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LAW SUMMARY
John Gabriel*
I. Introduction
The safeguard against inhumane prison conditions stems from the Eighth Amendment’s prohibition on “cruel and unusual punishments.”[1] For decades, the Supreme Court has interpreted Eighth Amendment protections to include the physical safety of incarcerated individuals, as well as their access to medical care and humane treatment.[2] Yet, the reality of incarceration often falls short of these standards, particularly for women.[3] Women who are incarcerated face distinct medical, psychological, and social needs that for the most part were not considered in the process of creating correctional facilities.[4] These needs become most apparent during pregnancy, childbirth, and postpartum care, where women have been subjected to inadequate medical attention through the use of restraints and forced separation from their newborn children.[5] Recently, discussion of prison reform has raised constitutional and human rights concerns, leading to progressive policymaking and reforms around the United States.[6]
Missouri has begun implementing reforms that reflect a growing awareness of gender-specific concerns.[7] In 2022, the state legislature authorized the creation of a correctional center nursery program that allows eligible incarcerated mothers to nurture their infants for up to eighteen months after giving birth.[8] Missouri has also strengthened anti-shackling protections and proposed new legislation requiring prenatal care standards, postpartum mental health evaluations, and restrictions on solitary confinement during the postpartum period.[9] In addition, Missouri’s participation in the Justice Reinvestment Initiative (“JRI”) demonstrates an effort to address structural and societal factors that contribute to the fastest-growing female prison population in the nation.[10] With these new initiatives, Missouri has shown that it wants to shift its focus towards gender-responsive care, reflecting a desire to not only comply with the Eighth Amendment’s deliberate indifference standard, but also to raise the constitutional bar to ensure that women are being treated for their serious medical needs.[11] However, questions remain as to whether these policy advancements ensure that women in custody are receiving care consistent with medical and ethical norms at a statewide level.[12] Comparing Missouri’s reforms with those in states such as California and Illinois—each of which has enacted more substantial protections for incarcerated women—reveals the limitations of Missouri’s current approach.[13]
This law summary argues that while Missouri’s recent policy reforms are promising, meaningful work remains because the constitutional baseline for women’s healthcare in prison is too low to guarantee the effective implementation of these reforms. By reviewing the development of Eighth Amendment doctrine, Missouri case law, and the state’s new legislative initiatives, this summary suggests that continued attention to both the substance and implementation of these reforms is necessary to ensure that incarcerated women receive care that is consistent with evolving constitutional expectations.
II. Legal Background
This Section lays out the legal foundation for evaluating claims of inadequate medical care in correctional facilities. Part A shows the development of the “deliberate indifference” standard under the Eighth Amendment, beginning with the Supreme Court’s recognition in Estelle v. Gamble that prison officials may be held liable for ignoring serious medical needs, a standard later refined in Farmer v. Brennan to include both objective and subjective elements.[14] Part B addresses how Missouri courts have applied this framework in cases involving women’s healthcare, most notably in Dulany v. Carnahan, where the Eighth Circuit set a precedent making it immensely difficult to establish liability for Eighth Amendment claims. This discussion reveals a significant gap between federal law and state practice, showing the realities that incarcerated women must deal with on a day-to-day basis.
A. The Eighth Amendment and the Development of the “Deliberate Indifference” Standard
The Eighth Amendment to the United States Constitution prohibits the infliction of “cruel and unusual punishments.”[15] The Supreme Court originally understood the Eighth Amendment to limit barbaric physical punishments; however, the Court has since recognized that the Eighth Amendment also imposes limits on the conditions within prisons.[16] The state has an affirmative obligation to provide humane living conditions to those in their custody, including adequate medical care and protection from harm.[17] The state’s failure to abide by this obligation can constitute cruel and unusual punishment in violation of the Eighth Amendment.[18] Under the Eighth Amendment, a prison official may be held liable for denying humane conditions of confinement if the official (1) knows that inmates face a substantial risk of serious harm, and (2) there is a subjective showing that the officials knew of the risk and disregarded it.[19] This framework emerged through a string of cases; it began with Estelle v. Gamble and was refined in Farmer v. Brennan.[20] Together, these decisions form the foundation for evaluating Eighth Amendment claims concerning inadequate medical care, including those implicating women’s reproductive and postpartum health.[21]
The modern framework for analyzing prison conditions claims based on inadequate medical care began with Estelle v. Gamble.[22] In Estelle, a Texas state prisoner, Gamble, filed a complaint under 42 U.S.C. § 1983 alleging that prison officials violated his Eighth Amendment rights by providing inadequate treatment for a back injury that was sustained while performing labor.[23] Gamble had been seen by medical staff on seventeen occasions over a three-month period and received medication and treatment.[24] Gamble alleged that the failure to order additional diagnostic tests, such as X-rays, amounted to cruel and unusual punishment.[25]
The Supreme Court held that “deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’ . . . proscribed by the Eighth Amendment.”[26] However, the Court distinguished deliberate indifference from mere medical malpractice or negligence, clarifying that “a complaint that a physician has been negligent in diagnosing or treating a medical condition does not state a valid claim of medical mistreatment under the Eighth Amendment.”[27] Instead, liability attaches when prison officials act in a manner that demonstrates a conscious disregard for an inmate’s serious medical needs.[28] The Estelle Court articulated two necessary components of Eighth Amendment medical care claims.[29] First, the prisoner must have “serious medical needs.”[30] Second, officials must act with “deliberate indifference” to those needs.[31] This decision created a rule that deliberate indifference to a prisoner’s serious medical needs constitutes cruel and unusual punishment.[32] While Estelle involved a male prisoner, the “deliberate indifference” framework it created has governed claims concerning women’s healthcare needs, including pregnancy and postpartum care, where denial of adequate treatment may result in substantial harm to both the mother and child.[33]
Nearly twenty years later, the Supreme Court refined the deliberate indifference standard in Farmer v. Brennan.[34] In that case, Dee Farmer, a transgender woman incarcerated in a male penitentiary, brought a Bivens action alleging that prison officials violated the Eighth Amendment by failing to protect her from sexual assault.[35] Farmer stated that officials knew she was vulnerable due to her gender identity, but she was nevertheless placed in general population, where she was beaten and raped.[36] The Court in Farmer reaffirmed that the Eighth Amendment imposes duties on prison officials to ensure humane conditions within their facilities, including the obligation “to protect prisoners from violence at the hands of other prisoners.”[37]
