Opioid use disorder (OUD) is a growing United States (US) public health concern affecting pregnant individuals and their children. Between 1999 and 2014, the prevalence of OUD in pregnancy increased more than four-fold, to 6.5 cases per 1000 delivery hospitalizations in 2014 (Haight et al., 2018). Simultaneously, maternal mortality rate from OUD quadrupled to 48.5 deaths per 100,000 live births and is responsible for 5.6% of maternal deaths (Hogan et al, Mitra et al., 2020). OUD is also associated with adverse birth outcomes including poor fetal growth, preterm birth, birth defects, and neonatal opioid withdrawal syndrome (NOWS), a postnatal withdrawal syndrome occurring in infants exposed to opioids in utero (Yazdy et al., 2015, Patrick et al., 2020).

Many pregnant individuals with OUD interface with the carceral system annually. An estimated 3% of women admitted to U.S. jails are pregnant, projecting to nearly 55,000 pregnancy admissions per year (Sufrin et al., 2020). Data from a 2020 national study found that 14%, roughly 8000, of pregnant women admitted to jails had OUD, a number which has steadily increased from 2010 to 2019 (Jail Inmates in 2020, 2022, Sufrin et al., 2020). Moreover, incarceration during pregnancy or the postpartum period is associated with an increased risk of opioid overdose within 12 months of delivery (Nielsen et al., 2020). Certain subpopulations of women are already at greater risk of opioid use and delayed diagnosis of OUD including rural women and women of color (Villapiano et al., 2017, Gao et al., 2022, Kozhimannil et al., 2018). Fear of being reported to law enforcement or child protective services (CPS) deters substance-using pregnant women from seeking prenatal care, substance use treatment, and social support (Stone, 2015). This is particularly concerning for Black women, who are disproportionately incarcerated at twice the rate of white women. Black birthing individuals are also four times more likely to be reported to CPS than their white counterparts despite similar rates of substance use (Paltrow and Flavin, 2013, Harp and Bunting, 2020). Thus, structural racism contributes to the policing, criminalization, and reproductive oppression of pregnant Black women, leading to adverse maternal and child health outcomes (Hayes et al., 2020).

The standard of care treatment for OUD during pregnancy is long-term treatment with opioid agonist pharmacotherapy, also known as medications for opioid use disorder (MOUD) such as methadone and buprenorphine (Opioid Use and Opioid Use Disorder in Pregnancy, 2023). Detoxification, or withdrawal, is not recommended in pregnancy due to higher rates of relapse and overdose death as well as lower rates of treatment retention (Terplan et al., 2018). MOUD in pregnancy has been associated with improved maternal, perinatal, and neonatal outcomes including a lower risk of maternal overdose, preterm birth, low infant birth weight at term, as well as a lower risk of post-incarceration drug use and overdose (Brinkley-Rubinstein et al., 2017, de Andrade et al., 2018, Green et al., 2018, Krans et al., 2021). These benefits underscore the importance of access to MOUD treatment for pregnant and postpartum people in custody.

Despite the evidence supporting the provision of MOUD for pregnant women, many do not receive treatment (King et al., 2021). While the proportion of pregnant women with OUD admitted to publicly funded substance use disorder (SUD) treatment programs has increased from 17% in 1996 to 41% in 2014, the proportion of pregnant women receiving MOUD has stayed roughly the same—at around 50% (Short et al., 2018). Furthermore, an individual’s carceral history negatively affects their access to MOUD, with women referred by criminal legal institutions receiving significantly less access to MOUD compared to women who were self-referred to the treatment programs (Short et al., 2018).

The implications of MOUD provision in jails differ from prisons because jails are locally operated, short-term (<1 year) confinement facilities with weekly turnover rates around 50% (Jail Inmates in 2020, 2022). Therefore, jails are a critical step in the continuum of care for incarcerated pregnant individuals with OUD (Brinkley-Rubinstein et al., 2018, Knittel et al., 2020, Ducharme et al., 2021). However, the availability and provision of MOUD in jails are widely variable. As reported in our team’s 2022 national, cross-sectional analysis of U.S jails, only 60% of surveyed jails continued a pregnant person’s pre-incarceration MOUD; only 32% of jails both initiated and continued MOUD in pregnancy. Even among the jails that did provide MOUD, less than one-quarter continued MOUD in the postpartum period (Sufrin et al., 2022).

Although carceral policies for treating OUD among incarcerated pregnant people exist, there is little effort to formally classify, compare, and codify these policies in practice due to lack of institutional governance, oversight, and capacity. Given the unique, intersectional challenges faced by incarcerated pregnant people, greater attention must be devoted to addressing the needs of this population. This study aims to characterize the variability of MOUD jail policies for incarcerated pregnant people and assess how well they align with self-reported practices.