SystemsnotGetting

Social Science & Medicine 370 (2025) 117881

Contents lists available at ScienceDirect

Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

“The system’s not getting my grandchild”: A qualitative study of caregiver relationship formation for children born to incarcerated mothers Bethany Kotlar a,* , Aisha Yousafzai b , Carolyn Sufrin c , Monik Jimenez d , Henning Tiemeier b a

Harvard Graduate School of Arts and Sciences, 62 Wenham Street, Boston, MA, 02130, USA Harvard T.H. Chan School of Public Health, Boston, MA, USA Johns Hopkins School of Medicine, Baltimore, MD, USA d Harvard Medical School, Boston, MA, USA b c

A R T I C L E I N F O

A B S T R A C T

Handling editor: Medical Sociology Office

Women who give birth during their incarceration in most states in the US are separated from their newborns, who are placed with non-maternal caregivers. Infants of incarcerated mothers are a highly vulnerable population for which caregiving relationships may be particularly important for their wellbeing. Despite this, incarcerated mothers may be responsible for selecting a caregiver with no formal guidance. However, this process is poorly understood. The goal of this study was to understand how families form caregiving relationships during a mother’s incarceration in state prisons in Georgia. Data were drawn from initial interviews from a mixed methods cohort of children exposed prenatally to incarceration. Thirty-six interviews with caregivers and 13 interviews with mothers released from incarceration were analyzed using thematic analysis. Researchers vali­ dated data through focus groups with caregivers and nonprofit staff. Caregivers and formerly incarcerated mothers discussed avoiding child welfare custody when making caregiving decisions. Mothers prioritized care­ givers who they believed would help them reunify with the child. Caregivers and mothers discussed keeping the child with a family member if possible; mothers overwhelmingly preferred their own parents as caregivers. When mothers choose between several potential caregivers, they prioritized the safety and security of their infant, rejecting those who were substance users, had a history of incarceration, had serious health issues, or who they deemed irresponsible. These factors were frequently brought up when discussing children’s fathers as potential caregivers. Thus, choice of caregivers for infants born during incarceration was motivated by family unity and safety and security. Policymakers should target these children and their families for intensive support through social services.

1. Introduction The United States (U.S.) has the highest women’s incarceration rate in the world (Kajstura, 2018). While women account for approximately a tenth of the incarcerated population, their numbers have skyrocketed in the past several decades, increasing six-fold since 1980 (Monazzam and Budd, 2023). Scholars and advocates have proposed this increase to be driven by several factors, including increases in violent crime con­ victions, disproportionate criminal legal consequences for women due to the War on Drugs and a higher reliance on policing lower-level crimes (Sawyer, 2018). Women experiencing incarceration in prison in 2016 reported over 100,000 minor children (Maruschak et al., 2021), and

recent estimates suggest 4% of people in state were pregnant at admis­ sion (Sufrin et al., 2020; Sufrin et al., 2019).

A large body of research has demonstrated that mass incarceration systematically targets marginalized racial groups and the poor (Alexander, 2012; Pettit and Western, 2004; Roberts, 1997), exacer­ bating existing forms of structural inequities (Wakefield and Wildeman, 2014; Wildeman et al., 2018). Women’s pathways to prison are often characterized by poverty, mental health issues including substance dependence, trauma, and chronic illness, all of which are parenting related risk factors for child development (Dallaire et al., 2015). Thus, children of mothers experiencing incarceration are particularly vulner­ able group and at high risk of adverse health and poor social and

* Corresponding author.

E-mail address: bkotlar@hsph.harvard.edu (B. Kotlar). https://doi.org/10.1016/j.socscimed.2025.117881 Received 3 January 2024; Received in revised form 18 February 2025; Accepted 22 February 2025 Available online 25 February 2025 0277-9536/© 2025 Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

B. Kotlar et al.

Social Science & Medicine 370 (2025) 117881

interpersonal outcomes, particularly in infancy and young childhood, a critical period in human development. Yet, there has been little research on the consequences of maternal incarceration at infancy on child out­ comes, and even less on the impact of non-maternal caregiving in the context of maternal incarceration during infancy on child wellbeing.

This research is critical both to inform criminal legal policies that impact pregnant women and to target interventions that would promote the wellbeing of infants of incarcerated mothers.

Studies on the impact of maternal incarceration on children and their families have largely focused on school-aged and adolescent children, with mixed results. While some have linked maternal incarceration to behavioral issues and juvenile delinquency in adolescence and adult­ hood (Huebner and Gustafson, 2007; Trice and Brewster, 2004; Turney and Wildeman, 2015), others have found null results when accounting for pre-incarceration risk factors (Wildeman and Turney, 2014).

Qualitative studies contextualize this heterogeneity, suggesting that for some children, maternal incarceration may lead to no change or an improvement in their lives. Issues such as substance dependence and mental health disorders common among mothers experiencing incar­ ceration are also likely to have strained family functioning and nega­ tively impacted child wellbeing prior to her incarceration (Turanovic et al., 2012). Hanlon et al., 2007. found that among families of substance dependent African American mothers who were incarcerated, nearly 80% of children expressed satisfaction with their caregivers, largely their grandparents, and reported living in a “peaceful and caring” home environment (2005). Other qualitative studies have suggested that while this may be the case for some families, many see the mother’s incar­ ceration as harmful. In a qualitative study of 100 caregivers of children with an incarcerated parent, Turanovic et al. found that most caregivers suffered negative consequences because of their role such as increased childcare duties and financial strain; only 20% described the mother’s incarceration as an improvement, largely due to the removal of house­ hold disruptions due to alcohol and/or drug use and 22% reported no change (2012). Booth, in a study focused on caregivers of children of incarcerated mothers in the U.K. found that while a minority of children were already living with other relatives at the time of the mother’s incarceration, over 80% of mothers were actively engaged in their children’s lives prior to their incarceration. Furthermore, caregivers reported difficulties navigating complex neuropsychological health needs of children, negative impacts on their health, financial wellbeing, and having little support in assuming their caregiving role (Booth, 2020).

There is an abundance of evidence that “maternal incarceration is a stressor that proliferates to engender chronic strains in family life” (Turney and Wildeman, 2018), primarily borne by urban, low-income families (Wildeman, 2009). Caregivers of children of mothers experi­ encing incarceration struggle with poverty (Pendleton et al., 2021), food insecurity (Cox and Wallace, 2013), and housing instability (Shaw, 2023). Furthermore, there is evidence that families of mothers experi­ encing incarceration are negatively impacted through loss of income (Glaze and Maruschak, 2008), potential loss of child support (Arditti et al., 2003), and the cost of legal fines and fees and maintaining contact (Sandiford, 2007). The stress of the incarceration of a family member may lead caregivers to experience poor mental health (Dallaire et al., 2015).