The Court clarified the mental state required to establish deliberate indifference, holding that “a prison official cannot be found liable under the Eighth Amendment . . . unless the official knows of and disregards an excessive risk to inmate health or safety.”[38] Under this standard, “the official must both be aware of facts from which the inference could be drawn that a substantial risk of serious harm exists, and he must also draw the inference.”[39] Thus, the test requires both an objective showing of a substantial risk and subjective proof that the officials actually knew of and disregarded the risk.[40] Farmer built upon Estelle by emphasizing the constitutional duty of prison officials to address known threats to inmate health and safety.[41] While the facts concerned assault rather than medical neglect, the case solidified the deliberate indifference standard as the governing test for all Eighth Amendment claims.[42] In the context of incarcerated women, officials who knowingly disregard pregnancy-related risks, fail to provide prenatal care, or permit shackling during labor may violate the Eighth Amendment if their acts reflect deliberate indifference to medical issues.[43]
B. Missouri Jurisprudence and the Application of Eighth Amendment Standards
The Supreme Court’s deliberate indifference standard provides a clear legal foundation, but the standard’s application is still inconsistent.[44] Like many states, Missouri historically designed its correctional system around male populations and overlooked the specific medical and psychological needs of women.[45] As female incarceration rates have risen, courts have been forced to confront whether prison healthcare systems satisfy the Eighth Amendment’s protections for women facing reproductive, prenatal, and postpartum challenges.[46]
The Eighth Circuit’s decision in Dulany v. Carnahan illustrates the difficulty incarcerated women in Missouri face in establishing Eighth Amendment violations under the deliberate indifference standard.[47] In Dulany, a group of female inmates confined in Missouri state prisons brought a class action under 42 U.S.C. § 1983, alleging that prison officials and medical staff were deliberately indifferent to their serious medical needs.[48] The plaintiffs claimed that the prisons failed to provide adequate medical treatment.[49] They also alleged violations of the Americans with Disabilities Act (“ADA”) based on inadequate accommodations for women with disabilities.[50] The Eighth Circuit affirmed summary judgment in favor of the defendants, finding insufficient evidence of deliberate indifference to plaintiffs’ medical needs.[51] The court emphasized that “inmates have no constitutional right to receive a particular or requested course of treatment, and prison doctors remain free to exercise their independent medical judgment.”[52] The Eighth Circuit concluded that disagreements between inmates and prison staff regarding the adequacy of treatment do not rise to the level of constitutional violations.[53] The court held that the officials were not deliberately indifferent, reasoning that the medical care did not amount to the “wanton infliction of pain” required under Estelle.[54]
The Dulany decision emphasizes the high bar that plaintiffs must meet in Eighth Amendment medical claims.[55] Even when women present evidence of inadequate or negligent treatment, courts may view these alleged shortcomings as disputes over medical treatment rather than constitutional violations.[56] This can be problematic in the context of women’s reproductive healthcare, where failures in prenatal or postpartum care may not appear to be life-threatening, but still implicate the physical and psychological harm that women suffer from while incarcerated. By denying relief, Dulany reflects the structural limitations of the deliberate indifference standard in addressing inadequacies in women’s prison healthcare.[57] The case shows how the framework established in Estelle and Farmer struggles to account for the realities of women’s incarceration.[58] Missouri has since undertaken legislative reforms, which must be viewed in light of Dulany’s narrow interpretation of deliberate indifference.[59] Despite recent policy changes, many women in custody continue to face challenges in medical care, suggesting the constitutional requirements are still not being fully met.
III. Recent Developments
Recently, Missouri has turned its focus to legislative reform and different administrative initiatives to address the unique healthcare needs of incarcerated women, showing that Missouri aims to become a state that leads by example, rather than just meeting the constitutional minimum requirements.[60] These developments were prompted by multiple factors, such as having the fastest-growing population of female inmates in the country, public concern regarding childbirth and early infant separation, and reports by advocacy organizations showing inconsistent mental healthcare access across Missouri prisons.[61] Due to public scrutiny and the rapid growth of the female prison population, Missouri has implemented multiple programs to improve maternal and reproductive healthcare for incarcerated women.[62] This includes the establishment of a prison nursery program, enhanced anti-shackling legislation, and gender-responsive reforms under the Missouri Justice Reinvestment Initiative.[63]
A. Prison Nursery Program
In 2022, the Missouri General Assembly enacted legislation allowing the Department of Corrections (“DOC”) to establish a prison nursery program at one or more women’s correctional facilities.[64] The law required the DOC to have the program up and running by July 1, 2025, and it allows eligible incarcerated mothers to live with their newborns for up to eighteen months after giving birth.[65] The DOC implemented the program at the Women’s Eastern Correctional Center in Vandalia, Missouri, in early 2025.[66] However, not every mother in prison can join; the program is limited to women who are close to finishing their sentences and do not have convictions for violent sexual offenses or crimes against children.[67] If chosen for the program, incarcerated women are expected to take parenting classes, go through therapy, and start reentry planning.[68] The facility also offers on-site childcare training, which is meant to help the mothers focus on finding work once they are released.[69] The first group included seven infants and mothers who would stay together at the facility for eighteen months.[70] During that time, the mothers were required to participate in various programs to rehabilitate them for the outside world.[71]
B. Anti-Shackling Protections and New Legislation
In March 2025, the Missouri General Assembly enacted legislation prohibiting the use of restraints on incarcerated pregnant women in their third trimester, during labor, and for forty-eight hours postpartum, except under extraordinary circumstances.[72] The statute states that restraints may be used only when there is “a substantial flight risk or some other extraordinary medical or security circumstance that dictates restraints be used to ensure the safety and security of a pregnant offender in her third trimester or a postpartum offender within forty-eight hours postdelivery.”[73] The law also requires prenatal care for the inmates, including initial health evaluations, access to prenatal vitamins, and nutrition plans that are designed to meet the dietary needs of pregnant women.[74] Further, the law does more than just address pregnancy; it also assists with postpartum recovery by blocking prisons and jails from putting new mothers in solitary confinement during the first six weeks after giving birth and requires a medical professional to be present during all prenatal and postpartum exams.[75] Representative Chad Perkins and State Senator Mary Elizabeth Coleman sponsored the law, which aims to protect incarcerated mothers and their newborn children.[76] The law has successfully implemented protections that now extend to city and county jails, thereby ensuring that there is a uniform code that all state prisons must abide by.[77] Missouri aims to strengthen its national reform efforts by establishing intake protocols, nutritional standards, and postpartum confinement protections, representing a significant advancement in Missouri’s correctional policy, and while there are still questions as to statewide implementation, it marks a shift in how the state approaches Eighth Amendment violations.[78]
