Imagine yourself working on the obstetrics unit of a large urban hospital. Your shift just started and you're making rounds. You go to check on the laboring patient in room 1510, an inmate from a nearby correctional facility, and are startled to find her lying on her back, shackled to the hospital bed by her ankles and wrists, and restrained around the abdomen with wide metal “belly shackles.” Sitting near her bed is an armed male corrections officer.
Figure. Inmate Laura...Image Tools
A flood of concerns races through your mind. Observing that the shackles not only prevent the patient from getting out of bed, but also from even changing position, you're concerned about the dangers they pose for both mother and fetus. They will certainly make assessment difficult, likely impeding the progress of labor. And if an emergency cesarean section is required, the shackles will probably delay the procedure, possibly causing irreversible hypoxic damage to the newborn and psychological trauma to the mother. Understanding the physiologic changes pregnancy causes, you worry about the elevated risk of venous thrombosis the restraints impose. And, as a nurse, you recoil at the physical discomfort and insult to patient dignity posed both by the shackles and the presence of the officer. Do you feel prepared to advocate for this patient's rights? Are you aware of federal and state laws regarding the confinement of incarcerated pregnant and laboring women? Do you know your facility's policies concerning such patients?
The purpose of this article is to broaden nurses’ knowledge of practices used in the transfer and treatment of pregnant inmates; practices that—while all too common in U.S. correctional facilities and in hospitals that treat incarcerated pregnant women—may negatively affect maternal and fetal health or well-being. Some of these practices conflict with standards of obstetric care, violate federal or state laws, and are considered unethical or inhumane by such organizations as the American College of Nurse-Midwives; the American College of Obstetricians and Gynecologists; the Association of Women's Health, Obstetric, and Neonatal Nurses; the American Medical Association; the Rebecca Project for Human Rights; Amnesty International; the American Civil Liberties Union; and the World Health Organization.1-8 In this article, I'll discuss the rise in female incarceration that's occurred over the past 20 years, the structural problems imprisonment poses for pregnant women, federal and state laws that ban the use of certain correctional facility practices with regard to pregnant inmates, and how nurses can advocate for pregnant, incarcerated women—both on a political level and at the point of care.
THE RISE IN FEMALE INCARCERATION
There are more women held in both prisons (long-term correctional facilities operated by federal or state authorities) and jails (short-term correctional facilities, usually operated by local law enforcement for the purpose of housing people awaiting sentencing, trial, or transfer to another facility) today than at any other time in U.S. history.9 Although women constitute only 7% of the incarcerated U.S. population, their numbers are rising at a much faster rate than that of their male counterparts: while the number of men incarcerated in the United States nearly quadrupled between 1977 and 2004, the number of women serving sentences longer than one-year grew nearly eightfold.10 To a large degree, the rise in female incarceration may be attributed to federal and state drug laws of the past several decades under which those with minimal or indirect involvement in the drug trade may be imprisoned. These laws have had a tremendous effect on women, particularly minorities and those who are economically disadvantaged.11
In New York, for example, the laws enacted in 1973 under the direction of Governor Nelson Rockefeller established mandatory minimum sentences for possession of controlled substances and allowed judges little discretion in sentencing, regardless of such extenuating factors as the crime being a first offense. Under these laws, the minimum sentence for possessing 500 mg or more of a controlled substance was one year in prison.12 Since the Rockefeller drug laws were enacted, the number of women incarcerated for drug offenses in New York State has increased 787%.13
The health care of incarcerated women has been neglected largely because correctional facilities have been structured to meet the needs of male inmates.14 With the introduction of “gender-neutral” policies in the 1970s, nonviolent female offenders were treated in much the same way as violent male felons, which meant that they were shackled during hospitalization for any reason, including labor and delivery.14 Providing reproductive health care to female inmates, including complete gynecologic and obstetric services, is supported by both the National Commission on Correctional Health Care and the World Health Organization.8, 15 But according to the Bureau of Justice Statistics, in 2004 only 54% of incarcerated pregnant women received some type of pregnancy care.16 Even when gynecologic and reproductive health care services are provided, the quality of care delivered varies widely among correctional institutions.17
In addition to inadequate prenatal care, incarcerated pregnant women face environmental and work-related health risks, including inadequate ventilation and poor temperature control in the correctional setting, as well as workloads and schedules that are inappropriate for pregnant women. As a member of the Correctional Association of New York, an organization that works with nurses and other health care providers to monitor and report on conditions in the state's correctional facilities, I heard accounts of similar health risks from former female prisoners at an October 2012 meeting of our Women in Prison Project's Incarcerated Mother's Committee. Former female inmates told us of having been required to perform strenuous tasks during pregnancy, such as cleaning with heavy industrial mops and brooms while using “harsh chemicals” and to comply with schedules that did not allow for sufficient rest.
