Contextualising the Intersection

of Reproductive Wellbeing
and Incarceration:
The Case of Filipino Women in
Prison

Romulo F. Nieva Jr

A thesis submitted for the degree of

Doctor of Philosophy
at the University of Otago,
Dunedin, New Zealand

December 2021
 Abstract
Women in prison have distinct reproductive wellbeing needs. Most are of reproductive age, and
many are mothers. Despite an extensive literature on prisoners’ health, the reproductive
wellbeing of incarcerated women remains under-researched. Building on Goffman’s (1961)
‘total institutions’ and ‘mortification of self’, Syke’s (1958) ‘pains of imprisonment’, and the
expanded concept of ‘gendered pains of imprisonment’, this research project used reflexive
thematic analysis to examine the data from semi-structured interviews with 42 Filipino
incarcerated women and focus groups with eight prison staff members to answer the following
research questions: 1) What is women’s experience of reproductive wellbeing, 2) What are the
roles of social networks in incarcerated women’s reproductive wellbeing, and 3) What is the
institutional dimension of women’s reproductive wellbeing?

This research project contributes to the growing literature on the gendered pains of imprisonment
experienced by incarcerated women. Several participants in the current study described their
experience of limited access to reproductive health care and lack of autonomy and control over
their reproductive wellbeing. This study also extends the frameworks to encompass the pains
associated with women’s reproductive wellbeing. The women’s reproductive wellbeing in this
study was experienced and expressed in three broad themes: a) increased reproductive
discomforts and decreased relief, b) disempowering experiences, and c) prisoner identity
overriding reproductive wellbeing. These themes reflect the women’s experiences of
imprisonment, intensifying their reproductive issues and creating distinct needs. Furthermore, the
findings demonstrate how reproductive wellbeing needs appeared secondary to their
institutionally imposed ‘prisoner identity’, a situation exacerbated by their experience of
systemic scarcity and limited autonomy.

The current project demonstrates that social networks serve two functions in women’s
reproductive wellbeing. First, findings indicate how women’s hygiene practices, routines and
dress were subject to institutionally imposed peer surveillance, negatively affecting their
reproductive wellbeing experience. Second, despite the pains of imprisonment and surveillance,
women used their social networks as resources to help them maintain their reproductive
wellbeing. Specifically, family members’ emotional, instrumental, and financial support helped

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women cope with reproductive wellbeing issues. For women with limited family support, peers
played a family-like role by providing emotional and material supports to sustain women’s
reproductive wellbeing. Several participants in this study formed a community to help each other
cope with prison deprivations. For instance, sharing menstrual pads and pooling resources to
help other women (e.g., women undergoing surgery or paying hospital bills) embody the Filipino
cultural value of damayan (helping one another), where inmates contribute to assisting peers in
need.

Drawing on Goffman’s total institution, the current project demonstrates how the prison staff
navigated the tension between custodian concerns and accommodating the distinct needs of
women. The data reveals the impact of prison rules on prison officers’ decisions when
confronted with opposing circumstances. In addition, prison nurses expressed the dilemma of
managing the difference between the ideal caring role and the actual care because of prison job
expectations. Using the concept of carceral geography, this project underscores how prison as a
total institution extends beyond the prison walls through disciplinary measures, routines, security
practices, and symbols (i.e., prison uniform, prison vehicle) that are continually attached to
women during hospital appointments.

This thesis underscores the importance of examining the intersection of reproductive wellbeing
and incarceration to lay the groundwork for understanding how prison deprivations are linked to
incarcerated women’s reproductive wellbeing. Lastly, the findings highlight the urgent need to
reform correctional policies and practices to address incarcerated women’s distinct needs.

iii
 Acknowledgements
They say doing a PhD is a lonely and dreary experience, but in my journey, it took a village to
make this thesis dream into an incredible reality. It also could not have been done without the
individuals who supported, encouraged, and nurtured me throughout the learning process.

First and foremost, I would like to remember my lola (grandmother) Vicky, who instilled in me
the value of education. Growing up without my biological parents was difficult, but she served as
our stand-in parent who sacrificed a lot to send us to school. I am sure she is very proud of me,
looking after me from above.

I want to express my deep and sincere gratitude to my supervisors, Assoc. Prof. Bryndl
Hohmann- Marriott, Assoc. Prof. Melanie Beres and Dr Fairleigh Gilmour, for their constant
enthusiastic guidance, motivation, patience, and incredible knowledge that helped me produce
this magnificent scholarly piece of work. Without my supervisors’ support and unwavering faith
in me, I don’t think I would find the right direction for my PhD thesis.

Besides my supervisors, the whole Sociology, Gender Studies and Criminology family, the staff,
and my fellow postgraduate students have been helpful and supportive. I would also like to
express my most profound appreciation to the University of Otago for the scholarship that helped
me achieve this dream and provided extensive personal and professional growth opportunities. I
am thankful to Graduate Research School, Higher Education and Development Centre, and IT
services for their constant support through writing sessions, training, seminars, and research-
related materials.

A special ‘Thank You’ also goes to different professional networks and organisations that
provided funding support for the conferences I participated in, which contributed a lot to my
thought process, network building and character formation: Otago Humanities Division, Otago
Global Health Institute, Harvard Project for Asian International Relations, and Johns Hopkins
Gates Institute for Population and Reproductive Health.

My entire PhD journey is way more prosperous and memorable, thanks to my fabulous 6th floor
Shenanigans family for the endless conversations (ups and downs), our delicious lunch and
potlucks: KC, Sandhiya, Supriya, Nishanti, Gihani and Tahere. I am thankful to Ola, Joana,

iv
Laura, and Tamlyn. I am forever grateful to my PhD siblings and shut-up and write buddies,
who served as my sounding board, witnessed my ‘Aha’ moments, and provided comfort,
especially during the ‘pandemic’ time: Kirsten, KC, and Kayla.

I am forever thankful to the incredible people I considered family in Dunedin. I cannot express
enough gratitude for great chit chats, Filipino potlucks, and road trips: Team Boo- Bea, Cliff,
Adria, Sham, Lorraine, and Art; my beauty queen family: Jamie, Syaliny, Adria, Yann; to my
Dunedin potluck sisters: Shruthi, Kath, and Ka ki. I would also like to thank my fellow Pinoy
Otago postgrads for their love and support. Thanks to my Wellness Walk family for such
incredible weekend hikes, lunch together, and endless laughter during the walks. To the Filipino
community in Dunedin for the warm welcome and for hosting Filipino events that make me feel
at home.

I would like to express my gratitude to my mentors in the Philippines who have prepared me for
the bigger challenge as a researcher: Assoc. Prof. Alice Manlangit, Assoc. Prof. Cristina
Rodriguez, Dean Carina ‘CJ’ Barroso, and Prof. Lalay Jimenez. I am super thankful to my
friends in the Philippines for their good wishes and support. Special thanks to my Cultured
trekker family for the constant laughter, chats, food hopping, and trek: Venia, Ching, Jem,
Elaine, & Jen.

My sincere gratitude goes to Usec. Atty. Kris Alban, Bureau of Corrections, Correctional
Institution for Women, for their invaluable assistance during my fieldwork in the Philippines.
This work would not have been possible without the time and help that the prison staff provided
me: a particular thanks goes to CIW Corrections Officers Inday and Rosette for their daily
support during my interview and focus group days.

A big thank you to my family and relatives for all the support they have shown me through this
PhD journey. My gratitude and love go to my wonderful sister, April.

Finally, at the heart of this research project are my interview and focus group participants. I am
appreciative of their time, trust, courage, and willingness to share their stories with me. I hope
this thesis faithfully captures and conveys the stories of my prisoner participants. I am thankful
for allowing me to take a ‘sneak peek’ of their daily life. By them, I am deeply humbled, and to
them, forever grateful.

v
 Table of Contents
Abstract ii

Acknowledgements iv

List of Figures xi

List of Tables xii

List of Abbreviations xiii

Chapter One Introduction and Background

1.1 Why focus on Filipino incarcerated women’s reproductive wellbeing? ................... 1

1.2 Research questions ..................................................................................................... 6
1.3 Outline of the thesis ................................................................................................... 7
1.4 Chapter summary ....................................................................................................... 9
Chapter Two The Nexus Between Incarceration and Reproductive Wellbeing

2.1 Women’s incarceration as a reproductive justice issue ........................................... 10

2.1.1 Summary ...................................................................................................... 14
2.2 The reproductive wellbeing needs of incarcerated women: The global context ..... 14
2.2.1 Women’s pre-incarceration status shapes prison wellbeing ........................ 14
2.2.2 Women’s reproductive health during incarceration ..................................... 16
2.2.3 Summary ...................................................................................................... 18
2.3 The functions of social networks in prisoners’ wellbeing ....................................... 18
2.3.1 Summary ...................................................................................................... 23
2.4 Theoretical framework ............................................................................................. 24
2.4.1 Total institutions and mortification of self................................................... 25
2.4.2 Pains of imprisonment ................................................................................. 32
2.4.3 Summary ...................................................................................................... 40
2.5 Chapter summary ..................................................................................................... 41
Chapter Three Reproductive Wellbeing and Women’s Incarceration in the Philippines

3.1 The Philippine health system and reproductive health care..................................... 43

3.1.1 An overview ................................................................................................. 43

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 3.1.2 Health financing and maternal health care................................................... 44
3.1.3 Prenatal care ................................................................................................. 47
3.1.4 Menstrual wellbeing of Filipino women ...................................................... 48
3.1.5 Contraceptive services ................................................................................. 50
3.1.6 Summary ...................................................................................................... 51
3.2 Reproductive politics: The sociopolitical dimension of Philippine reproductive
health ........................................................................................................................ 51
3.2.1 Summary ...................................................................................................... 54
3.3 Philippine prisons and the situation of women ........................................................ 55
3.3.1 The organisation of the penal system in the Philippines.............................. 55
3.3.2 Socio-economic circumstances of Filipino incarcerated women ................. 55
3.3.3 Specific needs of Filipino incarcerated women ........................................... 56
3.3.4 Reproductive wellbeing of incarcerated Filipino women ............................ 57
3.3.5 Summary ...................................................................................................... 59
3.4 Research and knowledge gaps ................................................................................. 59
3.5 Chapter summary ..................................................................................................... 61
Chapter Four Methodology: Approaches and Tools

4.1 Choosing qualitative approach ................................................................................. 63

4.2 Feminist qualitative research design ........................................................................ 64
4.3 Ethical considerations .............................................................................................. 65
4.3.1 Institutional ethics approval ......................................................................... 65
4.3.2 Informed consent ......................................................................................... 65
4.3.3 Power dynamics ........................................................................................... 66
4.3.4 Incarcerated women’s vulnerability ............................................................. 67
4.3.5 Researcher’s professional background ........................................................ 69
4.4 Research procedures ................................................................................................ 70
4.4.1 Sampling and recruiting processes............................................................... 70
4.4.2 Data collection procedures ........................................................................... 71
4.4.3 Data analysis: Reflexive thematic analysis .................................................. 75
4.5 Researcher’s positionality ........................................................................................ 80
4.6 Rigour and trustworthiness ...................................................................................... 82

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 4.7 Participants’ characteristics ..................................................................................... 83
4.7.1 Interviews with incarcerated women ........................................................... 83
4.7.2 Focus groups with prison staff ..................................................................... 85
4.8 Chapter summary ..................................................................................................... 86
Chapter Five The Pathways of Women from the ‘Outside World’ to Prison: The Philippine
Context

5.1 Pre-incarceration stories: The status of Filipino women in the broader society ...... 88
5.1.1 The nature of their crime.............................................................................. 93
5.1.2 Summary ...................................................................................................... 95
5.2 Women’s incarceration stories ................................................................................. 95
5.2.1 The prison filters: Entry, screening, and classification ................................ 95
5.2.2 The daily reality in ‘regular dorms’: Routinising women’s prison life ....... 98
5.2.3 Into the prison infirmary: The health care triage ....................................... 102
5.2.4 Navigating the prison reproductive health care ......................................... 104
5.2.5 Summary .................................................................................................... 107
5.3 Chapter summary ................................................................................................... 107
Chapter Six Lived Experiences of Reproductive Wellbeing of Filipino Incarcerated Women

6.1 Theme 1: Increased reproductive discomforts and decreased relief ...................... 109
6.1.1 Prison aggravates women’s reproductive discomforts .............................. 109
6.1.2 Reduced capacities to manage needs and discomforts .............................. 112
6.1.3 Summary .................................................................................................... 116
6.2 Theme 2: Disempowering experiences .................................................................. 117
6.2.1 Lack of control and autonomy ................................................................... 117
6.2.2 Shameful experiences ................................................................................ 120
6.2.3 ‘I felt helpless’ ........................................................................................... 123
6.2.4 Summary .................................................................................................... 124
6.3 Theme 3: Prisoner identity overriding reproductive wellbeing ............................. 125
6.3.1 Summary .................................................................................................... 130
6.4 Chapter summary ................................................................................................... 130
Chapter Seven The Relational Context of Incarcerated Women’s Reproductive Wellbeing

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 7.1 Theme 1: Social surveillance ................................................................................. 132
7.1.1 Peer’s gaze ................................................................................................. 132
7.1.2 Tattling ....................................................................................................... 135
7.1.3 Gossiping ................................................................................................... 136
7.1.4 Summary .................................................................................................... 137
7.2 Theme 2: Social networks as resources to cope with reproductive issues ............. 137
7.2.1 Maintenance of (reproductive) wellbeing .................................................. 137
7.2.2 Prison peers’ family-like role..................................................................... 141
7.2.3 Summary .................................................................................................... 145
7.3 Chapter summary ................................................................................................... 145
Chapter Eight The Institutional Dimension of Incarcerated Women’s Reproductive Wellbeing

8.1 Navigating the total institution............................................................................... 147

8.1.1 Over-attention to schedule and routines .................................................... 148
8.1.2 Bureaucracy and under a single authority .................................................. 149
8.1.3 Prisoners are treated alike .......................................................................... 152
8.1.4 Rational institutional plan .......................................................................... 156
8.1.5 Summary .................................................................................................... 159
8.2 Theme 2: Extension of the total institution ............................................................ 160
8.2.1 Summary .................................................................................................... 162
8.3 Chapter summary ................................................................................................... 163
Chapter Nine Discussion and Conclusions

9.1 The nexus between women’s reproductive wellbeing and the pains of
imprisonment ......................................................................................................... 164
9.2 Mortification of self and reproductive wellbeing .................................................. 166
9.3 The relational dimension of incarcerated women’s reproductive wellbeing ......... 170
9.4 The institutional dimension of women’s reproductive wellbeing.......................... 173
9.5 Limitations of the study ......................................................................................... 177
9.6 Contributions to knowledge ................................................................................... 178
9.7 Recommendations .................................................................................................. 182
9.8 Self-reflection ........................................................................................................ 184
9.9 Conclusion ............................................................................................................. 185
ix
References 188

Appendices 210

Appendix A – Philippine Bureau of Correction’s letter of support ................................... 210

Appendix B – Ethics committee approval ......................................................................... 211
Appendix C – Consent form for interview participants .................................................... 213
Appendix D – Interview participant information sheet ..................................................... 217
Appendix E – Consent form for focus group participants ................................................. 221
Appendix F – Focus group participant information sheet ................................................. 225
Appendix G – Interview guide .......................................................................................... 229
Appendix H – Focus group guide (prison staff) ................................................................ 231
Appendix I – Focus group guide (prison nurses) .............................................................. 232

x
 List of Figures
Figure 1 The number of Filipino women in prison over time......................................................... 4
Figure 2 The Philippine map......................................................................................................... 44
Figure 3 The CIW prison cell ....................................................................................................... 99

xi
 List of Tables
Table 1 Examples of linking of codes and categories................................................................... 77
Table 2 Interview participants' demographics .............................................................................. 83
Table 3 Focus group participants' demographics .......................................................................... 85

xii
 List of Abbreviations
BJMP Bureau of Jail Management and Penology
BuCor Bureau of Corrections
CIW Correctional Institution for Women
DOH Department of Health
DOJ Department of Justice
ICPD International Conference on Population and Development
PDL Persons Deprived of Liberty
PhilHealth Philippine Health Insurance
STI Sexually Transmitted Infection
UN United Nations
WHO World Health Organisation

xiii
 Chapter One
Introduction and Background
In this chapter, I discuss the research problem of the current project. I present both the focus and
motivation for this study. I also discuss how incarceration magnifies women’s existing
reproductive wellbeing issues globally and, in the Philippines, and creates distinct wellbeing
issues. This chapter concludes by providing the thesis structure, where I present the aim of each
chapter.

1.1 Why focus on Filipino incarcerated women’s

reproductive wellbeing?
In 2015, I came across an article1 in The Guardian written by Chandra Bozelko. Bozelto narrates
her experience and observation on how prison fails to sustain incarcerated women’s reproductive
wellbeing needs. She spent six years at York Correctional Institution in Connecticut, where
female dormmates received five menstrual pads per week to split. She writes, “The lack of
sanitary supplies is so bad in women’s prisons that I have seen pads fly right out of an inmate’s
pants…fails to stick to her underwear, and the [menstrual] pad falls out”. Her story caught my
attention as a public health professional. At the same time, as a researcher who has been
investigating reproductive health for several years, I am aware that structural and societal factors
systemically affect women’s ability to sustain their reproductive wellbeing needs. My
professional knowledge and lessons from previous research projects have exposed me to various
reproductive health issues faced by poor and marginalised Filipino women due to limited access
to quality health care, socioeconomic factors, and broader social norms. After reading Bozelko’s
article, my curiosity led me to a 2014 Philippine study2 that documents the specific needs of

1
Bozelko, C. (2015). Prisons that withhold menstrual pads humiliate women and violate basic rights. The
Guardian. https://www.theguardian.com/commentisfree/2015/jun/12/prisons-menstrual-pads-humiliate-
women-violate-rights

2
Baker, J. (2014). Conditions for Women in Detention in the Philippines: Needs, vulnerabilities and good
practices. Danish Institute Against Torture (DIGNITY).
1
Filipino incarcerated women. The report noted that Filipino incarcerated women had limited
access to reproductive health care, such as pain medications and iron supplements. The study
indicated that women’s poor reproductive wellbeing could be attributed to overcrowding, lack of
nutrition and inadequate sanitary facilities in Philippine prisons.

Concerned by the lack of access to quality reproductive health care among a marginalised group
of women, my curiosity and public health experience were the initial motivations to propose
researching incarcerated women’s experience of reproductive wellbeing. As a reproductive
health advocate, I have seen the progress made towards improving the health and lives of
Filipino women since the passage of the Philippine Reproductive Health Law (R.A. 10354) in
2012. The law has paved the way for robust investment in universal access to reproductive health
services. Despite this progress, the current national efforts fail to address other pressing issues,
including women’s reproductive health in prison. Based on my advocacy work, I have
discovered that mainstream reproductive health advocacy has not paid much attention to women
prisoners. For instance, although the existing reproductive health law has indicated the need to
support poor and disadvantaged women, it has not explicitly stated the need to support
incarcerated Filipino women’s reproductive health.

Women in prison have diverse and distinct reproductive wellbeing needs. Most incarcerated
women globally are of reproductive age, and many are mothers (Moore & Elkavich, 2008;
Sufrin et al., 2017). Research has revealed that imprisonment aggravates incarcerated women’s
reproductive wellbeing issues due to the stressful environment (Gallant & Derry, 1995; C.
Smith, 2009) and limits access to essential health services (van den Bergh et al., 2011). Their
reproductive wellbeing needs concerning menstruation, childbearing, and newborn care are often
overlooked (Mignon, 2016; Sufrin et al., 2015), unmet by correctional health care and negatively
affected due to the male-centric prison environment (Bastick & Townhead, 2008). Several
factors have been identified that explain how incarceration both magnifies existing reproductive
health issues of women and creates distinct challenges.

First, women constitute between two to nine per cent of the whole prison population worldwide,
either as sentenced or pre-trial detainees (van den Bergh et al., 2011; Walmsley, 2017). As a
minority prison population, and despite the growing number in many counties, they are
neglected, to the detriment of their dignity, wellbeing and fundamental human rights, such as

2
access to reproductive health care (Baker, 2014). A ‘one-size-fits-all’ model has shaped the penal
institutions based on a population of men, where uniquely female reproductive conditions, such
as regular gynaecological and breast examinations, are not given strong consideration
(Braithwaite et al., 2005; Flavin, 2008; Hayes et al., 2020). The World Health Organisation
[WHO](2009a) indicates that a fraction of female inmates has been compelled to cope with the
same routines and services as their male counterparts. This pattern illustrates a disregard for
women’s distinct, primary needs in prison.

Second, although women are a small group of the whole prison population, the number has risen
dramatically over the last few decades and increased more than six-fold, outranking the growth
rate of the male prison population (Bastick & Townhead, 2008; Van Hout & Mhlanga-Gunda,
2018; Walmsley, 2017). This growth has primarily been attributed to policy changes, including
harsher drug-sentencing laws that profoundly impact women (Shlafer et al., 2019). For example,
in the United States, it has been theorised that determinate and compulsory sentencing in parallel
with ‘war on drugs’ policies is the primary driver underpinning the growth (Bloom et al., 2004;
Kruttschnitt, 2010; Mauer et al., 1999; McIvor, 2010). The dramatic and substantial increase in
the female prison population and scarce prison resources negatively affect their reproductive
wellbeing and living conditions (van den Bergh et al., 2009; World Health Organisation, 2009a).
This pattern demonstrates an urgent need to focus on incarcerated women’s reproductive
wellbeing (Owen et al., 2017).

Similarly, the Philippine correctional system is considered the most overcrowded globally, with
an average congestion rate of 582 per cent, including incarcerated women (World Prison Brief,
2018). Though it was already congested before President Rodrigo Duterte’s ‘war on drugs’, the
prison population has increased by more than 67 per cent, from 120,000 in 2016 to 200,000 in
2018 (Narag & Jones, 2020). For example, as shown in Figure 1, in 2018, 21 349 women were in
prison, 11 per cent of the entire incarcerated population, a proportion higher than the global
average of 6.9 per cent (World Prison Brief, 2018). The significant increase in female prisoners
between 2016 and 2018 could be attributed to the Duterte administration’s ‘war on drugs’ (Narag
& Jones, 2020).

3
 Figure 1 The number of Filipino women in prison over time
The Philippine government has further intensified its enforcement of Republic Act 9165 or the
‘Comprehensive Dangerous Drugs Act of 2002’, which criminalises various drug-related
activities, including possession, selling, and manufacturing (Panes, 2019). This ‘war on drugs’
policy has significantly contributed to highly congested prisons in the country due to drug-
related cases. Similar to the global pattern, punitive drug laws and the ‘war on drugs’ approach
have disproportionately impacted women and contributed to the rise in Filipino incarcerated
women (Fentiman, 2008; Roberts, 1991; Ross & Solinger, 2017). The Correctional Institution for
Women (CIW), the largest women’s prison in the Philippines, houses most sentenced women. In
February 2021, it was overcrowded, with 3,364 women in a space meant for only 1,500, which
means it had a congestion rate of 234 per cent (Bureau of Corrections, 2021). Of the 3,364
women, most were in the age groups 22-39 (n=1,001) and 40-59 (n=1,799).

Third, most incarcerated women come from the margins of society (van den Bergh et al., 2011).
Global studies have shown that women involved in criminal activity share similar life
experiences, such as poverty, underemployment, and poor education (Carlen & Worrall, 2013;
Radosh, 2002; Richie, 2001). The injustices they encounter in wider society reach deep into
prisons (Bastick & Townhead, 2008). These pre-imprisonment circumstances profoundly impact
women’s capacity to sustain their wellbeing needs in prisons (Chen & Gueta, 2015; Gueta,
2020).

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Lastly, several studies have indicated that most incarcerated women are at risk of poor
reproductive health due to inadequate access to quality reproductive health care before
imprisonment (Clarke et al., 2006; Owen et al., 2017; Peart & Knittel, 2020). Incarcerated
women are characterised by pre-incarceration health risks, such as homelessness, abuse and
trauma, addiction, high-risk sexual behaviours, and low health literacy (Carlen, 1983; Harner &
Riley, 2013). While confined, this pre-imprisonment vulnerability interacts with prison
deprivations, limited health care, and restricted access to family support, contributing to complex
wellbeing issues (Douglas et al., 2009; Harner & Riley, 2013). For example, women of colour in
the U.S. represent a vulnerable group with inadequate access to medical insurance prior to
imprisonment (Bonney et al., 2008; Mahaffey & Stevens-Watkins, 2016).

The International Conference on Population and Development Declaration (1994) defines

reproductive health as a state of complete physical, mental and social wellbeing related to
reproductive wellbeing needs. The 1994 ICPD outlines core elements of reproductive health:
menstruation, hygiene, management of reproductive discomforts (e.g., endometriosis, heavy
bleeding), pregnancy, prenatal and postnatal care, and access to birth control, fertility
information and education, prevention and treatment of sexually transmitted infections. In this
study, I explore the aspects of reproductive wellbeing related to menstruation, hygiene,
management of reproductive-related discomforts (e.g., endometriosis, heavy bleeding), and
pregnancy.

Despite the extensive literature on prisoners’ wellbeing and some studies on the distinct
wellbeing needs of incarcerated women, little is known about how reproductive wellbeing is
experienced in prison. The global mainstream discussion on the reproductive wellbeing of
female inmates has centred on women’s access to family planning or birth control services using
a health perspective (Clarke et al., 2006; Hale et al., 2009; Jiraporncharoen et al., 2011; Liauw et
al., 2016). Existing research has largely neglected the reproductive health care of incarcerated
women (Gueta, 2017). The broader criminology literature has overlooked the impact of
imprisonment on the reproductive wellbeing of female prisoners and the extent of their unmet
needs (Bronson & Sufrin, 2019; Mignon, 2016). Finally, most studies that examined the
gendered pains of imprisonment experienced by women were primarily focused on western
perspectives, and little is known about the experience of incarcerated women in the global south.

5
As a public health researcher, shifting from a public health perspective to criminological and
sociological approaches would help me critically understand the nexus between incarceration
and reproductive wellbeing. This approach allows me to delve into the underlying norms around
gender and prison and how these phenomena intersect in women’s prison reproductive wellbeing
experiences. Goffman’s (1961) sociological examination of ‘total institutions’ and ‘mortification
of self’, Syke’s (1958) ‘pains of imprisonment’, and the expanded concept of ‘gendered pains of
imprisonment’ are appropriate and substantial perspectives that examine the distinct needs of
incarcerated women. I apply these approaches to the current research project as the guiding
theoretical lenses to explore the intersection of reproductive wellbeing and women’s
incarceration.

Determining the reproductive wellbeing of Filipino women in prisons will contribute to the
growing discourse about the nexus of incarceration and reproductive wellbeing. Furthermore,
identifying incarcerated women’s experiences of reproductive wellbeing will help understand the
context and unique experiences of these women. The study also seeks to identify the support
mechanisms in the correctional facilities that help women prisoners cope with the prison
regimes, scarce resources, and reproductive health needs. Apart from the current study’s core
objective, which gives a voice to Filipino incarcerated women’s experiences of reproductive
wellbeing, it is envisaged to help practitioners and policymakers understand women’s
experiences further and recognise the social and institutional dimensions of their experiences,
rather than purely describing the gaps of reproductive health services in prison. This
acknowledgment may facilitate developing and providing holistic strategies to support
incarcerated women’s reproductive wellbeing.

1.2 Research questions

The ultimate goal of the proposed study is to identify and contribute empirical evidence to the
study of women’s reproductive wellbeing experiences in prison. The specific questions include:

1. Lived experience: What is the experience of reproductive wellbeing of Filipino incarcerated

women?

6
2. Relational context: What are the roles of social networks in Filipino incarcerated women’s
reproductive wellbeing?

3. Institutional context: What is the institutional dimension of Filipino incarcerated women’s

reproductive wellbeing?

1.3 Outline of the thesis

This thesis has nine chapters, comprising an introduction, literature review (chapters two and
three), methodology (chapter four), findings (chapters five to eight), and discussion and
conclusion (chapter nine). An outline of the structure of the thesis follows.

This doctoral thesis begins by introducing the broader themes of the project. Specifically, I
discuss the study’s problem statement and the key questions shaping the research inquiry.

Chapters two and three summarise the literature on women and incarceration, the distinct needs
of incarcerated women, their reproductive wellbeing, and the Philippine context. Specifically,
chapter two explores the intersection of reproductive wellbeing and incarceration by providing
the context of women’s imprisonment as a reproductive justice issue. I then investigate the pre-
imprisonment circumstances affecting women’s wellbeing in prison and complex reproductive
wellbeing needs during incarceration. I also discuss the roles and functions of social networks in
prisoners’ wellbeing. This chapter presents the theoretical frameworks employed in the study, its
rationale, and its context: Goffman’s (1961) sociological examination of ‘total institutions’ and
‘mortification of self’, Sykes’ (1958) ‘pain of imprisonment’ and the expanded ‘gendered pains
of imprisonment’.

Chapter three explores the social construction of reproductive wellbeing in the Philippines. A
Philippine case is examined, emphasising how reproductive politics and governance have been
shaped over time by the intersection of colonialism, Catholicism, and socioeconomic context. It
then deals with the local context of the prison system and the unique condition of the women’s
prison population in the Philippines.

Chapter four provides an overview of the methodology employed to address the main research
questions. It justifies the relevance of the qualitative approach to the current study. I also explain
the recruitment, data collection, analysis processes, and reflections on my positionality as a

7
researcher. Rigour within the research and ethical dimensions of the research project are also
presented.

The following four chapters are the results chapters. Chapter five is a descriptive chapter that
presents the pre-incarceration stories of the participants, their pathways to prison and everyday
prison experiences concerning their reproductive wellbeing. Although this chapter does not
address any specific research question, it provides context to lay the groundwork for answering
the research questions. Specifically, it gives a glimpse of the incarcerated women’s stories before
and during imprisonment. The succeeding results chapters explore the main research questions
and engage with theories to analyse the findings.

In chapter six, I present Filipino incarcerated women’s reproductive wellbeing experiences that
address the first research question. I begin this chapter by introducing the first theme that
describes how prison aggravates women’s discomforts and reduces their capacity to manage their
reproductive issues. I then discuss the second theme of how women express and construct the
meaning of disempowering experiences. Finally, I illustrate the last theme, showing how
women’s institutionally imposed prisoner identity overrides their reproductive wellbeing needs.

Chapter seven examines the second question, the relational context of the participants’
reproductive wellbeing. This chapter explores the roles and functions of social networks in
incarcerated women’s reproductive wellbeing. Firstly, I explore the participants’ experiences of
social surveillance and its entanglement in their reproductive wellbeing. I then describe how the
incarcerated women’s social networks serve as resources to cope with the pains of imprisonment
concerning their reproductive wellbeing.

To answer the last research question, chapter eight examines the institutional dimension of
women’s reproductive wellbeing experiences by analysing the data from the focus groups with
the medical and prison staff, parallel with incarcerated women’s accounts. This chapter is
divided into two sections: a) navigating the total institutions and b) extension of the total
institution. Firstly, I examine how the characteristics of Goffman’s (1961) total institutions
manifest in a prison setting in the context of reproductive wellbeing. Secondly, building on the
experiences of incarcerated women accessing reproductive health care outside health facilities, I
explore how the total institution extends beyond the prison spaces by analysing the prison
regulations and policies concerning medical transport and outside hospital care.

8
In the final chapter, I discuss the main findings of the present study and situate them in the
broader theoretical foundations. Furthermore, I present the study’s limitations, the crucial
recommendations for future research, policy and programmes, and my reflection as a researcher.
I then end the chapter with the conclusions.

1.4 Chapter summary

The present study brings together the sparse and poorly integrated discussion around the nexus
between reproductive wellbeing and incarceration. This chapter has introduced the issues of
incarcerated women’s reproductive wellbeing globally and locally (Philippines). I have also
presented the main research questions shaping the research inquiry.

This thesis is a unique and holistic project and the first to explore the intersection of Filipino
women’s reproductive wellbeing and incarceration. The study is both descriptive and analytical.
The project envisions helping policymakers and professionals further understand women’s
experiences and recognise the social and institutional dimensions of their experiences, rather
than purely describing the gaps in reproductive health services in prison. This acknowledgment
may facilitate developing and providing holistic strategies to support women’s reproductive
wellbeing in prison.

9
 Chapter Two
The Nexus Between Incarceration and
Reproductive Wellbeing
This research project is anchored on three research questions. The first question examines
women’s experiences of reproductive wellbeing. The second question explores the relational
context of their reproductive wellbeing. Specifically, what are the roles and functions of
incarcerated women’s social networks in their reproductive wellbeing? Finally, the third question
analyses the institutional dimensions of women’s reproductive wellbeing.

The questions guiding the present study are informed by a theoretical discourse within the
criminological and sociological theories on how incarcerated individuals cope with prison life.
This chapter contextualises the intersections of incarceration and reproductive wellbeing. To do
so, I have split this chapter into four sections. The first section examines women’s imprisonment
as a reproductive justice issue. Second, I discuss the different pre-imprisonment circumstances
affecting women’s wellbeing in prison. I then outline their various distinct and complex
reproductive wellbeing needs during imprisonment. In the third section, I describe the roles and
functions of social networks in prisoners’ wellbeing. The last section presents the theoretical
framework employed in the study, its rationale, and its context. Specifically, I explore the
various institutional attributes of prisons using Goffman’s (1961) sociological examination of
‘total institutions’ and ‘mortification of self’. Further, I illustrate the impact of prison conditions
on the experiences of prisoners using Syke’s (1958) ‘pain of imprisonment’ and the unique
experiences of incarceration of women using the concept of ‘gendered pains of imprisonment’.

2.1 Women’s incarceration as a reproductive justice

issue
Reproductive justice advocates have argued that women’s incarceration is a pressing
reproductive justice issue (Ross & Solinger, 2017). The profound economic inequity and
unemployment have contributed to women’s pathway to prison (Bastick & Townhead, 2008;
Bloom, 1997; Carlen, 1983; Radosh, 2002; Richie, 1996). They are trapped in the system that

10
affects their vulnerability to incarceration and their reproductive issues in various ways (Ross &
Solinger, 2017). Several scholars have highlighted the drug war's impact on constructing drug
use and addiction as pure matters of crime rather than health, social and human rights issues
(Fentiman, 2008; Janssen, 1999; Paltrow, 1990; Roberts, 1996, 1997; Stone-Manista, 2009).

Incarceration amplifies existing reproductive health inequities of women and creates an

additional layer of reproductive health issues unique to their prison experiences (Ross &
Solinger, 2017; Roth, 2017). Imprisonment infringes on women’s fundamental reproductive
health and rights by confining them, limiting their access to quality reproductive health care, and
separating them from their children (Roth, 2017). Roth (2017) argues that prisons reflect and
reinforce social disadvantages by primarily confining marginalised and poor women.
Reproductive justice is embedded in the belief that structural inequities and institutional factors
have always shaped people’s decisions, behaviours, and reproductive health experiences (Ross,
2017).

Several scholars have pointed out how women are regulated by law and how mothers, in
particular, are viewed as ‘good’ or ‘bad’ through their adherence to the social expectations of the
‘normative mother’ (Boyd, 1996; Kline, 1993; Smart, 2013). Dorothy Roberts (1993) explains
that these mothers are penalised primarily for violating gender norms. Carol Smart (1995) offers
a thorough feminist critique of how the criminal justice system reinforces and institutionalises
these gender norms:

The forms of social control to which women are subject vary from primary
socialisation within the family, and secondary socialisation (by peer groups,
education system, the media etc.), which reinforces the ways of acting,
thinking and feeling ‘characteristics’ of the female role, femininity and
womanhood to the more formal processes of institutional intervention through
legislation by the state, the implementation of the law, the penal system, and
criminal process (Smart, 1995, p. 2).

Jeanne Flavin’s (2008) Our Bodies, Our Crimes illustrates that imprisoned women’s bodily
autonomy, right to have or not have children, and raising children in an enabling environment are
disrupted. Roberts’ Killing the Black Body: Race, Reproduction, and the Meaning of Liberty

11
(1997) has uncovered compelling stories of how some women of colour and economically
marginalised women encounter intrusive activities, such as surveillance of behaviours because
they use publicly-funded services. These situations negatively affect women’s fundamental
rights and threaten reproductive autonomy (Paltrow, 1998). Flavin (2008) explains how women’s
non-normative reproductive behaviours generate numerous punitive responses from the criminal
justice system.

Reproductive justice and reproductive rights are interconnected. Reproductive rights “refer to the
opportunity to make decisions related to family planning and childbearing” (Smith, 2017, p.
221). Furthermore, reproductive justice “repositioned reproductive rights in a political context of
intersecting race, gender, and class oppression” (Roberts, 2015, p. 79). The reproductive justice
concept was introduced in 1994 by SisterSong, a coalition of US women of colour who
participated in the International Conference on Population and Development (ICPD) in Cairo.
These feminist advocates argue that ‘reproductive rights’ discourse is confined to autonomy,
privacy, and abortion. They add that the movement was not responsive to many marginalised
women, such as immigrants and women of colour (Chrisler, 2013; Ross et al., 2016). The
advocacy group then combined ‘reproductive rights’ and ‘social justice’ to arrive at
‘reproductive justice’, which underlines the importance of supporting those who decide not to
become parents and creating enabling parenting environments. In their book Reproductive
Justice: An Introduction, Loretta Ross and Rickie Solinger (2017) claim that at the heart of
reproductive justice is the notion that everyone deserves safe and dignified experiences for their
reproductive and sexual health and rights.

Like the general population, prisoners are entitled to receive quality health care. Adequate health
care for female prisoners is mandated under several global commitments and guidance, such as
the United Nations (U.N.) Standard Minimum Rules for the Treatment of Prisoners (Nelson
Mandela Rules), the U.N. International Covenant on Economic, Social and Cultural Rights
(Article 10), the U.N. Body of Principles for the Protection of All Persons under Any Form of
Detention or Imprisonment (Principle 5), the U.N. Rules for the Treatment of Female Prisoners
and Non-Custodial Measures for Women Offenders (the Bangkok Rules), and Sustainable
Development Goal’s (SDG) 3, 5, and 16. The Nelson Mandela Rule 2 states that in applying the
non-discrimination principle, penal management shall consider the distinct needs of prisoners,

12
particularly vulnerable groups (United Nations General Assembly, 2016). Moreover, Rule 24 of
the Nelson Mandela Rules stresses the state’s responsibility to provide the same standard of
health care for prisoners as those available in the community without discrimination. Rule 5 of
the U.N. Bangkok Rules specifically stipulates:

the accommodation of women prisoners shall have facilities and materials

required to meet women’s specific hygiene needs, including sanitary towels,
provided free of charge and a regular supply of water to be made available for
the personal care of children and women, in particular women involved in
cooking and those who are pregnant, breastfeeding or menstruating (United
Nations General Assembly, 2011, p. 9).

Additionally, the U.N. Bangkok Rule 6 recommends that the “health screening of women
prisoners shall include comprehensive screening to determine their primary health-care needs”
(United Nations General Assembly, 2011, p. 9). However, the success of these global goals
hinges on governments’ commitment to providing quality health care to women prisoners. These
complex situations may affect the prison health care operation, given its isolation from
community health services, lack of women-responsive care and limited resources (van den Bergh
et al., 2011).

Additionally, attaining the reproductive justice goal largely depends on access to comprehensive
health and social support, such as housing, education, and a living wage. Furthermore, safe
fertility management, pregnancy, and parenting are impossible without these resources. This
argument is essential to highlight as reproductive justice is rooted in the belief that structural
inequality has significantly shaped people’s decisions concerning childbearing and parenting,
particularly vulnerable women like incarcerated women (Ross, 2017). Similarly, the pioneering
organisation Forward Together argued that reproductive justice could only be attained if
everyone had access to economic and social resources to make healthy decisions about their
bodies, sexuality and reproduction (Asian Communities for Reproductive Justice, 2005). Ross
and Solinger (2017) explain that reproductive justice transcends the pro-choice and pro-life
arguments. They argue that the advocacy framework promotes sexual autonomy and gender
freedom for all. Therefore, it decentres contraception to show how other social issues, such as

13
imprisonment and immigration adoption policies, impact reproductive health (Alexander, 2012;
Paltrow & Flavin, 2013).

2.1.1 Summary
This section outlines why women's incarceration is a pressing reproductive justice issue. It
specifically discusses the context and underlying principles of reproductive justice as a feminist
and critical advocacy framework. Women’s imprisonment intensifies existing reproductive
health inequities of women and creates an additional layer of reproductive health issues that are
unique to their prison experiences. Feminist criminologists have argued that prisons reflect and
reinforce social disadvantages by primarily confining marginalised and poor women.
Furthermore, reproductive justice is rooted in the belief that systemic inequities and institutional
factors have always shaped people's decisions, behaviours, and reproductive health experiences.
Although access to reproductive health is globally recognised as a fundamental human right,
there is a lack of access to quality reproductive care in the prison system.

2.2 The reproductive wellbeing needs of incarcerated

women: The global context
Considering that many imprisoned women are in their reproductive age, are often mothers and
are usually the primary carer for their children before incarceration, their reproductive wellbeing
must be regarded as an utmost priority alongside their other fundamental human rights (Bastick
& Townhead, 2008). This section has two objectives. First, I illustrate how women’s pre-
imprisonment circumstances affect their wellbeing in prison. I then discuss their various distinct
and complex reproductive wellbeing needs during incarceration.

2.2.1 Women’s pre-incarceration status shapes prison wellbeing

Pre-incarceration health conditions shape the poor health of female prisoners (Gueta, 2020).
Global studies have indicated that most incarcerated women have myriad mental and wellbeing
issues, histories of physical and sexual abuse, substance addictions and violence exposure (Chen
& Gueta, 2015; van den Bergh et al., 2011).

14
Feminist criminologists have argued that female inmates’ socio-demographic characteristics and
pre-incarceration circumstances best explain their distinct needs rather than prison conditions
alone (Chesney-Lind, 2002; Kennedy, 2011; Potter, 2013). Research has indicated that structural
inequalities, such as poverty, racism, housing insecurity, and unemployment, contribute to health
care barriers (Grella, 2008). Hannah‐Moffat (2006) explains that focusing on the structural
determinants that affect women’s health is vital rather than primarily addressing individual or
micro-level issues. Women involved in criminal activity share similar life experiences,
particularly poverty, underemployment and poor education, which are universally viewed as
factors that drive women’s initial engagement in criminality (Carlen, 1983; Carlen & Worrall,
2013; Radosh, 2002; Richie, 2001).

Most incarcerated women are at risk for poor reproductive health due to inadequate access to
quality reproductive health care (i.e., birth control) before imprisonment (Clarke et al., 2006;
Peart & Knittel, 2020). Earlier studies have underscored that women in prison are more likely
than the general population to have had an unintended pregnancy (Clarke et al., 2006;
LaRochelle et al., 2012). For instance, Clarke and colleagues in 2006 found that among women
in the US Rhode Island Adult Correctional Institute, 84 per cent had an unplanned pregnancy.
This figure was substantially higher than nationally reported data, where 45 per cent of US
pregnancies were unplanned (Finer & Zolna, 2016).

Imprisoned mothers and pregnant women are considered a vulnerable prison population.
Motherhood may affect women’s access to medical care due to the fear of losing custody and a
lack of prison childcare programmes (Grella, 2008; Gueta, 2020). Pregnancy and motherhood
experience, in general, is a significant psychosocial change for most women (McVeigh, 1997).
Some mothers face significant challenges such as psychological and emotional distress and an
inability to cope effectively (Rallis et al., 2014; Razurel et al., 2013). Psychological, social, and
material resources are important factors that enable a positive transition to take on a new
motherhood identity (Razurel et al., 2013; Tarkka et al., 1999). These social resources are
protective by buffering the impact of life stress on the emotional wellbeing of pregnant mothers
(Glazier et al., 2004). These facilitating transition and enabling environments are challenging for
first-time mothers in prison because they are detached from their psychosocial resources at home
and in the community.

15
Race and class intersect, creating distinct motherhood experiences (Collins, 2015). This
intersection highlights how motherhood can contribute to poor health among poor and minority
inmates. The good and bad motherhood discourses create severe stigma among imprisoned
women, particularly low-income mothers and black women incarcerated for drug use (Campbell,
2002; SmithBattle, 2007). Based on economic marginalisation theory, if women are not given
economic opportunities, "they are relegated to the economic periphery of society where
monetary disadvantages are associated with higher crime rates" (Hunnicutt & Broidy, 2004, p.
131). Barberet (2014) explains that women in most low-income countries are generally poorer
than their male counterparts; thus, they usually depend on social welfare programmes (e.g., cash
transfer assistance). However, these assistance programmes are often restricted (Barberet, 2014).
Hence, women may turn to criminal activities to respond to poverty and economic insecurity
(Bloom et al., 2002). Hunnicutt and Broidy (2004, p. 131) contend that most women’s crimes are
non-violent, such as drug crimes, and "can be characterised as fundamentally economic”.
Considering the profound stigma and discrimination surrounding drug use and mothering
(Campbell, 2002), children of minority and low-income women are more likely to be assessed as
at risk and more likely to be removed from their homes than those of affluent women (Enosh &
Bayer-Topilsky, 2015). Enosh and Bayer-Topilsky (2015) add that the threat of removing
children from poor and minority mothers is pervasive, discouraging them from accessing health
and social services.

2.2.2 Women’s reproductive health during incarceration

The prison environment further exacerbates the pre-imprisonment health status of women. First,
two-thirds of women in prison globally are mothers to minor children (Glaze & Maruschak,
2008), which may cause profound implications for their wellbeing.

Second, common reproductive health issues among imprisoned women are related to their access
to hygiene and menstrual products. A study in New York State prisons showed that women
received insufficient sanitary products. There were also cases where incarcerated women were
asked to bring their used hygienic products to the health care unit before getting more (Walsh,
2016). Similarly, studies in Africa (e.g., Cameroon, Zimbabwe, Malawi, Nigeria, Central African
Republic, Benin, South Africa, Zambia, and Ghana) have found that female prisoners had
inadequate hygiene and sanitation facilities (Agboola, 2016; Dixey et al., 2015; Todrys & Amon,

16
2011; Twea, 2004). The WHO (2009a) has noted that prisons do not always consider the distinct
needs of women, such as access to menstrual products, water and disposal facilities. Weiss-Wolf
(2017), in her book titled Periods gone public: Taking a stand for menstrual equity, argues that
inadequate menstrual and hygiene products are a lingering form of social injustice. She further
explains that ‘menstrual inequity’ as a human rights violation against women is exacerbated by
social, economic, institutional and policy factors. The concept of ‘menstrual inequity’ or ‘period
poverty’ has caught the attention of scholars, activists, and policymakers. Feminist activists have
argued that this situation not only marginalises women’s bodily function (i.e. menstruation) it
also aggravates the conditions of poverty, undermining their health, endangering their lives, and
curtailing their opportunities (Weiss-Wolf, 2017). It may also lead to severe infection and
menstrual complications (Head, 2018).

Third, imprisonment aggravates the menstrual discomforts of women. This complicated

menstrual distress has been linked to high-stress levels in prison and poor nutrition. Smith and
Borland (1999) and C. Smith (2009) argue that prison is stressful, and it is likely that anxiety and
stress affect incarcerated women’s period experience. Genders and Player (1990) also argue that
the stressful experience of women in prison may be due to their isolation from their support
networks, relationships, homes, and jobs. Cunningham-Burley and Backett-Milburn (1998, p.
151) suggest that the “body gives out messages of bodily change and indications of difference,
which need to be ‘read’, interpreted and sometimes acted upon”. Weideger (1975, p. 148)
indicates that “all forms of stress (pleasant or painful) can alter menstrual experience”.
Moreover, chronic and severe stressful situations may aggravate period symptoms and cause
altered period cyclicity and irregularity (Gallant & Derry, 1995; C. Smith, 2009). Several studies
have established the link between poor nutrition and menstrual complications among women
(Fujiwara, 2007; Kimmel et al., 2016; Penland & Johnson, 1993). This finding is relevant to
prisons, given that many imprisoned women are more likely to be undernourished (Ravaoarisoa
et al., 2019; Van Hout & Mhlanga-Gunda, 2018).

Finally, lack of financial support affects women's health during incarceration, particularly access
to quality health care. For instance, in about 70 per cent of US prisons, prisoners are charged a
fee of between $2 and $10 for each request for health care, which has been shown to decrease
access to health care and delay treatment due to financial burden (Fisher & Hatton, 2010).

17
2.2.3 Summary
The earlier section underscores women’s restricted or non-universal access to comprehensive
reproductive health services and support. The discussion suggests that many incarcerated women
are unnecessarily exposed to health risks associated with reproductive health issues.
Furthermore, women’s pre-incarceration health risks and socioeconomic situation significantly
contribute to poor reproductive wellbeing. Global studies have shown that most incarcerated
women face complex health issues, sexual and physical abuse histories, and violence exposure.
Although the reproductive health needs of incarcerated women have already been explored, little
is known about how women make sense of this experience and express their stories. The current
project examines how women in prison describe their experience of reproductive wellbeing.

