Hospital Restrictions Experienced by Women who Give Birth While Incarcerated

Abstract

Women who are incarcerated give birth in community hospitals, but under conditions that differ dramatically from women who present from community settings. However, systematic examinations of the full breadth of possible restrictions imposed upon incarcerated women hospitalized for childbirth and recovery are lacking, limiting knowledge on how carceral status affects hospital practices for this population. To bridge this gap, we identified the electronic medical records of 180 women who gave birth in a community-based hospital while in custody of a state prison between June 2014 and July 2022 and extracted textual data related to care restrictions imposed during hospitalization for childbirth and recovery. We found that 45 records contained documentation of one or more atypical restrictions. Specific restrictions documented related to mother-infant contact (n=14), shackling (n=12), breastfeeding (n=10), infant-caregiver visitation (n=8), infant pictures (n=6), and health service access/involvement (n=3). Implications of restrictions are discussed.

From 1980 to 2019, women’s incarceration in the United States (U.S.) grew approximately 550%, a rate twice as high as the rate of growth in men’s incarceration during the same period.^1,2 Black and Latina women are disproportionately incarcerated, with rates that are 2.3 and 1.5 higher than those of White women, respectively.⁷ In comparison with men, women are more likely to be incarcerated for non-violent drug or property offenses.^2,3 They are also more likely to have been experiencing societal disadvantages such as unemployment prior to incarceration⁴ and to have lower levels of education.^5,6 Many have also experienced pregnancy. Of the women who enter prisons, 75% are of childbearing age, 61% are mothers, and nearly 4% are pregnant,^1,8 resulting in approximately 900 births in custody per year.⁸

Although there are no broadly enforced carceral standards of care or guidelines for perinatal women who are incarcerated and treatment varies significantly by facility,⁹ the general conditions of confinement within prisons lead to pregnancy and childbirth experiences that differ considerably from those of women in the community. Indeed, past research has shown that women who give birth while in prison are subjected to various conditions and restrictions throughout labor, delivery, and postpartum recovery due to their custodial status.¹⁰ For example, women are oft en forced to labor and give birth without someone to provide physical and/or emotional support,^11,12 but in the presence of a prison officer stationed inside the room.^10,13 In states without mother-infant nursery programs, which are not common, women are generally separated from their newborns within 24 to 48 hours after childbirth.¹⁴

Women may also be shackled by handcuff s, leg irons, and/or waist chains during transport to prenatal care appointments and during childbirth.^10,13,* Shackling continues to occur despite the passage of anti-shackling laws in some states and position statements from national organizations such as the American College of Obstetricians and Gynecologists (ACOG) and National Commission on Correctional Health Care (NCCHC). These statements assert that physical restraints should not be used during pregnancy, labor, delivery and up to six weeks postpartum. Most women who are incarcerated during pregnancy are nonviolent and pose a low security or flight risk, especially during labor and postpartum recovery.^16,17 Goshin and colleagues found that nearly 83% of 690 nurses who cared for pregnant and postpartum women who gave birth while incarcerated reported that their patients were shackled some or all of the time during hospitalization.¹⁸ In a national review of obstetric health care policies in 22 prisons and six jails, Kramer et al. found that half of the prisons’ policies allowed for restraint use during transportation to medical appointments and hospital stays; 59% of the prisons were in states with active anti-shackling legislation.

Although the body of knowledge related to the care and treatment provided to women who give birth in prison custody is growing, investigation into conditions of confinement during childbirth in community hospitals has been largely limited to qualitative investigation of shackling and restrictions on labor and birth support.¹⁹ To the authors’ knowledge, no study has systematically examined the full breadth of possible hospital-based restrictions imposed upon women who give birth while incarcerated—a gap that we aimed to address in this novel, open-ended investigation of the impact of incarceration on women’s childbirth experiences, which made use of health care provider documentation in hospital records.

