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Abstract

Introduction

Around 55,000 pregnant individuals enter US jails annually, with over one-third having a substance use disorder (SUD), putting them at risk of perinatal morbidity and mortality. Yet, uptake of perinatal/SUD care best-practices into jails is slow, impacted by many organizational factors. This study explores the organizational contexts that shape decision-making structures and policy development regarding perinatal/SUD care in North Carolina (NC) jails.

Method

We conducted semi-structured interviews with employees at 26 NC jails in 2023. Interview transcripts were de-identified and analyzed using ideal-type analysis methodology. Two team members created organizational context summaries, proposed ideal-types (i.e., categories based on shared characteristics), and categorized each interviewed jail. A third team member performed a credibility check, and discrepancies were resolved through team consensus.

Results

We constructed three jail ideal-types based on organizational capacity to implement new care policies, identify medical care alternatives to incarceration through community and judiciary connections, and foster collaborative decision making between custody and medical staff regarding perinatal/SUD care. Proactive and Collaborative jails (n = 6) had recently implemented evidence-based programs and/or policies, facilitated referrals to alternatives to incarceration, and collaborated across roles in perinatal/SUD care innovation. Responsive and Coordinated jails (n = 15) had more limited perinatal/SUD implementation experience, fewer connections for alternatives to incarceration, and less management collaboration. Traditional jails (n = 5) had not implemented new programs and/or policies, did not identify local alternatives to incarceration, and maintained centralized and siloed decision-making structures.

Conclusions

These typologies provide a conceptual framework for understanding leadership structures and care innovation in NC jails regarding perinatal/SUD care. This framework can be applied to collaborative initiatives with jails to help develop context-specific implementation teams and strategies for integrating perinatal/SUD best-practices. Understanding these organizational contexts is crucial for developing tailored approaches that support jails in their uptake and delivery of perinatal/SUD evidence-based practice to ultimately improve perinatal outcomes.

Plain Language Title

Understanding How North Carolina Jails Organize Care for Pregnant People With Substance Use

Plain Language Summary

What was the problem?

Every year, about 55,000 pregnant people go to jail in the United States. Many of these individuals have problems with drugs or alcohol, which can make pregnancy more dangerous. Even though we know effective ways to help pregnant people with substance use problems, jails are often slow to start using these methods.

What did we do?

We talked to staff members at 26 different jails in North Carolina to understand how these facilities make decisions about caring for pregnant people with substance use problems. We analyzed these conversations to identify different types of jails based on how they organize care and make decisions for these individuals.

What did we find?

We found three categories of jails. Proactive and Collaborative jails (6 facilities) had experience starting new programs to help pregnant people, had medical and jail staff who worked together as teams to make decisions about care, and helped connect people to treatment programs in the community as alternatives to jail. Responsive and Coordinated jails (15 facilities) had some experience with new programs, teamwork, and connecting with community treatment options, but less than the first group. Traditional jails (5 facilities) had not started new programs for pregnant people with substance use problems, did not help connect people to community treatment, and had decisions made only by the highest-ranking official, like the sheriff.

Why does this matter?

Understanding these different types of jails can help researchers and healthcare providers work more effectively with each facility. By knowing how a jail is organized, we can better plan how to start helpful new programs in ways that will be successful and long-lasting. This can ultimately lead to better health outcomes for both pregnant people and their babies.

Keywords

Perinatal substance use disorder jails implementation science organizational context ideal-type analysis typologies qualitative research incarceration organizational assessment

Introduction

Women & Pregnant People in the Carceral System

While women comprise a minority of the U.S. carceral population, female incarceration rates have increased over 500% since the 1980s and remain relatively stable even as overall incarceration rates have declined since 2007 (Heimer et al., 2023; Zeng, 2021). Of those incarcerated, over 75% in jails and 65% in prisons are of reproductive age (15–44) (Federal Bureau of Prisons, 2025; Zeng, 2021). Thus, there has been a significant increase in the proportion of pregnant people entering the carceral system, with estimates suggesting they make up about 3% to 5% of jail admissions yearly, extrapolating to around 55,000 pregnant people entering U.S. jails annually (U.S. Government Accountability Office, 2024; Sufrin, Jones et al., 2020a).

