Reproductive Health Care for Incarcerated Women: Promoting Justice Through Research

>> DENISE: So first, I want to welcome everyone to the U3 lecture series The purpose of this series is to educate people about the health disparities among populations of women who are (1) understudied, (2) underrepresented, and (3) underreported in biomedical research

So, those three things are where we get the U3 abbreviation My name is Denise Stredrick, and I have the pleasure — I get to coordinate the U3 program and bring really smart people to the NIH to talk to you about various populations And you know, I have to confess that there are times when we'll bring people in to discuss populations that I didn't even consciously realize were populations Or maybe better wording is that they're forgotten populations And that is why I think that this program is so important

That's also why I'm excited that you decided to take time out of your day to hear about one such population And that's incarcerated women So, today we are privileged to have Dr Carolyn Sufrin tell us about her work with incarcerated women Dr

Sufrin is a medical anthropologist and an obstetrician-gynecologist specializing in family planning at Johns Hopkins University She's an assistant professor in the department of gynecology and obstetrics at the School of Medicine She's an assistant professor in the department of health, behavior, and society at the Bloomberg School of Public Health And she's the associate director of the Center for Medical Humanities and Social Medicine at Johns Hopkins University She has worked extensively on reproductive health issues affecting incarcerated women, from providing clinical care in jail to research, policy, and advocacy

Her work is situated at the intersection of reproductive justice, health care, and mass incarceration Dr Sufrin was a BIRCWH Scholar And BIRCWH stands for Building Interdisciplinary Research Careers in Women's Health During that time that she was a Scholar, she conducted the first prospective study to collect data on pregnancy outcomes in U

S prisons I hope I have given you a small taste of what you can look forward to over the next hour Now I'm going to pass the mic over to Dr Sufrin

Dr Sufrin? Are you on mute? >> CAROLYN SUFRIN: Nope >> DENISE: Oh, there you are Can you hear me? >> DENISE: Yes >> CAROLYN SUFRIN: OK

It might have just taken a moment Well, I wanted to say thank you so much, Denise, for that introduction And thank you to the Office of Research on Women's Health for hosting this webinar I'm very excited to be virtually with all of you today to talk about some of the things I've learned over the years in conducting research with this group that certainly meets the criteria of all three of those U's So I'm going to pause for a moment and share my screen and hope that this has — OK

Slideshow — here we go Sorry I can't get to my icon in the corner here There we go OK

OK Hopefully, everything is up and running for folks and you can follow along with my slides If not, hopefully my narration of it will take you along So again, thank you very much And what we're going to discuss today are, just at a very basic level, why should we care about research on issues facing incarcerated women, especially reproductive health issues? So I'll give some background on our criminal justice system and reproductive health care and who the people are who are incarcerated

And then I'm going to highlight some of the research that I and my group, ARRWIP, which I'll tell you what that stands for, because it's an important part of our research mission But that's the name of my research group at Johns Hopkins So I'll share some highlights from our group's research and from research that I've done in the past And then I'm going to also spend a lot of time discussing some of the unique considerations of conducting research with and about incarcerated women So, a little bit of background on incarceration in the United States and why we should recognize its connections to health and health care

There really are some profound social and health foundations to thinking about mass incarceration And "mass incarceration" refers to the phenomenon of the last four decades in the United States where we have seen an unprecedented and exponential rise in the number of people behind bars And that rise has not been proportional and is differentially distributed across different population groups, as I'll describe The phenomenon of mass incarceration is something that we could spend hours, days, weeks, months talking about But it is a phenomenon that is deeply rooted in our country's history and present of racism and white supremacy

And these come to bear on health and the health care experiences of people behind bars Incarceration itself is a social and structural determinant of health and also has — it has deep roots in people's pre-incarceration health but also impacts their health once they leave institutions, as well as while they're there And for a variety of reasons, some of which will become apparent as I go through further the background today, mass incarceration is a public health epidemic If we think about the connections that make us think of a problem as public health and as an epidemic, mass incarceration and the effects that it's had on individuals' bodies and psyches and on the communities really make it a public health issue and an epidemic So specifically thinking about women — and I'm foregrounding this before even getting into more background in incarceration, because oftentimes, women are neglected, not discussed, forgotten, and so I really want to foreground this

So, in the United States, there are, according to the latest statistics from the Bureau of Justice Statistics, over 225,000 adult females in prisons and jails across the country And those data come from the 2017 census This represents an increase of 26% from the prior year So we continue to see the number of women behind bars rising, while overall, we see a decline in the incarcerated population

This represents a substantial increase from 40-plus years ago And since 1980, there's been a 750% increase in the number of women behind bars And this graphic, from The Sentencing Project, shows those numbers and distributed by jail, State prison, and Federal prison So you can see that it continues to rise for all women And it's a pretty substantial exponential rise since 1980

So, most of these women in the United States are mothers — and are mothers to young children And these are people who were the primary caregivers prior to being incarcerated So when you think about the incarceration of females in this country, it's not only about those individuals; it's about the impact that it has on their children, on their families and communities when the primary caregivers of these children are left behind 101 00:07:57,370 –> 00:08:03,370 In addition, relatedly, the majority of these women are between the ages of 18 and 44, or what we commonly think of as reproductive age Most of these women are arrested for property, drug, or other minor charges

And while some women also are arrested, convicted, and serving sentences for violent charges, it's important that while this may help us think about some of the reasons why some people are incarcerated, that in no way means they deserve less health care or less-quality health care than people who are convicted of other charges But it is important to think about this when thinking about the overlaps between the social determinants of health that characterize many people's lives and also the pathways to incarceration We know that women have been disproportionately affected by what has commonly been called the war on drugs, which is a very broad term but refers generally to a series of policies and laws and judicial enforcements that have resulted in, for one, in people with drug addiction being managed in prisons and jails disproportionately rather than with drug treatment in the community So these trends and longer sentencing for drug-related charges, these have disproportionately affected women And one way you can see this is by the rates of increase in incarceration, but we also see this in how women continue to rise

And if we compare rates of incarceration between 2005 and 2017, we've actually seen a pretty substantial drop in the male population of people in jail — a 12% drop — but a mirrored increase in the number of women who are in jail And so women remain the fastest-growing subsection of the incarcerated population in the US As I alluded to, and it's something that I can't emphasize enough, the profound racial disparities and inequities in our system of incarceration are true for females, as well as the overall population, and Black women are incarcerated at about twice the rate of White women Now, while every individual woman who is incarcerated is different, there are certainly some trends