Methods

We used purposive sampling to identify the electronic medical records (EMRs) of 180 women who gave birth in a hospital medical center in a mid-Southern state between June 2014 and July 2022 while incarcerated in a state prison. The identification was based on searchable record indicator variables that had been developed in past research using the same EMR.^20,21 Indicator variables included 1) female gender, 2) the presence of a “prisoner” flag or diagnosis code indicating “imprisonment or other incarceration” within the chart, 3) an address indicative of incarceration, 4) prenatal care receipt in the clinic note associated with the prison, and 5) presence of clinical notes specific to labor and delivery. The EMRs were from the single hospital to which all women in the state prison system were transferred for labor and delivery services, providing the opportunity to examine care for the entire population of women who gave birth while incarcerated in state prison custody during the study period.

We reviewed obstetric provider, nursing, and staff clinical notes within identified records to extract textual data related to the restrictions incarcerated women experienced throughout the labor, delivery, and postpartum recovery period. Restrictions were defined as any condition or practice related to carceral status that differed from 1) common obstetric practices for non-incarcerated women and 2) standard prison policy in the study state (i.e., no phone access while hospitalized, constant guard supervision, no labor/childbirth support or visitation). The first author independently coded the text excerpts extracted from each chart. The first and the second authors, the latter of whom is an experienced qualitative researcher, engaged in an iterative peer debriefing process to discuss interpretations and codes.²² We used a combination of descriptive statistics and qualitative content analysis to describe results.

The study was reviewed by the institutional review board at University of Arkansas for Medical Sciences; the project, which was initiated to provide data for quality improvement efforts, was designated as not human subjects research.

Results

The sociodemographic characteristics of the study population are presented in Table 1. The mean age of women at the time of childbirth was 28.43 years and ranged from 18–43 years. They were primarily non-Latina White, consistent with the prison demographic at the time of the study. Nearly three quarters had at least a high school diploma, GED equivalent, higher education credit, or degree.

Table 1.

CHARACTERISTICS OF STUDY POPULATION (N = 180)

Variable	n (%)
Age at Delivery (years ± SD)	28.43 ± 5.06
Race and Ethnicity
Black, non-Hispanic	30 (16.7%)
Hispanic	5 (2.8%)
White, non-Hispanic	145 (80.5%)
Education
Less than high school diploma	40 (22.2%)
HS diploma or GED	81 (45.0%)
Some college credit; No degree	45 (25.0%)
College/University degree	5 (2.8%)
Unknown or missing	9 (5.0%)

Of the 180 EMRs reviewed, 25% (n=45) documented one or more atypical restrictions (i.e., restrictions beyond constant guard supervision, no phone access, no birthing support, and no visitation, which were standard prison policy). Documented restrictions related to mother-infant contact (n=14), shackling (n=12), breastfeeding (n=10), infant-caregiver visitation (n=8), infant pictures (n=5), and health service access/involvement (n=3). A summary of documented restrictions appears in Table 2, with greater detail and examples of associated chart notes described below.

Table 2.

HOSPITAL CARE RESTRICTIONS (N = 45 CHARTS)^A

Restriction Category	n (%)
Mother-Infant Contact
Mother-infant dyad prohibited from couplet care; infant transferred to NICU	14 (31.1%)
Mother could visit NICU; no restrictions on physical contact with infant noted	5 (11.1%)
Unspecified if mother could visit NICU and/or if physical contact with infant was permitted	3 (6.7%)
Mother could visit NICU; no physical contact with infant allowed	3 (6.7%)
Mother may not visit NICU; no physical contact with infant allowed	3 (6.7%)
Shackling During Hospitalization
Mother was documented to have been shackled during hospitalization	12 (27%)
Breastfeeding
Mother prevented from breastfeeding or providing breastmilk	10 (22.2%)
Stated rationale was infant going into Department of Humans Service (DHS) custody	3 (6.7%)
Stated rationale was previous charges	2 (4.4%)
Stated rationale was non-enrollment in prison lactation program	1 (2.2%)
Stated rationale was (a nonexistent) state law against feeding from the breast	1 (2.2%)
No rationale was documented	3 (6.7%)
Infant-Caregiver Visitation
Infant prevented from visitation by approved caregiver	8 (17.8%)
Restricted visitation prior to mother’s discharge	5 (11.1%)
Restricted visitation prior to infant’s discharge	2 (4.4%)
Infant visitation is only permitted in ‘end of life’ circumstance	1 (2.2%)
Mother-Infant and/or Infant Picture Limitations
Number and/or type of pictures allowed was limited	6 (13.3%)
Limited Involvement in Broader Health and Support Services
Mother denied information about or decision-making capacity for infant	2 (4.4%)
Mother denied pastoral care visit	1 (2.2%)

