Thousands of women enter jails and prisons while pregnant each year. As Rewire and other media outlets have documented, jails and prisons are often ill-equipped to address women’s medical, physical and emotional needs during pregnancy. Despite their pregnancies, they are still subjected to punitive practices common in correctional facilities throughout the United States. These range from placing women in solitary confinement and shackling them during labor and delivery, to ignoring urgent requests for medical care, sometimes with fatal results.

Dr. Carolyn Sufrin, a medical anthropologist, OB-GYN, and assistant professor at the Johns Hopkins School of Medicine, knows all of these facts. She’s been called upon to testify in numerous lawsuits against jails that have failed to provide adequate, and at times critical, reproductive and prenatal care to women in their custody.

Sufrin spent more than four years as the OB-GYN at the San Francisco County Jail. Once a week, she walked into the jail, past the metal detectors and the security staff, to administer reproductive health care to the women locked inside. More than half the people she saw inside the women’s health clinic lacked health insurance pre-incarceration. Many also lacked stable housing, employment, and access to drug or mental health treatment. As in cities and towns across the country, incarceration disproportionately affects people of color; most of the women in the jail were Black, though Black people comprise only 6 percent of San Francisco’s population.

What she learned, over the course of those years and through many conversations, is that jail was not only a place of punishment for many women, but also their safety net. It was the place where they received medical care and made plans to change their lives and to become the mothers they desperately wanted to be for their children.

In her forthcoming book Jailcare: Finding the Safety Net for Women Behind Bars, Sufrin illustrates this paradox—that for many women, jails often provide the medical care and routine stability that they lacked on the outside, allowing them to explore their maternal identity. She spoke with Rewire about this unexpected finding as well as the ways that jail care illustrates the failure of the safety net to provide the most marginalized with health care and other survival needs. At the same time, she is clear to emphasize that medical care behind bars is often inadequate, and sometimes life-threatening; in her view, the care available in the San Francisco Jail is the exception rather than the rule.

Rewire: In Jailcare, you explore the ways in which jail can and has served as a space for women to receive health care—essentially filling a void for many women who don’t have care outside. How do you grapple with both understanding this, promoting better services in jails and prisons, while also working to challenge the patterns and structures of the criminal system? Is it possible to do both at the same time?

Carolyn Sufrin: That’s a central tension that I feel in my work and in my own positionality. The way I grapple with it is by reminding myself of the women themselves and their stories. It is essential that we work for broader system change so that women don’t have to see jail as a place where they can get prenatal care or other health care, that they don’t have to experience jail as the only place where they’re going to be provided with a relative version of safety compared to their lives on the streets.

We can advocate for those kinds of changes while also ensuring that the care they receive while they’re in jail meets the community standard of care and is comprehensive. This does not mean that we should make jails less safe or less resourced to provide health care so that we can make communities more resourced. We need to work on both at the same time.

In the book, I describe the San Francisco jail, which is by no means perfect, but relative to many other systems, fairly comprehensive and equivalent to community standards of care [or public health care available on the outside]. We need more jails to provide that level of standardization. I think it’s possible to advocate for improved health care inside jails at the same time we advocate for improved services and criminal justice reforms outside of jail.

Rewire: Sometimes jail and prison practices prevent people from accessing health care. For instance, at Rikers Island, New York City’s island-jail complex and the second largest jail in the United States, only 80 percent of scheduled health-care appointments were seen, while scheduled mental health care [appointments] were 70 percent. This is in part because it’s up to the housing unit officers to submit lists of health-care requests to medical staff, and they don’t always do so. In addition, last year, only 30-to-40 percent of off-site medical appointments were fulfilled. Can you talk more about the potential barriers to accessing health care in a restricted environment?

CS: In some cases, there are issues of limited resources that prevent people from getting sustaining and important health care. Sometimes it’s indifference or inappropriate triaging about what constitutes a serious medical need.

Yes, we need more resources, but we also need to ask the bigger question of why we’re locking up so many people with health-care needs. It should give us pause to ask why all these people end up behind bars.

Another issue is not only the need to have handcuffs or secure transportation for going off-site to medical appointments. Going to the hospital in handcuffs and orange jumpsuits can be humiliating especially if patients might see people from their community. They may prefer to avoid that situation, even if it means avoiding health care. I took care of several patients in the San Francisco jail, including a woman with cervical cancer, who did not want to go to the hospital because of who she would see and how they would see her.

Rewire: Throughout Jailcare, you point out that the San Francisco County Jail is uncharacteristic of jails in the rest of the country. Can you explain more?