And we know that among incarcerated women, research has shown that they have a high prevalence of sexually transmitted infections, and that's often related to the high rates of being engaged in sex work and not having access to adequate sexually transmitted infection treatment, prevention education, and screening So we see very high rates of STIs and also very high rates of mental illness and prior histories of trauma And these are higher when compared to nonincarcerated women, as well as incarcerated men And I really want to emphasize the mental health and trauma issues and just how high those rates are And I would say in my own clinical experience when I was providing health care in a jail, I would say that more than 90% of my patients had histories of prior physical or sexual abuse

So even higher than what some of the literature shows And that's really important when thinking about research questions, providing clinical care, or other services is recognizing the trauma, the potential post-traumatic stress disorder that women experience but also the re-traumatization that many of them may experience while being incarcerated So now, stepping back again to talk more broadly about the United States and our context, so we have the largest and most expensive prison system in the world And this graphic represents rates of incarceration So, although we certainly don't have the largest population of any country in the world, we have the highest incarceration rate — higher than other countries which we may think of as being extremely punitive

But we have the highest incarceration rate And that reflects the ways that our society has come to rely on incarceration for a variety of things — for managing social and health problems, in many ways Certainly, that is not the express purpose of it, but by default and by policies that have been implemented, this has contributed to this phenomenon of mass incarceration and our high incarceration rates There are many, many things that characterize our system, and there have been hundreds and hundreds of books written about it We read about it all the time in the news media

And so it's really hard to boil down our system to one or two or three or four key characteristics But for the purposes of the ways that I think about research questions and reproductive health and reproduction in this setting, there are four key themes that I think emerge and are important to ground this in One is that our system is characterized by high cost and, actually, profit So, it's estimated that our country spends at least $80 billion a year on prisons And there are actually several corporations that profit off of incarceration from privately running prisons, from privately running health care services, and from other activities, as well

It is characterized, as I have already mentioned, disproportionately by people of color It is characterized by high recidivism rates, meaning that when people get released from prison or jail, they're extremely likely to be rearrested and come back to prison or jail And if part of the purpose of our system, which some argue would be a failed purpose, but a part of the purpose is to help reform people, if they are, indeed have been convicted of something, we are doing a very bad job of preparing them for reentry and helping them reintegrate into society And our system is also characterized by its mass proportion This graphic, you don't need to worry about the exact numbers

Just look at the shape of that curve from 1980 until now Just the steepness of that rise in incarceration rates and the number of people behind bars in the United States And it's estimated now there are about 22 million adults behind bars on any given day, compared to about 500,000 in 1979 And that exponential rise, again, relates to a complex set of social, political, and economic phenomena

So, related back now to the racial inequities in incarceration, the legal scholar Michelle Alexander has written a very often-cited and well-read book called "The New Jim Crow," which details the ways in which our current incarceration system is a legacy of Jim Crow segregation And if you haven't read it and you're interested, it's a very good and important read, and it really outlines the racial differences and inequities in incarceration rates in a very easy-to-understand and well-researched way From a health care perspective, one way to think about it, too, is about addiction and drug use We know that people who are — Black individuals and White individuals in this country have equal rates of drug use But Black individuals are 13 times more likely to be in prison for drug-related crimes

And although they comprise about 14% of the US population, they represent nearly half of the incarcerated population These disparities are true for females, as well as males Another important distinction to understand in our country is the difference between prison and jail

And I'll be honest, before I started working as a physician in a jail about 13-14 years ago, I had no idea what the difference was But there are a lot of differences that have implications for research and for health care So, prisons are generally under State and Federal jurisdiction People are in prisons because they're serving a sentence if they've been convicted of a felony-level charge In addition, if they are on parole and they have violations of their parole, they will often serve their sentence in prison

People in prisons are generally serving sentences that are longer than a year And geographically, prisons are often located far from people's communities Someone goes to a particular prison based on their classification level on their crime, on other things related to their custody, not because of where they were arrested or where their family is And many prisons in some States are located in rural areas So that has implications, especially, for mothers who are incarcerated

They may be very far from their children Jails, on the other hand, are typically under city and county jurisdiction They hold people who are detained pretrial, where people who have been convicted of a crime that are awaiting sentencing or awaiting transfer to prison People who are serving a sentence in jail are typically serving a short sentence And they're typically more minor crimes, more minor charges that people are in jails for

And so jails are very high-turnover places There's a lot of transition Sometimes people have unpredictable release dates They may be there for a few hours, 24 hours, a week, a few months Depending on where you are, the median time length of stay in a jail might be 1 month or 4 months

But they're very high-turnover places Jails are located within communities, within the places where people live Someone gets arrested and generally goes to the nearest — the jail that's closest to where they get arrested So that also has implications when thinking about continuity of health care upon release and connections with people's families So now, very briefly, just a little bit about health care for incarcerated people

There are lots of ways to think about it And one of them is a public health perspective We know that people who are incarcerated and who are cycling through the criminal legal system, they generally have poor status pre-incarceration And that's often related to various social determinants of health that characterize their lives and often that they've had limited access to health care So, when they become incarcerated, they have access to health care, although it's highly variable what that looks like

And so it often becomes an opportunity for new diagnoses As an OB-GYN and reproductive health provider, one of those is pregnancy And many people first learn about a pregnancy when they get their screening in prison or jail It's also a moment for people to access preventative health care, as well as maintaining care for chronic health care But prisons and jails can actually, in addition to providing health care to people who may not have had access, can be health hazards for people, depending on the environment that people are in — the chronic stress that people experience while inside, the violence they may be exposed to

In addition, you may note that I put the word "opportunity" in quotes People often refer to this, you know, as an opportunity to provide health care But that perspective needs to be placed in the broader context of the fact that it may appear that way because in the community, many people who are incarcerated may have had limited access to health care But prisons and jails are not health care providers They are places of confinement and punishment

And so thinking of it as an opportunity really misses the mark of diagnosing the deficiencies of our broader systems in the community Prisons and jails should not be thought of as health care providers, although they do have an obligation to provide health care And then, of course, most people are ultimately released into society And there's a lot that needs to be done at that vulnerable and important moment of release when it comes to continuity of health care, recognizing the competing priorities that people may have And reflecting what a vulnerable and important time this is, a landmark study out of the State of Washington found that in the first 2 weeks from release from State prison, people had a nearly 13 times greater odds of dying in those first two weeks when compared to community-matched controls

