USA: prisons neglect pregnant women in their healthcare policies

This past August, released surveillance footage showed 26-year-old Diana Sanchez alerting Denver County Jail deputies and medical staff that she was in labor just hours before she gave birth to her son, alone in her cell. With her pleas ignored by staff, Sanchez was forced to give birth without any medical aid or assistance. Her experience is not isolated, as a number of reports by women in prisons and jails across the country have revealed a similar disregard for pregnant women’s basic needs.

What’s more, the documentation of pregnancies and pregnancy care is sparse, sometimes anecdotal, and rarely generalizable on a national level. The most recent data from the Bureau of Justice Statistics (BJS) was collected more than 15 years ago. In 2002, BJS found that 5% of women in local jails were pregnant when admitted. For prisons, BJS reported that in 2004, 4% of women in state prisons and 3% of women in federal prisons were pregnant upon admission. The government has not released any further national data since.

A recent study of 22 U.S. state prison systems and all U.S. federal prisons, published in the American Journal of Public Health, found a similar pregnancy rate; roughly 3.8% of the women in their sample were pregnant when they entered prison from 2016-2017. While the rate of pregnancy in prison may have remained stable since the early 2000s, the additional 10,000+ women imprisoned since then indicates that the number of women who are incarcerated while pregnant has grown, too. As long as the mass incarceration of women endures, incarcerated pregnancies will continue to rise.

Given the scale and stakes of this issue, it is imperative that correctional systems set policies that ensure the health and well-being of pregnant women in their custody. Provisions for adequate nutrition and prenatal medical care must be codified in policy to protect against negative health outcomes, such as miscarriages and low fetal birth weights, that can impact mothers and their children for the rest of their lives.

To see the extent to which these concerns are currently being addressed, we evaluated the policies of each state’s prison system and the federal Bureau of Prisons (BOP) to screen for adherence to nationally recognized guidelines. Troublingly, many states fail to meet even basic standards.

Most states lack important policies on prenatal care¶

All U.S. prisons and jails are required to provide prenatal care under the Eighth Amendment to the Constitution, but no detailed federal standards have been set to ensure that women are actually receiving the care they need.

The National Commission on Correctional Health Care (NCCHC) has published a set of standards for the treatment of pregnant women in prison, such as appropriate medical examinations as a component of prenatal care, specialized treatment for pregnant women with substance use disorders, and limited use of restraints throughout the course of the pregnancy. (A handy summary of the NCCHC’s standards is available from the Nursing for Women’s Health Journal, and the NCCHC’s full position statement provides additional context.)

Often, though, states fail to make their Department of Corrections policies publicly available, or even write guidelines on the care of incarcerated pregnant women in the first place. Despite the work of advocacy groups like the Rebecca Project for Human Rights and the ACLU, who have previously attempted to track available policies state-to-state, significant information gaps remain. Informed by this prior work, we tracked which states currently provide written policy on bare-minimum health standards for incarcerated pregnant women.

The data show that the lack of codified protocols for the care of pregnant women in state prisons is a widespread issue, and even policies that do exist frequently do not include adequate provisions for basic medical needs.

Although a majority of state prison systems require some form of medically provided prenatal care, 12 states failed to provide any policy on this vital component of a healthy pregnancy. This helps to explain why the Bureau of Justice Statistics, in the 2004 survey, found that only half (54%) of pregnant women in prison reported receiving some form of prenatal care while incarcerated.

Incarcerated pregnant women are particularly vulnerable to pregnancy complications related to substance use disorders, poor nutrition, and sexually-transmitted infections because they often come from precarious social and economic environments that exacerbate these risk factors. Their pregnancies are often designated as “high risk,” requiring special treatment to ensure their children are born in good health. We found that the federal BOP and 22 states have not provided any guidelines for specialized care for “high risk” pregnancies.

