Desiree Robles, a student midwife at Midwives College of Utah, shares with the MANA community the current state of maternity care for incarcerated women in the United States, along with policy recommendations for improving outcomes for mothers and babies. This post is a part of our student midwife guest post series. Are you a student? Please consider sharing a guest post with us! Contact MANA at publicaffairs@mana.org for more information.

Pregnancy and birth have the remarkable ability to be a common process for all women, regardless of economic status, race, or culture. They can occur at any time in a woman's reproductive life, including when they are sentenced to time in jail or prison. How these instances are handled in the United States is the subject of controversy and varies greatly depending on location but, collectively, is in need of reform. In the United States, incarcerated pregnant women deal with several reproductive issues that need to be addressed, including lack of proper prenatal care and nutrition, use of restraints during transport, labor, and postpartum, and a lack of birth education and support.

Despite the importance of prenatal care and proper nutrition during pregnancy, many inmates are not guaranteed access to them. According to the Committee on Health Care for Underserved Women (CHCUW), thirty-eight states have failed to institute policies requiring that incarcerated pregnant women receive basic prenatal care. In addition, forty-one states do not require prenatal nutrition counseling or do not ensure that these women receive proper nutrition (2011). What is important to note is that, according to a study done by Martin et al. in 1997, prisons are required to provide all pregnant inmates with appropriate prenatal care. However, according to a Women's and Children's Health Policy Center publication, less than half of correctional systems require screening of new female inmates for pregnancy and STD's (2000). Even with more than half of the United States correctional facilities not providing the proper prenatal care and nutrition for these inmates, some of these same women may still be at the same high risk or may actually be better off than if they were pregnant at home. A study done by Clarke et al. points out that pregnancies among incarcerated inmates are usually unplanned, high risk, and have poor outcomes because of, among other things, lack of or failure to access prenatal care and many of these women having poor nutrition (2006). Thankfully, many studies, including one done by Martin et al., have found that incarceration allows these women to have improved maternal and fetal health thanks to access to shelter and regular meals (1997). It is important that we implement screening protocols for incoming inmates at all correctional facilities so that their reproductive health can be addressed if need be, as well as making sure these inmates receive the proper care needed if they are found to be pregnant. 

Using restraints on pregnant inmates during the process of labor is a sensitive issue that has been the subject of scrutiny for years. There have been various studies that have delved into the adverse effects of restraining women in labor both physically and psychologically. While progress has been made in stopping the use of restraints on pregnant inmates, according to the Committee on Health Care for Underserved Women, thirty-six states and the Immigration and Customs Enforcement agency of the Department of Homeland Security have failed to limit the use of restraints on pregnant women during transportation, labor and delivery, and postpartum (2011). Use of "shackling," as it is called, causes discomfort for the pregnant inmate during a time when she is most vulnerable and many times the officers present are male. In an article done by Anderson, there is implication that birth transport often results in numerous medical and mental health complications, thanks to the security precautions used, including shackling. These precautions increase instances of injury and stress while stress in itself can cause complications in labor. Also, the women have limited movement, which adds discomfort and restricts their ability to protect themselves in instances such as falling (2003). An Amnesty International article brings to attention the traumatizing experiences of shackling on the laboring inmates. These included having their legs shackled to their bed post for almost the entirety of their labor which, again, caused restricted movement and hindered their ability to position themselves in more favorable positions during labor (2000). To add to their distress, according to Codd, women in prison many times give birth to their babies who are taken away almost immediately or at discharge from maternity ward, causing the mother much distress and robbing the baby of their mother's important breast milk (2004). Laboring inmates deal with these stressful situations that, while slowly being resolved, would be helped, in part, with childbirth education and support from, at the very least, female officers during labor. 

Birth education and support for pregnant inmates is lacking in many correctional facilities but are excellent resources that would greatly benefit these vulnerable women. According to Hotelling, with the right support and prenatal care, expectant new mothers often discard lifestyle behaviors which would compromise the health of their babies. Some programs have been initiated to provide physical and mental health care to incarcerated women. These programs depend on help from volunteers, grant money, and various organizations coming together in order to thrive (2008). The Bell et al. study noted that what is needed for incarcerated pregnant women is comprehensive programs that include enhanced prenatal care services in the community and greater transitional resources. This would be ideal, given that most women are incarcerated for smaller crimes with shorter sentences than men (2004). A great place to start would be birth education and breastfeeding workshops. In a study by Huang et al., pregnant inmates showed positive views on pregnancy and link it to a new start for them as mothers and in their life in general (2012). Childbirth education and support for pregnant inmates should be available at all correctional facilities as a way to help these women deal with the stress of pregnancy in an already stressful situation for the sake of their health and future as well as their children's.