C. Missouri’s Justice Reinvestment Initiative
The Justice Reinvestment Initiative (“JRI”) is a national policy strategy aimed at lowering correctional costs and redirecting the savings to programs that enhance public safety.[79] In response to rising incarceration rates, the high cost of corrections, overcrowding, and poor recidivism outcomes, Missouri adopted the JRI in 2018.[80] In 2017, Missouri had the eighth-highest incarceration rate in the United States, the fastest growing female prison population in the country, and an increasing violent crime rate.[81] These concerns led to Missouri’s adoption of the JRI to combat systemic problems and provide meaningful opportunities for people trying to reintegrate into society.[82] The savings from JRI reforms are directed at serving community-based programs, including gender-responsive supervision, trauma-informed services, and rehabilitative programming tailored to women.[83] Through the JRI, the District 26 Community Supervision Center in Fulton, Missouri, was converted into an all-female, trauma-informed facility specifically designed to address the unique needs of women in custody.[84] The Community Supervision Center has implemented a four-phase program that includes employment training, on-site substance use disorder treatment, cognitive interventions, housing plans, family reunification planning, and life skills education.[85] The inmates also work with counselors and advisors from various organizations to ensure that they have the means to rehabilitate themselves through goal setting and community reentry support.[86] These programs are individualized to address the specific needs of each and every incarcerated woman that is eligible for these programs.[87] Through these reforms, the JRI aims to provide a statewide model for reducing incarceration, redirecting savings to community programs, and improving outcomes for incarcerated women.[88]
IV. Discussion
States vary widely in their efforts to reform women’s correctional facilities. Some have made only incremental changes to their prison reform policy, while others have taken a deeper look to address the unique medical needs that women face throughout their incarceration.[89] Recently, Missouri has advanced meaningful programs that focus on trauma, postpartum care, and gender-responsive supervision, suggesting a desire to be a state that leads by example, rather than one that makes only incremental changes.[90] However, a comparison of Missouri with states that have more progressive policies will show that there are many ways in which Missouri can improve.[91] For example, California and Illinois have introduced more expansive measures that range from enhanced prenatal and postpartum care to statewide task forces aimed at reducing women’s incarceration—measures that Missouri has implemented, but could expand further.[92] Comparing Missouri’s policies with these examples emphasizes both the state’s achievements and the gaps that need to be filled, thus creating a framework for adopting the best practices and advancing the best approaches for women and their families.
This discussion argues that while Missouri has made notable progress toward improving conditions for incarcerated women through the adoption of gender-responsive policy reforms, its approach is at risk of being applied unevenly at a statewide level and may be hindered by a constitutional standard that is already too low. Part A examines Missouri’s gender-responsive initiatives and explains why raising the constitutional baseline is essential to preventing a “race-to-the-bottom” approach to women’s healthcare in prison. Part B compares Missouri’s efforts to achieve the more complete framework adopted in states such as California and Illinois, which have advanced broader correctional reforms and maternal-health protections, illustrating how Missouri’s progress could be strengthened in certain areas. Part C takes an in-depth look at the potential benefits from Missouri’s reforms and discusses a forward-looking plan for Missouri, proposing reforms that build on existing momentum, including expanding maternal-health protections, statewide coordination to ensure implementation of these reforms, and a women-led justice task force like that of Illinois’s. This plan would offer a model for other states to follow in developing their own reforms, helping ensure that correctional systems meet not only the Eighth Amendment’s minimum requirements, but also provide a more progressive standard for addressing women’s serious medical needs in prison.
A. Missouri’s Gender-Responsive Reforms and the Need to Raise the Constitutional Baseline
Missouri’s JRI reforms emphasize the importance of evidence-based assessment and delivering unique services to incarcerated individuals that need them.[93] The Department of Corrections (“DOC”) has adopted validated risk-assessment tools along with a structured system of sanctions and incentives to promote behavioral change and curb probation and parole violations.[94] In practice, these tools allow correctional staff to tailor supervision and interventions to each person’s personal needs, representing a major departure from a one-size-fits-all approach that historically characterized women’s incarceration.[95] The repurposing of Community Supervision Centers has been central to this effort.[96] Missouri recently established the Fulton Community Supervision Center, which became the first female-only, trauma-informed facility in Missouri, where they offer gender-responsive programs designed to reduce recidivism and promote reentry into society.[97]
For example, one program that Missouri has adopted is the “Moving On” program, which provides cognitive-behavioral interventions, life skills training, employment readiness, and family reunification planning.[98] The effectiveness of the “Moving On” program has been notable, as over 200 women at high risk for revocation participated in the program, and only one participant returned to the prison in the first year of its operation.[99] These outcomes suggest that gender-responsive programming tailored to maternal needs and stopping criminal behavior can significantly improve behavioral outcomes while still promoting constitutional compliance that goes above and beyond the requirements of the Eighth Amendment.[100]
Beyond the “Moving On” program, Missouri has codified protections that address prenatal and postpartum health.[101] New legislation has mandated initial health evaluations, access to prenatal vitamins, nutrition plans, and restrictions on postpartum solitary confinement.[102] These measures reflect a desire from the state to understand and address the critical importance of maternal health for incarcerated women while bolstering their Eighth Amendment protections.[103] Moreover, the integration of trauma-informed services addresses the prevalence of violence within prisons and mental health challenges among incarcerated women, ensuring that rehabilitation and care extend beyond confinement.[104] However, the implementation of Missouri’s JRI is ongoing.[105] While the Fulton Community Supervision Center serves as a model facility for other prisons in Missouri to follow, it seems that gender-responsive programming is not evenly applied across all facilities statewide.[106] One of the goals of the JRI is to repurpose the state’s Community Supervision Centers.[107] However, this will take time and resources to complete.[108] While the Fulton Community Supervision Center is a great step towards ensuring that Eighth Amendment violations will be absent from correctional facilities, the distribution of resources could be spread more evenly to ensure that women across the state are receiving adequate medical care. Missouri has made substantial progress, but the current framework could be strengthened to ensure consistent, statewide adoption of the best practices possible.