Note:

^aOnly atypical restrictions were coded. Constant guard supervision, no phone access, no birthing support, and no visitation were standard prison policy and would have applied to all women in this study.

Mother-infant contact.

Of the 45 records with documented restrictions, 14 records noted restrictions related to mother-infant contact. In all these cases, infants were not permitted to room in with their mothers and were transferred to the neonatal intensive care unit (NICU) for their hospital stay. Five of these records noted that mothers were allowed to visit their infants in the NICU with no documented limitations on physical contact. Examples of related documentation included, “Spoke with [DOC staff] who reports baby will be going into DHS custody at discharge. Worker reports baby cannot room in with patient, but mom can visit baby in the nursery.”

Three records noted that mothers could not touch or hold their newborns but could visit them in the NICU when supervised. Notes documented statements such as, “infant will be transferred to NICU and patient is allowed to visit infant in the NICU but not hold her.” Another three records documented that mothers were to have no physical contact with their infant, but provided no additional information to ascertain if NICU visitation was allowed. For example, chart notes from the record of a mother who chose adoption for her infant noted that DOC staff communicated the “baby will be placed for adoption. Baby may not be in room with patient after delivery and patient may not touch baby.”

The remaining three charts noted that these mothers were to have no physical contact and no NICU visitation with their infant due to prior convictions, prior DHS involvement, or other noted concerns. For example, “Mom is currently incarcerated and will not have access to infant during this hospital stay, so infant was admitted to special care nursery due to social issues.” In another example, one mother was initially given permission by hospital staff to visit her infant in the nursey. Notes stated, “patient requesting to visit baby in the NICU … per DHS the patient can visit the baby she just can’t have the baby room in with her. However, after hospital staff consulted with DOC staff, visitation permissions were revoked altogether due to history of DHS involvement.

Overall, in many cases it was not clear how the decision to implement the visitation and physical contact restrictions was made and by whom. Notably, several of these cases involved infants who would enter DHS custody at discharge. However, for most patients, little to no additional detail was documented, no rationale was provided, or the rationale provided was ambiguous.

Shackling during hospitalization.

Shackling was noted in 12 of the 45 medical records with documented restrictions. All chart notes in these 12 records specified that shackling occurred but provided no rationale or justification of need. Notes from multiple records included brief statements such as, “guard at bedside as patient is incarcerated. Handcuffs around both ankles”, “Guard present. Right ankle cuffed to bed”, “guard at bedside & patient is loosely shackled to bed by left ankle”, and “Level of activity: bed only at this time—shackled to bed.” The record of one patient, who was two days postpartum following a cesarean, stated, “The patient is not ambulating well due to being cuffed to the bed at her Rt ankle. The Guard has been allowing her to ambulate around the unit x2 today.”

Breastfeeding.

Ten of the 45 medical records with documented restrictions noted restrictions that prevented breastfeeding or providing breastmilk. In five of these cases, the rationale provided for such restrictions involved the infant being placed in DHS custody (n = 3) or the mother’s previous charges (n = 2). In these charts, nursing staff noted, “Since the baby will be going into DHS custody, MOB is not allowed to breastfeed while in the hospital”, “cannot breastfeed due to [infant] going into DHS custody”, and “MOB cannot breastfeed or room in with the baby due to previous charges.”

