Perinatal Care for Incarcerated Patients: Title and subTitle BreakA 25-Year-Old Woman Pregnant in Jail

DR DELBANCO: Since 2003, Ms A, a 25-year-old unmarried woman (gravida 3, para 2) has been involved with the justice system. She has had 10 incarcerations, including 2 episodes that led to a jail sentence. During the second trimester of her current pregnancy, Ms A received a 1-year jail sentence for a nonviolent crime. On admission to jail, Ms A reported a 6-year-long habit of heroin use of 3 to 4 inhaled bags per day, a long-standing 1-pack-per-day cigarette smoking habit, and inhaler-dependent asthma. Screens for human immunodeficiency virus, syphilis, gonorrhea, and chlamydia were negative. Serologic evidence for hepatitis B and C was present with negative viral titers, normal liver function test results, and absence of symptoms or physical findings suggestive of active liver disease.

Ms A's prenatal course was significant for smoking cessation (enforced by the jail's no-smoking policy) and methadone replacement at 30 mg/d, increased to 40 mg/d late in the third trimester. While incarcerated, Ms A went into labor near term and was transferred to a community hospital wherein she experienced an uneventful labor and delivery under epidural anesthesia. Her female newborn required supportive morphine and phenobarbital-supplemented care over several weeks for neonatal abstinence syndrome. Although intent on breastfeeding, Ms A was unable to do so because of a combination of inhospitable surroundings and lack of privacy attributable to having a prison guard in the room at all times. Following an uncomplicated postpartum course, Ms A was discharged from the hospital 36 hours after giving birth.

Shortly after returning to jail, Ms A was granted paroled release to a community-based, residential parenting program. Offered family planning services, Ms A selected an oral contraceptive rather than a long-term injectable contraceptive, with plans to have an intrauterine contraceptive device placed at the 6-week postpartum visit. While Ms A and her infant are being cared for in the residential parenting program, her 2 older children remain in the care of her family.

It was sad being pregnant while I was in jail. In the beginning I was all right with it because I was having a bad life before I came to jail. And I’m glad I came to jail to get cleaned up so my child could be born clean. So, I was all right when I first came here. Then, after a while, I started getting really sad because I’m gonna have my baby in jail.

How am I gonna do this? She needs somebody to hold her, and I’m not there. I had good medical care in jail. I thought it was gonna be worse, being pregnant in jail. But I was very well taken care of. I saw other ladies in here that were pregnant, and I tell them, “It's all right, you're lucky that you're in here, being clean and pregnant instead of out there.”

I went to the hospital that morning I went into labor. They sat me down until the ambulance came, because the doctor had said, “Make sure you call the ambulance, you're going to give birth pretty quick, because you're already 6 centimeters dilated.” So I went to the hospital, and I was in pain. I gave birth about an hour and a half after I got to the hospital. And that went all right. There were 2 pushes and she was out.

I had an officer with me the whole time that I was there. I was trying to get away with not having an officer there. You know, it depends on where you stand in jail, if you're bad or you're good. But I was in between. So I had an officer there with me, and they didn't leave my side.

I wasn't treated differently at the hospital. I was grateful, really, for the nurses and the doctors that I had. Even the officers were telling me, “Thank God you have these nurses that are so kind,” because they’d been there other times with other pregnant women. And I guess other women had been treated really unfair.

They didn't let the baby in the room with me. I don't know why. The officers told me that with other ladies they had been in the hospital with, they had let the baby in the room.

They had to call me every time she needed to be fed. In the hospital, they asked me if I wanted to breastfeed. And at first I wanted to. And then I was uncomfortable. There was an officer in the room every time I went to feed the baby. So it took away the urge that I had to breastfeed.

My children are what helped me, what keeps me going. If I didn't have my children, I wouldn't be thinking the way I’m thinking now. Because my kids still love me to this day. I feel like I did wrong, but in their eyes, I haven’t. They still look up to me. So I have to do it for them.

What are the incidence and prevalence of pregnant women in jail or prison? For women jailed or imprisoned, how does medical management differ from those not incarcerated? What is appropriate medical management for women who are both pregnant and addicted to narcotics when newly incarcerated? Where do deliveries take place, and how are such deliveries managed in hospitals when women are transported there from jail or prison? To what degree can the women make choices? What are the outcomes for the new mother, the child, and the nuclear family? How might the United States improve care for such patients? What do you recommend for Ms A?