Reports of women who have been forced to give birth in improper conditions, like Diana Sanchez, are far too common. In addition to reducing uncertainty and anxiety, hospital births provide a clean environment and adequate care in the event of complications. Illuminating the shortcomings of health care for pregnant women in prison, 24 states fail to codify any pre-existing arrangements for deliveries.

The use of restraints (often referred to as shackling) has serious health impacts on pregnant women. According to the American College of Obstetricians and Gynecologists, shackling exacerbates pain, inhibits diagnosis of complications, and limits movement during the birthing process. Despite national standards condemning the practice, 12 states still provide no policy limiting restraints on women during pregnancy.

Incarcerated pregnant women require highly specific care in order to protect against adverse pregnancy outcomes. According to recent data from the Johns Hopkins School of Medicine, in some states, over 20% of prison pregnancies resulted in miscarriages; in others, preterm birth rates exceeded the national average (about 10%). The variability of these outcomes speaks to the inconsistent medical care afforded women in prisons across the country, and suggests that more universal policy standards could make pregnancy outcomes more equitable.

Critical pregnancy nutrition standards are also missing from policy¶

In an April 2019 tour of the Arizona State Prison Complex at Perryville, the Prison Law Office found that pregnant or recently pregnant women universally reported receiving inadequate nutrition during their pregnancies. Here, diets were reported to be largely lacking in fruit and vegetables, and the only additional food pregnant women received was an extra peanut butter sandwich and a carton of milk per day.

National guidelines clearly state that adequate nutrition is essential for a healthy pregnancy. Furthermore, the American Public Health Association cites unbalanced, inadequate diets as risk factors for preterm birth, birth defects, and other developmental problems in early childhood.

In our analysis, we found that 31 states lack any policy on nutrition for incarcerated pregnant women (see the Appendix). However, even the prison systems with policies mentioning nutrition provide too much room for substandard enforcement. For example, in 12 states, no guidelines exist beyond vague phrasing such as “adequate” or “appropriate” nutrition. This allows for a wide range of abuses and deficiencies, like the lack of nutritious options reported in the Arizona State Prison Complex at Perryville.

California is a notable exception, providing an important policy model that includes specific requirements for supplemental nutrition for incarcerated pregnant women. By provisioning “two extra eight ounce cartons of milk or a calcium supplement if lactose intolerant, two extra servings of fresh fruit, and two extra servings of fresh vegetables daily” with extra allowance for “additional nutrients” ordered by a physician, the nutritional supplement pregnant women need is explicitly detailed. Unfortunately, California was the only state found to have provided a meaningful nutrient breakdown of additional food allowances for pregnant women.

Improving prison policies is just the first step¶

Even when it exists, state policy is not always adhered to. In the Prison Law Office’s tour of the prison in Perryville, women reported being shackled during transport to the hospital as well as in-cell deliveries as a result of inadequate monitoring. Arizona policy requires prisons to make arrangements for deliveries in advance and prohibits shackling during transport in their state policy, but the stories of these women reveal a critical implementation gap.

Further, our analysis focuses on policy affecting state and federal prison systems, excluding county-operated jails. Policy for local jails is even more variable, inaccessible, and incomplete, which makes it difficult to assess the care of pregnant women in jail custody. Policy gaps likely also make it harder for jail staff to provide adequate care for pregnant women. Given the higher pregnancy rate among women admitted to jails and the large share of women held in jails, egregious failures like Diana Sanchez’s experience are likely far too common.

Given enforcement gaps and the shortage of available jail data, it is clear that equitable standards of care for pregnant women are urgently needed to protect the health of incarcerated women and their children. Of course, policy is just a stepping stone to adequate conditions. Beyond explicit standards of care, comprehensive data collection and insights from incarcerated pregnant women are key to evaluating the true impact of locking up this especially vulnerable population.

The long-term effects of inadequate health care are an insidious collateral consequence of incarceration. When the future health and well-being of mothers and their children are at stake, comprehensive policy and reform is past due.