While there are few studies of caregiving in the context of maternal incarceration from birth, this situation could have a more severe impact on family wellbeing than caregiving for an older child. Outside of the limited prison nursery programs or community-based alternatives to incarceration for pregnant women, those who give birth while incar­ cerated are separated from their newborns who may be placed with nonmaternal caregivers (Kotlar et al., 2015). For mothers, this represents both a traumatic separation and a gross violation of the tenets of reproductive justice, i.e. that people, regardless of their race or socio­ economic status, have the right to parent their children free from governmental harm (Ross, 2017). Women of color bear the brunt of

these separations as they are more likely to be aggressively policed and incarcerated than white women (Alexander, 2012; Pettit and Western, 2004; Roberts, 1997; Wildeman, 2009). Caregivers, regardless of whether they feel relief over a mother’s incarceration, may still be called on to assume care of a newborn, potentially in addition to the mother’s older children. The addition of a family member, even in optimal cir­ cumstances, is a significant familial transition. In the context of care­ giver adversity and the stress of maternal incarceration, assuming care of a newborn could increase family strain, with potential consequences for child wellbeing.

In studies of older children of incarcerated mothers, caregiver re­ lationships had consequences for child wellbeing and family unity.

Caregiving is markedly different for children of incarcerated fathers compared to children of incarcerated mothers. When fathers are incar­ cerated, mothers typically care for children. When mothers are incar­ cerated, children are five times more likely to enter foster care than when fathers are incarcerated (Glaze and Maruschak, 2008; Wildeman et al., 2018). Outside of foster care, grandparents or other kin typically serve as caregivers; fathers rarely do so (Stringer, 2020; Glaze and Maruschak, 2008; Hairston, 2007; Pendleton et al., 2021). A study of 60 children of incarcerated mothers between the ages of 2 and 7 years old found that caregiver sociodemographic risk factors predicted child cognitive outcomes, and that the quality of the family relationship mediated this relationship (Poehlmann, 2005a). In addition, caregiving relationships influence frequency and quality of maternal/child contact, with maternal grandparents more likely to co-parent with and maintain contact with incarcerated mothers (Loper and Clarke, 2013). While the literature on parental contact and child wellbeing is mixed, in-person visits with meaningful and quality interactions are associated with improved child attachment and adjustment, better family relationships, decreased parenting distress for incarcerated parents, and improved parenting skills in parents of children between the ages of 2 and 18 (Dallaire et al., 2012; Poehlmann, 2005b; Beckmeyer and Arditti, 2014).

Contact between mothers experiencing incarceration and their children can also reduce recidivism and promote future reunification (Poehlman et al., 2010) and reduce depression in incarcerated mothers (Loper et al., 2009).

Caregiver placement in the context of maternal incarceration can also influence the stability of caregiving relationships. A study including 92 mothers experiencing incarceration found that whether a caregiver placement was the mother’s choice and whether the relationship be­ tween the caregiver and the incarcerated mother was perceived as positive influenced its stability over time (Poehlmann et al., 2008).

Foster care particularly threatens the stability of caregiving relation­ ships and future reunification with mothers (Hairston, 2007). Studies of children in foster care have shown a high rate of placement disruptions, an issue with known negative consequences for children’s social and emotional development (Newton et al., 2000). Furthermore, as argued

by Dorothy Roberts, the criminal legal system and the child welfare system work hand in hand to police families, particularly low-income families of color (2022). Mothers ensnared in both systems find it nearly impossible to reunify with their children (Roberts, 2022). Current federal policy has made maintaining custody difficult for incarcerated women once a child welfare case has been opened. The Adoption and Safe Families Act of 1997, 1997, removed the requirement that “reasonable efforts” be made to reunify children with their parents if parents had been convicted of certain crimes, had abandoned their children, or had their parental rights terminated for another child. States must also file a termination of parental rights petition if a child has been in foster care for 15 or more of the previous 22 months (Pub. L. No. H. R.867). Even if an incarcerated mother’s sentence is shorter than 15 months, her parental rights could be terminated for failure to complete a child welfare case plan within the allotted time. Child welfare case plans often include in person attendance at family court, supervised visitation with children, and intensive therapy and treatment. Carceral policies, which restrict visitation, coupled with the potential lack of parenting 2

B. Kotlar et al.

Social Science & Medicine 370 (2025) 117881

courses or access to therapy or substance dependence treatment make completion of these case plans during incarceration extremely difficult (Halperin and Harris, 2004; Roberts, 2022).

Thus, maternal incarceration from birth can be thought of as a family stressor, necessitating important choices and role shifts within the family system with downstream consequences for wellbeing. Children born to incarcerated mothers are a highly vulnerable group, for whom a caregiving placement is likely to impact their health and wellbeing. For mothers, the choice of a caregiver will influence whether they remain in their infants’ lives during and after incarceration. For caregivers, assuming care of the child may benefit the infant and his or her mother but could have negative consequences for their own health and wellbeing.

Despite of the importance of caregiver choice, only two studies have sought to understand caregiving for children born during their mother’s incarceration. Pendleton et al. focused on caregivers of children born to incarcerated mothers in Minnesota, finding that caregivers were pri­ marily grandparents or other relatives, and that many felt that they were the only option to care for the infant (2021). Rodriguez Carey focused on mothers who gave birth during their incarceration; she found that among the 22 women who placed their infants with caregivers, seven chose foster parents, ten chose relatives, and five infants were cared for by their biological fathers (Rodriguez Carey, 2019). Rodriguez Carey identified three themes: a) the importance of caregiver economic sta­ bility, b) the caregiver’s proximity to the prison, and c) the ability of the caregiver to care for older children in addition to the infant. While these studies provide important preliminary evidence of caregiving for infants of incarcerated mothers, they were not able to interview both mothers and caregivers, thus restricting narratives to a single member of a family system. In addition, both studies were conducted significantly after the child was born, which could influence narratives of caregiving choices.

Pendleton et al. identified and interviewed caregivers up to a year after assuming care for the infant, at which point 55% were no longer caring for the infant. Over half of the interviews conducted by Rodriguez Carey occurred eight years or more after the interviewees’ pregnancy.

The purpose of the current study was to add to the literature on the impact of maternal incarceration from birth by assessing how families formed caregiving relationships for children born during their mothers’ incarceration. In addition, results of this study were used to inform recommendations for policy and practice for caregivers and children of incarcerated mothers. To achieve these goals, we conducted a thematic analysis of qualitative data from postpartum mothers and caregivers of their infant children in Georgia, a state which has a particularly high women’s incarceration rate and restrictive carceral policies, including a lack of policies promoting community-based alternatives to incarcera­ tion for pregnant and parenting women. The purpose of this analysis was to examine how caregiving relationships were formed for infants born during their mother’s incarceration.

were formed. Second, we assumed that caregiver relationship formation was at least partially motivated by the family processes present prior to the birth of the infant. Finally, we assumed that maternal incarceration represented a familial stressor in which previous roles, hierarchies, and feedback mechanisms could change.

2. Methods

In this manuscript, “caregiver” refers to anyone other than the mother providing care. “Mother” refers to biological mothers.

In Georgia, BBB Study participant recruitment was implemented in collaboration with Motherhood Beyond Bars (MBB) (Motherhood Beyond Bars, 2023), a nonprofit organization providing services to pregnant and postpartum women experiencing incarceration, their families, and their children’s caregivers. Staff at MBB approached non-maternal caregivers to explain the study either during the mother’s pregnancy or at the birth of the target child. Participants were enrolled after the birth of the child. Researchers recruited formerly incarcerated mothers on their release from prison.

