Women remain the primary caregivers for children, making the imprisonment of women and mothers potentially more complicated for families. Women in the prison system often have significant health problems and lack access to care even before incarceration. While women constitute a minority in the prison system, they have gender-specific needs, often related to pregnancy, birth, and the postpartum period. Often, prisons are not equipped to provide appropriate care, and many state policies vary concerning the healthcare needs of incarcerated pregnant and postpartum women. This article offers an overview of current issues in reproductive healthcare for this vulnerable population by providing a brief background on the topic and exploring how nurses can become their advocates. A review of selected literature describes current relevant research, followed by viewpoints from various healthcare organizations. Recommendations include prison programs and services targeted to pregnant and postpartum women, such as birth doulas and prison nurseries, which are known to benefit this population. Nurses can advocate for this unique population by using a trauma-informed framework of care and participating in legislative efforts to support pregnant and postpartum women who are incarcerated.
Key Words: incarcerated women, prison health, prison nurseries, prison services, incarcerated mothers, birth doula, reproductive health, women’s health
Nationally, women constitute a small portion of the prison population in the United States (U.S.) at about 6.8%, yet the number of incarcerated women has grown substantially over the past few decades (Federal Bureau of Prisons, 2023). Efforts to arrest and convict citizens for drug-related offenses in America’s War on Drugs, starting in the early 1970s, have led to substantial increases in arrests and incarcerations (The Center for Prisoner Health and Human Rights, 2018). Currently, 25% of imprisoned women are sentenced for drug-related crimes, compared to 12% of imprisoned men (Monazzam & Budd, 2023).
Women represent the least violent portion of prison populations with female incarcerated persons representing 45% of those jailed for violent offenses compared to 63.9% of men (Carson, 2022). Roughly 5 to 10% of women entering prisons are pregnant (Sapkota et al., 2022). Women remain the primary caregivers for children, making imprisonment of women and mothers potentially more complicated for families.
Women in the prison system often have significant health problems and lack access to care prior to incarceration
Women in the prison system often have significant health problems and lack access to care prior to incarceration (Paynter et al., 2020). In a survey of prison inmates by the U.S. Department of Justice (Maruschak et al., 2021), findings showed that women in both state and federal prisons were more likely than men to have a chronic health condition or infectious disease. Women in prison settings have five times the rate of mental health disorders compared to women in the general population, with a high prevalence of psychotic illness, bipolar disorder, and personality disorders (Hidayati et al., 2023). Women often report histories of sexually transmitted infections, mental illness, sexual and physical abuse, and drug and alcohol abuse at rates higher than those of imprisoned men (National Commission on Correctional Health Care, 2020).
Despite efforts to reform prison policies to focus on better health promotion, it is well known that the health of those in prison is poorer than those in other groups. (Woodall & Freeman, 2019). Interestingly, in a unique study that considered corrections officers’ knowledge and perspectives of programs and policies for pregnant women in prison, many officers remarked on how the prenatal care in prison was, in their opinion, better than what the pregnant inmates would receive on the outside (Pendleton et al., 2020). However, this view was not shared by all officers, with some stating that there were not enough healthcare staff and that inmates did not receive as much care as they would if they were free to come and go.
While women constitute a minority in the prison system, they have gender-specific needs that many prisons are not equipped to provide. This article offers an overview of a current issue in healthcare, the healthcare needs of incarcerated pregnant and postpartum women. The purposes of this review are to give readers a brief background of the present state of incarcerated women’s health; to explain why this remains an ongoing issue in healthcare; and to explore how nurses can become advocates for this population. Viewpoints from various healthcare organizations are compared, concluding with recommendations for prison programs and services that target incarcerated pregnant and postpartum women.
Summary of Prison Policy
A literature search was conducted using online databases, primarily the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed to find statistics and relevant literature about current prison policies surrounding the care of incarcerated pregnant and postpartum women, as well as nursing care of this population. A Google search was also conducted to identify specific organizational policies regarding care of underserved women, including incarcerated pregnant and postpartum women. There is a large body of research evidence to support the assertion that the healthcare needs of incarcerated women are unmet (Friedman et al., 2023; Maruschak et al., 2021; Paynter et al., 2020). Three important areas of concern for this population are nutritional needs, the use of shackles, and separation of mothers and babies.
