CCHS has provided the attention, time, resources, and leadership to recognize the dilemma and degree that addressing this issue impacts countless elements of the overall system of care. The opportunity to implement this practice substantiated recognition that cooperative relationships among traditional and non-traditional partners was the only way to effectively develop interventions to address the social determinants of health that impact adverse perinatal outcomes related to this population.
Permanent relationships with the County Office of Education and In-Custody Drug Treatment have been established to educate women and men detainees about prenatal and interconception health, alcohol and other drugs, domestic violence, trauma, perinatal depression and anxiety, and parenting. FMCH participated in a collaborative of health and social service providers addressing inequities in CFS reports to decrease the number of unnecessary CFS referrals made after labor and delivery. During intake, LEV assists clients in creating newborn plans; and works with family members, hospital social workers, CFS, probation, parole, substance abuse programs, mental health and others to implement the plan. When clients go into labor, LEV advocates on their behalf. In 2010, 200 service providers participated in the LEV conference titled “See Them as Women, See Them as Mothers” (not ‘just’ inmates and criminals). An educational video was created from this conference. It has been used to train detention health services, correctional staff, and other service providers. The video is of a panel of LEV clients who have made positive life choices and are successfully parenting their children. The video promotes a ‘promising practices model’ for working with at-risk women. In 2011, LEV developed a WCDF workshop.
Workshop objectives were to: to educate and empower at-risk women; challenge them to make positive changes and take personal responsibility; and provide useful information and resources. It was well received by more than 60 women. Keynote speaker Dr. Angela Y. Davis, along with Project WHAT! and 15 community resources, including Planned Parenthood, Contra Costa College, Youth Services Bureau, STAND! Against Domestic Violence participated in this community service. Healthy Start and other case conferences are attended regularly regarding LEV clients. In California, the majority of low-income pregnant women are served by CPSP providers. Shackling women during Labor and Delivery has been illegal in California, since January 2006. It was not being implemented at CCRMC. FMCH initiated meetings with several Lieutenants and then the Commander to implement the policy. Finally, LEV participated in reentry strategic planning and reentry meetings to advocate for comprehensive supportive services for pregnant and reproductive age women.
LEV would not be effective without the collaboration of organizations and agencies both within WCDF and in the community. FMCH learned it took two to three years of consistent, clear and respectful transparent communication, in order for the Sheriff to continue to allow LEV in the jail and to institutionalize this practice within WCDF. This consisted of a long history of demonstrating what LEV was about and evolving positive program processes. This same systematic relationship building achieved the creation of a multidisciplinary team from a variety of disciplines and departments within WCDF to provide optimum services to LEV clients. LEV could not afford to make a mistake. A requirement for LEV institutional success included strategic planning and ethical behavior, excellent listening skills, humor, flexibility, and being supportive of all of the WCDF staff. Many WCDF staff opened up to LEV confidentially and shared their personal and professional goals and frustrations.
Barriers: There was an initial lack of trust and lack of clarity within WCDF about LEV’s overall purpose.
The jail system is male-dominated and created for male inmates. It is not accustomed to providing comprehensive support services for women.
The security and structure of the jail is a barrier. LEV does not have the authority or is granted the flexibility to freely access new and returning LEV clients.
It continues to be a barrier for the Sheriff and Detention Health Services to release old concepts of punishment and chastisement. Stereotypes continue to be perpetuated that anyone that uses drugs or are in jail are bad people. Fundamentally, any woman who is incarcerated is an ‘unfit’ mother. In developing a countywide, integrated, coordinated approach to the delivery system for incarcerated pregnant and reproductive age women, agencies and organizations are working in silos.
The system is fragmented. A more inclusive system needs to be created that includes traditional and non-traditional partners, including housing, workforce development, and faith-based organizations.