One of the leading causes of death was overdose But this is a very vulnerable time, and so a lot of research can and should focus on that release care Now, there's also a legal perspective on health care for incarcerated people They actually have a constitutional right to health care Prisons and jails are constitutionally mandated to provide health care

And that relates to the Eighth Amendment's prohibition on cruel and unusual punishment and a Supreme Court case from 1976 in which the Supreme Court affirmed that prisons and jails are required to provide health care and not to do so would be cruel and unusual punishment But what's important is, the wording from this Supreme Court decision is somewhat vague Justice Marshall said that the deliberate indifference to serious medical needs of prisoners is cruel and unusual punishment But there is no official definition of what health care services count as a serious medical need And that ability to decide, that discretionary open power, leads to a lot of variability

So when we think about what health services delivery looks like on the ground for incarcerated people, it really depends So there is no mandatory standardization Now, there are several voluntary accreditation programs that exist that advance voluntary standards There is a variability in terms of what health care services are routine, versus what can be requested, what's available on-site, versus off-site, versus just not available at all At some places, they require incarcerated people to pay in order to see a health care provider in prison or jail

And these are people who already have limited resources So that's a barrier that can impair access to health care for people There are some prisons and jails that have chosen to contract out their services to private corporations And so that also has implications in terms of the variability and accountability and, in some cases, the profit motives for providing health care So, when anyone asks me what health care looks like for pregnant incarcerated people or what are the standards or how often are pregnancy tests done, all I can say is it depends

And that presents a challenge but also a lot of opportunities when it comes to research Now, when it comes to thinking about women's health in the setting of health care in incarcerated settings, women's health has really received limited attention Because they represent a smaller proportion of the incarcerated population, there has often been neglect And in addition, people sort of assume that they are the same or interchangeable with male incarcerated people And they presume female — they neglect, rather, women's gender-specific health care needs

It sends the message that males are the default prisoner And we see this highlighted really notably when we have conversations — whether it's research or advocacy here or legislative, in the media — about issues like shackling pregnant women in labor or the ability of incarcerated people to have access to menstrual hygiene products Women are still shackled in labor There are only 29 States that have laws prohibiting it, and even in States that have laws, it still happens The fact that we have to have a conversation about a practice that is dangerous and that is a human rights violation signals again that women are often an afterthought

The same is true with needing to pass laws, which only a few States have, but ensuring adequate access to menstrual hygiene products So, again, these deficiencies and the neglect and the variability, it means that there are a lot of gaps and a lot of — a potential large impact that research can have And understanding these things, this is a matter of health equity and health justice when we think about the people who are behind bars and how forgotten they are and also how vulnerable the situation of incarceration is in the power dynamics So research really has the potential to promote real policy change and have a real impact on people's lives to support alternatives to incarceration and also to ensure that until that time comes, women get the health care that they need while they're in custody So now, with that background in mind, I want to share just some examples of recent and some past research from our group at Johns Hopkins

Some research that my colleagues have conducted at other institutions and since I've been at Hopkins has focused largely on family planning And what these research studies have found is that there's an unmet need for family planning in incarcerated settings And some people may be scratching their heads, thinking, "Family planning, huh? Contraception — do women need access to contraception?" And the short answer is yes These are women who are predominantly women of reproductive age Some of them enter correctional facilities on birth control methods, and they should be allowed to continue those as they would any chronic medication they're on

And also, ultimately these women are going to be released into society And so this is part of their comprehensive health care And so some of the research that we've conducted that supports that include various needs assessments that we've conducted with women who are just entering jails And have found that most of these women have been pregnant before And most of them have been sexually active with men in the either weeks or months, depending on which study, prior to their arrest

A landmark study by my colleague in Rhode Island, Jennifer Clarke, has found that most of these women planned to be sexually active with men upon release And research that we've conducted has also shown that on admission to prison or jail, most women were not using a reliable method of contraception And most women did not have positive attitudes about pregnancy So you can see, this is depicting a picture of women who we know are of reproductive age, who are heterosexually active, not using birth control, and don't want to be pregnant, so there is a need for family planning And in addition, about 60% said that they wanted to access contraception while they were in custody

Now, I do want to also highlight that although one of these studies found that 77% did not have positive pregnancy attitudes, there are women who do have positive pregnancy attitudes and want to be pregnant upon release And so it is also a moment for truly family planning and preconception counseling and helping them think about next steps when they get out So although there is a need for accessing contraception for people who are incarcerated, contraception is infrequently available for either continuation or initiation And one study of health care providers in prisons and jails that we conducted found that only 38% had birth control available on-site And only about half of providers who were surveyed said that women could continue their pre-incarceration methods

So that also presents some challenges when they get released from prison or jail They are not on a method of birth control that they had been using before, and they're at risk for an undesired pregnancy We've also found, when we look at the need for emergency contraception, that nearly one-third of women entering an urban jail, at the San Francisco jail where we conducted this, had had unprotected sex within the last 5 days before arrest and wanted to get emergency contraception In our survey of services, we found that abortion services were inconsistently available, even though we know that incarcerated women retain their legal right to abortion while they're incarcerated And we've also highlighted programs and shown ways that it actually is feasible to provide contraception in prison and jails

Now, as I've already highlighted, a majority of these women in prisons and jails in the US are of reproductive age and have not been using contraception before they enter into institutions And so some of them are going to be pregnant So, how many? Well, previously in my research and my background sections, I would cite some statistics like this: 6 to 10% of incarcerated women are pregnant

Or 3 to 5% There are about 1,400 births per year But as I started citing these statistics over and over, I really started to question where they came from And I realize that they're incredibly outdated and not systematic in what they report And so my group conducted a study that reflects this notion that, you know, the lack of data signals women who don't count don't get counted

And the women who don't get counted, well, they don't count when it comes to — if we don't have the data, how can we inform policies that will change things and improve conditions for them? And so to address this gap in knowledge, we conducted the Pregnancy In Prison Statistics (PIPS) project And this was my BIRCWH project, so I want to acknowledge the Office of Research on Women's Health for this and also funding from the Society of Family Planning So, the PIPS study was an epidemiologic surveillance study in which we collected data on a monthly basis from participating prisons — mostly prisons — and jails across the country to report certain pregnancy outcomes And this was a voluntary study, but we were able to recruit 22 State departments of corrections, getting State-level data We also got participation from the Federal Bureau of Prisons