People who are pregnant in the carceral system face elevated risks of maternal morbidity and mortality related to perinatal substance use disorders (SUD) and co-occurring conditions. When Hendricks et al. (2024) sampled this population, up to 34% had an SUD, 27.4% had a mental health disorder, and 20% had hepatitis C (HCV). Another study found that from 2016 to 2018, over 50% of pregnant people at one North Carolina (NC) carceral facility had a history of an SUD (Knittel et al., 2020). Comparatively, the general U.S. pregnant population rates are much lower: 5% to 10% for SUD, around 14% for mental health disorders, and 1% to 3% for HCV (Abdelhafez et al., 2023; Asafo-Agyei & Samant, 2024; Wendell, 2013). This disparity is significant considering 23% of maternal deaths are attributed to behavioral health conditions (including deaths from suicide and overdose/poisoning related to SUD) (Trost et al., 2021). Recent incarceration itself is also a risk factor for SUD-related morbidity and mortality (Nielsen et al., 2020; Ranapurwala et al., 2022; Schiff et al., 2018; Sufrin & Knittel, 2021). In addition, due to systemic racism, Black women are both more likely to be incarcerated, less likely to access medications for SUD treatment, and at higher risk for both maternal and SUD-related morbidity and mortality (Schiff et al., 2024; Wildeman & Wang, 2017; Wilper et al., 2009).

It is imperative that evidence-based practices (EBPs) be instituted in the carceral system to improve care for this vulnerable population. Yet, the carceral system is known for its slow uptake of EBPs, leaving pregnant individuals even more susceptible to increased risks of morbidity and mortality (Sufrin et al., 2022; Sufrin, Sutherland et al., 2020b; Zielinski et al., 2020).

Increasing Uptake of Evidence-Based Practices in the Carceral System

There have been recent proposals in the carceral health field to employ implementation science approaches, which involve studying methods and strategies that facilitate intervention uptake, to enhance EBP adoption (Van Deinse et al., 2023; Zielinski et al., 2020). A crucial element of effective implementation is a thorough understanding of the determinants—factors that influence uptake and delivery. The Consolidated Framework for Implementation Research (CFIR) is a widely used implementation science framework (Breimaier et al., 2015). It highlights the significance of evaluating all factors that can affect implementation, including the inner setting (the organization where implementation occurs) and the outer setting (the environment in which the inner setting exists) (Breimaier et al., 2015).

Performing jail-level organizational assessments is a vital step for implementing perinatal EBPs because nearly all people who enter the carceral system will enter through a jail, and the majority of the female population in the carceral system is housed in jails (Heimer et al., 2023; Zeng, 2021). Given that jails are operationalized on a local level and the management of jails varies significantly, understanding the variations among jails is an essential step for identifying context-specific strategies to increase uptake of SUD interventions for pregnant and reproductive-aged women experiencing incarceration.

Study Aims

This study examines the organizational contexts of NC jails affecting the care and management of pregnant people, particularly those with SUD, during incarceration. Using the data from qualitative interviews, we applied ideal-type analysis—a method that constructs typologies by grouping cases into distinct categories based on shared characteristics—to describe different organizational approaches to decision-making and care innovation, with the aim of supporting future implementation of perinatal and SUD care best practices (Stapley et al., 2022).

Methods

Study Context

This analysis is part of a larger mixed-methods study to assess the prevalence and availability of treatment for perinatal substance use in NC jails. The goal is to increase the uptake of EBPs through alternatives to incarceration for this population in NC. This portion of the study analyzes semi-structured qualitative interviews that inquired about the policies/programs, management, and decision-making pertaining to pregnant individuals, especially those with SUD, in NC jails. We developed a semi-structured interview guide to understand four domains: scope of the problem, local resources and programs, jail and county context, and process of innovation. The guide was informed by both Ward et al.'s framework for knowledge transfer and Dryden-Palmer et al.'s review showing context and implementation processes being strongly associated with intervention adoption (see Supplemental materials for complete interview guide) (Dryden-Palmer et al., 2020; Ward et al., 2009).

Ethical Considerations

This project was reviewed by the University of North Carolina at Chapel Hill Institutional Review Board (Study #22-1508) and was determined to be nonhuman subjects research given that the participants were reporting on the facilities and policies they encounter in their work.