Nutritional Needs
Many state policies vary in relation to prenatal care and dietary requirements for pregnant incarcerated women (Friedman et al., 2023). There are no federal regulations that mandate nutritional standards in prisons and, often, meal options are sufficiently lacking in fresh fruits and vegetables and other highly nutritious foods (Forestell & Dallaire, 2018). These limitations make it difficult for women to adequately care for themselves and to maintain healthy pregnancies, making them more likely to have poor health outcomes related to the births of their newborns. By improving the health of pregnant women in the prison system and subsequently, the health of the unborn fetuses, these women are establishing a healthy start for their future children. This investment has the potential to save resources and costs associated with the care of a sick newborn.
Use of Shackles
The use of shackles on women during labor and delivery has been studied and shown to pose serious health risks to both the mother and unborn fetus. Restraints are typically used when there is a risk of elopement (i.e., running away to escape) from a hospital or prison (Friedman et al., 2023). To date, there are no documented cases of a pregnant or laboring incarcerated person fleeing a hospital (House et al. 2021). Furthermore, restraints restrict an incarcerated mother’s ability to change position during labor and can prevent healthcare providers from performing necessary lifesaving procedures during delivery (Friedman et al., 2023).
Separation of Mothers and Babies
Many women in U.S. prisons are not able to have their infants remain with them during the first few months of life (Paynter et al., 2020). Policies on separation of mothers and babies have the potential to cause a great deal of emotional stress for women who have just given birth. Evidence suggests that new mothers experience increased rates of poor mental health measures, such as self-harm and suicide, when separated from their newborns in prison and community settings (Abbott et al., 2023). In addition, the opportunity to breastfeed or express breast milk is often not possible in a prison setting (Jeronimo dos Santos Mariano & Silva, 2018). Many incarcerated women view breastfeeding as a form of protection for both themselves and the child, in that there is a preservation of the mother’s sense of self and her abilities to parent (Jeronimo dos Santos Mariano & Silva, 2018). Mothers and infants in this setting are denied breastfeeding as a bonding experience when separation policies are in place.
Organizational Viewpoints Related to Prison Policy
The American College of Obstetricians and Gynecologists
The American College of Obstetricians and Gynecologists (ACOG) houses a committee dedicated to the healthcare of underserved women. Their policy on the healthcare of incarcerated pregnant and postpartum women considers the special considerations of this population (ACOG Committee on Health Care for Underserved Women, 2021). Examples of these considerations include screening for Human Immunodeficiency Virus (HIV) and past and present history of drug and alcohol use. It is recommended by ACOG that every woman of childbearing age be assessed for pregnancy risks upon entering the prison system. Regular prenatal appointments should be scheduled for imprisoned women who choose to continue their pregnancies and follow up care should be provided during the postpartum period (ACOG Committee on Health Care for Underserved Women, 2021).
Many healthcare, law, and public organizations have published position statements that oppose shackling of incarcerated women during labor and birth
Many healthcare, law, and public organizations have published position statements that oppose shackling of incarcerated women during labor and birth (ACOG Committee on Health Care for Underserved Women, 2021; Association of Women’s Health, Obstetric & Neonatal Nursing [AWHONN], 2018). ACOG specifically states that the use of restraints on incarcerated pregnant women not only poses a healthcare risk but is also rarely necessary, as most imprisoned women are nonviolent offenders who pose no risk of elopement (ACOG Committee on Health Care for Underserved Women, 2021).
The Association of Women’s Health, Obstetric & Neonatal Nursing
The AWHONN (2018) position statement, Nursing Care of Incarcerated Women During Pregnancy and the Postpartum Period, states that a woman’s ability to harm others or flee is already physically limited during pregnancy and labor. This organization thus opposes the use of restraints and recommends that registered nurses (RNs) work together with correctional officers to promote and provide patient safety (AWHONN, 2018). Shackling should not be a practice used as a substitute for adequate monitoring.
