Pregnancy in incarcerated women: need for national legislation to standardize care

Mental health of incarcerated pregnant women

Incarcerated women are particularly at risk for problems with mental health, with nearly two thirds reporting a history of mental health problems [9, 10]. Although women may have improved access to behavioral health treatment while incarcerated as compared to their level of access prior to incarceration, this is due to their having received little to no treatment for mental illness in their communities prior to incarceration [11]. With pregnancy, women are particularly vulnerable to mental health problems and with the added stress of incarceration, their mental health status may be further compromised.

Mental health screening in the prison before, during, and after pregnancy allows for the early detection of mental health issues, the worsening of mental health status and its early management. Early intervention improves not only maternal, but also fetal outcomes, such as low birthweight and premature delivery [12]. There also have been associations of adverse birth outcomes with maternal anxiety. After delivery, there is forced separation of child from mother, further maternal stress occurs, creating a high-stress environment conducive to mental trauma.

Physical/sexual trauma

Among female inmates, trauma, be it sexual, physical or both, is often a shared experience. A history of sexual or physical trauma may contribute to a high risk-pregnancy or pregnancy related complications, and providing therapeutic interventions for these individuals may positively impact their and their child’s health [13]. A trauma-informed approach by the prison health care team can reduce this negative impact on mental health. For instance, in the case of a pregnant patient with a history of sexual abuse, pelvic and breast exams may be traumatic and have to be done in a way that takes this issue into consideration. Physical exposure of the genitalia during childbirth also can cause traumatization in previously abused women and in some C-section may be the best option.Those who have PTSD may need to have special birthing accommodations as PTSD symptoms can be triggered by a high stress birth [14].

Opioid abuse/treatment

Up to 90% of the female prison population, inclusive of pregnant women, report drug addiction problems [14]. Currently, Medication-assisted treatment (MAT) is the treatment strategy for pregnant women with Opioid Use Disorder (OUD) [15] which correctional facilities should be legislated with the resources to provide. In the case of opioid misuse, a multifaceted approach incorporates many avenues of treatment and support, including cognitive behavioral therapy, support groups, MAT, and close monitoring for progress. Such programs in the women’s prison would not only benefit the mother, but also the newborn. In order to prevent withdrawal symptoms, newly incarcerated pregnant women should immediately be screened for substance abuse so there is no delay in their treatment. MAT medications, including methadone, offer many benefits to the pregnant mother with OUD. This treatment has been associated with decreased levels of drug use post-release, while withdrawal associated with discontinuation of opioid use without MAT is associated with a higher risk of relapse and later overdose post-release [16]. MAT is not offered by most correctional facilities and should be a part of the standard care in correctional facilities.

Peeler and Fiscella [17] describe several options that are currently used by jails and prisons to treat pregnant women with Opioid Use Disorder (OUD). The first option is to provide treatment for the pregnant incarcerated woman at a community Opioid Treatment Program (OTP) or hospital. However, daily transport might pose limitations regarding this option. The second is to partner with community OTP to provide in-house treatment within the correctional facility. An essential part of this option is the strict monitoring and documentation of dose transport, requiring all unused medication to be returned to the medical facility for further documentation. The third utilizes prescriptions from correctional clinicians holding buprenorphine licenses. Any inmates requiring this medication can obtain it through such prescriptions as recommended by the clinician. A fourth is for the correctional facility to obtain a facility license to have a unit operating as an OTP. Such a facility license would allow inmates to have the option of being prescribed methadone or buprenorphine. The last is unlocked if the health care services unit within the jail or prison obtains the necessary state and federal licenses in order to receive hospital level exceptions regarding the use of these MAT medications for treatment of OUD or the treatment of other health conditions. Each of these options present their own sets of benefits and drawbacks, however all result in the increased availability of treatment options for incarcerated women with OUD.

Diet and nutrition

Regarding nutrition, there are currently no federal regulations setting a national standard for inmate nutrition. As well, in many states, correctional facilities do not have strict minimum standards regarding appropriate prenatal nutrition and supplements for pregnant inmates. A maternal diet inadequate in folic acid can lead to neural tube defects in the child, along with other complications such as low birth weight and premature birth [18]. In order to protect the unborn child from developmental risks, a diet supplemented with necessary vitamins and minerals should be mandated for pregnant prisoners. Data have shown that incarcerated pregnant women are more likely to have babies of lower birth weight than control populations [19]. Furthermore, to ensure an adequate diet, women should have access to interventions that combat excessive nausea along with access to fluids.