Prior unmet health care needs. Not only do imprisoned pregnant women fail to receive sex-specific health care following incarceration, but many enter prison with prior unmet health care needs. Often, they have received poor nutrition and inconsistent prenatal care, have been victims of domestic violence, or have an untreated sexually transmitted infection or substance abuse problem.17 The specialized treatment required by pregnant women with a substance addiction is seldom available in correctional facilities.18 Incarcerated women, of whom roughly 10% are pregnant at the time of incarceration, often have undiagnosed or untreated chronic conditions, such as depression, diabetes, hypertension, or asthma.15, 19, 20 All of these issues can have a negative impact on both mother and fetus.
Inadequacy of rendered care. In a study examining health care services available to pregnant women in state prisons nationwide, investigators found that rendered care was often inadequate.21 The researchers invited the wardens from 50 women's correctional facilities, one in each state, to participate in a survey study; wardens from 19 of the facilities responded. The survey sought to evaluate prenatal care, including provisions for adequate nutrition, rest, and education; location of prenatal care; and use of restraints during transport, labor, delivery, and recovery. To obtain qualitative data, the researchers included four open-ended questions regarding difficulties in caring for this population, barriers to providing care inherent in correctional policies, prison nurseries, and alternatives to incarceration. Although prenatal care was provided by all 19 responding facilities, none reported having standards as to how many visits the women received, where care was provided, and who provided the care (obstetrician, midwife, NP, or non-obstetric provider). All 19 responding facilities fell short in meeting pregnant women's needs for adequate nutrition and rest. Specifically highlighted deficiencies included a lack of fruit and vegetables in the menu and a shortage of lower bunk beds. Women's workloads were not altered to accommodate pregnancy, and such services as childbirth education, counseling, and breastfeeding support were offered in fewer than half of the 19 responding facilities.
Nationwide, responsibility for perinatal care of inmates is often shared by providers within the correctional facility and the community.17 This can cause gaps in treatment and—in conjunction with the trend of hiring for-profit corporations to manage prison health services in an effort to cut costs—result in inadequate, sometimes deadly care.22, 23 Furthermore, few prisons or jails have medical facilities for childbirth, requiring women in labor to be transported to an appropriate medical facility, a responsibility that is often not prioritized, resulting in delay; undue anxiety and fear for the mother; and too often, dangerous, unsupervised births.18, 24 The delay in obstetric care not only reduces a woman's opportunity to request analgesia, but also may result in her not being transported, having her labor needs ignored, and ultimately delivering her newborn alone in a cell. Instances of women in early pregnancy miscarrying alone in a cell have been documented.24
In Estelle v. Gamble (1976), the U.S. Supreme Court ruled that the government is obligated to provide medical services for prisoners under the Eighth Amendment, which prohibits federal and state governments from imposing cruel and unusual punishment.25 The Court held that “deliberate indifference” to the medical needs of prisoners constitutes an “unnecessary and wanton infliction of pain” and upheld the right of inmates to specific standards of care. This ruling has been used as the legal standard in cases of shackling and other instances related to failure to provide appropriate obstetric care to incarcerated women.14, 18 In another landmark legal decision, Nelson v. Correctional Medical Services, the U.S. Court of Appeals for the Eighth Circuit, which has appellate jurisdiction over district courts in Arkansas, Iowa, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota, ruled in support of the district court, which had held that shackling a woman “while she was in labor, without regard to whether she posed a security or flight risk, violated her Eighth Amendment rights.”26 Unfortunately, there is no accreditation that requires correctional facilities to demonstrate adherence to recognized standards of health care, and it is very difficult to obtain relevant information from them.27 Thus, the health care received by many incarcerated pregnant women fails to meet recognized medical and legal standards.