Other Organizations
Other organizations opposing this practice include The American Medical Association (2023) and American Civil Liberties Union (n.d.), among many others. In fact, the American Public Health Association (2024) recently updated its policies to reflect opposing the shackling of any person, pregnant or not, who is seeking or receiving healthcare.
The American Nurses Association
The American Nurses Association (ANA) does not mention incarceration specifically but does have a position statement that addresses the treatment of pregnant and breastfeeding women with substance use disorders. In the statement, this association discusses the harmful effects of criminalization and prosecution of pregnant women with substance use disorders. The ANA acknowledges that treatment for substance abuse is a more effective tool for eliminating substance use disorders than punishment and incarceration (ANA, 2017). It is the duty of the RN to identify women in need of treatment for substance abuse and to act as an advocate, providing competent, evidence-based care.
Impact on Healthcare, the Public, and Nursing
The rise of women entering the prison system, specifically during pregnancy, has become a serious public health issue. The cost of not addressing the healthcare problems that women have prior to incarceration is a huge financial burden to the correctional system and to individual states (Owens, 2021). In 2019, it was estimated that the cost of a prison sentence for a drug-related crime was $26,188, while the cost of a drug treatment sentence was just $3,143 (Owens, 2021).
Nurses are in an optimal position to provide education and support to incarcerated women who have recently given birth.
Nurses are in an optimal position to provide education and support to incarcerated women who have recently given birth. In a study that surveyed nurses caring for incarcerated women during pregnancy and postpartum, nurses showed support for imprisoned women by acting as a patient advocate (Goshin et al., 2019). Examples of this advocacy included knowing their state laws regarding shackling incarcerated pregnant women and asking for removal of shackles in accordance with state law. During the woman’s hospital stay, nurses can encourage the practice of “rooming-in” where mothers and newborns stay together as much as possible. Providing education about infant care can give mothers a sense of independence and a new maternal identity.
Many women entering prison have histories of one or many traumatic experiences that nurses must take into consideration when giving care (Hidayati et al., 2023). “Trauma-informed care,” as suggested by Lehrer (2021), offers knowledge to healthcare providers and those working in the correctional system about what it means to be the victim and survivor of extensive or chronic trauma. Nurses must understand a woman's trauma in the context of her life and take time to develop a trusting relationship. Trauma-informed care may help to prevent further trauma, repeat offenses, and harmful familial cycles (Lehrer, 2021). Nurses must be aware of their own preconceived biases and judgments before taking on care for women with a traumatic or criminal background.
Once released from prison, women face many economic challenges upon re-entering their communities. These challenges include, but are not limited to, finding employment, family reunification, arranging transportation, and finding stable housing (Miller, 2021). In a guide written by the Substance Abuse and Mental Health Services Administration ([SAMHSA], 2020), women demonstrate different re-entry services than men and are often ill-equipped to face the realities of life after prison. Finding childcare during working hours or while in substance abuse or mental health treatment programs remains a priority for women exiting the prison system (SAMHSA, 2020). Reestablishing family relationships, such as reuniting mothers with their children, is another important factor to consider with re-entry (SAMHSA, 2020).
Recommendations to Improve Nursing Care
Many programs and services have been identified as helpful for the treatment of pregnant and postpartum women in the prison system. Among these include two important support interventions, birth doula programs and prison nurseries (Barnas, 2021; DONA International, 2023). Incarcerated women retain the same right to adequate prenatal care, education, and birthing services as do all women who reside in the community. Jails and prisons can improve care to pregnant and parenting women by offering some of the services mentioned above. This section offers additional information support about using birth doulas and prison nurseries.
Birth Doulas
A birth doula is a trained professional who offers physical, emotional, and informational support to women during pregnancy, labor, and birth (DONA International, 2023). Doulas have been shown to have a positive impact on families during their child birthing experiences (DONA International, 2023). In addition, doula services for women in the prison system have been shown to rate highly not only among the incarcerated pregnant person, but also the doctors and nurses who serve these women (Dahl et al., 2020). To increase affordability, jails and prisons can consider using volunteer doula programs or those funded by nonprofit organizations. Medicaid reimbursement for doula services is also an option, however this is limited to only a few states. Doula care can help imprisoned women to experience a positive birth experience that may not otherwise happen for them.