While healthy diets are an important part of prenatal care, it is often costly for correctional facilities to provide this. Thus, especially when faced with poor funding, dietary provisions provided to the pregnant inmates may be inadequate [20]. Shlafer and Stang outline six recommendations to improve the nutritional intake of pregnant inmates in correctional facilities [21]. These are: 1) take a pregnancy test upon intake, which is not the standard process in all prisons. Early identification of pregnancy can lead to earlier administration of prenatal care and supplements, minimizing any harm posed to the unborn child; 2) prescribe prenatal vitamins to those inmates who are diagnosed as pregnant [22]; 3) follow the nutritional guidelines set forth by the Academy of Nutrition and Dietetics for a healthy pregnancy. Adequate folic acid, iron, calcium, zinc, and Vitamin D should be a template of care for all incarcerated individuals who are pregnant; 4) provide additional food to pregnant inmates: 5) ensure regular access to fluids, especially water. Pregnant women require up to three liters of fluid a day, and dehydration during pregnancy can lead to increased risk of preterm labor and contractions [23]; 6) provide pregnant inmates with educational resources regarding nutrition and the importance of a balanced diet during pregnancy. This will assist with inmate compliance, and allow the pregnant inmate to understand the importance of her supplemented diet.

Shackling

In 2008, the Federal Bureau of Prisons ended routine shackling in federal correctional facilities, and state legislation also has begun to enact policies to end this practice. In the states of California, Colorado, Illinois, New Mexico, New York, Pennsylvania, Texas, Vermont, Washington, and West Virginia, pregnant women are prohibited from being shackled [24]. Currently, 24 states have policies that limit the use of restraints on pregnant women in correctional facilities, and of these states, 18 include room for broad exceptions to this rule [24].

Shackles can limit motility and range of motion, making medical intervention difficult when necessary. During labor, shackling can increase pain [25]. Furthermore, the use of shackles and restraints on pregnant inmates can increase the risk of falls along with the risk embolic conditions that can introduce risks into the pregnancy [26]. The use of restraints can also worsen pre-existing mental health conditions such as depression or post-traumatic stress disorder [27].

Internationally, the shackling of pregnant incarcerated women is a practice that violates several international human rights laws. The Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment and the International Covenant on Civil and Political Rights are both treaties ratified by the United States that are violated by the United States’ tolerance of shackling pregnant inmates [28].

Mother-Baby Units

While only four nations separate incarcerated mothers from newborns (United States, Bahamas, Liberia, and Suriname), many other countries offer a system known as Mother-Baby Units (MBU). Data note that it is in the child’s best interest to not be separated from the mother after birth. MBU are offered by a quarter of the 50 US states. The National Women’s Law center noted that only three of the 13 existing prison nursery programs offered treatment and services for both the mother and child [29]. Within the existing American programs, mothers meeting specific criteria can cohabitate with their newborns up to 12 or 18 months [29]. MBUs should have the goal of promoting healthy child-rearing practices with a focus on parental education for all incarcerated mothers. Lessons and counseling regarding lactation, parenting, anger management, and substance use are especially important to these mothers. Parental education is key in this vulnerable time, and these units can facilitate the formation of a healthy mother-child bond. Furthermore, the implementation of such a project can actually decrease the reoffending rate. After participation in an MBU, the states of New York and Washington saw a decrease in reoffending rates. Furthermore, Nebraska observed a decrease in 10-year recidivism rates [30]. A study later found that mothers who participated in MBUs were less likely to return to prison when compared to mothers who were separated from their newborns shortly after birth [31]. While many states do not currently participate in an MBU, the implementation of this practice should be universal for it provides benefits to not only maternal and fetal health, but also provides a social and financial benefit to the state through lower readmittance rates.

Pregnancy outcomes

Clearly, incarcerated pregnant women have several risk factors, that may include drug use, alcohol use, and smoking [32]. However, when comparing the incarcerated population with a similarly disadvantaged but not incarcerated population, a meta-analysis found that incarceration may improve outcomes in pregnancy [19]. This appears to be due to separation from environmental risk factors such as access to drugs, alcohol, and other high-risk behaviors. Furthermore, incarceration provides shelter, food, and other necessities, which some inmates might otherwise not be guaranteed outside of incarceration. Although women in a correctional facility have access to care, the unique deleterious effects of incarceration on pregnancy outcomes must be actively addressed.