And because there are over 3,000 jails in this country, we knew that we were not going to be equipped to collect data systematically from jails So we decided to focus on the five largest jails in this country We also used snowball sampling, and through our recruitment, one small jail just asked if they could participate, and then three juvenile detention facilities also participated But primarily, PIPS was focused on prison- level data And although we don't have all 50 States, our data do represent information from — that represent 57% of women in prison in the United States

Now, from a research perspective, I really want to emphasize that being able to get this level of recruitment really relied on my collaborative networks that I've established over the years with other academic researchers but also with Government agencies and nonprofit advocacy organizations So the National Institute of Corrections and the National Resource Center on Justice Involved Women were really very helpful in promoting recruitment for the study through their materials And I was able to indicate in my recruitment materials that they supported that In order to get the Bureau of Prisons to participate, I did have to get a letter from several representatives of Congress, and that's what convinced DOJ to agree to participation So it was a long process, but ultimately, they did agree to participate

So, I'm really excited to share with you some of the results from our study And these were published in March online in the American Journal of Public Health These data are open-access So if you are interested, you can freely download the publication But the key findings from the study — and it's just from our prisons; we haven't published the jail data yet

But there were approximately 1,400 pregnant people who were admitted to these sites in one year There were about 750 live births, 46 miscarriages, 11 abortions, 4 stillbirths, 3 newborn deaths, 2 ectopic pregnancies, and no maternal deaths Of all the pregnancies that happened in the study, 6% were preterm, which is actually lower than the national preterm birth rate of about 10% And the cesarean delivery rate was 30%, which is pretty close to average Now, one of the most striking findings of the PIPS study is actually the variability from State to State

So, the highest preterm birth rate from one State was 16%, which is significantly higher And the highest C-section rate from any given State was 58%, which is significantly higher So it's important to think about the disaggregation of these data by State I am eager to get out the many other results we have to share from the PIPS study So, we have to share our — publish our results on the pregnancy outcomes in jails and our three juvenile detention systems

We collected data on opioid use disorder in pregnancy, both in policies and on outcomes And I should mention that in addition to collecting the monthly outcomes data that people reported to our study database, we also, at baseline, collected information about various policies related to pregnancy care and services — so some of those policies related to how they treated pregnant women with opioid use disorder Did they go through withdrawal? Did they have access to methadone or morphine? So we are excited to publish those results soon And in fact, these PIPS data, as an example of how — they certainly fill in some gaps, but they also create other research questions And so I am now funded by a K23 from NIDA to further investigate opioid use disorder in pregnancy management in our Nation's jails

We are also going to be publishing more detailed information about abortion and contraception policies from our PIPS sites; other pregnancy policies and services, parenting programs, and policies around the use of restraints; other medical and mental health comorbidities, like diabetes, hypertensive disorders, mental health conditions, other substance use disorders We'll be publishing information on tubal sterilization occurrence and policies and information on breastfeeding and what happens to the infants after they are released So I'm going to be busy Our team is going to be busy, and we have a lot of information to share and get out there An important limitation of the PIPS study is that we collected aggregate de-identified data

So each reporter designated at our participating sites, they just reported a number each month There were 20 pregnant women admitted to our prison this month But we didn't have any information on the demographics of these women They were all de-identified And while that was important, an intentional design of our study, a limitation is not only that we don't have detailed demographics about people but also each number represents a real lived experience for a person who experiences pregnancy behind bars

And those experiences are profoundly different for everyone and can be extremely isolating and stressful, among other things And so our team is also conducting a qualitative study on people's lived experiences of pregnancy and incarceration and how the experience of being incarcerated impacts their pregnancy- related decision-making In addition, I have also conducted ethnographic research This was actually my PhD

dissertation My PhD is in medical anthropology And for my dissertation research, I conducted ethnographic research of the San Francisco jail on pregnancy care and other health care among women and also spent time with them and jail workers, both in and out of jail, and published these findings as a book, published by University of California Press

There's a lot of findings from this research, but one of the key findings and the argument that I make in the book is that jail has unwittingly and unfortunately become an integral part of the medical and social safety net for many women who are on the margins of society And although many women only were able to access health care in jail, that doesn't mean that we should think of jails as good places or that we should try to make jails more harsh to discourage people from being in jails It really, again, diagnoses the failings of our broader society if their lives are so chaotic and in such disarray that jail is the only place where they can find care So now, after highlighting just a little bit of our group's research, I want to move on to talk now about some unique research considerations for conducting research in this setting, and especially on reproductive health and health care issues One of the things that I certainly didn't think about my language very intentionally when I started this research over a decade ago, but it's something I'm much more critically thoughtful about now, and I feel like it's constantly evolving

So, for instance, I do reproductive health care research I'm an OB-GYN, and most of the people I take care of and do research with are women However, there are transgendered individuals who are incarcerated and people with female anatomy but may not identify as women, and they can be pregnant, as well And so in order to be trans-inclusive, I often use "person" or "individual" But sometimes I do use "woman" or "female," especially when the person herself identifies as female gender

I also do this when I'm referring to statistics from other studies or from publicly available information that refer to them as women or female The term "inmate" is one that is very commonly used and commonly understood to refer to someone who's incarcerated And I'll break that down in a second, but I would encourage people never to use the word "offender," although that is used among people, administrators who are on the custody side of things who work in prisons or jails It's a very pejorative term, and it's not person-centered at all Similarly, "felon," "convict," "criminal" — these are all very loaded terms and very discriminatory

I have started veering away even from using the term "inmate" and instead just describing the person as who they are — incarcerated person, incarcerated individual This is person-first language It also makes incarceration an adjective, a temporary state It's not the noun of who they are In addition, "correctional" is commonly used — correctional facilities, correctional health care

And that is, you know, that comes from the context of thinking that prisons or jails or the tradition of prisons and jails being places where rehabilitation happens, that we can somehow correct people's behaviors But I've found that that word, "correctional," is loaded It has a specific history to it And in addition, it implies that the problem with incarceration is with the individual's behavior that needs to be corrected rather than recognizing that incarceration is a complex political, social, racial phenomenon And then I think relatedly, "correctional facility" and even "facility" is just sanitizing

And so I prefer to be direct Instead of using "correctional," I say "carceral" That includes the root form of "incarceration" And then for "correctional facility," I just call it what it is If I'm talking about a prison or a jail or a detention center or if it becomes too wordy to list all of them, then I say "institutions of incarceration