Prison Nurseries
John Bowlby developed a theory of attachment based on observing hospitalized and institutionalized children separated from their parents (Bretherton, 1992). He concluded that it is imperative for the mental health of children to have a continuous and intimate relationship with their mother as an infant and young child (Bretherton, 1992). Prison nurseries can facilitate this early attachment and bonding and decrease the likelihood of emotional and development problems that could arise in children who are separated from their mothers during infancy and toddlerhood.
Prison nurseries offer the opportunity for newborns to reside with their mothers in a designated area of the jail or prison for a specified period of time to promote bonding and help to prevent the harmful effects of separation. Participation in prison nursery programs has been shown to result in lower rates of recidivism among incarcerated women, increased attachment of mother and child, and improved parenting knowledge and skills (Pace et al., 2021). There are currently eight states that offer a prison nursery program (Barnas, 2021).
In settings with prison nursery programs, nurses can promote breastfeeding among mothers who have recently given birth. The World Health Organization ([WHO], 2023) and American Academy of Pediatrics ([AAP], 2022) recommend exclusive breastfeeding for the first six months of life. Incarcerated women who were interviewed about their beliefs and experiences with breastfeeding reported feelings of intense attachment with their child and less burden of imprisonment due to the demands of living with and caring for their child (Jeronimo dos Santos Mariano & Silva, 2018).
While in the hospital setting, nurses can assist mothers to put babies to the breast within an hour of birth to promote milk production. In instances where babies and mothers are separated after the initial hospital stay, mothers should have access to a breast pump if they desire to express breast milk. Similarly, an incarcerated mother who had previously been nursing an infant at home should be able to pump breast milk for her child while serving jail time.
Nursing Advocacy and Legislative Reform
There are many gaps to address in the healthcare of incarcerated pregnant and postpartum women in order to promote optimal well-being for this population. Access and consistency of care for women prior to incarceration remain a challenge facing correctional facilities. State and federal policies vary as to how women are treated once entering prison and what specific modifications are made for mothers and pregnant women. Outdated prison policies create a barrier to addressing the unique needs of women in the prison system.
The National Commission on Correctional Health Care (2020) has issued a position statement calling for restrictions on the use of restraints among pregnant women and adolescents during the labor and delivery and postpartum periods. However, these standards only serve as guidelines and are not mandatory for state and local prisons and jails (ACOG Committee on Health Care for Underserved Women, 2021).
Currently 22 states have adopted laws that address shackling of women during labor and birth (Ferszt et al., 2018). State legislators must be made aware of the need for a state policy prohibiting the use of shackles on incarcerated pregnant and laboring women. While the current policies mentioned are a small start, there remains a significant lack of regulation to address the reporting of each incidence of restraint use and consequences for individuals or agencies when the use of restraints is unjustified.
Gender-specific policies in prison systems are necessary to ensure that needs of incarcerated pregnant women are met. Nurses can help to change these reforms by acting as a voice for policy improvement. Prison nurses can advocate for updated regulations for incarcerated pregnant women. Similarly, nurses who work in hospitals where they care for prison patients can lead their units to create policies specific to the care of this group. Speaking to state legislators on behalf of the nursing profession is another way to make an impact on the reproductive healthcare rights of female prisoners.
The healthcare needs of incarcerated pregnant women remain a complex issue in the United States today. Nurses and healthcare providers play a key role as advocates for the health of this minority population. Updated legislation on both the federal and state level can help improve healthcare practices in correctional facilities. Improving care of incarcerated women during pregnancy and postpartum can help to keep families together and promote positive and sustainable health practices (i.e., reentry services) among this vulnerable population.
Author
Allison Flynn Becker, MSN, RNC, IBCLC
Email: allison@rnhealthwriter.com
ORCID ID: https://orcid.org/0009-0005-0429-5576
Allison Flynn Becker is a registered nurse who has been in practice for 14 years. She received a bachelor’s degree in science at New York University in 2010 and a master’s degree in nursing education from Monmouth University in 2020. Allison has over 10 years of experience working in women and children’s health in hospitals and school settings and has taught in associate and bachelor’s degree nursing programs. She is board-certified in maternal-newborn nursing and as a lactation consultant. Allison currently practices in a hospital-based family health clinic serving racial and ethnic minority populations.