Sampling & Participants

Out of 97 NC county jails, all of whom were contacted, 77 participated in the initial quantitative survey portion of our larger study. From this pool, we selected 39 jails to contact for follow-up interviews by email and/or phone based on a sampling matrix designed to achieve diversity across four jail characteristics: size (target n = 5 each), region (target n = 1 from each of the 9 state regions), safekeeping use (target n = 5 each for yes/no), and prior perinatal SUD program partnership experience (target n = 5 each for yes/no). Ultimately, 26 jails responded to our request and had a staff person participate in a semi-structured interview. We chose the jail subsample to ensure diversity in location, population size of the county, jail capacity, and potential existing management programs for those who are pregnant and/or have SUD. We recruited participants who were either custody or medical staff deemed knowledgeable about the management of pregnant individuals in the facility.

Data Collection

A research coordinator (JJ) and program manager (ZS) conducted interviews by phone, which were recorded and transcribed, except for four interviews during which a notetaker (IF) took extemporaneous notes because the interviewees did not want to be recorded. Interviews took place during a 7-month timespan in 2023. Prior to starting the interview, we conducted a verbal consent conversation that disclosed to participants the name of the program/research team conducting the interview, the goal and topics of questions that would be asked, and the study funder. We offered participants a $50 gift card incentive for completing the interview and they were notified of the incentive at time of recruitment.

Data Analysis

As described in our study aims, we sought to create a typology characterizing different jail organizational approaches to the care and management of pregnant individuals with SUD, specifically focusing on policies/programs, decision-making structures, and innovation processes. We performed an ideal-type analysis to develop this typology (Stapley et al., 2022). Ideal-type analysis is a qualitative methodology that identifies groupings (“types”) of participants within a dataset to organize and understand cases according to their within-group similarities and between-group differences. Originally developed by sociologist Max Weber and later adopted into psychology research, this approach creates conceptually pure forms that highlight key distinguishing features by systematically comparing cases to form groupings, with each group representing a different pattern of characteristics within the dataset (Swedberg 2018; Weber 1904).

We selected this approach because, while jails share some commonalities, each is uniquely managed at the county level. Thus, successful implementation across these settings at scale requires understanding both their similarities and differences. We surmised that ideal-type analysis would allow us to assess this in a systematic manner.

Prior to analysis, we de-identified the counties and assigned them each a letter designation. Two research team members (PA and AK) then created case reconstructions, or summaries, based on the responses to questions geared toward decision making about policy changes and management of pregnant individuals in jail custody. After the full team reviewed the case reconstructions, PA and AK constructed ideal-types with descriptions and identified an optimal case for each ideal-type—a jail that most closely illustrated the pattern of characteristics of that ideal-type—to serve as the reference point for categorizing all interviewed jails. They then placed each interviewed jail into an ideal-type category based on the case reconstruction.

Another team member (JJ), who was not previously involved in the creation of case reconstructions or typology formation, performed a credibility check. During the credibility check, 15 of the 26 jails (58%) were initially assigned to the same ideal-type by all three reviewers. For the remaining 11 jails, discrepancies were primarily between the original analysts (PA and AK) rather than with the credibility check reviewer (JJ). In fact, the team member performing the credibility check (JJ) achieved 96% agreement with the final consensus classification (25 of 26 jails correctly assigned).

Discrepancies were resolved through team consensus. When a jail demonstrated mixed characteristics spanning two ideal-types, we assigned it to the most appropriate category based on predominant features, typically when at least two of the three defining criteria were met. Through the consensus process, the ideal-types themselves did not change substantively; rather discrepancies were resolved by clarifying their descriptions and reaching agreement on the boundaries between them.

Results

Overview of Interviewed Participants and Jails

Of the 26 jails sampled, 18 were in rural counties (69.2%), five in urban counties (19.2%), and three in suburban counties (11.5%). This compares to the overall NC county makeup of 78% rural counties, 16% suburban, and 6% urban. All nine regions of the NC area health educational center geographical regions were represented in this sample. In our sample, eight were small jails (<100-person capacity), 12 were medium sized (100–999-person capacity), and four were large (>1000-person capacity). In NC, there are 26 small, 65 medium, and four large jails. Nine county jails had a prior interaction with the university-based treatment program for pregnant individuals with SUD where the research team was based, and 20 reported use of safekeeping, a legal procedure in NC which can be used to transfer people from jails to prison facilities to meet medical care or other needs (King et al., 2023; N.C. Gen. Stat. § 162, 2019). Five interviewees were custody staff and 21 were medical staff.