While Missouri’s new policies reflect a progressive approach to Eighth Amendment compliance, it is important to recognize that the nationwide standard for addressing women’s healthcare needs in prisons is already too low. The “deliberate indifference” framework allows states to meet the bare constitutional minimum rather than requiring them to ensure that the medical needs of incarcerated women are being met with serious consideration.[109] Relying on these minimum standards creates a serious problem when it comes to nationwide implementation of progressive reforms. If the only requirement is the constitutional minimum, then what stops states from adopting the cheapest possible practices and competing to do the least? This “race to the bottom” approach is especially dangerous in the context of women’s healthcare, where cutting corners directly affects health outcomes.[110] A study of twenty-two state prisons found that prisons across the country vary significantly when it comes to addressing prenatal care and pregnancy across prisons.[111] The study suggests that when prisons only meet the constitutional minimum, women in poorer-resourced facilities may face significantly worse health outcomes.[112] If Missouri truly wants its new reforms to make a significant contribution to addressing healthcare needs, it must commit to raising its standard of care above the national baseline. Real change requires building a system that actually protects women’s well-being, rather than treating their medical needs as a standard to avoid liability.
B. Comparative Policy Analysis: Lessons from Other States
Missouri’s reforms can be further enhanced by looking towards the policies of other states that have prioritized maternal and gender-responsive care in correctional facilities. States like California and Illinois are leading the charge for progressive expansions on healthcare for incarcerated women, and the progress has been substantial.[113] California’s statute offers a more progressive framework for prenatal and postpartum care, going further than the vast majority of states when it comes to addressing the needs of incarcerated women.[114] The legislation mandates that incarcerated pregnant inmates be referred to a social worker within seven days of intake to discuss planning for the care of the newborns.[115] Further, the bill requires the implementation of individualized prenatal care plans, additional meals and beverages for pregnant mothers, postpartum hospital stays to ensure that the mothers recover safely, breastfeeding support, and an expedited family visitation process.[116] This is arguably one of the most broad and protective frameworks in the nation when it comes to addressing the needs of incarcerated mothers, embracing the view that health care in correctional settings is not a privilege, but a constitutional necessity under the Eighth Amendment’s prohibition against deliberate indifference to serious medical needs.[117]
While state-level reforms are integral to protecting women’s serious medical needs, program-specific initiatives have also had a great impact on shaping policy.[118] Illinois offers a model similar to California’s through its 2018 Statewide Women’s Justice Task Force.[119] The task force’s report, “Redefining the Narrative,” identifies multiple systemic contributors to the mass incarceration of women, including the criminalization of drug use, punitive sentencing for low-level offenses, extended prison stays under outdated policies, and parole systems that are insufficiently responsive to the unique needs of women.[120] The report outlines a plan to reduce the women’s prison population by over 50% while focusing on five critical areas for reform: health and wellbeing, relationship safety, supporting families, economic security and empowerment, and safe, stable housing.[121] The report highlights disparities in county-level incarceration rates, noting a 98% increase in admissions in forty-three of the state’s 102 counties between 2010 and 2019, driven largely by drug-related offenses linked to the use of methamphetamine.[122]
By focusing on the five key areas they have outlined, the Women’s Justice Task Force has developed a solution with a very realistic chance of success if implemented correctly.[123] Regarding relationship safety, the report notes that over 90% of incarcerated women have experienced abuse.[124] By investing in interventions aimed at preventing violence against women, Illinois could reduce the risk that these individuals are further traumatized while in custody.[125] For the health and wellbeing prong, the report notes that seventy-five percent of women in prison suffer from PTSD and trauma, and many also suffer from substance abuse and mental health issues.[126] Their plan to combat this issue is to invest in community-based support groups to assist with women’s psychological needs.[127] As for safe and stable housing, their suggestion is to invest in safe, stable, and affordable housing rather than continue to overpopulate prisons and spend $48,000 per year and prisoner to keep them incarcerated.[128] Their suggestion to boost the economy and empower women is to invest in their communities, and their suggestion for creating more supportive families is investing in alternatives to incarceration to keep families together.[129] While Illinois has taken action on several of these fronts—such as creating the Healing-Centered Illinois Task force to promote trauma-informed policies and establishing the Illinois Reentry Council to support housing and reentry needs—fully implementing the Women’s Justice Institute’s plan will still require significant time and resources.[130] Nonetheless, it provides a comprehensive framework that the state can continue to gradually build on in the years ahead.