DRS CLARKEAND ADASHI: The US correctional system has the highest documented incarceration rate in the world.^{1 - 2} The United States also lacks a universal health care system, but federal law mandates the provision of basic health care to prisoners.³ Hence, the implications of incarceration in the United States are different from that of many other industrialized nations, and we focus on the United States herein.

Ms A is one of millions of individuals involved with the US correctional system each year. Composed primarily of prisons and jails, the system is also entrusted with overseeing probation and parole. In the United States generally, prisons are home to individuals sentenced for more than 1 year of incarceration and are run by a state or the federal government, while jails house individuals awaiting trial as well as those sentenced to less than 1- to 2-year terms and may be run by local law enforcement agencies, cities, or counties. Jails are generally geographically close to where a person was arrested, while those sentenced to prison may be transported hundreds of miles away from their homes and families.

In 2008, the most recent year for which national data are available, more than 6 million men and 1 million women—1 in every 31 US adults—were under correctional control, be it jail, prison, probation, or parole.^{4 - 5} Of those, 2.3 million men and women were behind bars, an all-time high and a prevalence exceeding that of all other sovereign nations.^{1 - 2} Among those incarcerated in federal and state prisons in 2001, 115 000 were women, more than at any other point in US history, a number representing a 12-fold increase in prevalence since 1975 and an imprisonment rate of 62 per 100 000 US residents.⁶ Ms A represents as many as 5000 to 10 000 who may concurrently be pregnant.^{7 - 8} Women represent the fastest-growing segment of the US prison and jail populations.⁵

The core protections of incarcerated pregnant women and their rights to medical care draw on the Eighth Amendment to the US Constitution. While the language of the amendment is vague, the seminal 1976 Supreme Court case of Estelle v Gamble explicitly affirmed that the Constitution requires prisons to provide medical care to inmates by holding that “deliberate indifference to serious medical needs of prisoners” violates the Eighth Amendment's prohibition on cruel and unusual punishment. The court further asserted that “[i]t is but just that the public be required to care for the prisoner, who cannot by reason of the deprivation of his liberty, care for himself.”³ Federal, state, and local correctional authorities are legally obligated to meet this standard, which itself sets a relatively low bar. In addition, the concept of safe motherhood, in or out of prison, is further rooted in a number of variably ratified treaties, most notably the Convention on the Elimination of All Forms of Discrimination Against Women and the American Convention on Human Rights.^{9 - 10}

According to the Bureau of Justice Statistics, most women incarcerated in the United States are white (44%), with blacks and Hispanics accounting for 25% and 15%, respectively.⁵ In prisons, 65% are older than 35 years but this percentage decreases to 50% in jails.^{11 - 12} Only 43% have completed high school or have a GED.¹³ As was the case for Ms A, female inmates are frequently medically underserved, especially when reproductive health and family planning are at stake. Most of the women in question receive sentences of less than 1 year in duration, often for first-time nonviolent offenses such as the use and/or sale of illicit drugs.¹² In fact, the proportion of women incarcerated for drug offenses now eclipses that of male counterparts.¹²

Moreover, most imprisoned women are mothers, a statistic that gives rise to an ever-growing number of “motherless” minors, now estimated at 200 000.^{14 - 15} In 1998, independent Centers for Disease Control and Prevention and General Accounting Office reports placed the national number of pregnant inmates at 1900 to 2200 and the total number of births at 1300 to 1400.^{16 - 17} Other data, largely self-reported by correctional agencies and likely an underestimate, note admission pregnancy rates between 3% and 6%.^{12 ,18 - 19} Validated, precise measurements of the prevalence and incidence of pregnancy are difficult to come by because of limited or absent reporting requirements and inconsistent pregnancy testing on admission.