Intake assessments with caregivers occurred as close to the birth of the child as possible; 91% occurred when the child was three months or younger. Intake assessments with mothers were conducted as close to her release from prison as possible; on average, mothers were inter­ viewed eight months after the birth of the child. Researchers included completed interviews in the sample for this study until saturation was

2.2. Setting This study was conducted in Georgia, which is the state with the 11th highest women’s incarceration rate in the U.S., incarcerating 55 per 100,000 women (Carson, 2021). Approximately 38% of incarcerated women in Georgia identify as Black, and 60% identify as white (Georgia Department of Corrections, 2023). In a one-year period from 2016 to 2017, the Georgia Department of Corrections admitted 85 pregnant women (Sufrin et al., 2019). While Georgia has four state prisons for women, pregnant women are incarcerated at a single medical facility in Atlanta and postpartum women are transferred to a large, rural prison in Northern Georgia.

In Georgia, women who give birth during their incarceration are separated from their newborns shortly after their birth, as there are no prison nursery programs (Kotlar et al., 2015) nor are there systematic community-based alternatives to incarceration (assessed through a state policy review in WestLaw). Furthermore, unless the mother has an open child welfare case and maternal custody is not deemed to be safe for the infant, in which case infants would be placed into child welfare custody, there is no formal process by which caregivers are identified; choice of caregiver is left solely to the incarcerated mother. Although Georgia has high women’s incarceration rates compared to the rest of the U.S., its policy regarding separation of postpartum women from their newborns is typical in the U.S., in which prison nurseries and community-based alternatives to incarceration are rare (Kotlar et al., 2015).

2.3. Sample & recruitment Data for the current study were drawn from intake interviews from the Georgia arm of the Birth Beyond Bars Study (BBB Study), an ongoing birth cohort of children exposed prenatally to incarceration (see sup­ plement for more information). In the BBB Study, children are enrolled at birth along with their primary caregiver, either a formerly incarcer­ ated mother or a non-maternal caregiver. The BBB Study is unable to enroll mothers currently incarcerated due to research privacy and participant safety concerns.

Participants were included in the current study if. a. They were the primary caregiver of a child born during their mother’s incarceration in prison or b. A formerly incarcerated mother who gave birth to a child during their incarceration in prison.

2.1. Theoretical framework This research was guided by the theoretical framework of family systems theory (Kantor, 1975), which posits that families are systems, in which an individual’s choices are constrained by roles, hierarchies, and familial culture. The family system is further embedded in the social and cultural contexts of its environment. Within the family system, behav­ ioral feedback loops among members can either contribute to resilience or harm in individuals. Guided by this theoretical framework, re­ searchers made several key assumptions during data collection and analysis. First, we assumed that caregiving decisions are not made by a single family member, but by the family system as a whole. Thus, we included both caregivers and incarcerated mothers in the study sample and designed interview questions to address the thoughts and feelings of other family members when ascertaining how caregiving relationships 3

B. Kotlar et al.

Social Science & Medicine 370 (2025) 117881

reached. The study team defined saturation as interviews yielding no new themes or relevant content for existing themes. This study was approved by the Harvard Longwood Institutional Review Board (IRB 201215, IRB 21-1247).

described. Transcripts from formerly incarcerated mothers were induc­ tively analyzed. We did not conduct a full coding of these interviews because not all infants represented in the sample had a mother released and we did not want codes from some narratives to be overrepresented.

Conclusions from the inductive analysis were integrated into code de­ scriptions. Full code descriptions were discussed to develop preliminary themes.

To validate themes, the team conducted three “member checking” focus groups, two with staff from MBB, and one with caregiver partici­ pants. MBB staff focus groups were attended by the entire staff, con­ sisting of four participants. Five caregivers were included in the research participant focus group. Preliminary themes were presented to partici­ pants who were then asked whether they agreed with the theme and whether they had anything to add or clarify. Focus group transcripts were used to deepen preliminary themes, but did not yield new themes or quotes. Participant pseudonyms were used for included quotes.

2.4. Data collection The study team drew data for this study from the qualitative portion of the BBB Study intake interviews conducted between August 2020 and January 2023. Authors, in collaboration with other experts in the field and MBB’s Executive Director, Program Director, and program co­ ordinators developed qualitative topic guides. One MBB staff member has lived experience of incarceration, and the remainder have experi­ ence working with incarcerated people. In addition to subject matter expertise, researchers developed questions using the theoretical frame­ works of family systems theory to guide the selection of interview topics and phenomenological theory to guide how questions were posed. The study team designed questions to elicit histories of how caregiving re­ lationships were formed. Interviewers paid particular attention to the mother’s rationale for choosing a particular caregiver as well as any other people she considered. Interviewers asked caregivers why they chose to assume the role of caring for the child. See Table S1 for inter­ view questions. The authors extracted quantitative data on participants’ age, sex, race/ethnicity, relationship to the child, and household poverty.

All but one of the interviews (conducted by BK) were conducted by four staff members from MBB. MBB staff were chosen as interviewers as they had built rapport with participants during the mothers’ pregnancy.

Staff completed training in qualitative interviewing. BK monitored interview quality. BK flagged five early interviews conducted by one staff member as low in data quality. This staff member did not conduct further interviews, and all 12 participants interviewed by her were approached to be re-interviewed by two trained qualitative researchers.

Re-interviews were compared to original interviews to ensure no key details were changed. Interviews were conducted over the phone or Zoom, lasted between 20 and 60 min and were audio recorded. Partic­ ipants were informed that their participation was voluntary and declining to participate would not change their eligibility for services through MBB. Interviews were transcribed verbatim. Researchers compensated study participants $25 for intake interviews and $40 for being re-interviewed (as these were lengthier).

3. Results 3.1. Descriptive analysis of participants Thirty-eight caregivers and 13 formerly incarcerated mothers completed an intake survey during the data collection period. Re­ searchers excluded one low-quality interview, and one audio recording of a caregiver was lost. Thus, 36 caregiver intake interviews and 13 released mother interviews were included.

Most caregivers identified as grandparents (n = 19), predominately maternal grandparents (n = 12). Caregivers also included other relatives (n = 7), biological fathers (n = 3), and a same sex partner. Six had no kinship relationship to the child. Five caregivers identified as men and the remaining 31 identified as women. Ten caregivers identified as Black, non-Hispanic/Latinx; two identified as white, Hispanic/Latinx and the remaining 24 identified as white, non-Hispanic/Latinx. The average age of caregivers was 45 years; seven caregivers were over the age of 55 years. Eleven caregivers reported living under the Federal Poverty Line (FPL) (see Table S2).

On average, mothers were released eight months after the birth of the child. Three mothers identified as Black and the remaining 10 identified as white. All mothers identified as women. Ten mothers were in their twenties and three mothers were in their early thirties. Nine mothers reported living under the FPL (see Table S3).

