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Nursing Care of Incarcerated Women During Pregnancy and the Postpartum Period

  • Association of Women’s Health, Obstetric and Neonatal Nurses
Published:February 09, 2018DOI:https://doi.org/10.1016/j.jogn.2018.01.001

      Position

      AWHONN supports comprehensive, high-quality, perinatal care for women who are incarcerated during pregnancy and the postpartum period. Incarcerated women should have access to pregnancy testing, pregnancy counseling, and if requested, referral for abortion or adoption services. Women who wish to continue their pregnancies while in custody should have access to regular perinatal care from a clinician with obstetric expertise, adequate nutrition and exercise, a lower bunk, pregnancy clothing, and accommodations for rest and work. Women should be safely transported to a licensed hospital for birth and postpartum care.
      Because breastfeeding is the ideal method of infant nutrition, incarcerated women who choose to breastfeed their newborns should receive the same education and support as nonincarcerated women, regardless of whether the dyad will remain together at hospital discharge. Separation of a woman and her newborn may be traumatic for both; therefore, AWHONN advocates for consideration of options that allow women to remain in the community. For women who are ineligible for such options, the correctional infrastructure should support maternal–infant contact; this includes prison nurseries with adequate developmental support, placement in a correctional facility near the family, and family visiting spaces that allow women to hold and breastfeed their infants.
      AWHONN opposes nonmedically indicated inductions of labor or cesarean birth for incarcerated women for the convenience of health care providers or correctional staff. AWHONN also opposes the practice of shackling women who are pregnant or who have given birth within eight weeks. While shackles may be needed for some extraordinary circumstances, including imminent risk of harm to the pregnant woman, risk to others, or risk of escape, the least restrictive option should be used for the shortest possible amount of time.
      When an incarcerated woman is shackled during pregnancy or the postpartum period, a correctional staff member must be available to remove the shackles immediately upon request of health care personnel, when it is determined to be safe. Each use of shackles should be properly documented, and regular, independent monitoring of this practice to ensure its limited and justified use should be employed. Because the safety of nurses and other health care personnel is essential, adequate correctional staff must be available to monitor incarcerated women during routine prenatal examinations, labor and birth, and the postpartum recovery period. Shackles should not be used routinely or as a substitute for adequate correctional staff monitoring.

      Background

      Historically unprecedented numbers of women are incarcerated in the United States. More than 200,000 women, which represents nearly one-third of the world's incarcerated women, are in U.S. prisons and jails (
      • Walmsley R.
      World female imprisonment list, third edition, Women and girls in penal institutions, including pre-trial detainees/remand prisoners.
      ). In the United States, most women in jails are there for nonviolent charges (
      • Swavola E.
      • Riley K.
      • Subramanian R.
      Overlooked: Women and jails in the era of reform.
      ), and approximately 64% of women in prisons have been convicted of nonviolent crimes (). Increased incarceration rates for women are related to drug policy and law enforcement changes over time (
      • National Resource Center on Justice Involved Women
      Fact sheet on justice involved women in 2016.
      ) not to increases in overall criminality or violent behavior by women.
      Women who are incarcerated are highly vulnerable and are more likely to have experienced poverty (
      • Rabuy B.
      • Kopf D.
      Prisons of poverty: Uncovering the pre-incarceration incomes of the imprisoned.
      ), interpersonal violence (
      • Grella C.E.
      • Lovinger K.
      • Warda U.
      Relationships among trauma exposure, familial characteristics, and PTSD: A case control study of women in prison and in the general population.
      ), human immunodeficiency virus infection (
      • Centers for Disease Control and Prevention
      HIV among incarcerated populations.
      ), mental illness (
      • Fazel S.
      • Hayes A.J.
      • Bartellas K.
      • Clerici M.
      • Trestman R.
      The mental health of prisoners: A review of prevalence, adverse outcomes and interventions.
      ), and substance dependence (
      • Fazel S.
      • Yoon I.A.
      • Hayes A.J.
      Substance use disorders in prisoners: An updated systematic review and meta-regression analysis in recently incarcerated men and women.
      ) than women without histories of incarceration. The imprisonment rate for Black women is approximately double that for White women ().
      Most incarcerated women are of reproductive age, and the highest rates of incarceration are among women 30 to 34 years old (). Approximately 3% to 6% of incarcerated women are pregnant upon intake into a correctional facility (
      • Sufrin C.
      Pregnancy and postpartum care in correctional settings.
      ). However, estimates are imprecise and may be less than actual numbers because testing and reporting are not standardized across correctional facilities (
      • Sufrin C.
      • Kolbi-Molinas A.
      • Roth R.
      Reproductive justice, health disparities and incarcerated women in the United States.
      ). Also, the federal government does not require prisons or jails to collect data on pregnancy and childbirth among female inmates (). Most incarcerated mothers are eventually released, and they generally report plans to resume care of their children (
      • Glaze L.E.
      • Maruschak L.M.
      Parents in prison and their minor children.
      ).
      Pregnancies among women who are incarcerated are often high risk and complicated by histories of intimate partner violence, drug and alcohol dependence, mental illness, suboptimal nutrition, and limited access to prenatal care (
      • Sufrin C.
      Pregnancy and postpartum care in correctional settings.
      ). Although recommended standards of care for pregnant, incarcerated women are available (), correctional facilities are not required to adhere to these standards and often provide care that is poor quality (
      • Ferszt G.
      • Clarke J.
      Health care or pregnant women in U.S. state prisons.
      ,
      • Kelsey C.M.
      • Medel N.
      • Mullins C.
      • Dallaire D.
      • Forestell C.
      An examination of care practices of pregnant women incarcerated in jail facilities in the United States.
      ).
      Shackles, or nonmedical restraints, are routinely applied to the hands, feet, and/or abdomens of incarcerated pregnant women when they are outside of prisons and jails, including when they present to labor and delivery units. The ostensible reason for routine shackling is to prevent incarcerated people from escaping, harming others, or harming themselves. A woman's ability to harm others or flee is already physically limited during pregnancy and labor, and corrections officers are expected to remain with incarcerated pregnant women in noncorrectional settings, such as hospitals and birthing centers (
      • International Human Rights Clinic
      The shackling of incarcerated pregnant women: A human rights violation committed regularly in the United States.
      ).
      Shackles can place an incarcerated woman and unborn fetus at serious risk. For example, shackles increase the risk for falls and may interfere with the ability of a nurse or other health care provider to adequately assess and treat an incarcerated pregnant woman. In emergency situations, such as maternal hemorrhage or abnormal fetal heart rate patterns, shackles may cause unnecessary delay in the administration of potentially lifesaving measures.
      Shackles and other physical restraints can also make the labor and birth process more difficult than it needs to be. The inability to walk, move, or change positions can result in longer labor, more severe pain, and increased need for pain medication. Shackling can prevent women from holding and bonding with their newborns and may interfere with a woman's ability to safely handle her newborn ().