Restraint and injury. Amnesty International takes the position that there is no reason for pregnant women, or women who have just given birth and are being guarded by corrections officials, to be handcuffed or shackled.5 In accordance with international standards, jails and prisons should use restraints only when an inmate poses a risk of escape, of injury to themselves or others, or of damage to property. Nevertheless, the majority of states continue to permit the physical restraint of pregnant inmates. And when pregnant women incarcerated in U.S. prisons are transferred to a hospital for delivery, they are often shackled to the bed by the ankles and wrists, and may also be restrained around the abdomen. The practice of physically restraining pregnant women during transport between correctional and health care facilities or during treatment poses undue risks to the mother and fetus (see Health Risks Linked to Shackling Pregnant Women2, 7, 17).
Figure. Health Risks...Image Tools
Antishackling legislation. Some state legislatures have begun to address the issue of physically restraining incarcerated pregnant women (Table 17, 28). In 2009, Governor David Paterson of New York signed legislation banning shackling of pregnant inmates during labor and after delivery. Hawaii, Rhode Island, Idaho, and Nevada passed similar bills in 2011. In 2012, Florida became the first Southern state to enact a law banning the use of shackles on pregnant inmates except in “documentable extraordinary” circumstances. And California recently passed the most comprehensive antishackling law, restricting the use of restraints on incarcerated pregnant women at any point during pregnancy. Although the Virginia General Assembly's House Militia, Police and Public Safety Committee failed to pass a bill that would have limited the practice of shackling pregnant inmates, supporters of the bill persuaded the Department of Corrections to amend its policies, such that pregnant inmates may now be restrained only by handcuffs during transport outside of the prison, unless they are determined to be a danger to themselves or others.29 In such cases, additional restraints must permit walking, standing, and changing position, and the reason for their use must be explained in an incident report. Furthermore, restraints must be removed immediately at the request of medical staff.
Implementation challenges. These laws and policies are a step in the right direction, but their implementation presents challenges. For example, at a September 2011 meeting of the Correctional Association of New York, I heard reports from former inmates who had been restrained during childbirth at a New York City hospital, despite that the 2009 New York State law prohibits the use of restraints on pregnant inmates during labor, childbirth, and recovery unless they attempt to escape or exhibit threatening behavior. At the same meeting, in response to this anecdotal evidence, the association's Women in Prison Project announced that it would initiate a study to evaluate the effectiveness of the state's antishackling law. The official report is scheduled to be released this fall, but on June 5, when the Correctional Association of New York went to Albany to lobby legislators to improve implementation of the current law and to ban the practice of shackling women at any point during pregnancy, investigators presented preliminary findings that indicated compliance is poor among New York prison and jail officials. Numerous interviews with women who gave birth while incarcerated after the law had gone into effect revealed that women had been shackled while in labor; while breastfeeding; shortly after giving birth; and three days following a cesarean section, with a waist chain.
The prevalence of shackling in states that have enacted laws banning the practice is further evidenced by the number of lawsuits filed by inmates claiming to have been shackled while pregnant. In May 2012, a federal court awarded a $4.1 million settlement to about 80 women held in the Cook County Jail in Chicago who charged that they had been shackled while in labor despite Illinois's antishackling legislation.30
Resistance to change. The majority of states continue to permit the physical restraint of pregnant inmates, even during childbirth. State corrections departments are resistant to antishackling laws, out of concern that they undermine the authority of corrections officers. The position of the Association of State Correctional Administrators is that antishackling legislation prevents officers from using their professional judgment. They have justified the practice of shackling, citing concerns that “it is not possible to craft legislation to cover the variety of conditions and circumstances under which pregnant inmates might require some form of physical restraint.”31 Implicit in this position is the assumption that the pregnant women may escape or turn violent, even during labor, though the majority of women in prison and jails are nonviolent offenders, and there has not been a single report of a woman attempting escape during childbirth.32
More must be done to provide pregnant inmates with safe and ethical care. In addition to a universal ban on the shackling of pregnant prisoners, there is a need for policies that protect the privacy of pregnant women, requiring corrections officers—ideally, female corrections officers—to maintain an appropriate distance during pregnancy, labor, and delivery.