" In addition, "guard" or "CO," or "correctional officer," that also can be variable And although I personally have not explored how people who work in prisons and jails feel about the terminology, just anecdotally, some of them do not prefer this language And so a common term instead is "custody administration" or "custody staff" So that's just a little bit on language And I think it matters in how we communicate in our publications and in our instruments and with research subjects

I also want to talk about the fact that when studying incarcerated people, we need to think about their perspectives And the organization the National Council for Incarcerated and Formerly Incarcerated Women and Girls taught me this phrase I don't know if they coined it, but it's something they use a lot "Nothing about us without us," meaning if you're going to do research that will impact us, you need to involve directly impacted folks And that means everything from designing your research questions and making sure there are things that matter and that will have an impact, hopefully a positive one, on the directly affected people, making sure that the methodology that you're proposing is appropriate and ethical, and even getting input from directly impacted people on what the best methodology is — qualitative, survey, epidemiologic surveillance methodology — also, at the very least, getting input on survey instruments and interview guides

And we do this in our group We have a network of people whom I've collaborated with who are previously incarcerated who are willing to look at and provide input But we always provide them with compensation for their time, recognizing their expertise And I believe that ethically, that is important Relatedly, from a methods perspective — and this comes strongly from my anthropological training — recognizing the researchers' own positionality

And as feminist scholar Donna Haraway once wrote, "there is no view from nowhere," so we always have to recognize where we are coming from in our methodology and how we're asking questions and that our own identities — my identity as a white physician at an academic university, that shapes how people perceive me and how I ask questions, what I might be missing, the degrees that I have, the institution I'm with, my lack of personal experience of being incarcerated — all of these things matter, as do the power dynamics that are inherent to the researcher and research subject Now, there are a lot of ways and a lot of potential sources of data on research in this area, in addition to research with incarcerated subjects The Bureau of Justice Statistics is congressionally mandated to collect certain demographic data every year from jails and prisons across the country And their data is free and downloadable if you just go to their website, and I use it all the time I can't tell you how many times a week I go to their website

They don't typically collect robust health care data, and every several years, they do publish some information on medical issues But unfortunately, the information they have on health care is limited And so if you want to do database research or policies, you have to go to individual State and county websites or the Federal Bureau of Prisons But there is a lot of information that is publicly available There is a lot that is not, which speaks to the broader issue at the beginning of the neglect of focus on this population and just how opaque these institutions can be

Probation and parole offices and officers can be a source of information and also a place to recruit subjects who are previously incarcerated, especially that it can take time to get approval and recruit incarcerated subjects Freedom of Information Act requests can certainly be sent to prisons and jails to collect information And then, you know, some people, myself included, want to collect information on policies at jails I mentioned there are over 3,000 jails at least in this country, and so really trying to understand what's happening, there must be some comprehensive list of jails that are available, right, just, like, you know, all 50 States so we could somehow contact their DOCs? Well, no There actually is no comprehensive list of jails that you can look at

So trying to do any systematic research on jail policies is very challenging There are a lot of things to talk about when thinking about having incarcerated people as research subjects I think we're all aware that there is a long and unfortunate, really shameful history of coercion and exploitation on incarcerated subjects from pharmaceutical trials that harmed people And as a result, there are a lot of safeguards in place, appropriately so And it does raise the question, Are they able to consent? These are people who give up most of their rights

They are in an inherently coercive environment And I think ultimately, they can consent, but you have to be cautious and careful in how you go about doing that And some ways to do that that I've learned from my IRBs in the past are to think about additional safeguards Sometimes we've had waiting periods for consent in between when a research assistant tells them about the study and then returning a few days or a week later to see if they're interested in participating You have to be careful about confidentiality and their decision to participate and make sure that their nonparticipation will not impact their receipt of health care, their legal proceedings, how they're treated in custody and keep that confidential and that there are are no consequences for them

There are a lot of regulatory considerations, and I'm actually not going to spend much time on this, because there's a lot of publicly available information And I'm sure everyone's IRB has information about this, as well But there are Federal regulations on doing research when incarcerated people are research subjects They're classified as a vulnerable population or vulnerable research subject Each IRB has to have a prisoner representative on the committee when reviewing your research application

There are also regulatory considerations, in terms of getting approval from Department of Corrections or jails If you actually want to go in and recruit incarcerated subjects, you absolutely need approval from those sites to get access, and they need to know about your study and approve it Sometimes that also — it's also good to have a backup document that's an MOU or data transfer agreements But beyond those regulatory considerations, there are also a lot of logistical considerations that you might not have thought of You have to get security clearance to enter a site, and that often requires fingerprinting, a background check

There are very strict dress codes, and they vary from prison to prison and jail to jail There are a lot of things you cannot bring — phones, of course, but some research things, like audio recorders, pens, research tablets These are things you have to get approval for, and often you have to get a special clear bag that you bring everything in You can't go whenever you want You have to follow their routines, their schedules, and work that out ahead of time as to what times you're able to go

Are you allowed to give people copies of their consent form? Can they have staples in them? And if not, then no staples You should have a phone number on the consent form so that people can contact you or the IRB, but it needs to be a phone number they can reach and one that can accept collect phone calls Compensating research subjects — that's a complex set of ethical discussions And some people do worry that it's coercive But I believe that if a research subject is giving their time, then they should be compensated, and so my studies always provide some level of compensation

But we often have to conform it to the prison or jail where people are Are you going to have private space in which to conduct research — if you're doing interviews or surveys, for instance? So, with all of these logistics, my research group has developed an approach and a template form where we discuss certain operational logistics with custody and health care administrators at the start of each study so we can be on the same page, know when our team can go, etc, etc Follow-up with incarcerated subjects can be challenging If they're still in custody, it's quite easy, but if they're out of custody, you have to follow a lot of different leads

And there has been some research published on what strategies are successful If collecting this information from research subjects ahead of time so that if they get released during the study, you have a way to follow up with them Doing research in this setting requires a lot of patience and flexibility, a lot of waiting You may be waiting in the prison waiting room for an hour or two before you're allowed to get in And then you might be waiting in the housing unit or the clinic for another hour for them to bring the patient or the research subjects to you