2.3 The functions of social networks in prisoners’

wellbeing
The impact of the social environment on one’s holistic wellbeing has been known and explored
in psychological and sociological scholarship (Baumeister & Leary, 1995; Durkheim, 1951).
Earlier studies have established the connection between social networks and prisoners’ wellbeing
(Cochran & Mears, 2013; Haney, 2018). To understand the relational context of prison
wellbeing, I begin the discussion with the functions of outside social networks in prisoners’
health. I then outline the relationship between the inside social environment and prisoners’
wellbeing.

A social network is defined as a “set of individuals within a bounded setting who are connected
through social ties” (Sentse et al., 2019, p. 1049). A social network structure affects individual
and collective behaviours over time (Steglich et al., 2010). These relationships are related to
emotional connection, power dynamics, and the level and type of communication, including
bargaining and negotiation processes (Cox et al., 2013). In the prison context, these social
networks can be grouped into inside and outside social environments. The inside interpersonal
networks may refer to their prison peers. The outside social ties include family members, friends,
and private organisations. Earlier studies have shown the negative and positive impacts of the

18
inside and outside social networks on prisoners’ wellbeing (Cochran & Mears, 2013; Haney,
2018).

Outside social networks are hypothesised to “connect inmates to the free world, linking them to
their previous lives” (Lindquist, 2000, p. 434). Gibbs (1982) argues that external social
connections are critical for prisoners’ emotional and mental wellbeing, particularly during early
imprisonment. Additionally, maintaining ties to family and friends, mainly through visitation,
improves inmates’ mental wellbeing (Cochran & Mears, 2013). The social networks are known
as resources that help prisoners cope with prison deprivations (i.e., deprivation of goods and
services) through emotional comforts and material resources, such as food, toiletries, clothing
and money (Ditchfield, 1994; Gibbs, 1982; Noble, 1995).

Marital and parental status have been found to significantly affect the external social integration
of prisoners (Lindquist, 2000). These results are not surprising since most inmates are parents,
around 67 to 77 per cent globally (El-Bassel et al., 1996; Gallagher, 1990; Lindquist, 2000).
Family serves as a critical source of support by creating a sense of belongingness (Ensel & Lin,
1991). For individuals in total institutions, family ties are significant indicators of social
integration, as they offer sustainable connections to the outside community (Lindquist, 2000).
Other factors, such as age, duration of incarceration, and gender, are known factors that shape
the degree of success or failure in maintaining outside relationships. For instance, among male
prisoners, older inmates have reported significantly more personal visits than younger inmates
(Gallagher, 1990). Gender has been considered as a significant factor that shapes the extent of
social integration (Lindquist, 2000). The differences in prison relationships between men and
women may be connected to broader gender norms and pre-incarceration conditions (Lindquist,
2000). Compared to incarcerated fathers, incarcerated mothers are far more likely to have
primary or sole custody of their children and have had at least one young child living in their
home at the time of their arrest (Datesman & Cales, 1983; Glaze & Maruschak, 2008).

Maintaining outside social connections in prisons is difficult because of the limited means and
time to communicate (Bronson, 2008). Thus, prison peers are often the only directly available
‘interpersonal sources’ to fulfil prisoners’ basic and social needs. In settings with social
deprivations, connections to inmate peers may enable prison adjustment through access to
knowledge and resources, improving their prison experience and overall wellbeing (Kruttschnitt

19
& Gartner, 2005). Kruttschnitt and Gartner (2005) add that social integration with peers lessens
rejection, isolation, and marginalisation. In addition, the nature of interpersonal resources in
prison can be emotional (e.g., affection, caring) and instrumental (e.g., practical help, getting
something done) (Sentse et al., 2019).

A Philippine study provides additional features of community prison solidarity connected to

Filipino norms and values, such as family-like and communal support networks (Narag & Jones,
2020). Narag and Jones argue that these distinctive coping strategies and prison dynamics
develop a livable environment. The authors explain that the Filipino values and cultural norms of
padrino (patron-client relationship), bayanihan (community spirit), and damayan (helping one
another) are imported into the prisons. These Filipino values help the prisoners cope with prison
deprivations (Narag & Jones, 2020). Prison scholars have suggested that inmates bring their pre-
incarceration characteristics and cultural values into the prison (Irwin & Cressey, 1962). Several
studies on Filipino culture have noted that the Philippines can be characterised by vertical and
horizontal social relations (Ang, 1979; Enriquez, 1993; Veneracion, 1996). Horizontal
community relations refer to the collectivist nature of Filipino society, which includes a sense of
social cohesion and oneness with the community members. The common Filipino values,
bayanihan (community spirit) or damayan (helping one another), reflect horizontal social
relations (Ang, 1979; Enriquez, 1993; Veneracion, 1996). Bayanihan is also known as “tulongan
or damayan (tulong-help; damay-aid), a system of mutual help and concern which has become
the backbone of Filipino family and village life” (Ang, 1979, p. 91). On the other hand, vertical
relations pertain to the enduring effects of colonial legacy in the country (Veneracion, 1996).
The colonial governments in the past used the Filipino elites to subjugate the Filipino masses,
creating a social and class divide that endured up to the present day (Ang, 1979; Enriquez, 1993;
Veneracion, 1996). As a result, Filipinos tend to give a premium to patron-client relationships,
where individuals in a lower economic hierarchy give deference to more affluent and elite people
(Narag & Jones, 2020).

For incarcerated women, themes from early research studies portray women’s prisons as
supportive, caring and homelike (Giallombardo, 1966; Ward & Kassebaum, 1966).
Giallombardo (1966) notes that women form family structures using traditional feminine roles,
such as wives or mothers. These imaginary kinship groups dominate social and economic life in

20
women's prisons (Williams & Fish, 1974). These families are often referred to in the literature as
family-like relationships or kinship networks (Giallombardo, 1966; Larson & Nelson, 1984;
Propper, 1982; Ward & Kassebaum, 1966). Incarcerated women establish these family-like
relationships to fulfil lost familial roles, such as daughter, wife, father, cousin, grandmother, and
partner (Giallombardo, 1966; Larson & Nelson, 1984; Propper, 1982; Ward & Kassebaum,
1966). Additionally, several scholars contend that female inmates re-create prison family units to
cope with the pains of imprisonment, particularly separation from families (Harner & Riley,
2013; Kruttschnitt et al., 2000; Severance, 2005). In Barbara Owen’s 1998 book, In the mix:
Struggle and survival in a women’s prison, she argues that emotionally intimate but non-sexual
relationships characterised by intense emotional relationships are common among women
prisoners. A prison ethnographic study found that women’s prison social structures mirror the
interpersonal networks in the community (Irwin & Cressey, 1962). These relationships are
developed based on similarities in socio-demographic characteristics, such as age, educational
level, religion, and race (Bronson, 2008; Crewe, 2011; Skarbek, 2014).

However, some quantitative studies in psychology indicate that prison peer relationships may
jeopardise prisoners’ wellbeing (Haynie, 2001; Haynie et al., 2018; Kreager et al., 2016).
Imprisoned individuals are involuntarily brought together with peers from different cultures and
circumstances, and social networks may promote risky and unhealthy behaviours (e.g., smoking,
unhealthy eating patterns) through peer influence (Massoglia, 2008). A quantitative study by
Lindquist (2000) on social integration and mental wellbeing of male and female inmates in jails
found that interpersonal support was not associated with lower levels of depression and anxiety.
Lindquist explains that the internal social network contributed to higher hostility and stress
among female inmates. These outcomes may be attributed to the transitory population in jails,
and Lindquist (2000) could not document the positive impacts of peer social integration on the
inmates’ wellbeing in her study. Similarly, Kreager et al. (2016), in their quantitative research in
Dutch male detainment facilities, found that peers’ social network was not associated with
inmates’ positive wellbeing. They also argue that detainees who trusted other inmates had
reported more significant distress and poor wellbeing than those without trusting ties. They
conclude that “the association between peer integration and health may reverse in conditions of
confinement because trust placed in criminal peers reinforces health-risky behaviour and
contributes to poor mental health” (Kreager et al., 2016, p. 97).

21
Similarly, several qualitative studies have indicated that incarcerated women struggle to build
positive connections with peers due to their difficulty to trust (Einat & Chen, 2012; Greer, 2000;
Kruttschnitt et al., 2000; Severance, 2005). In separate studies, Bronson (2008) and Severance
(2005) conclude that the development of interpersonal connections among women prisoners
includes a process of cautious scrutiny and assessment of peers. The authors argue that women
prisoners tend to form bonds with peers they trust and discuss personal matters (Bronson,
2008). Several scholars have noted that gossiping or making idle talk is a significant issue and a
common source of conflict in women’s prisons (Einat & Chen, 2012; Severance, 2005). In
Severance’s (2005) study, female prisoners expressed discomfort and distrust towards their peers
due to gossiping. Einat and Chen (2012) indicate that gossiping or making idle talk about others’
personal affairs causes social conflict, reduces positive relationships, and contributes to
psychological harm and poor wellbeing. Kruttschnitt et al. (2000) and Greer (2000) suggest that
the incarcerated women’s limited cohesive connections may be associated with the modern
prisons’ changing physical structure (e.g., shift from homelike spaces to highly regulated
dormitories).

One dominant idea in the mainstream sociological scholarship is that the ‘inmate code’, the
unwritten rules and values that have been developed among prisoners, is an expression of the
prisoners to cope with the prison deprivations and to survive in the coercive subculture
(Clemmer, 1940; Irwin & Cressey, 1962; Wooldredge, 1997). The inmate code also mirrors the
shared behaviours of the prisoners against the institution and staff (e.g. do not share information
with correctional staff about other inmates) (Sykes, 1958). Violating the inmate code has resulted
in social conflicts and distrust among prisoners, and non-adherence is equated with being
labelled a ‘snitch’ (Wooldredge, 1997). The inmate code is verbally transmitted and learnt from
long-term prisoners to newer ones (Sykes & Messinger, 1960; Wooldredge, 1997). The codes
also prohibit prisoners from interfering with peers’ business and stealing from other inmates
(Sykes, 1958).

The high degree of policing and institutional control in an environment where trust and
supportive interpersonal connections are limited makes the prison setting a complex and highly
dynamic social environment (Liebling & Arnold, 2012). Prisoner researchers argue that social
hierarchy exists in prison, and staff tend to work with those at the higher end of this hierarchy,

22
trading freedoms for cooperation and self-policing among the prisoners (Liebling & Arnold,
2012). Many scholars believe that using inmates to help supplement the custodial force is an
extension of the institutional power of prison and a systemic attempt to preserve institutional
identity (Hayner & Ash, 1940; McCorkle & Korn, 1954). Using inmates to manage other
inmates, also known as Building Tender System (BTS), is common in developing countries
(Fong, 1990; Marquart & Crouch, 1984). Under the BTS, inmates managing their peers may
create power dynamics (Fong, 1990; Marquart & Crouch, 1984). In Western prisons, white,
professional, older prisoners are usually chosen to act as prison leaders (Liebling, 1999). These
prison leaders act informally as spokespeople, negotiators, and mentors for younger, less
articulate prisoners, contributing to order and rules compliance (Liebling, 1999). However,
disparities in social and power hierarchies may result in prison conflicts (McEvoy, 2001). The
establishment of power is affected by the structures formed from the top and the dominant
system of social control (Foucault, 1978) and the complex actual interactions between individual
prisoners (Goffman, 1968).

Marquart and Crouch (1984, p. 491), in their research conducted in Texas, USA, Coopting the
kept: Using inmates for social control in a southern prison, stress that one of the “most striking
features of prison social topography is the cadre of dominant inmates- ‘the elites’”. These
prisoners have translated pre-prison reputations and special skills into power to control many
prison outcomes, such as prison conduct for other inmates. Additionally, Cloward (1960, p. 48)
concludes that "the inmate elite constitute the single most important source of social control in
prison”, achieving the order and stability desired by the elites and the prison institution.

Studies on the relationship between social integration and prison wellbeing have shown varying
results. Given the diverse impacts of social interactions on prisoners’ wellbeing, it is essential to
explore the roles and functions of social networks in the reproductive wellbeing of incarcerated
women.

2.3.1 Summary
This section presents the ‘relational’ context of prison wellbeing. Earlier studies on the link
between social networks and prison wellbeing have shown varying results. Many factors have
been identified that significantly affect prisoners’ wellbeing. In the context of prisoners’ external

23
social resources, parental status, gender, age, and duration of imprisonment have influenced the
link between external social connection and prison wellbeing. Considering the limited means and
time to connect with outside social networks, prison peers are often the only directly available
‘interpersonal sources’ to fulfil prisoners’ social and wellbeing needs. Given the varying effects
of social interactions on incarcerated people’s wellbeing, it is essential to explore how social
interactions shape the wellbeing of women in prison. Although the relationship between
interpersonal resources and prisoners’ wellbeing has been extensively examined, little is known
about the functions and roles of incarcerated women’s social networks in their reproductive
wellbeing.

2.4 Theoretical framework

All academic disciplines contain significant theories and concepts that facilitate focused inquiry
and discussion. These concepts and theories provide a common vocabulary and demarcate
disciplinary boundaries (Haggerty & Bucerius, 2020). Goffman’s (1961) sociological
examination of ‘total institutions’ and ‘mortification of self’ and Syke’s (1958) ‘pains of
imprisonment’ are critical theoretical perspectives examining imprisonment's impacts on the
prisoners’ experiences. Furthermore, the expanded concept of ‘gendered pains of imprisonment’
is appropriate for studying the distinct needs of women prisoners. In the current project, I apply
these approaches as the guiding theoretical lenses to explore the nexus between reproductive
wellbeing and women’s incarceration.

To understand how institutions affect the experiences of prisoners, it is crucial to explore the
unique institutional characteristics of the prison environment. Several institutional factors shape
the inmates’ experiences, and “one central component is the ‘totality’ of the organisation” (Stohr
& Walsh, 2017, p. 115). In the current project, I have used Goffman’s (1961) sociological
examination of ‘total institutions’ and ‘mortification of self’. I have also explored other relevant
theories that critiqued and expanded Goffman’s work.

Being interested in exploring incarcerated women's distinct reproductive wellbeing experiences,

I have drawn on the deprivation model using Syke’s (1958) ‘pains of imprisonment’ and various
studies exploring women’s ‘gendered pains of imprisonment’.

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2.4.1 Total institutions and mortification of self
The section’s goal is two-fold. First, I introduce Goffman’s (1961) sociological examination of
‘total institutions’, outlining his analysis of the characteristics of the total institution and research
studies that applied his theory. I also discuss Goffman’s (1961) ‘mortification of self’ to examine
the impacts of imprisonment on prisoners’ identity and sense of self. Finally, I explore the
expansion of Goffman’s total institutions.

Goffman (1961) used the concept of ‘total institutions’ to describe the nature of mental hospitals
and prisons in the United States. Goffman (1961, p. xiii) defines a total institution as “[a] place
of residence and work where a large number of like-situated individuals, cut off from the wider
society for an appreciable time, together with lead an enclosed, formally administered round of
life”.

Based on Goffman’s (1961) analysis, total institutions exhibit four primary characteristics: 1)
bureaucracy and under the same authority, 2) prisoners are treated alike, 3) over-attention to
rules and routines, and 4) rational institutional plan. First, all dimensions of everyday life are
done in the same setting and under the same bureaucratic organisation (Goffman, 1961). Within
this framework, all prison activities provided adhere to one prominent characteristic of total
institutions: “collectively regimented persons and the handling of many human needs by the
bureaucratic organisation of whole blocks of people” (Goffman, 1961, p. 6). This condition
mirrors the prisons, where, as Goffman sees it, all activities in inmates’ lives are organised and
overseen by the management and prison officers.

Second, “each phase of the member's daily activity is carried on in the immediate company of a
large batch of others, all of whom are treated alike and required to do the same thing together”
(Goffman, 1961, p. 6). This condition in total institutions contrasts with the common belief of
individual living and personal choice in the outside community. Furthermore, prison officers
often face the realities of managing the tension between institutional restrictions and
accommodating the various needs of prisoners; hence, they are often torn between the rigid
application of the sameness principle and the practice of greater flexibility (Crawley, 2005;
Sparks et al., 1996).

25
Third, Goffman argues that in total institutions, “all phases of the day's activities are tightly
scheduled, with one activity leading at a prearranged time into the next, the whole sequence of
activities being imposed from above by a system of explicit formal rulings and a body of
officials” (Goffman, 1961, p. 6). In prisons, the environment is characterised by formal rules and
regulations and a tight schedule that allows little or no free time (Goffman, 1961). Total
institutions have strict rules for behaviour imposed on those within them. In addition, a privilege
system also provides rewards and special privileges for good behaviour (Goffman, 1961).
Goffman argues that this system is intended to promote obedience to the institution's authority
and to deter non-adherence to prison rules.

Finally, the different institutionalised activities are developed into a single rational plan
supposedly designed to fulfil the institution's primary goals (Goffman, 1961). Discussion on total
institutions focuses on views that prisoners improve because of their imprisonment.
Improvement is measured by high and consistent conformity to “prison standards of behaviour”
(Karmel, 1969, p. 134). For example, Sykes (1958, pp. 111-112) argues that prison is supposed
to “make a criminal into a non-criminal either through retribution, deterrence, or reform”.
Goffman (1961, pp. 5-6) discusses features of total institutions with the observation that a “basic
social arrangement in modern society is that the individual tends to sleep, play and work in
different places, with different co-participants, under different authorities, and without an over-
all rational plan”. Hence, the main element of total institutions is the “breakdown of the barriers
ordinarily separating these three spheres of life” (Goffman, 1961, p. 6). In total institutions, the
environment typically consists of two groups: the managers and the managed (Goffman, 1961).
This binary management is common in prison (Jones & Fowles, 2008). Goffman (1961, p. 9)
argues that “two different social and cultural worlds develop, jogging alongside each other with
points of official contact, but little mutual penetration”. He adds that another crucial element of
the total institution is the distinct social boundary between inmates and the staff. Jones and
Fowles (2008) explain that managers have power, and social distance is their weapon. In prison,
being an inmate is degrading, and “staff tend to feel superior, and righteous and inmates tend …
to feel inferior, weak, unworthy and guilty” (Goffman, 1961, p. 7).

Several feminist criminologists have acknowledged the distinct impact of the prison regime on
incarcerated women (Carlen, 1983; Genders & Player, 1987). Pat Carlen (1983), in her classic

26
book Women’s Imprisonment, argues that the relatively small size of several women’s prisons
compared with men’s, which were apparent in Scotland in 1982, has a tremendous impact on
women’s experiences in custody. The women’s relatively small prison population has
contributed significantly to their “invisibility within the penal estate” (Carlen, 1983, p. 4). As a
result, women’s prisons are often organised and managed exactly like the men’s, thereby not
recognising women’s various physical and health needs, differential normative family
relationships, and cultural contexts (Carlen, 1983). This institutionalised indifference ranges
“from the architecture of prisons to security procedures, to facilities for health care, family
contact, work and training” (Bastick & Townhead, 2008, p. 1). Disciplinary and security
procedures (e.g., strip-searching, physical restraint) and access to health and other services are
critical practices experienced differently by women (Carlen, 1983, 1998; Moore & Scraton,
2014). This orientation is still evident in contemporary women’s prisons, where women are
imprisoned far from their homes, they are still subject to more petty restrictions than men, and
the practice of handcuffing pregnant women (Carlen, 1983, 1998; Carlen & Tchaikovsky, 1996;
Genders & Player, 1987). The practice of shackling pregnant women and women in labour is
primarily a remnant of policies designed for male institutions and is not based on genuine
security risks (Doetzer, 2007).

Studies that explored the impact of prison institutional attributes on the prisoners’ experience
showed the negative consequences of subjecting people with various needs (e.g. elderly, women,
and people with disabilities) to the prison regime (see Chen & Gueta, 2015; Crawley & Sparks,
2013; Gueta, 2020; Smith, 2005). For instance, Crawley (2005), in her study about the
experience of older prisoners in the U.K., found common examples of prisons’ inability to adapt
to the needs of older prisoners and of staff failing to mitigate the effects of those practices. She
adds that power relations might be manifested in the ‘institutional thoughtlessness’ of prison,
which she defined as “the ways in which prison regimes (routines, rules, time-tables) simply roll
on with little reference to the needs and sensibilities of the old” (Crawley, 2005, p. 16).

Earlier studies have recognised the connection between the features of total institutions and the
poor wellbeing of prisoners, particularly in the context of inmates’ mental health (Colsher et al.,
1992; Hurley & Dunne, 1991; Twaddle, 1976). The authors have argued that prisoners face a
stressful environment characterised by crowding, social isolation, and sex segregation.

27
Furthermore, inmates are forced to adhere to the rigid authoritarian organisation and extremely
ritualised schedule (Twaddle, 1976). Although the link between the characteristics of total
institution and the wellbeing of inmates has already been established, little is known about how
prisons shape the reproductive wellbeing of women prisoners. The current project explores how
the characteristics of total institutions are reflected in prison practices, programmes and
regulations concerning women’s reproductive wellbeing.

Goffman (1961) describes the impact of imprisonment on the inmate's sense of self and identity
as devastating. Goffman called this phenomenon “the mortification of the self”. Prisoners begin
“a series of abasements, degradations, humiliations, and profanations of self” (Goffman, 1961, p.
14). The individual’s self is “systematically, if unintentionally, mortified” (Goffman, 1961, p.
24). It is theorised that self-mortification happens because of the prison’s punitive and restrictive
atmosphere. In total institutions, prisoners enter the facility with an established way of life and
routines that are systemically neglected by the authority (Goffman, 1961). Also, the inmate
enters the institution with a conception of ‘self’ established through social interaction and
arrangements before imprisonment. However, in prison, people are deprived of support from the
outside world. The barrier prisons put between the inmates and the external community marks
the first curtailment of self. In ‘community life’, the progressive development of one’s roles,
both in life and in daily activities, ensures that no single role will prevent one’s social
performance in the social environment (Goffman, 1961). But in total institutions, “membership
automatically disrupts role scheduling, since the inmate’s separation from the wider world lasts
around the clock and may continue for years” (Goffman, 1961, p. 14). Role dispossession
happens because interaction with the outside community ceases, disrupting one’s past social
roles.

Additionally, self-losses and identity disruptions occur during the admission procedure due to
“the dispossession of personal property, the loss of one’s full name, and the stripping of one’s
identity kit, i.e., clothing and cosmetics that one has used to present oneself in one’s social
world” (Goffman, 1961, p. 20). ‘The mortification of the self” takes place parallel to the
conception of a new identity—the prisoner's identity. The erosion of the civil self, which existed
before incarceration, is supported by the prison administrative procedures, restrictions, and
routines. These procedures have a common goal to standardise the individual into an

28
‘administrative unit’ so that the unit can be effectively controlled (Goffman, 1961). Goffman
argues that the inmates might become mortified in prisons or suffer from losing the many roles
they occupied before imprisonment. He adds that only the status of ‘inmate’ is available, a
powerless and dependent identity. The prisoner has been reduced from a person with multiple
roles to a cipher with one: the ‘inmate role’ (Goffman, 1961). This categorisation becomes
problematic when one’s membership in a particular group, such as prisoners, becomes the
defining feature of one’s identity: their ‘master status’ (Goffman, 1963). Jones and colleagues
(1984, p. 296) assert that such dominant prison attributes can “engulf an individual’s identity,
becoming the filter through which his or her other characteristics are seen”.

Earlier studies have indicated that the conceptualisation of self has more profound implications
for female prisoners than their male counterparts because of enforced gender roles and social
limitations (Ray & Downs, 1986; Ward & Kassebaum, 1966). Hence, mothers' imprisonment has
broad social implications because of their multiple caregiving and family roles in their
communities (Valera et al., 2015; Villanueva & Gayoles, 2019). One study found that
incarcerated women struggled to sustain and define their sense of self because of limited family
support and restricted familial role- an integral part of their womanhood identity (Culbertson &
Fortune, 1986). Feminist theorists argue that women who transgressed the social expectations of
being a good mother, such as women in prison, face severe public shame and humiliation
(Gelsthorpe, 2004; Kennedy, 2011; Lockwood, 2018). Many incarcerated women face the
double burden, both seen as criminals and ‘unfit mothers’ (Ferraro & Moe, 2003). Although the
impact of incarceration on women’s sense of self and identity has been already established in the
earlier literature, little is known about how women’s prisoner identity shapes reproductive
wellbeing experiences. Building on Goffman’s (1961) sociological examination of
‘mortification of self’, this thesis examines how Filipino women experience reproductive
wellbeing as this experience intersect with their prisoner identity.

Apart from the impact of imprisonment on inmates’ wellbeing and identity, many studies have
revealed the effects of prison as a total institution on prison staff. Prisons have been described as
highly complex and emotional places, both for the institutionalised population (Crewe et al.,
2014; Sykes, 1958) and for the personnel, such as prison officers (Crawley, 2004; Humblet,
2020) and prison nurses (Humblet, 2020; Puthoopparambil et al., 2015; Walsh, 2007). One of the

29
common themes in the literature is how prison staff navigate the tension between their feelings,
expression of care and emotional requirements needed for job performance in prison settings
(Humblet, 2020; Puthoopparambil et al., 2015; Walsh, 2007). Prison represents an emotionally
stressful and painful environment for prisoners, shaping their relationships with prison officers
(Humblet, 2020). Hochschild (1983), in her concept of emotional labour, argues that workers
manage their emotions and expressions to align with the institutionally imposed emotional
requirements or expectations of a job. Emotions in the workplace are managed in response to the
‘display rules’ for the job and institution (Ekman, 1975; Goffman, 1959; Hochschild, 1983).
Although emotional labour is profound for workers who are in ‘people-work' settings or jobs that
require substantial social interaction or entail high emotional demands (Mann, 2004; Walsh,
2007), the management of emotions for prison officers working with inmates has been regarded
as complex, as it involves a population that is deemed ‘undeserving’ or unworthy of such
emotions (Crawley, 2005). Some studies have also revealed the difficulty of Corrections nurses
reconciling their traditional caring role with the prison culture because of prisons' regulations and
job expectations (Humblet, 2020; Puthoopparambil et al., 2015; Walsh, 2007).

The impacts of total institutions on prisoner’s wellbeing and the role of prison health officers
have created tension between care and custody (Arnold, 2016; Short et al., 2009; Sim, 2002).
Maroney (2005) argues that the dual roles of custody and caring are adversarial rather than
mutual, and custody usually rules. Navigating prison relationships in an environment of apparent
power imbalance has resulted in value tension (van Dijk et al., 2021). Liebling and Arnold
(2004a, p. 336) refer to “tensions between relationships, security, justice, and order”. One
common value tension concerning discretionary decision-making is the custody versus care
conflict (Short et al., 2009), also referred to as ‘security versus care’ (Arnold, 2016). One
commonly discussed in the literature on care and custody is nurses' experience providing care in
prisons (Droes, 1994; Willmott, 1997). Prisons are among the most complex settings for nursing
practice (Maroney, 2005). Unlike in other health care facilities where the ultimate goal is patient
care, the priorities of the prisons centre on control, order, and discipline (Maroney, 2005). In a
carceral environment, nurses must navigate the complex tension between prison responsibilities
and expectations and the nursing professional values (Willmott, 1997). Similarly, Droes (1994),
in her qualitative study of nursing practice correctional settings in two contiguous western states
of the United States, found that security issues had a profound impact on nurses' work in prisons.

30
Her study revealed that correctional nurses' conception of nursing and prison officers’
perspectives on inmate health care significantly influenced the nature and scope of nursing care
provided to prisoners. Imprisonment also alters care as it "reduces the prisoner's opportunity for
self-care and independent action as inmates have to consult nursing or medical staff for even the
simplest remedies" (Willmott, 1997, p. 333).

Several scholars have pointed out the limitations of Goffman’s theory of the total institution
(Baer & Ravneberg, 2008; Farrington, 1992). They argue that Goffman’s analysis of prisons is
viewed as ‘totally’ detached from other spaces, postulating an isolated physical environment. For
example, Farrington (1992) problematises the concept of total institutions and expands the
original idea, arguing that prisons are more socially permeable and structurally interconnected.
He, therefore, recommends the construct of a “somewhat-less-than-total institution with an
identifiable-yet-permeable membrane of structures, mechanisms and policies” (Farrington, 1992,
pp. 6-7). Baer and Ravneberg (2008) explain that Goffman works with an “overly simplistic
dichotomy between inside and outside” (Baer & Ravneberg, 2008, p. 213). Their analysis led
carceral geographers to view prisons in dualistic terms that “emphasise separateness and sharp
contrasts from life on the outside” (Baer & Ravneberg, 2008, p. 214). Their argument is echoed
by other prison geographers who adopt this standpoint in recent papers on carceral geography
and thus reproduce the limitations of Goffman’s work (see Moran, 2013; Moran et al., 2011).

Carceral geography examines the practices and institutions of incarceration (Moran et al., 2011).
Routley (2016, p. 105) argues that carceral geography “transcends the architectural, tangible
institution and is more than just a fancier name for the geography of prisons”. Carceral
geography is also interested in institutions beyond prison walls, such as detention centres for
migrants and halfway houses (Turner & Peters, 2016). In their research on carceral geography
and disciplined mobility in the Russian Federation, Moran et al. (2012) found the high costs and
inconvenience of transporting prisoners to hospitals. Follis (2015) argues that prisoners’
disciplined movement and mobility outside prisons are inherent to imprisonment and incur
substantial costs for the necessary security services. Martin and Mitchelson (2009) point out that
power relations are apparent in the decision-making and organisation processes in transporting
prisoners for health services. This power relation mainly relates to who can order a transfer,
decides which situation requires transport, and informs about transport schedules (Martin &

31
Mitchelson, 2009). Stoller (2003) argues that prisoners’ movements through the prison spaces,
including prison extensions (e.g., court and hospitals), are intensively controlled through prison
security practices and routines. Stoller contends that these regulations and procedures view
prisoners as a homogeneous group, making no distinction between health, age, and economic
factors.

As part of the prison environment, prisoners face numerous rules and regulations, strict prison
schedules, almost constant monitoring and observation and architecture and design that regulates
movement and interaction to prioritise policing and surveillance (Foucault, 1978; Moran, 2013;
Schwartz, 1972). Foucault (1978) argues that prisoners’ experience of being continually
monitored, watched, and controlled is a new mode of punishment. As a part of this punitive gaze,
incarcerated women’s bodies serve as an arena for surveillance and control (Soffer & Ajzenstadt,
2010). Dirks (2004, p. 106) explains that “assaults on the body are justified in the name of
security’’.

Although there have been studies conducted about the experiences of sick prisoners transported
to hospital (e.g.Edge et al., 2020; Follis, 2015; Haesen et al., 2021; Minayo & Ribeiro, 2016), the
discussion around the experiences of women needing reproductive health care outside prisons,
such as women with reproductive issues and pregnant prisoners has remained scant. This thesis
explores Filipino incarcerated women’s experience of reproductive wellbeing, including
accessing outside hospital reproductive health services.

2.4.2 Pains of imprisonment

The ‘pains of imprisonment’ is a significant theoretical framework in the social inquiry of the
impact of incarceration on prisoners’ experiences. Gresham Sykes introduced the concept in
1958 to theorise that prison experiences result from the depriving and restrictive prison
environment. He argues that the pains of imprisonment are best understood as a series of
"deprivations and frustrations" that create severe psychological and social impacts on one’s sense
of self (Sykes, 1958, p. 64). Subsequently, generations of authors took up his work and applied it
to various contexts and populations. This section details how Sykes’ concept has evolved and
expanded.

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Sykes (1958) identifies five ‘pains of imprisonment’: 1) deprivation of liberty, 2) deprivation of
goods and services, 3) deprivation of heterosexual relationships, 4) deprivation of autonomy, and
5) deprivation of security. His theory accentuates the deprivation experiences among male
inmates. Although these deprivations were observed in men’s prisons, it is a valuable perspective
in examining the general impacts of prison institutions on the everyday experiences of
institutionalised people.

Deprivation of liberty is the first pain of imprisonment identified by Sykes (1958). Sykes
describes the prisoner's deprivation of liberty in the context of limited movement and social
isolation. The loss of freedom is a two-fold pain of imprisonment because inmates are confined
to and within an institution. In the first issue, prisoners are “subject to a wide variety of control
measures like cells, checkpoints, passes, and military-style formations in moving from one part
of the prison to another”, which are rituals and routines of institutional processes (Shammas,
2017, p. 2). A secondary consequence of the loss of liberty includes the dissolution of bonds to
family and friends. Sykes (1958, p. 65) suggests that “inmates suffer a loss of relationships,
loneliness and boredom" due to restricted mobility. Additionally, they are detached from their
families and friends and encounter a “deliberate, moral rejection… by the free community”
(Sykes, 1958, p. 65). Coyle (1994, p. 27) indicates that “losing one’s liberty is one of the most
traumatic experiences any individual is likely ever to undergo”, and it has the potential to cause
the most significant distress. Scarce goods and services are the second deprivation. Sykes
suggests the prisoners want or need necessities, such as water, food, and other amenities (e.g.,
cigarettes, alcohol, personal clothing). Consequently, “the inmate population defines its present
material impoverishment as a painful loss” (Sykes, 1958, p. 68). This deprivation occurs when
they enter prisons, all personal belongings are removed from the inmates, and they are provided
with substitutes marked as belonging to the prison (Coyle, 1994; Sykes, 1958). When they lose
material possessions, they lose a vital feature of creating their self-image (Sykes, 1958).

The third pain of imprisonment is the deprivation of heterosexual relationships. This deprivation
arises because prison restrictions prevent and limit heterosexual relationships, causing prisoners’
involuntary celibacy (Sykes, 1958). Since Sykes focused on male inmates, he suggested that
male prisoners faced a loss of heterosexual interaction that contributed to inmates’
psychological, emotional, and mental health issues (Shammas, 2017; Sykes, 1958). Like other

33
deprivations, sexual deprivation has severe implications for male inmates’ identity, prompting
Sykes (1958, p. 71) to describe incarceration “as a process through which an essential component
of a man's self-conception as male is called into question". He believes that if half of the male
inmate’s significant audience is missing, i.e. the female audience, their sense of self-image may
become “half complete, fractured, a monochrome without the hues of reality” (Sykes, 1958, p.
72).

Fourthly, Sykes identifies deprivation of autonomy, including loss of control of prisoners over
their daily situation. Prisoners encounter many restrictions intended to control their behaviour,
daily activities, and bodily functions, such as when and how to eat and take care of bodily
functions (Coyle, 1994; Shammas, 2017). Thus, “prison life is completely routinised and
restricted, with few opportunities to make decisions or exert choice in their daily routine” (Irwin
& Owen, 2005, p. 98). Subsequently, inmates become “to all intents and purposes a passive
player to whom things [are] done” (Coyle, 1994, p. 27). Meisenhelder (1985, p. 43) suggests that
prisoners feel the institutions govern them and they are “effects rather than causes”. Sykes argues
that inmates are infantilised by being deprived of the right to make small daily decisions about
their activities, which reduces them to a child-like state. He states:

The important point, however, is that the frustration of the prisoner's ability to
make choices and the frequent refusals to provide an explanation for the
regulations and commands descending from the bureaucratic staff involve a
profound threat to the prisoner's self-image because they reduce the prisoner to
the weak, helpless, dependent status of childhood (Sykes, 1958, p. 75).

The final pain of incarceration is the deprivation of security, which is regarded as a profound
experience for new prisoners (Medlicott, 2001). Many inmates are compelled to live and exist
with other inmates with histories of violent and aggressive behaviour (Sykes, 1958). Sykes
discusses that the inmate's loss of security is a common source of anxiety and apprehension.

Since Sykes’ work focused on adult male life prisoners in an American prison in the 1950s,
critical and feminist criminologists have argued that Sykes’ work should not be treated as a
universal interpretation of prisoners’ experiences (Bosworth, 2000; Carlen, 1983; Crewe et al.,
2017; McCorkel, 2003; Padel & Stevenson, 1988). Multiple social circumstances and factors

34
shape the experiences of prisoners. Several prison scholars and criminologists have explained
that the prison experience is gendered (Bosworth, 2000; Carlen, 1983; Crewe et al., 2017;
McCorkel, 2003; Padel & Stevenson, 1988). Despite the diffuse discussion on women-specific
pains of imprisonment in the literature, most scholars have explained that women experience the
pain of imprisonment differently compared to men (Carlen, 1983; Enos, 2001; Genders & Player,
1990; Hairston & Lockett, 1987; Padel & Stevenson, 1988). Additionally, women’s socialisation
and social integration make prison a different and usually more distressing experience
(Giallombardo, 1966; Jones, 1993; Ward & Kassebaum, 1966).

Prison is a gendered space that generates complex and distinct gendered experiences. Carlen
(1994, p. 136) argues that acknowledging prison as a “state mechanism for legitimated pain
delivery” is significant. However, universalising the prison impact on all individuals of different
genders and simply adding in’ other social variables, such as class and race, is inadequate
(Carlen, 1994). Liebling (2009), echoing Carlen’s argument, discusses how the ‘added in’
approach resulted in a limited and concentrated discussion of incarcerated women’s issues
traditionally seen as female-centric (i.e., relationships and domestic roles). Carlen (1994) and
Liebling (2009) emphasise the significance of power and trust regarding women in prison and
how these issues could impact prison relationships and regime delivery. This approach allows
critical understanding and exploration of gendered and women-specific pains of imprisonment
(Carlen, 1983, 1994; Liebling & Arnold, 2004a). For instance, feminist researchers have
examined imprisoned mothers’ specific issues and explained that incarcerated mothers encounter
heightened, aggravated, and additional maternal pains of imprisonment (Carlen, 2004; Crewe et
al., 2017; Enos, 2001; Genders & Player, 1990; Shamai & Kochal, 2008; Walker & Worrall,
2000). The primary maternal pain of imprisonment includes removing women’s role as a mother
and their inability to fulfil their motherly responsibilities (Crewe et al., 2017; Datesman & Cales,
1983; Hairston & Lockett, 1987). Imprisoned mothers tend to face more burdens resulting from
the disrupted contact with their children than men (Belknap, 2007). This situation may be related
to their role as primary and sole carers for their children before imprisonment (Datesman &
Cales, 1983; Glaze & Maruschak, 2008). Berry and Eigenberg (2003) argue that while
imprisoned women keep the status of ‘mother’, they cannot fulfil their maternal responsibilities
resulting in a disrupted and strained role. These disrupted maternal status, and the sense of being

35
a ‘failed mother’ has been described as substantial sources of maternal suffering among
incarcerated mothers (Belknap, 2007; Shamai & Kochal, 2008).

Carlen’s (1983) pioneering research in Scotland’s women’s prison found apparent prison
practices that ignored women’s distinct needs. In her study, Carlen revealed a regime
characterised by dull and highly routinised and monitored activities, separation from families,
and long lock-up periods. The daily monotony, disciplinary procedures, institutional control of
women’s bodies and self-representation, and prison officers’ attitudes infantilising adult women,
resulted in women’s debilitation (Carlen, 1983). Women prisoners in her study described how
they had received little sympathy regarding menstrual discomforts and less recognition of their
increased need for sanitary and washing facilities during menstruation. Carlen found that
prisoners felt degraded by dress regulation, rigid institutional control of their self-presentation,
hygiene practices and bodies, degrading sanitary conditions and denial of privacy. Carlen (1983,
pp. 106-107) argues that these practices reflect a “bifurcation between official claims that women
are helped to regain self-respect, and the extra-discursive institutional conditions wherein their
self-respect is further battered and bruised”.

Genders and Player’s (1990) study of women lifers’ experiences of the initial stages of an
indeterminate sentence in an English prison revealed women-specific deprivations. These prison
pains included the loss of liberty, possessions, autonomy, and privacy. Genders and Player
(1990) argue that the most prominent deprivations experienced by women lifers are related to
loss of freedom and limited privacy. Several women in their study described “graphically the
feelings of claustrophobia and despair generated by the miniature scale of the prison unit”, which
permits few opportunities for privacy and liberty (Genders & Player, 1990, p. 52). Genders and
Player (1990) also found how women in their study expressed additional assaults on privacy by
reliance on staff for sanitary towels and inadequate sanitation. Significantly, women complained
of several physical wellbeing issues, such as menstrual issues, due to poor diet, lack of fresh air,
and anxiety (Genders & Player, 1990).

In her book Sledgehammer (1998), Carlen (Carlen, 1998)discusses various women-specific

prison deprivations. She argues how specific features of women's imprisonment deny prisoners
control of physical and functional spaces, which are integral to their pre-incarceration identities.
She adds that women encounter “petty rules, infantilisation and lack of control over their own

36
body, space and presentation” (Carlen, 1998, p. 90). Carlen (1998) found that women in her
prison study had experienced inadequate provision of washing and bathing facilities. She argues
that prisons do not recognise the different bodily needs of women prisoners in personal hygiene
and personal presentation (Carlen, 1998). Similarly, Owen (1999) discusses the women-specific
pains of imprisonment in US prisons concerning physical and mental health needs. She notes that
pregnancy and reproductive health issues are often neglected in prison, with many women
suffering long-term consequences of inadequate care. Catrin Smith’s (2009) study of female
prisoners’ experiences of menstruation demonstrates a distinct impact of prison restrictions on
women’s autonomy, extending to bodily autonomy- a gendered pain of imprisonment. She
describes how women rely on prison officers’ permission to access sanitary pads and
washrooms, which mirrors an administration of prison regime. She argues that not only women’s
privacy is violated, but “personal control is taken away as the prisoner and her body become the
objects of external forces” (C. Smith, 2009, p. 11).

Walker and Worrall’s (2000) study of the ‘gendered pains of indeterminate imprisonment’,
involving interviews with 47 imprisoned women in English prisons, found women-specific
prison deprivations concerning the impact of time and the constraints on their mothering role due
to prolonged and severe surveillance. Walker and Worrall (2000, p. 28) conclude that women
lifers “suffer differently from the pains of indeterminacy”, such as losing control over fertility
and disrupting relationships with children.

Crewe, Wright, and Hulley (2017), building on earlier studies on the pains of imprisonment,
took a comparative approach and explored the similarities and differences between male and
female life-sentenced prisoners. They identify four ‘gendered pains of imprisonment’:1) losing
contact, 2) loss of power, autonomy, and control, 3) mental health and psychological well-being
problems, and 4) loss of trust, privacy, and intimacy. Crewe et al. (2017) argue that women
experience more distinct and severe “pains” than men. Their findings showed common issues
reported by women and men, such as ‘having to follow other people’s rules and orders’,
‘worrying about people outside’, and ‘missing someone’.

However, significant differences in incarcerated men's and women’s experiences were evident in
their study. For example, Crewe et al. (2017) found that losing contact with family and friends
impacted women more than their male counterparts. For some women, family members

37
terminated communication and support after conviction, mainly when the victim was a family
member, while other women severed contact to respond to the abusive nature of their pre-prison
relationships. Furthermore, Crewe and colleagues argue that women are more likely to be
affected by losing privacy and autonomy than their male counterparts. They found that women
were more likely than men to complain about how the prison authority controlled their intimate
and daily practices. They underscore that loss of control was a more significant pain of
imprisonment for women than men, creating a sense of crisis. This crisis exacerbated stress
levels, affecting their mental wellbeing. Finally, the lack of privacy is significant for women. In
their interviews, women commented on the lack of privacy and personal space that incarceration
engendered when undertaking intimate practices, such as washing, getting dressed, and using the
toilet (Crewe et al., 2017).

A growing sociological and criminological scholarship indicates the need to shift away from the
narratives of western or global north thinking and uncover the unique prison experiences and
dynamics in global south countries (Carrington et al., 2015; Fonseca, 2018). Although prisoners
in both the global south and global north share several common pains of imprisonment (i.e., loss
of freedom and autonomy and scarce resources), their experiences and coping mechanisms are
also shaped by the country’s distinct norms and sociopolitical systems (Bracco, 2020; Carrington
et al., 2015; Drake, 2018; Narag & Jones, 2020). The invisibility of the unique prison dynamics
in the global south results from the lack of contextualisation and the dominance of western
framing of prison studies (Bandyopadhyay et al., 2013). This western-centric theorising has
resulted in a tendency to imagine prison as universal and pre-understood that hegemonic
approaches have created to understanding prisons and prisoners (Armstrong & Jefferson, 2017).
As a result, prisons in the global south are commonly described as extremely overcrowded,
understaffed, underresourced and violent (Armstrong & Jefferson, 2017; Bandyopadhyay et al.,
2013; Martin et al., 2014; Narag & Jones, 2020). The western literature suggests that limited
goods and services contribute to illegitimate inmates’ coping mechanisms and strained prisoner-
staff relationships (Sykes, 1958). For example, the lack of resources and staff may lead to a
vacuum of governance, where elite and powerful inmate gangs dominate and control the daily
prison cell operations (Butler et al., 2018; Darke, 2013; Dias & Darke, 2016). This generalisation
ignores the complex and dynamic prison culture and relationships (Armstrong & Jefferson, 2017;
Bandyopadhyay et al., 2013; Martin et al., 2014; Narag & Jones, 2020).

38
The recent approach to understanding imprisonment in the global south has recognised prisoners
as active subjects who navigate complex prison systems to maintain their collective and vibrant
prison relationships, management, conviviality, and wellbeing (Bracco, 2020; Darke, 2018).
Martin et al. (2014) argue that prisoner-staff relationships in the global south are generally
dynamic, interdependent and move between custody and care, creating negotiations and
interactions among prison actors. Birkbeck (2011) explains that prison surveillance and control
in the global north and global south are different. Western prisons’ bureaucracies are more
formalised, and prisoners are more isolated and have more surveillance (Birkbeck, 2011). Darke
and Karam (2016) explain that in Latin America, the staff-prisoner relationship is more flexible,
and prisoners’ active participation in prison management is apparent. Studies exploring men’s
prisons in Latin America have indicated the importance of self-management and co-governance
(Birkbeck, 2011; Darke, 2013). For example, Darke (2018) discusses the concepts of co-
production of order and conviviality in Brazilian prisons. The author explains that co-governance
between prisoners and staff demonstrates active interaction and negotiations, reciprocal
exchanges, and partnerships. He adds that multiple factors affect everyday prison life in
Brazilian prisons, such as trust, mutual dependencies, and interpersonal variables. These distinct
prison dynamics allow prison actors to survive harsh conditions, avoid conflict, and co-exist in
highly overcrowded environments (Darke, 2018).

Narag and Jones’ (2017) research in men’s prisons in the Philippines revealed unique prison
practices that reflect the country’s penal structure and the broader Filipino norms. The authors
found that most prison cells accommodate as many as 200 inmates, which is opposite to the
single occupancy (or two inmates) cells in western countries. They argue that the multi-
occupancy nature of the cells, where inmates live communally, impacts how cells are managed
(Narag & Jones, 2020). They discuss that Philippine prisons demonstrate vibrancy amid scarcity.
For example, they observed that most cells they visited were clean, tidy, and painted. They noted
that prisoners share resources and food given by their visitors. They also saw inmates from other
cells or cell blocks called brigades selling equipment and other personal belongings. Narag and
Jones (2020) argue that the role of inmate leaders, the construction of the kubols (makeshift
beds), and the presence of the rancho system (inmates with resources are paired with inmates
without resources) are defining characteristics of the multi-occupancy prison cells in the
Philippines. These collective coping mechanisms are designed and negotiated by inmates and

39
staff to respond to the shared experience of material deprivations and pains of imprisonment
(Narag & Jones, 2020). The collaborative and developmental nature of this ‘give and take’
relationship translates to a dynamic staff-inmate shared governance (Narag & Jones, 2017)

In summary, as research in the global south prisons demonstrates, the unique carceral dynamics,
governance system and staff-prisoner relations significantly impact the prisoners’ experiences
and how they cope with the pains of imprisonment. Thus, dynamics, such as negotiation
cooperation, are valuable to understanding prisoners’ experiences. Taking into account this
documentation of the distinct prison dynamics and prisoners’ experiences in the global south, the
current research project examines how Filipino women experience reproductive wellbeing and
navigate and negotiate prison complexity to address needs.

Although Sykes’ theory and the expanded ‘gendered pains of imprisonment’ offer vital
information about the deprivation encountered by prisoners and the specific experiences of
women, little is known about the distinct and complex experiences of incarcerated women
concerning reproductive wellbeing and pregnancy. In the current study, drawing on the concepts
of ‘pains of imprisonment’ and ‘gendered pains of imprisonment’, I examine Filipino
incarcerated women's distinct reproductive wellbeing experiences.

2.4.3 Summary
This section describes the theoretical underpinning of the current project. Goffman’s (1961)
sociological examination of ‘total institutions’ and ‘mortification of self’, Syke’s (1958) ‘pains
of imprisonment’, and the expanded concept of ‘gendered pains of imprisonment’ are
appropriate and substantial perspectives that examine the experiences and distinct needs of male
and female prisoners. I apply these approaches to the current research project as the guiding
theoretical lenses to explore the intersection of reproductive wellbeing and women’s
incarceration. Being interested in exploring imprisoned women's distinct reproductive wellbeing
experiences, I have drawn on the deprivation model using Syke’s (1958) ‘pains of imprisonment’
and the expanded ‘gendered pains of imprisonment’. These two concepts critically examine the
general prison deprivations and the impacts of incarceration on women. In the current project, I
apply both perspectives to critically understand how women’s reproductive wellbeing is
experienced as they encounter various prison deprivations. Most studies that examined the

40
gendered pains of imprisonment experienced by women were primarily focused on western
perspectives, and little is known about the experience of incarcerated women in the global south.
The current study fills this gap by providing a Philippine context with different socio-political
structures and cultural and social norms.