Privacy concerns. Amnesty International recommends that female prisoners be guarded by female corrections officers whenever possible. Even in states that ban shackling, there are no clear guidelines protecting a woman's privacy during labor, delivery, and the postpartum period. Female prisoners are often guarded by male corrections officers and may be under their constant surveillance during labor and childbirth, during which they are seldom afforded the supportive presence of a partner, family member, or friend. Throughout the majority of the labor, they are in the company of only the corrections officer and a series of unfamiliar providers.
The right to bond. Very often, when a woman delivers a child while incarcerated, she is separated from the newborn soon after birth. Few prison hospitals in the United States have policies that allow mothers to spend time and bond with their newborns in the immediate postpartum period.33 Even when delivery occurs in a community-based hospital, incarcerated mothers may not see their newborns until discharge, at which point the infants are placed in the care of relatives or the custody of a foster care agency until the mother completes her sentence, provided parental rights aren't terminated. At an April 2013 workshop sponsored by Hour Working Women, an organization that supports incarcerated mothers, one formerly incarcerated mother described delivering in a large county health facility in New York, after which she was sent to the facility's “prison ward,” shared by men, instead of to a postpartum unit.
Friends and family. In the early postpartum period, the need for support of and visitation by family members and friends is crucial, particularly since incarcerated women are usually separated from their newborns soon after birth. As during labor, however, visitation by family and friends is often restricted in the postpartum period. Mandatory minimum sentencing keeps many women separated from their infants for extended periods of time, often at distant locations.34 Unsurprisingly, this can negatively affect the development of parenting skills and attachment when the mothers are finally released from prison and reunited with their children.
HOW PRISONS MEASURE UP
The Rebecca Project for Human Rights worked in collaboration with the National Women's Law Center to produce a state-by-state “report card” on the conditions experienced by incarcerated pregnant and parenting women and their children.7 This report card graded state correctional facilities on the prenatal care services provided, shackling policies, and the presence of family-based alternatives to incarceration. When the grades for these parameters were averaged, 21 states received grades of D or F. Another 22 states earned a grade of C, and seven received a B. Only one state, Pennsylvania, earned an A-.
The goal of this endeavor was to encourage all stakeholders, including state and federal corrections officials and policymakers, to reevaluate policies that fail to protect the at-risk population of incarcerated pregnant women. Programs and policies that are tailored specifically to meet the needs of incarcerated pregnant women will help to break the cycle of abuse, addiction, and future incarceration and help these women become assets to their communities.
In the United States, the majority of incarcerated women are in state facilities, but a significant number are in federal custody—either federal prisons or immigration and customs detention centers. Between 1980 and 1998, the number of women in these facilities increased from 1,400 to more than 9,000 owing to federal mandatory sentencing for drug offenses. And while apprehensions for immigration violations dropped from 1.8 million in 2000 to just over half a million in 2010, with the Homeland Security Act of 2002, which strengthened federal authority to detain and deport people who were in the country illegally, the number detained by the U.S. Marshals Service for immigration offenses more than tripled between 2005 and 2010, from 25,205 to 82,438.7, 35 Although federal regulations require pregnant women to be provided with medical care and allowed to give birth in a hospital, there is limited information regarding the outcomes in such cases, and a report by the National Association of Women Judges for the Rebecca Project for Human Rights asserts that the health care provided to women in federal prisons is “unacceptable.”7
THE ROLE OF NURSES
The ethical obligations of the nursing profession are identified in the American Nurses Association (ANA) code of ethics, which calls for nurses to respect “the inherent worth, dignity, and human rights of every individual” and states that each nurse “has an obligation to be knowledgeable about the moral and legal rights of all patients to self-determination.”36 Limiting an individual's rights is a “serious deviation from the standard of care,” unless the concern for those rights is outweighed by concern for the public health and welfare. Nurses are to remain aware of unethical or illegal practices and to protect patients from the same. When providing care to pregnant women in the criminal justice system, nurses are thus called upon to
* know the current laws.
* advocate for humane laws.
* do all that is possible to ensure that the patient's dignity and human rights are respected at the point of care.
