The United States has witnessed a staggering 742% increase in the number of incarcerated women since 1980, primarily because of a complex phenomenon involving political, social, racial, and public health dimensions. Many incarcerated women are of childbearing age, are sexually active with men before incarceration, and do not use reliable contraception.1 It is critical to identify and support pregnancy immediately upon entry to improve pregnancy outcomes.
In 2019, Sufrin et al. emphasized the importance of systematic reports on pregnancy data in prison. They published the first prospective study to collect data on pregnancy rates and outcomes in US prisons.1 Their data, collected from 22 state prisons, showed that 4% of women were pregnant upon admission and that 0.3% became pregnant during incarceration pregnancies during a six-month follow-up period.1 Unfortunately, a significant proportion of these incarcerated women experience unfavorable pregnancy outcomes, including miscarriages, preterm births, stillbirths, newborn deaths, and ectopic pregnancies.1
Pregnancy can be associated with many problems, from minor symptoms to life-threatening conditions. Incarceration jeopardizes maternal and fetal health, as pregnant incarcerated persons endure high levels of additional stressors and lower access to health care. Despite this, data on the pregnancies and their outcomes of women in prison remain underreported, resulting in health inequities and maternal health disparities. We highlight the current challenges for pregnant incarcerated persons and offer suggestions regarding humane practices and policies to optimize pregnancy outcomes.
HEALTHY PREGNANCY IN PRISON
Pregnant incarcerated persons are generally predisposed to poor pregnancy outcomes before imprisonment, often related to substance use, mental illness, chronic medical conditions, and lower socioeconomic status.2 Only 38% of US jails perform pregnancy tests upon entry, delaying pregnancy diagnosis. The subsequent delays in access to early prenatal care and emergency services can have significant consequences for both the pregnant mother and her developing fetus.2 Additionally, transportation challenges to health care facilities further delay antenatal counseling, testing, and routine visits.2
Although some pregnancy complications result from health and social issues that were in place before incarceration, the prison environment significantly affects pregnancy outcomes. Pregnant incarcerated persons are often shackled and separated from their newborns, negatively affecting pregnancy outcomes and mother–infant bonding.2 Only 25% of US states provide mother–baby units (MBUs) in prison, and scant information is available on the services offered.2 The inability to provide a supportive parenting environment leads to higher levels of mental health issues, behavioral problems, and risks of recidivism.2 Existing MBUs currently allow children to coreside with their incarcerated mother until the child reaches age 12 or 18 months, regardless of the need for continued child support.2 For most incarcerated mothers, the absence of MBUs leads to the immediate separation of mother and child and may result in the termination of parental rights.2
The continued lack of mandated implementation and regulation of health care standards in prison reflects a systematic failure in ensuring safe pregnancies with improved outcomes.1,2 To appropriately address impediments to optimal pregnancy outcomes in prison, it is imperative to initiate systematic data collection. Although the Pregnant Women in Custody Act mentioned by Sufrin et al. is yet to be confirmed, the First Step Act was recently enacted, which prohibits shackling. The First Step Act provides some information on pregnancy outcomes in prison.2 This is an encouraging step; however, the act is legally driven and applies only to federal facilities. Similarly, proposed guidelines and recommended minimal standards for the care of incarcerated pregnant women have not been uniformly implemented. An integrated approach to correctional health care between policymakers and health care professionals would be favorable for consistent documentation, reporting, and optimal outcomes.
DURING THE COVID-19 PANDEMIC
The unprecedented COVID-19 pandemic has complicated the consequences for pregnant incarcerated persons. The facts that prisoners have a high prevalence of chronic disease and that the correctional environment is a congregated setting are factors that lead to correctional facilities harboring highly infectious diseases.3 Accurately describing the current COVID-19 mitigation practices, including vaccine availability for pregnant incarcerated persons, is challenging because of the wide variability in testing practices and data reporting across the United States. However, the confinement of incarcerated persons in poorly ventilated and overcrowded closed quarters coupled with limited and strictly controlled testing apparatuses, protective equipment, sanitary supplies, and precautionary guidance counteract the recommended preventive measures and increase the rate of contracting COVID-19.3 As COVID-19 has evolved, protective supplies have been scarce, and knowledge has been unavailable, especially among the incarcerated population. Health literacy tends to generally be lower in the incarcerated population.3 Hence tight control of information in prison may lead to higher rates of misinformation.3
Although the full ramifications of COVID-19 have not been not effectively studied in the incarcerated pregnant population, the physiological changes of pregnancy place pregnant incarcerated persons at higher risks for severe outcomes.4 Symptomatic disease in pregnancy increases the need for invasive mechanical ventilation and carries higher mortality rates.4 Severe disease is disproportionately greater for women of color, who constitute most of the incarcerated women population.4
Chmielewska et al. noted significant disparities in pregnancy outcomes between high-resource and low-resource settings during the COVID-19 pandemic.5 The authors described higher maternal deaths, stillbirths, and ruptured ectopic pregnancies for women in low-resource settings in the general population; however, women in prison may have similar pregnancy outcomes.5
The effects of high incarcerated person turnover—as they are admitted, released, transferred to facilities, or transported to court dates and medical visits—and the interaction of correctional staff with external contacts further stress the correctional system because of the associated increased risk of infection.3 Additionally, higher rates of mental health issues have been noted in the incarcerated population during the pandemic.3
MOVING FORWARD
Having established the current challenges that incarcerated pregnant women face, it is imperative to conduct national research, systematically collect pregnancy data in prison, and revise policies to ensure the safety of pregnant incarcerated persons and their babies.
Early access to antenatal care can be achieved by nationally standardizing pregnancy tests to women of childbearing age upon entry and 2 weeks after admission to prison. Pregnancy tests should also be readily available for incarcerated women beyond the admission period. Early pregnancy diagnosis allows effective pregnancy care and counseling, including termination and adoption.2 This enables incarcerated women to have freedom of choice and control over their pregnancy and its outcome. Once pregnancy and its desirability are established, pregnant incarcerated persons must have access to routine care and educational resources equivalent to those of their nonincarcerated counterparts. Provision of transportation to attend prenatal appointments and telemedicine are essential to protecting incarcerated persons’ rights to health care.2,6
Moreover, it is necessary to modify carceral settings to prevent easy transmission of infectious diseases. Social distancing, proper ventilation, and improved sanitation (including supplying soap, tissue, personal protective equipment, and laundry services) are vital in combating infectious diseases and alleviating the associated poor outcomes.4,6 Offering incarcerated persons COVID-19 testing and vaccinations also reduces the disease burden in prison.4,6
Legislating pregnancy-specific programs, including MBUs and doula programs, has shown beneficiary outcomes for pregnancy in prison.2 These programs aim to improve mother–infant bonding by creating an informative, supportive, and child-friendly environment. They allow incarcerated women to receive parental training, including breastfeeding education, maintain their parental rights, and promote healthy child development.2 The close follow-up of pregnant incarcerated persons by doulas or at MBUs may have a significant role in data collection and the evaluation of pregnancy outcomes.
Applying reforms secures the safety of a predominantly marginalized population and, subsequently, protects community health. Therefore, a collaboration between health care providers, correctional facilities, and policymakers is vital to ensure equal health care for all.
CONFLICTS OF INTEREST
The authors have no conflicts of interest and received no funds to write this editorial.
REFERENCES
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