States that have implemented prison nursery programs have experienced significant reductions in recidivism, demonstrating both social and economic benefits from these programs.[131] In Indiana’s Wee Ones Prison Nursery Program, women who participated had a rearrest rate of 26% within one year of release, compared with 31% for non-participants.[132] Only 10% of participants were re-admitted to the Department of Corrections versus 18% of non-participants.[133] While a quarter of the program reoffended within a year of their release, the nearly 50% reduction in readmission to the Department of Corrections suggests that offering bonding opportunities in the mother-child relationship corresponds with lower recidivism rates.[134]
Nebraska’s program further shows that prison nursery programs can contribute to significant reduction in recidivism.[135] A study showed that after a ten-year evaluation, women who had completed the nursery program had a recidivism rate of only 16.8% compared to the 50% rate among women who previously had to surrender their infants, showing a dramatic improvement.[136] A cost analysis of Nebraska’s program shows that these improved outcomes produced more than $6 million in savings between 1994 and 2012, demonstrating that these reductions in recidivism also translate into significant financial benefits as well.[137]
While Missouri’s framework has embraced the spirit of these progressive states’ reforms, one of the biggest challenges ahead is scaling and sustaining progress statewide. The Fulton Community Supervision Center represents a new hope for the rehabilitation of Missouri’s correctional facilities, but it is at risk of becoming an isolated success rather than a comprehensive transformation.[138] If implementing these programs statewide stalls or remains uneven, Missouri could fall back into only meeting the constitutional minimum and not providing the unique services that incarcerated women need—namely, adequate maternal healthcare and sufficient access to gender-responsive programs.
The risk of inaction for addressing Eighth Amendment needs becomes clearer when compared with states that have failed to modernize their correctional facilities.[139] States such as Alabama and Louisiana have shown that underfunding, overcrowding, and inadequate medical care have resulted in statewide constitutional violations and led to human rights concerns for incarcerated individuals.[140] The U.S. Department of Justice’s 2019 investigation of Alabama’s prisons found that they had reasonable cause to believe that “Alabama routinely violates the constitutional rights of prisoners housed in . . . Alabama’s prisons by failing to protect them from prisoner-on-prisoner violence and prisoner-on-prisoner sexual abuse, and by failing to provide safe conditions.”[141] These issues are enhanced by the State’s failure to address understaffing and overcrowding within their correctional facilities and have resulted in subsequent litigation to address these issues.[142] Though this investigation did not involve incarcerated women, the United States brought suit against the State of Alabama and its Department of Corrections for failing to protect male prisoners from prisoner-on-prisoner violence and sexual abuse, as well as failure to provide safe and sanitary conditions.[143] This ultimately constituted deliberate indifference towards their prisoners’ serious medical and psychological needs.[144] Louisiana’s women’s facilities have been criticized for their failure to comply with Eighth Amendment standards, specifically regarding neglect of maternal health and the unique medical needs that incarcerated women face on a daily basis.[145] The Louisiana Public Health Institute’s report shows that women have complained of inadequate medical supervision while giving birth, and in some instances, being restrained during labor, which can contribute to severe physical and mental health issues.[146] These conditions have caused avoidable health crises and reinforced the cycles of trauma that incarcerated individuals face throughout their daily lives.
The differences between Missouri and the other aforementioned states help explain why reform has progressed at varying speeds. California benefits from a large tax-paying population and a long history of progressive social policy, allowing it to invest in its correctional facilities beyond Eighth Amendment standards.[147] While Illinois is traditionally more moderate than California in its political views, the state capitalized on a rare moment of bipartisan agreement regarding the fiscal unsustainability of mass incarceration, as well as the racial disparities within its correctional system, to advance statewide reform.[148] Missouri has fewer resources and a political climate that historically favors punitive approaches to justice.[149] The state’s smaller population and budgetary limits make these overhauls more difficult to fund, even with a growing interest in reforming correctional facilities.[150] However, Missouri could demonstrate that effective, gender-responsive correctional practices are not dependent on these limitations, but can be achieved through the reallocation of statewide resources to address these concerns.
The comparison between Missouri’s framework with that of Illinois and California shows that Missouri must play catch-up when it comes to supporting the needs of incarcerated women. However, their recent policy changes have reflected a desire to strengthen the protections afforded by the Eighth Amendment. By implementing more progressive policies, the state could be a leader and provide a framework for many states who have only had incremental changes.
B. Missouri’s Path Toward Gender-Responsive Incarceration Policies
Missouri politicians have signaled that they are willing to approach women’s incarceration more progressively.[151] This is exemplified by Senator Mary Elizabeth Coleman’s law protecting pregnant and postpartum women in custody.[152] Senator Coleman hopes that the law will increase the safety of incarcerated women.[153] She argues that restraints during labor and postpartum recovery increase the risk of falls and should only be used in extraordinary circumstances.[154] The law mandates timely prenatal medical assessments, restricts the use of restraints during labor and postpartum recovery, and requires correctional staff to receive training on maternal health.[155] While the law was enacted in August 2025, early reactions from advocacy groups, such as Missouri Appleseed, have been incredibly supportive, noting their advocacy for the law and that Senator Coleman has had a “longstanding interest in and commitment to incarcerated women’s health.”[156]
While this law advances essential benefits to maternal health for incarcerated women, Missouri could further benefit by drawing on best practices from states such as California and Illinois.[157] Incorporating provisions such as extended maternal bonding time with newborns, guaranteed postpartum hospital stays, structured individualized care plans, and consistent access to trauma-informed mental health support would further align Missouri with leading standards for incarcerated women’s health and promote positive outcomes for both the mother and child.[158] Studies have shown that extended bonding time and early contact between mother and child is associated with significantly higher rates of secure attachment, which predicts improved emotional regulation and behavior in childhood.[159] In the prison context, infants who bond with their mothers in nursery programs achieve high rates of secure attachment, suggesting that policies supporting extended bonding in correctional settings can deliver immediate and long-term benefits for children.[160] Studies have further shown that prison nursery programs lead to a reduction in recidivism, thereby generating both economic savings by decreasing the costs of incarceration, and providing social benefits by supporting the mother-infant bond and promoting healthier family outcomes.[161]
Missouri should look beyond just individual protections and create broader reforms by establishing a women-led, statewide justice task force modeled on the Illinois initiative.[162] A women’s justice task force could evaluate which drug policy reforms would better support individuals with substance use disorders while also developing strategies to reduce harsh sentencing for low-level offenses.[163] Additionally, the task force could recommend policy provisions that extend mother-infant bonding time within the prison nursery to a full two years rather than eighteen months, provide individualized care plans, guarantee postpartum hospital stays, and provide consistent access to trauma-informed mental health support. Missouri could also establish specialized childcare programs for recently released mothers in an effort to facilitate their reentry into society by supporting employment opportunities and reducing the likelihood of recidivism. Together, these reforms would tackle the underlying public health and equity concerns by addressing systemic causes of incarceration rather than continuing to overcrowd prisons and separate families.[164] By aligning correctional policy with healthcare, mental health services, and family support, Missouri could establish itself as a national model for reform and prove that constitutional compliance, responsible spending, and public safety can coexist to enhance the quality of life for all citizens.[165]
V. Conclusion
Missouri has made substantial progress in addressing the healthcare and maternal needs of incarcerated women; yet meaningful gaps remain, creating an opportunity to further strengthen its policies, align with more progressive states, and position itself as a leader in prison reform.[166] Expanding mother-infant bonding, individualized care plans, postpartum hospital stays, and trauma-informed mental health support could provide substantial benefits to both the mother and child.[167] By implementing these reforms statewide, establishing a women-led justice task force, and supporting reentry, Missouri can move beyond constitutional minimums and serve as a national model where humane treatment, public safety, and fiscal responsibility come together to strengthen families and communities.