CS: Prisoners have a constitutional right to health care, based on a Supreme Court case from 1976 that determined that prisons and jails must provide health care and to not do so is cruel and unusual punishment. But the caveat is there’s no specificity to what comprises that health care, and so what you get is incredible variability. There’s no standardization of care that is required, and there’s no oversight.

Health care in jails and prisons is extraordinarily variable. At some facilities, there are people who may have medical licenses that aren’t up to date, or they’ve had their licenses revoked. There are people who may not be qualified to provide health care. Jails and prisons may be inadequately staffed, inadequately resourced. Some have protocols that only allow basic emergency care for those who are incarcerated, but not tending to their routine chronic illnesses or preventive health care. You have situations where people are forced to pay money in order to see a health-care provider in jail or prison, and these are people who already do not have much money and also don’t have access to their own money while incarcerated. Requiring co-payments for health care is also a deterrent.

There are also places that contract health care to outside private corporations. Oftentimes, the contracts that emerge from those arrangements can lead to cost-cutting care that does not meet the actual health-care needs on the ground. For many, health care in jails and prisons can make their conditions worse.

In San Francisco, what exists is a fairly comprehensive set of health-care protocols that is modeled on the health-care system in the community. Some of that comes from the health-care structure; they’re under the auspices of the San Francisco Department of Public Health, and many of the same processes and protocols that exist in the community public health clinic exist in the jail.

That also means there’s a broader perspective that acknowledges the public health dimensions of providing health care to people who are incarcerated. In addition, San Francisco is known for being a progressive city and there tends to be an understanding that providing health care to people in jail is part of a broader mission of helping the most vulnerable people in the community, and that is a priority for San Francisco. It is not common to have that orientation.

There are other jails that provide health care that is substandard, in some cases dangerous and very bare bones.

Rewire: How do you see U.S. Attorney General Jeff Sessions’ approach to drug policy affecting the criminal justice system, particularly with regard to the criminalization of taking drugs during pregnancy. You interviewed several women who avoided medical care while on the streets specifically because of the criminalization of drug use during pregnancy. How will this change under Sessions?

CS: Most likely, we’re going to see a regression of trends of the last ten or 20 years. I say regression because, in the last five years, we have been starting to see a glimmer of positive change in criminal justice reform. You can see this reflected partially in the numbers. For the first time in three or four decades, in 2015, we saw a slight drop in the number of women behind bars. In 2014, it was over 220,000. In 2015, it was 211,000. We’ve seen a drop for men over the past few years, but that was the first time we saw a drop for women [rather than an increase].

I fear now that, with the reinstatement of tougher sentences and penalties for drug-related crimes, we’re going to see a reversal of that trend. It’s going to disproportionately impact women because most women are behind bars for nonviolent crimes and often, though not exclusively, for drug-related crimes.

With the criminalization of drug use during pregnancy, although there was some recent encouraging news in Wisconsin, we have to be concerned that we’re going to see these laws and enforcement increase. Instead of investing in drug treatment and mental health treatment, women are going to be criminalized. The appointment of Sessions and his commitment to roll back the progress of criminal justice system reform are deeply tied to the rollback on health-care reforms and reinvesting in safety net programs. It’s all tied together and only going to make things worse for women in the criminal justice system.

Rewire: On a related note, you wrote: “The jarring failure of the safety net is inextricably tied to, among other things, government policies, underfunded public education and mental health care, and tremendous income inequality.” How do all of these inequities tie into the idea that jail is a safety net where judges should send pregnant people for the health of their fetus?

CS: We need to focus on making jails so that they’re not part of the safety net and instead reinvest in a stronger safety net so that judges don’t even have the mentality that jail is “better” for pregnant women. Fundamentally, it is still a place of punishment, where women are separated from their babies once they give birth. The women I talked to, they wanted to succeed. They didn’t want to be living on the streets. They didn’t want to be addicted to drugs. They wanted to be able to use their education, to enhance their job training skills and have employment.

One of the women, whom I called Evelyn, actually had training from a culinary institute but because of her criminal record, she had a hard time getting a job, and this contributed to her cycle of not being able to have a stable income [and] housing. She didn’t have drug treatment that met her needs. All of these conspire against these women to make it impossible for them to have a sense of stability outside of jail, and it made it possible for a judge to imagine that jail would be a good place for a pregnant woman. We need to get that out of people’s imaginations.

Rewire: We don’t know how many people are pregnant in jails and prisons each year. Talk about your research project to address this lack of information.