2.5. Data analysis

3.2. Themes

Qualitative transcripts were analyzed using a thematic analysis approach as described by Braun and Clarke (2006). This method offers a flexible, yet rigorous approach to theme development. Researchers grounded the analysis in phenomenological theory, which posits that experiences are co-created between the subject and the object; thus, an experience can only be described in relation to a subject (Creswell, 2013). While recognizing the subjective nature of descriptions of the experience of forming a caregiving relationship, the goal of the analysis was to identify themes that characterize this experience.

The analysis team consisted of a doctoral student, two master’s students and an undergraduate student trained in qualitative methods and the context of maternal incarceration from birth. The team was led

by BK. Researchers developed a codebook of inductive and deductive codes through intensive reading of six collected transcripts and team discussion. The codebook was further refined through code application in Dedoose version 9.0.86 by two independent coders to 12 transcripts.

Coders completed code application tests through Dedoose until a com­ posite .8 Cohen’s kappa was obtained. Two independent coders coded caregiver transcripts. Coding discrepancies were resolved through team discussion.

To develop preliminary themes, the team read and discussed code excerpts. Codes were grouped according to the research question and

3.2.1. Theme 1: keeping the family together 3.2.1.1. Preference for kinship caregivers. Both mothers and caregivers expressed a desire to keep the child in kinship care. Mothers over­ whelmingly preferred to place the child with their own parents, citing a trusting relationship with their parents as a source of relief that the child would be well cared for. Kiara summarized her reasoning for choosing her mother as a caregiver: “It was a no option kind of thing for me and her … we’re really close.”

Mothers’ preference for kinship care was maintained in situations where a mother/grandparent relationship was strained. Kennedy and her mother Linda had a contentious relationship both before, during, and after Kennedy’s incarceration. Yet, when asked why she had placed her daughter with her mother, Kennedy replied: “I mean, I’m not going to place my baby in nobody else’s care.”

Likewise, maternal grandparents viewed the choice to assume care for their grandchildren as a given. In several cases maternal grandpar­ ents described the caregiving decision as theirs, not the mothers’.

Wendy, a grandparent, recalled, “She said that she didn’t know where the baby was gonna go, and I told her that the baby could come with me.

I mean, we really didn’t have a conversation about it.” Cynthia stated, “I 4

B. Kotlar et al.

Social Science & Medicine 370 (2025) 117881

don’t even know who brought it up, but it was going to be a given anyway … that I would keep the baby.” Maternal grandparents expressed strong ownership and responsibility for the infant. In the words of Linda: “I’m not going to have no one else to take care of my grandbaby.”

When maternal grandparents were ruled out, mothers often turned to other kin, including siblings, aunts, or their own grandparent. Some­ times there was a particular reason a maternal grandparent was not able to care for the child, such as their poor health or substance use. In other cases, mothers approached a more distant family member because they felt more trust with that family member. Paula, a maternal great grandmother, stated: “She (the mother) finally realized that … the length I’ll go is a lot different from things that her mama and daddy will, because of things that happened in the past. I don’t care what’s happened in the past.”

Kinship caregivers also expressed wanting to maintain care of the infant within their family. Nicole, the infant’s aunt, described taking the baby because no one else in the mother’s family was able to do so: “Her other sister and her mom are both in active addictions, so I’m really the only person that was able to take her.”

involvement, nine families shared that the infant’s father was incar­ cerated or had an open court case that could lead to incarceration. Oc­ casionally, this dual incarceration caused changes in the caregiving plan for the infant. Kelsey’s daughter was cared for by her paternal grand­ mother, Dawn, because of her father’s incarceration. Dawn explained, “well, basically, my son was going to do it, and I was going to help him, but he’s been goin’ through some stuff too, so he’s incarcerated right now.”

3.2.2.2. Household suitability. In addition to lifestyle, mothers consid­ ered whether caregivers had the financial resources, whether they had the time and energy, and whether they were “good with children,” described predominately as liking children and having the personality to care for them. Victoria summarized: That’s when I was still with [infant’s father], and he was saying his mom and his sister, and I didn’t want them to get the baby. So, then I thought like maybe my aunt in Alabama, ’cause she doesn’t have no—she has grown children. And then I said if she can’t then I was gonna see if [infant’s father]’s mom or grandma would get the baby if nobody on my side could get the baby … I knew [infant’s father]’s family wasn’t a good choice because, you know, they use and stuff.

So, I wasn’t willing to take that route. And his dad and his stepmom were willing to get the baby, but they wanted custody, and I wasn’t willing to do that. And then my aunt was a good choice just because she doesn’t have any little kids, and she works at the Health Department.

5.2.1.2. Keeping siblings together. Keeping the infant and their siblings together was important to mothers. While mothers stated they preferred all their children to be cared for together, several placed the infant with a different caregiver so as not to overwhelm one caregiver. Cassandra placed her infant, Imani, with Imani’s paternal grandmother as her own mother had custody of an older child and wouldn’t be able to care for both. Courtney and Victoria had older children that were being cared for by their mothers, and both expressed relief when their mothers agreed to take their youngest children. Victoria said, “I was like, ‘I don’t know what I’m gonna do when I get to Helms [prison’s medical facility].’ And she’s like, ‘Well, I’m getting the baby.’ And then I was like, ‘Okay.’ That made me feel better … I just wanted her to stay with family, you know?”

Kelsey placed her child with her mother-in-law over her mother, because she felt her mother didn’t have the time or personality to care for her daughter.

Well, my mom still works full-time, and stuff. Dawn (the caregiver) is retired. And I think those were the only two options, and of the two, Dawn is the most—I don’t know how to word what I’m tryin’ to say.

She’s got other grandkids, and she’s used to bein’ around—my mom’s not used to bein’ around kids a lot, you know? Like she’ll see ‘em, she’ll spend time with ‘em, and then she’s ready to send ‘em home. She’s not—she’s isn’t clear mentally in the capacity to be able to care.

5.2.1.3. Non-kinship caregivers as a last resort. Fifteen mothers in our sample placed their infants with non-kinship caregivers. Most of these mothers considered and ruled out their own relatives before approach­ ing others, including friends or in one case a stranger. Stephanie, a friend of the mother, relayed how she was only approached after the mother had considered kinship options:

5.2.2.3. Caregiving to ensure the infants’ wellbeing. Caregivers discussed accepting the infant to ensure that he or she was safe and well-cared for.

Crystal, when asked why she agreed to take the baby said, “Well, because if I hadn’t, I would have to wonder what she was doing. Or did she go to the doctor’s appointment on time? I feel like the first year of a kid’s life is really, really, really important.” Two maternal grandparents, Diane and Beth, originally declined to take the baby, but changed their minds when no other suitable caregiver was identified. Beth, a maternal grandmother, at first said she would not be taking care of the infant because of her own poor health. Beth said:

She was skeptical about her family. They have a lot of health con­ ditions going on, and she didn’t feel comfortable leaving the baby with them. And so, her mom being 100% disabled, she didn’t have any family member that she would trust to take the baby.

3.2.2. Theme 2: safety and security of the baby When mothers had several potential caregivers to choose from, they considered the ability of the caregiver and their household to keep the infant safe and secure.