Quiz Ref IDPrior to incarceration, pregnancies are largely unplanned and often compromised by variable prenatal care, poor nutrition, domestic violence, illicit drug and alcohol abuse, sexually and parenterally transmitted infections, and exposure to potentially teratogenic psychotropics.^{20 - 23} The more common complications of such pregnancies include miscarriage, preeclampsia, preterm birth, and low-birth-weight infants.^{24 - 26}

The minimal national standards for pregnancy-related health care in correctional settings have been enunciated by several organizations including the Federal Bureau of Prisons,²⁷ the National Commission on Correctional Health Care (NCCHC),²⁸ the American Public Health Association (APHA),²⁹ the American Congress of Obstetricians and Gynecologists,³⁰ and, to a more modest degree, the American Bar Association.³¹ As an example, the NCCHC standard entitled “Care of the Pregnant Inmate” directs that “[p]regnant inmates receive timely and appropriate prenatal care, specialized obstetrical services when indicated, and postpartum care.”²⁸ This standard also sets forth specific compliance indicators for pregnancy care. The APHA's standards, generally comparable with those of the NCCHC, prohibit the use of restraints during labor and delivery, an element about which the NCCHC is silent.²⁸ Above and beyond national standards, 34 states have put forth explicit policies to ensure that incarcerated pregnant women receive adequate prenatal care.³²

Primary responsibility for perinatal care for imprisoned women is shared among medical staff in the prison and community-based clinicians. With high-risk pregnancies, such partnership can and must be extended to include a specialist in maternal-fetal medicine. Clinicians must be aware of the high rates of sexually transmitted infections (including human immunodeficiency virus), hepatitis B, hepatitis C, substance abuse, and violence in this population and adjust care as appropriate.^{33 - 34}

Quiz Ref IDAntepartum adjustments to care in correctional settings include advising inmates and correctional staff on levels of activity (eg, work assignments), safety (eg, use of the bottom bunk bed), and nutritional requirements (eg, a special diet). Provision of prenatal vitamins with folic acid is also important because patients are often unable to obtain them on their own. Other adjustments to care in correctional settings should include greater vigilance in identifying the presence of sexually and/or parenterally transmitted infections,^{35 - 36} the need for drug and alcohol treatment,^{25 ,37} and mental health needs.^{35 - 36} Smoking cessation is another important issue; the prevalence of smoking is as high as 90% for women in jail.³⁸ However, jails and prisons are increasingly becoming smoke-free.

Location of prenatal care (in-house vs at a nearby medical facility) is generally locally determined as a function of the availability of resources and expertise. Notably, intra-institutional prenatal care is often superior to that available prior to incarceration. As Ms A suggests, the multiple advantages of the jail/prison–based programs may include but are not limited to the provision of medical care, food, shelter, and relative security as well as the elimination of gender-based violence, smoking, and alcohol and other substance abuse.

Intrapartum Care and the Special Challenge of Shackling. Intrapartum adjustments tend to focus on the security-driven use of restraints during labor and even during delivery, an incompletely resolved and controversial matter. Apart from impeding the dignity and postural requirements of the labor and delivery process, shackles and handcuffs present a real hazard to imprisoned mothers-to-be. For example, shackling of the legs may promote standing imbalance and, thus, proneness to falls. Cuffing of the hands, in turn, may prevent breaking a fall and impede a woman's ability to protect her abdomen. Quiz Ref IDIn an effort to address the issue, the Bureau of Prisons, home to 14 000 female offenders in 28 federal facilities, resolved in 2008 to bar shackling pregnant inmates in all but the most extreme circumstances.³⁹ California, Illinois, New Mexico, New York, Texas, and Vermont followed suit. Most other states, however, continue to apply perinatal restraints despite opposing policies by the American Medical Women's Association, American College of Nurse Midwives, American Correctional Association, American Congress of Obstetricians and Gynecologists, and American Bar Association. Absent binding national policy or legal challenge, decisions as to perinatal restraints will remain in the domain of the states in question.

Postpartum Care. Postpartum adjustments are dominated by difficult decisions about the disposition of the newborn child and, thus, the integrity of the important mother-child unit. Few prison nursery programs exist nationally. Quiz Ref IDGiven a postpartum woman serving a long-term sentence in the absence of parole and in the absence of a prison nursery program, the mother and the newborn child are separated on discharge from the hospital. In this context, child placement options are limited to family, friends, or foster care. Absent eligible family or friend care, the ultimate disposition of a child placed in foster care is guided by the Adoption and Safe Families Act of 1997, which requires that the state initiate parental right termination proceedings should a child spend 15 of any 22 months in foster care.⁴⁰ A court order terminating the parent-child relationship—also known as parental rights—renders the child eligible for adoption.⁴⁰ Although the latter ruling is open to challenge, more often than not an intact mother-child unit constitutes a rare outcome in this context, and mother and child may never see one another again. More favorable outcomes depend on availability of a prison nursery program or on dependable family or friend care.