* B.A., University of Missouri, 2023; J.D. Candidate, University of Missouri School of Law, 2027; Associate Member, Missouri Law Review, 2025-2026. I am grateful to Professor C. Eric Hintz for his guidance and support during the writing of this Law Summary, as well as the Missouri Law Review for its help in the editing process.
[1] U.S. Const. amend. VIII.
[2] See Estelle v. Gamble, 429 U.S. 97, 104 (1976); Hutto v. Finney, 437 U.S. 678, 685 (1978), aff’g Holt v. Sarver, 309 F. Supp. 362, 380 (E.D. Ark. 1970).
[3] Ronald L. Braithwaite, Henrie M. Treadwell & Kimberly R. J. Arriola, Health Disparities and Incarcerated Women: A Population Ignored, 98 Am. J. Pub. Health 173, 173 (Supp. 2008), https://doi.org/10.2105/AJPH.98.Supplement_1.S173.
[4] Danya Ziazadeh, Inadequate Health Care: A Significant Problem Affecting Incarcerated Women, Univ. of Mich. Sch. of Pub. Health (May 30, 2019), https://sph.umich.edu/pursuit/2019posts/inadequate-healthcare-a-significant-problem-affecting-incarcerated-women.html.
[5] See id.; Anna Spoerre, Missouri cities and counties still shackle pregnant women in jail. A new bill would change that, KCUR (Jan. 12, 2025, at 4:00 CST), https://www.kcur.org/health/2025-01-12/missouri-pregnant-women-jail-bill-mary-elizabeth-coleman.
[6] See Ziazadeh, supra note 4;Spoerre, supra note 5; Redefining the Narrative, The Women’s Just. Inst., https://redefine.womensjusticeinstitute.org (last visited Apr. 15, 2026).
[7] See Incubating Hope, Mo. Dep’t of Corr., https://doc.mo.gov/media-center/newsroom/nursery-program (last visited Apr. 15, 2026); Fulton Community Supervision Center, Mo. Dep’t of Corr., https://doc.mo.gov/programs/fulton_CSC (last visited Apr. 15, 2026).
[8] See Incubating Hope, supra note 7.
[9] Anna Spoerre, Missouri senator renews push to ban shackling of pregnant women in city, county jails, Mo. Indep. (Jan. 10, 2025, at 7:00 CST), https://missouriindependent.com/briefs/missouri-bill-ban-shackling-pregnant-women-jails/.
[10] See Justice Reinvestment Initiative (JRI) Overview, Bureau of Just. Assistance, https://bja.ojp.gov/program/justice-reinvestment-initiative/overview (last visited Apr. 15, 2026) (discussing implementation of a data-driven policy approach that seeks to reduce incarceration and corrections spending and reinvest the resulting savings into programs that improve public safety and reduce recidivism).
[11] See Spoerre, supra note 9;Estelle v. Gamble, 429 U.S. 97, 104 (1976); Farmer v. Brennan, 511 U.S. 825, 841–42 (1994) (establishing that prison officials violate the Eighth Amendment when they knowingly disregard a substantial risk of serious harm to an inmate’s health or safety).
[12] See Samantha Laufer, Reproductive Healthcare for Incarcerated Women: From “Rights” to “Dignity,” 56 Am. Crim. L. Rev. 1785, 1803 (2019).
[13] See Redefining the Narrative, supra note 6; Cal. Penal Code § 3408 (2025); 55 Ill. Comp. Stat. 5/3-15003.6 (2025).
[14] See generally Estelle v. Gamble, 429 U.S. 97 (1976); Farmer v. Brennan, 511 U.S. 825 (1994) (clarifying that the standard for holding prison officials liable includes both objective and subjective elements).
[15] U.S. Const. amend. VIII.
[16] See Estelle, 429 U.S. at 103.
[17] Id. at 103–04.
[18] Id. at 104.
[19] Farmer, 511 U.S. at 847 (1994).
[20] Id.; Estelle, 429 U.S. at 103–04.
[21] See Estelle, 429 U.S. at 97; Farmer, 511 U.S. at 847.
[22] Estelle, 429 U.S. at 103–04.
[23] Id. at 97; 42 U.S.C. § 1983 (creating a civil cause of actions against persons who, under color of state law, deprive another of rights secured by the Constitution and federal law).
[24] Estelle, 429 U.S. at 97.
[25] Id. at 107.
[26] Id. at 104 (quoting Gregg v. Georgia, 428 U.S. 153, 173 (1976)).
[27] Id. at 106.
[28] Id.
[29] Id.
[30] Id.
[31] Id.
[32] Id. at 104–05.
[33] See, e.g., Archer v. Dutcher, 733 F.2d 14, 15 (2d Cir. 1984) (applying Estelle’s deliberate indifference standard to a pregnant prisoner’s claim that officials delayed treatment for severe cramping and vaginal bleeding before she miscarried).