Unexpected things, like lockdowns or if the person has a court appearance — these can all interfere with things, and you might spend 6 hours visiting a prison hoping to get one subject, only to find that on that day, you don't get anyone So now, in the final few minutes, before we switch to the discussion, I want to talk about advocacy and then why it's important and how we've used research that we've collected in order to have an impact, either directly or indirectly And I've already, you know, at the beginning, painted the picture of how there are tremendous inequities in our system of incarceration This comes to bear on people's health and unequal health outcomes, and especially with reproductive health and reproductive health care And so it's important to our group that we conduct research that can improve things and that is meaningful

And that is reflected even in our research group's name And I want to acknowledge my former research coordinator Lauren Beal, who — together, she and I brainstormed this name: Advocacy and Research on Reproductive Wellness of Incarcerated People And we thought about each and every word We thought research, that was pretty much a given, since we're at an academic center and research is what we do But we also do advocacy and try to make our research meaningful for change

We thought about reproductive wellness, as opposed to just reproductive health, recognizing that it's not only about health but many other aspects of people's lives and families We even thought about the preposition "of" and what would be appropriate and not cumbersome And then incarcerated "people," not "women" So, with our group, some examples of how we've incorporated advocacy, well, one project that we conducted in collaboration with colleagues at the Baltimore City Health Department, we did a reproductive health needs assessment at the Baltimore jail and found that there were needs for family planning services, among other things We summarized this and made recommendations to the State and local jail system

And they saw this, and they said, "OK, we need to make some changes" But earlier, in our interactions with them, before we had done this research project, they didn't really — we had presented the national data that existed, but they wanted to know what was happening in Baltimore It wasn't enough to know what a study in Rhode Island or San Francisco showed It was having local data that then led them to change their policies And so that's really important when thinking about things you could do locally

In terms of the PIPS study, from the start, advocacy was important And so we implemented that as our main results were being published And we promoted our results widely on social media, in the media, with interviews, and other things We have a study website that we promote So we definitely promote the research

We wanted our research publication to be open- access so that people could see the full publication We also presented the raw data by States So the tables in our study break all the raw numbers down by State so that people in their individual State can use the data and do what they want with them Some examples of what some of the participating sites in PIPS have done, so Cook County jail, they used the data that they were reporting to the PIPS study to make a case for not incarcerating pregnant women who were in their third trimester if they were arrested on nonviolent charges So now Cook County doesn't incarcerate pregnant people in their third trimester unless they are arrested for violent charges

So really, a policy change in terms of decarceration The State of California declined participation in the PIPS study And I noted that in the methods section of the academic publication, and somebody in the California legislative system and the Department of Corrections and Rehabilitations saw this and contacted me to find out what happened with that, why did California decline participation, and then came to me and said, "Well, based on these data that you found in other States, what recommendations do you have? Can you help us so that we can start to collect these data?" So this was really exciting for us to see that even nonparticipation effected some policy movement In addition, there is a House resolution, the Pregnant Women in Custody Act, that has a provision in it that is basically the PIPS study, meaning that it requires institutions of incarceration to collect pregnancy data This is still on the floor, and I'm not sure where it will go, but it's great to see it in legislation

So, before we open it up to questions, I just want to summarize a few key points, recognizing that mass incarceration has really deeply racialized roots And this has implications for health care and for research Incarceration and reproductive health are deeply intertwined with each other, and therefore, there's a tremendous role in the value of research And it's an overlooked area of research, but conducting thoughtful research in this area is absolutely essential to improving health care, promoting equity, and advancing health justice for everybody So with that, I want to thank everybody, and I think we will open it up to discussion

>> DENISE: Dr Sufrin, thank you That was a wonderful talk And we already have questions So, everyone can start sending your questions, but I'm going to give you the first question we have

Can you discuss home visiting programs in prison, specifically Family Spirit, because it is culturally sensitive to American Indians They make up over 50% of South Dakota's State prison population but only 8% of the State population That's the question they asked >> CAROLYN SUFRIN: OK, great Well, thank you for sharing that

It's important for everyone to understand that every State also has different demographic profiles of who's incarcerated But I think what unites it is that marginalized communities that are discriminated against in many ways are often the ones disproportionately incarcerated So although I didn't talk about Native populations, obviously that is true in South Dakota and other States So if I heard the question correctly, you were talking about the Family Spirit program If that's a formal program, I'm not familiar specifically with that one

In terms of visiting programs for mothers or parents who are in prisons or jails, it is highly variable whether those exist at all and what they look like We do know more generally that maintaining parental-child bonds when people are incarcerated is really important for the children and that there are profound intergenerational effects on children of having a parent who is incarcerated and that visiting programs do not get rid of those problems but they're one way to address and ameliorate some of those issues and maintain connections However, the data on those programs are limited and variable And it really depends on the kind of programs There are some prisons that have really robust visitation policies with frequency and the kind of contact that's allowed

But there are other places where visits only happen by video And when you think about the fact — when I mentioned that many prisons are in rural places and it can be really hard for children and family members to travel to these places, but they might They might travel hours and hours, get to a prison, and then all they get is a video visit, a video conference visit, in the prison Or if they're allowed a person-to-person visit, they're not allowed contact And then some places don't even have contact visits at all

There's a lot to be said about visits with newborns for people who give birth while in custody, and there's, again, a lot of variability in that And there are some programs that do allow women who have given birth in custody to bring their children back to the prison or jail with them But there are only a handful of State prisons and I'm only aware of one or two jails that do this While there is some research to suggest that these — they're often called prison nursery programs — have benefits for the mothers in terms of reduced recidivism rates in the future, you know, it's questionable whether those are women who already were at lower risk for recidivism and that perhaps we should be investing in community-based alternatives to really strengthen the bonds and connections between parents and children So, in summary, I can't speak specifically to the program that the questioner was asking about, but I can tell you that there's certainly opportunity for more research on this

Speaking again to the variability and the opacity of information, there are probably some good visiting programs out there, but there just isn't any centralized clearinghouse of information So we just don't know what best practices are and what they might look like >> DENISE: OK That's perfect And you answered another question that we just received about commenting on mother-baby programs

So that was good Another question is, How dangerous is it for someone who has a prolapsed uterus, and what can we do to help an individual with this issue? >> CAROLYN SUFRIN: So, uterine prolapse is a condition that happens usually to people who've had births before, and it's more common in postmenopausal women, though it can happen in premenopausal women It is a benign gynecologic condition, meaning it's not cancerous, there's no risk for cancer And so it is a condition that can be very uncomfortable and that can be embarrassing, and people can feel a lot of stigma over it And in some cases, it can put people at increased risk for urinary infections and other related gynecologic issues, as well