Through review of the interviews and case reconstructions, we developed three distinct ideal-types regarding organizational structures and policy approaches to perinatal and SUD care in NC jails based on their implementation of new policies and programs, leadership decision-making structures, and ability to identify medical alternatives to incarceration. Ideal-types are summarized in Figure 1, and facility characteristics by ideal-type are shown in Table 1.

Figure 1.

Description of jail ideal-types.

Table 1.

Jail Characteristics by Ideal-Type.

Characteristics	Ideal-Type 1: Proactive and Collaborative (n = 6)	Ideal-Type 2: Responsive and Coordinated (n = 15)	Ideal-Type 3: Traditional (n = 5)
Jail Location, % (n)
Urban	33% (2)	20% (3)	0% (0)
Suburban	33% (2)	7% (1)	0% (0)
Rural	33% (2)	73% (11)	100% (5)
Jail Size, % (n)
Small	17% (1)	27% (4)	60% (3)
Medium	67% (4)	53% (8)	40% (2)
Large	17% (1)	20% (3)	0% (0)
Uses Safekeeping, % (n)	83% (5)	73% (11)	80% (4)
Prior Perinatal SUD Program Partner, % (n)	50% (3)	33% (5)	20% (1)
Interviewee Role, % (n)
Medical	67% (4)	93% (14)	60% (3)
Custody	33% (2)	7% (1)	40% (2)
AHEC* Regions Represented	Northwest, Wake, Eastern, and South Piedmont	Mountain, Northwest, Piedmont, Wake, Eastern, Southern Regional, and South Piedmont	Mountain, Area L, Eastern, South East, and Southern Regional

Note. From west to east, the AHEC regions are descriptively named Mountain, Northwest, South Piedmont, Piedmont, Southern Regional, Wake, South East, Area L, Eastern.

AHEC = Area Health Education Center; SUD= substance use disorder.

Ideal-Type 1: Proactive and Collaborative Approach to Care and Policy Making (n = 6)

These jails demonstrated recent implementation of evidence-based programs, true multidisciplinary collaboration across custody and medical staff in perinatal/SUD care decision making, and the ability to identify alternatives to incarceration through community and judiciary connections. We identified the optimal case for this ideal-type as Facility O. This facility described that they “fall under [the health department]” and because of this, were able to “implement a breastfeeding program” for those still in jail after delivery. They also had set standards for medications for substance use disorder (MOUD) and SUD care including partnership with “a Methadone clinic just down the road, so every day they're taken to the clinic to get dosed” if already on methadone and “the psychiatrist [or the] medical provider [can] continue [suboxone]” in the jail as well as “standing orders” for withdrawal support when needed. They described “round table” collaborations between “nursing staff, medical provider, jail administrators, and health department” to make decisions and policies about pregnant individuals, with decision-making typically starting with “the nursing staff,” or medical staff, as “the key people who are involved when there is a pregnant inmate.” While they mentioned being in a more remote area without a lot of resources, they described an established relationship with a community organization that does “a lot with the outpatient rehab” and “they work with the inmate… [and] the attorneys” to help get people into this outpatient SUD center when appropriate.

Facilities in this ideal-type had also commonly introduced new programs or policies for pregnant individuals with SUD. Several facilities reported recent adoption of MOUD or medication assisted treatment (MAT) protocols: “We recently started a MAT treatment program, so if we were to get in females that were detoxing, we would detox them with suboxone... as long as they meet the criteria for the suboxone ” (Facility I), “We have a therapeutic housing unit… We just started initiating MAT” (Facility X), and “More recently, we have started using new treatment options for pregnant individuals with substance use disorders more than we used to” (Facility R).

Similar to the collaborative decision-making team in Facility O, other facilities described their multidisciplinary decision-making teams as including: “our Classification Officer, judicial officials, mental health staff, and substance use counselors” (Facility Z), “the captain, the lieutenant, the medical team, and the rehab coordinator” (Facility M), and “our classification team and medical team” (Facility I). One facility described their decision-making structures as “more of a democracy with a committee-type setting” (Facility R).

