Date of Award

1-1-2024

Document Type

Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Rafael Pérez-Escamilla

Second Advisor

Rebecca Shlafer

Abstract

The United States incarcerates women at the highest rate globally (Fair & Walmsley, 2022), while simultaneously failing to provide incarcerated individuals with adequate reproductive health care. Perinatal programs, including a combination of one-on-one and group prenatal and postpartum education, labor and birth support with a doula, separation support, and lactation care have been implemented as an alternative to standard care in around 21 states (Wilson et al., 2022). While the efficacy of these programs among incarcerated individuals has been established (Bard et al., 2016; Barkauskas et al., 2002; Schroeder & Bell, 2005; Shlafer et al., 2018; Shlafer, Saunders, Boraas, et al., 2021; Shlafer, Davis, Hindt, et al., 2021), the process of program implementation has not previously been explored. The objective of this study was to identify facilitators and barriers to implementing enhanced perinatal programs in seven state prisons in order to inform future program initiation. As part of the Enhanced Perinatal Programs in Prison (E4P) Study, we conducted semi-structured retrospective interviews with thirty-eight stakeholders representing diverse roles in seven states currently providing perinatal services, including DOC administrators, doula staff, and hospital personnel. The codebook was developed following the EPIS (Exploration, Preparation, Implementation, Sustainment) Implementation Science framework (Aarons et al., 2011). We identified six main facilitators (moral obligation, precipitating events, physical access to the facility, relationships and partnerships, champions, and pragmatism) and four key barriers (resistance, bureaucracy, lack of consistency around application of policies, and power imbalances). These results highlight the importance of legislation in codifying doula programs as well as provide insight into strategies for implementation of future perinatal programming in other states as a provisional effort while simultaneously continuing advocacy for expanded decarceration and furlough policies.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 05/07/2026

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