In US prisons, 62% of women are mothers of children younger than 18 years.⁴¹ Only 55.3% of women lived with their minor-aged children in the month prior to arrest, and 75% of these women lived in single-parent households.^{25 - 26 ,37 ,41} Once incarcerated, 37% of women report that a child lived with the other parent, 45% with grandparents, 30% with other family or friends, and 11% in foster care.⁴¹

Ms A, 5 months into her jail term, was paroled during the early phase of her postpartum care to serve out her sentence in a community-based residential parenting program. While her state has no prison nursery program, it has a certified community-based residential parenting program focused on promoting bonding between mother and child, providing parenting skills, and treating substance abuse. Importantly, the residential parenting program allows mothers to keep their children with them while they serve out their court-imposed sentence. In Ms A's case, access to the residential parenting program was being used as a condition for parole.

Few studies exist on the success of parenting or prison nursery programs. In Ohio, participants in a prison nursery program had 3% three-year recidivism compared with 38% for the general prison population.⁴² Other observational studies also have found decreased recidivism, high program satisfaction, improved infant bonding, and decreased drug use.⁴²

Ms A, like other mothers-to-be whom she met in prison, faces the challenge of drug addiction. While the treatment of addiction during pregnancy in the incarcerated setting is generally the same as in the community, some unique challenges and benefits exist. One of the greatest challenges in jails is the uncertainty of how long a woman will be incarcerated or where she will be cared for on release. If methadone is started in jail, plans for referral to appropriate community clinics must be available at all times in case of release. Another challenge is that abstinence from addictive substances is often resisted by patients, which may dampen engagement with the treatment.

As Ms A suggests, the major benefit of incarceration to pregnant women is the stabilization of living environment and activities. Access to addictive substances is greatly reduced, if not eliminated, during incarceration.^{43 - 44} In prison, clinicians also know almost exactly how adherent a patient is with her treatment. Moreover, communication between clinicians and patients is greatly facilitated by the single site of treatment.

A systematic review of pregnancy outcomes for incarcerated women (7 of 10 US studies) reveals that when compared with similarly disadvantaged populations, maternal and fetal outcomes improve with increasing lengths of incarceration.³⁷ One study observed that on average, for each day spent in prison during pregnancy, infant birth weight was 1.49 g greater than among infants born to women incarcerated at times other than during their pregnancies.⁴⁵ Prison is associated with lower rates of stillbirth (odds ratio, 0.35; 95% confidence interval, 0.14-0.84) as well as a decreased odds of low birth weight (odds ratio, 0.57; 95% confidence interval, 0.35-0.93) compared with disadvantaged controls.³⁷ The timing of incarceration during pregnancy may also be important; higher birth weights were found for infants of women incarcerated during the first 14 weeks of gestation.⁴⁶

These studies do not imply that prisons constitute the optimal environment for pregnant women; rather, the women in question have a poor preincarceration environment, often characterized by poverty, drugs, chaos, and danger, as well as inadequate nutrition and lack of safe shelter. Although not an issue for Ms A, the majority of pregnant incarcerated women are released before they deliver and need linkage to prenatal services in the community. Even with universal prenatal care before and after incarceration, as in Great Britain, the odds of stillbirth are lower among incarcerated women.⁴⁷ This suggests that the community needs of this population go beyond prenatal medical care and are likely to include issues such as shelter, food, safety, and substance abuse treatment.

Medical services can vary widely in correctional settings. Clinicians who treat pregnant inmates in the community must take into account the medical services available to the women at the correctional institution to which they return. Clear communication with the medical staff at the correctional facility constitutes the best way to ensure that pregnant women receive the medical care that they need. Questions to consider before discharging a woman back to jail or prison include those listed in the Box.