The impacts of imprisonment on women’s sense of self and identity have been explored in the
earlier literature, but the understanding of how women’s prisoner identity shapes reproductive
wellbeing remained under-theorised. Building on Goffman’s (1961) sociological examination of
‘mortification of self’, this thesis examines how Filipino women experience reproductive
wellbeing as this experience intersects with their prisoner identity.

Although the link between the characteristics of the total institution and prisoners’ wellbeing has
already been established, little is known about how prisons shape the reproductive wellbeing of
incarcerated women. The current project explores how the characteristics of total institutions are
reflected in prison practices, programmes and regulations concerning women’s reproductive
wellbeing. Specifically, in chapter eight, I apply Goffman’s concept to the focus group data from
the prison officers and health staff members.

The underlying principle of using the above approaches for the current project hinges on the
need to understand incarcerated women’s reproductive wellbeing at the broader and institutional
levels, beyond the micro and the individual conditions. These theoretical perspectives
complement and enable examining the different dimensions of Filipino women’s reproductive
wellbeing experiences.

2.5 Chapter summary

This four-part chapter has examined the intersections of incarceration and reproductive
wellbeing. In the first section, I contextualise women’s imprisonment as a reproductive justice
issue. This section argues that women's incarceration is a pressing reproductive justice issue.
Women’s imprisonment intensifies existing reproductive health issues for women and reduces
their capacities to sustain their reproductive health needs. The second section discusses the
different pre-imprisonment circumstances affecting women’s wellbeing in prison. I outline the
distinct and complex reproductive wellbeing needs during incarceration. The discussion

41
highlights the women’s limited access to comprehensive reproductive health services, which
shows that many of these women are unnecessarily exposed to many reproductive health risks.
Furthermore, women’s pre-incarceration health risks and socioeconomic situations significantly
contribute to poor reproductive wellbeing. Although the reproductive health needs of
incarcerated women have already been explored, understanding of how women make sense of
this experience and express their stories has remained scant. The current project examines how
women in prison describe their experience of reproductive wellbeing.

The third section describes the link between social networks and prison wellbeing. Earlier studies
have shown the negative and positive impacts of the inside and outside social networks on
prisoners’ wellbeing. Several studies have indicated that external social connections are critical
for prisoners’ emotional and mental wellbeing, particularly during early imprisonment.
Additionally, maintaining ties to family and friends, mainly through visitation, improves
inmates’ mental wellbeing. These social networks are resources that help prisoners cope with
prison deprivations (i.e., deprivation of goods and services) through emotional comforts and
material resources. Considering the limited means and time to connect with outside social
networks, prison peers are often the only directly available ‘interpersonal sources’ to fulfil
prisoners’ social and wellbeing needs. Given the varying effects of social interactions on
incarcerated people’s wellbeing, it is essential to explore how social interactions shape the
wellbeing of women in prison. Although the relationship between interpersonal resources and
prisoners’ wellbeing has been extensively examined, little is known about the functions and roles
of incarcerated women’s social networks in their reproductive wellbeing.

The last section presents the theoretical framework employed in the study, its rationale, and its
context. Specifically, I explore the various institutional attributes of prisons using Goffman’s
(1961) sociological examination of ‘total institutions’ and ‘mortification of self’. I have also
explored other relevant theories that critiqued and expanded Goffman’s work. Further, I illustrate
the impact of prison conditions on the experiences of prisoners using Syke’s (1958) ‘pains of
imprisonment’ and the unique experiences of incarceration for women by exploring literature on
the ‘gendered pains of imprisonment’. The rationale for using these approaches for the current
project centres on the need to understand imprisoned women’s reproductive wellbeing at the
broader and institutional levels.

42
 Chapter Three
Reproductive Wellbeing and Women’s
Incarceration in the Philippines
In this chapter, I explore women's reproductive wellbeing in prison using a Philippine context.
To do this, I have divided this chapter into three sections. I begin by reviewing the Philippine
health care system and reproductive health care services. I then discuss the socio-cultural and
structural factors that shape the country’s reproductive health. Lastly, to localise the discussion, I
present the prison structure and system in the Philippines as the context of interest. I also deal
with research and documentation of the situations of Filipino incarcerated women, including
their distinct needs and reproductive health. This chapter concludes by outlining the research and
knowledge gaps that shape the current research inquiry.

3.1 The Philippine health system and reproductive

health care

3.1.1 An overview
The Philippines is an archipelagic country located in the South-East Asia Region with a 104.9
million population as of 2017 [Figure 1. Map of the Philippines] (Dayrit et al., 2018). More than
80 per cent of the population is Roman Catholic (Philippine Statistics Authority, 2017). Health is
a fundamental human right enshrined in the 1987 Philippine Constitution. The Philippine health
care system consists of public and private sectors. The national and local governments provide
health services, and the public sector is funded by a tax-based financing scheme (Dayrit et al.,
2018). The Department of Health (DOH), the lead national agency, oversees the overall health
system and provides national direction. In contrast, local governments (i.e., provinces, cities, and
municipalities) provide health services (Dayrit et al., 2018). The private sector is mainly market-
oriented, where health care is paid through user fees at the point of service (Dayrit et al., 2018).

43
 Figure 2 The Philippine map
Source: United Nations Geospatial Information Section, 2010

3.1.2 Health financing and maternal health care

Based on 2016 government reports, the country’s total health expenditure, which measures both
government and private current health spending, increased by 39 per cent, but its share in GDP
remains at 4.5 per cent (Department of Health, 2018b). In 2015, The country’s health
expenditure per capita of US$323 was one of the lowest in Southeast Asia (World Health
Organisation, 2016). Health care financing in the Philippines is a combination of the
Beveridgean system (government tax-funded financing of DOH and local governments), the
Bismarckian system (insurance premium- and tax-funded financing), small-pooled private
prepayment schemes, and significant out-of-pocket (OOP) expenditures (Dayrit et al., 2018). The
allocation of health expenditures has not significantly changed over the past several years.
Private sector spending, mainly through OOP payments, remains the primary funding source,
surpassing the combined government expenditures from the state, local government and
government social health insurance (Department of Health, 2018b). For instance, in 2015, OOP
spending accounted for more than 60 per cent of total health expenditure, while government
(public) expenditure was consistently lower than 30 per cent (Picazo et al., 2015).

The country has complex public health financing pathways. The three main elements of public
health financing have overlapping coverage: DOH, local government and the national health

44
insurance program. The DOH provides funding support for regional and end-referral hospitals,
while local governments fund primary- and secondary-level care. Philippine Health Insurance
Corporation (PhilHealth), a National Health Insurance Program of the Philippine Government, is
mandated to provide health insurance coverage to enable Filipinos to access health care services
(Dayrit et al., 2018; Picazo et al., 2015). PhilHealth reimburses accredited government and
private health facilities for services given to the PhilHealth members (Dayrit et al., 2018).

Republic Act No. 10606, a legal foundation of PhilHealth, 1) mandates government and private
agencies to ensure that PhilHealth members can access cost-effective and quality health services;
and 2) directs the PhilHealth agency to enrol beneficiaries and provide PhilHealth members with
health insurance identity (ID) cards for identification, eligibility verification and utilisation
reporting (Dayrit et al., 2018). Although PhilHealth coverage has been increasing, its share of
total health spending remained relatively low (Department of Health, 2018b). The proportion of
PhilHealth in whole health expenditure increased from 5 per cent in 1991 to 14 per cent in 2014
(Dayrit et al., 2018; Picazo et al., 2015). This figure indicates that health insurance remains
insufficient and many Filipinos face the financial burden of health care (Picazo et al., 2015). This
situation suggests systemic issues, such as the limited scope of PhilHealth benefit packages
(Dayrit et al., 2018; Department of Health, 2018b; Picazo et al., 2015). Furthermore, PhilHealth
benefit packages are inadequate to cover the total medical cost because of fixed reimbursements
and limited cover, resulting in patients paying remaining hospital costs (Department of Health,
2018b). The unregulated drug prices and user fees for health services profoundly impact the poor
population (Dayrit et al., 2018; Picazo et al., 2015). As a result, low-income families do not buy
prescribed medications or forego hospital visits entirely due to adequate financial protection
(Department of Health, 2018b).

Obermann et al. (2018) explain that an integral approach to enhancing maternal and child health
is quality facility-based delivery and lowering the out-of-pocket cost through national health
insurance. A 2016 Philippine study on the relationship between health insurance and facility-
based delivery shows that insured women were five to 10 per cent more likely to go to the
hospital than those without insurance, with more tangible benefits among poor and rural women
(Gouda et al., 2016). This result was further substantiated by a 2015 survey on the barriers poor
mothers face when seeking health care, which found that four in every ten respondents (n=1,130)

45
were unaware of the PhilHealth benefits for pregnant mothers and newborns (Rivera, 2015).
Furthermore, those aware participants could not maximise the insurance due to administrative
requirements and indirect costs not covered by PhilHealth, such as user fees and transportation
costs (Rivera, 2015).

The same 2015 NAPC study showed that many went to health care facilities but could not avail
themselves of the health insurance benefits because the facilities were not accredited by
PhilHealth (Rivera, 2015). Accreditation is designed to improve the quality of health care and
lower the out-of-pocket health care costs among patients; however, it also decreases the number
of facilities that PhilHealth members can access due to a limited number of accredited hospitals
(Rivera, 2015). Dayrit et al. (2018) discuss the institutional factors contributing to limited
accreditation, such as lack of enabling support for the hospitals, stringent processes and costly
requirements. For instance, hospital directors mention the rigorous, perceived as ‘higher than
necessary’, PhilHealth standards as one main reason for their inability to meet the accreditation
conditions (Dayrit et al., 2018). Furthermore, some requirements, such as hiring specialist staff,
were considered too costly for the hospitals (Dayrit et al., 2018). As a result, the number of
accredited facilities was 68 per cent in 2014, which means a significant number of hospitals
remained unaccredited and could not access the PhilHealth reimbursements. The challenge is the
poor institutional mechanism for quality improvement and reducing the out-of-pocket
expenditure for the patients in these non-accredited hospitals (Dayrit et al., 2018).

Another main reason some health facilities opt not to comply with PhilHealth accreditation is the
untimely reimbursements or delayed refunds by PhilHealth. A 2018 Philippine study showed that
several hospitals and health facilities had experienced delayed and untimely reimbursements
despite filing claims (Querri et al., 2018). Not being reimbursed on time directly impacts the
quality of the services, including regular supplies of medications and equipment (Querri et al.,
2018). These situations discourage health facilities from complying or renewing their
accreditation status.

Another significant issue in health financing is the indirect medical costs, such as transportation
costs and lost wages. Mothers, who are PhilHealth members, spend, on average, a total cash-out
of 2275 PHP (45 USD) for their childbirth from their pocket to pay for medical supplies and
medicines not available in the hospital and not covered by PhilHealth (Dayrit et al., 2018). In

46
2015, only 752 public hospitals and infirmaries had been accredited by PhilHealth; eight in 10
cities and municipalities nationwide had at least one accredited outpatient clinic for maternal
care services (Rivera, 2015). This data highlights the challenges encountered by poor mothers
due to limited PhilHealth coverage, inaccessibility to the accredited health facilities, and indirect
costs, such as transportation (Rivera, 2015).

3.1.3 Prenatal care

Prenatal care has been defined as a range of health care services for pregnant women given by a
health provider in medical facilities or community settings (Matthews et al., 2001). Chamberlain
(1991) explains that prenatal care intends to (1) sustain maternal health, (2) manage fetal health
issues, (3) monitor early and avoid complications, (4) detect early and prevent fetal
complications, and (5) facilitate parental preparation for childbirth and childrearing. In the
Philippines, prenatal care is done by trained health providers, such as doctors, midwives, and
nurses (Lavado et al., 2010). Based on the 2017 government reports, nine in 10 Filipino women
received prenatal care from skilled providers, including midwives, doctors, and nurses. The
survey further indicated that three per cent of women had no prenatal care (Philippine Statistics
Authority, 2018). The report also showed that women with higher income status and education
levels were most likely to receive prenatal care from health professionals. Previous studies have
indicated that prenatal care significantly contributes to infant survival and maternal health
(Balcazar et al., 1993; Barros et al., 1996; Krueger & Scholl, 2000; Mustard & Roos, 1994). For
example, mothers without or with less prenatal care are more likely to experience complications
like preterm labour (Balcazar et al., 1993; Krueger & Scholl, 2000). Prenatal care has been
known to avert infant mortality (Mitchell et al., 1997).

Regarding the frequency of prenatal care in the Philippines, 87 per cent of Filipino pregnant
women had at least four prenatal visits in 2017 (Philippine Statistics Authority, 2018). Although
the figure was high, the data showed that many women had less than the recommended prenatal
frequency. Philippine DOH's goal is for Filipino women to have at least four prenatal visits
(Department of Health, 2009). The World Health Organisation (2009b) recommends that
pregnant women observe the quantity and periodicity of prenatal visits.

47
3.1.4 Menstrual wellbeing of Filipino women
Menstruation is a bodily process and part of the female reproductive cycle (Katsuno et al., 2019;
Kuhlmann et al., 2017). In several developing countries, menstruation remains a taboo topic that
has been associated with exclusion and shame among women, misconceptions, and unhygienic
practices (Chandra-Mouli & Patel, 2017). Early studies on young girls’ menstrual experiences in
developing countries indicate that adolescent girls express discomfort and fear (McMahon et al.,
2011; Sommer, 2009). Additional core challenges are limited access to menstrual pads, toilet and
water facilities, and inadequate information about healthy menstruation (House et al., 2013;
Sommer & Sahin, 2013). Previous studies suggest that these issues negatively impact girls’
wellbeing and development (Crichton et al., 2013; Phillips-Howard et al., 2016). Research has
shown that adult women also face inadequate resources and support, particularly in low-resource
settings (Garg et al., 2001; Parker et al., 2014), which may contribute to stress and affect their
productivity at home and in the workplace (Krenz & Strulik, 2019).

Menstruation has remained taboo and a social inequity issue in the Philippines. In a 2015 news
article, Virginity and menstruation myths behind Asia’s tampon taboo, Welle (2019) notes that
menstruation has remained taboo in many Asian countries, including the Philippines,
broadening knowledge gaps on female reproductive health. Filipino women and girls
grow up in a society that does not facilitate conversation about menstruation issues,
reproductive organs, and sex (Welle, 2019). There are misconceptions surrounding
menstruation among Filipino women, such as the myth that women should not bathe during
menstruation. A study by the World Health Organisation (1981) revealed that 72 per cent
(n=522) of the female respondents in the Philippines believed bathing during menstruation might
negatively impact menstrual blood flow and cause increased abdominal discomfort. The same
study found these beliefs common among older, less educated, and rural women. Although these
findings came from an older study, such menstrual beliefs may persist among Filipino women,
particularly those rural and less educated women and girls.

A more recent study on the young Filipino girls’ menstrual knowledge and beliefs showed that
misinformation and inaccurate guidance about behaviour during menstruation were apparent
(Haver et al., 2013). The study highlighted that the girls received information from family and
friends containing misinformation. The authors further explain that traditional guidance reduces

48
girls’ ability to practise proper menstrual and hygiene management. The misinformation and
knowledge deficit surrounding menstruation have been linked to limited appropriate
menstruation education in school and the community (Haver et al., 2013). The same study found
that school materials about menstrual health were often outdated and were not always available
for girls (Haver et al., 2013).

Period poverty has been a pressing issue in the Philippines. Sanitation and water facilities are
vital to enabling girls to practise menstrual hygiene management in school and the community
(Haver et al., 2013). A 2016 Philippine study on school girls’ access to hygiene facilities found
that limited access to water and toilet facilities and lack of disposal facilities for sanitary
products were the main barriers to effective menstrual management in schools in urban and rural
areas (Ellis et al., 2016). The findings on poor hygiene facilities are consistent with an earlier
study indicating that most Philippine public schools have poor sanitation facilities and
inadequate disposal systems (Haver et al., 2013). Sommer et al. (2016) argue that poor school
water, sanitation, hygiene conditions, and even the broader community profoundly affect girls’
menstrual wellbeing. The main barriers to addressing period poverty are the lack of
comprehensive support for women’s and girls’ menstrual needs and the insufficient menstruation
knowledge (Sommer et al., 2016).

In terms of frequency of changing menstrual pads, a 2019 Philippine study on high school female
students’ menstrual behaviour showed that most students (77 per cent) changed menstrual pads
at least once in school toilets while the rest did not change menstrual pads in school toilets. The
same study further indicated that the frequency of changing sanitary napkins was influenced
mainly by the access to quality hygiene facilities and the availability and affordability of
menstrual pads at schools or nearby stores (Katsuno et al., 2019). Inadequate menstrual pads can
be profound among girls and women with heavy menstruation and limited resources. This
situation would mean they need more menstrual pads or purchase bigger ones that are more
costly than the regular ones. The use of tampons is not a common option among Filipino women.
Aside from the availability problem of tampons in the country, there are negative connotations
and myths attached to using tampons. Philippine myths about tampons include the prevalent
belief that tampons break the hymen and destroy a woman’s virginity (Welle, 2019). In a

49
predominantly Catholic society, this belief is believed to have been influenced by the Spanish
colonisation when Filipino women were severely repressed (Welle, 2019).

3.1.5 Contraceptive services

Contraceptive methods are generally classified as 1) modern [barrier methods such as male and
female condoms, diaphragm, cervical cap and sponge; hormonal contraceptives that include oral,
injectable, transdermal, vaginal ring, and implants; intrauterine device (IUD)] and 2) traditional
[rhythm method (periodic abstinence), withdrawal (coitus interruptus), fertility awareness-based
methods, the lactational amenorrhea method and folk methods](Almalik et al., 2018).
Contraceptives in the Philippines are available and accessible in the primary health units,
including the public and private hospitals. The use of birth control methods or family planning
by married Filipino women of reproductive age has hovered between 50 per cent to 60 per cent
since 1995 (Department of Health, 2018a). In 2017, 54 per cent of currently married women
were using contraceptives, with 40 per cent using a modern method and 14 per cent using a
traditional approach (Department of Health, 2018a). The contraceptive pill (21 per cent) was the
most commonly used method, followed by withdrawal (10 per cent) and female sterilisation (7
per cent) (Philippine Statistics Authority, 2018). Of the current users of selected modern
contraceptive methods, more than half (56 per cent) received their supplies from government
facilities; 25 per cent of modern method users obtained their contraception from this source for
free (Philippine Statistics Authority, 2018). Pharmacies were the primary private-sector provider
of contraceptives, serving 30 per cent of users (Philippine Statistics Authority, 2018).

The low use of modern contraceptive methods has resulted in many unplanned pregnancies and
unsafe abortions in the Philippines (Finer & Hussain, 2013). Although abortion is criminalised in
the country, many women resort to unsafe abortion to space births or to meet their family-size
goals (The Alan Guttmacher Institute, 2003). Abortion was criminalised in 1870 under Spanish
colonial rule and was incorporated into the Revised Penal Code in 1930 under US colonisation.
This punitive approach has not prevented abortion cases and instead caused an unsafe
environment for several Filipino women who try to terminate their pregnancies (Center for
Reproductive Rights, 2010). For example, in 2008 alone, the country’s criminal abortion ban
resulted in more than 1,000 unsafe abortion-related deaths and 90 000 complications.

50
Abortion experiences of Filipino women cannot be separated from the sociopolitical dimension
of the country. Based on the Philippine constitution, abortion is a criminal act wherein both the
woman undergoing the procedure and the health professional doing it may be prosecuted (may
face up to 6 years in prison) (Center for Reproductive Rights, 2010). Furthermore, the Catholic
Church has described abortion as immoral and sinful. Considering the legal constraints and
stigma, many women choose to go to unskilled individuals for an unsafe abortion performed in a
dangerous place (Center for Reproductive Rights, 2010). Given the country's lack of
comprehensive support and heavily criminalised abortion, many women, particularly low-
income women, are vulnerable to unsafe abortion and complications (The Alan Guttmacher
Institute, 2003).

3.1.6 Summary
The Philippines has a complex health care system. Although PhilHealth coverage has increased
over the years, health insurance remains insufficient in protecting Filipinos from the health-
related financial burden. This situation suggests systemic issues, such as the inadequate scope of
PhilHealth benefit packages. For instance, pregnant mothers, who are PhilHealth members,
spend a total cash-out of 2275 PHP (45 USD) for their childbirth from their pocket to pay for
medical supplies and medicines not available in the hospital and not covered by PhilHealth.
Filipino women’s low use of modern contraceptive methods has resulted in many unplanned
pregnancies and unsafe abortions. Although abortion is criminalised in the country, many women
resort to unsafe abortion to space births or to meet their family-size goals.

3.2 Reproductive politics: The sociopolitical

dimension of Philippine reproductive health
The Philippine reproductive health care has been shaped by historical intersections of
colonialism, religion, economics, and the international development agenda (Natividad, 2012). In
other words, the history of the country’s reproductive health comprises sociopolitical, religious,
and institutional dimensions. Specifically, the Catholic Church has paved itself into the
Philippine political landscape and continued to influence the political debate and the moral
values and norms that uphold the nation (Collantes, 2018). The Catholic religious institution has

51
played a tremendous role in pushing for successfully elevating their supported politicians to
presidential leadership (Collantes, 2018).

The country’s reproductive politics has shown the complicated link between policymaking and
Catholic religious values (Collantes, 2018). As the 1987 Philippine Constitution indicates, the
state “shall equally protect the mother’s life and the life of the unborn from conception” (Article
2, Section 12). This constitutional statement reflects the country’s devotion to its conservative
Catholic norms, believing life starts at conception. This constitutional principle of sanctity of life
and protection of the ‘unborn’ child has resulted in the criminalisation of abortion, limited
sexuality education in schools, and inadequate access to reproductive health care (Collantes,
2018; Natividad, 2012). Furthermore, Church actors and conservative groups have equated all
forms of modern contraception with abortion (Austria, 2004; David et al., 2012). Poor women, in
particular, suffer the impact of these conservative policies, reflected in the high number of unsafe
abortion complications, maternal deaths, and intergenerational poverty (Collantes, 2018). In
response to these profound impacts on Filipino women, along with high population and
unemployment rates, the government in 2012 under President Benigño Aquino signed ‘The
Responsible Parenthood and Reproductive Health Act of 2012’ (The RH Law). To provide
comprehensive reproductive health care, the law calls for the state to provide:

… universal access to medically safe, non-abortifacient, effective, legal,

affordable, and quality reproductive health care services, methods, devices,
supplies which do not prevent the implantation of a fertilised ovum as
determined by the Food and Drug Administration (FDA) and relevant
information and education thereon according to the priority needs of women,
children and other underprivileged sectors … (Republic Act No. 10354,
Section 2, d)

The Catholic Church has used its influence to stop the passing and implementation of the RH
law. For instance, Church leaders have used Pope John Paul II’s ‘culture of death’ and equated
the concept with abortion, homosexuality, divorce, and euthanasia, regarded as moral ‘threats’ to
Filipino values (Collantes, 2018). Inspired by the previous Pope’s words and the Vatican, the
Philippine Church “has been able to argue that the campaign against the RH Law is not merely a
sexual health issue, but a general crusade against a broad spectrum of the moral harms of

52
Filipino society and culture” (Bautista, 2010, p. 37). The Catholic Church leaders and
conservative religious groups have used this religious and political rhetoric to shape reproduction
and family planning discussions (Collantes, 2018). After the RH law was enacted, the Catholic
Church leaders mobilised resources and lobbied the Supreme Court to stop the law’s
implementation because the law promotes the use of abortifacients. More than a year after it was
enacted into law, the RH Law was declared ‘constitutional’ by the Supreme Court in 2014, but
some provisions were declared unconstitutional, such as respecting the religious beliefs and
practices of health practitioners and educators (Batalla & Baring, 2019; Collantes, 2018). The
Supreme Court also struck down specific provisions that violated the constitution’s non-abortion,
non-coercion principle (Batalla & Baring, 2019). The RH law’s mandates have yet to be
comprehensively implemented across health facilities and academic institutions today (Collantes,
2018). These issues profoundly impact Filipino adolescents and unmarried young adults because
of the trends in sexual initiation, cohabitation and the increased need for reproductive health care
(Guttmacher Institute, 2015). For example, 49 per cent of sexually active, unmarried women
want to prevent pregnancy yet are not regularly using any contraceptive method (Philippine
Statistics Authority, 2018).

Scholars have pointed out the critical role of religion in shaping reproductive politics in different
parts of the world, including the Philippines (Blanc-Szanton, 1990; Sjørup, 1999). Despite the
large Catholic population, many Filipinos support the RH Law and the need for comprehensive
reproductive health care (Bautista, 2010; Curato & Ong, 2015). Cornelio (2013, p. 115) argues
that young Filipinos are ‘Creative Catholics’ because “they tend to depart from the Church on
issues such as the RH Law, but still affirm that moral actions and good conscience guide their
Catholic identities and spirituality”. Turner (2011, p. 18) examines the relationship between
religion and the female body and religion’s role in symbolically expressing norms and morals
and religion has the “immediate capacity to express sacred values, human sexuality and social
power”. When state policies and Catholic teaching intersect in the context of reproductive rights,
women face the impacts of these decisions (Collantes, 2018).

Filipino women have been negotiating the patriarchal depictions of women rooted in their
institutionalised faith as Catholics (Collantes, 2018). The idealisation of Filipino women’s roles
as devoted mothers and wives has been linked to the symbolism of the Virgin Mary (Peracullo,

53
2017). Like Virgin Mary, Filipino women are expected to sacrifice for their families and obey
their husbands (Collantes, 2018). The Philippines is family-oriented and pronatalist at normative
and institutional levels, which mirrors the dominant Catholic influence over the social
construction of motherhood (Alampay & Jocson, 2011; Licuanan, 1979). Grounded in the
conservative Catholic teaching, motherhood is socially valued and regarded as a national mission
in the wider Philippine society, reflecting the Virgin Mary image and a colonial vestige deeply
burrowed in Filipino women's cultural psyche (Peracullo, 2017).

Despite changes in some facets of Filipino culture, traditional gender norms on sexual and
reproductive behaviour have persisted (Medina, 2015). Filipino women have achieved more
significant gains in education than men, with female students now outranking their male
counterparts in secondary education (UNESCO Institute of Statistics, 2017). In the household,
Filipino women often decide on the household budget and how family expenses are managed
(Ashraf, 2009). However, data indicates that Filipino women’s power in these ‘public’ spheres
may not necessarily translate into ‘private’ dimensions, such as reproduction and sex (Casterline
et al., 1997). Historical studies indicate how Spanish colonisation resulted in regulating and
controlling Filipina women’s reproductive health and sexuality (Blanc-Szanton, 1990;
Mananzan, 1987; Reyes, 2008). Filipino women are expected to maintain cultural ideals of hiya
or propriety, such as maintaining virginity until marriage, with profound social consequences for
women who transgress these norms (Mananzan, 1987; Medina, 2015). This cultural value of
hiya, which also denotes ‘shame’ or ‘embarrassment’, can be applied to various contexts
(Jocano, 1998; Rafael, 1993). For instance, Rafael (1993, p. 126) explains that to be in the state
of hiya is “to be in a vulnerable position and an embarrassment that arises from being
overwhelmed”. Additionally, having hiya means that people may feel very sensitive to social
slights, and as a result, they may be cautious of the feelings of others (Jocano, 1998; Medina,
2015). What causes disgrace to one’s family or community is paramount in a collectivist culture
such as the Philippines, where social norms are valued over individual goals (Jocano, 1998;
Medina, 2015).

3.2.1 Summary
The earlier discussion indicates how the country’s reproductive politics has been shaped by
various sociopolitical and institutional factors, particularly the Catholic Church’s political

54
significance. The religious group has not only cemented itself into the political foundation of the
country, but it has also influenced the moral values and norms that uphold the country. This
situation can be observed in how the country’s reproductive health law’s path into enactment has
been distinctly hindered by ‘pro-life’ politicians and the Catholic Church

3.3 Philippine prisons and the situation of women

This section has three objectives. First, I provide specific information about the prison structure
and system in the Philippines as the context of interest. Second, I explore the socio-economic
circumstances of Filipino female prisoners. Finally, I describe their complex needs, especially in
the context of reproductive health, in the prison spaces in which they largely depend on the
available services provided by the institution.

3.3.1 The organisation of the penal system in the Philippines

The Philippines has two categories of detention facilities: jails and prisons. Local jails are
designed for short-term prison sentences, including pre-trial detention and those convicted to less
than three years. Jails are managed by the Bureau of Jail Management and Penology (BJMP),
under the Department of the Interior and Local Government (DILG). Based on 2015 BJMP
reports, 91,250 people were held in pre-trial detention (Prison Insider, 2017). People convicted
of long-term sentences (more than three years to life imprisonment) stay in national prisons or
prison farms. These facilities are managed by the Bureau of Corrections (BuCor), a branch of the
Department of Justice (DOJ). The structure of Philippine prisons is complicated by the numerous
actors and agencies involved. As noted above, the agencies involved in managing prisons include
DOJ, DILG, DOH for the health services and the Department of Social Welfare and
Development for the social welfare services. Coyle (2002) discusses in his book, Managing
prisons in a time of change, the structural and management complexities that negatively
influence the quality, gender-responsiveness, appropriateness, and continuity of services for
prisoners with distinct needs.

3.3.2 Socio-economic circumstances of Filipino incarcerated women

This section discusses Filipino women’s criminal and socio-economic profiles in the CIW based
on the latest data from the Philippine BuCor (2021). The February 2021 data showed that most
55
women were imprisoned for non-violent crimes: drug crimes (60 per cent) and property crimes
(20 per cent). Filipino women’s criminal history corroborates global studies, presenting the
nature of their pathways to crime are linked to policy reforms, drugs, and poverty (Bastick &
Townhead, 2008; Braithwaite et al., 2005; Jeffries & Newbold, 2015; Moloney et al., 2009).
Regarding their socio-demographics, most women in CIW were young and middle-aged, with 30
per cent (n=1,001) between 22-39 and 54 per cent (n=1,799) of women between 40-59 years old.
Regarding their pre-imprisonment occupation, many were jobless (25 per cent) or involved in the
business (14 per cent). The BuCor data indicates that most women had reached a higher
education level: about 49 per cent had reached high school (not necessarily completed), 28 per
cent had attended college, and roughly 20 per cent had only attended elementary school. Most
were either single at around 32 per cent or married at 31 per cent, and the rest were separated or
widowed (divorce is illegal in the Philippines).

Furthermore, many identified themselves as Roman Catholic at around 77 per cent, but a small
group mentioned affiliation with Iglesia ni Cristo, Born Again Christianity, Seventh Day
Adventist, and Islam. Finally, data revealed that many women come from communities outside
the Metro Manila area at about 49 per cent, which means their families and relatives live far
away from prison. The CIW figures align with the global data on incarcerated women’s
sociodemographic profile, indicating the marginalised status of women in both the wider and
prison communities (Coll et al., 1997; Corston, 2007; Messina et al., 2003; United Nations,
2000).

Most long-term Filipino incarcerated women are detained in the Correctional Institution for
Women (CIW) in Metro Manila, which BuCor governs under the Department of Justice (DOJ).
A few hundred convicted women are also imprisoned in a Mindanao-based BuCor facility in the
southern part of the country. The BJMP also holds women awaiting trial and those sentenced to
three years or less in local jails across the country.

3.3.3 Specific needs of Filipino incarcerated women

In this section, the discussion of Filipino women’s specific needs in prison is primarily based on
a 2014 study by Baker, which documented the characteristics and specific needs of Filipino
incarcerated women. Baker (2014) discusses the participants’ emotional difficulties with

56
separation from young children and their inability to fulfil natural caretaking and mothering
roles. This finding substantiates the global discussion of incarcerated women’s experiences of
separation from their families and children (Office of the United Nations High Commissioner for
Human Rights, 2008; Quaker Council for European Affairs, 2007; van den Bergh et al., 2011).
Furthermore, many pregnant prisoners in Baker’s (2014) study expressed stress, anxiety, and
trauma caused by giving birth while detained. The participants’ negative experience was linked
to the risk that their situation may cause their unborn or newborn because of limited control over
the pregnancy situation and inadequate resources. Baker (2014) points out that the stigma and
feelings of shame commonly encountered by the participants are associated with women’s
inability to fulfil their mothering roles for their children and families.

Baker’s study also found that other frequent sources of frustration among incarcerated women
included issues related to the physical condition of the prison and its impacts on their health and
dignity, such as overcrowding, inadequate sanitary facilities, and poor nutrition. The prison
service is generally not a priority policy area and remains underfunded, particularly in
developing countries like the Philippines. This finding shows the adverse outcomes of limited
resources and weak prison governance. The situation of Filipino incarcerated women reflects the
experiences of women in prisons in other developing countries, including, for example, in the
African region, where women’s basic needs are also not met (Agboola, 2016; Dixey et al., 2015;
Todrys & Amon, 2011; Twea, 2004). While Baker’s (2014) study extensively documented
women’s needs and reproductive health issues in the Philippine prisons, information about
Filipino women’s reproductive wellbeing experiences has remained sparse. The current study
uses a qualitative approach to explore Filipino women’s reproductive wellbeing experiences
concerning menstruation, access to hospital reproductive health care, and pregnancy.

3.3.4 Reproductive wellbeing of incarcerated Filipino women

In this section, some reproductive health issues of Filipino women in prisons are explored using
Baker’s (2014) study. In her research, she argues that health care was a pressing issue in all the
detention facilities visited, related explicitly to insufficient medical supplies and limited health
care staff. Baker added that some significant gaps expressed by the participants were in gender-
specific services, such as mental and reproductive health, pregnant women and new mothers, and
victims of gender-based violence (Baker, 2014). Furthermore, they found that facilities

57
(particularly in BJMP jails) had inadequate essential medicines and supplements, such as pain
medications, iron supplements, and vitamins. This lack of health care resources profoundly
affects pregnant women’s and newborns’ health (van den Bergh et al., 2009).

Baker found that mother inmates’ psychological and emotional stress from being separated from
their babies was common among the participants. This negative experience is connected to
prison practice on newborn care and the decision of women to have their babies taken care of by
‘outside carers’. As documented by Baker (2014) in the CIW, incarcerated women could keep
their children with them for one year; however, many women decided to give their babies to
outside carers early because of their inability to sustain babies’ needs (i.e., food, clothing,
vaccines and supplements). This situation indicates that women’s and babies’ needs are not
systemically supported and negatively affects women’s emotional wellbeing and increases their
risk of postpartum depression (Office of the United Nations High Commissioner for Human
Rights, 2008; van den Bergh et al., 2009; World Health Organisation, 2009a).

Lastly, the reporting process was one gendered gap in Philippine prisons (Baker, 2014). For
example, women were required to first report their health issues to a cell leader and duty officer,
leading to women’s embarrassment and underreporting of health concerns (Baker, 2014). As
noted by one health worker in Baker’s (2014, p. 48), “women keep Sexually Transmitted
Infections (STIs) and UTIs (urinary tract infections) to themselves…, it’s the Filipino culture”.
The study also indicates that preventive reproductive health care, such as HIV tests, Pap Smears,
and health education, was not regularly provided (Baker, 2014). This finding related to HIV/STI
risk among women inmates corroborates the earlier research conducted in the CIW regarding
women inmates’ high-risk sexual behaviours and STI prevalence (Simbulan et al., 2001).
Simbulan et al. (2001) found that about 36 per cent of women inmates in their study (n=100)
tested positive for STIs such as Trichomonas, Gonorrhea, Chlamydia and Hepatitis B. Their risk
of STIs can be linked to high-risk behaviours (i.e., multiple sexual partners and inconsistent birth
control use before incarceration) and a lack of comprehensive and regular reproductive health
care in prisons (Baker, 2014; Simbulan et al., 2001). There have been consistent results globally
related to incarcerated women’s higher risk of STI than their male counterparts as a result of pre-
imprisonment high-risk sexual behaviours (Clarke et al., 2006; Covington, 2007; El Ghrari et al.,

58
2007; Hogben et al., 2001; Jiraporncharoen et al., 2011; Simbulan et al., 2001; van den Bergh et
al., 2011; Willers et al., 2008).

3.3.5 Summary
This section describes the restricted access to comprehensive reproductive health services and
education among Filipino women in prisons, suggesting that they are unnecessarily exposed to
multiple reproductive health-related risks. The local findings on poor reproductive health care in
prison reflect the global studies, showing that incarcerated women’s wellbeing needs concerning
reproductive health, menstruation, childbearing, and newborn care are often overlooked and
unmet by the prison authority.

3.4 Research and knowledge gaps

Feminist scholars have established the distinct health needs of imprisoned women in the context
of reproductive wellbeing (Bostock, 2020; Hayes et al., 2020; Mignon, 2016; Sufrin et al., 2015).
Despite this abundant literature on women’s reproductive needs behind bars, there is a limited
understanding surrounding the lived experience of reproductive wellbeing among imprisoned
women and the institutional and social contexts of their experience, particularly in the
Philippines. The following section describes the specific research gaps identified through
scoping review of extant literature.

First, the mainstream discussion on the reproductive wellbeing of female inmates has centred on
the women’s access to birth control services using a health perspective (Clarke et al., 2006; Hale
et al., 2009; Jiraporncharoen et al., 2011; Liauw et al., 2016). Additional aspects of reproductive
health were also explored, such as STIs and HIV; however, the previous studies revolved around
the prevalence of STIs and HIV among women in prison and their risky sexual behaviour before
their imprisonment (El Ghrari et al., 2007; Hogben et al., 2001; Willers et al., 2008). Although
reproductive care needs of imprisoned women have already been extensively explored, most of
these studies were done quantitatively (see Clarke et al., 2006; Hale et al., 2009; Jiraporncharoen
et al., 2011; Liauw et al., 2016). Quantitative research methods can identify women’s access to
reproductive health care and common reproductive wellbeing needs in prison. However, a deep
understanding of how incarcerated women experience reproductive wellbeing and how they

59
make meaning of these experiences are difficult to capture with quantitative methods. The
current study utilises a qualitative approach to explore the reproductive wellbeing experiences of
Filipino incarcerated women.

Second, prison, women, and gendered facets of imprisonment have been widely studied (Carlen,
1994, 2002; Crewe et al., 2017; McIvor, 2010); however, studies in this area concentrate on ways
in which the criminal justice treats women and men and Correctional system (Carlen, 2002;
Gelsthorpe, 2004; Walklate, 2013), and how gender might influence prison experience (Carlen,
1994; Chesney-Lind & Pasko, 2013; Crewe et al., 2017; Padel & Stevenson, 1988). Additionally,
there is growing knowledge on carceral emotions concerning maternal imprisonment, especially
in the USA (Bloom et al., 2003; Enos, 2001; Flynn, 2014). While the knowledge about the
distinct impact of imprisonment on women’s experiences has been established, information
about their experiences of reproductive wellbeing remains scarce.

Third, although Sykes’ (1958) theory and the expanded concept of ‘gendered pains of
imprisonment’ offer helpful perspectives about the deprivation encountered by prisoners and the
specific experiences of women, little is known about the distinct and complex experiences of
incarcerated women concerning reproductive wellbeing and pregnancy. In addition, most studies
that examined the gendered pains of imprisonment experienced by women were primarily
focused on western perspectives (Carlen, 1983, 1998; Crewe et al., 2017; Genders & Player,
1987; Owen, 1999; Walker & Worrall, 2000), and little is known about the experience of
incarcerated women in the global south. The current study fills this gap by providing a Philippine
context with different socio-political structures and cultural and social norms.

Fourth, earlier studies have indicated that the conceptualisation of self has more profound
implications for incarcerated women than their male counterparts because of enforced gender
roles and social limitations (Ray & Downs, 1986; Ward & Kassebaum, 1966). Feminist theorists
argue that women who transgressed the social expectations of being a good mother, such as
women in prison, face severe public shame and humiliation (Gelsthorpe, 2004; Kennedy, 2011;
Lockwood, 2018). Incarcerated women experience double burden- as deviant for breaking the
law and ‘unfit mothers’ (Ferraro & Moe, 2003). Although the effect of incarceration on the
women’s sense of self and identity has been established in the earlier literature, understanding
how women’s prisoner identity shapes reproductive wellbeing has remained under-theorised.

60
Building on Goffman’s (1961) sociological examination of ‘mortification of self’, this thesis
examines how Filipino women experience reproductive wellbeing as this experience intersects
with their prisoner identity.

Lastly, although there have been studies conducted about the experience of sick prisoners
transported to hospital (e.g.Edge et al., 2020; Follis, 2015; Haesen et al., 2021; Minayo &
Ribeiro, 2016), the discussion around the experience of women needing reproductive health care
outside the prison, such as women with distinct reproductive wellbeing and pregnant prisoners
remains scant considering the significant increase of female prison population in the Philippines.
This thesis explores Filipino incarcerated women’s experience of reproductive wellbeing,
including accessing outside hospital reproductive health services.

Given the critical knowledge gaps, this present study examines the lived experiences of
reproductive wellbeing of Filipino female prisoners. Furthermore, it explores the social,
relational, and institutional factors that shape their experiences in prison. Ultimately, it is
envisaged to provide a holistic discussion of the nexus between incarceration and reproductive
wellbeing in the context of menstruation, gynaecological care, childbearing, and childrearing,
anchored on criminological and sociological conceptual lenses.

3.5 Chapter summary

This chapter has critically reviewed the sociopolitical context of the Philippine reproductive
health landscape. Apparent in the earlier discussion is how the country’s reproductive politics
has been shaped by various sociopolitical and institutional factors, particularly the political
significance of the Catholic Church. The religious group has not only cemented itself into the
political foundation of the country, but it has also influenced the moral values and norms that
uphold the country. This situation can be observed in how the country’s reproductive health
law’s path to enactment has been distinctly hindered by ‘pro-life’ politicians and the Catholic
Church. Determining the macro-level landscape of the country’s reproductive governance is vital
because certain marginalised and neglected groups of women are more critically vulnerable,
particularly those who entirely depend on the resources given by the government. The available
evidence demonstrates the restricted access to comprehensive reproductive health services and
education among women in prisons, suggesting that they are unnecessarily exposed to multiple

61
reproductive health-related risks. Currently, the advocacy for improving women’s reproductive
health care is primarily focused on hospitals and community health facilities, at least in the case
of low-resource settings, such as the Philippines. Most importantly, the scant information on
incarcerated women’s experiences in the Philippines, particularly their reproductive experiences,
affirms the need to research this area.

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 Chapter Four
Methodology: Approaches and Tools
This chapter provides an overview of the methodology employed to address the main research
questions. The chapter introduces the methodologic approach, outlining why and how the
qualitative approach was applied to the present study. I then describe the ethical dimensions of
the current research, followed by a detailed explanation of the recruitment, data collection,
analysis processes, and reflections on my positionality as a researcher. Rigour within the study
and the characteristics of interview and focus group participants are also discussed.

4.1 Choosing qualitative approach

The present study explores the intersection of incarcerated women’s reproductive wellbeing and
incarceration. At the start of the research process, I was aware of different types of qualitative
research from discussions with my supervisor. I also read various research studies on women's
reproductive health care in prisons and had public health experience as a nurse and researcher
interested in reproductive health. Although the reproductive care needs of imprisoned women
have already been extensively explored, most of these studies were done quantitatively (see
Clarke et al., 2006; Hale et al., 2009; Jiraporncharoen et al., 2011; Liauw et al., 2016).
Quantitative research methods can identify women’s access to reproductive care services and
common reproductive health needs in prison. However, a deep understanding of how
incarcerated women experience reproductive wellbeing and how they make meaning of these
experiences are difficult to capture with quantitative methods. Qualitative research is “well
suited for ‘why’, ‘how’ and ‘what’ questions about human behaviour, experiences, motives,
views and barriers” (Neergaard et al., 2009, p. 2).

Qualitative research is an interactive and systematic approach to describing people’s experiences

and the meaning of their accounts. When formulating a framework for qualitative research, it is
necessary to identify the worldview that guides the researcher (Guba & Lincoln, 1994). As a
qualitative researcher, it was essential to view the interview and focus group participants as
active contributors and understand that the contexts in which they operated would influence their
experiences. Also, I recognised that my views and experiences would impact the research and

63
analysis of the data. A qualitative approach was the appropriate choice for me because it
acknowledges the multiple perspectives (participants and researchers) and that the knowledge
generated by the research is constructed and produced through a critical and questioning
approach (Braun & Clarke, 2013).

4.2 Feminist qualitative research design

The ultimate goal of the current study is to situate Filipino women’s experience of reproductive
wellbeing as incarcerated and criminalised individuals within the broader institutional and social
dimensions in which it transpired. In particular, I was interested in investigating how these
structures and systems shape their experiences of reproductive wellbeing behind bars. Consistent
with the nature and goal of the current project, feminist perspective-informed qualitative research
is the appropriate and relevant approach. In uncovering women’s experiences of reproductive
wellbeing in prison, feminist perspectives shaped this qualitative study. Feminist criminologists
have argued that men have designed prison institutions for male prisoners without considering
the needs of women (Gelsthorpe, 2004; Liebling & Arnold, 2012). The early scholarship
reinforces the perspective of feminist research representing powerless and marginalised women,
such as female prisoners (Kirsch, 1999). Brayton (1997) suggested that incorporating feminist
perspectives into research must raise critical questions while challenging systemic inequalities,
institutionalised power differentials, and patriarchy. The ultimate goals of feminist perspective-
informed research are to hear women’s stories and contextualise women’s narratives and
experiences (Bryman & Cassell, 2006).

Feminist research explores the gendered dimensions of women’s experiences and inequalities
and enhances women's social status (McHugh & Cosgrove, 1998). Furthermore, Jaggar (2015,
p. ix) describes feminist research as a vehicle for gender justice and its “commitment to
producing knowledge useful in opposing the many varieties of gender injustice”. And the
feminist commitment to women’s emancipation necessitates understanding women’s situations
and circumstances and determining what needs to be “criticised, challenged or changed” (Burt &
Code, 1995, p. 20).

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In line with the study’s feminist qualitative approach, research questions were constructed to
examine the lived experiences of Filipino female prisoners’ reproductive wellbeing holistically
and flexibly. The research questions were framed as open-ended and broad:

• What is the Filipino incarcerated women’s experience of reproductive wellbeing?

• What are the roles of women’s social networks in their reproductive wellbeing?
• What is the institutional dimension of women’s experiences of reproductive wellbeing?

In the feminist qualitative approach, research must augment description and discovery by being
creative and holistic in accessing the participants’ stories, ideas, and felt experiences (Fisher,
2000). The main goal of this qualitative study is to bring the historically neglected research area
of Filipino incarcerated women’s experiences of reproductive wellbeing to the fore. The
succeeding sections outline the details of the current study's ethical dimensions, data collection
and analysis procedures.

4.3 Ethical considerations

In this section, I describe the ethical dimensions of the current study: institutional ethics
approval, informed consent, confidentiality, and aspects of power dynamics.

4.3.1 Institutional ethics approval

Before submitting the ethics application, I contacted the Philippine Bureau of Corrections
(BuCor) to get a permission letter in August 2019. To get official approval, I sent a formal letter
to the agency explaining the research project’s objectives and the PhD research brief. After one
month, permission was granted (Appendix A). I then applied for ethics approval (with the
BuCor’s letter of support) in early October 2019. My supervisors and I were invited to the
Human Ethics Committee meeting to discuss the application. The Committee approved the ethics
application (Ref: 19/137) in late October 2019 (Appendix B).

4.3.2 Informed consent

I provided informed consent forms for my two samples: incarcerated women (interview) and
staff focus groups. Before I began the interview with the incarcerated women, I gave the
informed consent form in Tagalog (Appendix C), along with an information sheet (Appendix D).

65
Similarly, I gave each focus group participant a copy of the informed consent agreement
(Appendix E) and information sheet (Appendix F). I outlined my duty and obligation of
confidentiality in all interviews and focus groups. I informed the interview and focus group
participants that I would use their accounts, stories, and thoughts they shared and some of the
actual words in a written project. I also told the participants that their participation was entirely
voluntary and no monetary incentive would be offered.

4.3.3 Power dynamics

Prisoners represent a vulnerable population because of their limited autonomy, and their
decisions are generally under the institution’s control (Martin, 2000; Silva et al., 2017). Prisoners
live in an environment exposed to a disproportionate balance of power (Field et al., 2019). These
existing power differences then raise questions about the voluntariness of prisoners’ research
participation (Arboleda-Flórez, 2005). I was conscious of the power dynamics between myself,
as a researcher, and my prisoner participants. Many prison researchers have argued that prisoners
may feel unable to decline participation or may agree to participate in research because they
believe doing so will have positive future consequences while in prison, or they want to appear
cooperative in hopes of being treated better (Arboleda-Flórez, 2005; Genders & Player, 1990;
Martin, 2000). To manage these issues, I thoroughly explained during my meeting with the
prison management that only women who expressed willingness to join would be invited to
participate in the interview. I also emphasised that the primary objective of the project would be
to explore the reproductive wellbeing experiences of prisoners, and not to evaluate the
effectiveness of specific programmes of the prison. It is vital to clarify and highlight the
prisoner’s voluntariness and main objective of the project because prison staff members were
tasked by prison management to send invitation letters to potential research participants.