In one record, chart notes stated that mothers who were not enrolled in the prison’s lactation program cannot pump breastmilk or breastfeed their infants while hospitalized. In this case, hospital staff advocated pumping breastmilk for a critically ill infant. Although the DOC staff reluctantly allowed pumping during the hospital stay, the record notes stated, “[DOC staff] says mother is not in the pumping program and still will not be given permission to pump” upon return to prison. Another record (incorrectly) justified a restriction on breastfeeding by stating that, “It is state law that couplet cannot breastfeed, but she is allowed to pump so will initiate pumping on.”

The three remaining records provided no rationale for the breastfeeding restriction, but merely offered vague statements such as, “[DOC staff] reported that MOB can room in and visit with [infant name] but cannot breast feed.” Although not explicitly documented as a rationale for preventing breastfeeding, two of these three records involved infants who would be placed in DHS custody.

Infant-caregiver visitation.

Eight of the 45 medical records stated that the infant’s approved caregiver was not allowed to call about and/or visit the infant during hospitalization. In five of these cases, hospital (n = 4) and prison staff (n = 1) communicated that the infant’s mother must be discharged back to prison before the caregiver was allowed to visit the infant. These records included statements such as, “[Caregiver] was notified and made aware that cannot visit the baby as long as the mother is here … can visit when the mother is charged and sent back to facility” or “[Caregiver] may visit NICU and call to check on baby only after mother is discharged.”

In two cases, hospital staff called to notify appointed caregivers of the infant’s birth; however, staff also informed the caregivers that they could not call about or visit the infant while he or she was hospitalized. Appointed caregivers were told they should only arrive to the hospital after being notified that the infant is ready for discharge. One record documented, “The temporary guardian has been notified and instructed her she will be notified in the am when to arrive and receive the baby at discharge. The guardian was informed she cannot call or visit.” The other record stated, “[Hospital staff] informed [caregiver] that baby has been born but will not be able to come to hospital until baby is ready for discharge.” In these cases, no additional context was provided and it was not clear why such restrictions were imposed given the appointed caregiver’s custody.

In one case, prison staff did approve visitors but only due to an end-of-life circumstance. In this case, the infant’s maternal grandmother and aunt were given approval to visit the infant while the infant was still hospitalized; however, prison staff denied the father’s request to visit the infant because he was denied approval to visit the infant’s mother through the prison. Chart notes documented, “[Hospital staff] called [prison staff] to see if she spoke with her supervisor and her supervisor said father of baby cannot visit infant because he is not an approved visitor on [mother’s] visitation list. [Prison staff] said mother of baby’s mother and sister can visit “if end of life” but not father of baby.”

Infant pictures.

Six of the 45 records referenced prison policy about the number and kinds of pictures that can be provided to mothers returning to prison. Our team did not have a copy of this policy, but charts indicated a pattern suggesting that policy adherence and/or interpretation was inconsistent across patients. Some mothers were noted to have received an unlimited number of pictures; however, five were only given between two and three pictures and one mother received none. For those who did receive pictures, some received only pictures of their infant, while others were given the option to take a picture with their infant, which was noted to be prohibited per the policy in some records. For example, one record stated, “patient inquired about photos of baby after her delivery and guard indicated that patient would not be allowed to have photos.” Records of the mothers who received pictures included statements such as, “[hospital staff] will take pictures of infant and allow MOB to pick two pictures to take back to prison with her,” “… MOB can receive 2 pictures of baby, but cannot be in pictures,” and “guard states that MOB is allowed to take 3 pictures with her.”

Health service access/involvement.

In three of the 45 records, patients were noted to be restricted from involvement in services that are provided to non-incarcerated birthing patients. For example, one record documented that a mother who requested a pastoral care visit had been denied it. Notes from the pastoral care team documented, “Went to visit [patient] and was interrupted by her correctional officer by stating she’s not allowed visitors. Explained we too are a state-run facility and each and every patient is entitled to a pastoral visit upon request … The officer then stated I was to check with her supervisor about this. She was told to not allow any visitors at all.”