There are also several assumptions to avoid:

A major area for improvement is the provision of family planning services prior to release. In 1 study, most women incarcerated while pregnant had been incarcerated in the past, and about half conceived within 90 days of leaving jail.⁴⁹ Other studies have shown that most incarcerated women are not planning to become pregnant and that they welcome a birth control method before they are released. Quiz Ref IDWhen birth control is offered free of charge in the prison, women are 15 times more likely to start a method than if it is offered for free in the community.⁵⁰ We have found that women welcome family planning counseling and services prior to release.^{50 - 51} At a minimum, women are given referral information for community-based Title X services (US federally funded services for reproductive health targeting poor and underserved populations) so that they may start or continue contraceptive practices. Women may also prefer longer-acting contraceptive methods, which generally require less effort in a chaotic environment. Women who are uncertain about family planning are encouraged to discuss the issue with their partners, family, and friends. When a woman desires contraception, in general only reversible contraceptive methods are initiated during incarceration because of a history of forced sterilization of prisoners and real or perceived coercion of sterilization may exist.^{52 - 53}

Since being granted parole, Ms A has done well. An intrauterine device placed during the postpartum visit now provides long-term reversible contraception. Furthermore, Ms A, no longer taking methadone, remains actively engaged in inpatient substance abuse treatment while caring onsite for her newborn. Ms A's 2 other children continue to be raised by family members. It is Ms A's hope and intention that she raise her infant daughter. Ms A continues to be tobacco-free and is trying to remain active. Our recommendation is that Ms A continue to engage in the substance abuse treatment program and that she use all of the support services available to her.

QUESTION: What would you advise President Obama to do about incarcerated women?

DR ADASHI: What we obviously need is a major prison reform. The current state of affairs dates back to earlier administrations, great excitement about the war on drugs, much harsher sentencing guidelines, “3 strikes and you're out,” and a real desire on the part of politicians to appear tough on crimes. The fact is that is that we have done just that, albeit at great expense, especially in terms of human suffering. We have filled our prisons and jails to the gills. Mostly, I would recommend expanding prison diversion programs. Community drug treatment facilities reduce costs and provide an opportunity to keep families together. Ms A reported that once she found out she was pregnant, she tried to enter a community treatment program, only to be placed on a waiting list. Jail ended up being the substance abuse treatment facility for her; a very expensive route of treatment. We clearly need to build up the capacity of our community drug treatment programs.

QUESTION: What is the role of the correctional officers during labor and delivery, and do you have any suggestions on how to work with them? Sometimes correctional officers insist on being in the room during a cesarean delivery, and I have to insist that they leave the room.

DR CLARKE: Use of restraints and the role of the correctional officer are issues being addressed nationally by the Rebecca Project (http://www.rebeccaproject.org). Officers generally follow policies set forth by their correctional institutions, which were historically male-dominated and are in the process of adapting to the needs of women in labor. In this area, it is extremely important for physicians to advocate for their patients. If you believe that the shackles are a threat to the health of the mother, then you can tell the officer that they need to be removed. If unshackling is against policy, then the officer will need to speak to his or her superior officer or shift commander. If shackling continues to be a problem, you can speak to the shift commander or to the warden of the facility.

If possible, it is better to address and resolve these issues prior to labor and delivery. The prison staff may be unaware of the medical dangers of shackles during labor and delivery, and it is a clinician's duty to educate them. Arrange a meeting with prison administration and staff so that the needs of all involved are understood and respected. When it comes to the health and safety of the pregnant woman, there is often more common ground than one might expect. It is important to have a plan for prenatal and delivery care that includes flexibility for the many issues that may arise: early release, facility transfer, postrelease changes in housing, changes in family support, etc.

QUESTION: You mentioned that at the time of admission or admittance to the jail system, a series of screens were done for infection. Specifically, do prisoners have the right to refuse, and, in a broader sense, what rights do they have in deciding what type of health care they get?

DR CLARKE: Laws differ by state, but 3 basic rights for prisoners follow the US Supreme Court case of Estelle v Gamble: the right to access care, the right to care that is ordered, and the right to professional medical judgment.³ This does not allow a full range of choices (eg, which physician a patient will see, and where) but it does afford inmates the basic rights to health care. Issues such as use of an epidural during labor and delivery would be a choice made by the woman and her physician. Also, patient consent for medical treatment or a procedure is needed in prison, just as in the community. Physicians need to uphold the same ethical standards for their community and prison patients.

Concerning declining health care, inmates have rights similar to individuals in the community. The NCCHC and APHA both affirm a patient's right to refuse medical care, as one can in the community. Exceptions to this right vary by state and country. For example, a patient may refuse tuberculosis testing but then be housed in isolation until the patient is released or decides to be tested. Some states have laws mandating human immunodeficiency virus testing after sentencing.