Advocacy. Laws and policies intended to meet the needs of incarcerated women are meaningful only if those responsible for enforcing them are properly trained and educated. After becoming familiar with legislation applicable within the jurisdiction in which they practice, nurses who provide care to pregnant women can seek instruction on how to best ensure its implementation from their facility's risk management department.
In areas lacking legislation protecting the rights of pregnant prisoners, nurses can contact their legislators to make them aware of the need for such legislation. They can become active in federal, state, and local organizations that advocate for laws protecting incarcerated women. These organizations seek the help of nurses and others in public service to disseminate information regarding practices that violate human rights.
Nurses can volunteer to work as childbirth educators in local prisons. Student nurses who have completed a course in obstetrics can participate in correctional facility programs that prepare incarcerated women for childbirth and serve as doulas to incarcerated women in labor. Nurses who have contact with correctional facilities, whether directly or indirectly, can help develop similar programs at those sites (see Programs for Incarcerated Pregnant Women 8, 21, 33, 37-42) Finally, nurses can advocate for pregnant inmates by working with professional organizations such as the ANA to develop position statements affirming that the practice of shackling incarcerated pregnant women is a violation of human rights. Position statements along these lines have been published by the Association of Women's Health, Obstetric, and Neonatal Nurses; the American Medical Association; the American College of Nurse-Midwives; and the American College of Obstetricians and Gynecologists.2-4, 6
At the point of care. Keep in mind that the overall health of many incarcerated women is poor prior to entering the criminal justice system. A thorough patient history, including prior physical and sexual abuse, is crucial. Many incarcerated women struggle with alcohol or substance abuse. Addictions, chronic conditions, and sexually transmitted diseases may not have been previously diagnosed or addressed because of lack of funding or available services. Some pregnant inmates have had no prenatal education or childbirth classes. All will benefit from a careful explanation of procedures and care during labor and delivery.
To help prevent vertical HIV transmission, HIV testing, education, and counseling should be offered to all pregnant women, and those with positive tests should be offered antiretroviral therapy in accordance with recommendations from the Centers for Disease Control and Prevention and the Health Resources and Services Administration.19 Most prisons provide HIV testing for inmates who request it, and in some prisons, HIV testing is mandatory. If antiretroviral therapy is prescribed, the degree to which confidentiality is maintained often depends on prison policy regarding the method by which medication is dispensed—directly observed therapy or “keep on person.”
During labor, delivery, and throughout the postpartum hospital stay, be mindful of the dangers posed by restraints and do all you can to ensure that your patient has freedom of movement and privacy. Nurses are in a unique position to protect patient dignity and privacy. If a pregnant patient is shackled, ask the corrections officer to remove all restraints so that you can conduct a proper assessment. In areas in which shackling is banned by law, inform the officer of that fact. Know your facility's policy on how to respond if your request is denied—and if your facility doesn't have such a policy, work with administrators and risk management personnel to develop one. Similarly, if a corrections officer is in the examination room, ask the officer to step outside the door; if the request is denied, pull the curtain when examining the patient or providing care. Let the patient know that if she needs to use the restroom, you, rather than the corrections officer, can escort her. After delivery, if the newborn is not immediately taken from the patient, ensure that she can breastfeed and bond in relative privacy—with the officer outside the room or with the curtain drawn.
Before discharge, investigate medical services available to the patient at the correctional facility. Consider the availability of medical staff 24 hours a day; the presence of a contact person to coordinate any necessary care; and provisions for a prompt return to the hospital if needed. If conditions at the correctional facility are unsafe, inform the primary care provider and suggest delaying discharge.
Care of the incarcerated pregnant woman is an area in which there are tremendous gaps in nursing research. For many nurses, this patient population is invisible. The nursing profession would benefit greatly from investigation exploring the experiences of these women and the interventions that have been most effective in meeting their needs.
Programs for Incarcerated Pregnant Women
Prenatal, labor, and postnatal support can reduce recidivism and improve mother–child bonding.
A small number of programs provide care for the specialized needs of incarcerated pregnant women. Nurses can contact local correctional facilities to explore the possibility of working with or establishing similar programs. Such programs can provide valuable experiences for student nurses who have completed an obstetrics course, as well as substantial opportunities for much needed nursing research.