Like the optimal case, most facilities in this ideal-type actively sought ways to connect pregnant individuals with SUD with alternatives to incarceration when appropriate. One facility described engaging judicial actors: “Depending on the charge, I may talk with the appropriate legal authorities and try to see if there's a way for house arrest or some way for the patient to get out of jail” (Facility Z) and “we would contact mental health and the DA and the attorney” (Facility X). Others coordinated directly with community organizations to support alternatives to incarceration: “We work closely with [a community organization] here in the region” (Facility X) and “We have grant funding that helps find community resources for those being released… they have medication and a clear plan to continue care” (Facility I). Others similarly described efforts to coordinate direct pathways to treatment: “We initiate the lab work here, so they can leave directly from here to go straight to rehab” (Facility M).

Ideal-Type 2: Responsive and Coordinated Approach to Care and Policy Making (n = 15)

These jails exhibited more limited perinatal/SUD implementation experience, defined jail and medical staffing roles with some decision-making collaboration, and fewer connections to identify alternatives to incarceration. We identified Facility D as the optimal case for this ideal-type as they had not implemented large scale changes but had some experience with implementing new policies, such as a recently established policy that if a pregnant individual comes in and “they’re on Suboxone to continue the Suboxone.” They described the facility's reliance on chain-of-command protocols but suggested that collaboration is possible. When asked who makes key decisions they answered, “probably be our jail administrators,” but when probed about what they would do if they wanted to change something for all pregnant inmates in their jail they said they “would contact our [medical leadership] and jail administration to make it a joint effort.” They were “in the process of setting into place local resources for when they get out, [that] they can be referred to—like clinics that allow them to continue their Suboxone,” but without currently established relationships. Though they did describe that they sometimes use their medical provider to make informal recommendations: “our provider is very proactive. We can text her anytime to ask for recommendations [for community MOUD programs] even if she's not on site.”

Other jails similarly reported some modest prior experience with the implementation of EBPs related to perinatal and SUD care. Facility A noted their past engagement with nonprofits to support women but acknowledged that such efforts have stalled: “The closest we came was before COVID. They were doing some luncheons with local nonprofits… but the luncheons stopped, and I don't think we've returned to it” (Facility A). Other facilities described limited but notable changes to substance use treatment protocols, often continuing medications rather than initiating new interventions: “The latter part of last year, they implemented where we would, in fact, continue methadone and suboxone within the jail instead of detox, as long as they were compliant with it on the outside prior” (Facility G). Others had instituted new programs related to establishing connections for care but had not implemented the programs themselves: “Yeah, we don’t have really no MAT program right now. We do use, like, resources… detox programs, counseling, trying to set up stuff with them on the outside.” (Facility H) and “We just started a new [program]…[they] actually have ways of contacting the same chaplains and therapists and counselors even once they leave.” (Facility S).

Other jails of this type had examples of programmatic or policy changes within their medical unit, but not specific to pregnancy or SUD: “We started with an electronic medical record system last year” (Facility P) and “We were quarantining [for COVID] for 10 days when I first came in and now they quarantine for 5 days as long as they’ve had 2 shots—at least 2 shots. That's the only policy that I that I know of” (Facility V). One jail also referenced new initiatives still in development, highlighting the early-stage nature of policy change: “So we're actually working [on something] now. But I'm not allowed to discuss it because it's a grant and we're doing the research stage” (Facility U).

Similar to the optimal case of Facility D, many jails within this ideal-type maintained structured leadership roles with some, but varying, degrees of collaboration. Facilities B, L, and V described how new plans are discussed across medical and jail leadership teams on a case-by-case basis only: “We (medical team) would sit down with the captain, with jail administration to make sure that a new plan was implemented” (Facility B), “If we (medical team) have an issue that is concerning, we will let them know. We need to identify an issue and bring it to everyone's attention.” (Facility L), and “That would be between myself [medical personnel], the lieutenant and my first sergeant. Usually, we would all have a discussion on what needed to be done.” (Facility V).

Some other facilities in this ideal-type identified limited collaboration within these structured roles. For example, Facility N described their decision-making model as “the jail administrator and my medical director” having a role in decisions for pregnant individuals housed in the facility, but not necessarily collectively. Other facilities noted that staff relationships allow for informal collaboration when issues arise, even if official policies keep decision-making processes separate: “If I (medical personnel) didn't like what a jailer was doing, I’d probably just go straight to jail admin… It's easier for me to go to him instead of going through the channels.” (Facility T).