References
Abbott, L., Scott, T., & Thomas, H. (2023). Compulsory separation of women prisoners from their babies following childbirth: Uncertainty, loss and disenfranchised grief. Sociology of Health & Illness, 45(5). 971-988. https://doi.org/10.1111/1467-9566.13423
American Academy of Pediatrics. (2022). Policy statement: Breastfeeding and the use of human milk. Pediatrics,150(1). https://doi.org/10.1542/peds.2022-057988
American Civil Liberties Union. (n.d.). ACLU BRIEFING PAPER: The Shackling of Pregnant Women & Girls in U.S. Prisons, Jails & Youth Detention Centers. https://www.aclu.org/wp-content/uploads/legal-documents/anti-shackling_briefing_paper_stand_alone.pdf
American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. (2021). Reproductive health care for incarcerated pregnant, postpartum, and nonpregnant individuals: Committee opinion no. 830. Obstetrics & Gynecology, 138(1), e24-e34. https://doi.org/10.1097/AOG.0000000000004429
American Medical Association. (2023). Shackling of Pregnant Women in Labor H-420.957. https://policysearch.ama-ssn.org/policyfinder/detail/shackling?uri=%2FAMADoc%2FHOD.xml-0-3700.xml
American Nurses Association. (March 2017). Position statement: Non-punitive treatment for pregnant and breast-feeding women with substance use disorders: ANA position statement. https://www.nursingworld.org/globalassets/docs/ana/non-punitive-alcohol-and-drug-treatment-for-pregnant-and-breast-feeding-women-and-the-exposed-childr.pdf
American Public Health Association. (2024, January 19). APHA adopts new public health policy statements. https://apha.org/News-and-Media/News-Releases/APHA-News-Releases/2023/APHA-adopts-new-public-health-policy-statements
Association of Women's Health, Obstetric, & Neonatal Nursing. (2018). AWHONN position statement: Nursing care of incarcerated women during pregnancy and the postpartum period. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(2), 236-238. https://doi.org/10.1016/j.jogn.2018.01.001
Barnas, J. (2021, August 25). Prison nursery programs. MOST Policy Initiative. https://mostpolicyinitiative.org/science-note/prison-nursery-programs/
Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28(5), 759-775. https://doi.org/10.1037/0012-1649.28.5.759
Carson, E.A. (2022). Prisoners in 2021-Statistical tables. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/p21st.pdf
The Center for Prisoner Health and Human Rights. (2018). Incarceration, substance abuse, and addiction. http://www.prisonerhealth.org/educational-resources/factsheets-2/incarceration-substance-abuse-and-addiction/
Dahl, C.M., Geynisman-Tan, J.M., & Premkumar, A. (2020). Birth behind bars: The need for labor support in the incarcerated population. Obstetrics & Gynecology, 136(5). 1036-1039. https://doi.org/10.1097/AOG.0000000000004119
DONA International. (2023). What is a doula? https://www.dona.org/what-is-a-doula/
Federal Bureau of Prisons. (2023). Inmate gender. https://www.bop.gov/about/statistics/statistics_inmate_gender.jsp
Ferszt, G.G., Palmer, M., McGrane, C. (2018). Where does your state stand on shackling of pregnant incarcerated women? Nursing for Women’s Health, 22(1). 17-23. https://doi.org/10.1016/j.nwh.2017.12.005
Forestell, C.A. & Dallaire, D.H. (2018). Pregnant behind bars: Meeting the nutrition needs of incarcerated pregnant women. In C.J. Lammi-Keefe, S.C. Couch, & J.P. Kirwan (Eds.), Handbook of Nutrition and Pregnancy (pp. 295-307). https://scholarworks.wm.edu/asbookchapters/112
Friedman, S.H., Kaempf, A. & Kauffman, S. (2023). The realities of pregnancy and mothering while incarcerated. Journal of the American Academy of Psychiatry and the Law Online, 51(3). https://doi.org/10.29158/JAAPL.003924-20