[34] Farmer v. Brennan, 511 U.S. 825, 825–27 (1994).
[35] Id. at 830–31 (recognizing a federal prisoner’s Bivens action for alleged Eighth Amendment violations). A Bivens action is an implied cause of action for damages against federal officials, similar to a 42 U.S.C. § 1983 action against state officials. Id. at 839.
[36] Id. at 830–31.
[37] Id. at 833.
[38] Id. at 837.
[39] Id.
[40] Id. at 837–38.
[41] Id.
[42] Id. at 825.
[43] See id. at 837.
[44] See Marcella Alsan et al., Health Care in U.S. Correctional Facilities – A Limited and Threatened Constitutional Right, 388 New Eng. J. Med. 847, 847 (2023).
[45] See Aleks Kajstura & Wendy Sawyer, Women’s Mass Incarceration: The Whole Pie 2024, Prison Pol’y Initiative (Mar. 5, 2024), https://www.prisonpolicy.org/reports/pie2024women.html.
[46] See, e.g.,Archer v. Dutcher, 733 F.2d 14, 15 (2d Cir. 1984) (applying Estelle’s deliberate indifference standard to a pregnant prisoner’s claim that officials delayed treatment for severe cramping and vaginal bleeding before she miscarried).
[47] Dulany v. Carnahan, 132 F.3d 1234, 1236 (8th Cir. 1997).
[48] Id.
[49] Id.
[50] Id. at 1237.
[51] Id. at 1245.
[52] Id. at 1239.
[53] Id. at 1241.
[54] Id.
[55] See id. at 1245.
[56] See id. at 1239.
[57] See id. at 1245.
[58] See id.
[59] See id.;Spoerre, supra note 5.
[60] See Incubating Hope, supra note 7.
[61] Kajstura & Sawyer, supra note 45; Justice Reinvestment Initiative, Mo. Dep’t of Corr., https://doc.mo.gov/initiatives/justice-reinvestment-initiative (last visited Apr. 15, 2026); Anna Spoerre, Missouri prison nursery opens to bipartisan fanfare with goal of keeping mothers with babies, Mo. Indep. (Feb. 3, 2025, at 5:55 CST), https://missouriindependent.com/2025/02/03/vandalia-prison-nursery-opens-missouri; Mental Health Needs in Missouri Jails Part I: Surveying County Sheriffs & Jail Administrators, Mo. Appleseed 22–23 (Sept. 2025), https://mcusercontent.com/798dc004b2022af5b90159a3f/files/97f94d49-ea88-bb8c-fc61-27c8d234d8bf/FINAL_Mental_Health_in_Jails_Report_9.23.25_1.pdf.
[62] See Spoerre, supra note 5.
[63] Id.; Incubating Hope, supra note 7; Justice Reinvestment Initiative, supra note 10.
[64] Prison Nursery Program, Mo. Dep’t of Corr., https://doc.mo.gov/initiatives/prison-nursery-program (last visited Apr. 15, 2026).
[65] Mo. Rev. Stat. § 217.940 (2022).
[66] Incubating Hope, supra note 7.
[67] Spoerre, supra note 61.
[68] Incubating Hope, supra note 7.
[69] Id.
[70] Id.
[71] Id.
[72] Four Wins for Missouri Families!, Mo. Appleseed (Apr. 4, 2025), https://missouriappleseed.org/in-the-news/four-wins-for-missouri-families/.
[73] Mo. Rev. Stat. § 221.520 (2025).
[74] Four Wins for Missouri Families!, supra note 72.
[75] Spoerre, supra note 5.
[76] Four Wins for Missouri Families!, supra note 72.
[77] Id.
[78] See id.
[79] See Justice Reinvestment Initiative (JRI) Overview, supra note 10; Justice Reinvestment Initiative, supra note 61.
[80] Justice Reinvestment Initiative, supra note 61.
[81] Id.
[82] Id.
[83] Id.
[84] Fulton Community Supervision Center, supra note 7.
[85] Id.
[86] Id.
[87] See Community Supervision Centers (CSCs), Mo. Dep’t of Corr., https://doc.mo.gov/initiatives/justice-reinvestment-initiative/csc-repurpose (last visited Apr. 15, 2026).
[88] See Justice Reinvestment Initiative, supra note 61.
[89] Id.
[90] Community Supervision Centers (CSCs), supra note 87.
[91] Id.
[92] See Cal. Penal Code § 3408 (2025); 55 Ill. Comp. Stat. 5/3-15003.6 (2025); Redefining the Narrative, supra note 6.
[93] Justice Reinvestment Initiative, supra note 61.
[94] Incentives & Sanctions in Offender Management, Mo. Dep’t of Corr., https://doc.mo.gov/justice-reinvestment-initiative/incentives-sanctions_offender-management (last visited Apr. 15, 2026).
[95] See Family and Friends Newsletter, Mo. Dep’t of Corr. (July 2019), https://content.govdelivery.com/accounts/MODOC/bulletins/24d84bd.
[96] See Community Supervision Centers (CSCs), supra note 87; Fulton Community Supervision Center, supra note 7.
[97] Fulton Community Supervision Center, supra note 7.
[98] See The Justice Reinvestment Initiative Improves Community Supervision, Bureau of Just. Assistance 3 (May 2021), https://bja.ojp.gov/sites/g/files/xyckuh186/files/media/document/jri-improves-community-supervision.pdf.
[99] Id.
[100] See id.; U.S. Const. amend. VIII.
[101] Mo. Rev. Stat. § 221.523 (2025).
[102] Id.; Spoerre, supra note 5.
[103]See Justice Reinvestment Initiative, supra note 61.
[104] See Storm Ervin et al., Addressing Trauma and Victimization in Women’s Prisons, Urb. Inst.: Just. Pol’y Ctr. 5–6 (Oct. 2020), https://www.urban.org/sites/default/files/publication/103017/addressing-trauma-and-victimization-in-womens-prisons-trauma-informed-victim-services-and-programs-for-incarcerated-women_3.pdf.