As demonstrated with Facility D, facilities in this ideal-type showed varying levels of engagement with external partners, or established referral patterns, to find alternatives to incarceration. Some jails had support staff to facilitate continuity of care, but primarily for after release rather than as an alternative to incarceration. Some jails also expressed an individualized rather than institutional approach to referrals, with one respondent noting they personally recommend community options based on prior experience: “If they were not going to prison and didn't have resources on the outside, I would recommend them to [local health centers]… I know that because I actually used to work there” (Facility T). Similarly, even jails with more structured early-release programs still relied on case-by-case evaluations rather than standardized processes. Facility W described having “a person that calls early release…and tries to determine whether or not it is even feasible.” Facility U similarly described a process where “the administrator,” on a case-by-case basis, advocated for alternatives to incarceration where “he would contact the DA's office or probation…whoever brought them in,” but did not necessarily facilitate the connection to community programs. Facility Y emphasized their “social worker really gets involved with them and meets with them weekly [and] tries to get them into [a community program]” but noted limited involvement or advocacy by jail leadership.

Ideal-Type 3: Traditional Approach to Care and Policy Making (n = 5)

Jails in this ideal-type had not implemented new policies or programs aimed at improving perinatal and SUD care. Decision-making structures remained highly centralized, with little collaboration between medical and jail administrators, and there was no formal identification of local alternatives to incarceration. All the jails in this category were in rural areas; three were small and two were medium-sized jails. The optimal case for this ideal-type was Facility J. The interviewee described the jail as “kind of old school” and “[didn't] think anything [had] changed” in many years. When it comes to decision making about pregnant individuals, the facility staff “don't do [anything] without the head man, the sheriff… he makes the final decision” and emphasized that “if I had a problem like I said before it's chain of command.” In terms of getting pregnant people out of jail and into treatment, the jail did not directly interact with the judiciary system but “usually talk to the family if they call… [and say] they should talk their lawyer and then the lawyer [will] get them to the right place.” When asked about community resources to help pregnant people who use substances, the interviewee who had “been [at the jail] for 10 years” had “never came across anything like that.”

Like Facility J, this ideal-type was characterized by facilities without significant implementation experience: “We haven't had any changes… We've been doing things the same way for a long time” (Facility Q) and “No, not really… As far as inmates who are pregnant females, no, I can’t think of any [new programs]” (Facility K).

Hierarchal leadership models with decisions made almost exclusively by jail administrators were common, as with the optimal case. While respondents identified different levels of administrative leadership, the unifying characteristic was that custody personnel, rather than medical staff or a collaborative leadership structure, had final decision-making authority. When asked who they would contact to make a change in the management of pregnant individuals, responses similarly included: “the captain of the jail” (Facility C), “the captain or the lieutenant” (Facility F), and “my jail administrators” (Facility Q). Others emphasized that decisions are made by the highest-ranking official: “any changes in the jail come down from the sheriff” (Facility K).

Facilities in this ideal-type followed suit with Facility J and generally did not identify alternatives to incarceration, although several also emphasized that access to programs in their areas may be limited. When asked about community-based alternatives, one respondent explicitly stated: “No. There's really nothing like that here” (Facility Q). Even when jails engaged with legal officials, it was not done with the intention to support therapeutic or rehabilitative transitions from incarceration to treatment: “Sometimes you can go to the magistrate and ask him to lower the bond to where they can get out. Or you can go to the judge and try to make a case stating why they don't need to be in this facility” (Facility C). Some facilities mentioned having the health departments as a resource for help facilitating alternatives to incarceration, but were not actively utilizing them: “The health department does a lot… Maybe if they have some type of drug problem, they can recommend something for them. But at the moment, there just isn’t [a program for that]” (Facility K).

Discussion

This study set out to understand policy and programmatic innovation in NC jails related to perinatal and SUD care. We found three distinct ideal-types that link a jail's capacity for implementing evidence-based perinatal and SUD care with other organizational factors such as leadership structure, inter-role collaboration, and community connections. The Proactive and Collaborative jails had recently implemented evidence-based programs and/or policies, facilitated referrals to alternatives to incarceration, and collaborated across roles in perinatal/SUD care innovation. The facilities considered Responsive and Coordinated had comparatively more limited perinatal/SUD implementation experience, fewer connections for alternatives to incarceration, and less management collaboration. Finally, jails in the Traditional ideal-type had not implemented new programs and/or policies, did not identify local alternatives to incarceration, and maintained centralized and siloed decision-making structures.