So, in terms of its danger, it's not something that is an acute problem usually, but it is something that has some health consequences and some important psychological consequences that can affect people's quality of life and functioning In terms of the treatment of this for women who are in incarcerated settings, I would say although the majority of incarcerated females are of reproductive age, there are a lot of women who are older and who are postmenopausal, and we're seeing more and more of that than ever before because of policies like mandatory minimum sentences, life sentences without the possibility of parole So the prisoner population for females is also aging And so probably, health care providers in prisons are going to be seeing — are seeing more of this And so treatment involves referral to a gynecologist or a urogynecologist, who can assist either with pessary management or with surgical management

>> DENISE: OK Can you speak more to strategies for connecting with formerly incarcerated individuals to get their input or consultation on the details of one's research study or methodology? >> CAROLYN SUFRIN: Great question And it's one that I'm actively working on I don't have a perfect recipe yet, and actually, it probably will always be "yet" because I'm not sure that there — you know, there's always room for improvement But some strategies include finding an advocacy organization in your community that works on reentry issues or works with or employs previously incarcerated people or, in some cases, places that work on substance — support people with substance use disorder, because many of them have been incarcerated before

But finding the community-based organizations that might directly service previously incarcerated folks or employ or be led by them So first it's just identifying organizations that you can partner with and then working with them, explaining to them, you know, why research is important, you know, saying, "We want to do research that will help you and people in your position" So being clear at the outset that you have the humility to know your limits And then details like figuring out who ideal people would be, what the outlining — what is the time commitment? Are you going to develop a community advisory board that meets on a regular basis or an ad hoc basis? What kind of a place are you going to meet at? Are you going to be able to provide child care? These are some of the nitty-gritty details that are important to provide And then one that is also very important is compensation — again, recognizing people's time is valuable and their expertise

Also — this is partially related to getting input on research development — but also when people incarcerated or formerly incarcerated people are research subjects, recognizing that sharing — them telling you about their experiences, or what you might call "sharing their stories" — you know, it's not their stories — their lived experience, but, you know, when they share their experiences, it can be traumatizing for them I have some colleagues who are formerly incarcerated and who are very outspoken and are leaders in the policy realm and have had real impact on passing legislation — for instance, in Georgia and other States on anti-shackling laws — and they have had to tell their stories over and over and over and over again about being shackled in labor to lawmakers, to the media And so as myself as a researcher, when people talk to us about their experiences, I acknowledge that at the outset and express gratitude for their being willing to disclose those experiences and their information And I think the same is true when you seek input from formerly incarcerated people on research protocols and development >> DENISE: OK, so along those lines, can you speak — let me see here

Can you comment on the role of the physical environment in the prison on the health of incarcerated women — for example, the presence of lead paint or temperature or ventilation, etc? >> CAROLYN SUFRIN: So, I can't comment in great detail about that, other than to note, as your question brings up, that the physical space of incarceration facilities can be dangerous for people's health, as the questioner already alluded to, with the paint, the ventilation problems Water is an issue And, you know, even if the water might meet chemical standards of safety, sometimes it looks awful I shouldn't say "sometimes

" We don't know how often, but I have certainly heard from people who have been incarcerated at facilities, read media reports of this And it can taste — it can have a really bad taste And it could be room temperature and warm It makes it really hard to stay hydrated, especially if you're a pregnant person There's also the physical conditions of crowding and the impact that could have on transmission of infectious diseases and other conditions

And, you know, this is a brief story about a study that involved focus groups that I conducted at the San Francisco jail And in one of the open-ended questions we asked about, you know, what their thoughts are on health care services in the jail A lot of people, when they heard that question, and what they answered it with was describing what they perceived as unhygienic conditions or the dirty carpeting or how the toilets were dirty or, you know, the physical environment So it is also, you know, something that people living in those conditions notice And then, related, it's not the physical environment but the stress of being incarcerated and the way that people are talked to, the separation, the trauma that it can involve, just being in that environment and not having any choice as to what or when you eat, having to ask permission to go to the bathroom — those psychological stressors can also have an impact on people's health

There is some research being conducted — and I don't know the data myself, I just know that the research is being conducted and is out there — on the environment and impact on obesity and that obesity rates are rising especially in prisons And that has, you know, connections to nutrition and access to exercise and those sorts of things So it's an excellent question I'm not deeply knowledgeable about it, but I know that there is some research about it >> DENISE: OK

From a public health perspective, how much energy do you think we should dedicate to institution-level interventions, such as providing family planning services, versus efforts to reshape the justice system in the United States on a macro level? >> CAROLYN SUFRIN: That is the question I ask myself almost every day And that is a guiding question and balance that I think about with our group's research, and so I don't have a proportion or percent Instead, the way that I reconcile this is that I think we need to do both at the same time I do not have formal training in public policy or law or political science And so I'm not the best person to be developing strategies and working on strategies to reduce our country's overreliance on incarceration

But I know enough that from a public health and a health and a human rights perspective to know that we need to do that And I speak about that I try to emphasize that when framing my research, and I support efforts that focus on that While that is happening and until the day comes when we are a society that has de-carcerated, we cannot forget about people who are there right now, and we cannot forget about the fact that that they have a constitutional right to health care and, frankly, a human right to health care and that in order to ensure that they are safe and they get the health care they need and deserve, we need to do research to make sure that it is optimal and safe and addresses their needs And, you know, the abysmal state of health care in some prison and jail systems is exemplified by the fact that there is a very long multiyear lawsuit brought against the California Department of Corrections and Rehabilitation because of a large number of deaths that happen in custody

And it was determined that this excess of deaths in custody — I mean, there shouldn't be any deaths while people are in custody, but, you know, if you have people there serving a life sentence, you know, someone who's in their 90s, that's, you know, potentially — but an excess of expected deaths in the California system, and they determined that it was related to the overcrowding and to the inadequate medical care, that they couldn't match — the medical services didn't match the need And that made it, like I said, to the Supreme Court And they required the State of California to depopulate their prisons by about 30% as a way to respond to this medical malfeasance So, it's just to speak to the fact that we can and we should work on both We cannot forget about the fact that if we don't try to improve health care conditions right now and try to understand them better and try to also improve things so that when people get released, we can help them with reentry in this very vulnerable time, if we forget about that, then we're putting people — we're perpetuating their risks of deaths