[105] See Angela Gunter & Alison Martin, Missouri: Monitoring Data Trends After 2018 Justice Reinvestment Initiative Reforms, The Council of State Gov’ts: Just. Ctr. (July 2022), https://csgjusticecenter.org/publications/missouri-monitoring-data-trends-after-2018-justice-reinvestment-initiative-reforms/.
[106] See id.
[107] See Justice Reinvestment Initiative, supra note 61.
[108] See id.
[109] See Farmer v. Brennan, 511 U.S. 825, 835 (1994).
[110] See Carolyn Sufrin et al., Pregnancy Outcomes in U.S. Prisons, 2016–2017, 109 Am. J. Pub. Health 799, 803–04 (2019) (finding that pregnancy outcomes were more negative for incarcerated women compared to the general population).
[111] Id. at 799 (reporting that in a study of 22 state prison systems, miscarriage rates reached 20% in some states, preterm births occurred in 6% of live births, and cesarean deliveries occurred in 30%, with outcomes varying widely by state).
[112] Id. at 804.
[113] See Redefining the Narrative, supra note 6; Cal. Penal Code § 3408 (2025); 55 Ill. Comp. Stat. 5/3-15003.6 (2025).
[114] See Cal. Penal Code § 3408 (2025).
[115] Id.
[116] Id.
[117] Id. See also U.S. CONST. amend. VIII.
[118] See Redefining the Narrative, supra note 6.
[119] Id.
[120] Id.
[121] Id.
[122] Id.
[123] See id.
[124] Id.
[125] Id.
[126] Id.
[127] Id.
[128] Id.
[129] Id.
[130] See Healing-Centered Illinois Task Force, Juliana Stratton: Off. of Lt. Governor, https://ltgov.illinois.gov/councils/hcitf.html (last visited May 1, 2026); Ill. Reentry Council, Strategic Plan 1–2 (Oct. 9, 2025), https://illinoisreentrycouncil.org/wp-content/uploads/2025/10/Current-Strategic-Plan-10.09.2025.pdf.
[131] See Audrie Marie Ward, The Effectiveness of Prison Nursery Programs in Reducing Recidivism, Ind. Dep’t of Corr. 25 (2018), https://www.in.gov/idoc/files/Ward_Nursery-Recidivism.pdf.
[132] Id.
[133] Id.
[134] See id.
[135] See Joseph R. Carlson, Jr., Prison Nurseries: A Pathway to Crime-Free Futures, 34 Corrs. Compendium 17 (2009).
[136] Id.
[137] See Establishing a Prison Nursery in Missouri, Mo. Appleseed, https://missouriappleseed.org/establishing-a-prison-nursery-in-missouri (last visited Apr. 15, 2026).
[138] See Gunter & Martin, supra note 105.
[139] See U.S. Dep’t of Just., Notice Regarding Investigation of Alabama’s State Prisons for Men 1 (Apr. 2, 2019), https://www.justice.gov/d9/press‑releases/attachments/2019/04/03/notice_letter_and_report_aldoc.pdf; La. Pub. Health Inst., Pregnancy and maternal health for incarcerated women in Louisiana 21 (May 2023), https://www.incarcerationtransparency.org/wp-content/uploads/2024/02/HCR-85-Report-Final-Corrected.pdf.
[140] See U.S. Dep’t of Just., supra note 139, at 1; La. Pub. Health Inst., supra note 139, at 21.
[141] See U.S. Dep’t of Just., supra note 139, at 1.
[142] See id.; United States v. Alabama, No. 2:20-CV-01971-RDP, 2021 WL 4711841, at *1 (N.D. Ala. Nov. 19, 2021).
[143] U.S. Dep’t of Just., supra note 139, at 1; United States v. Alabama, 2021 WL 4711841, at *1.
[144] United States v. Alabama, 2021 WL 4711841, at *1.
[145] La. Pub. Health Inst., supra note 139, at 21.
[146] Id.
[147] See The 2025-26 California Spending Plan: Judiciary and Criminal Justice, Cal. State Legislature: Legis. Analyst’s Off. (Oct. 24, 2025), https://lao.ca.gov/Publications/Report/5085.
[148] Redefining the Narrative, supra note 6.
[149] See Improving Community-Based Treatment and Addressing Violent Crime, Just. Reinvestment Initiative (Mar. 2024), https://justicereinvestmentinitiative.org/wp-content/uploads/2025/01/MO-JRI-assessment-brief_FINAL.pdf; How Missouri Taxes & Revenue Compare to Other States, Mo. Budget Project (Mar. 11, 2025), https://mobudget.org/mo-taxes-revenue-comparison-2025/.
[150] See How Missouri Taxes & Revenue Compare to Other States, Mo. Budget Project (Mar. 11, 2025), https://mobudget.org/mo-taxes-revenue-comparison-2025/.
[151] See Spoerre, supra note 5.
[152] Mo. Rev. Stat. § 221.520 (2025).
[153] Spoerre, supra note 5.
[154] See id.
[155] Mo. Rev. Stat §§ 221.520–221.523 (2025).
[156] Spoerre, supra note 5.
[157] See Establishing a Prison Nursery in Missouri, supra note 137; Cal. Penal Code § 3408 (2025); Redefining the Narrative, supra note 6.
[158] See Establishing a Prison Nursery in Missouri, supra note 137.
[159] See Luke Muentner et al., Parental Incarceration, Attachment to Caregivers, and Young Children’s Physiological Stress, Developmental Psychobiology, Sept. 2025, at 1, 8–9 (2025).
[160] See M.W. Byrne, L.S. Goshin & S.S. Joestl, Intergenerational Transmission of Attachment for Infants Raised in a Prison Nursery, 12 Attachment & Hum. Dev. 375, 375 (2010).
[161] See Carlson, supra note 135.
[162] See Redefining the Narrative, supra note 6.
[163] Id.
[164] Id.
[165] Id.
[166] See Spoerre, supra note 5; Redefining the Narrative, supra note 6.; Cal. Penal Code § 3408 (2025).
[167] See Muentner, supra note 159, at 8–9.