Furthermore, ensuring that my research participants consent to the study and are not coerced is
essential. At the start of every interview, I clarified that their decision to or not to participate in
the study would hold no rewards or disadvantages (Liebling, 1995; Martin, 2000; Maxfield &
Babbie, 2014). I added that the study was independently conducted and not funded by the
government or the prison management. Likewise, I explained that their participation or non-
participation would not affect the earned prison privileges, sentence length, and work
assignments (Liebling, 1995; Maxfield & Babbie, 2014). Additionally, during the introduction

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session with the incarcerated women, I discussed my role, research objectives, and the research
projects I had completed in the past. I also told the participants that their participation was
entirely voluntary, which meant they did not have to answer any question they did not want to
and could leave at any point in the interview (Borrill et al., 2005).

Researchers have noted the power dynamics in qualitative research (Barbour, 2013; Brinkmann
& Kvale, 2005; Mullings, 1999). Hence, qualitative researchers must observe empathy at all
times (Alvesson & Sköldberg, 2017; Letherby, 2002), and this approach can be achieved through
building rapport (King & Horrocks, 2010). This recommendation is very relevant to prison
research. Building trust and rapport was vital for the researchers in exploring sensitive and
personal topics such as women's reproductive wellbeing in prison. Rapport is an essential skill of
the researcher that allows interviewees to ‘open up’ (King & Horrocks, 2010). As a public health
nurse, my experience and skills in building rapport with my patients have been refined over the
years. This skill has helped me as a researcher conducting studies on reproductive health. I made
sure that my interviews were carried out in a friendly, professional, and warm manner. This
approach contributed to building a rapport and positive working relationship with the
participants. Qualitative researchers have stressed that interviewer style can affect the
relationship with the research participants (King & Horrocks, 2010; Kvale, 2008). As a
researcher, I adhered to Fontana and Frey’s (2005, p. 696) recommendation of interviewing as a
“process that leads to a contextually bound and mutually created story”. This principle is in
harmony with the feminist approach of seeing participants as co-equals in the interview process.
Building rapport with prison staff and incarcerated women was beneficial when positioning
myself as a researcher. The professional and enabling relations I built with the prison officers
and management were valuable when accessing the study participants.

4.3.4 Incarcerated women’s vulnerability

Considering the nature of the research project posing an inherent risk to the respondents and
researchers, especially in the context of the Philippines’ highly punitive drug-related policies,
adequate security measures were sought at every step of the process. The records of the
interviews have been kept in a locked file with limited access. All electronic data, including
audio recordings and pertinent documents, were coded and secured in an encrypted, password-
protected device.

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The 2017 Philippine National Ethical Guidelines and Bureau of Corrections recommend that the
participants’ information remains confidential once the data is collected. Similarly, some prison
researchers contend that it is vital to ensure interviewees’ information is protected in any
interview (King & Wincup, 2008; Liebling & Arnold, 2004b). I did not record the names of the
interview participants. Where interviewees were quoted in the analysis chapters, pseudonyms
were used. Deductive disclosure, also known as internal confidentiality (Tolich, 2004), happens
when the characteristics or information about the participants make them identifiable in research
reports (Sieber, 1992). Since my qualitative study contains detailed descriptions of my
participants’ reproductive health conditions, internal confidentiality is of particular concern.
After discussing with my supervisors, I decided to omit the names of specific reproductive health
conditions that would identify the participants. Instead of using medical diagnoses, I used other
terms and descriptions that are more relevant and useful to my analysis, such as mild or chronic
reproductive conditions or menstrual problems. As such, I would still be able to provide detailed
and accurate accounts of their reproductive wellbeing experience without breaching internal
confidentiality.

The significance of ethical research must not be overlooked, mainly when the study involves
vulnerable populations like incarcerated women. Interviewing imprisoned people raises the
ethical issue of causing potential distress and discomfort. For instance, one participant, Claire,
who had a pregnancy experience in prison, cried while sharing her story of losing her first baby
in prison. As this interaction implies, an interview with imprisoned women who experienced a
lack of autonomy is sensitive and ethically complex. The appropriate response to this situation
hinges on the researcher’s expertise and skills. As a public health nurse with over a decade of
experience, my profession has helped me employ valuable skills. Observing and responding to a
distressed participant, like Claire, by giving her options to continue the conversation or stop or
seek professional help made her perceive my recognition of her discomfort and allowed her to
decide. My experience working with vulnerable populations enabled me to reduce possible
discomfort among the research participants.

The prison environment's lack of privacy is a common characteristic, and prisoners tend to
normalise this everyday prison reality (Crewe et al., 2017; Moran, 2013). However, it is essential
for me to respect the privacy and confidentiality of the conversation with the participants, given

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the highly personal and sensitive nature of the interview topics (i.e., reproductive wellbeing). I
asked the prison management if I could get a room where staff and other prisoners could not hear
the conversation. I also explained that having a separate room with less distraction would
facilitate focused discussion, and I was also mindful that my request did not violate any prison
safety regulations. The prison staff members provided me with a small room with a glass
window and appropriate lighting.

4.3.5 Researcher’s professional background

Carrying out this study presented difficulties regarding the possible overlap between my
professional background and training as a public health practitioner and a researcher. Geddis-
Regan et al. (2021) argue that the professional background among health practitioners may cause
specific dilemmas and tension. The difficulty of whether or not to disclose a professional
background or role, and if so, at what point, is likely more significant in qualitative than
quantitative research (Geddis-Regan et al., 2021). Researchers have recommended three
approaches to disclose a professional background: a) disclosing at the onset or beginning of an
interview; b) mid-interview disclosure; or c) only answering when asked (Geddis-Regan et al.,
2021. Finlay (2002) explains that deciding which approach to take is considered ‘reflexive
accounting’. In my case, I had to disclose my public health background before the interview
because doing so would ensure transparency and show my professional ability to ask and discuss
reproductive health-related questions. But I needed to clarify that the primary purpose of the
interview was to hear their stories and experience and not diagnose them or give health advice. I
was mindful of defining the boundaries of my role so that participants would be aware that my
professional background was public health, but my primary role there was as a researcher.

Wearing my researcher’s hat while listening to participants’ accounts was sometimes difficult, so
I had to take extended breaks during the interviews. Lofland and Lofland (2006) discuss the
possibility of extreme emotional responses among researchers that certain situations may cause. I
needed to balance the necessity for transparency as I managed my emotion. As indicated earlier
in this chapter, having experiences in both roles – the public health nurse and the researcher –
facilitated my professional boundaries and applying my skills.

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4.4 Research procedures
This section outlines the details of the sampling and recruitment processes. Additionally, I
present the data collection and analysis techniques employed in this research project. Finally, the
steps undertaken to maintain rigour and trustworthiness are discussed.

4.4.1 Sampling and recruiting processes

This research project has two samples: 1) interview participants and 2) focus group participants.
I begin this section by outlining the recruitment and sampling procedures employed to access
interview participants. I then present the details of how focus group participants were recruited.

4.4.1.1 Incarcerated women

I recruited the participants through the institutional prison mechanism. I sent a formal letter,
endorsed by the Sociology, Gender Studies and Criminology Programme at the University of
Otago, to the office of the Director-General in the Philippine Bureau of Corrections (BuCor)
through the Presidential Communications Office. The letter explained the primary objectives of
the research project, target participants, and schedule. After one month, the researcher received
BuCor’s letter of approval. The Corrections agency also instructed the Correctional Institution
for Women (CIW) to facilitate the research process. The CIW director assigned two prison staff
members to help with recruitment, interviews, and focus groups. When I arrived in the
Philippines, I scheduled a meeting with Corrections staff members to explain the study further,
and then I met the Corrections point persons/staff to plan and finalise the schedule. All
interviews were completed in late March 2020 before the Philippine government imposed a total
lockdown due to the COVID-19 pandemic.

The next step involved recruiting a purposive sample of 42 incarcerated women. Purposive
sampling was essential to achieve optimum and diverse aspects of reproductive wellbeing
experiences. Given the broad description of reproductive wellbeing, I needed to provide specific
components of the concept. Therefore, providing a list of inclusion criteria allowed me to assist
the staff in finding potential study participants. The inclusion criteria included women with
menstrual issues, specific reproductive health problems, and pregnancy experience in prison. The
CIW point person/ staff member sent an invitation to 60 potential women based on the list

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provided by the prison health infirmary to participate in the study. After receiving initial
confirmation, the prison staff developed a timetable of interviews according to the participants’
availability and prison regulations. Of the 60 prisoners invited, 42 agreed to participate, and the
rest declined for various reasons. The common reasons cited were lack of interest, tight schedule,
and lack of confidence to talk.

4.4.1.2 Prison staff

As outlined in the earlier section, institutional support and meeting with the CIW prison officers
allowed me to explain the study's objectives and expectations. During the meeting, I told the
CIW administration that the focus group’s goal was to explore the experiences and perceptions
of prison staff managing women’s reproductive health needs. I also added that I would discuss
policies, practices, and programmes related to reproductive health care. The CIW Director
recommended that the best prison staff for interview were the Gender and Development
Committee members. She explained that the team is responsible for crafting policies and
programmes to respond to women's distinct and various needs in prison.

The management then sent invitation letters to potential staff for two focus groups: 1) health staff
and 2) Gender and Development (GAD) members. After receiving approval from the CIW
Director, the prison staff developed a timetable of possible dates for focus groups according to
the participants’ availability and prison rules. I conducted two focus groups. I facilitated the first
group with three correctional nurses and the second focus group with five GAD members.

4.4.2 Data collection procedures

This section describes the data collection procedures used in the study. Specifically, I outline the
rationale and processes of using interviews and focus groups to gather the qualitative data.

4.4.2.1 Semi-structured interviews

Congruent with the present study’s main objectives, I provided a chance for the incarcerated
women to share their experiences and employed a methodology that allowed them to express
their personal reproductive wellbeing experiences. This approach requires a flexible and holistic
research instrument and tool (Osborn & Smith, 2008). Reinharz and Davidman (1992)
underscore that a semi-structured interview:

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 has become the principal means by which feminists have sought to achieve the
active involvement of their respondents in the construction of data about their
lives. (p. 21)

A semi-structured interview was chosen for this study because it combines an open-ended
exploration of an unstructured interview and predefined questions used in structured interviews
(Wilson, 2014). Compared with the structured interview, the semi-structured approach allows
interviewers to ask broadly the same questions with the flexibility to explore the response given
(Dearnley, 2005). This approach allowed me to probe participants’ answers to gain more depth.
In semi-structured interviews, the sequence of the questions can vary between interview
participants depending on the responses given (Dearnley, 2005).

As feminist qualitative scholars consider the study informants as the experiential experts,
participants must be given an optimal opportunity to share their experiences and stories (Osborn
& Smith, 2008). In this context, the interview guide of the present study was designed to allow
for in-depth conversations with the participants. It was also not planned for an absolute and rigid
interview structure. Guided by the feminist qualitative approach, I aimed to “create a rapport of
social interaction that transcended the boundaries between interviewer and interviewee, and
which facilitated the interviewee’s transformation from common-sense person to research
participant” (Levesque-Lopman, 2000, p. 110). So, when I developed the semi-structured
interview guide, I included vital relevant open-ended and broad questions about participants’
experiences of reproductive wellbeing so that my conversations with them were purposive and
free-flowing and not dictated by the interview guide (J. A. Smith, 2009). Furthermore, during the
interview, I introduced the relevant questions at points in the discussion rather than following the
exact order or structure of the guide. As a result, participants could share a more holistic
experience, and I could obtain diverse and richer data (Osborn & Smith, 2008).

The interview questions contained three key elements: women’s experiences of reproductive
wellbeing, the roles of social networks in their reproductive wellbeing, and the institutional
dimension of women’s reproductive wellbeing (Appendix G). General questions concerned their
reproductive wellbeing experience encompassing topics broadly related to menstruation,
hygiene, management of reproductive-related discomforts (e.g., period pain, heavy bleeding,
etc.), and access to reproductive health care. For participants who had been pregnant in prison, I

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added questions about their childbearing experience. I talked mainly about their access to
pregnancy, prenatal and postnatal care, nutrition, and education. The semi-structured interview
was an appropriate data collection channel for this research because it allowed the participants to
speak about what they perceived as essential to their reproductive wellbeing. The interviews
were conducted in Tagalog, the common local language spoken and understood by all
participants. I am also a fluent Tagalog speaker. In addition, I translated the interview extracts
into English. Tagalog is one of the local languages in the Philippines. Filipino, a standardised
version of Tagalog, and English are recognised as two official languages. Both languages are
commonly used in education, government, business, print, and broadcast media (Schneider,
2007). Many participants in this study came from provinces where Tagalog is their second
language. Although the interview was conducted largely in Tagalog, many participants also used
English words. So, we switched between Tagalog and English during the interview, commonly
known as Taglish. Taglish or Tagalog-English code-switching is common in the country,
wherein Filipinos combine Tagalog (or Filipino) and English words in daily conversations
(Bautista, 2004). For example, I asked the participants to describe their menstrual experience in
prison, below are some phrases that indicate Taglish:

• Mas (more) stressful kung malakas (heavy) period [menstrual] mo at napaka (very)
crowded ng mga dorms dito (the dorms are extremely crowded)
• Mahirap kasi hindi naman regular ang napkin [menstrual pads] dito (difficult because
pads are not regularly provided), pero kailangan mo maghanap ng way para mag survive
diba? (but you have to find ways to survive, right?)
• Naalala ko one time grabe dysmenorrhea ko, ang hirap talaga (I do remember I had
severe menstrual cramps, it was challenging)

All the face-to-face interviews were undertaken in a private room assigned by the staff. The
interviews were audio-recorded. I gave snacks to the participants at the end of the interview. The
interview duration ranged from 45 minutes to one hour and 25 minutes, and each contained six to
20 single-spaced transcript pages. The semi-structured interview format was designed to elicit a
conversation that started with the statement, “Could you describe your experience”. It concluded
with questions about participants’ demographic characteristics, such as age, civil/marital status,

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number of children, income status, educational attainment, previous job, and the type of crime
involved.

4.4.2.2 Focus groups

I facilitated two focus groups with the medical staff and Gender and Development Committee
(GAD) members. The first focus group with the three medical staff lasted for 65 minutes. The
general questions covered reproductive care services available in prison, such as menstrual,
pregnancy, and routine reproductive examinations (Appendix H). Furthermore, I probed the
staff’s experiences and perceptions of the reproductive wellbeing of prisoners. The second focus
group with the five GAD committee members lasted for 75 minutes. The second focus group
involved questions related to policies, programmes, funding support, and plans related to the
reproductive care of incarcerated women (Appendix I).

At the beginning of each focus group, I explained the main objective of the group conversation. I
then emphasised that each member’s ideas must be respected, and everyone would be allowed to
critique and respectfully clarify others’ statements. Consensus-building is not the focus group's
primary goal, and members’ silence does not mean agreement (Sim, 1998). I informed the focus
participants that I did not expect a consensus and encouraged diverse ideas. The goal of the focus
group was to explore the participant's perceptions regarding reproductive health care services and
programmes for incarcerated women. The semi-structured format facilitated a discussion of
broad topics while allowing conversation around issues on their experiences managing the
distinct needs of prisoners. Participants also took chances to clarify and add to other participants’
answers.

The semi-structured focus group structure was designed to enable a conversation that started
with the statement, “Could you share your thoughts”. It concluded with participants’
demographic characteristics such as age, nature of the current job and number of years in service.

Data obtained from focus groups may cause difficulties for researchers and participants. Given
that it is challenging to conceptualise one’s ideas while actively listening to others, two types of
‘production blocking’ may happen (Fern, 2001). On the one hand, the interruption between the
opinions created and the opportunity to share one’s idea may result in thoughts being forgotten
(Fern, 2001). On the other hand, rehearsing thoughts while waiting to speak may result in

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participants failing to listen to peers (Fern, 2001). I was mindful of these issues by having
balanced facilitation of the waiting time and subject matter changes and giving equal
opportunities to every member to speak. I also keenly observed the participants' critical gestures
and body language that denote discomfort. Indeed, these concerns could have been managed
with a cofacilitator's support, but the presence of another facilitator may have hindered the group
from sharing. Furthermore, an additional co-facilitator may create another problem, given the
complex process of asking permission to conduct prison interviews and focus groups.

Regarding sensitive topics, such as reproductive health, the chance to observe group dynamics
and shared understanding added another element to the present study. A group discussion
emphasises the way issues were individually and collectively expressed, discussed, and critiqued.

4.4.3 Data analysis: Reflexive thematic analysis

Data analysis involves data organisation, synthesis, and interpretation to enhance understanding
of the research topic (Creswell et al., 2007; Creswell & Poth, 2017). I transcribed all interviews
verbatim. The transcripts were then imported into NVivo 12, a qualitative data management
programme. Qualitative data analysis approaches include thematic-focused, structural, linguistic,
performative, and dialogical (Braun & Clarke, 2006; Douglas, 2002). In the present study,
reflexive thematic analysis was selected to expand understanding of the imprisoned women’s
experiences of reproductive wellbeing. I examined the similarities and differences between the
participants' words and accounts to describe their experiences. The primary method of data
analysis is outlined below.

The reflexive thematic analysis allows researchers to identify and examine recurrent patterns of
meaning in the interview data (Braun & Clarke, 2019). Braun and Clarke added that reflexive
thematic analysis is suitable for research projects exploring people’s experiences and views. In
the current study, two approaches of thematic analysis were used. Inductive (data-driven)
thematic analysis was conducted to answer the first two research questions. This approach is
very relevant to understanding the meaning and experiences of the prisoner participants. I then
used a theoretically driven and critical system to answer the final research question on the
institutional dimension of women’s experience of reproductive wellbeing. Choosing a
theoretically-driven analysis was essential to the final research objective as I looked into how

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concepts around prison institutional characteristics manifest in the accounts of prison and
medical staff members. Anchored on Braun and Clarke’s (2006) perspective, these two thematic
analysis approaches seek to explore the socio-cultural and institutional dimensions that underpin
participants’ accounts.

4.4.3.1 Analysing interview data

To analyse the interview data, I used reflexive thematic analysis. Codes comprised of brief words
or phrases were used to emphasise relevant ideas and narratives. NVivo, a computer-assisted
qualitative data management software package, facilitated the initial stage of manual coding.
Rigour in the analysis was attained by following Braun and Clarke’s (2006, p. 87) six phases of
thematic analysis: “familiarising myself with the data, generating initial codes, searching for
themes, reviewing themes, defining and naming themes, and producing the report”. In the
succeeding sub-sections, I outline the phases of the reflexive thematic analysis to the accounts of
incarcerated women.

To immerse myself in the interview data, I transcribed the forty-two interviews. The interviews
were transcribed verbatim and typed using Microsoft word. One main advantage of transcribing
the interviews myself was that it allowed me to feel the interviewees’ voices and expressions of
their emotions. I was guided by the notion that a researcher analysing the data must read the texts
multiple times and note relevant patterns for interpretation (Braun & Clarke, 2006). Transcripts
and field notes were read several times, initial ideas were written down, and important phrases
and sentences were underlined.

To facilitate the coding process, NVivo was used to organise the interview data. NVivo offered
an easy way of handling a significant amount of data in one place, given I had 42 transcribed
interviews. After transferring the transcripts into the software, I coded the interview transcripts
and used English coding labels. I attended workshops on thematic analysis, NVivo software, and
qualitative data management offered by the University of Otago before and during the data
collection period.

Codes were chosen to highlight relevant ideas related to the first two research questions. To
obtain a systematic process, I coded the transcripts per research question. For instance, I coded
all the interview transcripts concerning the first question on the participants’ reproductive

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wellbeing experiences. In the entire coding process, I was mindful of words and phrases that
appropriately describe the participants’ experiences. The same method was employed for the
second research question. This approach allowed me to use a focused coding procedure. After a
series of coding processes across the entire data set, initial codes were developed while
systematically coding essential features of the interview data. I was able to identify initial
categories through a line-by-line open coding technique. I then identified similar and common
data and collated them together. Although the coding process was laborious, it facilitated deeper
engagement with the data.

To capture critical patterns in the participants’ narratives about their experiences of reproductive
wellbeing around menstruation, gynaecological care, pregnancy, childbearing, and child-rearing
in prison, I reviewed the lines and sentences in field notes and transcripts. Re-examining the text
segments allowed me to develop subcategories and main categories (Table 1). This strategy
allowed me to transition to the subsequent phase of theme development.

Table 1 Examples of linking of codes and categories

Codes Categories Main themes

‘More disturbing’ Buryo complicates Prison
menstrual discomforts discomforts aggravates
More irritable Buryo and period reproductive Increased
pain is a terrible discomforts reproductive
combination discomforts and
Period seems heavier Periods are more decreased relief
irregular
Menstrual distress is Worse pregnancy
more exhausting in symptoms
prison
Struggling to cope with Inability to do Reduced
menstruation menstrual routine capacities to
Restrictive prison The prison is more manage
regulation stressful discomforts

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 Helpless with nausea and Limited or no
vomiting resources
Lack or no family Harder to manage
support period pain

Voluminous interview data have been described as a “daunting task for qualitative researchers”
(Ritchie et al., 2013, p. 289). Still, as I slowly got familiarised with NVivo and immersed in my
interview data, the process became less overwhelming. Several qualitative researchers have
recommended utilising software for organising the data and coding themes within a hierarchical
tree indexing system (Fielding, 2008; Lofland & Lofland, 2006).

In the present project, the codes used were basic ideas to name a set of words, phrases, and
sentences relevant to the research questions. I labelled every code and developed a memo with a
clear definition because some codes seemed to fall under another category. For instance, the code
‘menstrual problem is more exhausting in prison’ could be under both ‘prison complicates
reproductive distress’ and ‘more disturbing menstrual discomforts.’ Memos helped describe and
define each code. According to Lofland and Lofland (2006, p. 192), memos provide a
“distinction between initial and focused coding”.

The initial themes were developed by categorising codes based on similar features, patterns,
logical linkage, and intersecting concepts. Buetow (2010) validates this phenomenon: “the
groups of codes that recur through being similar or connected” (Buetow, 2010, p. 123).
Similarly, Braun and Clarke (2006) underscore that it is vital to obtain a repeated and distinct
pattern across a dataset and organise an overarching idea (Braun & Clarke, 2006). Thus, a theme
indicates “something important about the data concerning the research question” and the
“meaning within the data set” (Braun & Clarke, 2006, p. 82). Boyatzis (1998) notes that it is
helpful to develop the themes first and then interpret them based on the data-driven inductive
approach. At this data analysis stage, I organised and re-organised the codes in every theme. I
then combined them into broad themes.

Hammersley and Atkinson (2007) recommend that qualitative data must be reviewed several
times until saturation is achieved. This iterative process in the present study began towards the
end of the fieldwork in 2020 and was completed in several months. Specifically, I reviewed all
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the text segments to make sure that they were coherent with their assigned themes and that the
data in each theme matched logically and meaningfully. Furthermore, I revisited the research
questions and conceptual framework to ensure that the themes encapsulate the study results. This
iterative manner allowed me to obtain the study’s salient themes.

At this stage of thematic analysis, I continued refining and re-naming the main themes. I
reviewed the text segments, codes, sub-themes, and the corresponding supporting data to refine
the themes. More importantly, I ensured that the themes were “specific enough to be discrete and
broad enough to encapsulate a set of ideas” (Attride-Stirling, 2001, p. 392). Furthermore, a
theme description was made, and specific data were added to every theme. In addition, I created
a concise and clear title for the themes. To enhance the process credibility, I had a series of
meetings with my PhD supervisors regarding the initial reports. Based on the discussion, themes
were refined and finalised.

4.4.3.2 Analysing focus group data

A theoretically-driven analysis was performed to answer the final research question concerning
the institutional context of women’s reproductive wellbeing. In the first two research questions,
an inductive, data-driven approach was used to explore female prisoners’ experiences and the
roles of social networks in their reproductive wellbeing. To examine the prison institutional
dimension of women’s reproductive wellbeing experiences in the final analysis chapter, I
analysed the data from the focus groups with the medical and prison staff.

To develop the theoretical themes, I split the final analysis chapter into two main sections: a)
navigating the ‘inside’ prison regime and b) extension of the prison regime. First, I articulate
how prison institutional attributes manifest in a prison setting in the context of reproductive
wellbeing using Goffman’s (1961) ‘total institution’ and Crawley’s (2005) ‘institutional
thoughtlessness.’ Second, I explore how prison institutions operate as an ‘enabler’ of public
shame and humiliation and exclusion in the ‘outside’ world anchored on the concepts of carceral
geography and disciplined mobility.

In the first analysis phase, I applied Goffman’s (1961) ‘total institution’ to the data sets obtained
from the focus groups with Corrections health staff and GAD members. For example, to ensure a
focused analysis that captured all instances of Goffman’s theory, I needed to address the key

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characteristics of his concept in the analysis: 1) bureaucracy, 2) sameness principle, 3) over-
attention to rules, and 4) rational institutional plan. Throughout the analytic process, I was
mindful of the concept– repeatedly asking the data: What are the prison practices and regulations
in the context of women’s reproductive wellbeing that depict a total institution? How do the
concepts reflect in the accounts of prison staff during the focus group discussion?

In the second analysis phase, I employed the same process as the first one, anchored on the
concepts of carceral geography and disciplined mobility. I explored various prison practices
concerning hospital appointments and the movement of prisoners from prison to health facilities.
I was conscious of the concept– repeatedly asking the data: What are the prison policies and
regulations in the context of women’s reproductive wellbeing that depict carceral geography and
disciplined mobility? How do the concepts manifest in the accounts of the focus group
participants?

4.5 Researcher’s positionality

Understanding the researcher’s positionality as part of the social world being investigated is a
salient element in qualitative research (Berg, 2007). Positionality allows the researchers to
recognise and locate their perspectives, views, beliefs, and values concerning the research
process (Savin-Baden & Major, 2013). These views and values are often shaped by researchers’
age, gender, sexuality, race, culture, ethnicity, social class, linguistic tradition, political and
religious beliefs, and personal experiences (Sikes, 2004). Based on my experiences as a public
health researcher, health professional and advocate, I developed the research questions that
guided this project. As noted in the introduction chapter, I am aware of the structural and social
dimensions of women's reproductive health issues in the Philippines because of my advocacy
and professional work. In addition, as a Filipino, my familiarity with the political system,
culture, and norms and my fluency in local languages removed possible barriers that might
otherwise have impeded this research. Given my experiences, partnership with various
government agencies and non-government organisations, and active participation in analysing
the country's socio-political dimensions of reproductive wellbeing, I was uniquely positioned to
undertake this project. Although I have had experience conducting interviews about reproductive
health, my gender as a male interviewer influenced my interaction with women and their

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responses because of the highly personal nature of the topic and the general conservative attitude
of Filipino women toward reproductive health topics. Because of this positionality, it is
significant for me to recognise the limitations of their response when I analysed and
conceptualised the findings concerning women’s reproductive wellbeing experiences.

During the focus groups with medical staff and prison officers, my positionality as a nurse and
public health advocate facilitated creating an atmosphere for a vibrant conversation about
structural factors of reproductive wellbeing in prison. I was able to ask questions and probe their
response concerning the institutional dimension of incarcerated women’s reproductive wellbeing.
Specifically, I asked them about existing institutional interventions to address women’s
reproductive wellbeing in prison and the staff's pressing needs and systemic challenges. I also
probed their response to uncover their individual and collective perspectives concerning the
tension between care and custody and the policy gaps on different levels of government.

Being a researcher and an outsider in a closed institution for women involves being in a liminal
position between the staff and the prisoners. In total institutions like prisons, incarcerated women
and officers are polarised groups due to the extensive control that the institution has over
prisoners (Henriksen & Schliehe, 2020). Thus, a researcher’s position should be carved out in the
institutional space, facilitating a certain degree of fluidity for the researchers (Rowe, 2014).
Naples (2003, p. 49) argues that there is a “fluidity in being an outsider and that the position is
not static”. As an outsider dressed in civilian clothes with an ID badge that marked me as an
‘official’ visitor, I could freely walk out of prison, leaving the women inside. This reality creates
an apparent power imbalance, and I continually retained the role of outsider. The prison
structures make it difficult for an outsider to assume anything other than a marginal position
(Rowe, 2014). Due to this power imbalance, I developed the specific interview questions with
substantial sensitivity and concern for the research participants’ situation and predicament. I also
clarified that their participation or non-participation would not affect the earned prison
privileges, sentence length, and work assignments. I made sure that my interviews were
conducted in a friendly, professional, and warm manner. This approach contributed to building a
rapport and positive working relationship with the participants. Finally, in my data analysis, I
recognised the significant impact of prison deprivations and the various pains of imprisonment
on participants’ reproductive wellbeing and their ability to sustain their needs.

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4.6 Rigour and trustworthiness
Guba and Lincoln (1994) note that qualitative research aims to portray diverse perspectives and
rich ideas from primary data. One of the key parameters by which qualitative research's scientific
rigour or trustworthiness can be established is credibility, which denotes the “truth value or the
believability of the findings” (Leininger, 1990, p. 43). In the present study, credibility was
attained by precisely documenting the narratives and stories expressed by the participants. The
participants’ actual words were integrated into the results to provide credibility to the analysis.
Hence, the terms used by the participants became the foundation of the present study (Schwandt,
2000), and I relied on the narratives they shared in the conversation.

Confirmability refers to “establishing verifiable direct evidence with the people or from primary
experiences or documents” (Leininger, 1990, p. 43). This criterion was observed by probing
questions and asking the participants to provide specific examples. For instance, I asked my
participants who had pregnancy experience in prison to describe their prenatal care; most of their
response was ‘inadequate support’. I also asked them the number of times they had their prenatal
care. Apart from frequency, I asked about the timeliness of the service and their preparation
before the prenatal care. The same questions were asked to other participants to obtain their
individual first-hand experiences. I also asked the medical assistants (inmate volunteers)
assigned to the mother’s ward to describe the prenatal services in prison.

Leininger (1990, p. 43) defines meaning-in-context as “data that is understandable and relevant
within certain situations, settings, and life experiences”. This approach offered a holistic
depiction of the participants’ reproductive wellbeing. I preserved some critical Filipino words
and their original meanings and maintained their authenticity. For example, when participants
were asked to describe their experience of prenatal appointments outside the prison, hiya was
one of the common expressions they used. This Filipino term, which means shame, was kept in
its original form, and the context was preserved to enrich the analysis and discussion. Crystal
(1991, p. 346) defines translation as: “meaning and expression in one language (source) is tuned
with the meaning of another (target) whether the medium is spoken, written or signed”. I noted
all those words for some prison terminologies, and I asked several participants about the terms'
meaning, description, and examples. This technique allowed me to understand the context of
prison slang fully. For example, my first few participants often mentioned ‘hobby’, and I thought

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they were referring to their interests. But I was confused because it did not make sense as I asked
about the common source of their money to buy menstrual pads and other hygiene essentials. So,
I had to clarify and validate the term multiple times with different participants and asked for
specific examples. The participants explained that ‘hobby’ is a prison term used to describe
income-generating activities done by prisoners apart from livelihood programmes. It involves
doing laundry, preparing coffee, and cleaning other inmates’ beds, and then they get paid by
peers or staff members.

To support trustworthiness, I regularly discussed the findings with my PhD supervisors. After
data collection, I provided a summary of the data with my reflection and shared this with my
supervisors. This regular feedback session was helpful because it allowed me to clarify and
discuss the meaning, contexts of the themes, analysis, and interpretations.

4.7 Participants’ characteristics

The present study involved two sets of samples. In the first research phase, I recruited a
purposive sample of 42 incarcerated women. I then conducted two focus groups with the prison
health staff and GAD members. The following section outlines the sociodemographic
characteristics of my interview and focus group participants.

4.7.1 Interviews with incarcerated women

Forty-two incarcerated women from diverse geographic, religious, educational, and economic
backgrounds participated in the interviews. The interview participants’ demographic
characteristics are listed in Table 2. Women were between 21 and 58 years, with a mean age of
40. The majority were married (n=25), ten had common-law partners, and a small number were
widowed or separated (the Philippines has no divorce law). All had at least one child, with a
number of children ranging from one to 12.

Table 2 Interview participants' demographics

Demographics Number of
Participants
Age 20s 10
30s 8

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 40s 19
50s 5
Marital status Single 13
Married 25
Widowed 2
Separated 2
Number of 1-3 25
children
4-6 14
7-9 2
10-12 1
Pre- Self-employed 20
imprisonment
Office-based 14
occupation
Professional 3
Overseas Filipino 5
workers

Mirroring the country’s demographics, many identified as Roman Catholics (n=26), but some
mentioned religious affiliation with Iglesia ni Cristo, Born Again Christianity, Seventh Day
Adventist, and Islam. Regarding their educational attainment, 21 participants had reached a
college level, and the rest had either finished secondary (n=19) or primary education (n=2).
When asked about their hometown, many (n=25) came from provinces outside Metro Manila
(where Correctional Institution for Women is located). Most (n=29) stated they had an unstable
jobs and were low-wage earners before imprisonment. Many belonged to the informal economy
and worked as vendors, beauticians, and sex workers, among many others. Some participants
were part of the service sector, such as sales, hotel service, and call centre agents.

The interviews revealed that 18 women had pregnancy experiences in prison, which means they
were pregnant when they were arrested (the Philippine women’s prison has no conjugal visits).
Of the 18 women who were pregnant in prison, five were first-time mothers, and two had lost
their first babies through miscarriages while in prison.

Most participants were imprisoned for drug-related crimes (n=28) and non-violent offences, such
as theft and human trafficking. Regarding how long they had served in prison, nineteen

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participants had been imprisoned for less than five years during the data collection period. Nine
had been imprisoned for six to ten years, and fourteen had more than ten years. Regarding their
sentence length, twenty-nine participants were sentenced to life imprisonment, and the rest
received less than 15 years of a prison sentence.

4.7.2 Focus groups with prison staff

The second phase of data collection involved two focus groups. I facilitated the first group with
three correctional nurses. In the second focus group, I conducted a discussion with five GAD
members. All the focus group participants were female and had varying roles in prison, such as
health, reformation, social work, security, and education (Table 3). Their various prison jobs
made the focus group rich and relevant to the discussion topics on policies and programmes
concerning the reproductive wellbeing of prisoners.

Table 3 Focus group participants' demographics

Demographics Number of
Participants
Age 20s 2
30s 3
40s 2
50s 1
Prison Reformation 1
assignment/ Health 4
unit Security 1
Social Service 1
Education 1
Years in 1-3 2
prison service 4-6 3
7-9 1
10-12 1
13-15 1

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4.8 Chapter summary
This chapter has described the conceptual underpinning, methodological approaches, and data
collection methods and analysis utilised to examine interview and focus group data. The present
study explores the intersection of incarcerated women’s reproductive wellbeing and
incarceration. Although quantitative research methods can identify women’s access to
reproductive care services, a deep understanding of how incarcerated women experience
reproductive wellbeing and the different dimensions of these experiences are difficult to capture
with quantitative methods. A qualitative approach was chosen because it acknowledges the
multiple perspectives (interview and focus group participants and researchers) and that the
knowledge generated by the research is constructed and produced through a critical and
questioning approach.

Incarcerated women represent a vulnerable population because of their limited autonomy, and
their decisions are generally under the institution’s control. I was conscious of the power
dynamics between myself, as a researcher, and my prisoner participants. Considering the nature
of the research project posing an inherent risk to the respondents and researchers, especially in
the context of the Philippines’ highly punitive drug-related policies, adequate security measures
were sought at every step of the process. In addition, I have discussed the intersectionality of my
positionality as a Filipino public health professional, advocate, and a male researcher exploring
imprisoned women’s reproductive wellbeing. This process allows me to acknowledge and locate
my perspectives, views, beliefs, and values concerning the research process. Congruent with the
present study’s main objectives, I provided an opportunity for the incarcerated women to share
their experiences and employed a methodology that allowed them to express their personal
reproductive wellbeing experiences. Semi-structured interviews and focus groups were employed
for this study because it combines open-ended exploration of an unstructured method and
predefined questions used in a structured approach.

In the current study, two approaches of thematic analysis were used. Inductive (data-driven)
thematic analysis was conducted to answer the first two research questions. This approach is
very relevant to understanding the meaning and experiences of the prisoner participants. I then
used a theoretically driven and critical system to answer the final research question on the
institutional dimension of women’s experience of reproductive wellbeing. Choosing a

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theoretically-driven analysis was essential to the final research objective as I looked into how
concepts around prison institutional characteristics manifest in the accounts of prison and
medical staff members.

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 Chapter Five
The Pathways of Women from the
‘Outside World’ to Prison: The
Philippine Context
This descriptive chapter presents the pre-incarceration stories of the participants, their pathways
to prison and everyday experiences in prison concerning their reproductive wellbeing. Rather
than addressing any specific research questions, it provides context to lay the groundwork for
answering the research questions. Specifically, I begin by illustrating some pre-incarceration
stories of the participants and how these are linked to the broader social realities of Filipino
women. I then describe the circumstances that propelled them into the criminal justice system
and women’s experiences concerning their prison entry, access to welfare, social, and health care
services in prison.

5.1 Pre-incarceration stories: The status of Filipino

women in the broader society
In this section, I describe the pre-imprisonment circumstances of the participants in the context
of socio-economic constraints and opportunities in their everyday lives. Furthermore, I look at
the footprints of their relationships with social units, such as family, community, and authority
(i.e., state and Church), as these relate to their experiences and practices of reproductive
wellbeing.

Ranging in age from 21 to 58 years, most incarcerated women in this study had experienced
hardships early in life. Many women talked about having a ‘simple life’ before imprisonment:
being born into a large family living below the poverty line and growing up in households where
both parents were low-wage earners.

Lanie: “I have eight siblings. My mother worked as a laundrywoman while my

father worked for a car washing store. Our life was hard because, at that time,
we could barely get enough food, and we had to share”.

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 Marianne: “I was born into poverty and destined to have an impoverished life.
I just reached high school and failed to complete it. But I had to learn how to
survive”.

Most of the women came from underprivileged socio-economic backgrounds with an insecure
income source and were entirely dependent on their husbands' earnings. Most participants
(n=29) stated that they were low-wage earners and had unstable jobs before imprisonment.
Although many participants had reached at least a university level (n=21) education, they
believed it would not necessarily mean you would get a good job in the Philippines. Gretchen
noted, “Having a college degree is not a guarantee. You need to be lucky or to have connections
with influential people to get a high-paying job”. Many women found that society expected them
to care for the family and support their husbands.

Lorraine : “…and many people, particularly men, still expect women to be the
ones taking care of the entire family and to support their husbands”.

Many were married (n=25), and the remaining were single or separated. Many married women
got married only after getting pregnant. For many participants, their experience of childbearing
and childrearing began with a disgrasya or unplanned situation, such as unplanned pregnancy.

Marietta : “No family planning3 at all. It was a sudden decision, you know. We
grew up together in the slums, so I know him very well. I had no idea about
safe sex or how to protect myself, and I was just 18 then”.

Ching : “We were both curious about sex, so it just happened. When I told my
parents that I had had no menstruation for two months already and I might be
pregnant, they were very angry. That’s when I stopped schooling to care for
my first baby”.

The participants discussed various ways they hold on to Filipino norms. These values involved
adhering to marriage vows and traditional roles of a wife, such as household responsibilities and
childrearing, in addition to their income-generating work. In other words, these women play
multiple household roles. Their economic role was viewed as secondary to their domestic role.

3
‘Family planning’ is a widely used term in the Philippines, meaning ‘birth control’

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 Jessica: “My husband was a taxi driver, so I did all the household chores plus
taking care of our four kids. On top of this, I managed my online
business...well, that’s the job of being a wife, you have to take care of your
family”.

Anna: “Once you get married, it is a lifetime commitment for me, no turning
back, and the priority is really to nurture your children and not so much about
yourself anymore”.

Since marriage and raising a family came to most of these women unplanned and were even
unwelcome (at least, in the beginning), in some cases, they believed such circumstances hindered
them from achieving their aspirations of steady employment or opportunities. Hence, marriage
and family raising seemed to be the only choice left for many women. For Lanie, who expressed
a desire to work but had no skills or any sort of economic connection, nothing would give her the
advantage to obtain gainful employment. The experience of Lanie coincides with June’s remark
on the lack of economic opportunities, “I wanted to work for companies that could give high pay,
but because in my situation as a school dropout it is impossible, maybe in my dreams
(laughing)”. This marginalisation, which implies a wide disconnect between women’s dreams of
self-development and economic prosperity, on the one hand, and what they can realistically
achieve, given the painfully limited resources that are available to them, on the other hand,
serves as a conduit that pushes women into the single direction of marriage and raising a family.
In this instance, the women need only to rely on their perceived ‘natural’ nurturing abilities and
reproductive capacity as their primary resources to qualify for this path of marriage and family.

Several women believed that every child is God’s gift, a view that aligns with Catholic
teachings. This belief is more common among Catholic women (n=26). Several participants
believed that children are God’s blessing and that the Almighty Being plans the number of
children one has. Neri noted, “I came from a big family, and I believe that a child is a blessing.
And I don’t dream of having lots of money, so long as we can eat three times a day”. Tanzo
shared her thoughts about divine intervention, “As a devoted Catholic, God always has plans for
us, He will never give us any struggle beyond our ability to handle, right?” Yet, when I probed
how they felt about the subsequent pregnancies, many expressed ambivalence about managing
additions to the family, given their limited resources.

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Many participants expressed a desire to limit the number of children. However, their attempts at
using birth control had been inconsistent and thwarted by some myths, side effects, religious
beliefs, and their partners’ decisions. More than half of the participants had used contraception
inconsistently; contraceptive pills were the most common modern method, but they stopped
because of their experience with side effects. The frequently mentioned side effects were weight
gain, headache, and appetite change. Due to side effects, they feared losing their ability to
perform physical tasks, including childcare and household chores. Lourdes stated that she had
not used any artificial means to prevent pregnancy because of fear of side effects, “I’m very
scared because I heard stories from friends about getting extremely tired when taking pills…I’m
okay with calendar methods”. Additionally, many were against female sterilisation because they
feared the procedure would result in their inability to do household chores that require heavy
loads (e.g., fetching water and washing heavy clothes). Women’s perceptions of the effect of
female sterilisation on their bodies and ability appeared to affect their decisions regarding birth
control. Although birth control services are free and publicly funded, the low uptake has been a
product of misinformation, fear, and negative experience with side effects.

When asked about their thoughts on other birth control methods, such as condoms, women
consistently explained that their husbands did not like to use condoms. Regarding long-acting
methods, many stated that their partners did not support long-acting injectables due to possible
health complications. Their narratives indicate that their spouses play a significant role in their
reproductive decision-making regarding contraceptive use.

Gretchen: “My husband doesn’t like to use condoms because, for him, it is
uncomfortable and no sexual pleasure at all”.

Chalemie: “He believes injectables have long-term consequences…I guess

he’s just worried about the side effects; we don’t know what these chemicals
are in your body”.

April: “No, for sure he won’t like male sterilisation because he thinks the
procedure would make him less manly (laughing)”.

For those who identified lack of priority as the main reason that prohibited them from
consistently using birth control, women’s contraceptive needs competed with their multiple

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roles. Although birth control methods, such as contraceptive pills and condoms, were free in
their community, the various roles the women played, such as housewife, employee, and
community member, were perceived to be more important than their contraceptive needs.

Leslie: “I tried using pills once, but I stopped because I had no time to think
about it as I had several things to do…I took care of the kids, did household
chores, and then my online selling job”.

Venia: “Pills are free; you must visit the village health units. In my case, I had
no time to go there because I had lots of stuff like cleaning the house, doing
laundry, and I’m also a member of a women’s group for livelihood activities in
our village”.

Angelie: “My husband was a jeepney driver, so I had to accompany him from
early morning to nighttime…my job was to collect the fares, basically to assist
him. On top of that, I cooked food for the kids and did other household
chores”.

Remarks on religious beliefs came from a few women who stated they did not use ‘artificial’
methods as these go against Catholic teaching. They thought ‘artificial’ birth control methods
were abortifacients that ‘kill life’ and were immoral and sinful. For instance, Christina asserted
that pills could induce abortion, “I firmly believe that pills could have an impact on the health of
the babies in the long run”. Julia also noted what she learned from the Church about the use of
artificial birth control methods, “I heard from a priest during a homily that ‘artificials’ are a work
of evil and if you use it, you are doing the devil’s work”. A statement on religious belief was
echoed by Mercy, who had never used artificial birth control methods and only relied on
breastfeeding as her natural way, “I never used pills or any artificial means because my belief
was it could harm the babies, and my way to prevent pregnancy is through breastfeeding”.

Contrary to the beliefs of Christina, Julia, and Mercy, many women indicated the necessity of
birth control as part of responsible parenthood. Maria, who became a mother at 15, claimed that
family planning is a woman’s decision, not the Church’s. In arguing against the Catholic belief,
as Maria said, many women thought that using birth control allows them to better care for their
families and eases the burden of poverty.

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In sum, most of the women in the sample came from underprivileged socio-economic
backgrounds with an insecure source of income and entirely relied on their husband’s earnings.
The women had between one and 12 children. Regarding their reproductive health, many
participants expressed little attention and priority for their reproductive health needs before
imprisonment. Most of them described their attempts to seek regular reproductive health services
and use birth control but were hindered by some myths, side effects, religious beliefs, and their
partners’ decisions.

5.1.1 The nature of their crime

Determining the participants’ crime profile is significant to understanding the circumstances that
propelled them into prisons. Most women were imprisoned for drug-related crimes (n=28) and
non-violent offences, such as theft and property crime (n=14). Interviews revealed that women's
main reasons for engaging in such activities were survival and supporting their family’s needs.
The reason to support their family was more pronounced among women imprisoned due to drug
crimes. Their role was to help their husbands in the drug business. Most of those convicted of
drug crimes (n=34) stated that their partners introduced them to the drug business.

Lou Ann: “I got exposed to the drug business through my husband...I knew it
was illegal, but, in our case, it is our way to earn money and to feed our kids”.

Jessica: “I was arrested because my husband got caught using drugs at home. I
was there. My three kids were there during the police operations… Both of us
are now sentenced to life. Yes, I helped my husband…My kids are now with
my sister”.

Clarissa: “I’m now in prison because of my husband, I told him to stop the
drugs, but he never listened…he’s still at large as far as I know because he
managed to escape during the police operations”.

The stories of Lou Ann, Jessica, and Clarissa mirror the dominant experiences of women who
helped their husbands carry out drug activities. Their ‘support role’ portrays their vulnerable
situation, considering that most had difficult economic problems and depended on their husbands
before prison admission. Of those sentenced for drug crimes, many reported they had used drugs

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and had been influenced by their partners. Neri recalled her first encounter with drugs, “Coming
from the provinces, I was so surprised about the university and city life, I was like looking for
more adventures, I got hooked on alcohol, cigarettes and later drugs with my boyfriend”. Neri’s
story is also consistent with Nora’s story about her experience of drug use, “I tried to do my best
to provide things that were needed by my children, so the drug trade was my way to do that”.
Despite their peripheral involvement in the drug trade, women in the sample were heavily
penalised in the current criminal justice system. All forms of drug use incur heavy penalties in
the Philippines.

In most cases, women attempted to escape from their perceived dysfunctional family of origin
and sought the positive environments they lacked at home by dating boyfriends who then
influenced their criminal behaviour, especially drug involvement.

Victoria: “I grew up in a big and chaotic family, my parents were often

fighting, it is like an everyday thing for them…I left home and spent most of
my time with friends”.

Mercy: “When I met my boyfriend, I decided to leave, and that’s when I

started to be very independent. Unfortunately, my life went in the wrong
direction”.

Sixteen participants mentioned that one of their parents was incarcerated due to drug crime.
Parental incarceration had been a significant experience for them and affected their childhood.
Six women specifically said that most of their family members (i.e., parents or siblings) had been
arrested during the buy-bust operations. They stated that the drug trade was a family business.
Nenita remembered when she was apprehended at home alongside her mother, father, and
brother, “It was around 10 p.m., we were packing the drugs for delivery the following day, and
then we heard police officers shouting at our doorstep. There was no escaping that time as we
were surrounded, I was so scared, and we had no choice but to surrender”. For Marietta, she
thought that she was destined to have a tough life being born into poverty, “Maybe God’s
showing my family and me the right path that we had to stop. I realised at one point I may be
destined for this, yah, I know how awful it may sound”. Josie left home because of the drug
use—both her parents were high most of the time, and she observed many people coming in and

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out of their house even at night. Women in this study overwhelmingly expressed fear that their
kids might face similar struggles in the future.

5.1.2 Summary
The interviews with the participants revealed their poor social and economic pre-incarceration
circumstances. Many participants came from underprivileged socio-economic backgrounds with
an insecure source of income and entirely depended on their husband’s earnings. The women had
between one and 12 children. In terms of their reproductive health before imprisonment, many
participants expressed little attention and priority for their reproductive health needs. Most of
them expressed their attempts to seek regular reproductive health services and use birth control
but were thwarted by some myths, contraceptive side effects, religious beliefs, and the decisions
of their partners.