Up until he was born, I told her I could not take him physically, mentally, financially, I was not able. I’m 50 years old and I have a lot of leg issues, but I’m dealing with myself. So, my physical health, I knew I couldn’t do it. Her supposedly best friend decided she would take Jackson and keep him [until] she got out … He was born, and the best friend was notified, we went three days later to the hospital.

I went with her to pick the baby up and at the hospital, that was when I decided that this girl was not fit to take care of this baby. I mean, even the nurse looked at me and told me, you know, I cannot release this baby to this woman. So, at that moment, he came home with me.

3.2.2.1. Fathers’ stability. Many mothers considered the infants’ fathers as caregivers but rejected them because of their own justiceinvolvement, substance use, lifestyle, or perceived irresponsibility.

Samantha shared: I was in prison, and of course my baby daddy, he was supposed to take her, but I just felt like he wasn’t gonna get a house and get his stuff straight to provide for her. So, I went ahead and asked my sister if she could do it.

When fathers assumed care of the infant, mothers expressed that they approved the placement because they felt assured that the infant would be in a stable household. Aliyah shared, “I knew that his father had a stable residence and job, and that he was able and willing to come get the child. So, there was no question about who would come get him.”

Although interviewers didn’t ask questions related to father’s justice-

3.2.3. Theme 3: future reunification 3.2.3.1. Mothers seek reunification. Although mothers preferred kinship care, they also took pains to ensure that caregivers were willing to relinquish care to the mother on her release. Several mothers rejected 5

B. Kotlar et al.

Social Science & Medicine 370 (2025) 117881

potential caregivers for fear they would sue to retain custody. According to Stacy, the caregiver for Riley, Riley’s mother “originally wanted her parents, her dad and her stepmom, to get the baby, but then [she] kind of find out, maybe they weren’t going to give her a chance to get her back or anything,” so Stacy, her friend, assumed care. Although Victoria’s mother, Maria, eventually became the caregiver for Victoria’s daughter, she considered several others before Maria agreed. Victoria shared that she considered her daughter’s other grandparents, “but they wanted custody, and I wasn’t willing to do that.”

were incarcerated with the mothers and agreed to take the children because they had earlier release dates. When asked how she became a caregiver, Tina replied, “So, I was there most of the whole time we was in jail and she was worried about the baby going to foster care and stuff like that. And I was like, well, I get out before you, ‘cuz [because] she was going to prison, and I was like, I’ll take care of it.”

Katherine never met the infant’s mother, who contacted her after hearing that she had assumed care of another incarcerated mother’s twins. Katherine shared why she became a caregiver: There are cases where these moms don’t have anyone that is viable or able, or stable or safe, and they don’t want their children to go into the system. Obviously, nobody wants that for their children. So, I think just knowing that this is a real need and finding out that these moms are sitting there crying out to God and whoever for an answer for their baby.

5.2.3.2. For caregivers, reunification is a preference, not a given. Care­ givers overwhelmingly described accepting care of the child in the hope that the mother would eventually resume custody. Caregivers used phrases like: “it’s her baby” or “she’s his mother.” Susan, a paternal grandmother, provides an example of a typical narrative: “I didn’t take the baby to take the baby from her. I took the baby to help her, you know? I want her to have the baby as long as she’s livin’ a decent life.”

Caregivers, particularly kinship caregivers, said the mother would need to complete steps before resuming full custody. These included treatment for substance dependence or other mental health issues and securing a job and housing. Sarah, the child’s maternal aunt, simply stated: “As long as she stays off the drugs, we can be good.” Nicole elaborated: “If she gets into a treatment center and does what she’s supposed to do, I’d love for her to have her daughter back. But I’m not going to turn her over to somebody who I know is actively using and probably has a warrant for her arrest.” The mother’s romantic partners or friends were the least likely to discuss stipulations before returning the child to their mother.

Caregivers also discussed a desire to assist the mother in successfully reunifying with the child by providing support after release. Most caregivers planned to have the mother live with them to help the mother get a job or find treatment and allow her and her child to bond. Sharon, the infant’s maternal grandmother, said: “She gonna stay with me … she’s gonna get a job, and when she’s working, I’ll keep him and when she’s off she’ll keep him.” Paula agreed: “She’s going to come here and get acclimated with the baby, which I’m gonna help her do that because he’s attached to me.”

Although caregivers were actively planning for the child’s reunifi­ cation with their mother, a minority expressed doubts as to the mother’s ability to become a full-time parent. Several already had custody of the mother’s older children. When discussing whether Malcolm’s mother would be able to care for him in the future, Kelly, who has legal custody of Malcom’s two older siblings expressed doubt, stating: “Every time [his mother] has gotten out of jail somehow she hits the streets and then we never hear from her, or she goes out on a bender and then you might hear from her like three weeks later.”

One child in the BBB Study, Jessica, was placed from birth with a foster parent, Luz, who was caring for the mother’s older child. Luz told the interviewer that Jessica’s mother contacted her before she was born to ask Luz and her husband to adopt Jessica so she wouldn’t be under the care of child welfare. Luz refused, citing issues with Jessica’s sibling.

5.2.4.2. Caregivers lived experience of child welfare. For caregivers, avoiding child welfare custody was motivated by their desire to keep the child in familial care and their own negative experiences. Dawn, a paternal grandmother, stepped in when the maternal grandmother couldn’t assume care because of her work schedule. When asked why, she said, “I was like, well, the system’s not gettin’ my grandchild. So, that’s why we took over.”

Caregivers who had experience with the child welfare system expressed that child welfare would complicate their lives as well as their plans to reunify the infant with the mother. Additionally, they felt that child welfare would potentially harm the infant. Kelly, the mother’s aunt, stated: I’m a foster parent, but if we can do it where DFCS [is] not involved, oh yeah, ideally everybody thinks that you should involve them but for me, if they don’t have to be involved, it’s much, much easier, because clearly, she is incarcerated. So, it would make it a lot more difficult to have a plan in place if they were involved.

Caregivers with lived experience of child welfare removal commu­ nicated real desperation to avoid child welfare custody. Tina described her motivation to take on the care of Henry, the infant, as primarily stemming from her distrust of the child welfare system. She said, “I have a lot going on, but I’m willing to take the baby ‘cuz [because] I don’t like foster care. I don’t want no kid going to foster care. My nieces and nephews was in foster care and they were mistreated. They were separated.”

3.2.4. Theme 4: avoiding child welfare

4. Discussion

3.2.4.1. Mothers’ strategies to avoid foster care. Mothers related making extremely difficult care decisions to avoid foster care. Aliyah chose to place her four-year-old son up for adoption during her incarceration under threat of having her future child involved with the child welfare system. She shared:

This study found that caregivers of infants born to mothers experi­ encing incarceration in Georgia were primarily maternal grandparents or other relatives. Non-kinship caregivers were also used when no kinship caregiver was deemed suitable. Fathers were rarely caregivers for their infants. Narratives of participants in our sample point to family unity, specifically avoiding child welfare placement, and the safety and security of the child as primary motivating factors for families when forming caregiving relationships. For mothers, resuming custody after their release was particularly important. These findings represent the first study to characterize caregiving placements from a family perspective for children born during their mothers’ incarceration and serve to further illuminate potential caregiving-related pathways be­ tween maternal incarceration and family wellbeing.