The implementation tasks taken to achieve LEV’s goal and objective have been as follows:
Client Education - 2005 - present: A strength-based and gender specific approach was used in order to educate incarcerated pregnant and women of reproductive age. The curriculum covered: domestic violence; problem-solving and self management skills; substance abuse and treatment; marketing skills toward self-sufficiency (i.e. BEST, GED, community college, etc.); family planning and sexually transmitted infections; preventive care; and parenting from a distance.
In March 2011, LEV sponsored a workshop for women within WCDF and invited 25 community-based organizations for resource sharing.
Case Management: 2005 - present: Case Management was provided to incarcerated pregnant and reproductive age women. The Case Management services included: assessment of strengths and risks; access to health care and linkage to a medical home; assistance and support within the probation and parole system; strength-based and gender specific approach; and support to the mothers and caregivers in appropriate developmental stages of newborns.
Advocacy: 2008 - present: Advocated for incarcerated women by assisting with probation/parole judicial requirements; participated in collaborations that support reproductive justice; met with the Lieutenants and the Commander to implement a policy that would discontinue the shackling of incarcerated women during labor and delivery; worked with advocacy programs to sponsor AB 458 (Skinner Bill) to eradicate shackling of all pregnant women; and participated in reentry meetings and advocated for gender specific services for pregnant and reproductive age women.
Provider Education: 2006 - present: LEV educated correctional staff, Detention Health Services, CPSP providers, alcohol and other drugs and mental health providers, CFS, 0-5 providers, and others about the health status of incarcerated pregnant and reproductive age women.
In March 2010, LEV sponsored a provider conference titled “See Them as Women, See Them as Mothers” for 200 participants in order to improve provider skills when working with incarcerated women, as well as enhance collaborative relationships among programs serving incarcerated women. As a result, an educational video was developed which has been used for correctional and detention health staff, and health and social services providers.
Process & Outcome
Objective 1: LEV will make contact with sixty (60) incarcerated women prior to their release from West County Detention Facility (WCDF). Performance measures: LEV serves an ongoing caseload of incarcerated pregnant women at the WCDF. LEV provides a minimum of one 15-minute contact per week with each woman up to 3 months after birth for mothers who retain custody of their newborn. A minimum of 70% of children born to a woman who is incarcerated women will be placed with the parent, appropriate family member, or designated relative or guardian. A Mom and Baby Care Plan (individualized care plan) will be developed with each woman, identifying a plan for the care of the newborn. Ultimately, women will feel supported during their pregnancy; will learn about resources, such as education and support, health insurance enrollment assistance; and will know how to access necessary services and support for their child(ren). Data: As a Contra Costa First 5 funded program, LEV utilized the Outcomes Collection Evaluation and Reporting Service (OCERS) for data collection. Data collected included the following: number of women enrolled in LEV; number of contact units provided per visit per woman; number of women and/or relative caregivers who retained their infant after birth; number of individualized care plans developed; and the number of referrals and resources provided to LEV women. In addition, demographic information regarding ethnicity, age, region, frequency of incarcerations, region in the county, alcohol and other drug use, etc. was collected. Results: 95% of women receive a contact per week up to 3 months after the birth for mothers who retain custody of their newborn. 95% of women develop an Individual Care Plan. 80% of LEV client deliveries were placed with their mothers. 50% of women are placed in alcohol and other drugs residential programs. 80% of women learn about resources available to them. Feedback: To date, women in WCDF (pregnant and non-pregnant) continue to request LEV services. Women, the Sheriff and Detention Health Services have indicated that LEV is a viable service. Women communicate to Sheriff, Detention Health Services, other WCDF staff, and LEV that they feel supported during their pregnancy.