This analysis also revealed patterns related to geographic location and jail size in the distribution of jails across ideal-types, signifying the potential ways in which their outer contexts might influence them. For instance, all Traditional jails were located in rural counties and were predominantly small to medium-sized facilities. In contrast, two-thirds of Proactive and Collaborative jails were in urban or suburban settings. This geographic pattern likely reflects differences in resources, staffing, and access to specialized healthcare services within a community, all of which can impact innovation capacity and be contributing barriers to implementation ofperinatal SUD-related EBP into carceral systems (Benck et al., 2023; Grella et al., 2020). Understanding these contextual factors is particularly important given that over 90% of the United States is considered rural, representing approximately 20% of the US population (U.S. Census Bureau, 2023). Additionally, incarceration rates have risen disproportionately in rural areas in the years since the start of the COVID-19 pandemic, further underscoring the urgency of expanding access to EBPs in these facilities (Kang-Brown et al., 2023).

The characteristics that proved most useful in defining this ideal-type typology echo characteristics and experiences that have previously been identified as influential to implementation processes in jail facilities. For example, studies exploring the implementation of SUD treatment initiatives in carceral settings identified community partnerships as critical facilitators of successful implementation (Grella et al., 2020; Showalter et al., 2021). This aligns directly with our finding that Traditional jails lacked community partnerships while Proactive and Collaborative jails had established these relationships and implemented recent new programs or policies. Another important facilitator for implementation success in carceral settings identified by Showalter et al. was selecting the right champion based on the organizational context (Showalter et al., 2021). This further supports the relevance of our typology framework, as understanding existing leadership and decision-making structures is key to selecting the correct champion for implementation success. From an outer setting perspective, our finding that ideal-type categories are associated with jail size and rurality also aligns with Mackey et al.'s (2024) findings showing negative associations between smaller rural county jails and implementation of EBPs, as was seen with our Traditional ideal-type. The overlap between our findings and existing implementation work in carceral health highlights how our typology framework captures fundamental organizational characteristics that can be used to inform tailored implementation strategies for different jail contexts.

Using a typology framework can offer an efficient approach to understanding jail organizational contexts to assist in the time intensive process of formal organizational assessments needed to guide successful implementation efforts. By asking targeted questions about decision-making structures, recent policy innovations, and community partnerships, teams may be able to anticipate potential barriers and facilitators to change and tailor their implementation approach accordingly. More specifically, these ideal-types can help inform implementation efforts by allowing teams to more strategically choose where to direct implementation efforts, the composition of implementation teams, and selection of champions within the facility. For instance, in Traditional jails, implementation strategies may need to more intensely address the CFIR inner context subdomains of relational connections and communication to address the barrier of their current siloed decision-making structures, while this might require less emphasis in Proactive and Collaborative type jails (Breimaier et al., 2015). Additionally, understanding these ideal-types may help identify the most effective champion at each site. At a Proactive and Collaborative jail, an individual with recent implementation experience may prove a better champion, able to leverage insights and connections from their prior policy-change or program initiation experience that might be unavailable at a facility of a different type.

Beyond utilizing this typology framework in the jail context, this study represents a novel methodological approach in implementation science by applying the ideal-type analysis methodology to characterize organizational contexts for implementation planning. While typological approaches are being used in implementation science adjacent realms to assess topics such as stakeholder engagement relationships among nonprofit organizations (Woo et al., 2022), learning archetypes in healthcare settings (Kim et al., 2025), and policy diffusion of improvement science in education (Cunningham & Osworth, 2023), ideal-type analysis itself has not been specifically applied in implementation science research, especially not for organizational context analysis. We hypothesize that this methodology provides a systematic but more streamlined approach to analyzing qualitative data and assessing organizational contexts, offering an alternative to time-intensive formal organizational assessments and/or traditional thematic analysis. This may be especially valuable when implementing evidence-based interventions at scale across comparable organizations such as schools, hospitals, and community health centers. This approach may allow teams to anticipate potential barriers and facilitators through targeted assessment of key organizational characteristics. However, the utility of our specific jail typology and the broader applicability of ideal-type analysis in implementation science research requires further empirical validation.