Most participants were imprisoned due to drug involvement, theft, and property crime, often
committed as a response to poverty and economic insecurity. Specifically, their ‘support role’
portrays their vulnerable situation, considering that most had difficult financial situations and
financially relied on their husbands before incarceration. Furthermore, family and social
networks were often frayed, and substance-abusing partners and family members provided
limited support.

5.2 Women’s incarceration stories

In this section, I outline the experiences of incarcerated women concerning their prison entry,
their daily routines, and access to welfare, social, and health care services in prison. Determining
the participants’ general prison experiences helps contextualise the prison deprivations
concerning reproductive wellbeing.

5.2.1 The prison filters: Entry, screening, and classification

Women shared their experiences when they first arrived at the Correctional Institution for
Women (CIW)4. Most of their responses revolved around having mixed or ambivalent feelings

4
The Correctional Institution for Women is the largest and most crowded prison for women in the
Philippines. It houses female prisoners with sentences of more than 3 years (3 years to life sentence)
95
when entering the prison gate. Edelina recalled: “Many things were popping up in my mind at
the time. I was thinking about my family and, at the same time, my safety and health here in
prison”. Edelina’s experience is also consistent with Leni’s remark, “I had lots of questions while
walking through the prison gate; I had no idea about how to survive and sustain my needs in
prison”. For Julia, her ambivalent feelings were a result, on the one hand, of feeling relieved at
having the final verdict on her case, but on the other hand, she was worried about the welfare of
her six children.

The participants spoke of the different stages they had to go through when they stepped into the
prison spaces. Their first contact was the arrival stage, also known as the Reception and
Diagnostic Centre (RDC), where they usually stayed for around three months (including a 5-day
quarantine period). The RDC receives and classifies prisoners as maximum, medium, or
minimum, based on their security status. When prisoners arrive at CIW, they are immediately
brought to the Receiving Office, where they are turned over officially to the receiving officer by
their jail escorts, either from the guards of the city jails or provincial jails, which are both under
the Bureau of Jail Management and Penology5. In the Receiving Office, inmates undergo routine
inspection of items in their possession. Some prohibited items, such as money and medicines, are
removed and documented. The receiving officer then issues receipts. Medications and other
health products are given to the health staff at the infirmary for safekeeping and proper
dispensation. The rest of the belongings are given back to inmates. They are then taken pictures
for identification and provided with prison uniforms. Several participants stated that the practice
of isolating new prisoners in a communal area for three months was overwhelming.

Azuna: “I think it is too overwhelming because the place was very crowded
then. And I had no idea about the process”.

Venia: “The staff asked lots of questions…I could remember I was a bit
anxious when I was told I had to stay here for three months”.

At the RDC, senior inmates and prison officers orient the inmates about the rules and
expectations in prison. Although some inmates appreciated the gradual introduction to the prison
regulations, the RDC environment appeared to be highly restrictive. Several participants stated

5
The Bureau of Jail Management and Penology oversees all the city and provincial jails
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that inmates were in crowded spaces, unable to use telephone calls, and kept from communal
activities. They could only leave the area in limited situations, such as family visits, and the
hours were more limited than regular inmates. Some reported that being so confined heightened
their apprehension and anxiety.

Angelie: “No, we were not allowed the time to go out. Unlike the regular
inmates, we couldn’t participate in most prison activities because we were
under quarantine to check that we don’t have any infections, such as
Tuberculosis”.

Mercy: “The policy was very strict, and we were strictly monitored, no visits
for family or telephone calls”.

While in quarantine, inmates undergo medical and physical examinations to determine their
physical capacity to work and receive necessary medications if found suffering from any ailment.
If necessary, inmates with infection are segregated from the rest and moved into an isolation
facility. In this stage, inmates undergo psychological, medical, and other examinations.
Specifically, the health screening process in the holding facility is designed to identify health
conditions that need immediate treatment and signs of substance abuse. Nora noted, “I could
recall one woman was diagnosed with Tuberculosis, and she had to be separated and put into the
isolation facility. For me, it is good given the area is very crowded – it would be terrible to have
an outbreak”.

After three months at the RDC, women convicted of drug crimes are transferred to the
Therapeutic Community (TC) dorm and stay there for at least six months. A Therapeutic
Community Modality Programme is a rehabilitation tool for substance abusers in the TC area.
This programme uses structured activities, social group work, and leadership training overseen
by the Inmate Welfare Development officer. The programme usually starts with a morning
prayer followed by a group meeting and a range of group activities until early evening.
Participants generally appreciated the programmes in the TC as these had helped them condition
their lives before being fully immersed in the prison community. Elma affirmed, “It is good
because it is about self-reflection and self-development, why you are here, and how you should
be responsible for each other”. Sheenah validated this positive feedback on the TC, “I like my

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time there because it is all about self-acceptance and being comfortable in a group given the
crowded nature in prison”. Venia shared her daily routine in TC, “We usually wake up at 6 a.m.
for prayer, then breakfast time. After that, we had a list of different activities such as sharing a
story, a group activity, modular training like art class”. The TC is the most crowded area because
of the increasing number of drug offenders at CIW. Jessie, who once stayed in TC, noted,
“During my time in TC, there were around 350-400 people in the area, it is very crowded that’s
why many slept on the floor (on floor mats) due to a shortage of beds”. For those who are non-
drug offenders, upon classification at the RDC, they are recommended by the RDC In-Charge
and Overseer’s Office where they would be placed, based on their possible working assignment.
The following section highlights the daily reality of women once they move into the regular
dorm of CIW.

5.2.2 The daily reality in ‘regular dorms’: Routinising women’s prison

life
Women’s daily life in regular dorms occurs according to a daily schedule. This schedule includes
wake-up time, roll calls, meals, studying and working, and the time for social events, such as
sports events, religious activities, telephone calls, and walks.

Women usually wake up between 5 and 6 a.m. for regular prayer and are counted by prison
officers. Each dormitory in the CIW has between 50-400 women to accommodate the growing
number of incarcerated women (Figure 1). Hence, women must get up early to take showers and
reduce the queue. After getting up, they make their beds and then shower before queuing for
breakfast, where they typically receive about 30 minutes. Then they go to their assigned and
scheduled tasks or activities. Every prisoner has a range of paid and voluntary jobs. These jobs
include kitchen tasks, janitorial roles, serving food, doing laundry, and other miscellaneous tasks.
Many of the women interviewed also carried out specific functions that require leadership or
more technical skills, such as being a medical assistant or instructor for vocational training and
education programmes.

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 Figure 3 The CIW prison cell
(Photo credit: Correctional Institution for Women)

When I asked participants about their motivation to do both paid and voluntary work in prison,
their responses varied, such as getting good conduct time allowance (GCTA); helping other
prisoners, particularly those who are in need like the elderly and those with medical conditions;
and doing some work to prevent boredom. Victoria shared information on GCTA, “My primary
reason was really to avail myself of GCTA…if you behave well while serving your sentence,
like having good conduct, doing volunteer work, attending training, and showing some
leadership capacity, you’re earning rewards”. This information on GCTA was confirmed by
Marietta, who has been a medical assistant for five years, “Because I have a midwifery
background, I thought I could use my technical knowledge and skills to take care of pregnant
women or other Persons Deprived of Liberty (PDL)6 and also to earn my GCTA”. Depending on
how time-consuming the tasks are, inmates usually work until lunchtime or resume in the
afternoon.

Income is often significant to women detainees to sustain their basic needs. Many participants
stated that their earnings were often spent buying food, sanitary and laundry items, paying for

6
Person Deprived of Liberty (PDL) refers to all prisoners regardless of gender and years of
imprisonment. This is the official term used by the Corrections Bureau in the Philippines and commonly
used among incarcerated people.
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their telephone calls, and purchasing raw materials for their handicraft products. Although
women in the dormitory can communicate with their family through phone calls, this service is
not free (P5 or US$ 0.1 per 5 minutes). Some women give their children pocket money for
school when they visit. This situation shows how women retain their parenting roles even when
away from their family, which is perceived to be good for their morale. Additionally, women
noted that they tended to earn P50-200 (US$ 1-4) per week from handicrafts, and this amount
depends on their products.

Another widespread practice among poorer incarcerated women to earn money is doing tasks
and chores for peers or prison staff, which is very informal and a more unregulated arrangement
among the prisoners. This common practice is known as ‘hobby’7 or ‘trustee’ system. Many
participants relied heavily on these opportunities, and they can earn P50 - 300 (US$ 1–6) per
week for performing those tasks, such as washing dishes, doing laundry, fetching water, and
assisting visitors. Inmates also combine their earnings for communal purchases (e.g., new
flooring) or to support the needs of other women, such as surgery or medicines. Some women are
prohibited from participating in income-generating activities, such as the elderly, women with
medical conditions, and pregnant women.

Bianca: “I’ve been doing hobby for four years now…doing laundry for other
PDLs, and I get paid. It is my main means to earn and save money so that I
could buy my essentials here”.

Barbara: “I do volunteer work here, and at the same time, I do some hobby like
fetching water and assisting visitors”.

Eula: “No, I don’t have other sources to support my needs, so I fully depend on
the support from CIW or my family because I stay in the Mother’s ward with
my six-month-old baby, so I’m not allowed to work”.

Many women were thankful for the opportunities to earn money, despite being detained.
Through these small means, they could purchase food, menstrual pads, and hygiene items (e.g.,

7
‘Hobby’ is a prison term used to describe income-generating activities done by inmates apart from
livelihood programmes in prison. It involves doing laundry, preparing coffee, and cleaning other inmates’
beds and then they get paid by other prisoners or staff.
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toothpaste, deodorant, and soap). However, the prison store’s prices were higher than regular
items from the outside establishment. Women often encountered difficulty buying anything but
absolute necessities if they did not receive family or institutional support. Sheenah noted, “If you
have money, you can buy items at the CIW store, but it is a bit more expensive than the regular
price outside”. And, given their low earnings and the fact that some have no support from their
family, women often cannot afford even that much.

Like breakfast, prisoners are given 30 minutes to an hour for lunch before returning to scheduled
tasks, training, education programmes or enjoying their free time for social activities. Most of
their time in the afternoon is spent resuming their jobs and participating in any livelihood,
vocational or educational training. Some training programmes include baking, massage,
computer training, and language courses. Elmarie, who underwent the training programme,
shared her experience, “I’m very thankful because I was able to gain new computer skills and
basic Japanese language”. The CIW also has reformation programmes – performing arts groups
and inmates’ organisations. Elma, who happened to be a leader in a religious volunteer
organisation, said, “Since 2011, I’ve participated in RVO’s events, and it is has been a
meaningful journey. Now I’m a volunteer leader, and I’ve been recruiting new members to help
them find their God’s purpose”. Inmates can participate in religious activities, such as prayer
meetings, holy mass, and other religious activities inside the prison chapel.

Inmates are also encouraged to pursue their education at the CIW. In coordination with other
education agencies, the institution provides classes for a few hours each day, catering from
primary to high school. The institution’s education programme consists of a computer literacy
programme, vocational courses provided by the Technical Education Skills and Development
Authority and the Alternative Learning System of the Department of Education. Inmates are also
given certificates of completion during the graduation ceremony.

Clarissa: “When I completed the programme two years ago, I was so grateful
to complete my high school, as I was a school dropout…very thankful”.

Marie: “When I was still a student here , it felt great because I had a busy
schedule to divert my attention from boredom and loneliness…the most

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 exciting part too was the different social events like social sports, teachers’ day
and cultural day”.

After being evaluated, some inmates who have gone through the programme have been promoted
to instructors or trainers. Elma, who is now an instructor for the vocational programme,
indicated, “It is undeniably fulfilling to be in this role as you can feel the authority and respect,
and more than that, you get the opportunity to gain more knowledge and experience”. The
various projects allow the prisoners to discover skills they may not have known before
incarceration.

At 6 p.m. they have dinner. Inmates can buy food at the prison store if they have money, and
they don’t like the free food provided. The foods provided are often limited and lack nutritious
ingredients due to the limited budget of the CIW allotted by the Government (P60, or US$2, for
every prisoner per day). Angela complained about the lack of nutritious food being served, “I’ve
been here in prison for more than five years, and I’ve never experienced having good, and
quality food served…it is always bland and not cooked well, the meat is greasy, but we have no
other choice”. After dinner, they take their last shower of the day and are monitored as to how
many times they have taken a shower a day (at least twice a day). Some areas or groups of
women hold religious services in the evening.

Women can go to sleep between 8 p.m. and midnight. The institution usually turns off lights
around 11 p.m. When prisoners return to their dormitories, they can choose their activities. The
inmates are counted again by the prison officers before they sleep. The following day, the whole
same cycle is repeated. While the daily routine can be monotonous, they get visited by families
and friends on some days. Women can spend time with visitors for at least three hours on most
weekdays and spend longer with children on weekends inside the prison’s communal area.

5.2.3 Into the prison infirmary: The health care triage

Health care for incarcerated women at CIW is given in the institution’s infirmary, which houses
30 medical beds. Severe health conditions that the prison facility cannot handle are referred to
government hospitals. I asked the participants to share the process once they get sick in CIW.
They consistently noted a specific protocol followed before they are admitted into the infirmary
or transferred to a nearby hospital if needed. Maria said, “There is a protocol that you have to

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follow. You cannot just go directly to the infirmary to get checked…you need to inform the
medical assistants in your dormitory so they can assist you”. The first process is to tell the
‘medical assistants’ assigned in every dormitory about health complaints for an initial
assessment. These medical assistants are volunteer inmates who have undergone basic
orientation to be part of the prison health system management. They serve as gatekeepers to
prevent an influx of patients. They carry out the initial screening by asking some basic questions.
If the health needs require further action by prison nurses, they refer them to the other medical
assistants based in the infirmary for additional assessment and action by nurses. Although
medical assistants play a significant role in the entire prison health care system, their function
has many restrictions: they are not allowed to give medical advice, give medicines, or perform
medical procedures. For prisoners with ‘maintenance medications’ like drugs for hypertension,
diabetes or asthma, medical assistants would get the medicines from the infirmary and give them
to the prisoners and document the intake.

The medical assistants (n=20) I interviewed gave a host of reasons why they chose to volunteer.
Most of them said they wanted to help their fellow prisoners with distinct and complex needs
like elderly or pregnant women, and some noted that they wanted to use and apply their health
knowledge and skills.

Lorna: “I love doing this job, especially taking care of elderly patients, as it
reminds me of my beloved grandma”.

Camille: “I have a nursing background, so I thought I could use my technical

skill to help those PDL with medical needs…very fulfilling because I was still
able to use my knowledge and technical ability”.

Cynthia: “Apart from learning new skills from this job, I would be able to earn
more for my GCTA”.

The health care system is scarcely funded. The prison fund for health is only around P5 ($US
0.1) per inmate per day. One medical assistant clarified, “The fund is insufficient, definitely
knowing many PDLs have lots of health needs…you may be lucky if your family had enough
resources to support your health needs”. Many women informed me that the infirmary was

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under-stocked with limited essential medications, such as painkillers and antibiotics, which were
not regularly supplied.

Another significant health care gap is an inadequate number of medical staff. Currently, the CIW
has only three regular corrections nurses serving the health concerns of almost 4,000 female
prisoners. They don’t have a permanent doctor; hence, a visiting doctor from another prison has
to prioritise the needs of prisoners that require immediate care. During the interview, participants
noted that they had had no in-house medical doctor for six months. The situation signifies the
crucial role of medical assistants who compensate for the deficiency in prison health care.

Christina: “I have had diabetes since 2012, and I need a regular supply of
medication. I usually get it from the infirmary, but there are times that they
have no stock, so I have to wait or ask my family to buy it from outside”.

April: “I wish we had a medical doctor and more health staff who could assess
our health problems, given we are more than 3,000 here”.

5.2.4 Navigating the prison reproductive health care

This section covers menstruation, pregnancy, labour and delivery, postpartum care, and access to
reproductive health care services in prison. Several women (n=32) discussed their monthly
struggle sustaining their menstrual needs, such as inadequate menstrual pads and limited access
to reproductive services. Since the infirmary is ill-equipped to manage extreme reproductive
conditions, inmates are usually referred to nearby hospitals. Hence, some women diagnosed with
chronic reproductive conditions could not pay for the treatment costs and had to wait a long time.

Clarissa: “No, [menstrual pads] not adequate… it is the first time in 2019 that
we were given free napkins8 from CIW, but only in that year, having been here
for ten years. I had to look for other ways to support my monthly period. It is
hard to say how much per month, as periods are not the same every month. I
can’t just say that I need two packs monthly. It is not fixed, you know”.

8
‘Napkin’ means menstrual pads and is a widely used word in the Philippines.

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 Mercy: “I’m a bit afraid as I’m at risk because my sister also had an abnormal
growth on her chest. So, I do not know my risk because I’ve never heard about
any screening honestly here at CIW”.

Several women discussed that sanitary items, such as shampoo, soap, toothpaste, and towels,
were not regularly provided by the prison authority. As a result, women had to find ways to
sustain those needs. For instance, Nora said that economic opportunities in CIW provided the
means to buy those essential items, “Through hobby and some paid work, I get to save money
and then buy my daily needs like personal and laundry soaps and shampoo as they are not
regularly and sufficiently provided”. Neri talked about the support from RVOs that constantly
give essentials during their religious activities, “RVOs are helpful because right after our
gawain9, we get essential items, so they are a common source, and without them, I would
struggle…very grateful”.

Pregnancy and childbirth are difficult situations for prisoners. While participants spoke of being
brought to a government hospital for appropriate care during the birthing process, the
participants stated that prenatal and pregnancy support was inadequate. Prison nurses medically
assess incarcerated pregnant women upon prison admission. They are housed separately in the
mother’s ward and other pregnant and lactating women. Several women were frustrated by the
limited supply of nutritious food, supplements, vitamins, and vaccines for pregnant mothers.
Sealdi, who was pregnant in prison, recalled, “I arrived in CIW when I was five months
pregnant, I had my first prenatal visit in our village health centre, and it turned out to be my first
and last one”. The number of prenatal visits received by Sealdi is below the standard on prenatal
care set by the DOH. As discussed in chapter three on maternal health care in the Philippines, the
WHO guidelines stress that mothers must have at least four prenatal visits to ensure proper care
is observed. The DOH adopted this guideline as part of the National Maternal, Newborn, and
Child Health and Nutrition strategy. Rona, who complained about poor nutrition at CIW, noted,
“No, there are no special foods for pregnant women. In my experience, my food was the same as
the other inmates…I don’t like it because so greasy, so unhealthy for us, right?”

9
‘Gawain’ refers to religious activities in prison organised by religious volunteer organisations, such as
worship, prayer, or group activities.
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Participants also cited the lack of essential equipment for prenatal care, such as ultrasound
machines and blood tests. The health staff member usually gives prenatal care. If no doctor is
available, they need to request an outside hospital referral but must secure permits approved by
the Department of Justice (DOJ permits). Pregnant women are referred to the nearest government
hospital for their labour. Although several participants were PhilHealth members, they noted that
the insurance did not cover all the medical costs related to prenatal, pregnancy and childbirth.

Jenky: “I do remember I paid for blood test around P450 ($US 10), so if you
don’t have the money, you have to wait or ask for support from your family”.

Sealdi: “I am a PhilHealth member, and most medical expenses were covered

by the insurance. But I had to pay for some laboratory costs, medicines and
supplements not included in the PhilHealth coverage. It’s not 100% covered, to
be honest”.

All expenses incurred at the hospital are usually shouldered by the female prisoners and not the
prison institution. It is relevant to stress the financial capacity of the female prisoners, given that
poor pregnant mothers in the Philippines still encounter a multitude of barriers to accessing
health care. As elaborated in chapter three on maternal health care and health financing, this
health inequity faced by poor mothers is a product of low PhilHealth coverage and indirect costs
not covered by PhilHealth.

According to the women interviewed, the baby can stay with the mother for one year after birth.
One medical assistant in the mother’s ward noted, “I think it is not safe for babies to stay longer
here because the risk is too high given the institution has no specific programmes for them like
nutrition, vaccines and vitamin”. Currently, the institution does not have proper health care
workers, such as obstetricians, midwives, and pediatricians, to care for pregnant women and
newborns. Only the prison nurses and medical assistants attend to their immediate health care
needs. With these limited resources, women need support from NGOs, RVOs and other
government institutions.

Conjugal visits, which are allowed for male prisoners, are not permitted for women in the
Philippines. Venia argued that the policy is unfair, “Although I understand their reservation on
conjugal visits, the policy destroys family bond as it does not encourage quality time for

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couples”. When asked about their views on conjugal visits, I received various responses. Twenty
women would support conjugal visits if enough resources were in place to prevent pregnancy
and provide family or couple counselling. Ten women did not support conjugal visits because
they believed prison should focus on rehabilitation and an opportunity to get closer to God. They
also argued that conjugal visits are a waste of funds given the limited prison resources. The rest
were ambivalent about it as they wanted to have more children, but they were afraid of the
negative impact of prison on pregnancy and newborns. Four participants specifically cited the
risk of getting sexually transmitted infections considering the uncertainty surrounding their
partners’ risky sexual behaviour.

5.2.5 Summary
Several women expressed the need to earn and work in prison. Their desire to make money was
primarily linked to the scarcity of the essential items they needed, such as sanitary items,
menstrual pads, and medicine. Participants experienced various health and comfort issues,
particularly overcrowding, lack of nutritious foods, and limited sanitary facilities. The interview
revealed gaps in general and women-specific health programmes, particularly reproductive
health and specific care for pregnant and postpartum women and those with reproductive
conditions. The participants uniformly considered visits from their families, peer support, and
religious activities to be the most significant boost to their spirits and wellbeing. Furthermore,
visitors often bring necessary supplies, such as nutritious food, medicine, and money.

5.3 Chapter summary

Given the participants’ poor socio-economic backgrounds, as mothers and living below the
poverty line, their prison needs are inarguably complex. Many participants came from
underprivileged socio-economic backgrounds with unstable income sources. Most participants
were imprisoned due to drug involvement, theft, and property crime, often committed as a
response to poverty and economic insecurity. Specifically, their ‘support role’ portrays their
vulnerable situation, considering that most had difficult financial situations and financially relied
on their husbands before incarceration. Participants also noted the common health and safety
issues, such as overcrowding, lack of nutritious foods and limited sanitary facilities. The
interview revealed gaps in general and women-specific health programmes, particularly
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reproductive health and specific care for pregnant and postpartum women and those with
reproductive conditions.

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 Chapter Six
Lived Experiences of Reproductive
Wellbeing of Filipino Incarcerated
Women
In this chapter, I present women’s experience of reproductive wellbeing in prison to address the
first research question: What is the Filipino incarcerated women’s experience of reproductive
wellbeing? This chapter captures the dominant ideas, perspectives, and themes that consistently
occurred in all the participants' narratives. Their experiences of reproductive wellbeing were
expressed in three overarching themes: 1) Increased reproductive discomforts and decreased
relief, 2) disempowering experiences, and 3) prisoner identity overriding reproductive wellbeing.
Firstly, I describe how prison aggravates women’s discomforts and reduces their capacity to
manage their reproductive issues. Secondly, I demonstrate how women express and construct the
meaning of disempowering experiences. Finally, I illustrate how women’s institutionally
imposed prisoner identity overrides their reproductive wellbeing needs.

6.1 Theme 1: Increased reproductive discomforts and

decreased relief
This first theme describes how incarceration exacerbates women’s reproductive health concerns
and makes managing reproductive health discomforts more difficult. This theme is structured
into two sub-themes: 1) prison aggravates reproductive discomforts, and 2) incarcerated women
have reduced capacities to manage discomforts.

6.1.1 Prison aggravates women’s reproductive discomforts

In this section, I describe how participants’ imprisonment worsened their experiences of
menstruation, gynaecological problems, and pregnancy discomforts (for participants who were
pregnant in prison). Their experiences indicate that while deprived of their liberty, they face
aggravated reproductive needs and discomfort in prison.

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When asked about their menstruation in prison, women described their menstrual experience as
‘more distressing’. A wide range of period discomforts were named: period pain (n=30),
headache (n=10), irritability (n=18), breast tenderness (n=28), body malaise (n=25), irregular
period (n=20), appetite changes (n=10), bloating (n=7) and lightheadedness (n=4). Nine stated
they had heavier menstruation and consumed at least three packs of menstrual pads (12 pieces
each) monthly in prison. Several participants discussed that menstruation in prison was a dual
struggle.

Maria: “Honestly, I have observed that it is more tiring now because of my

heavy period and the fact that I am in a crowded and noisy place”.

Sheenah: “I became more sensitive and more irritable to noise, especially

during my menstrual period days, and here you have to deal with a lot of
people with different personalities and who are experiencing buryo10 as well”.

Maria and Sheenah’s descriptions of their menstruation reflect the common experience of the
participants. Their use of expressions such as ‘more tiring’ and ‘more irritable’ emphasises the
aggravating effect of imprisonment on their menstrual wellbeing. Some women stated that the
noise level was disturbing, particularly during menstruation days, and they preferred to be alone,
mainly for their comfort and wellbeing. Most participants associated their worsened menstrual
discomforts with the prison’s high stress, noise levels, and crowded living spaces. Etaugh and
Bridges (2004) argue that differences in women’s social and environmental contexts may shape
their menstrual experiences. Smith and Borland (1999) and C. Smith (2009) argued that a prison
is a stressful place, and it is likely that anxiety and stress affect menstruation experiences.
Genders and Player (1990) also emphasise that the stressful experience of women in prison may
be due to their isolation from their support networks, relationships, homes, and jobs.

Several women pointed out that their menstrual discomforts significantly affected their quality of
life compared with pre-incarceration because imprisonment had made their discomforts much
worse and more troubling. They specifically pointed out an increased severity of their menstrual
discomforts, including period pain and cramps and changes in cyclicity and blood volume.

10
Buryo is a common Filipino prison term which means a state of uneasiness and anxiety or cabin fever
110
 Nora: “Since I was detained, I’ve observed my period seems heavier than it
used to be, and I seem to bleed longer. I also suffer a lot more with cramps,
painful periods…These weird symptoms may be related to stress or poor
nutrition. That’s why I lost weight here”.

Sheenah: “Period pain is not new to me. I’ve experienced it since my teenage
years; however, you know it feels like my period is more irregular now due to
stress maybe. I am now anxious because I observed some changes in my
period”.

Neri: “The pain seems to be more intense somehow now…no, I’m not used to
taking the medication even before I got detained, so maybe here because of
stress, irritability, lack of quality food, and the environment”.

The participants’ perceived menstrual changes depict their bodily signals of being distressed in
prison. These accounts validate earlier research conducted in an English prison, showing that
several women reported significant menstrual changes during incarceration (C. Smith, 2009).
Cunningham-Burley and Backett-Milburn (1998, p. 151) explain that the “body gives out
messages of bodily change and indications of difference, which need to be ‘read’, interpreted and
sometimes acted upon”. In the present study, the menstrual change appears to be an expression
of the bodily message. Weideger (1975, p. 148) indicates that “all forms of stress (pleasant or
painful) can alter menstrual experience”. Moreover, chronic and severe stressful situations may
aggravate menstrual symptoms and cause altered cyclicity and irregularity (Gallant & Derry,
1995; C. Smith, 2009).

In addition, Neri and Nora associated their menstrual changes with poor nutrition and diet in
prison. When I asked the participants about the quality of prison food, all described it as
inadequate and unpleasant, with several women reporting weight loss. Although they appreciated
the free food and the institution’s efforts, they wished it could have been improved. Several
studies have established the link between poor nutrition and menstrual distress among women
(Fujiwara, 2007; Kimmel et al., 2016; Penland & Johnson, 1993). This finding is relevant to
prisons, given that imprisoned women are more likely to be undernourished (Ravaoarisoa et al.,
2019; Van Hout & Mhlanga-Gunda, 2018).

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6.1.2 Reduced capacities to manage needs and discomforts
This sub-theme depicts the challenges of women managing their reproductive problems due to
limited resources, lack of institutional and family support, disrupted coping strategies, and
restrictive prison regulations.

Most participants (n=32) discussed their struggle concerning access to hygiene and menstrual
necessities due to scarce resources. For example, Nora reported her experience of inadequate
menstrual pads: “I experienced in my first year here at CIW, I had no pads… I had no idea what
to do, and I was just crying, and one Person Deprived of Liberty (PDL)11 told me not to cry”.
Similarly, Ana, who had been imprisoned for ten years, shared a similar sentiment: “Napkins12
are not adequate and not free and available at all times. It is either you buy it if you have money
or request from your family or friends”. Many participants argued that menstrual products should
be a priority. Jessica stated: “I fully understand that not all our needs can be met here, but I wish
napkins could be free for all, that’s very basic knowledge we have no other means to sustain it,
right?” Apparent in the earlier narratives are the challenges of women accessing feminine
products due to inadequate provision of these items in prison. This difficulty is profound for
women who do not have the financial capacity to purchase feminine products or have limited
support from family, as in the cases of Nora and Ana.

The lack of adequate and functional menstrual products is a prevalent prison shortage. Most of
the interviewed women (n=36) said they had preferred products and brands, but these were not
available at the prison store and were not accessible due to prison restrictions.

Chalemie: “No, I’m not comfortable with the given and available pads
here…so sad having limited options as pads are not free at all. The common
pads are thin. There were months that I had to wear three to four pads at a
time”.

11
Person Deprived of Liberty (PDL) refers to all prisoners regardless of gender and years of
imprisonment. This is the official term used by the Corrections Bureau in the Philippines and is
commonly used among incarcerated people.
12
Napkin means menstrual hygiene products and is a widely used word in the Philippines
112
 Elma: “I don’t like the pads as the quality and texture are different. It is tough
to get my preferred pads. The pads I often get irritate my skin and cause a
rash…so itchy”

Gretchen: “If I had extra money, I could buy additional supplies at the prison
store, but it is a bit more expensive…yes, if you have no money, it is hard to
access them”.

Many participants reported that gynaecological health care was limited, especially for women
diagnosed with reproductive conditions. Rona, diagnosed with a chronic reproductive
condition,13 stated: “I’m exhausted with this condition. Having this condition here is so difficult
to describe. It is like dealing with everyday pain…It is really painful”. She added the lack of
regular medicine supply contributed to her difficult situation: “Since the pain medicines are not
available 24/7 at the infirmary, sometimes I have to bear the pain. If I’m lucky, I receive some
from my family, other PDLs, or religious organisations”. Edelina shared her similar experience
of limited support: “Because of my condition, my [menstrual] period day is hell and not
predictable. I have extreme pain and bleeding”. She continued that her condition became worse
due to lack of regular medication supply: “If I am fortunate, I can get some medications from the
infirmary if they have supplies to stop the bleeding somehow…If they run out of supply, I have
no choice because I have no money to buy them from the outside”. The challenges of women in
managing their menstrual and reproductive conditions are compounded by the lack of timely,
regular, and adequate services. Given that many participants had limited or no access to
comprehensive reproductive health care before incarceration (as noted in chapter five), this lack
of access to care can mean these women are vulnerable or have undiagnosed conditions that may
require specific services not available in prison. Previous studies have shown that women in
prison face serious reproductive issues due to their low socioeconomic status, lack of good
nutrition, lack of preventive health care before imprisonment and poor access to health care
during incarceration (Clarke et al., 2006; Fearn & Parker, 2005; Wilper et al., 2009). These
prison deprivations concerning women’s reproductive wellbeing characterise the gendered pains
of imprisonment women encounter (Genders & Player, 1990; Owen, 1999; Walker & Worrall,

13
Specific names of the reproductive conditions were omitted to protect the participants’ internal
confidentiality
113
2000). In the current study, incarcerated women with menstrual issues and chronic reproductive
conditions did not receive quality health care (i.e., regular supply of pain medications and timely
professional care).

Because of the profound scarce resources in prison, some women had to use available materials
as their improvised menstrual pads. April stated that using clean cloth was very convenient: “I
discovered that using cloth is more convenient because I can wash and reuse it. Nothing to worry
about every month about buying pads”. Marietta shared a similar remark: “I am grateful that an
NGO visited here a couple of years ago and taught us how to use a cloth as [menstrual] pads, and
I find it very convenient, been using it for three years now”. Another participant, Marife, said she
used the cloth because she had no choice: “I’ve been here for a long time, so I tried to improvise
and use cloth because I had nothing to buy pads regularly”. When asked about their capacity to
wash reusable menstrual pads, many noted that the water supply was adequate. Marife
responded: “It is alright because we have a free water supply here, and we get to receive free
laundry soap from CIW. Although the soap is not regularly supplied, I can get it from my family
or buy it at the prison store. I can still save for my succeeding use”. Clarice confirmed the
adequate water source in CIW. Still, she noted that some female dormitories did not have their
faucet or toilet: “I think one challenge is not all dorms have their water source, so we need to
wake up early or queue to fetch water in other dorms with a water source. It is undeniably
physically exhausting sometimes, but we have no choice”.

For some with severe reproductive conditions, their symptoms appeared to be exacerbated by the
uncertainty and restrictions in prison.

Angela: “I feel my condition is more exhausting today because I’m in a

crowded room, unlike before. Every time the symptoms appear, I prefer to be
at home. The feeling of being in my room where I can just lock myself and rest
gives me a wholesome feeling of comfort. And if I need anything, I just ask my
husband to buy me pain medicines or comfort foods. I wish I could do the
same things here”.

Venia “I had this condition even before I was imprisoned, and being here at
Corrections is like a curse. And it is sad to say that there is so much discomfort

114
 that I can no longer do things that I usually did before. In my outside world, if
this gynaecological problem hit me, I used to take a warm shower and rest to
relieve the discomfort. But here, many things are impossible to do, the new
reality that I have to face and bear. For how long, I don’t know”.

The stories above indicate that imprisonment disrupts participants’ coping strategies and
capacities to manage their reproductive conditions and symptoms. Women in prison struggle
with how their intimate and daily practices are controlled by the institution (Carlen, 1983; Crewe
et al., 2017; Genders & Player, 1987; Owen, 1999). As the current study demonstrates, prison
heightens women’s reproductive discomforts due to the altered intimate and personal practices
related to their menstrual and reproductive health needs. The extracts from Venia and Angela
explicitly mentioned how the prison environment prohibited them from their usual ways of
managing their menstrual and reproductive conditions.

Women who had been pregnant in prison (n=18) confirmed that pregnancy care was sparse.
They argued how inadequate prenatal care was, and accessing it was challenging. Bianca shared
her experience of limited prenatal care: “I had only one prenatal appointment here. I was brought
to the nearby hospital. I underwent a series of blood and urine tests; they took my blood
pressure”. Ada, who was also imprisoned while pregnant, revealed a similar experience: “Based
on my experience, there is a shortage of prenatal service for pregnant women, I’ve never
received any vaccines, I received some supply of iron and vitamins but not regular, most of the
supply came from my family”. Jenky commented on her experience of receiving no prenatal
care in prison at all: “I had two prenatal visits before my incarceration. I was five months
pregnant when I arrived here at CIW. That was the last prenatal care, so I received no prenatal
service at all here”. Common in the narratives above is how imprisonment disrupts pregnant
women’s access to prenatal care. These findings are consistent with the literature, showing that
women who experience incarceration are substantially less likely to receive adequate antenatal
care than are women in the general population (Carter Ramirez et al., 2020).

Another profound reproductive problem of the participants, mainly those pregnant in prison, is
their struggles managing pregnancy-related symptoms and discomfort in prison. Among the
women who were imprisoned while pregnant (n=18), their challenging prison pregnancy
experience was related to reduced capacities to cope with pregnancy symptoms. Ada, a first-time

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mother in prison, had difficulty dealing with her pregnancy symptoms because she had no
pregnancy experience and was unprepared for her first pregnancy. She felt helpless and
exhausted when her nausea and vomiting became worse. For mothers who had pregnancy
experiences pre-incarceration, their problem centred on their inability to adequately manage the
discomforts because of limited resources and lack of family support. Bianca recalled that
although her previous pregnancies were delicate and complicated, she was able to manage
because it was easier to visit the nearby maternity clinic in their village. She added that being at
home is a source of comfort because she has the resources to cope with the pregnancy symptoms.
These findings corroborate the earlier studies in Brazil (Fochi et al., 2017) and England (Abbott
et al., 2020), showing that the struggles of pregnant women with pregnancy discomforts in prison
are due to detachment from their support networks and the limited prison resources. In the
outside community, pregnant women can successfully manage the discomforts of pregnancy
because of the supportive social and physical environment and access to health care (Lagadec et
al., 2018; Van der Gucht & Lewis, 2015). This enabling environment is disrupted in prison due
to scant resources, and most of the study participants’ families are situated in their home
provinces, as in the cases of Bianca and Ada.

6.1.3 Summary
The interviews with the participants revealed how imprisonment aggravates reproductive health
issues and reduces their capacity to manage reproductive health discomforts effectively. Evident
in the women’s accounts were their experiences of heightened discomforts concerning
menstruation, gynaecological problems, and pregnancy (for women who were pregnant in
prison). In addition, the participants pointed out that the increased severity of their menstrual and
gynaecological experiences (i.e., pain and cramps, and changes in cyclicity and blood volume)
and pregnancy discomforts were linked to the stressful environment and poor nutrition in prison.
Furthermore, the participants discussed their challenges of coping with their reproductive health
issues due to limited resources, lack of institutional and family support, disrupted coping
strategies, and restrictive prison regulations.

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6.2 Theme 2: Disempowering experiences
The second theme encompasses the common experiences of disempowerment of the participants
concerning their reproductive wellbeing. This theme is divided into three categories: 1) lack of
control and autonomy, 2) shameful experiences, and 3) ‘I felt helpless’.

6.2.1 Lack of control and autonomy

The participants diagnosed with gynaecological conditions identified various disempowering
prison practices, such as lack of timely care, reduced opportunity to control health care, and
complicated processes before being sent to the hospital. For instance, Joyce described her
experience with prison health care as debilitating. She said that she was not brought into the
hospital immediately when she had extreme pain and bleeding. She added that it was frustrating,
given that the staff already knew she was diagnosed with a specific reproductive condition. Some
women said that often they were informed on the day of their hospital appointment; hence, it was
‘impossible to anticipate’, and they had no chance to prepare mentally or physically. Kara
clarified that although she understood the rationale of the practice for security reasons, she
believed the practice was ‘disempowering’ due to not being consulted or informed in advance.
Julia concurred with Kara’s sentiment and added that with limited time to prepare for a hospital
consultation, she felt she could not prepare the questions she wanted to be clarified by doctors.
She wanted to use the time, considering it was challenging to seek treatment outside the prison.

Participants’ lack of control was described in their reliance upon the institution and other
prisoners as gatekeepers to the programmes and services in prison. The lack of control was most
painfully experienced by the women in the absence of opportunities to control health care and
make health decisions. The findings are in consonance with the study conducted in an English
prison on the experiences of sick prisoners (Edge et al., 2020). Although their research was not
explicitly based on women’s experiences with reproductive issues, their main findings resonate
with the current study because the loss of autonomy around health care and delayed access and
transport were identified as the main issues faced by prisoner patients (Edge et al., 2020).

The interviews with incarcerated women confirmed the constraints associated with hospital
appointments. All reported the challenges they experienced every time they sought community-
based health care. Bianca compared her experiences of prenatal care in the community with that

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in prison: “If I were home, I know I’d be in a maternity clinic that day, rather than sitting in my
cell, not knowing what to prepare and what time exactly”. She added: “So, from the point where
they told me they booked the appointment, every day I was kind of anxious to know is this the
day I’m going to go?” Rona recalled her experience of a hospital appointment for reproductive
condition treatment. She pointed out that protocol was challenging for her to prepare because of
the uncertainty around the time and place: “I didn’t have any time to prepare, [...] from the
moment that they informed me, I’ve probably got [...] 10 min to prepare myself [...]I could have
been in the middle of cleaning or preparing myself to clean and not found myself in a presentable
state that I would want to go”. She also expressed her disappointment in the lack of transparency
in follow-up and clear instructions for subsequent treatment and medications. Joy verbalised her
frustration because she felt the circumstances caused some inconvenience to the hospital staff
during her prenatal visit: “…then, you get to the hospital [...] an hour late because of the strip
searches and delayed transportation. I feel embarrassed and such a pain to them as well, like I’m
an inconvenience to them, which it shouldn’t be. But unfortunately, the circumstances we’re in
and the logistics just don’t work”. Similarly, most women who were pregnant in prison
expressed their frustration with practice around DOJ permits in CIW. Ada shared her
disappointment about delayed prenatal care in prison: “In my previous pregnancies I received at
least three prenatal visits in my entire childbearing months, but here I got only one prenatal care
visit”. She also added the difficulty of receiving prenatal care due to complicated processes like
getting a DOJ permit: “It is also very hard to get a DOJ permit because you need someone who
will do the follow-up and manage the paperwork needed for the request, plus I had to wait for the
schedule. You know the process is very frustrating and makes you feel helpless”.

The accounts of Bianca, Rona, Joy, and Ada showed the women’s prominent negative
experience of hospital visits due to prison security restrictions. Participants described being told
that they were going to the hospital on the day of their appointment and that appointments were
difficult to anticipate and prepare due to limited opportunities. Security measures, such as strip
searches, DOJ permits, and delayed transportation, resulted in prisoners arriving late for hospital
appointments. This situation made women guilty even though this factor was out of their control.
Furthermore, women stated that the hospital’s prescribed medication is unavailable in prison, or
they must ask their family members to look for supplies outside. From their perspective, after the
hospital visits, they faced uncertainly about when their appointment would take place.

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The sense of powerlessness was profound among pregnant and lactating women due to loss of
autonomy. The absence of control over their pregnancies generated distress among most
participants.

Frany: “I felt sad when I learned I would not be allowed to go to the previous
O.B. doctor. I was scared because I had no other experience with other doctors.
I tried to ask them to reconsider my request, but they received no response. I
was sad when they brought us to a nearby public hospital for our prenatal
care”.

Trisha: “When the prison staff confirmed that I was pregnant. I asked God why
it happened to me. Who will take care of me and baby during the whole
pregnancy?”

Joy: “It was the most difficult pregnancy I’ve ever had. It was depressing not
to get my supplements on time. That feeling when I had to beg just to get those
medications for my baby because I was so scared for my baby’s health”.

The extracts of Frany, Trisha, and Joy illustrate the shared experience of many women and how
they described the feeling of being controlled by the institution. Loss of agency is a common
‘gendered pain of imprisonment’ (Crewe et al., 2017). Although being confined is a general
imprisonment experience, the disempowering feeling was distinct among pregnant women.

Many participants considered the impending separation from their newborn as an extreme form
of loss of control over their mothering situation.

Trisha: “I wish I had another option to be with my kid. It was the most difficult
decision I have ever made as a first mother. It was painful and I felt
powerless”..

Bianca: “Yes I am a prisoner; I am a criminal. But I am still a mother. I care

about my kid and it is difficult to be separated from my newborn baby. It is
hard to be separated again from my kid like I was detached from other
children”

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How Trisha and Bianca verbalised their frustration of being separated from their newborns
mirrors the common feeling of anticipatory anxiety of all women interviewed who were pregnant
in prison. This hopelessness was caused by their total lack of control, limited options, and
difficult prison circumstances. The data is congruent with the literature indicating that
hopelessness, apprehension, regret, and anger following the separation from newborns are
common emotions of mothers in prison (Abbott et al., 2020; Fochi et al., 2017; Fritz &
Whiteacre, 2016; Wismont, 2000)

6.2.2 Shameful experiences

Several women expressed a sense of shame when asking the prison officers or other prisoners for
menstrual and sanitary products (i.e., menstrual pads, soap).

Ching: “It was like an insult to my ability and being a woman to ask for
donations for menstrual needs. But I have to face that reality, that is my only
way to survive”.

Cindy: “My first few months were the most difficult as I had to learn very fast
while navigating the complex situation here. I had to show some brave heart to
swallow my pride by asking for help…that feeling when I had to ask for extra
menstrual pads because mine was inadequate. Like I have never done that
before. I have never asked my partner to buy me my pad. I felt ashamed”.

These narratives encapsulate the general feeling of being powerless and the degrading feeling of
depending on the institution and other people for their personal needs. The prison regime causes
a loss of dignity, forcing the inmates to ask for their basic individual needs (Goffman, 1961).
This assertion is palpable in the narratives of Ching and Cindy, where they described their
experiences of asking for menstrual pads as ‘insulting’ and ‘shameful’. As their accounts
highlight, prisons create institutionalised shame and humiliation concerning women’s
menstruation (Anderson, 2009).

Many women identified the lack of privacy and personal space as a substantial source of shame
and humiliation.

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 Victoria: “Well, there is nothing private in prison. Everyone knows when you
go to the comfort room14 (CR). They know when you have [menstrual] period,
nakakahiya (embarrassing). Slowly, you get used to it”.

April: “If you’re at home, the comfort room is a hidden space, a private place.
Here, our CR is an open space because it has no door and lock, which makes it
weird when you have a heavy period”.

Lorna: “I wanted to have my bed, but my request was not granted. I shared a
bed with another inmate with a small baby. There was also no space where we
could get fresh air, you know. We are not allowed to go to public spaces
because we might get infections in crowded areas. I was five months pregnant
at that time”.

Bianca: “I hate when other women touch my stuff. I think it is a common

practice in the mother’s ward that other women tend to borrow items. Some
even just pick your things without asking permission…I know it is a prison,
but people must be mindful of others’ privacy, right?”

The extracts from Victoria and April indicate that women’s experiences of lack of boundaries
and privacy in prison reinforce a feeling of degradation and humiliation. As expressed by Lorna
and Bianca, the lack of control over personal boundaries was a primary concern for pregnant
prisoners. These narratives mirror Crewe et al.’s (2017) argument that lack of privacy is a
significant gendered pain of imprisonment among women. They argue that female prisoners find
the literal lack of privacy that imprisonment engenders as a form of intrusion into daily private
practices (e.g., using the toilet, getting dressed, washing). The loss of privacy is a key
characteristic of the prison environment. There are many systemic barriers to privacy, such as
numerous rules and regulations, strict prison schedules, almost constant monitoring and
observation, and architecture and design that regulates movement and interaction to prioritise
policing and surveillance (Foucault, 1978; Moran, 2013; Schwartz, 1972).

Wearing prison uniforms, using a prison vehicle, using a different entrance, and being
accompanied by uniformed officers during hospital appointments were described by participants

14
Comfort Room (CR) is a widely used word in the Philippines, which means toilet or washroom
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as highly humiliating. Most participants talked about public reactions they receive at the hospital.
For instance, incarcerated women with chronic reproductive conditions who were transferred to
the hospital for routine appointments felt public humiliation and embarrassment, especially seen
in prison uniforms and accompanied by prison staff.

Elaine: “I had an observation during my regular treatment for my reproductive

condition when many people in the hospital were staring at me maybe because
I had handcuffs, and I was escorted by Corrections staff members. Grabe
nakakahiya talaga (I was too embarrassed)”.

The expression of institutional shame was profound among pregnant women. Venia talked about
her experience of public humiliation: “When I was brought into the nearby maternity clinic for
prenatal care, I observed other pregnant women in the queue talking about me. They were like
guessing that I was an inmate because I was wearing the orange prison uniform”. This story is
also consistent with Anas’ remark: “During my day of labour at a birthing clinic, I observed the
medical staff were whispering, and I knew they were talking about me because I was wearing a
prison uniform and two prison staff members were accompanying me at the time”.

The extracts of Venia and Ana indicate their experiences of public shame and humiliation as
pregnant women in the maternity clinics while wearing the prison symbols, such as their
uniform, handcuffs, and the presence of security staff. This experience results from how the
participants perceive the negative public reaction to their pregnancy as a prisoner. This situation
is consistent with the previous literature regarding the humiliation encountered by female
prisoners, where feminist theorists argue that women who transgress the social expectations of
being a good mother, such as women in prison, face severe public shame (Gelsthorpe, 2004;
Kennedy, 2011; Lockwood, 2018). The public humiliation is substantial among Filipino
incarcerated women because their situation contradicts the country’s ideal and normative
construction around motherhood and womanhood. Even today, the concept of ‘good mother’
remains a dominant defining characteristic for Filipino women, and mothers who deviate from
these expectations are viewed negatively (Mananzan, 1987; Peracullo, 2017).

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6.2.3 ‘I felt helpless’
The feeling of disempowerment was expressed by many participants because of experiences of
being left unsupported and helpless in labour, and not being transported early to the hospital. The
environment was perceived as very hostile for women in labour in prison.

Janna: “I told the medical assistant in our ward that I think I was about to give
birth because my pain was getting intense. She told me that it was not true
labour. They could only send me to the hospital when it’s already true labour.
Because I was so scared, I lied to her...I said I couldn’t bear the pain anymore,
and then they brought me to the hospital. I felt helpless!”

Leslie: “That was the most difficult part of my life…I felt helpless. I was
alone. I could have saved my baby if I had not been imprisoned. I told them it
was my first pregnancy, and I had no prior experience. They never listened to
me. I rarely visited the hospital for my prenatal care”.