Our results both replicate Pendleton et al.’s that most caregivers for

I felt like it was a lost cause. I didn’t want them to terminate my rights, because I was informed that if my rights were terminated that they could also take away any child that I had in the future. I found out that I was pregnant with Jayce at the time when all this stuff was going on with DFCS [Department of Family and Child Services], and they were threatening to terminate my rights, and telling me that if I had a child in the future that they would more than likely intervene.

So, I made the decision to sign him (her older child) over.

When mothers could not locate kinship care, they turned to ac­ quaintances and, in one case, a stranger. Caregivers Tina and Stephanie 6

B. Kotlar et al.

Social Science & Medicine 370 (2025) 117881

infants born to mothers experiencing incarceration are kin and build on their qualitative results by providing nuance to caregiver motivations in taking infants as well as adding the maternal perspective (2021). In this study, grandparents were frequently seen as the natural caregiver choice. Perhaps due to hierarchical family roles between the incarcer­ ated mother and her own parent, placement of an infant with their maternal grandparent was described not so much as a decision of the mothers, but a joint decision, or the decision of the grandparent.

Mothers frequently discussed trusting their own parents above any other potential caregiver. This trust may be particularly justified. Studies have shown that grandparental caregivers are more likely to maintain contact with the incarcerated mother and facilitate her reunification with her child in the context of incarceration (Loper and Clarke, 2013). However, this comes at a price; grandparental caregivers may suffer adverse mental health consequences (Kelley et al., 2021) and decreased physical health (Danielsbacka et al., 2022) as compared to grandparents not providing custodial care for grandchildren. Narratives of both mothers and caregivers in our sample, acknowledge the burden that assuming care for a newborn places on a caregiver, especially those who are older or in poor health. The poor health of family members in some cases led to their reluctance or inability to assume care, and mothers discussed needing to place their children in multiple households to lessen the burden of caregiving. This added strain is likely to influence caregivers’ ability to maintain the frequent and high-quality contact necessary for infants to bond with their mothers (Shlafer and Poehlmann, 2010).

While fathers were considered as potential caregivers by incarcer­ ated mothers, they rarely assumed this role. This finding is in line with quantitative analyses of caregiving in the context of parental incarcer­ ation. Jackson et al., 2023. found that while living outside of parental care was exceedingly rare for children with parents without a history of incarceration, a quarter of children with parents who had a history of incarceration were living with someone other than their parent, pri­ marily a grandparent (2023). Our results add nuance to this phenome­ non. Mothers discuss their choice as being motivated by the fathers’ own justice-involvement or perceived lifestyle. While interviewers did not ask about family members’ justice-involvement, more than a quarter of families in our sample voluntarily disclosed that the father was justice-involved. This finding may at least partially explain increased foster care placement experienced in the context of maternal incarcer­ ation as compared to paternal incarceration (Maruschak, 2021).

Approximately a fifth of caregivers had no kinship relationship with the child. Participants discussed these placements occurring because mothers could not identify a family member to care for the child and had a deep fear of child welfare, motivating measures to find any other caregiver. Here, our findings differ markedly from Rodriguez Carson (2021). Foster care placement was rare in our sample, but quite common in Rodriguez Carey’s. Furthermore, this placement was communicated as the mothers’ choice in Rodriguez Carey’s study, while mothers in this study universally and forcefully rejected child welfare as a viable option for care. It is possible that this contrast is due to factors peculiar to Georgia’s child welfare system. In many states, policing through the criminal legal system and through the child welfare system are inter­ twined and largely target families of color living in poverty. While this may be the case in Georgia a full analysis of its child welfare system is outside the scope of the current study. However, our findings necessitate a future careful consideration of child welfare policies in Georgia, with an eye towards whether current practices are disproportionately harming the family unity of incarcerated mothers.

This forceful rejection of child welfare observed in the present study, while reasonable given policies such as the Adoption and Safe Families Act, may lead to particularly tenuous caregiving arrangements. Indeed, several non-kinship caregivers were formerly incarcerated and struggled with poverty and substance use. Others had no relationship with the mother before agreeing to take the child. These households may leave children particularly vulnerable to caregiver instability.

While our results have highlighted several aspects of caregiver

relationship formation important for family wellbeing, future research is needed. First, more research is needed to fully understand mothers’ roles in caregiver choice. Future studies should prioritize interviewing incarcerated women during pregnancy to ensure that their decisionmaking processes are fully represented. Second, research should focus on the stability of caregiving relationships and any potential predictors of instability, including caregivers’ kinship relationships to the child.

Second, future research should focus on how dual involvement in these systems may influence child wellbeing and development. Finally, research should investigate the health and wellbeing of older kinship caregivers, who may be seriously impacted by the demands of raising a newborn.

5. Limitations This study is qualitative and is thus concerned with the subjective experiences of caregiver formation among women who gave birth dur­ ing incarceration in Georgia. Our results give a deep and nuanced ac­ count of these experiences but cannot speak to the experiences of mothers and caregivers outside of Georgia, where policies differ. This study sought to understand decision-making surrounding care for in­ fants born to incarcerated women. This decision necessarily comes before the birth of the child, yet we were unable to interview some participants until several months to a year after the child was born. For caregivers in particular, bonding with the child may have led them to report thoughts and feelings surrounding their choice differently than if they had been interviewed before they assumed care of the child. We were able to interview most caregivers in our sample were interviewed shortly after assuming care for the infant, mitigating this concern.

However, a small group were interviewed several months afterwards.

Although caregiver experiences during that time could have affected narratives of how and why they assumed care of the infant, we carefully compared codes from later interviews with codes from interviews con­ ducted shortly after the birth of the child and found no substantive differences. We also acknowledge that to fully capture mothers’ care­ giving decisions, mothers would have ideally been interviewed while pregnant and incarcerated. However, mothers in our sample were interviewed on average less than a year after the birth of the child, minimizing the risk of limited recall.

6. Conclusion This study found that the formation of caregiving relationships for children born to incarcerated mothers is a process that occurs between multiple members of the family system and is motivated primarily by the system’s desire for family unity, the safety and security of the child, and the avoidance of a child welfare placement. While the practice of maternal incarceration continues, it is of utmost importance to under­ stand how caregiver placement from birth affects childhood experi­ ences, health, and development in the context of maternal incarceration.

These findings have several important policy implications.

6.1. Targeted social support for caregivers When attempting to provide a placement that would ensure the safety and security of the infant, family choices are constrained by the resource requirements of caring for a newborn, particularly in the context of poverty. Caregivers of children of incarcerated mothers should be specifically targeted for social support either through Statesponsored programs such as Women, Infants, and Children (WIC), Supplemental Nutrition Assistance Program (SNAP), and Temporary Assistance for Needy Families (TANF), or through nonprofit program­ ming. Indeed, in studies of both infants and older children of incarcer­ ated parents, access to government assistance was shown to moderate the effects of parental incarceration on child health and wellbeing (Testa and Jackson, 2020; Tolliver et al., 2024).