      Role of the Nurse

      Nurses are uniquely positioned to advocate for women who are incarcerated during pregnancy and the postpartum period. It is important for nurses to be familiar with the laws in their states and institutional policies related to shackling incarcerated pregnant women. In keeping with these laws and policies, nurses can work directly with incarcerated pregnant women, other members of the care team, and correctional officers to promote safe, quality care.
      Nurses should also be aware of the special health care needs of incarcerated pregnant women; many have histories of trauma (
      • Grella C.E.
      • Lovinger K.
      • Warda U.
      Relationships among trauma exposure, familial characteristics, and PTSD: A case control study of women in prison and in the general population.
      ), are disproportionately sicker than the population at large (
      • Centers for Disease Control and Prevention
      HIV among incarcerated populations.
      ,
      • Fazel S.
      • Hayes A.J.
      • Bartellas K.
      • Clerici M.
      • Trestman R.
      The mental health of prisoners: A review of prevalence, adverse outcomes and interventions.
      ,
      • Fazel S.
      • Yoon I.A.
      • Hayes A.J.
      Substance use disorders in prisoners: An updated systematic review and meta-regression analysis in recently incarcerated men and women.
      ,
      • Maruschak L.M.
      • Berzofsky M.
      Medical problems of state and federal prisoners and jail inmates, 2011–2012.
      ), and may have had limited access to health care (
      • Ferszt G.
      • Clarke J.
      Health care or pregnant women in U.S. state prisons.
      ,
      • Kelsey C.M.
      • Medel N.
      • Mullins C.
      • Dallaire D.
      • Forestell C.
      An examination of care practices of pregnant women incarcerated in jail facilities in the United States.
      ). Nurses can collaborate with other health care providers to develop action plans for breastfeeding (
      • Shlafer R.J.
      • Davis L.
      • Hindt L.A.
      • Goshin L.S.
      • Gerrity E.
      Intention and initiation of breastfeeding among women who are incarcerated.
      ) and child care and housing for women upon release (
      • Guthrie B.
      Toward a gender-responsive restorative correctional health care model.
      ).

      Policy Considerations

      AWHONN considers access to comprehensive, quality, health care services a basic human right (
      • Association of Women's Health, Obstetric and Neonatal Nurses
      AWHONN position statement: Access to health care.
      ). Laws in 22 states and the District of Columbia restrict in some way the use of restraints on incarcerated pregnant women, and they vary widely by jurisdiction in terms of when and how shackling is restricted (
      • Ferszt G.G.
      • Palmer M.
      • McGrane C.
      Where does your state stand on shackling of pregnant incarcerated women?.
      ).
      A number of professional organizations, including the American Medical Association (2010), oppose the use of shackles during labor, birth, and the immediate postpartum period. Further, and
      • Amnesty International
      USA: Rights for all: “Not part of my sentence” violations of the human rights of women in custody.
      oppose the use of restraints for all incarcerated pregnant women. Federal courts have ruled that shackling during active labor violates the Eighth Amendment to the U.S. Constitution (
      • Dignam B.
      • Adashi E.Y.
      Health rights in the balance: The case against perinatal shackling of women behind bars.
      ).
      AWHONN supports institutional policies that prohibit the shackling of women who are incarcerated during pregnancy or the postpartum period in the absence of an imminent risk of flight, harm to self, or harm to others. Similarly, at the state and federal levels, comprehensive legislation is needed to prohibit shackling throughout pregnancy and for eight weeks after birth in the absence of an imminent risk of flight, harm to self, or harm to others (
      • Goshin L.S.
      • Arditti J.A.
      • Dallaire D.H.
      • Shlafer R.J.
      • Hollihan A.
      An international human rights perspective on maternal criminal justice involvement in the United States.
      ). As trusted health care professionals, nurses can promote these efforts through local and state nursing organizations and in partnership with members of other health care provider and legal advocacy organizations that oppose this practice.