Goshin L.S, Sissoko D.R.G., Neumann G., Sufrin C., Byrnes L. (2019). Perinatal nurses' experiences with and knowledge of the care of incarcerated women during pregnancy and the postpartum period. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 48(1). 27-36. https://doi.org/10.1016/j.jogn.2018.11.002
Hidayati N.O., Suryani S., Rahayuwati L., Widianti E. (2023). Women behind bars: A scoping review of mental health needs in prison. Iranian Journal Public Health, 52(2). 243-253. https://doi.org/10.18502/ijph.v52i2.11878
House, K.T., Kelly, S., Sontag, D.N., & King, L.P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). e364-368. https://doi.org/10.1001/amajethics.2021.364
Jeronimo dos Santos Mariano, G. & Silva, I.A. (2018). The meaning of breastfeeding in prison. Texto & Contexto - Enfermagen, 27(4). e0590017. https://doi.org/10.1590/0104-07072018000590017
Lehrer D. (2021). Trauma-Informed care: The importance of understanding the incarcerated woman. Journal of Correctional Health Care, 27(2). 121-126. https://doi.org/10.1089/jchc.20.07.0060
Maruschak, L.M., Bronson, J., & Alper, M. (2021). Medical problems reported by prisoners. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/mprpspi16st.pdf
Miller, H.V. (2021, May 19). Female reentry and gender-responsive programming: Recommendations for policy and practice. U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. https://nij.ojp.gov/topics/articles/female-reentry-and-gender-responsive-programming
Monazzam, N. & Budd, K.M. (2023, April 3). Fact sheet: Incarcerated women and girls. The Sentencing Project. https://www.sentencingproject.org/fact-sheet/incarcerated-women-and-girls/
National Commission on Correctional Health Care. (2020). Women's health care in correctional settings: Position statement. https://www.ncchc.org/position-statements/womens-health-care-in-correctional-settings-2020
Owens, S. (2021). Prioritizing prison over substance use treatment costs Kansans safety and money. Justice Center: The Council of State Governments. https://csgjusticecenter.org/2021/02/25/prioritizing-prison-over-substance-use-treatment-costs-kansans-safety-and-money/
Pace, A.E., Krings, K., & Zhang, K. (2021). Maternal pre- and post-release behaviors in a residential parenting program (prison nursery). In J. Poehlmann-Tynan & D.H. Dallaire (Eds.), Children with incarcerated mothers: Separation, loss, and reunification (pp. 49-74). Springer Briefs in Psychology. https://doi.org/10.1007/978-3-030-67599-8_4
Paynter, M., Jefferies, K., McKIbbon, S., Martin-Misener, R., Iftene, A., & Tombin Murphy, G. (2020). Mother-child programs for incarcerated mothers and children and associated health outcomes: A scoping review. Nursing Leadership, 33 (1). 81-99. https://doi.org/10.12927/cjnl.2020.26189
Pendleton, V., Saunders, J.B., & Shlafer, R. (2020). Corrections officers’ knowledge and perspectives of maternal and child health policies and programs for pregnant women in prison. Health and Justice, 8(1). https://doi.org/10.1186/s40352-019-0102-0
Sapkota, D., Dennison, S., Allen, J., Gamble, J., Williams, C., Malope-Rwodzi, N., Baar, L., Ransley, J., & McGee, T.R. (2022). Navigating pregnancy and early motherhood in prison: A thematic analysis of mothers’ experiences. Health & Justice, 10(32). https://doi.org/10.1186/s40352-022-00196-4
Substance Abuse and Mental Health Services Administration. (2020). After incarceration: A guide to helping women reenter the community. https://store.samhsa.gov/sites/default/files/pep20-05-01-001.pdf
Woodall, J. & Freeman, C. (2019). Promoting health and well-being in prisons: an analysis of one year’s prison inspection reports. Critical Public Health, 30(5). 555-566. https://doi.org/10.1080/09581596.2019.1612516
World Health Organization. (2023). Breastfeeding. https://www.who.int/health-topics/breastfeeding#tab=tab_2