And then, you know, related to the question about visiting programs and my comment about how we don't know, I want to be clear that although there is tremendous variability in health care, quality and quantity, and there are some places where it is downright dangerous and harmful, there are also some prisons and jails that provide excellent care and have innovative programs And yes, they are in prisons and jails and we should still be having these conversations about alternatives and the need to be investing in our communities, but it is also important that we try to find these places that are implementing best practices — for instance, allowing postpartum people to breastfeed or provide breast milk for their babies So that was a great question, and I'm so glad that person brought that up, because that balance is one I think about all the time And I think that both efforts need to be researched and advocated for in parallel >> DENISE: OK

Do you know of any research into how incarceration impacts individuals' ability to construct their desired family size — for instance, people who hope to have multiple children who are incarcerated during their final years of their reproductive window? >> CAROLYN SUFRIN: Yeah, great question So, in terms of systematically asking that question about how incarceration is impacting their family size, I don't know of any studies that have had that, you know, sort of primary focus on that In my ethnographic research, it is definitely something that came up Not so much with the hypothesized situation or — not hypothesized, real situation that the questioner just asked But some of the people in my ethnographic research study, they are women — and they all identified as women — who have been in and out of jail their whole adult lives and many of them their adolescent lives in juvenile detention systems, and when they're not in jail, most of them have the involvement of child protective services in their parental relationships and have not had custody of their children

And so some of the women in my study talked about how they felt that being pregnant in jail, getting prenatal care, getting some parenting classes, even if they gave birth they would be giving birth sober, they felt that this gave them a chance to focus on their pregnancies and their motherhood in ways they hadn't had outside of jail and hoped that it would give them a chance to get custody of their children, ironically, even though they gave birth, at least for the short term, in jail And that is deeply problematic, the way that they've become conditioned to expect the involvement of child protective services in their reproduction So some of my ethnographic research that emerged in that study and then the qualitative research that the ARRWIP group is conducting now is focused on how the experience of incarceration impacts their pregnancy- related decision-making And also, to some degree, we do follow up or attempt to follow up with women after they've given birth, and we try to get a sense of how incarceration has impacted their thoughts about family size So it's a really great question, and it's not one that I think has been systematically studied as the primary outcome

But I think it's really interesting and compelling, especially when thinking about the ways that many of these women are just used to institutions, whether it's prison or jail or child protective services, have been deeply involved in their reproduction >> DENISE: OK Can you discuss a mother's health postpartum over the life course, such as depression, infections, etc, and whether it is adequately addressed for individuals in prison? >> CAROLYN SUFRIN: We don't know That is again a fantastic question

So, if we know little about pregnancy in prison and jails, we know even less about the postpartum time period And I can tell you that in the PIPS study, one of the outcomes we assessed in our supplementary surveys — so for the PIPS study, each month every site had to report the number of pregnant people who were admitted, how many gave births, had miscarriages, abortions, preterm births, C-section, newborn deaths, and maternal deaths, and then we had two supplemental sections that they could choose to answer or not for 6 months And most of them did complete that supplemental section And so one of those supplemental sections asked about postpartum depression And we haven't fully looked at these data

I've just had a cursory look at it So please don't cite this, because I can't, you know, I haven't finalized the analysis But about 6% of women who gave birth in custody were reported as having postpartum depression That is significantly lower than the national rates, and it is significantly lower than I would expect I would expect incarcerated women to have higher rates of postpartum depression, because at baseline, these are women who have higher rates of mental illness, to begin with, and secondly, the trauma that I can imagine is involved in being separated from your child immediately after birth likely has a profound impact on their risk for depression

So I suspect that there is under-screening and that postpartum issues are not adequately addressed in this setting Now, I should also acknowledge that on a national level, in just community perinatal health care, including efforts from the American College of OB-GYNs, there's really a growing recognition that we need to rethink the entire postpartum period and the intersections with health care systems and really revamp how we approach that So I think that we don't know a lot about the postpartum period for incarcerated people But I have a lot of hypotheses that it is a potentially psychologically troubling time, isolating time, and that there are higher rates of postpartum depression than we think In terms of infections, that's something that I haven't seen studied and I'm not familiar with

You know, if someone has any medical concerns after delivery, I would hope that they would be able to access health care in the prison or jail and then, if needed, be referred to an OB-GYN or a midwife outside of the prison or jail if needed But we don't know how all those systems happen And there can often be barriers to people accessing health care systems in prisons and jails >> DENISE: OK This is our final question

Given that there are high re-incarceration rates, is it of interest to treat and empower both the incarcerated person and nonincarcerated family members as a unit? >> CAROLYN SUFRIN: I think that's a really great perspective And I think there's a lot of potential in that Part of it is — and I would encourage research efforts that focus on maintaining linkages between families and individuals from that perspective of empowerment to support their reentry, to try to reduce recidivism and re-incarceration rates, but I would also add the broader context that recidivism and re-incarceration is not solely an individual problem And it is not necessarily an issue with an individual's behavior It is a broader structural problem with how we process and deal with people who are enmeshed in the criminal legal system and the ways that they're set up or not set up on release for housing, for reinstating their Medicaid benefits

One of the things I didn't have time to discuss is that people get — if they have Medicaid or Medicare in the community, that gets suspended when they're incarcerated And then, when you get out, you have to reinstate your benefits And people might lose their access to supportive housing that they may have been living in before incarceration And so there are a lot of structural factors, as well, that can contribute to re-incarceration And so while I absolutely think that empowering the family and the individual as a unit is important and can potentially have a profound impact, it also has to come with the recognition that we need more structural and systemic changes, as well

>> DENISE: So, thank you so much Dr Sufrin, thank you What a wonderful presentation And as a matter of fact, one of the comments that we got from the listeners — someone said, "Amazing presentation from an exceptional speaker

" And I have to say that we agree 100% >> CAROLYN SUFRIN: Aw, well, thank you so much I really appreciate everyone's participation And I just, for the last moment, shared our contact information If anyone is interested further, this is how you can find us

And I hope that some of you will go on to conduct research in this way And even if you don't work with incarcerated people on a research or advocacy or health care perspective, I hope that these issues we've brought up will be of relevance for any underserved group that you conduct research with >> DENISE: Wonderful Thank you so much And we hope to have this presentation on the Office of Research on Women's Health website as soon as possible

But thank you again We really appreciate it >> CAROLYN SUFRIN: Thank you >> DENISE: All right, take care Bye-bye