The other two medical records noted mothers were denied health-related information or decision-making for their infant. One record logged the transfer of an infant to a NICU at a nearby children’s hospital. Nursing staff documented, “patient wants to call [NICU], however, I was informed by guard that patient is not allowed to use phone per supervisor.” In the other record, notes documented the need for caregiver consent to perform a procedure. At the time, the infant had no approved caregiver, nor was DHS in the process of obtaining custody. Notes indicated, “[DOC staff] states that DHS will be giving consent on the baby and MOB is not allowed to … attempted to explain DHS has not placed a hold on baby yet.” Ultimately, the infant’s mother was denied the ability to provide consent for the procedure.

Discussion

Our novel investigation of obstetric care restrictions experienced by women who gave birth while incarcerated revealed an array of atypical restrictions. Specifically, provider documentation revealed that a quarter of women experienced restrictions that prevented or augmented typical practices regarding mother-infant contact, infant-caregiver visitation, and provision of breastmilk; resulted in shackling, in some cases even after the passage of a state anti-shackling law; or limited involvement in broader health or supportive services. Our findings regarding limiting or preventing mother-infant contact and breastfeeding confirm anecdotal reports of practitioners;²³ however, other restrictions such as limitations on infant-caregiver visitation and on mother’s receipt of infant pictures upon discharge have not to the authors’ knowledge been reported in previous studies.

It was notable that many records lacked documentation of the rationale for restrictions that were imposed, and very few clearly identified the agency or individual who ordered the restriction. In the rare instances where the individual ordering the restriction was identified, we noted that the restrictions were imposed based on dubious authority. For example, one chart contained documentation stating that prison staff had ordered that an infant born to an incarcerated mother may not receive a visit by a designated caregiver, even though the prison never assumes custody of the infant. Further, many of the restrictions also appeared to be arbitrarily deployed—in some cases even contrary to the policies and/or laws known to the research team to be in place (e.g., anti-shackling legislation that was enacted in the state in 2019). The most arbitrary restriction involved significant variability in practices regarding how many and what kind of newborn pictures could be provided to mothers as a keepsake upon prison discharge. Although some restrictions in our sample were speculated to be implemented in the interest of safety, others seemed more punitive in nature, such as denying mothers pictures of their newborn upon discharge, which would likely have no impact on the safety of the public, hospital, or prison staff.

Our findings are troubling given that many of the restrictions imposed have negative health consequences for affected mothers and/or deprive them the potential to benefit from health-promoting care practices in which they would have otherwise engaged. For example, skin-to-skin contact and breastfeeding reduce risk of postpartum depression, anxiety, self-harm, suicidal ideation,^7,24 and adverse obstetric outcomes (e.g., hemorrhage) when initiated in the hour following childbirth;²⁵ incarcerated women who were deprived of the ability to engage in skin-to-skin contact and/or breastfeed when desired were deprived of these health benefits.

Importantly, although we have framed our work as investigating restrictions on incarcerated mothers, the restrictions revealed by this study are in many cases also restrictions on newborn infants—who are not incarcerated, yet whose care in their first hours of life are dramatically and negatively affected by the restrictions. The immediate forced removal and separation of the mother and newborn, prevention of breastfeeding and care, and shackling is contradictory to the widely accepted standard of care for non-incarcerated women that encourages routine, unlimited skin-to-skin contact between medically stable mother-infant dyads²⁶ and is inconsistent with health care standards encouraged for prisons.^16,17 These practices can negatively affect fetal health, birth outcomes, and maternal-infant psychological well-being and attachment, particularly the practices that resulted in prolonged separation or prevented contact for nonmedical indications.^27–29 Moreover, these practices deprive infants of known positive benefits of maternal care that would be afforded to infants born to non-incarcerated mothers. For example, skin-to-skin contact following birth optimizes infant psychophysiological functioning, including by supporting thermoregulation, glucose stability, and reductions in infant stress.^26,30,31 Initiation of breastfeeding during hospitalization ensures that newborns receive colostrum, a nutrient-rich substance produced immediately before or after childbirth that promotes immune system development and reduces risk of infectious disease.³²

Limitations.