Prenatal, labor, and postnatal support. Nurse researchers at the University of Washington developed a multiagency program that provides trained doulas to incarcerated pregnant women scheduled to deliver at a large teaching hospital.33 The impetus for the program was the concern that a negative birth experience might discourage women from seeking future prenatal care or social services, including treatment for drug and alcohol abuse.
Informational support. Nurse researchers at the University of Rhode Island developed an educational support group for pregnant women in a Northeast state correctional facility after the facility's parenting coordinator conducted a needs assessment showing that the nurses there—whose background was mainly medical and surgical nursing—felt unprepared to answer many of the questions they received from pregnant inmates.21 Program topics include the labor and delivery process; fetal development; adverse effects of smoking, alcohol, and other substances on the fetus; and prison rules regarding transportation to the hospital, labor, delivery, and the subsequent care of the newborns.
Nursery programs. According to the World Health Organization, women who give birth while in prison or have an infant in their care when incarcerated should be allowed “to nurture and bond with the child.”8 In many European countries, newborns and young children are allowed to reside with their incarcerated mothers, often up to the age of three.
In the United States, prison nursery programs are relatively rare, but the number is growing.37 Such programs allow incarcerated women to live with their newborns for a limited period to promote bonding. Based on research I conducted in 2013, nine states have prisons that operate nurseries, and one has an “alternative to incarceration” program that prioritizes pregnant and parenting women. Only one jail in the nation, the Rose M. Singer Center on Rikers Island in New York City, has a prison nursery program.
Emerging research shows that prison nursery programs can reduce recidivism substantially. Before the Nebraska Correctional Center for Women introduced a prison nursery in 1994, women who gave birth while incarcerated were separated from their infants shortly after delivery. Over the five years prior to the nursery's opening, the three-year recidivism rate for these mothers was over 33%, compared with 9% at five-year evaluation for women who had participated in the prison nursery program.38 At New York's Bedford Hills and Taconic correctional facilities, a three-year follow-up of female inmates who participated in the prison nursery programs found that recidivism was 13.4% for participants versus 25% for the general female prison population in New York.38
A prospective, longitudinal study followed 100 mother–baby dyads throughout their participation in the Bedford Hills prison nursery program, and compared them with dyads that had not experienced incarceration.39 The proportion of infants with a “secure” attachment among those who had been in a yearlong coresidence prison program did not differ significantly from the proportion among those who had been residing with low-risk mothers in the community. The crucial role that secure infant attachment plays in childhood development—-including social competence, self-reliance, and emotional regulation—has been well established.40
Residential programs. A small number of comprehensive residential programs have been developed specifically for pregnant women who are incarcerated. Michigan's Women and Infants at Risk (WIAR) program is aimed at pregnant women who have substance abuse issues. Its goal is to reduce the effects of drug exposure for the newborn, prevent relapse for the mother, and promote awareness of the needs of pregnant prisoners.41 Pregnant inmates who are willing to provide primary care for their infant, remain drug free, and stay in the program at least four months after giving birth, regardless of the length of their sentence, reside in a furnished, carpeted room in the WIAR house, located in a Detroit residential neighborhood. In addition to prenatal care, the women receive individual counseling, group therapy, and help with abuse issues. They are also enrolled in a general education development (GED) program. Of 45 infants born to program participants between 1991 and 1995, all were drug free and only one required neonatal intensive care. One was born with fetal alcohol syndrome, which can occur when alcohol is consumed within the first trimester despite subsequent abstinence, and there were four with congenital anomalies or serious complications. By comparison, a review of 120 pregnancies of women incarcerated during the four years preceding the launch of the program found that two had resulted in fetal death and two in neonatal death. There were 45 major complications and medical problems, and 17 of the 118 infants born live required neonatal intensive care.
The U.S. Federal Bureau of Prisons also offers a community residential program called Mothers and Infants Nurturing Together (MINT) to certain women who are pregnant when incarcerated.42 To be referred to the program, inmates must be low risk (nonviolent) offenders, in their last trimester, and eligible for furlough, with fewer than five years remaining on their sentence. The stated purpose of MINT is to promote bonding and parenting skills among pregnant inmates. Generally, women are allowed to remain in the program for three months after giving birth, though in some MINT programs, the bonding period is longer. A drawback to this program is that the inmate herself or a guardian must assume financial responsibility for the child's medical care while residing in the program.
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