Claire: “I told the staff that I have high blood pressure and my OB told me that
my pregnancy is risky for me and my baby, so Cesarean delivery was the better
option. I told CIW about that information… I felt my labour pain at 9 pm, I
had extreme bleeding. But I was only brought to the hospital at 11 pm. When I
arrived at the hospital, the staff could still hear my baby’s heartbeat in the E.R.,
but they could not hear the baby’s pulse anymore when I arrived at the
operating room. I wish I had more control to decide to go to the hospital much
earlier. That difficult situation made me small and helpless”.

There was a sense of helplessness in Janna’s, Leslie’s and Claire’s extracts due to lack of control
over their pregnancy condition. This situation, coupled with fear, pushed Jana to lie in her
attempt to pull back her control. Apart from the sense of helplessness, a feeling of grief can be
noted in the narratives of Leslie and Claire. They associated the loss of their baby with the lack
of timely care from the staff and prison restrictions.

All participants in the study consistently noted the strict protocol being followed before they
were admitted into the infirmary or transferred to a nearby hospital. These prison practices
contributed to a sense of helplessness among the participants.
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 Sheenah: “We need to follow a protocol here. We cannot just go directly to the
infirmary, you need to tell the medical assistants in your dormitory to assist
you. I had one experience when I had an excruciating menstrual cramp and
headache. But I still needed to inform the medical assistants before they
brought me into the infirmary. That’s the reality here, and you feel helpless and
left with no choice”.

Jenny: “During my first month in CIW I had an extreme headache during my

menstruation week, so I went to the infirmary to ask for pain medications. The
medical assistant there told me to inform the medical assistant assigned in our
dormitory to assist me. I had no idea at the time about the infirmary process”.

Apparent in the extracts of Sheenah and Jenny were the extreme prison regulations around health
care protocols. Although participants acknowledged the rationale of the process (as noted in
chapter five), to prevent the influx of patients into the infirmary, the process was perceived as the
cause of health care delays.

In sum, the participants’ experiences of disempowerment were significantly linked to their

limited autonomy over their reproductive wellbeing and lack of personal space and privacy in
prison. Sykes (1958) identifies the deprivation of autonomy, including the loss of control of
prisoners over their situation, as one of the major pains of imprisonment. Prisoners encounter
many restrictions designed to control their behaviour and, even to a large degree, their bodily
functions (Coyle, 1994; Crewe et al., 2017; Sapsford, 1983; Sykes, 1958). The participants’
accounts indicate that their bodily functions concerning menstrual and reproductive health needs
and pregnancy are restricted, controlled, and neglected. Furthermore, Irwin and Owen (2005)
argue that prison life is completely routinised with limited opportunities to make decisions over
prisoners’ daily routine, space, and time. Their argument resonates in the present study because
several women described the prison as a space lacking boundaries and privacy. These situations
reinforced a feeling of humiliation and shame.

6.2.4 Summary
All the stories of the women interviewed represent powerlessness, helplessness, and the impacts
of the loss of autonomy and lack of privacy on their reproductive wellbeing. Specifically, women

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found that the lack of control and limited choices for their menstrual needs and those with
reproductive health conditions were debilitating. These experiences were caused by the
restrictive and scarce prison environment that limited their ability and opportunities to
adequately manage their personal and health needs. For participants with childbearing experience
in prison, losing autonomy over their pregnancy was profoundly disempowering.

6.3 Theme 3: Prisoner identity overriding reproductive

wellbeing
The third theme illustrates women’s narratives of how their reproductive wellbeing needs
appeared secondary to their institutionally imposed ‘prisoner identity’.

The loss of personal and social roles is a common consequence of incarceration for both men and
women (Bosworth, 2000; Carlen, 1983; Crewe, 2009; Goffman, 1961; Sykes, 1958); however, it
appears that women with gynaecological issues experience the impact of the loss of identity
differently compared with other female prisoners.

Rona: “I am exhausted with this condition. Having this condition here in

prison is difficult to describe. It is like dealing with everyday pain. It is
excruciating… the feeling is weird in the beginning when you have a medical
problem, but you are not a patient inside the prison... you get used to that
feeling eventually”.

Edelina: “Because of my condition, my menstruation days are like hell and not
predictable, I have extreme pain and bleeding. This situation makes me think
that my life would have been different if I were outside because you feel you
are a real patient who needs urgent medical support. But here, it’s totally
different”.

Lorna: “Well, that’s the reality in prison. You have to follow the schedule and
rules here. There were instances when I had bad menstrual cramps due to my
condition. And I told them I couldn’t participate in the activity; I was just told

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 that cramps are normal. So, I lied that the pain was unbearable, and that’s when
I was told to take some pain medications and rest”.

Having chronic reproductive issues in prison and being detached from their families contributed
to the participants’ difficult situation. These women were only diagnosed during their
imprisonment; hence, they had no previous experience adjusting to their changing identity as
prisoners diagnosed with chronic reproductive conditions. Their complicated adjustment can also
be attributed to their delicate medical condition, uncertainty, scarcity, and lack of support. Their
experience in prison deviates from the general belief around the ‘special status’ of people with
chronic reproductive conditions in the community who are perceived to be vulnerable, are to be
protected, and worthy of special treatment. In prison, this status is overruled by having an
identity as a prisoner and a criminal (Goffman, 1968).

Several participants discussed how prison regulations reinforced their prisoner identity during
hospital appointments.

Ana: “As a patient, I had several experiences wherein health workers rushed
me straight through the room, and I couldn’t sit in the waiting area with other
patients. They stick you in a room. I wanted to explain to them like, come on, I
am not a killer, and I am harmless”.

Elaine: “It really feels weird every time I get to visit the hospital for my regular
treatment for my condition because I still feel that I am a prisoner, not a patient
with lots of prison regulations in place even when you are outside the prison
facility, you know what mean”.

Goffman (1961) argues that public perception happens when membership of a particular group,
in this case as prisoners, becomes the defining feature of one’s identity: their ‘master status’.
Goffman’s (1959) mortification of self, although not specifically related to female prisoners, has
echoed in the present study, illustrating how female prisoners with reproductive conditions were
given wearable marks of prison that identify them as prisoners in the hospital, such as handcuffs,
prison uniforms, prison vehicle. These prison symbols and attributes can engulf an individual’s
identity, becoming “the filter through which his or her other characteristics are seen” (Jones et
al., 1984, p. 296). The stories of Ana and Elaine exemplify how their ‘prisoner identity’ becomes

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a master status, fundamentally affecting how the public understand women prisoners accessing
hospital care.

Many participants indicated that the prison authorities perceived reproductive-related

discomforts as irrelevant; hence, these discomforts did not warrant exemption or special
consideration from any prison restrictions and limitations.

Jenny: “When you are sharing a room with many women, nakakahiya yun (it
can be quite embarrassing), especially if you are having your [menstrual]
period and you are not used to crowded places, but slowly you get used to it.
Everyone here becomes the same. We are all inmates”.

Ching: “During the daytime, we have to wear white shorts, which can be quite
distressing when you have your period…and my menstrual pads do not give
much protection, and several times I leaked through. But I need to find ways to
survive in prison because of my life imprisonment...although I have a heavy
period and I am different from other women, the prison does not see it that way
because, for them, we are prisoners, so I have to live with it”.

Jocelyn: “Although I have this condition here in prison, I have to survive and
set aside my discomforts...there were days I had to carry a pail of water from
the source to our room for everyday consumption. It is part of my assigned task
in our dormitory. We have to work here...yes, I am not like the others because
of my condition, but no one is special here, you know”.

The above remarks illustrate how prison practices and attributes (i.e., crowded place, white
shorts, assigned tasks) override the participants’ reproductive wellbeing. These prison
characteristics contributed to women’s experience of disrupted identities concerning their
reproductive needs. Jocelyn, Jenny, and Ching’s expressions, such as ‘everyone becomes the
same’, ‘we are all prisoners’, ‘no one is special’, show how institutionally imposed ‘prisoner
identity’ shaped their experiences. These experiences contributed to their sense of depersonalised
and fractured identity as women with unique reproductive health needs. Additionally, the
storylines of Ching and Jenny indicate how the carceral environment has transgressed over their
menstrual wellbeing. Their descriptions of a menstrual experience as distressing (period leak)

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and embarrassing (period in a crowded place) in prison reflect an enforced dehumanised
experience.

Goffman’s (1968) ‘mortification of self’, which was based on male inmates’ experiences,
resonates with the current study. It demonstrates how pregnant prisoners expressed a significant
loss of identity as mothers and pregnant women.

Bianca: “That was my third pregnancy, but it is very different as it is my first

pregnancy in prison... Thus, here inside, it is complicated for us, for the
pregnant women... Because here we are too far from our families and friends,
who end up unaware of any of this. The sad thing is this, but due to the
pregnancy, I am happy ... I always wanted my children, and I was always very
happy in the pregnancy. You know, I wasn’t in the state that I’m in now, right?
I’d never felt emotional like this. Very sad, nervous, uncertain, sometimes a
little depressed as well, a little uncomfortable?”

Lorna: “I got arrested when I was four months pregnant because my husband
was caught selling drugs, and the authority thought I was involved. I had one
of my first prenatal care sessions in the nearby village health facility, and the
service was free. But when I came here, there was no continuity in my prenatal
care, I got examined after a couple of months, and I was a few weeks before
my labour. It feels like pregnant women are no different from the rest”.

In Goffman’s (1968, p. 6) concept of mortification, he stated that the “barriers that the prison
institution places between the inmate and the outside world, the inmate is dispossessed of
specific roles that are part of one’s self”. The accounts of the participants indicate that the
unique social identity of pregnant women disappeared the moment they entered the prison
environment: the pregnant inmates underwent the mortification process (e.g., entering the prison
spaces and being deprived of external social resources), and most of the time they faced
significant restrictions, such as being unable to regularly connect with their family and support
network, as expressed by Bianca and Lorna.

For first-time mothers, their first pregnancy in prison caused a turbulent and ambiguous
experience of motherhood. Jeanneth explained that she could not clearly describe her emotions

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when she knew she was pregnant. It was an ambivalent feeling of being excited as a first-time
mother and fearing for her baby because of her situation as a prisoner. She added that she was
scared and anxious during labour because she felt alone and vulnerable. Similarly, Ada reported
being clueless for several months about what to expect. She indicated she had no childbearing
experience and received no support from the institution about pregnancy expectations. Ada said
that “prison is not really for pregnant mothers” and should not be imprisoned. She continued that
the prison regulation was complicated and only made pregnancy riskier. The storylines of
Jeanneth and Ada demonstrate how their inmate status altered their new identity as first-time
mothers. For first-time mothers, pregnancy and motherhood experience is a significant
psychosocial change for most women (McVeigh, 1997). First-time mothers may face
considerable challenges, such as psychological and emotional distress and an inability to cope
effectively (Rallis et al., 2014; Razurel et al., 2013). Psychological, social, and material resources
are important factors that enable a positive transition to a new motherhood role (Razurel et al.,
2013; Tarkka et al., 1999). This enabling transition appears impossible for first-time mothers in
prison, who are cut off from their psychosocial resources. Lack of social support and absence of
prison psychosocial programmes for first-time mothers were noted in the accounts of Jeanneth
and Ada.

Many participants with children faced an additional loss of identity as mothers. They expressed
guilt at having left their other children. For example, Jenky stated her apprehension about leaving
her three children behind, “…to be honest, I feel bad because I left my children behind, and they
will grow up without their parents”. Similarly, Alicia stated her perception of being an
‘incomplete’ mother because of her inability to support her family, particularly her children,
“sometimes I couldn’t help but think of the current situation of my family. I used to be the
primary carer of the family, but my imprisonment changed our lives…it feels parang hindi kana
kompletong ina (incomplete mother)”. She noted that it was a difficult situation because she used
to be the family’s breadwinner. Being imprisoned made her feel like a ‘useless mother’. Like
Jenky and Alicia, mothers in the study stated how imprisonment interrupted their ability to fulfil
their parental roles. The disrupted mothering role of the participants, as reflected in the narratives
of Jenky and Alicia, is intertwined with the Filipino normative construction of motherhood.
Although the normative parental role around child-rearing, discipline, and managing the home in
the Philippines has significantly changed over the years, this traditional family role has remained

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predominantly women-centred, considerably shaping the Filipino women’s mothering identity
(Alampay & Jocson, 2011; Licuanan, 1979). Hence, this parental role disruption in prisons
created a sense of despair among some women in the sample. This understanding aligns with
previous studies indicating that mothers’ imprisonment has broad implications because of their
multiple familial and community roles (Valera et al., 2015; Villanueva & Gayoles, 2019).

6.3.1 Summary
When entering prison, women leave everything that belonged to them and adapt themselves to
the new way of ‘carceral life’. Participants in this study expressed how their institutionally
imposed prisoner identity overrides their reproductive wellbeing needs. They faced several
challenges sustaining their reproductive health needs while navigating the restricted prison
processes and scarce resources. The study found the implication of imprisonment for the
participants’ pre-incarceration roles and expectations as women with complex reproductive
health needs, patients, pregnant women, and mothers.

6.4 Chapter summary

This chapter has answered the first research question on incarcerated women’s experience of
reproductive wellbeing. Participants’ reproductive wellbeing was expressed in three themes: 1)
increased reproductive discomforts and decreased relief, 2) disempowering experiences, and 3)
prisoner identity overriding reproductive wellbeing. Participants’ accounts indicate how
imprisonment exacerbated their reproductive health issues and decreased their capacity to
manage their discomforts. For example, participants discussed the increased severity of their
menstrual discomforts (i.e., pain and cramps and changes in cyclicity and blood volume). These
challenges were linked to a stressful prison environment and reduced coping strategies (i.e.,
limited resources, lack of institutional and family support).

Several women expressed a sense of disempowerment because of helplessness and the impacts
of the loss of autonomy and lack of privacy on their reproductive wellbeing. For participants
with childbearing experience in prison, losing autonomy over their pregnancy was profoundly
disempowering. These experiences indicate that limited autonomy and lack of privacy are
significant gendered pains of imprisonment among women.

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Finally, participants discussed how institutionally imposed prisoner identity outweighed their
reproductive wellbeing needs. Their overall experiences centred on how incarceration disrupted
their pre-incarceration roles and social expectations as women with complex reproductive health
needs, patients, pregnant women, and mothers.

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 Chapter Seven
The Relational Context of Incarcerated
Women’s Reproductive Wellbeing
In this chapter, I explore the second research question about the roles and functions of
incarcerated women’s social networks in their reproductive wellbeing. The functions as
articulated by the participants are clustered into two broad themes: 1) social surveillance and 2)
social networks as resources to cope with reproductive wellbeing issues. First, I explore the
participants’ experiences of social surveillance and its entanglement in their reproductive
wellbeing. I then describe how the incarcerated women’s social networks serve as resources to
cope with the pains of imprisonment concerning their reproductive wellbeing.

A social network is defined as a group of people within a bounded setting who are connected
through social interactions (Sentse et al., 2019). This relationship affects individual and
collective behaviours over time (Steglich et al., 2010). In the current study, these social networks
can be grouped into inside and outside social environments. The inside interpersonal networks
may refer to their prison peers and staff. Outside social ties include family members, friends, and
private organisations.

7.1 Theme 1: Social surveillance

Social surveillance refers to the complex activities performed by incarcerated women on the
behaviours of their peers. In this section, I outline various situations of social surveillance of the
behaviours and actions of incarcerated women: 1) peers’ gaze, 2) tattling and 3) gossiping. I also
illustrate how the social surveillance role shapes the participants’ reproductive wellbeing and
experiences.

7.1.1 Peer’s gaze

Several scholars have argued that using inmates to help supplement the custodial force and rules
enforcement extends the institutional power and a systemic attempt to preserve prison identity
(Hayner & Ash, 1940; McCorkle & Korn, 1954). My interviews with incarcerated women

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revealed how some of their peers performed rule enforcement. For example, they framed the role
of nanunungkulan (inmate leader) and the trustees as a gaze. Inmate leaders are female prisoners
who are informally deputised by the correctional officers to implement some custodial roles,
such as executing dorm rules, mediating conflicts among prisoners, imposing disciplinary action
for violations, and preserving the upkeep of the dorms and unis. Additionally, correctional
officers utilise inmate trustees to help the inmate leaders. Trustees are chosen by the inmate
leaders and are assigned to augment the prison officials’ administrative and clerical work. For
example, medical assistants for health services are an example of trustees (see chapter five for
specific functions of medical assistants).

Jessica commented on the gaze role of inmate leaders and trustees: “They try to act just like
prison personnel. But they forget that they went through the same prison process as we did and
wore the same prison attire just like the rest of us”. Several participants discussed how the ‘gaze’
role of inmate leaders and trustees shaped their menstruation experience.

Maine: “Many women always keep an eye on your cleanliness and hygiene. I
had many encounters being scolded because I leaked through during my period
days. It is hard on my part to keep tabs as I have a heavy period. I understand
their concern, but they must be compassionate because not all women are
alike. I hope they can feel what I have been through and not judge other
women and me about our hygiene”.

Elaine: “I do not like when I have to explain and justify to them that I have
extreme period pain, which is why I cannot follow some rules. Here in prison,
we have to follow our daily structure or routine from when we wake up in the
morning until nighttime. Sometimes I fail to follow those rules because of
period discomforts, and I need to explain these to the inmate leaders.

Evident in the above extracts of Maine and Elaine were their experiences of prison regulation
over their space, routines, dress, and comportment needs. Their narratives also demonstrate that
these prison regulations disrupted their menstrual needs and behaviours. These experiences
reflect Crewe et al.’s (2017) gendered pains of imprisonment, indicating how women struggle
with the prison and other people’s ‘rules and orders’ over their behaviours and activities.

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The narratives of Maine and Elaine also indicate how their personal and intimate activities were
subject to institutionally imposed peers’ gaze. Though they acknowledged that these peers were
performing the assigned tasks, the institution’s rigid rules infringed their privacy and personal
space, including their menstrual practices. Evident also in the interviews were the practices of
using inmates to manage other inmates, which is known in the literature as the Building Tender
System (BTS). This arrangement describes an existing power hierarchy among prisoners. As
Liebling and Arnold (2012) stress, prison institutions tend to work cooperatively with those at
the higher end of this hierarchy, trading freedoms and trust for cooperation and some degree of
self-policing among the inmates. Similarly, Cloward (1960, p. 48) concludes that the inmates in
the power hierarchy constitute a significant source of social control in prison to achieve the
stability and order desired by the elites and the prison authority. Hence, the establishment of
power is affected by the structures formed from the top and the dominant system of social
control (Foucault, 1978) and the complex interactions between individual prisoners (Goffman,
1961).

Liebling (1999) argues that white, professional, older prisoners sometimes occupy these higher
and more influential roles in Western prisons. These prison leaders act informally as go-
betweens, spokespeople, negotiators, and mentors for younger, less articulate prisoners while
contributing to order on the wing (Liebling, 1999). This analysis is relevant to the present study,
as complaints of over-policing by peers were more palpable among newly imprisoned, younger,
and less educated women. Those at the top of the hierarchy had been affluent professionals and
had longer incarceration years.

Several participants discussed how their peers monitored their daily shower or bath frequency.

Venia: “We take showers at least twice a day in the morning and at
nighttime…yes, we are being monitored by other prisoners and write it down
in the logbook how many times we take showers a day”.

April: “There is no severe penalty if you fail to follow the recommended

shower frequency. But you get reprimanded, and I am not sure what the
maximum number of offences is and the long-term consequence. The not-so-

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 good is you might be judged and labelled as matigas ulo or hard-headed, and
much worse a ‘messy’ person because of your hygiene”.

The accounts of Venia and April mirror the common experience of policing over their hygiene
practices. Their experience demonstrates the institutional impact of prison on women’s bodies,
the diffuse power of prison, and how it was exhibited in peers’ surveillance.

7.1.2 Tattling
In the current study, women discussed their peers' various forms of social surveillance in the
context of reproductive wellbeing. The participants described one common form of peer
surveillance: sumbungera or ‘tattler’. Sumbungera is a prisoner who discloses secrets or shares
information about their peers’ activities with the inmate leader or prison officers.

Sara: “There was one instance when I asked my husband to buy me a specific
brand of pain medicine because it was not available in the infirmary. One
dormmate found out I had this medication without telling the medical
assistants. So, she informed the dorm head, and I was reprimanded”.

Gicel: “I was caught selling menstrual pads to other women. It is not illegal
here, but it is extremely regulated because prison staff might think you are
taking advantage of other women or selling menstrual pads provided by the
institution or NGOs. I would also add you are competing with the prison store,
and you know what I mean. Later, I found out that an inmate in my dorm was
the one who told the prison staff. But I am still doing it- selling those stuff but
in a more subtle way”.

The stories by Sara and Gicel reflect the inmate code – the unwritten rules and values developed
among prisoners (Clemmer, 1940; Irwin & Cressey, 1962; Wooldredge, 1997). As explained by
Clemmer (1940), Irwin and Cressey (1962) and Wooldredge (1997), inmate code is a collective
response of the prison community to cope with the pains of imprisonment. The value attached to
the ‘no tattling’ norm is apparent among women in the current study.

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7.1.3 Gossiping
Einat and Chen (2012) indicate that gossiping or making idle talk about others’ personal affairs
causes social conflict, reduces positive relationships, and contributes to psychological harm and
poor wellbeing. Both Kruttschnitt et al. (2000) and Greer (2000) suggest that the limited
cohesive connections among women prisoners may be associated with the changing physical
environment of modern prisons (e.g., shift from therapeutic homelike spaces to a highly
regulated dormitory setting). While a few participants in the current study considered themselves
loners or preferred to be loners, they noted that it would be impossible to avert interactions with
peers and prison officers. Some participants stressed the need for cautious interaction and being
surrounded by reliable peers to avoid conflict. Marlet remarked her ‘calculated’ contact with
peers: “It is really better to be friendly, but not too much, as you have to be mindful also of your
interaction with other people to avoid conflicts”. She continued that one dorm mate shared
information about another inmate’s history of sexually transmitted infection. She added: “…we
got surprised because many people knew, and she was even being labelled as a prostitute. So,
gossip sucks, you know!” Some participants discussed their experience of peers’ gossiping:

Angela: “I heard other women talking about my pregnancy because I was too
young and involved in drugs. I arrived in CIW three years ago when I was 18
years old, and I was three months pregnant then”.

Jing: I have had only two close friends in my dorm since I came here…well, I
am not comfortable having too many friends because you cannot really control
how they interact with peers. The many, the more chaotic. You know, women
are women, and we love to talk and chat. I often hear people talking about
others”.

Evident in the narratives of Marlet, Angela and Jing was their sense of distrust due to the
gossiping behaviour of some peers, based on their first-hand experiences of gossip in prison.
According to the literature, gossip in prison increases social tension and distrust, reduces a
cohesive prison community, and creates inequality among women (Einat & Chen, 2012).
Revisiting Jing’s extract, her reason was different, and her calculated interaction with other
women was due to her negative perception of others’ behaviour. This distrust about extending

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trust is intensified by the perceived ‘jungle-like’ culture of women’s prisons (Genders & Player,
1990) because their relationships are continually compromised by ‘relationship talk’ (Crewe et
al., 2017), which was portrayed in the current study as ‘backstabbing’ and ‘gossiping’. Thus, the
narratives above suggest that these behaviours were viewed as unfavourable in prison.

7.1.4 Summary
The narratives from the participants indicate how their personal and intimate activities, time and
dress were subject to their peers’ gaze. The findings also show how prison institutions used
inmates to help supplement the custodial force, which mirrors an extension of the institutional
power of prison. The participants’ accounts also illustrate that these prison regulations disrupted
their menstrual needs and behaviours. These experiences reflect the gendered pains of
imprisonment, showing how women struggle with the prison and other people’s ‘rules and
orders’ over their behaviours and activities. As a result, several participants employed different
ways to manage the constant gaze of others, such as limiting interaction with other prisoners.
Furthermore, the interviews revealed the power and social hierarchy among the inmates. For
example, those at the upper end of the hierarchy tend to perform the policing role over other
inmates’ behaviours. Such social surveillance is the primary source of social control in prison to
achieve the order and stability imposed by prison authorities.

7.2 Theme 2: Social networks as resources to cope

with reproductive issues
This theme encapsulates how the incarcerated women’s social networks (i.e., family, NGO, and
prison peers) serve as resources to cope with the pains of imprisonment concerning their
reproductive wellbeing. The interviews revealed how the participants described the functions of
their social networks as 1) maintenance of their reproductive wellbeing and 2) prison peers’
family-like role.

7.2.1 Maintenance of (reproductive) wellbeing

Many participants verbalised that their social networks’ financial and material supports helped
them manage their reproductive wellbeing needs. Families were one of the largest financial and

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material support sources. These supports included money, medicines, food, and hygiene items,
such as soap, shampoo, and sanitary pads. Several participants received substantial comfort
because their families had remained supportive of them.

Elmarie: “My family has been the source to sustain my basic needs. They
sometimes provide hygiene items like soap, shampoo, toothpaste, and napkins.

Angelie: “Currently, my parents and kids are in my home province, and I am in

CIW here in Metro Manila, so we are like islands away…Despite our distance,
my mother has been sending money to help me with my everyday needs here
in [name of the prison]. Without my family support, it would be difficult on
my part to sustain those needs as the resources in prisons are extremely
limited”.

Apart from being a significant source of financial and material support, families were uniformly
considered by many women as their source of emotional support. Specifically, they discussed
their families’ support, love, and time as ‘enablers’ that helped them cope with their reproductive
health conditions and prison adjustment.

Marietta: “My condition was diagnosed in 2015, a year after I was

arrested…there is an on-and-off pain, but every time I get visited by my
family, I feel the comfort through their support. I wish I were with my family
now and spending quality time with them”.

Camille: “When I heard of this condition, I cried so much. I had difficulty

telling my husband about it. During his visit, I told him about my situation, and
he reassured me everything would be okay. During those difficult moments, he
never left me. He frequently visited and checked my situation. He bought some
things that I need, and I am thankful for his support, his presence and for not
giving up on me”.

The stories above show how incarcerated women’s families acted as a ‘buffer’ when they coped
with their reproductive health conditions. As elaborated in the literature chapter, inmates’
constant communication and interaction with their family and friends, mainly through visits, is

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associated with improved wellbeing and health (Cochran & Mears, 2013). Consistent with
previous studies, family members’ emotional, instrumental, and financial supports serve as a
buffer against the pains of imprisonment (Gibbs, 1982; Hairston & Lockett, 1987; Irwin &
Cressey, 1962; Noble, 1995).

Women with limited family support encountered substantial challenges finding resources to
sustain their basic needs. They discussed the role of prison social welfare, NGOs and religious
groups in helping them find resources, such as donations and linkage with support groups. Some
women shared that they were grateful for religious volunteer organisations' (RVO) assistance.
Women discussed how they participated in RVO’s gawain15 to obtain hygiene, menstrual
products, and items for their daily needs.

Eliane: I found out that by attending gawain through RVOs, you can get free
hygiene kits including pads, that is why I have been participating in their
activities to get more items, and I can save them”.

Venia: “I participate in gawain for two reasons, on the one hand for my
spiritual and mental health because there you get to share a story and hear
others’ experiences. On the other, you receive many items for free [laughing]”.

Considering the prisoners' limited resources and inadequate prison health services, participants
recognised the significant support from RVOs and NGOs helping prisoners in need. Some
women in the study stated that RVOs and NGOs were primary providers of material support for
their essential needs, including essential reproductive health care.

Jessie: “I am very thankful, you know, because of them, I was able to undergo
a medical procedure to get my condition assessed, and they were very
supportive to all prisoner patients like me who were diagnosed with chronic
reproductive conditions and also received similar support from NGO”.

15 Gawain refers to religious activities in prison organised by religious volunteer organisations such as
worship, prayer, and group activities.

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 Edelina: “Because I have had no contact with my family since I was
imprisoned, I felt lucky and thankful for the support from an NGO that
shouldered the expenses in the hospital when I underwent the therapy”.

Mothers with limited contact with their children expressed apprehension and distress from being
isolated from their loved ones and communities. The CIW social welfare department
spearheaded an outreach programme to address this challenge. The programme allows the
prisoners to gain information about their families and communicate through phone calls and
letters. Many women in the study stated that this programme lessened apprehension and isolation
and contributed to a greater sense of wellbeing.

Eula: “Although telephone calls are not free here, I am still grateful because
we have a chance to communicate with our family. I get to talk to my kids
weekly to know their situation, whereabouts, and school life. So, it is
reassuring to know they are okay and comforting to hear their voice”.

Bianca: “The social welfare staff have been very supportive of me. I was so
depressed during my pregnancy because I was away from my family. The staff
members were present assuring me and linking me with my partner even
though the family time was very limited due to strict policy on visits with
pregnant women”.

Maria: “I have observed that the staff always do their best to help us connect
with our family, especially our kids and family, given our limited resources
and competing priorities here in CIW. The livelihood programmes somehow
provide us with an opportunity to earn money for our telephone calls, and
many of us still provide financial support to our family, especially to our kids
during family visits or send money to our family”.

The participants’ accounts illustrate how their social networks served as resources to help them
maintain their reproductive wellbeing. The interviews also revealed the layering of support
provided by their social networks. For instance, their families served as their significant outside
social supports (i.e., material and emotional). These external social resources appeared to help
them with their reproductive health issues and played as a buffer against the pains of

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imprisonment. In addition, for women with limited family support, prison social welfare, NGOs,
and religious groups served as a significant source of resources, such as donations and linkage
with support groups.

7.2.2 Prison peers’ family-like role

Maintaining external social relationships is challenging because of the limited means and time to
communicate with the outside community (Bronson, 2008). Prison peers are often the only
directly available ‘interpersonal sources’ to fulfil their basic and social needs. Giallombardo
(1966) argues that female inmates re-create family units in prison as a coping mechanism, which
is often referred to in the literature as family-like relationships (Forsyth & Evans, 2003;
Giallombardo, 1966; Kolb & Palys, 2018; Larson & Nelson, 1984; Propper, 1982; Ward &
Kassebaum, 1966). This section discusses how incarcerated women’s peers play an enabling
family-like role in reproductive wellbeing.

Women’s peer networks can affect their behaviour, or as Giordano et al. (2002, p. 1045) suggest,
they may “reflect as ‘blueprints’ on how to change or behave in multiple ways through
interaction, particularly among prisoners”. Many participants found encouragement to lead a
more normal life and cope with their reproductive health issues from their peers in prison.

Rona: “I am very fortunate as many of my cellmates have been helping and

supporting me in many ways. They are like my pamilya (family) to me. For
example, when I first knew my [name of the condition] diagnosis, I cried very
hard, and they were there to support me. They accompanied me from my cell
to our common areas, so I didn’t feel alone. Honestly, it was a huge help
during those difficult times”.

Edelina: “My reproductive condition causes severe bleeding every time I have
a period. It is my most hated day because I rarely get up and I feel very tired.
Without the big help from my cellmates, who are like my kapatid (siblings), I
would not get through those tough times. They always remind me to take care
of myself and to be brave for myself and my family”.

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 Zara: “My nanay (mother) here in prison is very supportive. I call her nanay
because she always gives me advice and lessons about surviving here in CIW
during my early years and during tough times when I heard I had [name of the
condition]. Apart from giving me additional material support for my everyday
needs, she was always present when I needed help. She is like a mother to me”.

The extracts from Rona, Edelina and Zara illustrate that peer support provided reasons and
motivated them to cope with reproductive issues despite their difficult circumstances. This
finding is consistent with the literature, showing that prison peers are often the only directly
available ‘interpersonal sources’ to fulfil prisoners’ need for social connectedness (Bronson,
2008). These interpersonal relations provide social support that can be practical, material or
emotional (e.g., affection, caring) (Sykes, 1958). The use of Filipino terms like kapatid
(siblings), pamilya (family) and nanay (mother) mirrors the Filipino cultural norms of family-
like, communal living, and friendship support networks in the wider Filipino society. This
understanding aligns with the study conducted in Philippine men’s prisons, which showed that
Filipino values are endemic and unique in prison dynamics and coping mechanisms (Narag &
Jones, 2020). These Filipino cultural norms contributed to the development of liveable space,
despite the prison deprivations, as reflected in the narratives of Rona, Edelina and Zara.

Several women indicated that sharing problems with their peers served as an outlet for their
apprehension in prison. Sheenah, who had experienced heavy periods, attributed her ability to
sustain her menstrual needs to a friend’s support. She noted, “I felt hopeless during my first few
months in prison because I had no idea how to survive and had no resources to sustain my
everyday needs”. She added, “I remember when I had my first period here in prison, I leaked
through because of my heavy menstruation, and I had no money to buy pads”. My dormmate saw
my period leak and gave me support”. She expressed how grateful she was to her dorm mate.
Since then, her dorm mate has been sharing resources because she does not have resources, and
her family is in her home province. Sheena’s narratives depict the shared experience of women
who had less family support. These accounts illustrate Sykes’ (1958) notion of how prisoners
adapt to the ‘pains of imprisonment’ by fostering shared solidarity by helping other inmates in
need, as in the case of Sheena. This adaptation is known to minimise the deprivations and resist

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institutional dehumanisation. Thus, prisoner–peer relations may reduce the pains of
imprisonment (Sykes, 1958).

The interviews revealed that some women created a circle of friends based on shared
characteristics, such as speaking the same local language, coming from the same hometown, and
having similar reproductive wellbeing issues.

Angela: “…it started when I told one of the cellmates about my reproductive
condition, and it was too hard for me to adapt to the prison environment with
this condition. She told me she has the same reproductive condition as mine
and knew a few women here with the same condition. Our circle grew, and we
kind of developed that friendship because we shared stories about it. We
shared resources sometimes and helped each other because it is like a shared
struggle”.

Chai: “My close friend in our dormitory is like my sister. We are very close,
maybe because we share somewhat similar situations. We had our first babies,
and unfortunately, our first pregnancy experiences were inside the prison.
When I was imprisoned, I was five months pregnant. I was so quiet and
hesitant to talk. She approached me and asked questions. Then she shared the
story, and I felt comfortable. That was how our friendship began, and we
always talked about life, baby, and family”.

The narratives of Angela and Chai indicate how their similar reproductive and pregnancy
conditions were the main reason for their newly formed friendship. As noted in the previous
research, prison relationships are generally created based on similarities in race, age, educational
level, religion, or other sociodemographic attributes (Bronson, 2008; Crewe, 2009; Skarbek,
2014). What is unique in Angela’s and Chai’s cases is their shared reproductive health and
pregnancy situations that bond them, which was not captured in earlier studies.

Childbearing in prison is challenging for various reasons, including pregnancy without family
support and giving birth without a partner or support persons. Psychological, social, and
material resources are important factors that enable mothers to successfully cope with pregnancy,
particularly during labour and delivery (Glazier et al., 2004; Razurel et al., 2013; Tarkka et al.,

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1999). These supports are challenging for first-time mothers in prison, who are detached from
their psychosocial resources at home and in the community. Many pregnant women found
comfort and support from their prison peers in the mother’s ward.

Arbe: “I do not know how to describe the challenge I experienced as a

pregnant prisoner. If there were words much worse than ‘very difficult’, that
would be it. That feeling of being alone because your family is not here
physically…The presence of other women is a big boost to my spirit. It is
comforting to see other pregnant women, and you realise that you are not
alone, and they are there giving me advice and encouragement”.

Jeanneth: “As a first-time mom, I am inexperienced and scared about

pregnancy. But I managed the difficult time through the help and support of
other women in the mother’s ward. They always provided me with advice and
support. They reminded me to be strong for my baby and not get worried as
they are always by my side to support me if I need help”.

The extracts of Jeanneth and Arbe show that peer and companion support alleviated the absence
of their partner or family members throughout their pregnancy. This peer support lessened
participants’ anxiety and isolation during pregnancy in prison. The data above validate the
findings of earlier research studies, showing the existence of family-like kinship networks
formed by women to fulfil lost familial roles, such as daughter, mother, and partner
(Giallombardo, 1966; Larson & Nelson, 1984; Propper, 1982; Ward & Kassebaum, 1966).
Additionally, several scholars argue that involvement in family-like relationships is a women’s
way of coping with the pains of imprisonment, particularly separation from families (Harner &
Riley, 2013; Kruttschnitt et al., 2000; Severance, 2005).

Furthermore, as described in chapter six, the data indicate that although incarcerated women’s
‘prisoner identity’ overshadowed their other status (i.e., pregnant women, patients, menstruating
women), their peer relationships appeared to acknowledge their neglected identities. Specifically,
participants’ accounts of their peers’ family-like roles illustrate how prisoners recast their
negotiated and evolving identities, reflecting resistance to the institutionally imposed dominant
prisoner status.

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7.2.3 Summary
The above discussion shows how incarcerated women’s social networks served as resources to
help them maintain their reproductive wellbeing. The interviews also indicate the layering of
support provided by their social networks. For instance, their families served as their significant
outside social supports (i.e., material and emotional). These external social resources appeared to
help them with their reproductive health issues and played as a buffer against the pains of
imprisonment. Women with little family support encountered difficulty finding resources to
sustain their basic needs. These women found support from prison social welfare, NGOs and
RVOs that provide essential items and other services.

Furthermore, the findings illustrate that for those women with limited family support, prison
peers were the only directly available ‘interpersonal sources’ to fulfil their basic and social
needs. Their narratives also validate the dominant features of incarcerated women’s social
networks in earlier studies, which are family-like, caring, and demographics based. Moreover,
the interviews found how women create prison friendships with peers with similar reproductive
health conditions and experiences. Finally, the research reveals how Filipino cultural values and
norms shaped women’s coping mechanisms in prison.

7.3 Chapter summary

This chapter has examined the second research question about the roles and functions of
incarcerated women’s social networks in their reproductive wellbeing. The interviews with the
incarcerated women reveal two broad themes that describe the functions of social networks: 1)
social surveillance and 2) social networks as resources to cope with reproductive wellbeing
issues.

Participants’ accounts indicate how prison institutions use inmates to help enforce custodial
force, mirroring an extension of the institutional power. Several women discussed how their
personal and intimate activities, routines and dress are subject to institutionally imposed peer
gaze. These experiences reflect gendered pain imprisonment, showing how women struggle with
the prison and other people’s ‘rules and orders’ over their behaviours and activities. As a

145
response, several participants employed different ways to manage the constant surveillance, such
as limiting interaction with peers.

Despite the institutionally imposed social surveillance and its negative impacts on women’s
reproductive wellbeing, several women in this study described the enabling function of social
networks as their resources to cope with reproductive wellbeing issues. The interviews indicate
the layering of supports provided by the women’s social networks. For instance, their families
served as their significant outside social supports (i.e., material and emotional). These external
social resources helped them cope with their reproductive health issues and played as a buffer
against the pains of imprisonment. For women with limited family support, prison peers were
often the only directly available ‘interpersonal sources’ that helped them sustain their
reproductive wellbeing needs.

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 Chapter Eight
The Institutional Dimension of
Incarcerated Women’s Reproductive
Wellbeing
To answer the last research question on the institutional dimension of women’s reproductive
wellbeing experiences, the current study used theory-driven thematic analysis to examine the
data from focus groups with prison and health staff juxtaposed with incarcerated women’s
narratives. This chapter is divided into two broad theoretical themes: 1) navigating the total
institution and 2) extension of the total institution. First, I articulate how the characteristics of
Goffman’s (1961) total institutions manifest in a prison setting in the context of reproductive
wellbeing. Second, building on the experiences of incarcerated women accessing reproductive
health care outside health facilities (as described in chapter six), I explore how the total
institution extends beyond the prison spaces by analysing the prison regulations and policies
concerning medical transport and outside hospital reproductive health care.

8.1 Navigating the total institution

In this section, I apply Goffman’s (1961) concept of ‘total institution’ to the data sets obtained
from the focus groups with prison nurses and the Gender and Development (GAD) committee
members. Specifically, I begin the analysis with a discussion of the ways that staff members’
accounts reflect ‘total institutions.’ This process allows a better understanding of the prison
regulations and policies concerning incarcerated women’s reproductive wellbeing. This sub-
section presents the four theoretical themes that describe the prison as a total institution: 1) over-
attention to schedules and routines, 2) bureaucracy and under the same authority, 3) prisoners are
treated alike, and 4) rational institutional plan (Goffman, 1961).

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8.1.1 Over-attention to schedule and routines
According to Goffman (1961, p. 6), one of the characteristics of prisons as total institutions is
“all phases of the day’s activities are tightly scheduled, with one activity leading at a prearranged
time into the next, with the whole sequence of activities being imposed from above by a system
of explicit, formal rulings and a body of official”. As illustrated in chapter five, all incarcerated
women described the tightly scheduled and highly routinised daily prison activities. This
schedule includes wake-up time, roll calls, mealtime, studying, working, and social events (e.g.,
sports events, religious activities). In addition, some women pointed out how the prison’s over-
attention to schedule and routines impacted their distinct reproductive wellbeing needs. For
example, revisiting Jocelyn’s accounts in chapter six, she remarked that she set aside her
menstrual discomfort because she needed to participate in the daily activities and perform her
assigned tasks. Her story mirrors the common experience of many incarcerated women in this
study of how prison practices and attributes override women’s reproductive wellbeing.

The prison staff members were asked if there were considerations to the prison schedule and
routines, particularly the distinct needs of incarcerated women.

GAD member 2: “With regard to your question about some women who are
unable to perform some prison tasks or follow the schedules due to menstrual
complaints and reproductive issues. We accommodate those complaints
because we acknowledge that women have various problems and needs that are
distinct. But the universal policy is everyone must adhere to the schedule and
rules, and no one is special and exempted from these rules.

GAD member 3: I’d like to highlight also that it depends on the decision of the
prison leaders in their dorm since they know their fellow inmates and peers
better than us. We also encourage prison leaders to manage their peers in their
dormitories. Because you know some prisoners make excuses to stay away
from their assigned tasks. We need to be clear about schedule and rules and be
consistent with the rules here”.

The prison staff members emphasised the importance of the consistency of rule compliance and
policy implementation. They also discussed different scenarios that require consideration and

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exemptions from the rules. Although they acknowledged the various needs of women, some
prison officers argued that consistency and strict compliance prevent prisoners from abusing the
exemptions by making excuses and false complaints. In addition, evident in the focus group
discussion was the role of inmate leaders as gatekeepers and enforcement of schedules and
routines, which was thoroughly described in chapter seven. Criminologists have argued that this
prison characteristic can be observed in daily routines and schedules that do not only exist
because time is highly controlled within the wider criminal justice system, but also because they
help to maintain order, rule adherence, smooth operations, and institutional control (Bottoms,
1999; Cope, 2003; Sparks et al., 1996).

8.1.2 Bureaucracy and under a single authority

All dimensions of everyday life are done in the same place and under the same central authority
(Goffman, 1961). Within this framework, the various activities provided comply with one
prominent feature of total institutions: “collectively regimented persons and the handling of
many human needs by the bureaucratic organisation of whole blocks of people” (Goffman, 1961,
p. 6). Several studies found the negative impacts of rigid authoritarian and bureaucratic
organisation in prison on the prisoners’ experiences, including their wellbeing (Colsher et al.,
1992; Haesen et al., 2021; Hurley & Dunne, 1991; Twaddle, 1976). In the present study, many
incarcerated women consistently noted the strict protocol to be followed before being admitted
into the infirmary or transferred to a nearby hospital. These prison practices contributed to their
sense of helplessness.

The prison staff acknowledged how complex bureaucratic layers exacerbated the prisoners’
negative experiences of reproductive health problems. For example, in the focus group with the
health staff, all participants recognised the prisoners’ concerns about the slow and complicated
healthcare processes.

Nurse 1: “I believe the concerns about slow processes are valid. But we need to
institute protocols to make it easier to manage the different needs and
prioritise. The CIW cannot address all their concerns. The protocols are in
place to promote a more organised approach. For example, an inmate must first

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 inform the medical assistant in their dormitory for proper referral to the
infirmary”.

Nurse 2: Let me add that it is difficult for all the health staff to handle all the
complex needs of 3000 plus inmates. That is also why we ask for the help of
the medical assistants- they are volunteers who assist us in managing the
patients’ schedules and other basic stuff. These medical assistants are
gatekeepers to prevent the influx of patients to the health infirmary”.

As illustrated in the above extracts, although health staff members acknowledged the
complicated health care processes, they noted that the prison protocols are designed to manage
and prioritise the varying health needs of the prisoners, given the limited number of health staff
and scarce resources.

In ‘On the characteristics of total institutions,’ Goffman (1961, p. 6) underscores that in total
institutions, “all aspects of life exist in the same place and under the same single authority”. This
notion is evident in the present study, as many incarcerated women consistently mentioned the
need for Department of Justice (DOJ) permits before prisoners can access health care services
outside prison. The health staff members in the focus group were asked about the policy on DOJ
permits. While sympathetic, prison nurses were powerless to help incarcerated women with
distinct needs due to regulations beyond their control.

Nurse 1: “We wish we could help all the PDLs for their health needs, but there
are protocols that we are also bound to follow. This rule is beyond our
control”.

Nurse 2: “Although the concern centres on health, the request for hospital
appointments and transport is still under the DOJ. The CIW is under the
administrative jurisdiction of the DOJ. That’s why it is a long and complicated
process. All outside appointments and transportations (e.g., hospital
appointments, court visits, prenatal) must be approved by DOJ or court order
depending on the recommendation.

During the focus group with the GAD committee, members discussed the decision-making
process, organisation, and administration of DOJ permits for prisoners that require outside
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hospital care. All participants reported that the decision around the DOJ permit primarily
depends on the prison health care team’s recommendation to seek outside health care, usually the
doctor. However, since the institution had no in-house physician during the data collection
period, they had to wait for a visiting doctor from another prison. This situation contributed to
the health care delay. Finally, when asked if there were exemptions from the rule, all noted that
the only criteria are emergency cases that require immediate hospital medical attention.

GAD member 1: “We follow a protocol here. Before sending a request to the
DOJ, we ask the health unit for the recommendation because the DOJ will
assess it. Because most requests are not only for health reasons, CIW has to
manage multiple requests”.

GAD member 2: “If I may add all right, you asked about cases that need
regular hospital appointments like prenatal care and cancer treatment. The
permit is only done once because it indicates the frequency is outlined there.
But the implementation depends on the CIW as recommended by the health
unit.

GAD member 3: “In terms of some exemption from the rule, emergency cases
do not need DOJ permits, such as chronic medical conditions, life-threatening
cases, and women in labour. The health unit will assess it, and the CIW
director will approve the request. It is a very rare case”.

Health staff members also discussed other factors that contributed to health care delays. These
reasons included limited health staff and inadequate equipment.

Nurse 1: “I would like to explain that the delay is due to limited medical staff.
Currently, we have only three full-time Corrections nurses, and we don’t have
an in-house doctor.

Nurse 2: “Apart from limited health human resources, the infirmary does not
have all the equipment like specialised laboratory tools to diagnose
reproductive health conditions. For instance, we need to refer some inmates to
nearby government hospitals for reproductive cancer treatment and prenatal

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 care. The referral also depends on the capacity of the prisoners to pay since
hospital payment is outside of the prison’s responsibility. Those services are
not free, and CIW has no funding for those cases, so we need to assess their
financial capacity and prepare for a referral. It is a complicated process”.

Nurse 3: In terms of payment, the sick prisoners primarily shouldered the fees,
not the prison. But prisoners with a PhilHealth card get subsidised by
Government insurance. We have no records about their insurance because it is
an arrangement between prisoners and the hospitals”.

Goffman generally describes total institutions as a rigidly authoritarian and bureaucratic

organisation, but he does not explicitly state other institutional factors that may contribute to
rigid and highly bureaucratic processes concerning health care in prison. In the present study,
accounts of the health staff revealed how limited resources in terms of funding and staffing
requirements contributed to rigid protocols, subsequently causing health care delays. The focus
group showed the fundamental institutional causes of the delay. First, the limited medical staff
was considered one of the systemic factors of health care delay. Given the number of inmates,
the prison instituted protocols to manage many prisoners with various reproductive health needs.
Second, the deficiency of medical equipment was one of the main causes of health care delay.
Lastly, inadequate funding was considered the prime reason for insufficient staff and equipment.

Goffman’s description of a total institution as a rigid bureaucratic organisation resonates with the
present study. The accounts of interview and focus group participants consistently indicated the
need for Department of Justice (DOJ) permits before prisoners can access health care services
outside prison. These complex bureaucratic layers exacerbated the prisoners’ negative
experiences of reproductive health problems.

8.1.3 Prisoners are treated alike

Goffman (1961, p. 6) argues that in total institutions, “each phase of the member’s daily activity
is carried on in the immediate company of a large batch of others, all of whom are treated alike
and required to do the same thing together”. This feature of total institutions deviates from the
common belief of individual living and diverse and personal choices in the outside community.
In this study, interviews with incarcerated women revealed specific examples of prison

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institutions’ disregard for women’s distinct reproductive wellbeing needs. As indicated in
chapter six, most women struggled to access feminine hygiene products, such as menstrual pads
and soap. In the focus group with the GAD members, the participants were asked about the
insufficient menstrual pads and hygiene items that many women consistently described. They
were also asked how the institution defines basic needs and addresses those common needs of
women prisoners.