Our study is subject to several limitations. First, our sample is qualitative in nature, and despite impressive diversity of facilities and broad geographical representation, includes only 27% of NC jails. These qualitative research findings are not intended to be generalizable to all facilities in the state or to jails outside of this specific state, but rather to generate hypotheses about what organizational characteristics might usefully guide implementation efforts. Secondly, relying on a single interviewee from each jail might not fully capture the complexity of organizational contexts, particularly given that interviewees may include either custody or medical staff who could possess varying knowledge or perspectives.

Another issue to acknowledge is the positionality of the researchers in this analysis. Our research team includes individuals with a variety of lived experiences—familial incarceration and SUD, health care provision in jails and prison, and longitudinal research engagement with perinatal individuals with SUD in carceral settings, among others. However, no one on the research team has worked as a healthcare administrator or custody staff member in a jail. Initially, our team discussed the ways that jails in the Traditional ideal-type were resistant to change and authoritarian. However, through team discussions we recognized that these jails were actually operating within their traditionally defined roles in U.S. society. What we had preliminarily flagged as resistance to change could also be interpreted as adherence to longstanding institutional norms that jails are primarily security institutions rather than health care providers. This shift in perspective—from viewing jails as “resistant” to implementing EBPs to recognizing them as navigating the strain between their “traditional” roles and new, emerging expectations that they participate in health promotion and foster alternatives to incarceration—may also improve understanding of these jails for more effective engagement, including using strategies that respect historic norms while fostering innovation.

Conclusions

This study presents a novel typology framework for understanding the organizational contexts that shape perinatal and SUD care in NC jails. By categorizing jails as Proactive and Collaborative, Responsive and Coordinated, or Traditional, we provide a potential conceptual structure for creating tailored implementation blueprints for different jail types that address their specific contexts and leadership structures. Ultimately, this nuanced understanding of jail organizational contexts may improve the successful implementation of perinatal and SUD EBPs in carceral settings to further improve health outcomes for this vulnerable population. Future research should further explore the utility of this framework by testing ideal-type specific implementation strategies and their impact on EBP uptake in these carceral environments. In addition, studies should examine the broader applicability of ideal-type analysis as a methodology for characterizing organizational contexts across other settings.

Supplemental Material

sj-docx-1-irp-10.1177_26334895261426558 - Supplemental material for Perinatal and Substance Use Care in North Carolina Jails: A Qualitative Organizational Context Ideal-Type Analysis

Supplemental material, sj-docx-1-irp-10.1177_26334895261426558 for Perinatal and Substance Use Care in North Carolina Jails: A Qualitative Organizational Context Ideal-Type Analysis by Paige M Anderson, Jamie Jackson, Zakiya Stewart, Isabelle Falk, Armani Anderson, Essence Hairston and Andrea K Knittel in Implementation Research and Practice

Footnotes

Acknowledgments

The authors would like to thank Sreya Upputuri, Amaya Wallace, and Liv Neely for their contributions to the project. Without the generous participation of jail staff across North Carolina, this work would not have been possible.

ORCID iDs

Paige M Anderson

Jamie Jackson

Essence Hairston

Andrea K Knittel

Ethical Considerations

Consent to Participate

Verbal informed consent was obtained from all participants prior to interviews. Participants were informed about the study purpose, procedures, and their rights as research participants.

Author Contributions

AKK: Study concept and design

JJ: Project administration

AA, JJ, ZS, IF, AK: Data collection

JJ, AK, PA: Analysis of data

PA: Drafting of the manuscript

AK, JJ, ZS, AA, EH, IF: Critical revision of the manuscript

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by a Clinician Scientist Development Award from the Doris Duke Foundation (PI Knittel) and Dr. Knittel's time was additionally supported by the National Institute of Child Health and Human Development (NICHD) under the University of North Carolina at Chapel Hill Women's Reproductive Health Research Career Development Program (K12 HD103085, PI Neal Perry).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability

The datasets generated and/or analyzed during the current study are not publicly available due to privacy concerns surrounding the richness of qualitative data but are available from the corresponding author upon reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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