CS: We have no idea how many pregnant women there are behind bars, how many give birth every year, and how many have abortions, miscarriages, stillbirths and other pregnancy outcomes. [Sufrin and her research coordinator, both of whom are based at Johns Hopkins School of Medicine] are conducting a study that includes 22 state prison systems, the federal Bureau of Prisons, and six jails, including the nation’s largest jails. They are reporting to our database once a month for a year with reports of how many pregnant women there were in their facility and their outcomes. We’ve been pleasantly surprised by how many state systems wanted to participate and the geographical diversity. We’re entering the final months of this study and don’t have any data to share yet.

That we’re doing this data collection speaks to several absences in our system. One is, in general, when it comes to health care outcomes in prisons and jails, there’s no systematic surveillance. Number two, women in particular, especially pregnant women, are largely neglected in health-care systems and policy reform discussions.

Having this data will give us the scope of these issues and make the case for services for pregnant women while they’re in custody and also build the case for programs and reforms that help pregnant women in places other than jails or prisons.

Rewire: You recall your first encounter with the shackling of a woman in labor as a first-year resident in Pennsylvania in 2004, six years before the state passed a law banning shackling during pregnancy. You wrote, “I was deeply troubled by this moment, and horrified at my own complicity in the act. A scripted authority figure in the birth room, I did not demand that the guard unshackle the mother.” Why not?

CS: I felt disempowered. That is a funny thing for a physician in our society to say because society invests physicians with a lot of power. I felt very disempowered to ask a law enforcement agent to do something for the health and well-being of the patient. That was in part because I was a young new physician and it was in part because the officer had various weapons on his belt. Also, it was such a confusing situation that I didn’t know what I could ask. It’s possible that if I had asked the guard to remove the shackles that that would have happened, but I was just so overwhelmed and confused that I didn’t feel like I could.

Now, if I were in that situation, I would insist on removing the shackles. I know the rules now by state, but at the time, I felt really confused and disempowered. I suspect that other health care providers who do not know the laws in their state might feel the same way.

I hear [similar stories] often from colleagues who work at hospitals around the country where they occasionally take care of incarcerated patients. It doesn’t happen routinely that they see these patients in the hospital, so when it does, they’re not sure what to do and what the policies are.

Rewire: What recommendations do you have for health-care providers who might find themselves in that position?

CS: Work with hospital administration to have policies in place that are consistent with state law and, more importantly, that are prioritizing patient care. Devise those protocols, or enhance them if they already have them. Work with the local jail and prison administrators so that everybody is on the same page when it comes to having that policy in place. So it’s working together and also educating health-care workers on specific units of the hospitals, such as the obstetrics units, so they know what is allowed and what is not allowed and they know what their power as the health–care provider is.

In the moment, remember to prioritize patient care. We have the authority to demand that guards and law enforcement agents enable our ability to provide health care.

Rewire: Do you believe we will see an increase in jail care being the primary or only source of medical care for some if the Affordable Care Act (ACA) is repealed?

CS: I do. The ACA, while not a perfect answer to health care for vulnerable people, made a genuine concerted effort to expand that through Medicaid expansion, through requirements for coverage for mental health and addiction treatment and family planning. Those things are going to fade away if the ACA is repealed, if it’s revised. We’ve already seen hints that those elements of safety care are going to be shaved away. That’s only going to compound the problems that we’ve already seen in terms of people being enmeshed in the criminal justice system because of mental health and substance abuse. What we’re going to see is going to make jailcare worse.

Jails are not mental health–care providers. They’re not hospitals. They’re places of punishment. They’re not going to be equipped to deal with these increased burdens.

Rewire: What are you hoping that policymakers will take away from your book?

CS: Two things I hope they will take away. One is that we need standardization and oversight of health care in prison and jails. Having a constitutional mandate is not enough.

Number two, comprehensive criminal justice system reform. That’s a broad ask, but in particular, one area that could help, particularly women and mothers, is comprehensive bail reform. So many people who are there are there for minor offenses or haven’t been convicted of anything but don’t have the money for bail. Comprehensive bail reform is one way to decrease the number of people behind bars because it’s tied with poverty and inequality.

Rewire: What are you hoping that the general public will take away from your book?

CS: I’m hoping that people will take away the recognition that there are women behind bars and there are pregnant women behind bars. The default assumption is to imagine a man. And as they recognize that there are women behind bars, they develop a sympathetic understanding of the challenges they face.

What we do to these women behind bars tells us about society more broadly and how we value women and reproduction and how this plays out in how we view reproduction for poor women and women of color who are disproportionately represented in incarcerated populations.

This interview has been lightly edited for length and clarity.