GAD member 1: “The concerns about insufficient pads are valid and
understandable. I would like to explain that CIW has no permanent fund for
menstrual pads. Sometimes we have extra funds to buy hygiene items, but it is
not regular. Thus, we depend on support from NGOs. Our health budget is
only P5 ($US 0.1) per prisoner per day”.

GAD member 2: “You know in here we have to prioritise because prisoners

have various and different needs. It is not practical that we provide everything.
The basic needs regularly provided by the institution are food and water.
Sometimes, we provide some hygiene items, such as bath and laundry soaps
and shampoo. So, other personal items like their hygiene are prisoners’
primary responsibility. But we provide some support for individuals in need
like abandoned prisoners or those who have no means to sustain their other
basic needs”.

GAD member 3: What we can provide are food and water. The funding is
minimal. For example, the budget for food is P60, or US$2, for every prisoner
per day. To be honest, prisoners have various needs to be regularly sustained,
and the institution has struggled to provide for them. I don’t know what we’d
do if we didn’t get outside help from NGOs and religious groups”.

The focus group revealed the institutional causes of inadequate menstrual pads and other hygiene
items. These reasons were lack of regular funding and competing priorities in prison. The
discussion also indicates how staff members framed basic needs. As shown in their reports, they
commonly equated basic needs with food, water, and some hygiene items and outside of these
needs are prisoners’ responsibilities. Furthermore, staff members also highlighted that despite the

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limited resources, they gave attention to the distinct health of prisoners in need, such as women
without family support and the means to sustain their everyday needs.

Prison officers often face the realities of managing the tension between institutional restrictions
and accommodating the various needs of prisoners; hence, they are often torn between the rigid
application of the sameness principle and the practice of greater flexibility (Crawley, 2005;
Sparks et al., 1996). This situation is palpable in the accounts of prison staff members. Most of
the focus group participants recognised the distinct needs of prisoners that require special
attention, but they also stressed that they are guided primarily by the equality and sameness
principle. They argued that everyone must be treated alike and no one is special.

GAD member 1: “You asked if we have special food for pregnant women or
sick patients. The answer is no because rancho (food supply) is prepared for
everyone. Also, pregnant and sick prisoners are not a big group, so we do not
think it is necessary. We have a special arrangement for them. We usually ask
volunteer inmates to collect the rancho and deliver it to their rooms. The
policy here is everyone must follow the schedule for mealtime, and they should
queue”.

GAD member 2: “We don’t allow pregnant prisoners and sick patients to go
public and shared spaces to protect them from infection because they are
vulnerable and have low immunity. You know prison is extremely crowded”.

The focus group with the GAD members illustrates how the prison staff navigated the tension
between custody, culture, and care. Prominent in the focus group discussion was the impact of
prison rules on prison officers’ decisions when confronted with opposing circumstances.
Furthermore, the reports from the focus group demonstrate how the institution reinforced the
prisoner identity of pregnant and sick women.

The tension between care and custody is profound when correctional nurses and prison officers
enter each other’s professional boundaries. The focus group revealed the collective frustration of
nurses and prison officers. According to prison officers, there were instances wherein they had to
intervene with caring concerns among the prisoners. This situation resulted from limited health
staff (e.g., prison nurses are preoccupied with helping other sick patients). One prison officer

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expressed how she maintained a clear boundary between her custodial role and the provision of
care: “Our main job as prison officers is custodian, and sometimes I want to help wherever
necessary and possible, but I am not a caretaker”. This role demarcation was disrupted when
prison officers faced situations that pushed them to provide care for prisoners, even if it was
perceived to deviate from primary prison obligation:

GAD member 1: “I had this experience accompanying a pregnant prisoner in

labour to the hospital. I was the officer on duty that night. The nurse was busy.
So, I was the lone officer in charge. On our way, the pregnant prisoner was in
pain. I didn’t know what to do. I tried to motivate her and held her hands. I felt
sad that her family was not there. I then had to remind myself that my primary
job is prison officer, not a health worker”.

GAD member 2: “Many of us had similar experiences. But it is important that

we also set the boundary as prison professionals- not to get attached personally
to the prisoners. That’s why we have gatekeepers, the prison leaders and
trustees, who should help and support their peers”.

The accounts of prison officers revealed how they struggled to remain detached from prisoners
because they sought to avoid expressions of personal and emotional connection with prisoners.
The prison officers’ accounts reflect Hochschild’s (1983) concept of emotional labour, which
she describes as managing feelings and expressions according to a job’s emotional requirements
or expectations. The focus group’s reports showed prison officers’ usual way of reducing
interaction with prisoners by using prison leaders and trustees as gatekeepers of their peers.

For prison nurses, the difficulty of reconciling their professional caring role with the prison
culture and ideology was profound.

Nurse 1: “I remember in the first few years in prison, I struggled to understand

how we nurses work in a very restricted workplace. I slowly got used to it. We
must be mindful and cautious about many restrictions and less personal
interactions with prisoners”.

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 Nurse 2: “It is difficult, to be honest, to see very sick prisoners or those with
chronic conditions and pregnant women here in prison. As a nurse, I cannot
help but ask why we are putting them in jails? They should be in the hospitals,
not here”.

Nurse 3: “You get you used to this kind of story. So, what we do is just focus
on our job. We focus on giving health care- the technical aspect of our job.
That’s what we are paid for, after all, right?”

As illustrated by the prison nurses’ accounts, undertaking both caregiving and custodial
dimensions of the job caused professional and personal conflict when they were compelled to act
opposite to the nature of their health care job and feelings of compassion. This observation
coincides with the previous research, indicating the dilemma of prison nurses managing the
difference between the ideal care role of their profession and the actual care they provide
because of prison regulations and job expectations in prison (Humblet, 2020; Puthoopparambil et
al., 2015; Walsh, 2007). Moreover, the incarcerated women’s experiences about the prison’s
inability to address their reproductive wellbeing needs and the prison officers’ tendency to
adhere to the institutional rules mirror Crawley’s (2005, p. 356) ‘institutional thoughtlessness’,
which was based on her study on imprisoned elderly men. She defines it as “the ways in which
prison regimes simply roll on with little reference to the needs and sensibilities of the old”. Her
view is relevant to the current study because prison is institutionally thoughtless in addressing
women’s complex reproductive wellbeing needs.

The focus group participants’ accounts of the prison sameness policy reflect Goffman’s idea.
Although the staff members recognised the distinct needs of prisoners that require special
attention, they stressed that their decisions and actions concerning prisoners’ needs were guided
primarily by the prison equality and sameness policy. As their reports highlight, prison
standardised the needs of prisoners, including women’s reproductive wellbeing.

8.1.4 Rational institutional plan

Goffman (1961) argues that in total institutions, the different institutionalised activities are
brought together into a single rational plan supposedly designed to fulfil the official goals of the
institution. Discussion on total institutions focuses on believing prisoners improve because of

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their imprisonment (Karmel, 1969; Sykes, 1958). In prison parlance, improvement is measured
by the high and consistent conformity to “prison standards of behaviour defined by the institution
as desirable” (Karmel, 1969, p. 134). This view on prison’s official goal resonates with the
present study. Many participants in the focus group consistently stressed that some women’s
situations could not be accommodated because, apart from the extremely limited resources in
prison, they deviate from the prime purpose of prison, which is to ‘improve’ the prisoners
through rule conformity.

GAD member 1: “In terms of pregnancy support, we recognise the various

gaps that we often face. Yes, we have very limited support for pregnant women
because we currently don’t have an obstetrician, psychologist, or pediatrician
to support them. But we also need to consider whether investing in these kinds
of support is practical since we have limited resources and prison is not a place
for pregnant women and their babies. For me, prison is designed to improve
prisoners and help them improve psychosocially before they go back to the
community”.

GAD member 2: Just to add to that, we don’t have laws very specific to
support pregnant women and babies in prison. So, it is hard on our side how to
go about it. It is easier said than done. To do it, we need staff, training, spaces,
and financial resources. But again, it goes back to the discussion, is prison a
place for pregnant women and babies? That’s why we don’t have conjugal
visits for women – primarily to avoid pregnancy. And that’s the reason too
why we only allow babies to stay for one year”.

GAD member 3: I agree. It is hard to imagine if we allowed conjugal visits for

women. What if the woman gets pregnant, who will support them? Guidelines
are needed on how to conduct conjugal visits. Family planning and issues on
sexually transmitted infection must be given primary importance. How do we
deal with pregnant women with limited resources? Who will take care of the
baby if the family cannot raise the child? I am afraid all these cases do not
support the primary goal of the prison of improving the prisoners before they
reconnect with the community”.

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The institutional aim of the prison, which is to improve prisoners’ behaviour, dominated the
focus group with the GAD members. The focus group data revealed that although staff
acknowledged the need for holistic support for women’s sexual and pregnancy needs, they
argued that complex situations, such as conjugal visits and pregnancy needs, must be understood
in the context of carceral relevance and practical approach. This view emerged when staff
members were asked whether the prison must support conjugal visits and allow longer stay of
babies in prison as part of comprehensive support for mothers and babies. They stated that
prison, for now, is not prepared for these programmes due to limited resources, lack of clear laws
and guidelines, congestion issues, and health issues for pregnant mothers and babies.

When asked about other institutions’ programmes designed to ‘improve’ women prisoners, the
focus group participants enumerated different programmes, namely the Therapeutic Community
Modality Programme, religious activities, education programmes, livelihood and vocational
training, recreational activities and family visits.

GAD member 1: “The Therapeutic Community Modality Programme is used

to rehabilitate substance abusers. This programme has structured activities,
social group work, leadership training, which aims to ‘rehabilitate’ detainees,
and is overseen by the Inmate Welfare Development officer. Its goal is to teach
responsibility, good behaviour, and communication skills within a framework
of mandatory activity- a more ‘community-like’ environment. The activity
usually starts with a morning prayer followed by a group meeting and carries
through ― via duties and activities ― until early evening”.

GAD member 2: “CIW also has different programmes to support their

education so they can continue their education here based on their baseline
competency. Additionally, we also offer vocational and livelihood training
programmes, so the inmates have the opportunity to learn new sets of skills or
use their existing skills to earn and use them (hopefully) once they get back to
their community”.

GAD member 3: We also have many recreational activities and events that
allow inmates to socialise with their fellow inmates. Lastly, we believe that

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 family visits support the female inmates’ rehabilitation, especially having
quality time with their children”.

The discussion with GAD members revealed the different programmes perceived to improve
prisoners’ behaviours. The focus group data also showed the lack of specific programmes to
address the reproductive health needs of women prisoners.

The accounts of staff members mirror Goffman’s idea of the official aim of imprisonment. The
focus group revealed how institutionally defined goals (i.e. prisoner’s improvement) shaped
prison regulations and staff behaviours, consequently neglecting prisoners’ distinct needs, such
as reproductive wellbeing.

8.1.5 Summary
This section demonstrates various ways the prison practices mirror ‘over-attention to schedules
and routines’, ‘bureaucracy and under the same authority’, ‘prisoners are treated alike’, and
‘rational institutional plan’ – all components of total institutions. First, prison staff members
emphasised the importance of prison rule compliance and policy implementation. Although they
acknowledged the various needs of women, some prison officers argued that consistency and
strict compliance prevent prisoners from abusing the exemptions by making excuses and false
complaints. Second, the accounts of interview and focus group participants consistently indicated
the need for Department of Justice (DOJ) permits before prisoners can access health care
services outside prison. Third, prison officers argued that everyone must be treated alike and no
one is special. Prominent in the focus group discussion was the impact of prison rules on prison
officers’ decisions when confronted with opposing circumstances. Lastly, many participants in
the focus group consistently stressed that some women’s situations could not be accommodated
because, apart from the extremely limited resources in prison, they deviate from the prime
purpose of prison, which is to ‘improve’ the prisoners through rules conformity.

The prison officer’s accounts of prison’s over-attention to routines and schedules, bureaucratic
processes, and their decisions and actions in addressing the distinct of prisoners are primarily
guided by the sameness principle and prison’s institution’s goal mirror Goffman’s description of
total institutions.

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8.2 Theme 2: Extension of the total institution
As elaborated in the literature chapter, several scholars have pointed out the limitations of
Goffman’s total institutions (Cresswell, 2010; Follis, 2015; Moran et al., 2012). They argue that
imprisonment transcends the physical and architectural environment of the penal institution and
that punishment can be felt even outside of those static spaces (Cresswell, 2010; Follis, 2015;
Moran et al., 2012). Jefferson (2014) points out that to understand the experience of
confinement, it is vital to look not only at institutions or sites but also at their practices, rituals,
symbols, and meanings. Hence, prisoners’ movements through the geographical space of the
prison – including its extensions (for example, court, home/furlough, and hospital) – are
intensively controlled through prison security practices and routines (Follis, 2015; Moran et al.,
2012; Stoller, 2003). In this section, drawing on carceral geography and disciplined mobility, I
examine how prison as a total institution extends beyond the carceral boundary. To do so, using
the focus group data with prison staff, I explore how features of total institutions reflect in prison
regulations and practices concerning medical transport and hospital visits of incarcerated women.

Follis (2015) underscores that prisoners’ disciplined movement and mobility outside prisons are
inherent to imprisonment and incur substantial costs for the necessary security services. The
focus group with GAD members revealed that prisoners were not allowed to know the date and
time of their hospital visits. The rationale behind the policy hinged on the prison security
conditions that need to be observed.

GAD member 1: “That’s really a protocol we need to follow. All types of

transportations like a court hearing, home visits or health-related, we don’t tell
them the exact date and time of the transportation and appointment”.

GAD member 2: “Yes exactly, that’s for security purposes. That’s for the
safety of the staff, the hospital, and for the prisoners themselves, too”.

Prison officers are compelled to execute the prison's primary institutional interests, which are
maintaining order (Sparks et al., 1996; Sykes, 1958), and attention to security and consistent rule
enforcement (Liebling, 2000). GAD members' accounts confirm that hospital visits were
operationalised within constraints due to prison security conditions. Thus, prison security
conditions overrule the health needs of female prisoners during hospital visits. Ross et al. (2011,

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p. 263) argue that the “health care service is deeply embedded within the institution and reflects
the prison ‘culture’, with health care staff adopting the prison ‘climate’”. This complex prison
reality adversely affects women that require special services, such as pregnant prisoners and
those with chronic reproductive conditions, due to being perceived as part of a homogenous
group.

The spatial and social boundaries of prison remain intact even while the prisoners move outside
of the prison walls because the disciplinary measures, routines and symbols are continually
attached to them (Follis, 2015; Moran et al., 2012; Stoller, 2003). As elaborated in chapter six,
wearing handcuffs and prison uniforms and being in prison vehicles and accompanied by
uniformed officers were described by incarcerated women as highly humiliating. They argued
that these prison practices and symbols identify them as prisoners to other patients and staff,
producing negative emotions and fears around hospital attendance. These prison symbols (i.e.,
handcuffs, uniforms, prison vehicles) remind the women that they are still prisoners even in
hospitals.

The GAD members were asked about the prison policy on using handcuffs during hospital
appointments. They explained that handcuffs are a universal policy in prison, mainly for
prisoners under medium to high-security classification. They also added that they factor in the
prisoner-to-staff ratio during transportation. Although the practice of handcuffs was common,
they discussed some exemptions, such as very sick prisoners and pregnant women. They cited
the 2013 CIW guidelines on gender-sensitive prison management. According to this policy,
restraints on pregnant women during transportation, prenatal care, and labour are not allowed.

GAD member 1: “Commonly, we use restraints when they leave the prison
building for a court hearing, home visits, transfer to another prison, particularly
for inmates under high-security categories. But there are considerations, like
for sick prisoners and pregnant women, we don’t use restraints”.

GAD member 2: “Yes, we have a guideline for that- the 2013 guideline on
gender-sensitive prison management, the use of restraints on pregnant women
during medical examinations, transport to hospital to give birth and during
birth shall never be allowed”.

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 GAD member 3: “We acknowledge that there were complaints that this policy
was not consistently observed by prison staff. That’s why we need to orient the
staff about it, especially the new ones. The common reason was the limited
number of staff accompanying the prisoners. For example, one staff member
was assigned to five prisoners. So, we have been reviewing this practice to
ensure everyone adheres to it”.

The narratives of the focus group participants revealed the policy and practices around inmates’
hospital appointments. As illustrated in chapter six, the interviews with female prisoners
confirmed the reported challenges related to restrictions they experienced every time they sought
community-based health care. Several women described being told that they were going to the
hospital on the day of their appointment and that appointments were difficult to anticipate and
prepare. The prison staff acknowledged the prison constraints experienced by prisoners and
underscored that the rationale behind the policy is anchored on the prison security conditions.
Inconsistency between guidelines and implementation was palpable. Although the prison
guideline indicated that restraint must not be used during medical transportation, some women
stated that there were instances when they were restrained during hospital appointments. This
disconnect results from a lack of institutional commitment to ensuring that policy is consistently
implemented. The focus group indicated that incarcerated women with distinct needs (i.e.,
pregnant and sick) are viewed primarily as a security risk, not vulnerable populations.

8.2.1 Summary
This section shows how prison as a total institution extends beyond the prison walls.
Specifically, I explore how features of total institutions reflect in prison regulations and practices
concerning medical transport and hospital visits of incarcerated women. The accounts of the
prison officers revealed the policy and practices around inmates’ hospital appointments
overruled prioners’ reproductive wellbeing needs. Their accounts coincide with incarcerated
women’ experiences of prison restrictions every time they sought community-based health care.
Incarcerated women described being told that they were going to the hospital on the day of their
appointment and that appointments were difficult to anticipate and prepare. Inconsistency
between guidelines and implementation was evident. Although the prison guideline indicated
that restraint must not be used during medical transportation, some women stated that there were

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instances when they were restrained during hospital transportation and visits. This disconnect
results from a lack of institutional commitment to ensuring that policy is consistently
implemented by prison staff members.

8.3 Chapter summary

This chapter has addressed the last research question by describing the institutional dimension of
female prisoners’ experiences of reproductive wellbeing using the accounts of prison and
medical staff members in parallel with incarcerated women’s experiences. This chapter
illustrates various ways the prison practices and regulations reflect the characteristics of total
institutions. First, prison staff members emphasised the importance of rule compliance, and strict
compliance prevents prisoners from abusing the exemptions by making excuses and false
complaints. Second, the accounts of interview and focus group participants consistently indicated
the need for Department of Justice permits before prisoners can access health care services
outside prison. Third, prison officers argued that everyone must be treated alike and no one is
special. Prominent in the focus group discussion was the impact of prison rules on prison
officers’ decisions when confronted with opposing circumstances. Lastly, many participants in
the focus group consistently stressed that some women’s situations (i.e., conjugal visits) could
not be accommodated by prison because they deviate from the prime purpose of prison, which is
to ‘improve’ the prisoners through rules conformity. Additionally, the findings indicate how
prison as a total institution extends beyond the prison walls through disciplinary measures,
routines, security practices, and symbols (i.e., prison uniform, handcuffs, prison vehicle) that are
continually attached to them during hospital appointments.

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 Chapter Nine
Discussion and Conclusions
This research project is anchored on three research questions. The first question examines
incarcerated women’s experiences of reproductive wellbeing. The second question explores the
relational context of their reproductive wellbeing. Specifically, what are the roles and functions
of incarcerated women’s social networks in their reproductive wellbeing? Finally, the third
question analyses the institutional dimensions of women’s reproductive wellbeing. The goal of
this final chapter is two-fold. First, I situate the key findings of the current research in the
theoretical foundations underpinning the study. Second, I discuss the study’s limitations, critical
recommendations for policy, programmes, and future research, and my reflections as a
researcher.

9.1 The nexus between women’s reproductive

wellbeing and the pains of imprisonment
Several feminist criminologists have argued that incarcerated women have distinct gendered
pains of imprisonment (Carlen, 1983, 1998; Crewe et al., 2017; Genders & Player, 1987; Owen,
1999; Walker & Worrall, 2000). The women’s relatively small prison population has contributed
significantly to their “invisibility within the penal estate” (Carlen, 1983, p. 4). As a result,
women’s prisons are often organised and managed exactly like the men’s, thereby not
recognising women’s various physical and health needs (Carlen, 1983, 1998). The current
research project extends the framework to encompass the pains associated with women’s
reproductive wellbeing.

The current study found that women’s experiences of reproductive wellbeing were commonly
described as negative and complex as they negotiate their entitlements and needs. The interviews
revealed how the painful prison deprivations negatively impacted the participants’ reproductive
wellbeing experiences, including deficiencies in accessing equivalence of quality menstruation,
gynaecological and obstetric health care, comfort, and wellbeing support. Lack of women-
specific services and goods (i.e., limited sanitary and washing facilities) is the common gendered

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pain of imprisonment (Carlen, 1983, 1998; Genders & Player, 1987). The findings of the current
project resonate with the earlier arguments and provide more context that in a low-income
country with limited reproductive health support, the scarcity is even more prominent, and the
impact is more palpable. For instance, incarcerated women in the present study with menstrual
issues and chronic reproductive conditions did not obtain health care services equivalent to those
in the community (i.e., regular supply of pain medications and professional care).

Furthermore, apart from the heightened reproductive discomforts due to prison stress and poor
nutrition, imprisonment affects women’s capacities to cope with, or manage, reproductive
discomforts, such as taking a break from work duties and self-treatment. Furthermore, in the
current project, the participants’ limited autonomy and control over their reproductive wellbeing
contributed to their experiences of disempowerment. The present study corroborates with the
earlier studies indicating that loss of autonomy and control is the most significant gendered pain
of imprisonment for women (Carlen, 1983, 1998; Crewe et al., 2017; Genders & Player, 1987;
Owen, 1999; Walker & Worrall, 2000). Carlen (1983) argues that women encounter petty rules,
infantilisation and institutional control over their bodies, space, and presentation. As the current
study demonstrates, incarcerated women’s bodily functions concerning menstrual and
reproductive health needs and pregnancy are restricted, controlled, and neglected. The
participants’ experiences showed how the prison environment prohibited them from their usual
ways of managing their menstrual and reproductive conditions (e.g., warm showers, comfort
food, regular supply of pain medications, and personal space). Furthermore, this research shows
that discipline, control, and constant surveillance profoundly impact women’s ability to cope
with the ‘pains of imprisonment’ during the menstrual phase and seek medical advice and
treatment without professional help (C. Smith, 2009).

One of the significant deprivations among incarcerated women is the complete and utter lack of
privacy (Carlen, 1983, 1998; Crewe et al., 2017; Genders & Player, 1987; Owen, 1999; Walker
& Worrall, 2000). A lack of intimate space and privacy is a key characteristic of the prison
environment (Moran et al., 2013; Schwartz, 1972). There are many systemic barriers to privacy,
such as numerous rules and regulations, strict prison schedules, almost constant monitoring and
observation and architecture and design that regulate movement and interaction to prioritise
policing and surveillance (Foucault, 1978; Moran, 2013; Schwartz, 1972). In the current study,

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the lack of privacy and personal space was commonly expressed among the participants. The
women’s experiences of lack of boundaries and privacy in prison reinforce a feeling of
degradation and humiliation. They also expressed some acceptance of being ‘used to’ such
invasion of personal boundaries, resulting in the feeling of helplessness. The lack of control over
personal boundaries was a primary concern for pregnant inmates. This concern was more
palpable due to the pregnancy discomforts they experienced.

9.2 Mortification of self and reproductive wellbeing

When entering prison, prisoners leave everything that belonged to them and adapt themselves to
the new way of ‘carceral life’ (Goffman, 1961). Goffman describes the impact of imprisonment
on the inmate’s sense of self and identity as immediate and devastating. He called this
phenomenon “the mortification of the self”. The individual’s self is “systematically if
unintentionally, mortified” (Goffman, 1961, p. 24). The current study illustrates the women’s
narratives of how their institutionally imposed ‘prisoner identity’ overrides their reproductive
wellbeing needs. The incarcerated women’s reproductive wellbeing begins to be suppressed and
is substituted by new realities imposed by the prison environment. These self-losses and identity
disruptions result from “the dispossession of personal property and belongings and the stripping
of one’s identity kit, i.e., clothing and cosmetics that one has used to present oneself in one’s
social world” (Goffman, 1961, p. 20). The interviews with incarcerated women expand
Goffman’s analysis because many participants framed the absence of coping strategies to
manage menstrual discomforts in prison as debilitating (i.e., lack of warm shower, absence of
comfort food, limited personal space).

‘The mortification of the self” takes place parallel to the conception of a new dominant
identity—the prisoner's identity (Goffman, 1961). The erosion of the civil self, which existed
before incarceration, is supported by the prison administrative procedures, restrictions, and
routines. These procedures have a common goal to standardise the individual into an
‘administrative unit’ so that the unit can be effectively controlled (Goffman, 1961). Goffman
argues that the inmates might become mortified in prisons or suffer from losing the many roles
they occupied before imprisonment. As the accounts of the present study indicated, several
women expressed a sense of shame and humiliation when asking the prison officers or peers for

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menstrual and sanitary products (i.e., menstrual pads, soap). Their accounts encapsulate the
general feeling of being powerless and the degrading feeling of depending on the institution and
others for their personal needs. These experiences mirror Goffman’s analysis of how prison
institutions reduce prisoners’ status to powerless and dependent identity (Goffman, 1961). The
prison regime causes a loss of dignity, forcing the inmates to ask for their basic or personal needs
(Goffman, 1961). This assertion is palpable in the participants’ narratives (as described in
chapter six), where they expressed their experiences of asking for menstrual pads as nakakahiya
(embarrassing). Hiya was a common experience among the participants, especially among young
women and during their early incarceration, due to their reliance upon the institution and peers
for menstrual pads. Although this Filipino cultural concept of hiya can be applied to various
contexts (Jocano, 1998; Rafael, 1993), the participants' accounts reflect their feeling of
humiliation and vulnerability. Rafael (1993, p. 126) explains that to be in the state of hiya is “to
be in a vulnerable position and an embarrassment that arises from being overwhelmed”. Their
overall experience centred on how incarceration has altered their ability to negotiate and manage
the situations relating to their menstrual wellbeing.

The loss of pre-incarceration social and personal roles is a common consequence of incarceration
for both men and women (Crewe, 2009; Goffman, 1961; Sykes, 1958); however, it appears that
women with distinct reproductive conditions experience the impact of a loss of identity
differently compared with other female prisoners. Many participants in the present study
indicated that the prison authorities perceived reproductive-related discomforts as irrelevant;
hence, they did not warrant exemption or special consideration from any prison restrictions and
limitations. The participants expressed how prison practices and attributes (i.e., crowded place,
white shorts, assigned tasks) override their reproductive wellbeing. These prison characteristics
contribute to women’s experience of disrupted identities concerning their reproductive needs.
Women’s expressions in the present study, such as ‘everyone becomes the same’, ‘we are all
prisoners’, ‘no one is special’, show how the institutionally imposed ‘prisoner identity’ shaped
their experiences. These experiences contributed to their sense of depersonalised and fractured
identity as women with unique reproductive health needs.

Furthermore, incarcerated women with chronic reproductive conditions who were transferred to
the hospital for routine appointments felt public humiliation and embarrassment, especially when

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seen in prison uniforms and accompanied by prison staff. Goffman (1961) argues that this public
perception occurs when membership of a particular group, in this case as prisoners, becomes the
defining feature of one’s identity: their ‘master status’. Although not specifically related to
female prisoners, Goffman’s (1959) mortification of self has echoed in the present study,
illustrating how women with reproductive health conditions were given wearable marks of prison
that identify them as prisoners, such as handcuffs and prison uniforms, during hospital visits.
These prison symbols and attributes can engulf an individual’s identity, becoming “the filter
through which his or her other characteristics are seen” (Jones et al., 1984, p. 296). The
participants’ narratives in this study exemplify how their ‘prisoner identity’ becomes a master
status, fundamentally affecting how the public understands women prisoners accessing hospital
care and eventually influencing how women perceive their status as patients overshadowed by
the ‘prisoner identity’. Their experience in prison deviates from the general belief around the
‘special status’ of people with chronic medical conditions in the community who are perceived to
be vulnerable, are to be protected, and worthy of special treatment. In prison, it appeared that the
‘special’ status was ignored by the institution and was overruled by having an identity as a
prisoner and a criminal (Goffman, 1968).

Goffman (1968, p. 6) argues that “the inmate is dispossessed of certain roles that are part of
one’s self” because of the barriers that the prison authority places between the outside world and
the prisoners. The current study demonstrates that the unique social identity of pregnant women
is dissolved the moment they enter the prison environment: the pregnant inmates undergo the
mortification process (e.g., entering the prison spaces and being deprived of external social
resources), and most of the time they face significant restrictions, such as being unable to
connect with their family and support network regularly. For first-time mothers in the study, their
first pregnancy in prison caused a turbulent and ambiguous experience of motherhood. Many
participants expressed ambivalence and could not describe their emotions when they knew they
were pregnant. Their reports demonstrate how their inmate status altered their new identity as
first-time mothers. For first-time mothers, pregnancy and motherhood experience is a significant
psychosocial change for most women (McVeigh, 1997). First-time mothers, in general, may face
considerable challenges such as psychological and emotional distress and an inability to cope
effectively(Rallis et al., 2014; Razurel et al., 2013). Psychological, social, and material resources
are important factors that enable a positive transition to a new motherhood role (Razurel et al.,

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2013; Tarkka et al., 1999). This enabling transition appears difficult for first-time mothers in
prison, who are cut off from psychosocial resources.

The expression of shame was profound among pregnant women. The extracts from all
participants who had been pregnant in prison indicate their experiences of public shame and
humiliation as pregnant women in maternity clinics while wearing the prison symbols, such as
their uniform, handcuffs, and the presence of security staff. The participants’ experience of
humiliation is consistent with the previous literature regarding the stigma encountered by female
prisoners, where feminist theorists found that women who transgressed the social expectations of
being a good mother, such as women in prison, face severe public shame (Gelsthorpe, 2004;
Kennedy, 2011; Lockwood, 2018). The public shame is more profound among Filipino
incarcerated women because the women’s situation in the study contradicts the country’s ideal
and normative construction around motherhood and womanhood. Even today, the concept of
‘good mother’ remains a dominant defining characteristic for Filipino women, and mothers who
deviate from these expectations are viewed negatively (Peracullo, 2017).

The current study found that participants’ inability to fulfil their pregnancy needs (maternal
responsibility) and protect their pregnancy in prison were expressed as deviation from their
traditional mothering role, the symbolic loss of a salient characteristic of the Filipino mother’s
identity. Their inability to sustain pregnancy needs contributed to helplessness and self-blame.
Their experience is perhaps a culture-bound phenomenon, given that the Philippines is family-
oriented and largely pronatalist, which mirrors the dominant Catholic influence over the social
construction of motherhood (Alampay & Jocson, 2011; Blanc-Szanton, 1990; Licuanan, 1979).
Grounded in the conservative Catholic teaching, motherhood is highly valued and deemed a
national mission in the wider Philippine society, reflecting the Virgin Mary image and a colonial
vestige very deeply burrowed in the cultural psyche of the Filipino women (Mananzan, 1987;
Peracullo, 2017).

The narratives of pregnant prisoners and mothers perfectly illustrate Goffman’s analysis that
prisoners can feel a change “from a whole and usual person to a tainted and discounted one”
(1968, p. 3). The deprivations and challenges experienced by women signify that prison control,
the power differentials within, and the various distinct needs of women play a significant role in
the mortified self of the incarcerated women in the study.

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9.3 The relational dimension of incarcerated women’s
reproductive wellbeing
The impact of social relationships on one’s holistic wellbeing has been known and explored in
psychological and sociological scholarship (Baumeister & Leary, 1995; Durkheim, 1951).
Earlier studies have established the connection between social networks and prisoners’ wellbeing
(Cochran & Mears, 2013; Haney, 2018). Research has shown the various functions (both positive
and negative) of the inside and outside social networks in prisoners’ wellbeing (Cochran &
Mears, 2013; Haney, 2018). The current research project expands the current understanding of
the social networks’ roles, particularly in the context of incarcerated women’s reproductive
wellbeing. Specifically, the data revealed that the functions of imprisoned women’s social
networks in their reproductive wellbeing were expressed in two themes: a) social surveillance
and b) resources to cope with reproductive wellbeing issues.

Sustaining external social connections in prisons is challenging due to limited means and time to
communicate with the outside environment (Bronson, 2008). The combination of high levels of
surveillance and institutional control in an environment where trust and supportive social
connections are limited makes the prison setting a complex and highly dynamic interpersonal
environment (Liebling & Arnold, 2012). Many scholars have argued that using inmates to help
supplement rule enforcement is an extension of the institutional prison power (Hayner & Ash,
1940; McCorkle & Korn, 1954). The present study revealed the various forms of social
surveillance role of women’s social networks concerning reproductive wellbeing. My interviews
with incarcerated women revealed how some incarcerated women’s peers performed the rule
enforcement through the gaze, such as the roles of nanunungkulan (inmate leader) and the
trustees. The participants' reports revealed their experiences of prison control over their hygiene
practices, routines, dress, and comportment needs. These experiences reflect Crewe et al.’s
(2017) gendered pains of imprisonment, indicating how women struggle with the prison and
other people’s ‘rules and orders’ over their behaviours and intimate activities. Several
participants in the current study discussed how rigid prison rules and institutionally imposed
peers’ gaze infringed their privacy and personal space, including their menstrual and hygiene
practices.

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The present study demonstrates the women’s distrust towards some peers due to tattling
(sumbungera) and gossiping. One typical form described by women during the interviews was
sumbungera or ‘tattler’. Their experience of tattling mirrors earlier studies showing that
incarcerated women struggle to build positive connections with peers due to their difficulty to
trust (Einat & Chen, 2012; Greer, 2000; Kruttschnitt et al., 2000; Severance, 2005). Research has
shown that women prisoners tend to form connections with peers they trust, discuss personal
matters and are reliable (Bronson, 2008). Furthermore, several scholars found that gossiping or
making idle talk is a significant issue and a common source of conflict in women’s prisons (Einat
& Chen, 2012; Severance, 2005). In Severance’s (2005) study, female participants expressed
discomfort and distrust towards their peers due to gossiping. Einat and Chen (2012) indicate that
gossiping or making idle talk about others’ personal affairs causes social conflict, reduces
positive relationships, and contributes to psychological harm and poor wellbeing. In separate
studies, Bronson (2008) and Severance (2005) conclude that establishing relationships among
women prisoners includes a process of cautious assessment of peers. A few participants
discussed the need to be mindful to avoid conflict, not trust many people, and just be surrounded
by a few inmates to get along. For example, one participant stated her experience when one
dormmate shared information about her peers’ history of sexually transmitted infections.
According to the literature, gossip in prison increases social conflict, weakens the setting’s
cohesive dynamics, creates inequality among women, isolates them, and may cause distrust
(Einat & Chen, 2012).

Despite the pains of imprisonment and social surveillance and their negative impacts on
women’s reproductive wellbeing, several women in this study described the enabling function of
social networks as their resources to cope with reproductive wellbeing issues. In particular,
women’s families served as their significant outside social supports (i.e., material and emotional)
to maintain their reproductive wellbeing. For women with limited family support, prison peers
played a family-like role in fulfilling the lost familial roles by providing material and emotional
support. Earlier studies have shown that external social connections, mainly through family
visits, are critical for the prisoners’ emotional and mental wellbeing (Cochran & Mears, 2013;
Gibbs, 1982). These social networks are resources that help prisoners cope with prison
deprivations through emotional comforts and material resources, such as clothing and money
(Cochran & Mears, 2013; Gibbs, 1982; Sentse et al., 2019). The participants’ accounts in the

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present study exemplify how women’s families act as a ‘buffer’ when coping with their
reproductive health conditions in prison. As elaborated in the literature chapter, inmates’
constant communication and interaction with their family and friends, mainly through visits, is
associated with improved wellbeing and health (Cochran & Mears, 2013). Consistent with
previous studies, family members’ emotional, instrumental, and financial supports serve as a
buffer against the pains of imprisonment (Gibbs, 1982; Hairston & Lockett, 1987; Irwin &
Cressey, 1962)

The present study’s findings validate the dominant features of women prisoners’ social networks
in the early scholarship: family-like, caring, and demographics-based (Bronson, 2008; Crewe,
2011; Giallombardo, 1966; Ward & Kassebaum, 1966). The present research found that for
incarcerated women with limited family connections and support, peers played a family-like role
by providing material and emotional support that helped women sustain their reproductive
wellbeing needs. This finding is consistent with the literature, showing that prison peers are the
only directly available ‘interpersonal sources’ to fulfil the need for social connectedness
(Bronson, 2008). These interpersonal relations provide social support that can be instrumental
(e.g., practical help, getting something done) or emotional (e.g., affection, caring) (Sykes, 1958).
The data also validate the findings of earlier research studies, showing the existence of family-
like kinship networks established by women to fulfil lost familial roles such as daughter, wife,
father, cousin, grandmother, and partner (Giallombardo, 1966; Larson & Nelson, 1984; Propper,
1982; Ward & Kassebaum, 1966). Additionally, several scholars have argued that involvement
in family-like relationships is a women’s way of coping with the pains of imprisonment,
particularly separation from families (Harner & Riley, 2013; Kruttschnitt et al., 2000; Severance,
2005).

In the present study, the use of Filipino terms like kapatid (siblings), pamilya (family) and nanay
(mother) reflect the Filipino cultural norms of communal living, family, and friendship support
networks in the broader Filipino society. Additionally, sharing menstrual pads and pooling
resources to help other women (e.g., women undergoing surgery or paying hospital bills)
embody the Filipino cultural value of damayan (helping one another), where inmates contribute
to assisting peers in need. Ang (1979, p. 91) argues that “tulongan or damayan (tulong-help;
damay-aid), a system of mutual help and concern, has become the backbone of Filipino society”.

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This finding is in consonance with the study conducted in Philippine men’s prisons, which
showed that Filipino values are endemic and unique in cell dynamics and coping mechanisms
(Narag & Jones, 2020). These Filipino cultural norms contributed to prisoners’ coping strategies
with prison deprivations.

Finally, the roles of nanunungkulan (inmate leader) and the trustees (medical assistants) reflect
the less formal and flexible relationships among staff, prisoners, and peers. These distinct prison
dynamics deviate from the formalised structure in western prisons and are a common practice in
the global south prisons (Birkbeck, 2011; Darke, 2018; Darke & Karam, 2016). Martin et al.
(2014) argue that prisoner-staff relationships in the global south are generally interdependent and
dynamic, allowing prison actors to move between care and custody. Prisoners’ active
participation in prison management and staff-inmate shared governance are developmental and
collaborative, allowing prisoners and staff to cope with the prison deprivations and pains of
imprisonment (Darke, 2018; Narag & Jones, 2020).

9.4 The institutional dimension of women’s

reproductive wellbeing
The findings of the present research point to the fact the characteristics of the total institutions
shaped the prison regulations and practices concerning incarcerated women’s reproductive
wellbeing. As illustrated in chapter five, all incarcerated women described the tightly scheduled
and highly routinised daily prison activities negatively affecting their distinct reproductive
wellbeing needs. For example, revisiting Jocelyn’s accounts in chapter six, she remarked that she
set aside her menstrual discomfort because she needed to participate in the daily activities and
perform her assigned tasks. Her story mirrors the common experience of many incarcerated
women of how prison practices and regulations outweighed their reproductive wellbeing.
Research has indicated that the highly routinised and scheduled prison activities are designed to
maintain order, rule adherence, and smooth operations (Bottoms, 1999; Cope, 2003; Sparks et
al., 1996). This prison characteristic resonates with the present study. Although the prison staff
acknowledged the various needs of women, they emphasised the importance of the consistency
of rule compliance. The finding illustrates the impact of institutionally imposed rules on prison
officers’ decisions when confronted with opposing circumstances (i.e., rule compliance versus

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women’s reproductive wellbeing needs). The potential of the prison to address the distinct and
holistic needs of women has been portrayed as illusory and unworkable, principally because it
contradicts the dominant roles and punitive purposes that define the institution and its routine
practices (Carlen, 1983, 1998, 2004).

In prisons, all dimensions of everyday life are done in the same place and under a single
authority (Goffman, 1961). Within this framework, the prison activities are enforced to adhere to
one prominent aspect of total institutions: “collectively regimented persons and the handling of
many human needs by the bureaucratic organisation of whole blocks of people” (Goffman, 1961,
p. 6). Several studies found the negative impacts of rigid authoritarian and bureaucratic
organisation in prison on the prisoners’ experiences, including their wellbeing (Colsher et al.,
1992; Haesen et al., 2021; Hurley & Dunne, 1991; Twaddle, 1976). In the present study, many
incarcerated women consistently mentioned the need for Department of Justice permits before
prisoners can access health care services outside prison. These prison practices contributed to
women’s helplessness because of limited autonomy over their reproductive wellbeing and
delayed health care.

Goffman (1961, p. 6) argues that in total institutions, “each phase of the member’s daily activity
is carried on in the immediate company of a large batch of others, all of whom are treated alike
and required to do the same thing together”. This feature of total institutions contrasts with the
common belief of individual living and diverse and personal choices in the outside community.
As a result, prison officers face complex situations of managing the tension between institutional
restrictions and accommodating the various needs of prisoners; hence, they are often torn
between the rigid application of the sameness principle policy and the practice of greater
flexibility (Crawley, 2005; Sparks et al., 1996). This situation is palpable in the accounts of
prison staff members. Most of the staff members in the current study recognised the distinct
needs of prisoners that require special attention, but they also stressed that they are guided
primarily by the equality and sameness principle in prison. They argued that everyone must be
treated alike, and no one is special in prison. The discussion also indicates how staff members
broadly equate basic needs with food, water, and some hygiene items (i.e., soap and shampoo).
Although menstrual pads and pain medications were considered by staff as essential items, they

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did explicitly frame them as basic needs that need to be institutionally provided by the prison
authority.

In her concept of emotional labour, Hochschild (1983) argues that workers manage their feelings
and expressions according to a job’s emotional requirements or expectations. Her idea resonates
with the present study as the accounts of prison officers revealed how they struggled to remain
detached from prisoners in the sense that they sought to avoid expressions of personal and
emotional connection with prisoners. Revisiting one prison officer’s accounts of how she tried
maintaining a boundary between her custodial role and the provision of care: “Our main job as
prison officers is custodian, and sometimes I want to help wherever necessary and possible, but I
am not a caretaker”. Additionally, apparent in the prison staff members’ reports was their
common way of reducing interaction with prisoners by using prison leaders and trustees as
gatekeepers of other prisoners.

The impacts of total institutions on prisoners’ wellbeing and the role of prison health staff have
created tension between care and custody (Arnold, 2016; Short et al., 2009; Sim, 2002). Maroney
(2005) argues that the dual roles of custody and caring are adversarial rather than mutual, and
custody usually rules. For prison nurses, the difficulty of reconciling their professional caring
role with the prison culture and ideology was profound. Undertaking both caregiving and
custodial dimensions of the job caused professional and personal conflict when they were
compelled to act opposite to the nature of their health care job and feelings of compassion. This
observation coincides with the previous research, indicating the dilemma of prison nurses
managing the difference between the ideal care role of their profession and the actual care they
provide because of prison regulations and job expectations in prison (Droes, 1994;
Puthoopparambil et al., 2015; Walsh, 2007; Willmott, 1997). Moreover, the incarcerated
women’s experiences about the prison’s inability to address their reproductive wellbeing needs
and the prison officers’ tendency to adhere to the institutional rules mirror Crawley’s (2005)
‘institutional thoughtlessness’, which was based on her study on imprisoned elderly men. She
defines it as “the ways in which prison regimes simply roll on with little reference to the needs
and sensibilities of the old” (Crawley, 2005, p. 356). The current study illustrates that prison is
thoughtless about incarcerated women’s distinct reproductive wellbeing needs. Ross et al. (2011,
p. 263) argue that the “health care service is deeply embedded within the institution and reflects

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the prison ‘culture’, with health care staff adopting the prison ‘climate’”. This perspective is
relevant to the present study as many participants expressed experiences of prison’s institutional
thoughtlessness in addressing the complex needs of women relating to their reproductive health
and comfort, such as menstruation, gynaecological services, and pregnancy support.

This thesis illustrates how prison as a total institution extends beyond the prison walls because
when prisoners get out of the prison building, they are not totally free. Various custodian rules
keep reminding the prisoners that they are still part of the prison spaces (Haesen et al., 2021).
The incarcerated women in this study confirmed that disciplinary measures concerning the
hospital appointments (i.e., time and location) occurred even before the actual medical visit. The
hospital schedule is fixed by prison staff, who coordinate with the health staff, and the prisoner is
unaware of the location, date and time of the hospital visits. Disciplinary measures include
transportation in a car that can be recognised as a prison vehicle, accompanied by prison officers,
using a separate entrance, and wearing prison clothing. In this way, the prison’s social and spatial
boundaries remain intact even as prisoners move from prison to hospital.

These findings are consistent with the literature, as several scholars argue that imprisonment
transcends the physical and architectural environment of the penal institution and that
punishment can be felt even outside of those static spaces (Cresswell, 2010; Follis, 2015;
Mincke, 2016; Moran et al., 2012). Jefferson (2014) argues that to understand the experience of
confinement, it is vital to look not only at institutions or sites but also at their practices, rituals,
symbols, and meanings. Hence, prisoners’ movements through the geographical space of the
prison – including its extensions (e.g., court, home/furlough, and hospital) – are intensively
controlled through prison security practices and routines (Follis, 2015; Moran et al., 2012;
Stoller, 2003). The current project demonstrates that prison security conditions overrule
incarcerated women’s reproductive wellbeing needs. Although staff acknowledged the prison
constraints experienced by prisoners, they underscored that the rationale behind the policy hinges
on the prison security conditions.

Follis (2015) underscores that prisoners’ disciplined movement and mobility outside prisons are
inherent to imprisonment and incur substantial costs for the necessary security services. Follis’
analysis resonates with the present study as several women indicated they were not allowed to
know the date and time of their hospital visits. In addition, prison staff argued that the rationale

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behind the policy hinged on the prison security conditions. The findings demonstrate that
incarcerated women are viewed primarily as a security risk rather than a vulnerable group. The
women’s experience of continually being monitored, watched and controlled inside and outside
of prison spaces reflects Foucault’s (1978) analysis of prison’s new mode of punishment. As a
punitive gaze, incarcerated women’s bodies are subject to institutional control and surveillance,
which is justified as part of prison security practices (Dirks, 2004; Soffer & Ajzenstadt, 2010). .
The present study indicates that the total institution diffuses through prison walls. For instance,
custodian measures during hospital appointments experienced by incarcerated women included
transportation in a car that can be recognised as a prison vehicle, accompanied by prison officers,
using a separate entrance, and wearing prison uniforms.

In sum, this project demonstrates how the characteristics of the total institution largely shaped
the prison regulations and practices concerning incarcerated women’s reproductive wellbeing.
This impact has created tension between care and custody. Specifically, the prison’s practices of
over-attention to schedules and routines, bureaucracy and under the same authority (i.e. DOJ
permits), ‘no special’ policy, and staff adherence to the primary institutional goal (i.e., prisoners’
compliance with rules) reflect Goffman’s (1961) characterisation of a total institution. These
prison practices are remnants of a system designed for male institutions and are not based on
genuine security risks (Carlen, 1983, 1998; Doetzer, 2007).

9.5 Limitations of the study

This thesis examines many concepts such as reproductive wellbeing, mortification of self, total
institutions, and the pains of imprisonment. The fundamental conceptual and methodological
limitations are described in this section.

Some limitations can be noted in the present study. First, I interviewed forty-two Filipino women
in one women’s prison in the Philippines. Furthermore, the data were self-reported. The data
only represent this specific group, which is not necessarily representative of all female prisoners
in the Philippines.

Second, although I was very conscious of the power dynamics in prison and thoroughly
explained during my meeting with the prison management that only women who expressed

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willingness to join would be invited to participate in the interview, there is a possibility that my
prisoner participants may feel unable to decline participation in research because they want to
appear co-operative for hopes of being treated better or they believe doing so will have positive
future consequences while in prison (Arboleda-Flórez, 2005; Genders & Player, 1990; Martin,
2000). This situation may have impacted the participants’ responses.

Third, since the study required the prison institution’s approval because the participant prisoner
must not pose a risk to researchers, women under the maximum-security category were not
interviewed, given the additional security measures and clearances needed. Therefore, the study
did not include incarcerated women who may experience extreme surveillance and the highest
levels of security during hospital visits.

Fourth, even though I have had experience conducting interviews about reproductive health, my
gender as a male interviewer may have shaped the participants’ responses, given the highly
personal nature of the topic and the general conservative attitude of Filipino women toward
reproductive health topics such as menstruation.

Finally, some elements of reproductive health were not captured, such as access to birth control
because conjugal visits for women in the Philippines are not allowed; thus, it was not applicable
to include in the interview questions. Questions on abortion services were not asked because
abortion in the Philippines is considered illegal; hence, such service is not provided as part of
general reproductive health service in the country. Despite these limitations, the study explored
an understudied phenomenon, offering a further understanding of Filipino incarcerated women’s
reproductive wellbeing.