      References

        • American College of Obstetricians and Gynecologists
        Committee opinion number 511: Health care for pregnant and postpartum incarcerated women and adolescent females.
        (Retrieved from)
        • Amnesty International
        USA: Rights for all: “Not part of my sentence” violations of the human rights of women in custody.
        (Retrieved from)
        • Association of Women's Health, Obstetric and Neonatal Nurses
        AWHONN position statement: Shackling incarcerated pregnant women.
        Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2011; 40: 817-818
        • Association of Women's Health, Obstetric and Neonatal Nurses
        AWHONN position statement: Access to health care.
        Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2017; 46: 114-116
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        • Anderson E.
        Prisoners in 2015.
        (Retrieved from)
        • Centers for Disease Control and Prevention
        HIV among incarcerated populations.
        (Retrieved from)
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        The restraint of pregnant inmates.
        (Retrieved from)
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        • Adashi E.Y.
        Health rights in the balance: The case against perinatal shackling of women behind bars.
        Health and Human Rights. 2014; 16: E13-E23
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        • Hayes A.J.
        • Bartellas K.
        • Clerici M.
        • Trestman R.
        The mental health of prisoners: A review of prevalence, adverse outcomes and interventions.
        Lancet Psychiatry. 2016; 3: 871-881
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        • Yoon I.A.
        • Hayes A.J.
        Substance use disorders in prisoners: An updated systematic review and meta-regression analysis in recently incarcerated men and women.
        Addiction. 2017; 112: 1725-1739
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        • Clarke J.
        Health care or pregnant women in U.S. state prisons.
        Journal of Health Care for the Poor and Underserved. 2012; 23: 557-559
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        • Palmer M.
        • McGrane C.
        Where does your state stand on shackling of pregnant incarcerated women?.
        Nursing for Women's Health. 2018; 22: 17-23https://doi.org/10.1016/j.nwh.2017.12.005
        • Glaze L.E.
        • Maruschak L.M.
        Parents in prison and their minor children.
        (Retrieved from)
        • Goshin L.S.
        • Arditti J.A.
        • Dallaire D.H.
        • Shlafer R.J.
        • Hollihan A.
        An international human rights perspective on maternal criminal justice involvement in the United States.
        Psychology, Public Policy, and Law. 2017; 23: 53-67
        • Grella C.E.
        • Lovinger K.
        • Warda U.
        Relationships among trauma exposure, familial characteristics, and PTSD: A case control study of women in prison and in the general population.
        Women & Criminal Justice. 2013; 23: 63-79
        • Guthrie B.
        Toward a gender-responsive restorative correctional health care model.
        Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2011; 40: 497-505
        • International Human Rights Clinic
        The shackling of incarcerated pregnant women: A human rights violation committed regularly in the United States.
        (Retrieved from)
        • Kelsey C.M.
        • Medel N.
        • Mullins C.
        • Dallaire D.
        • Forestell C.
        An examination of care practices of pregnant women incarcerated in jail facilities in the United States.
        Maternal and Child Health Journal. 2017; 21: 1260-1266
        • Maruschak L.M.
        • Berzofsky M.
        Medical problems of state and federal prisoners and jail inmates, 2011–2012.
        (Retrieved from)
        • National Resource Center on Justice Involved Women
        Fact sheet on justice involved women in 2016.
        (Retrieved from)
        • Rabuy B.
        • Kopf D.
        Prisons of poverty: Uncovering the pre-incarceration incomes of the imprisoned.
        (Retrieved from)
        • Shlafer R.J.
        • Davis L.
        • Hindt L.A.
        • Goshin L.S.
        • Gerrity E.
        Intention and initiation of breastfeeding among women who are incarcerated.
        Nursing for Women's Health. 2018; 22: 64-78
        • Sufrin C.
        Pregnancy and postpartum care in correctional settings.
        (Retrieved from)
        • Sufrin C.
        • Kolbi-Molinas A.
        • Roth R.
        Reproductive justice, health disparities and incarcerated women in the United States.
        Perspectives on Sexual and Reproductive Health. 2015; 47: 213-219https://doi.org/10.1363/47e3115
        • Swavola E.
        • Riley K.
        • Subramanian R.
        Overlooked: Women and jails in the era of reform.
        (Retrieved from)
        • Walmsley R.
        World female imprisonment list, third edition, Women and girls in penal institutions, including pre-trial detainees/remand prisoners.