First, we must note that our findings report only information documented and gathered from clinician notes within the EMR at the birthing hospital. It is possible that the other women who gave birth in custody in the sample experienced the same or similar restrictions that were not documented with the patient record. Second, we must note that some childbirths in the sample occurred during the height of the COVID-19 pandemic. Although COVID policies were never documented as rationale for restrictions, we can only speculate about the degree to which restrictions were influenced by hospital-based procedures during the pandemic. Moreover, we do not know the criminal-legal or behavioral histories of specific women included within our sample. However, a study by Zielinski et al., 2024, examined the criminal-legal histories of women who were incarcerated while pregnant and found that most pregnant women were incarcerated for drug-related offenses. While it is possible that some restrictions were implemented due to a valid safety concern, it should be noted that violent and child abuse-related offenses, as well as violent or aggressive disciplinary infractions during incarceration were rare. Generalizability is also a limitation. Our sample is exclusive to women incarcerated in a single prison in a mid-Southern state, and our work should be replicated in other states and health systems to examine similarities and differences and/or additional restrictions that our study did not uncover.

Recommendations

There is an urgent need to develop a nationally recognized, evidence-based standard of care specific to pregnant and postpartum women who are incarcerated, as well as guidelines to govern care provided in community-based hospitals used by the carceral system for obstetric care. We particularly note the need for national standards regarding practices such as skin-t o-skin contact and provision of breastmilk following childbirth. Currently, there is no national standard or guideline related to physical contact between incarcerated women and their newborns while hospitalized,²³ regardless of placement status.

In the absence of a national standard of care, hospital administrators could take action to protect incarcerated women and their infants by creating a tailored patient of bill of rights that adheres to the existing clinical guidelines and recommendations^16,17,34,35 for women who give birth in carceral custody and their infants (see Box 1 for considerations). We advocate for infants to be entitled in these policies to unrestricted access to their mother while hospitalized unless there is clear and compelling evidence that the infant’s safety would be imminently at risk. The threshold of imminent and clear risk is appropriate given that women who give birth while incarcerated are under continuous direct supervision by prison or hospital security staff; this should eliminate risk in all but the most extreme circumstances while ensuring that infants and mothers are not unnecessarily deprived of health-promoting contact. We note that a history of child welfare involvement alone should not be construed as imminent risk of harm, consistent with community standards.

Box 1. CONSIDERATIONS FOR A PATIENT BILL OF RIGHTS FOR PEOPLE WHO GIVE BIRTH WHILE INCARCERATED.