Pregnancy during incarceration happens whether correctional facilities want it to or not. For this reason, protocols should be made mandatory at all correctional facilities to screen for pregnancy, as well as STD's, to ensure the health of their inmates. While prenatal care is required for all pregnant inmates, screening for pregnancy is not. This very important loop hole should not occur in our correctional facilities, as early prenatal care and nutrition is imperative to the health of both the mother and her infant. For those women who do experience labor during their stay, the use of restraints and shackling should be limited to actual need instead of standard protocol. Women in labor should have the ability to move freely, regardless of their situation. Maternal and fetal health is put at stake when they are put under stressful situations, and shackling only exacerbates the situation. Lastly, childbirth education and support during pregnancy and birth are a great rehabilitation tool which correctional facilities should try to make mandatory. The benefits include healthier inmates both mentally and physically and shorter births which would cut healthcare costs tremendously, considering many incarcerated women are considered high risk. Implementing these policies would help these already vulnerable women and hopefully give them the needed support to change their situations for the better.

Reference List

Amnesty International. (2000). Pregnant and imprisoned in the United States. Birth, 27(4), 266-271.

Anderson, T.L. (2003). Issues in the availability of healthcare for women in prison. In S.F. Sharp & R. Muraskin (Eds.), The incarcerated woman: Rehabilitative programming in women's prisons (pp. 49-60). Upper Saddle River, NJ: Prentice Hall.

Baldwin, K. & Jones, J. (2000) Health issues specific to incarcerated women: Information for state title v programs. Retrieved from http://www.jhsph.edu/research/centers-and-institutes/womens-and-children...

Bell, J. F., Zimmerman, F. J., Cawthon, M. L., Huebner, C. E., Ward, D. H., & Schroeder, C. A. (2004). Jail incarceration and birth outcomes. Journal of Urban Health, 81(4), 630-644.

Clarke, J. G., Herbert, M. R., Rosengard, C., Rose, J. S., DaSilva, K. M., & Stein, M. D. (2006). Reproductive health care and family planning needs among incarcerated women. American Journal of Public Health, 96(5), 834-839.

Codd, H. (2004). Prisoners' families: Issues in law and policy. Amicus Curiae, 55, 2-7.

Committee on Health Care for Underserved Women. (2011). Health care for pregnant and postpartum incarcerated women and adolescent females. Committee Opinion, 511, 1-5.

Hayes, S. L., Mann, M. K., Morgan, F. M., Kelly, M. J., & Weightman, A. L. (2012). Collaboration between local health and local government agencies for health improvement. Cochrane Database of Systemic Reviews, 10, 1-141.

Hotelling, B. A. (2008). Perinatal needs of pregnant, incarcerated women. Journal of Perinatal Education, 17(2), 37-44.

Huang, K., Atlas, R. & Parvez, F. (2012). The significance of breastfeeding to incarcerated pregnant women: An exploratory study. Birth, 39(2), 145-155.

Kitzinger, S. (1997). Sheila kitzinger's letter from Europe: How can we help pregnant women and mothers in prison? Birth, 24(3), 197-198.

Martin, S. L., Rieger, R. H., Kupper, L. L., Meyer, R. E., & Qaqish, B. F. (1997a). The effect of incarceration during pregnancy on birth outcomes. Public Health Reports, 112, 340-346.

Martin, S. L., Kim, H., Kupper, L. L., Meyer, R. E., & Hays, M. (1997b). Is incarceration during pregnancy associated with infant birthweight? American Journal of Public Health, 87(9), 1526-1531.

Minkler, M., Glover Blackwell, A., & Thompson, M., Tamir, H. (2003). Community-based participatory research: Implications for public health funding. American Journal of Public Health, 93(8), 1210-1213.

Walker, J. R., Hilder, L., Levy, M. H., & Sullivan, E. A. (2014). Pregnancy, prison and perinatal outcomes in New South Wales, Australia: a retrospective cohort study using linked health data. BMC Pregnancy and Childbirth, 14(214).