Inequality on the inside: Using hospital data to understand the key health care issues for women in prison

Is good-quality health care being provided for women in prison? As the government proceeds with plans to build 500 more prison places for women, this new Nuffield Trust analysis uses HES data to look at women prisoners' use of hospital services, finding that they face a series of challenges and risks in prison because of barriers to accessing health and care services.

This new research, which was funded by the Health Foundation, underlines the challenges and risks women in prison face because of barriers to accessing health and care services. 

All prisoners have a right to receive the same standard of health care as people in the general population, irrespective of the situation in which they are currently living. Women in prison have distinct health care needs, and with the government recently committing to building 500 new prison places for female prisoners, getting a full understanding of how effectively health care is being provided for women in prison is vital.

We find that that pregnant women in prison are almost twice as likely to go into preterm labour compared to the general population. Prisons and those staffing them have not been well equipped to deal with these challenges, potentially putting both mother and baby at significant risk if they are unable to reach the hospital in time.  

Our work also finds that more than a fifth of midwifery appointments are being missed by pregnant prisoners, with a key reason for missed appointments being a lack of available escort staff. 

We have also collated data on the number of women in prison with children under the age of two. As data has not been routinely collected, it is very unclear whether this group and their children are receiving adequate support. Our figures suggest the capacity of mother and baby units throughout the prison estate in England could be overwhelmed if everyone who was eligible or would benefit from them were using them. While not all women will be able to go to mother and baby units, it is important to understand current need and demand and to project into the future to make sure capacity is sufficient and facilities are appropriate. 

A summary of the key findings is provided below, and this is followed by a series of recommendations based on the findings, which we developed jointly with stakeholders. Download the PDF above for the full detail.

Key findings

Pregnant women in prison are more likely to experience preterm labour than women in the general population.

Babies born premature have a higher mortality rate than those born full term and an increased risk of disability (Tommy’s). Of 127 women in prison who gave birth between 2016 and 2019, some 11% went into preterm labour and delivery. This is a significantly higher proportion than in the general population, where 6.5% of births were premature across a comparable time period for women of the same age. While there have been strides to at least acknowledge and plan for the unique health care needs of pregnant and postnatal women in prison, this highlights that although the number of pregnant women in prison may be small, the risks to these women and their babies are very real.

There are no official data on the number of women in prison who have children. Our work can fill in some of this gap. In 2019/20, 212 women had given birth in hospital within the four years before going to prison, 109 within the two years before.

While it is important to support the needs of pregnant women in prison, a much larger group of women have children before they spend time in prison and the needs of these women (and their children) need to be better understood. This information is essential to ensure that women who have had children before entering prison are able to access the right care and support. For example, the consequences of maternal separation for physical and mental wellbeing can be significant. It is vital that wider work on supporting families (for example through visits) is aligned with health care, recognising this impact.

Access to hospital services is poor and this is a long-term issue.

Access to services is an important part of good-quality care but women in prison continue to face challenges accessing hospital care. This is a long-standing issue that is showing little sign of improvement. In 2019/20 just under 45% of all outpatient appointments for women in prison were missed (n = 3,929). This is likely to be a symptom of wider problems the prison estate faces, in particular around staff availability. Prisons do not always communicate the reasons for delays in hospital care well to women and uncertainty around when appointments will happen, and fewer options for self-care in the interim, are a significant source of stress.

Hospital data highlight the complex needs of women in prison, particularly around trauma and substance misuse.

Meeting the health care needs of women in prison requires targeted support and recognition of the impact of previous trauma. Our work shows that the experiences women have had before prison, such as domestic abuse, directly impact on their health. We found hospital admissions as a result of brain injury and violence, which may be linked to experiences of domestic abuse before prison. In 2019/20 there were 28 hospital admissions by 25 women where diaphragmatic hernia (which in adults is often a result of blunt force trauma) was recorded as a diagnosis.

Substance misuse plays a part in a significant proportion of hospital admissions by women in prison.

In 2019/20 just under 30% (356) of inpatient admissions by women in prison had a diagnosis of substance use recorded. In the male prison estate there was a much higher number of admissions where substance use was recorded (2,680), but as a proportion of all admissions by male prisoners, substance use had less of an impact, making up under 20% (19.8%) of admissions. Stakeholders raised concerns that the management of substance misuse may lead to other health care needs being overlooked.

Women’s sexual and reproductive health care needs are not talked about openly and symptoms of normal changes to the body, such as the menopause, as well as conditions such as endometriosis, are not well understood or managed.

The lack of priority in terms of women’s health can impact on all women, but for women in prison, managing their reproductive health and normal changes to their body linked to the menopause can be particularly hard. Women in prison cannot always access the advice and support they need, and practical things, such as changing bedsheets to manage night sweats, or exercising as a lifestyle measure, may not be possible.

Recommendations

Ensure women have access to good-quality, understandable and targeted health care information.

Commit to better data collection to inform planning and address inequality.

Better understand and address the needs of those with children as an urgent priority ahead of the new prison places.

Acknowledge and address the range of reasons why hospital appointments might be missed.

Partners

The Health Foundation

Suggested citation

Davies M, Hutchings R and Keeble E (2022) Inequality on the inside: Using hospital data to understand the key health care issues for women in prison. Report, Nuffield Trust.