USA: filling the maternal-care gap

Triona Carter’s birth of her first son, in a county jail in Alabama, was “one of the most hurtful things to ever go through.” The pain was both physical and emotional. She was “handcuffed to the bed,” aware that she would soon be separated from her child. “[I was] holding him, knowing that I don’t know when I’ll be able to hold him again,” Carter said. But the birth of her second son during her 20-year stay in Julia Tutwiler Prison “was even more devastating … because I didn’t have much time to hold him: You had your child that day, the next day you’re going back to the prison … you don’t have time to heal at the hospital.”

Giving birth to her two sons while in the carceral system left Triona emotionally broken. Triona was one of approximately 1,300 women who give birth while incarcerated every year in the United States.

The number of incarcerated women has increased exponentially in the last four decades, with a rate over eight times higher than it was throughout most of the 20th century, according to a 2019 study by the Prison Policy Initiative. In prisons in particular, incarceration rates for women have more than doubled since 1978, compared to the rate for men. There has also been remarkable growth of incarcerated women at the state level—and as the incarceration rate of women continues to rise, so will the incidence of pregnancy behind bars.

Dr. Diane Morse, an internal medicine physician and associate professor in psychiatry and medicine at the University of Rochester Medical Center, told me, “Most prisons and jails do not give people birth control, even though the rate of unintended pregnancies is much higher among women who have been incarcerated.” The rate of unintended pregnancy is as high as 83 percent among recently incarcerated women, in contrast to the national rate of 45 percent.

According to an American Public Health Association study, “Pregnancy Outcomes in US Prisons, 2016–2017,” which studied 22 state prison systems and all federal prisons, “[t]hree quarters of incarcerated women are of childbearing age (between 18 and 44 years)” and “[t]wo thirds [of incarcerated women] are mothers and the primary caregivers to young children.” In other words, mothers define the carceral landscape of women in the U.S. Yet health standards for pregnancy care in prison remain inconsistent at best.

While prisons are constitutionally obliged to provide health care to those in their custody, no mandatory standards to guarantee health care provision exist. As a result, there is “tremendous variability in pregnancy care in prisons,” writes the American Public Health Association. When I asked Triona if she had any support after giving birth to her eldest son in prison, or received any prenatal care, she was quick to reply, “We had none of that.” A 2004 Bureau of Justice Statistics study found that 54 percent of pregnant women received “some type of pregnancy care,” but does not articulate the scope of such care.

Yet over the course of Triona’s 20 years in prison, a number of nonprofit pregnancy support organizations have been filling the gaps in the system. When Triona was in Tutwiler, Aid to Inmate Mothers facilitated the strengthening of her bond with her sons through visitations and recording bedtime stories, and encouraged personal development through book clubs and parenting classes.

More recently, over the last decade, nonprofits that specifically connect women who are incarcerated and pregnant with doulas have emerged. The Alabama Prison Birth Project (APBP) began providing support to pregnant women in Tutwiler in 2016. The organization offers weekly visits to the prison, during which they provide support and information about childbirth and the postpartum experience, and provide a healthy meal for expectant mothers. They also match pregnant women with a doula who provides informational, physical, and emotional support throughout pregnancy, labor, and the immediate postpartum period. This allows for continuity of care.

APBP was also instrumental in the establishment of a lactation room in Tutwiler. In 2018, a room that previously served as an isolation cell was turned into the “Serene Expressions” room, where women can pump breast milk that will be delivered to their newborns. Once a week, Chauntel Norris, one of APBP’s doulas, retrieves the stored bottles of milk and delivers them to the respective caregivers.

In creating a space for breastfeeding, and in serving as a constant presence from pregnancy to the postpartum experience, the doula supports mental health, well-being, and maternal empowerment among women in prison.

Similar organizations have emerged in other states, such as the Minnesota Prison Doula Project, founded in 2008; Motherhood Beyond Bars, founded in 2013 in Georgia; and the Michigan Prison Doula Initiative, which was founded in 2017 and officially launched its program to support pregnant women in Women’s Huron Valley Correctional Facility—also the state’s only women’s prison—in February 2019. “The mission of the organization is to provide compassionate birth and parenting support to incarcerated people,” Kate Stroud, the doula program director for the Michigan Doula Prison Initiative, told me. Since launching, they have provided support to about 30 women.

Maternal health outcomes in the carceral system map onto maternal health disparities writ large in the U.S. According to the American Public Health Association study, black women are incarcerated at twice the rate of white women. The interaction of poverty, substance abuse, and limited access to health care prior to incarceration means that when women enter the carceral system, they bring with them pre-existing health vulnerabilities that can only compound in the prison environment. And what passes for health care within prison is often the provision of over-the-counter medication rather than serious attempts at diagnosis and adequate treatment.

When people are released from prison, poor health trails them. A 2007 study by The New England Journal of Medicine looked at formerly incarcerated people who were released from 1999 to 2003 from the Washington State Department of Corrections, and found that the mortality rate among this population “was 3.5 times … that among state residents of the same age, sex, and race.”

Research shows that the pairing of pregnant women with doulas results in positive health outcomes, from shorter labor with fewer complications. In the setting of prison, doulas also help new mothers navigate the grief that comes with the inevitable separation from their newborn.

While these different doula initiatives operate in their respective state-specific contexts, “we do work together, and bounce ideas off each other … I am in touch with Amy Ard [of Motherhood Beyond Bars] down in Georgia, and Rae Baker [of the Minnesota Prison Doula Project] up in Minnesota … in the 20 years that I’ve done doula work, it’s always been a collaborative effort,” Stroud told me.

As women typically take on child-rearing responsibilities, “when the mother is removed, it upturns the whole system” of the family, Stroud told me. This upturning, which in many prisons occurs only 24 hours after birth, has tremendous implications for the long-term mental health and well-being of women behind bars.

In working within the maternal care gap, the doula initiatives and parenting support organizations operating in states across the U.S. are trying to bring both health and humanity to women in prison. Triona credits Aid to Inmate Mothers’ Storybook Project for the strong bond she has with her sons today. She recorded stories—originally through cassette, then video—up until her last day in prison in February 2018. When she was released and reunited with her sons, she told me, “it was like I never left home.”