9.6 Contributions to knowledge

In this section, I outline the critical contributions of the study to the mainstream discussion
around total institutions, mortification of self, and pains of imprisonment.

9.6.1.1 Contributions to pains of imprisonment discourses

This research project contributes to the growing literature on the gendered pains of imprisonment
experienced by incarcerated women. Feminist criminologists have argued that women in prison
have distinct gendered pains of imprisonment (Carlen, 1983, 1998; Crewe et al., 2017; Genders

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& Player, 1987; Owen, 1999; Walker & Worrall, 2000). The women’s relatively small prison
population has contributed significantly to their “invisibility within the penal estate” (Carlen,
1983, p. 4). As a result, women’s prisons are often organised and managed precisely like the
men’s, thereby not recognising women’s various physical and health needs (Carlen, 1983, 1998).
The current study extends the frameworks to capture the pains or deprivations connected with
women’s reproductive wellbeing. The findings of the current project resonate with the earlier
arguments and provide more context that in a low-income country with limited reproductive
health support, the scarcity is even more prominent, and the impact is more profound. For
instance, incarcerated women in the present study with menstrual issues and chronic
reproductive conditions did not obtain health care services equivalent to those in the community
(i.e., regular supply of menstrual pads, pain medications and access to professional care).

The current study corroborates with the earlier studies indicating that loss of autonomy and
control is the most significant gendered pain of imprisonment for women (Carlen, 1983, 1998;
Crewe et al., 2017; Genders & Player, 1987; Owen, 1999; Walker & Worrall, 2000). Carlen
(1983) argues that women encounter petty rules, infantilisation and institutional control over
their bodies, space, and presentation. As the current study demonstrates, incarcerated women’s
bodily functions concerning menstrual and reproductive health needs and pregnancy are
restricted, controlled, and neglected. The participants’ experiences showed how the prison
environment prohibited them from their usual ways of managing their menstrual and
reproductive conditions (e.g., warm showers, comfort food, regular supply of pain medications,
and personal space). Furthermore, this research shows that discipline, control, and constant
surveillance profoundly impact women’s ability to cope with the ‘pains of imprisonment’. This
research has shown that participants’ lack of control was described in their reliance upon the
institution and peers as gatekeepers of the programmes and services in prison. The lack of
control was most painfully experienced by the women in the absence of opportunities to control
health care and make health decisions. The participants’ experiences showed how the prison
environment prohibited them from their usual ways of managing their menstrual and
reproductive conditions (e.g., warm showers, comfort food, regular supply of pain medications,
and personal space).

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Furthermore, the current project provides a clear cultural meaning of women’s reproductive
wellbeing experiences in a contextually determined setting. Hiya (embarrassment or shame) was
a common experience among the participants, especially among young women and during their
early incarceration, due to their reliance upon the institution and peers for menstrual pads and
other basic needs. Although this Filipino cultural concept of hiya can be applied to different
contexts (Jocano, 1998; Rafael, 1993), the accounts of the incarcerated women reflect their
experience of humiliation and vulnerability. Rafael (1993, p. 126) explains that to be in the state
of hiya is “to be in a vulnerable position and an embarrassment that arises from being
overwhelmed”. The overall experience of women in the present study centred on how
incarceration disrupted their ability to negotiate and manage the situations relating to their
menstrual wellbeing.

The findings of the current study build upon the existing knowledge about gendered pains of
imprisonment in concluding that pregnant prisoners experience profound distinct deprivations.
Many participants expressed the feeling of disempowerment because of their experiences of
being left unsupported and helpless in labour and not being transported early to the hospital.
Participants’ frustration with being separated from their newborns mirrors the anticipatory
anxiety of all pregnant women interviewed. This feeling was caused by their total lack of control,
limited options, and difficult prison circumstances. In addition, the powerlessness was profound
among pregnant and lactating women due to the loss of autonomy. The absence of control over
their pregnancies generated distress among most participants who had been pregnant in prison.

Despite the pains of imprisonment and social surveillance and their negative impacts on
women’s reproductive wellbeing, several participants in this study formed a community to help
each other cope with prison deprivations. For instance, sharing menstrual pads and pooling
resources to help other women (e.g., women undergoing surgery or paying hospital bills)
embody the Filipino cultural value of damayan (helping one another), where inmates contribute
to assisting peers in need. These collective actions reflect the Filipino cultural norms of
communal living, family, and friendship support networks in the broader Filipino society.

9.6.1.2 Contributions to the mortification of self and master status concepts

The present study illuminates critical contributions to the concepts of mortification of self and
master status. First, in Goffman’s ‘mortification of self’, he describes the impact of

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imprisonment on the inmate’s sense of self and identity as immediate and devastating. Several
women in this research expressed how institutionally imposed ‘prisoner identity outweighed
their reproductive wellbeing needs. These self-losses and identity disruptions result from “the
dispossession of personal property and belongings and the stripping of one’s identity kit, i.e.,
clothing and cosmetics that one has used to present oneself in one’s social world” (Goffman,
1961, p. 20). The interviews with incarcerated women mirror Goffman’s analysis because many
participants framed the absence of coping strategies to manage menstrual discomforts in prison
as debilitating (i.e., warm shower, comfort food, personal space). These personal and intimate
belongings and menstruation practices shaped their pre-incarceration reproductive wellbeing.

Second, in the present study, incarcerated women with chronic reproductive conditions who were
transferred to the hospital for routine medical visits felt public humiliation, especially seen in
prison uniforms and accompanied by prison staff. They described their experience of shame and
embarrassment at being seen in the hospitals as prisoners instead of patients. Goffman (1961)
argues that this public perception happens when membership of a particular group, in this case as
prisoners, becomes the defining feature of one’s identity: their ‘master status’. Mirroring
Goffman’s analysis, this research has illustrated how incarcerated women with reproductive
health conditions were given wearable marks of prison that identify them as prisoners, such as
handcuffs and prison uniforms, in public spaces like hospitals. These prison symbols and
characteristics can engulf an individual’s identity, becoming “the filter through which his or her
other characteristics are seen” (Jones et al., 1984, p. 296). The participants’ narratives in this
study exemplify how their ‘prisoner identity’ becomes a master status, fundamentally affecting
how the public understand women prisoners accessing hospital care and eventually influencing
how women perceive their status as patients overshadowed by the ‘prisoner identity’.

Finally, while the loss of the mothering role as a source of pain was reported in previous studies
(Carlen, 2004; Crewe et al., 2017; Enos, 2001; Genders & Player, 1990; Shamai & Kochal,
2008; Walker & Worrall, 2000), the current study found that participants’ inability to fulfil their
pregnancy needs (maternal responsibility) and protect their pregnancy in prison were expressed
as deviation from their traditional mothering role, the symbolic loss of a salient characteristic of
Filipino mother’s identity. Their inability to sustain pregnancy needs contributed to helplessness
and self-blame.

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9.6.1.3 Contributions to the concept of total institutions
This project has shown how the characteristics of the total institutions largely shape the prison
regulations and practices concerning incarcerated women’s reproductive wellbeing. Specifically,
the prison practices of over-attention to schedules and routines, bureaucracy and under the same
authority (i.e. DOJ permits), ‘no special’ policy, and staff adherence to the primary institutional
goal (prisoners’ adherence to rules) reflect Goffman’s (1961) characterisation of a total
institution. In addition, this study contributes to the growing literature on the tension between
care and custody (Arnold, 2016; Maroney, 2005; Short et al., 2009; Sim, 2002). For prison
nurses, the difficulty of reconciling their professional caring role with the prison culture and
ideology was profound. Undertaking both caregiving and custodial dimensions of the job caused
professional and personal conflict when they were compelled to act opposite to the nature of
their health care job and feelings of compassion.

The results of the present study reflect the concept of carceral geography because the rituals and
practices of the total institution diffused through prison walls, such as prison regulations
concerning medical transportation and hospital visits. Several participants discussed the
custodian measures during hospital appointments, such as using a prison vehicle accompanied by
prison officers, using a separate entrance, and wearing prison clothing.

9.7 Recommendations
Translating research evidence into programmes and policy is crucial to improving health care
outcomes, particularly among marginalised incarcerated women. This section outlines the main
study recommendations, implications for policy and programmes, and future research.

9.7.1.1 Implications for future policy and programmes

With the recent significant increase in female incarceration globally and the Philippines due to
the ‘war on drugs’, there is an urgent need to reform prison regulations and practices to address
incarcerated women’s distinct reproductive wellbeing needs. These reforms must include
comprehensive and holistic support for incarcerated women during menstruation, pregnancy,
labour, delivery, and postpartum (e.g., breastfeeding, newborn care).

182
Prison authorities should promote healthy menstrual wellbeing by providing regular sanitary and
hygiene items. The U.N. Bangkok Rules explicitly state that governments must invest in
facilities and materials to meet women’s hygiene needs, including sanitary pads. The current
study's findings illustrate the urgent need for the Philippine government to amend the current
reproductive health law to include permanent funding for the regular supply of menstrual and
hygiene items, such as menstrual pads, soaps, and towels.

Additionally, the U.N. Bangkok Rule 6 recommends that the “health screening of women
prisoners shall include comprehensive screening to determine their primary health-care needs”
(United Nations General Assembly, 2011, p. 9). This recommendation is relevant to the current
research project as several participants indicated the lack of comprehensive reproductive health
services, such as pap smears and breast examinations. Thus, policy changes must include (a)
systematic identification of women with specific menstrual, gynaecological and pregnancy
needs; (b) targeted and context-specific reproductive health support programmes given to women
with distinct and diverse reproductive health.

The current study highlights the need to institute systemic reforms to provide timely health care,
including access to outside hospital appointments. To achieve this objective, the Philippine
Bureau of Corrections must remove the policy on court orders and DOJ permits.

Several women in the current study who had been pregnant in prison discussed their experiences
of limited pregnancy support and the adverse effects of prison restrictions and deprivations on
their pregnancy. Given the profound impact of imprisonment and lack of support on the
wellbeing of pregnant women and newborns, the government should consider the temporary
release from prison of all pregnant women and lactating mothers. The experiences of pregnant
prisoners and those with chronic reproductive conditions illustrate that security and custodian
rules override their distinct needs.

9.7.1.2 Implications for future research

This qualitative study has revealed several findings that need future investigations. Research
would help evaluate the value of supportive interventions for incarcerated women with chronic
reproductive conditions to explore programmes that could improve access to timely quality
health care. It would be helpful to further delve into the medical staff and medical assistants’

183
(volunteer) roles in caring for incarcerated women with extreme reproductive conditions to
explore the nuances and develop recommendations for best practices. Examining prison nurses’
experience with pregnant women would determine whether the systems gap is widespread across
the women’s prisons and jails. A survey of pregnant prisoners or women who have given birth
across prisons and jails could quantitatively examine the concepts of gendered pains of
imprisonment, institutional indifference, and bureaucratic layers. Research into reproductive
health service delivery networks and continuity of care need to be undertaken to examine the
specific challenges and needs of women moving from prison to health care facilities and vice
versa. Research into the experiences of pregnant prisoners concerning food, nutrition, and
comfort could be undertaken with a greater focus to build on the findings of the present study.
Studying further the experiences of expectant mothers separated from their newborns after
delivery would provide a clearer understanding of their wellbeing needs.

9.8 Self-reflection
I have had several lessons from my PhD thesis journey as a researcher. On a professional level,
prison as a total institution was undeniably a challenging space to navigate. There were instances
when my own resolve was tested due to my feeling upon hearing a range of complex and sad
stories from the participants, such as their personal sacrifice, lack of control and learned
helplessness. As a public health professional, it was difficult to understand some practices and
regulations that are detrimental and harmful to prisoners with pregnancy and medical needs. For
example, the policy around court orders or Department of Justice permits to seek medical
treatment or the delay of bringing pregnant prisoners to the hospital were complex stories to
ponder as these practices are detrimental to the wellbeing of pregnant women and sick prisoners.
The complexity of unravelling my emotions to ensure that I comprehensively documented
women’s stories needed persistent self-critique. I also questioned my ability to genuinely capture
and communicate their stories as I had difficulty looking for the appropriate words to describe
the diverse realities of their experiences. Additionally, as a health professional, I was
dumbfounded to hear prison nurses’ struggle to reconcile their caring role with the prison
culture. Their experience has made me realise the love and passion of these nurses who chose to
work in prison despite the limited resources and prison regulations that deviate from the caring
role of the nursing profession.
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On a personal level, I have learnt the value of being more compassionate, patient and
understanding. My research journey has reaffirmed many of my life principles: to take the risk of
exploring things that are less travelled, question deeper, and trust the process. As an advocate, I
have learned that advocacy work should be critical and actionable rather than rhetorical.

9.9 Conclusion
This qualitative research project examines the nexus between incarceration and reproductive
wellbeing using Goffman’s (1961) ‘total institutions’ and ‘mortification of self’, Syke’s (1958)
‘pains of imprisonment’, and the expanded ‘gendered pains of imprisonment’ as the conceptual
lenses. The research questions that guided this research undertaking are the following:

1. What is the lived experience of reproductive wellbeing of Filipino incarcerated women?

2. What are the roles played by the social networks in incarcerated women’s reproductive
wellbeing?
3. What is the institutional dimension of incarcerated women’s reproductive wellbeing?
Forty-two Filipino incarcerated women in the Philippines’ largest women’s prison participated in
semi-structured individual interviews. Most were of reproductive age, and all were mothers. All
had at least one child, with a number of children ranging from one to 12. The interviews revealed
that 18 women had pregnancy experiences in prison, which means they were pregnant when they
were arrested (the Philippine women’s prison has no conjugal visits). In terms of their
reproductive health before imprisonment, many participants expressed little attention and priority
for their reproductive health needs. Most of the participants were imprisoned due to drug
involvement, theft, and property crime, often committed as a response to poverty and economic
insecurity. Most stated they had an unstable job, were low-wage earners before imprisonment
and were entirely reliant on their husband’s earnings.

This project involved two phases of data collection procedures. Phase one of the study involved
semi-structured interviews with 42 incarcerated women. In phase two, focus groups with eight
prison staff members were conducted. I facilitated the first group with three correctional nurses
and the second focus group with five GAD members. All focus group participants were female
and had varying roles in prison (i.e., health, social work, security, and education), with years in
service ranging from one to 15 years.

185
A reflexive thematic analysis approach (Braun & Clarke, 2019) was used to analyse the data, and
major themes were identified and organised per the main research question. This research project
contributes to the growing literature on the gendered pains of imprisonment experienced by
incarcerated women. Several participants in the current study described their experience of
limited access to reproductive health care and lack of autonomy and control over their
reproductive wellbeing. This study also extends the frameworks to encompass the pains
associated with women’s reproductive wellbeing. The women’s reproductive wellbeing in this
study was experienced and expressed in three broad themes: a) increased reproductive
discomforts and decreased relief, b) disempowering experiences, and c) prisoner identity
overriding reproductive wellbeing. These themes reflect the women’s experiences of
imprisonment intensifying their reproductive issues and creating distinct needs. Furthermore, the
findings demonstrate how reproductive wellbeing needs appeared secondary to their
institutionally imposed ‘prisoner identity’, a situation exacerbated by their experience of
systemic scarcity and limited autonomy.

Given the various reproductive wellbeing issues and prison deprivations women face, social
networks have critical roles in women’s wellbeing. The current project has shown that social
networks serve two functions in women’s reproductive wellbeing. First, the data indicate how
women’s menstrual and hygiene practices, routines and dress are subject to peer surveillance,
negatively affecting their reproductive wellbeing experience. Second, despite the pains of
imprisonment and surveillance, women used their social networks as resources to help them
maintain their reproductive wellbeing. Specifically, family members’ emotional, instrumental,
and financial support helped women cope with reproductive wellbeing issues. For women with
limited family support, peers played a family-like role by providing emotional and material
supports to sustain women’s reproductive wellbeing needs. Several participants in this study
formed a community to help each other cope with prison deprivations. For instance, sharing
menstrual pads and pooling resources to help other women (e.g., women undergoing surgery or
paying hospital bills) embody the Filipino cultural value of damayan (helping one another),
where inmates contribute to assisting peers in need. These collective actions reflect the Filipino
cultural norms of communal living, family, and friendship support networks in the broader
Filipino society.

186
Drawing on Goffman’s total institution, the current project demonstrates how the prison staff
navigated the tension between custodian concerns and accommodating the distinct needs of
women. The data reveals the impact of prison rules on prison officers’ decisions when
confronted with opposing circumstances. In addition, this study contributes to the growing
literature on the tension between care and custody. Prison nurses expressed the dilemma of
managing the difference between the ideal caring role and the actual care because of prison job
expectations. The data also indicates how prison as a total institution extends beyond the prison
walls through disciplinary measures, routines, security practices, and symbols (i.e., prison
uniform, handcuffs, prison vehicle) that are continually attached to them during hospital
appointments.

This thesis makes a significant contribution by examining the intersection of reproductive

wellbeing and incarceration to lay the groundwork for understanding how prison deprivations are
linked to incarcerated women’s distinct needs. Lastly, the findings highlight the urgent need to
reform prison regulations and practices to address incarcerated women’s vulnerability and
reproductive wellbeing. In this sense, the study facilitates positive reforms to address
incarcerated women’s distinct reproductive wellbeing needs.

187
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 Appendices
Appendix A – Philippine Bureau of Correction’s
letter of support

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 Appendix B – Ethics committee approval
Academic Services 19/137
Manager, Academic Committees, Mr Gary Witte 18 October 2019

Dr B Hohmann-Marriott
School of Social Sciences

Dear Dr Hohmann-Marriott,

I am writing to let you know that, at its recent meeting, the Ethics Committee considered your
proposal entitled “Reproductive Wellbeing of Women in Philippine Prisons”.

As a result of that consideration, the current status of your proposal is:- Approved

For your future reference, the Ethics Committee’s reference code for this project is:- 19/137.

The comments and views expressed by the Ethics Committee concerning your proposal are
as follows:-

The Committee would like to thank Dr Beres, Dr Gilmour and Romulo Nieva for attending the
Human Ethics Committee meeting on 17th October 2019 to discuss the application.

Approval period: Approval is for up to three years from the date of this letter. If this project
has not been completed within three years from the date of this letter, re-approval must be
requested. If the nature, consent, location, procedures or personnel of your approved
application change, please advise me in writing.

Conditions of approval: Upon approval, it is expected that all members of the research
team are made aware of what the standard conditions of ethical approval covers. This includes

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the date ethical approval expires, as well as the process regarding applying for amendments to
the research.

Final Report: The Human Ethics Committee asks for a Final Report to be provided upon
completion of the study. The Final Report template can be found on the Human Ethics Web
Page

http://www.otago.ac.nz/council/committees/committees/HumanEthicsCommittees.html

Locality authorisation: Studies requiring locality authorisation, i.e. permission from the
organisations at which the study is taking place or from which participants are being accessed,
must be confirmed before the study commences.

Yours sincerely,

Mr Gary Witte
Manager, Academic Committees
Tel: 479 8256
Email: [email protected]

c.c. Professor L Smith Head of School School of Social Sciences

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 Appendix C – Consent form for interview
participants
English version

Reproductive Wellbeing of Women in Philippine Prisons

CONSENT FORM FOR PARTICIPANTS

(FEMALE PRISONERS)
I have read the Information Sheet concerning this project and understand what it is about. All
my questions have been answered to my satisfaction. I understand that I am free to request
further information at any stage.
I know that:
1. My participation in the project is entirely voluntary;
2. I am free to withdraw from the project before its completion in September 2021
without any disadvantage;
3. Personal identifying information (audio recordings) will be destroyed at the conclusion
of the project, but any raw data on which the results of the project depend will be
retained in secure storage for at least five years;
4. This project involves an open-questioning technique. The general line of questioning
includes your experiences, needs and perceptions related to menstruation, hygiene,
management of reproductive-related discomforts (e.g. endometriosis, heavy bleeding,
etc.), pregnancy intentions and choices, prenatal and postnatal care, access to birth
control, fertility information and education and self-care. The precise nature of the
questions which will be asked has not been determined in advance but will depend on
the way in which the interview develops and that if the line of questioning develops in
such a way that I feel hesitant or uncomfortable, I may decline to answer any particular
question(s) and/or may withdraw from the project without any disadvantage of any
kind;
5. The interview will be audio-recorded and transcribed in Filipino;
6. The researcher may use a short quote from the interview transcript, and he will ensure
that there is no identifying information in the quote;

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7. No financial or related incentives will be provided related to the participation in the
project;
8. If the topic makes me uncomfortable and stressed, I have the right not to respond, and
appropriate debriefing and counselling services must be provided;
9. Although I have the right to confidentiality, the researcher retains the ethical obligation
to report to proper authority any issues that may cause a threat to my safety and
wellbeing.
10. The results of the project may be published and will be available in the University of
Otago Library (Dunedin, New Zealand), but every attempt will be made to preserve my
anonymity.
I agree to take part in this project.
............................................................................. ...............................
(Signature of participant) (Date)
............................................................................
(Printed Name)
……………………………………………………..
Name of person taking consent
This study has been approved by the University of Otago Human Ethics Committee. If you
have any concerns about the ethical conduct of the research you may contact the
Committee through the Human Ethics Committee Administrator (ph +643 479 8256 or email
[email protected]). Any issues you raise will be treated in confidence and investigated
and you will be informed of the outcome.

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Tagalog version

Reproductive Wellbeing of Women in Philippine Prisons

CONSENT FORM FOR PARTICIPANTS

(FEMALE PRISONERS)

Nabasa ko ang mga impormasyon tungkol sa proyektong ito at naiintindihan kung ano ito.
Nasagot ang lahat ng aking mga katanungan. Naiintindihan ko na malaya akong humiling ng
karagdagang impormasyon sa anumang yugto ng pag-aaral na ito.
Naiintidihan ko na:
1. Ang aking partisipasyon sa research/pag-aaral na ito ay boluntaryo at kusang-loob;
2. Kung nanaisin kong hindi mapabilang sa research na ito sa kahit ano mang oras o
panahon, pwede po ninyong gawin ng hindi kailangan magbigay ng rason bago ito ma
kompleto sa Setyembre 2021;
3. Ang mga audio-recording at notes naming ay gagamitin sa pag-aaral lamang.
Pagkatapos ng pag-aaral na ito, kung ano mang audio-recording at notes na aming
nakuha ay idi-delete pagkatapos ng limang taon;
4. Inaasahan ko na ang mga panayam ay aabutin ng halos isang oras. Sa panahon ng
pakikipanayam ay tatanungin ako ng mga pangkalahatang katanungan tungkol sa aking
mga pang-unawa at karanasan tungkol sa kalusugan ng isang babae sa loob ng
kulungan, plano sa pagbubutis, pag-aalaga sa sarili, at pag-access sa mga serbisyo
tungkol sa kalusugan ng isang babae or reprodcuctive health;
5. Ang panayam ay irerekord at isasalin sa Filipino/Tagalog;
6. Ang researcher ay maaaring gumamit ng isang maikling quote mula sa transcript ng
usapan at titiyakin niya na walang pagtukoy ng mga personal na impormasyon sa
quote;
7. Wala pong bayad ang paglahok sa research na ito at ito po ay boluntaryo lamang;
8. Kung sakaling hindi ako komportable at meron akong nararamdaman, sinisiguro na
merong angkop na serbisyo at suportang propesyonal para sa akin;
9. Bagaman may karapatan ako sa pagiging kompidensiyal, pinananatili ng researcher ang
tungkulin na mag-ulat sa tamang awtoridad ang anumang ligal na isyu at naiulat na mga
krimen na maaaring magdulot ng banta sa aking kaligtasan at kalusugan ko;

215
10. Ang mga resulta ng proyekto ay maaaring mai-publish at magagamit sa University of
Otago Library (Dunedin, New Zealand), ngunit ang lahat ng pribadong impormasyon ay
hindi po kasali sa dokumentong ito;
Sumasang-ayon ako na makibahagi sa proyektong ito.
............................................................................. ...............................
(Lagda) (Petsa)
.............................................................................
(Pangalan
……………………………………………………..
Pangalan ng nagbibigay ng consent

Ang pag-aaral na ito ay na-aprubahan ng University of Otago Human Ethics Committee.

Kung mayroon kang anumang mga katanungan o paglilinaw tungkol sa etikal na proseso ng
pag-aaral na ito, maaari kang makipag-ugnayan sa komite sa pamamagitan ng Human Ethics
Committee Administrator (ph +643 479 8256 or email [email protected]). Ang
anumang mga isyu na ibabahagi mo ay ituturing na kumpidensyal at iimbestigahan ng
komite.

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 Appendix D – Interview participant information
sheet
English version

Reproductive Wellbeing of Women in Philippine Prisons

INFORMATION SHEET FOR PARTICIPANTS

(FEMALE PRISONERS)
Thank you for showing an interest in this project. Please read this information sheet carefully
before deciding whether or not to participate. If you choose to participate, we thank you. If you
decide not to participate, you will be at no disadvantage, and we thank you for considering our
request.

My name is Romulo Nieva Jr, a Filipino PhD student at the Sociology, Gender Studies,
Criminology Programme of the University of Otago, New Zealand. I am conducting my PhD
research on women's reproductive wellbeing in Philippine prison. Specifically, I am interested in
finding out more about your experiences, needs and perceptions related to menstruation,
hygiene, management of reproductive-related discomforts (e.g. endometriosis, heavy bleeding,
etc.), prenatal and postnatal care.

You are invited to participate in an individual interview. I welcome Filipino women in prison
over the age of 18. Those who can speak English or Filipino are welcomed. Pregnant and
lactating women in prisons are also welcomed to participate.

I anticipate that the interviews will take approximately an hour. During the interview, I will ask
general questions about your experiences, needs and perceptions related to menstruation,
hygiene, management of reproductive-related discomforts (e.g. endometriosis, heavy bleeding,
etc.), prenatal and postnatal care. You will also be asked about your age, income status, and
educational attainment. The interview will be open-ended and conversational, so you will have
the opportunity to share as much as you like. In the event that the line of questioning does
develop in such a way that you feel hesitant or uncomfortable, you are reminded of your right
to decline to answer any particular question(s) and also that you may withdraw from the

217
project at any stage before its completion in September 2021 without any disadvantage to
yourself of any kind. Furthermore, specific sensitive topics may come up in the interview. If you
get upset or stressed, you will be referred to the medical staff for appropriate services.

The project results may be published and available in the University of Otago Library (Dunedin,
New Zealand), but no identifying information will be included. You are welcome to request a
copy of the results the project should you wish. The interview will be audio recorded so that I
can accurately record what is said. The interview is confidential; however, if documented cases
from the interviews pose an imminent threat to your safety and reportable crimes are
obtained, it is the obligation of the researcher to report to the appropriate authority based on
government protocol. Only my supervisors and I can access the audio files and transcripts. As
required by the University’s research policy, any raw data on which the results of the project
depend will be retained in secure storage for five years, after which it will be destroyed. I may
use a short quote from the interview transcript, but I will ensure that there is no identifying
information in the quote. Your confidentiality is of utmost importance. I will not share what you
tell me, including other inmates or prison staff. There is one exception to this: if I am concerned
that you or someone else will experience violence or harm. In those cases, I am ethically
required to tell the staff to ensure the safety of everyone here.

If you have any questions about our project, either now or in the future, please feel free to
contact:

Romulo F. Nieva Jr
Sociology, Gender Studies & Criminology
[email protected]

Dr Bryndl Hohmann-Marriott
Sociology, Gender Studies & Criminology
Room 5C17, Richardson Building
[email protected]

This study has been approved by the University of Otago Human Ethics Committee. If you have
any concerns about the ethical conduct of the research you may contact the Committee
through the Human Ethics Committee Administrator (ph +643 479 8256 or email
[email protected]). Any issues you raise will be treated in confidence and investigated
and you will be informed of the outcome.

218
Tagalog version

Reproductive Wellbeing of Women in Philippine Prisons

INFORMATION SHEET FOR PARTICIPANTS

(FEMALE PRISONERS)
Maraming salamat sa pagiging parte sa research/pag-aaral na ito. Inaanyayahan po namin kayo
na basahin ang impormasyon tungkol sa pag-aaral na ito bago kayo maging bahagi sa
proyektong ito. Nais naming ipaalam sa inyo na bagama’t mahalaga ang inyong mga ibibigay na
impormasyon at opinyon, ang pakikilahok ninyo sa pag-aaral na ito ay boluntaryo.

Ako ay si Romulo Nieva Jr, a Filipino PhD student sa Sociology, Gender Studies, Criminology
Programme sa University of Otago, New Zealand. Ako ay gumagawa ng isang pag-aaral
patungkol sa kalusugan ng mga babae sa loob ng kulungan ng Pilipinas. Nais kong malaman ang
inyong karanasan patungkol sa iyong regla o mga problema tungkol sa regla (dysmenorrhea),
pagbubuntis o panganganak.

Inaanyayahan kang lumahok sa isang indibidwal na pakikipanayam or pag-uusap. Inaanyayahan

ko ang mga kababaihang Pilipino na may edad na higit sa 18 taong gulang. Ang mga buntis at
lactating kababaihan sa mga bilangguan ay tinatanggap din na lumahok.

Inaasahan ko na ang mga panayam ay aabutin ng halos isang oras. Sa panahon ng

pakikipanayam ay magtatanong ako ng mga pangkalahatang katanungan tungkol sa iyong mga
pang-unawa at karanasan tungkol sa kalusugan ng isang babae sa loob ng bilangguan,
pagbubuntis, pag-aalaga sa sarili, at pag-access sa mga serbisyo para sa babae. Tatanungin ka
rin tungkol sa iyong edad, kita, civil status, at antas sa edukasyon.

Kung nanaisin ninyong di mapabilang sa pag-aaral na ito sa kahit ano mang oras o panahon,
pwede po ninyong gawin ng hindi kailangan magbigay ng rason. Ang University of Otago ay may
responsibilidad na sumunod sa mga alintuntunin sa research ethics. Kung sagaling hindi kayo
komportable at meron kayong nararamdaman, sinisiguro namin na merong angkop na
serbisyoat suporta para sa iyo galing sa staff ng Corrections.

219
Ang inyong sagot ay makatutulong para malaman ang inyong karanasan at pangangailangan sa
loob ng kulkungan at ang mga ahensya ng gobyerno tulad ng Department Corrections at
Department of Health para suriin at mapabuti pa ang mga polisiya at programa. Ibabahagi
naming ang magiging resulta ng pag-aaral na ito, at makikipagpanayam para mapag-usapan ang
mga rekomendasyon namin. Nais po naming kayong hikayatin na sumagot ng nauukol sa paksa
at ng hindi nakakabahala sa inyo. Gagawa po kami ng audio-recording sa panayam na ito at
magtatala ng inyong sagot para maayos na makuha ang inyong sagot. Ang mga audio-recording
at notes naming ay gagamitin sa pag-aaral lamang. Pagkatapos ng pag-aaral na ito, kung ano
mang audio-recording at notes na aming nakuha ay idi-delete.

Wala pong bayad ang paglahok sa pag-aaral na ito at ito po ay boluntaryo lamang. Kung meron
po kayong mga katanungan o dagdag na impormasyong makakatulong sa pag-aaral na ito,
pwede po kayong makipag-ugnayan sa amin sa pamamagitan sa pagtawag o email:

Romulo F. Nieva Jr
Sociology, Gender Studies & Criminology
[email protected]

Dr Bryndl Hohmann-Marriott
Sociology, Gender Studies & Criminology
Room 5C17, Richardson Building
[email protected]

Ang pag-aaral na ito ay na-aprubahan ng University of Otago Human Ethics Committee. Kung
mayroon kang anumang mga katanungan o paglilinaw tungkol sa etikal na proseso ng pag-aaral
na ito, maaari kang makipag-ugnayan sa komite sa pamamagitan ng Human Ethics Committee
Administrator (ph +643 479 8256 or email [email protected]). Ang anumang mga isyu na
ibabahagi mo ay ituturing na kumpidensyal at iimbestigahan ng komite.

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 Appendix E – Consent form for focus group
participants
English version

Reproductive Wellbeing of Women in Philippine Prisons

CONSENT FORM FOR PARTICIPANTS

(PRISON STAFF)
I have read the Information Sheet concerning this project and understand what it is about. All
my questions have been answered to my satisfaction. I understand that I am free to request
further information at any stage.
I know that:
1. My participation in the project is entirely voluntary;
2. I am free to withdraw from the project before its completion in September 2021
without any disadvantage, but any information already shared during the focus groups
can no longer be taken out from the transcript;
3. Personal identifying information (audio recordings) will be destroyed at the conclusion
of the project, but any raw data on which the results of the project depend will be
retained in secure storage for at least five years;
4. This project involves an open-questioning technique. The general line of questioning
includes prison programmes and services related to reproductive care, family planning,
education, etc. The precise nature of the questions which will be asked has not been
determined in advance but will depend on how the interview develops and that in the
event that the line of questioning develops in such a way that I feel hesitant or
uncomfortable, I may decline to answer any particular question(s) and/or may withdraw
from the project without any disadvantage of any kind;
5. The interview will be audio-recorded and transcribed in Filipino;
6. The researcher may use a short quote from the interview transcript, and he will ensure
that there is no identifying information in the quote;

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 7. No financial or related incentives will be provided related to the participation in the
project;
8. The results of the project may be published and will be available in the University of
Otago Library (Dunedin, New Zealand), but every attempt will be made to preserve my
anonymity. No identifying information will be used for this project, and the researcher
cannot guarantee that other members of the focus groups will keep the information
confidential, but this will be discussed during the focus groups that information shared
should be confidential and cannot be shared to anyone outside of the group.
I agree to take part in this project.
............................................................................. ...............................
(Signature of participant) (Date)
.............................................................................
(Printed Name)

……………………………………………………..
Name of person taking consent

This study has been approved by the University of Otago Human Ethics Committee. If you have
any concerns about the ethical conduct of the research you may contact the Committee
through the Human Ethics Committee Administrator (ph +643 479 8256 or email
[email protected]). Any issues you raise will be treated in confidence and investigated
and you will be informed of the outcome.

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Tagalog version

Reproductive Wellbeing of Women in Philippine Prison

CONSENT FORM FOR PARTICIPANTS

(PRISON STAFF)

Nabasa ko ang mga impormasyon tungkol sa proyektong ito at naiintindihan kung ano ito.
Nasagot ang lahat ng aking mga katanungan. Naiintindihan ko na malaya akong humiling ng
karagdagang impormasyon sa anumang yugto ng pag-aaral na ito.
Naiintidihan ko na:
1. Ang aking partisipasyon sa research/pag-aaral na ito ay boluntaryo at kusang-loob;
2. Kung nanaisin kong hindi mapabilang sa pag-aaral na ito sa kahit ano mang oras o
panahon, pwede po ninyong gawin ng hindi kailangan magbigay ng rason bago ito ma
kompleto sa Setyembre 2021;
3. Ang mga audio-recording at notes ay gagamitin sa pag-aaral lamang. Pagkatapos ng
pag-aaral na ito, kung ano mang audio-recording at notes na aming nakuha ay idi-
delete pagkatapos ng limang taon.
4. Inaasahan ko na ang mga panayam ay aabutin ng halos isang oras. Sa panahon ng
pakikipanayam ay tatanungin ako ng mga pangkalahatang katanungan tungkol sa aking
mga pang-unawa at karanasan tungkol sa ng mga programang medikal o tungkol sa
pangangalaga sa pangkakusugan at pangangailanagn ng mga kababaihan sa bilangguan.
5. Ang panayam at irerekord at isasalin sa Filipino/Tagalog;
6. Ang researcher ay maaaring gumamit ng isang maikling quote mula sa transcript ng
interview/usapan at titiyakin niya na walang pagtukoy ng personal impormasyon sa
quote;
7. Wala pong bayad ang paglahok sa pag-aaral na ito at ito po ay boluntaryo lamang.
8. Kung sakaling hindi ako komportable at meron akong nararamdaman, sinisiguro na
merong angkop na serbisyo at suporta para sa akin galing sa staff ng Corrections.
9. Bagaman may karapatan ako sa pagiging kompidensiyal, pinananatili ng researcher ang
tungkulin na mag-ulat sa tamang awtoridad ang anumang ligal na isyu at naiulat na mga
krimen na maaaring magdulot ng banta sa aking kaligtasan at kalusugan ko.

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 10. Ang mga resulta ng proyekto ay maaaring mai-publish at magagamit sa University of
Otago Library (Dunedin, New Zealand), ngunit ang lahat ng pribadong impormasyon ay
hindi po kasali sa dokumentong ito;
Sumasang-ayon ako na makibahagi sa proyektong ito.

........................................................................ ...............................
(Lagda) (Petsa)
.............................................................................
(Pangalan)

……………………………………………………..
Pangalan ng nagbibigay ng consent

Ang pag-aaral na ito ay na-aprubahan ng University of Otago Human Ethics Committee. Kung
mayroon kang anumang mga katanungan o paglilinaw tungkol sa etikal na proseso ng pag-aaral
na ito, maaari kang makipag-ugnayan sa komite sa pamamagitan ng Human Ethics Committee
Administrator (ph +643 479 8256 or email [email protected]). Ang anumang mga isyu na
ibabahagi mo ay ituturing na kumpidensyal at iimbestigahan ng komite.

224
 Appendix F – Focus group participant information
sheet
English version

Reproductive Wellbeing of Women in Philippine Prisons

INFORMATION SHEET FOR PARTICIPANTS

(PRISON STAFF)
Thank you for showing an interest in this project. Please read this information sheet carefully
before deciding whether or not to participate. If you decide to participate, we thank you. If you
decide not to take part there will be no disadvantage to you and we thank you for considering
our request.

My name is Romulo Nieva Jr, a Filipino PhD student at the Sociology, Gender Studies,
Criminology Programme of the University of Otago, New Zealand. I am conducting my PhD
research on women's reproductive wellbeing in Philippine prisons. Specifically, I am interested
in learning more about how they perceive reproductive wellbeing. I am also interested in
documenting the reproductive care programmes and policies in place in prison.

You are invited to participate in a focus group (FG). I welcome prison staff involved in medical
and reproductive programme implementation, including reproductive education campaign, and
the Gender and Development Committee members responsible for planning and reproductive
care policy development.

I anticipate that the FG will take approximately an hour. During the FGD, I will ask general
questions about prison programmes and services related to reproductive care. You will also be
asked about your role/job, and years in prison service/job. The FG will follow these questions
but may not follow them precisely. In the event that the line of questioning does develop in
such a way that you feel hesitant or uncomfortable, you are reminded of your right to decline
to answer any particular question(s) and also that you may withdraw from the project at any
stage before its completion in September 2021 without any disadvantage, but any information
already shared during the focus groups can no longer be taken out from the transcript.

225
The project results may be published and available in the University of Otago Library (Dunedin,
New Zealand). You are welcome to request a copy of the project results should you wish. The
FGD will be audio recorded so that I can accurately record what is said. The interview is
confidential; however, if documented cases pose an imminent threat to your safety and
reportable crimes are obtained, it is the obligation of the researcher to report to appropriate
authority based on government protocol. Only my supervisors and I can access the audio files
and transcripts. As required by the University’s research policy, any raw data on which the
results of the project depend will be retained in secure storage for five years, after which it will
be destroyed. I may use a short quote from the interview transcript, but I will ensure that there
is no identifying information in the quote. Your confidentiality is of utmost importance. I will
not share what you tell me with anyone else, including other prison staff. No identifying
information will be used for this project, and the researcher cannot guarantee that other
members of the focus groups will keep the information confidential, but this will be discussed
during the focus groups that information shared should be confidential and cannot be shared
to anyone outside of the group.

If you have any questions about our project, either now or in the future, please feel free to
contact:

Romulo F. Nieva Jr
Sociology, Gender Studies & Criminology
[email protected]

Dr Bryndl Hohmann-Marriott
Sociology, Gender Studies & Criminology
Room 5C17, Richardson Building
[email protected]

This study has been approved by the University of Otago Human Ethics Committee. If you have
any concerns about the ethical conduct of the research you may contact the Committee
through the Human Ethics Committee Administrator (ph +643 479 8256 or email
[email protected]). Any issues you raise will be treated in confidence and investigated
and you will be informed of the outcome.

226
Tagalog version

Reproductive Wellbeing of Women in Philippine Prisons

INFORMATION SHEET FOR PARTICIPANTS

(PRISON STAFF)
Maraming salamat sa pagiging parte sa proyektong ito. Inaanyayahan po namin kayo na basahin
ang impormasyon tungkol sa pag-aaral na ito bago kayo maging bahagi sa proyetong ito. Nais
naming ipaalam sa inyo na bagama’t mahalaga ang inyong mga ibibigay na impormasyon at
opinyon, ang pakikilahok ninyo sa pag-aaral na ito ay boluntaryo.

Ako ay si Romulo Nieva Jr, a Filipino PhD student sa Sociology, Gender Studies, Criminology
Programme sa University of Otago, New Zealand. Ako ay gumagawa ng isang research/pag-
aaral patungkol sa kalusugan ng mga babae sa loob sa ng kulungan ng Pilipinas. Nais kong
malaman ang mga programa at polisiya sa pangangalaga sa kalusugan at pangangailangan ng
mg babae na nasa bilangguan (regla o mga problema tungkol sa regla (dysmenorrhea),
pagbubuntis o panganganak.

Inaanyayahan kang lumahok sa isang pakikipgpanayam. Inaanyayahan ko ang mga kawani ng

bilangguan na parte sa pagpapatupad ng mga programang medikal o tungkol sa pangangalaga
sa pangkakusugan at pangangailanagn ng mga kababaihan sa bilangguan at mga miyembro ng
Gender and Development Committee na responsable sa pagpaplano ng mga programa at
polisiyang ito.

Inaasahan ko na ang mga panayam ay aabutin ng halos isang oras. Sa panahon ng

pakikipanayam ay magtatanong ako ng mga pangkalahatang katanungan tungkol programang
medikal o tungkol sa pangangalaga ng pangkakusugan at pangangailanagn ng mga kababaihan
sa bilangguan. Tatanungin ka rin tungkol sa iyong trabaho/posisyon at taon sa serbisyo nyo
bilang opisyal/kawaning ng Correctional Institution for Women.

Kung nanaisin ninyong di mapabilang sa pag-aaral na ito sa kahit ano mang oras o panahon,
pwede po ninyong gawin ng hindi kailangan magbigay ng rason. Ang University of Otago ay may
responsibilidad na sumunod sa mga alintuntunin sa research ethics. Kung sagaling hindi kayo

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komportable at meron kayong nararamdaman, sinisiguro namin na merong angkop na serbisyo
at suporta para sa inyo.

Ang inyong sagot ay makatutulong para malaman ang inyong karanasan bilang kawani at iyung
kaalaman tungkol sa mga pangangailangan ng mga babae sa loob ng kulungan at ang mga
ahensya ng gobyerno tulad ng Department Corrections at Department of Health para suriin at
mapabuti pa ang mga polisiya at programa. Ibabahagi naming ang magiging resulta ng pag-aaral
na ito, at makikipagpanayam para mapag-usapan ang mga rekomendasyon namin. Nais po
naming kayong hikayatin na sumagot ng nauukol sa paksa at ng hindi nakakabahala sa inyo.
Gagawa po kami ng audio-recording sa panayam na ito at magtatala ng inyong sagot para
maayos na makuha ang inyong sagot. Ang mga audio-recording at notes naming ay gagamitin sa
pag-aaral lamang. Pagkatapos ng pag-aaral na ito, kung ano mang audio-recording at notes na
aming nakuha ay idi-delete.

Wala pong bayad ang paglahok sa pag-aaral na ito at ito po ay boluntaryo lamang. Kung meron
po kayong mga katanungan o dagdag na impormasyong makakatulong sa pag-aaral na ito,
pwede niyo pong makipag-ugnayan sa amin sa pamamagitan sa pagtawag o email:

Romulo F. Nieva Jr
Sociology, Gender Studies & Criminology
[email protected]

Dr Bryndl Hohmann-Marriott
Sociology, Gender Studies & Criminology
Room 5C17, Richardson Building
[email protected]

Ang pag-aaral na ito ay na-aprubahan ng University of Otago Human Ethics Committee. Kung
mayroon kang anumang mga katanungan o paglilinaw tungkol sa etikal na proseso ng pag-aaral
na ito, maaari kang makipag-ugnayan sa komite sa pamamagitan ng Human Ethics Committee
Administrator (ph +643 479 8256 or email [email protected]). Ang anumang mga isyu na
ibabahagi mo ay ituturing na kumpidensyal at iimbestigahan ng komite.

228
 Appendix G – Interview guide
A: Opening
- Greeting
- Introduction
- Consent form
B: Interview
- Recording setting: Make sure if a participant feels comfortable with recording

Topic 1: Experiences of reproductive wellbeing

1) Could you describe your experience here inside the Correctional Institution for women?
2) Could you tell me about your menses/period (menstruation) experience? Have you observed any
difference in your period experience now in prison compared to before?
3) Have you ever had discomforts or problems related to your menses/menstruation/ period (e.g.
menstrual problems, pains/discomforts, endometriosis, heavy bleeding, etc.)? Probe: before and
during imprisonment
4) What can you say about the safety and privacy of women here in prison?
5) Could you describe what you usually do if you experience menstrual problems like pain or heavy
bleeding? Do you regularly seek medical care if you experience any discomforts?
PROBES: access to hygiene materials/sanitary pads, management of menstrual discomforts (e.g.
endometriosis, heavy bleeding, etc.),
6) Do you think you need to see a doctor or a nurse if you have any menstrual problems?
Possible probes: What are the benefits or advantages of seeking health care? What are their
disadvantages or negative consequences?
7) Can you tell me specific programs/activities that educate women prisoners (or couples)
about menstruation, reproductive cancer, overall reproductive care
8) Could you describe your experience accessing outside health care/ hospital appointments?
Probes: process, challenges
9) Could you tell me about your pregnancy experience (before incarceration/ during incarceration)?
Note: only those with pregnancy experience
Could you tell me about your prenatal and postnatal experiences?

Topic 2: Social Networks

1)What role does your family, fellow prisoners or prison staff play when we talk about menstrual
discomforts (e.g. endometriosis, heavy bleeding, etc.), pregnancy care, prenatal and postnatal care
2) Do you get encouragement or support from your family, fellow prisoners, or officials regarding
reproductive care?

C: Demographics
1. In what month and year were you born? Month ___ ___ Year ___ ___ ___ ___
2. What is your highest educational attainment? Elementary High school College Post-graduate
3. What is your religion?
4. What is your current civil/marital status? Married/Single/Living with
Partner/Separated/Widowed
5. How many children do you have (if applicable)? __________________________

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6. What was your job before you were incarcerated?

D: Closing
- Thank the participants for their time
- Ask them if there is anything they would like to add

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 Appendix H – Focus group guide (prison staff)
A: Opening
- Greeting
- Introduction
- Consent form
B: Interview
- Recording setting: Make sure if a participant feels comfortable with recording

1. What are the common or basic needs of incarcerated women here?

2. What reproductive wellbeing needs do incarcerated women often express/encounter?
Probe: access to hygiene materials, management of menstrual discomforts (e.g. endometriosis,
heavy bleeding, etc.), pregnancy care, prenatal and postnatal care, access to reproductive health
care
3. What is the role of the Gender and Development (GAD) Committee concerning reproductive
care? Probe: meeting agenda, priorities
4. Do you think the reproductive wellbeing of women in prison is a priority policy agenda of the
institution or national government in general? Probes: reasons/ factors
5. Do you have policies supporting reproductive care for women? Probe: Specific policies,
Funding support for reproductive care, support for menstrual needs and pregnant women
6. What is currently being done to address women’s reproductive wellbeing needs? Probes:
gaps and issues
7. What do you think interventions should be in place to address reproductive care priorities
fully?
8. What are prison practices or regulations regarding women who cannot follow prison routines
due to their reproductive discomforts? Probes: considerations, exemptions, who decides for
the exemptions
9. Could you describe the process/ protocols regarding hospital appointments? Probes: gaps
and issues, bureaucracy, court order, DOJ permits
C: Demographics
-Age, roles/department, years in service
D: Closing
- Thank participants for their time
- Ask them if there is anything they would like to add

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 Appendix I – Focus group guide (prison nurses)

A: Opening
- Greeting
- Introduction
- Consent form
B: Interview
- Recording setting: Make sure if a participant feels comfortable with recording

Topic 1: Common reproductive wellbeing needs among incarcerated women

1. What reproductive wellbeing needs do incarcerated women often express/encounter?
Probe: access to hygiene materials, management of menstrual discomforts (e.g. endometriosis,
heavy bleeding, etc.), pregnancy care, prenatal and postnatal care, access to reproductive health
care
2. Could you describe the overall reproductive care service present inside the prison?
3. Why do you think this problem continues to happen? (despite the programs you have
mentioned?)
Topic 2: Services Uptake
1. Do you feel the prison is adequately equipped to offer reproductive services for women?
a. Probes: Factors that facilitate or hinder the provision of services?
If not, what needs to be put in place?
2. Have you referred women to outside health facilities for reproductive care services?
If so, where are they being referred to? What are the common services being sought outside?
3. What other services do you think are necessary to help women address their reproductive
wellbeing needs?

C: Demographics
-Age, roles, years in service

D: Closing
- Thank participants for their time
- Ask them if there is anything they would like to add

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