Policy Category and Example Considerations	Recommendations for Policymakers
General Expectation Setting  • Describe what mother can expect from her hospital stay (e.g., typical length of stay, typical policies/procedures, phone access, protections against shackling/restraints)  • Describe how carceral staff are involved in mother’s hospital stay (e.g., where stationed, access to health information), including choices mother and/or providers have regarding involvement	Mirror community norms to the greatest extent possible. Consider that more patient rights may need codified in writing compared with patients presenting for care from the community that carceral staff will likely err on the side of restricting rights not explicitly provided for.
General Decision Making  • State that mother has a right to make decisions about her health care  • Describe who has a right to make decisions about infant’s health care, including any transitions that may occur over the course of the hospital stay  • Explain which decisions are within the purview of medical providers versus within the purview of carceral staff or of other agencies or actors (e.g., child protective services, infant’s guardian)	Preserve mothers’ rights to make decisions about their own health care and that of their infant to the greatest extent possible. If mothers’ rights become more limited at a specific point (e.g., once a guardian assumes infant custody), this should be specified. Preserve medical providers’ decision-making authority over that of carceral staff; mirror community norms to the extent possible so that providers are able to offer dignified care and enact as many health-promoting care practices as possible.
General Communication and Information Sharing  • Explain who, if anyone, will be notified when mother is admitted to the hospital and/or if mother experiences a medical emergency  • State who will be notified, and when, regarding infant’s birth  • Explain who has a right to knowledge about mother’s health status and any privacy protections that are standard or are available upon request  • Explain who has a right to knowledge about infant’s health status and any privacy protections that are standard or are available upon request  • Describe how mother can access health records from the hospital stay	Incorporate direct statements that promote empowerment (e.g., that mother has a right to question medical recommendations, to receive information, to make requests even if she is not sure of allowability, to have medical information communicated to her rather than carceral staff). Maximize opportunities for communication with mother’s support network and anyone involved in mother and/or infant’s care, with deference given to mother regarding involvement. Notifications to infant caregivers should be made immediately given caregivers may have to unexpectedly travel long distances and make personal arrangements (e.g., taking off work, for other children) in many circumstances. Make sure that procedures for obtaining records are feasible for incarcerated women.
Mother-Infant Dyad’s Rights  • Cover mother-infant dyad’s rights regarding:   ⚬ Contact (e.g., rooming in, skin-to-skin, NICU visitation when applicable)   ⚬ Direct breastfeeding and/or providing/receiving expressed breastmilk   ⚬ Having photos taken	Mirror community norms. Approach policy through a health and empowerment lens. Restrictions should only be placed if compelling and imminent threat is evident as would be true if mother was not incarcerated. Hospital policy will need to clearly indicate how any decisions about restrictions are made and documented, and who has the authority to make and to revise decisions to empower providers.
Additional Mother’s Rights  • Cover mother’s rights regarding:   ⚬ Personal visitors (before, during, and/or after childbirth)   ⚬ Professional support (e.g., doulas, lactation consultants, pastoral care)   ⚬ Communication with family during hospital stay   ⚬ Communication with infant’s medical providers during and after hospital stay  • Give information for who mother can contact to express concerns about her treatment while hospitalized and have them addressed  • If there is potential for trainees to be involved in mother’s care, state how she can decline involvement	Mirror community norms to the greatest extent possible. Approach policy through a health and empowerment lens. Hospital policy will need to clearly indicate how any decisions about restrictions are made and documented, and who has the authority to make and to revise decisions to empower providers. Ensure that mother has the means to contact an advocate to express concerns about her care and to request remedies. Maximize a mother’s right to privacy, including stationing officers outside of the room—particularly during childbirth.
Infant’s Rights  • Explicitly cover infant’s rights to receive personal visitors, breastmilk, to be touched/held, and to receive all care that an infant born to a parent presenting from the community would receive	Ensure medical staff are aware that the infant is not in the custody of the carceral system and that infant rights should mirror community standards
Infant Caregiver’s Rights  • Cover caregiver(s)’ rights to information, visitation, contact, decisionmaking authority, timely notification regarding childbirth	A separate bill of rights for infant caregivers is warranted to address all needed information and rights thoroughly. As with infant rights, it is important for policy makers to consider that the infant is never under carceral control and as such caregiver rights should not be restricted by mother’s incarceration (e.g., caregiver(s)’ rights to information should be continuous).

Our study also makes clear an urgent need for tailored, mandatory education for those who supervise and/or are involved in the care of women who give birth while incarcerated (e.g., prison officers, hospital care providers, hospital security staff). This need was evident by the remarkable variability in patient care experiences and allowances, including some that seemed to be directly in conflict with state law, incorrectly cited state law or prison policy, and/or were characterized by restrictions imposed on dubious authority. Hospitals must thoroughly consider the rights of their patients and their commitment to a positive care experience for all when crafting these policies. They will likely need to consult with legal experts to distinguish their organizational rights and responsibilities versus any limitations that the prison system truly has a right to impose, so that provider education includes clear guidance regarding where authority lies for health care decisions such as infant contact and breastfeeding.

Conclusions

Women who give birth while incarcerated and their infants are a marginalized population at an increased risk for adverse health outcomes; it is unethical and a violation of constitutional rights to deprive them of obstetric and neonatal care that is on par with community standards.³⁶ However, there is yet to be a federal mandate regarding the provision of obstetric care for incarcerated perinatal women, resulting in varied carceral and hospital policies and procedures related to care and treatment.⁹ Our study and others that have documented women’s experiences giving birth while incarcerated^10–14 clearly indicate that hospitals that serve this population must commit themselves to take deliberate, targeted action that takes into account the intersections of health care and the carceral system to protect mother-infant health and to ensure dignified, equitable health care for all.