Objective 2: LEV will work with detention facility staff to advocate for policies and best practices to support pregnant incarcerated women to achieve optimal birth outcomes. Performance measures: LEV will facilitate the California Shackling Law’s implementation during Labor and Delivery at CCRMC. LEV participates in countywide reentry planning meetings and advocates for gender-specific services. Data: LEV and FMCH manager conducted two meetings with WCDF Lieutenants and staff and one meeting with the Office of the Sheriff Commander to discuss implementing the January 2006 California Shackling Law at CCRMC. Results: Since, November 2009, the Shackling Law has been implemented at CCRMC. Detention Health Services and Healthy Start Martinez regularly consult about the health status of pregnant incarcerated women. In addition, Healthy Start Martinez and CCRMC Labor and Deliver staff regularly consult, as well. Feedback: Prior to delivery LEV women are educated and informed about the Shackling law and thus are made aware of their rights. They are informed that restraints make it difficult for doctors to adequately assess the condition of the mother and the fetus, and to provide prompt medical intervention when necessary. Restraints also make the process of labor and delivery more painful. Women detained at WCDF and go to CCRMC to deliver their babies are no longer shackled.
Objective 3: LEV will work to help improve system organizational change practices when working with pregnant incarcerated women. Performance measures: LEV consults weekly with detention nursing staff on community resources and best practices regarding supporting incarcerated women; LEV educates providers such as jail nursing staff, deputies, health and social services providers, outreach workers, community based organizations and builds collaborative relationships in order to provide services to LEV clients; Health delivery and information is coordinated between the County perinatal program and WCDF. Data: In order to meet WCDF staff needs in improving their current system of care LEV participated in a variety of activities. These include the following: weekly meetings with detention nursing staff; in March 2010 and March 2011, LEV provided conferences and workshops that educated providers about pregnant incarcerated women; invited Healthy Start Martinez to attend a Detention Health Service staff meeting to support case consultation about pregnant incarcerated women; LEV attended CFS/CCHS collaboration regarding inequitable number of CFS referrals from CCRMC; participated in strategic reentry planning and monthly reentry meetings to advocate for gender specific supportive services for pregnant and reproductive age women who were formerly incarcerated. . Results: Healthy Start Martinez and CCRMC Labor and Deliver staff regularly consulted about the health status of pregnant incarcerated women. Mom and Baby Care Plan was developed and revised by LEV for use. LEV actively participates in reentry meetings. Feedback: WCDF staff report that more women request LEV services; WCDF staff feel more informed and supported around working with incarcerated pregnant women; and WCDF staff welcome and look forward to future LEV workshops.
In June 2011, First 5 ceased funding 50% of LEV. Moreover, CCHS has committed to sustain one full-time case manager for LEV. FMCH funds the LEV Medical Social Worker position. These funds are matched with Federal Financial Participation (FFP) federal funding. This funding does not, however, cover LEV management and overhead costs. Systems sustainability has also been facilitated through the collaborative and multi-disciplinary teams that support this practice, i.e., the Sheriff, other CCHS programs (AODS, MH, Hospital and Clinics), County Office of Education, CFS, reentry efforts and community based organizations. Services for incarcerated pregnant and reproductive age women are now considered an integral component of the services we provide to clients. These services are expected by the women, in the community a by the staff within WCDF. Based on the health equity and life course perspective framework, LEV has not only been a service for incarcerated pregnant and reproductive age women, it has been a practice that simultaneously focuses on addressing racism by successfully engaging and retaining low-income African American women who are experiencing the worst perinatal outcomes.
There is a need to expand LEV services to include more non-pregnant reproductive age women. Additional follow up and assistance to the parent(s) and/or care givers is needed to assess for proper development of the newborns. The Contra Costa Community College District (Contra Costa College, Los Medanos College, Diablo Valley College) has been a resource to orient and train student intern volunteers to work in LEV. A meeting to leverage this resource has already been initiated. LEV will continue to track positive outcomes and document LEV accomplishments. Stronger CCHS epidemiological organization is being created to develop a more thorough evaluation processes. Strengthening evaluation processes will promote continued and expanded funding. A great deal of time and research goes into resource development activities to expand funding for this program. To succeed in sustaining and expanding this practice over the next few years, we must bring in outside funding sources. Cross-sector grant funding is feasible through the continued partnerships that have been created and are being maintained through this practice.