7

B. Kotlar et al.

Social Science & Medicine 370 (2025) 117881

6.2. Child welfare reform

Appendix A. Supplementary data

Our findings contribute to the mounting evidence that child welfare policies must be reformed. Pressure for termination of parental rights in a short time period constitutes cruel and unusual punishment. The au­ thors join the rising call for the amendment of the Adoption and Safe Families Act to take into consideration the impact of incarceration on the ability of parents to successfully complete requirements to resume custody.

Supplementary data to this article can be found online at https://doi. org/10.1016/j.socscimed.2025.117881.

Data availability The data that has been used is confidential.

References

6.3. Criminal legal reform

Adoption and Safe Families Act of 1997, Pub. L. No. H.R. 867 (1997). https://www.govin fo.gov/content/pkg/BILLS-105hr867enr/pdf/BILLS-105hr867enr.pdf.

Alexander, M., 2012. The New Jim Crow: Mass Incarceration in the Age of Colorblindness, Revised edition. The New Press.

Arditti, J.A., Lambert-Shute, J., Joest, K., 2003. Saturday morning at the jail: implications of incarceration for families and children. Fam. Relat. 52 (3), 195–204. https://doi.org/10.1111/j.1741-3729.2003.00195.x.

Beckmeyer, J.J., Arditti, J.A., 2014. Implications of in-person visits for incarcerated parents’ family relationships and parenting experience. J. Offender Rehabil. 53 (2), 129–151. https://doi.org/10.1080/10509674.2013.868390.

Booth, N., 2020. Maternal Imprisonment and Family Life: from the Caregiver’s Perspective, first ed. Policy Press.

Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. Qual. Res. Psychol. 3 (2), 77–101. https://doi.org/10.1191/1478088706qp063oa.

Carson, Ann, 2021. Prisoners In 2020-Statistical Tables (NCJ 302776). Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/p20st.pdf.

Creswell, J.W., 2013. Qualitative Inquiry and Research Design: Choosing Among Five Approaches, third ed. SAGE Publications.

Cox, R., Wallace, S., 2013. The impact of incarceration on food insecurity among households with children. In: IDEAS Working Paper Series from RePEc. Dallaire, D.H., Ciccone, A., Wilson, L.C., 2012. The family drawings of at-risk children: concurrent relations with contact with incarcerated parents, caregiver behavior, and stress. Am. J. Bioeth. 14 (2), 161–183. https://doi.org/10.1080/ 14616734.2012.661232.

Dallaire, D.H., Zeman, J.L., Thrash, T.M., 2015. Children’s experiences of maternal incarceration-specific risks: predictions to psychological maladaptation. J. Clin.

Child Adolesc. Psychol. 44 (1), 109–122. https://doi.org/10.1080/ 15374416.2014.913248. The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53.

Danielsbacka, M., Křenková, L., Tanskanen, A.O., 2022. Grandparenting, health, and well- being: a systematic literature review. Eur. J. Ageing 19 (3), 341–368. https:// doi.org/10.1007/s10433-021-00674-y.

Georgia Department of Corrections, 2023. Inmate Statistical Profile. Georgia Department of Corrections.

Glaze, L., Maruschak, L., 2008. Parents in Prison and Their Minor Children, vol. 25.

Hairston, R., 2007. Focus on Children of Incarcerated Parents. The Annie E. Casey Foundation. Retrieved October 16, 2020, from. https://www.aecf.org/resources /focus-on-children-with-incarcerated-parents/.

Halperin, R., Harris, J.L., 2004. Parental rights of incarcerated mothers with children in foster care: a policy vacuum. Fem. Stud. 30 (2), 339–352. https://doi.org/10.2307/ 20458967.

Hanlon, T.E., Carswell, S.B., Rose, M., 2007. Research on the caretaking of children of incarcerated parents: findings and their service delivery implications. Child. Youth Serv. Rev. 29 (3), 348–362. https://doi.org/10.1016/j.childyouth.2006.09.001.

Huebner, B.M., Gustafson, R., 2007. The effect of maternal incarceration on adult offspring involvement in the criminal justice system. J. Crim. Justice 35 (3), 283–296. https://doi.org/10.1016/j.jcrimjus.2007.03.005.

Jackson, D.B., Testa, A., Vaughn, M.G., 2023. Parental incarceration and children’s living arrangements in the United States. Child Adolesc. Soc. Work. J. 40 (5), 695–711. https://doi.org/10.1007/s10560-021-00794-5.

Kajstura, A., 2018. States of women’s incarceration: the global context 2018. from. htt ps://www.prisonpolicy.org/global/women/2018.html. (Accessed 7 March 2021).

Kantor, D., 1975. Inside the Family, first ed. Jossey-Bass.

Kelley, S.J., Whitley, D.M., Escarra, S.R., Zheng, R., Horne, E.M., Warren, G.L., 2021. The mental health well-being of grandparents raising grandchildren: a systematic review and meta-analysis. Marriage Fam. Rev. 57 (4), 329–345. https://doi.org/10.1080/ 01494929.2020.1861163.

Kotlar, B., Kornrich, R., Deneen, M., Kenner, C., Theis, L., Von Esenwein, S., WebbGirard, A., 2015. Meeting incarcerated women’s needs for pregnancy-related and postpartum services. Perspect. Sex. Reprod. Health 47 (4), 221–225.

Loper, A.B., Carlson, L.W., Levitt, L., Scheffel, K., 2009. Parenting stress, alliance, child contact, and adjustment of imprisoned mothers and fathers. J. Offender Rehabil. 48 (6), 483–503. https://doi.org/10.1080/10509670903081300.

Loper, A.B., Clarke, C.N., 2013. Attachment representations of imprisoned mothers as related to child contact and the caregiving alliance: the moderating effect of CHILDREN’S placement with maternal grandmothers. Monogr. Soc. Res. Child Dev. 78 (3), 41–56. JSTOR. Maruschak, Laura M., Bronson, Jennifer, Alper, Mariel, 2021. Parents in Prison and Their Minor Children: Survey of Prison Inmates, 2016. U.S. Department of Justice, p. 8.

Monazzam, M., Budd, K., 2023. Incarcerated women and girls. The Sentencing Project. https://www.sentencingproject.org/fact-sheet/incarcerated-women-and-girls/.

Most importantly, this study would be impossible if the practice of mass incarceration in the U.S. did not ensnare a shocking number of pregnant and postpartum mothers. Many mothers are separated from their newborns only to be released in a matter of weeks or months. In the BBB Study at the time of writing, 12% of mothers of enrolled infants (n = 45) had a sentence of less than three months remaining after the birth of the child, and over 40% had less than a year remaining on their sentence. The separation of newborns from their mothers as a blanket carceral policy not only represents a human rights violation, but also constitutes a distressing waste of resources on continued punishment of a mother while depriving her newborn of the known benefits of a single stable caregiver. States can and should invest the resources currently spent on maternal incarceration towards community-based alternatives to incarceration that promote maternal treatment and allow mothers and their infants to remain together.

CRediT authorship contribution statement Bethany Kotlar: Writing – original draft, Visualization, Validation, Software, Resources, Project administration, Methodology, Investiga­ tion, Funding acquisition, Formal analysis, Data curation, Conceptuali­ zation. Aisha Yousafzai: Writing – review & editing, Supervision, Methodology. Carolyn Sufrin: Writing – review & editing, Supervision, Methodology. Monik Jimenez: Writing – review & editing, Supervision, Methodology. Henning Tiemeier: Writing – review & editing, Super­ vision, Software, Resources, Methodology, Funding acquisition, Formal analysis, Conceptualization.

Ethics approval All procedures for this study were performed in compliance with relevant laws and institutional guidelines and have been approved by the appropriate institutional committees.

The Harvard Longwood Medical Area approved this study under IRB 21–1247, approved in January 2022 and IRB 20–1215, approved in July 2020.

The privacy rights of all participants have been observed. Informed consent was completed with all participants on enrollment into the study.

Project funding statements This work was funded by the HRSA Center of Excellence in MCH grant, T03MC07648-12-06.

Bethany Kotlar’s work on this project was funded by the Reproduc­ tive Perinatal and Pediatric Epidemiology Fellowship, T32HD104612 and the CVD Epidemiology Training Program in Behavior, the Envi­ ronment and Global Health, T32 HL 098048.

Neither of these sponsors were involved in decisions regarding the study design, collection, analysis, or interpretation of the data.

Authors’ disclosure statements We have no conflicts of interest to disclose.

8

B. Kotlar et al.

Social Science & Medicine 370 (2025) 117881

Motherhood Beyond Bars, 2023. Motherhood beyond Bars. www.motherhoodbeyond. org. (Accessed 17 November 2023).

Newton, R.R., Litrownik, A.J., Landsverk, J.A., 2000. Children and youth in foster care: disentangling the relationship between problem behaviors and number of placements. Child Abuse Neglect 24 (10), 1363–1374. https://doi.org/10.1016/ S0145-2134(00)00189-7.

Pendleton, V.E., Schmitgen, E.M., Davis, L., Shlafer, R.J., 2021. Caregiving arrangements and caregiver well-being when infants are born to mothers in prison. J. Child Fam. Stud. https://doi.org/10.1007/s10826-021-02089-w.

Pettit, B., Western, B., 2004. Mass imprisonment and the life course: race and class inequality in U.S. Incarceration. Am. Sociol. Rev. 69 (2), 151–169. https://doi.org/ 10.1177/000312240406900201.

Poehlmann, J., 2005a. Children’s family environments and intellectual outcomes during maternal incarceration. J. Marriage Fam. 67 (5), 1275–1285. JSTOR. Poehlmann, J., 2005b. Representations of attachment relationships in children of incarcerated mothers. Child Dev. 76 (3), 679–696.

Poehlmann, J., Shlafer, R.J., Maes, E., Hanneman, A., 2008. Factors associated with young children’s opportunities for maintaining family relationships during maternal incarceration. Fam. Relat. 57 (3), 267–280. JSTOR. Roberts, D.E., 1997. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty, first ed. Pantheon Books.

Roberts, D.E., 2022. Torn Apart: How the Child Welfare System Destroys Black Families—And How Abolition Can Build a Safer World, first ed. Basic Books.

Rodriguez Carey, R., 2019. “Who’s gonna take my baby?”: narratives of creating placement plans among formerly pregnant inmates. Women Crim. Justice 29 (6), 385–407. https://doi.org/10.1080/08974454.2019.1593919.

Ross, L., 2017. Reproductive Justice: an Introduction, first ed. University of California Press.

Sandiford, F., 2007. Doing time together: love and family in the shadow of prison. Libr. J. 132 (20), 140–140.

Sawyer, W., 2018. The gender divide: tracking women’s state prison growth. from. https://www.prisonpolicy.org/reports/women_overtime.html#drugs. (Accessed 3 December 2024).

Shaw, M., 2023. Financial strain, the transference of stigma, and residential instability: a qualitative analysis of the long-term effects of parental incarceration. Fam. Relat. 72 (4), 1773–1789. https://doi.org/10.1111/fare.12763.

Shlafer, R.J., Poehlmann, J., 2010. Attachment and caregiving relationships in families affected by parental incarceration. Am. J. Bioeth. 12 (4), 395–415. https://doi.org/ 10.1080/14616730903417052.

Stringer, E.C., 2020. Managing motherhood: how incarcerated mothers negotiate maternal role-identities with their children’s caregivers. Women Crim. Justice 30 (5), 336–355. https://doi.org/10.1080/08974454.2020.1750538.

Sufrin, C., Beal, L., Clarke, J., Jones, R., Mosher, W.D., 2019. Pregnancy outcomes in US prisons, 2016–2017. Am. J. Publ. Health 109 (5), 799–805. https://doi.org/ 10.2105/AJPH.2019.305006.

Testa, A., Jackson, D.B., 2020. Incarceration exposure during pregnancy and infant health: moderation by public assistance. J. Pediatr. 226, 251–257.e1. https://doi. org/10.1016/j.jpeds.2020.06.055.

Tolliver, D.G., Hawks, L.C., Holaday, L.W., Wang, E.A., 2024. Exploring parental incarceration, US government support programs, and child health and well-being: a national cross-sectional study. J. Pediatr. 264, 113764. https://doi.org/10.1016/j. jpeds.2023.113764.

Trice, A.D., Brewster, J., 2004. The effects of maternal incarceration on adolescent children. J. Police Crim. Psychol. 19 (1), 27–35. https://doi.org/10.1007/ BF02802572.

Turanovic, J.J., Rodriguez, N., Pratt, T.C., 2012. The collateral consequences of incarceration revisited: a qualitative analysis of the effects on caregivers of children of incarcerated parents. Criminology 50 (4), 913–959. https://doi.org/10.1111/ j.1745-9125.2012.00283.x.

Turney, K., Wildeman, C., 2015. Detrimental for some? Heterogeneous effects of maternal incarceration on child wellbeing. Criminol. Publ. Pol. 14 (1), 125–156. https://doi.org/10.1111/1745-9133.12109.

Turney, K., Wildeman, C., 2018. Maternal incarceration and the transformation of urban family life. Soc. Forces 96 (3), 1155–1182. https://doi.org/10.1093/sf/sox070.

Wakefield, S., Wildeman, C., 2014. Children of the Prison Boom: Mass Incarceration and the Future of American Inequality. https://doi.org/10.1093/acprof:oso/ 9780199989225.001.0001.

Wildeman, C., 2009. Parental imprisonment, the prison boom, and the concentration of childhood disadvantage. Demography 46 (2), 265–280. https://doi.org/10.1353/ dem.0.0052.

Wildeman, C., Goldman, A.W., Turney, K., 2018. Parental incarceration and child health in the United States. Epidemiol. Rev. 40 (1), 146–156. https://doi.org/10.1093/ epirev/mxx013.

Wildeman, C., Turney, K., 2014. Positive, negative, or null? The effects of maternal incarceration on children’s behavioral problems. Demography 51 (3), 1041–1068.

9