“I Wish I Could Hold Your Hand”: Inconsistent Interactions Between Pregnant Women and Prison Officers

Abstract

Much of the literature on pregnant women who are incarcerated focuses on perinatal outcomes for infants, access to and quality of medical care, mental health concerns, prison nurseries, and shackling. This research adds a unique contribution by exploring women's interactions with prison officers during pregnancy, labor, and birth. Based on in-depth interviews with 18 pregnant or postpartum women incarcerated at a maximum-security state prison, the findings suggest inconsistent interactions between women and prison officers. Officers served as gatekeepers and/or advocates. Women reported dehumanizing behaviors, yet they also experienced compassion, especially in the delivery room, though limited by prison regulations. The findings have implications for training in trauma-informed care, clear expectations for prison officers, and consideration of doula programs.

Introduction

In response to the dramatic increase in female incarceration, scholars highlight the unique health concerns of incarcerated women as many have high rates of mental health and substance abuse concerns as well as extensive trauma histories (Covington, 2007; Eliason et al., 2004; Fearn & Parker, 2005). Researchers also explore the health effects of incarceration on the family as two thirds of women who are incarcerated are mothers with children under 18 (Enos, 2001; Baldwin, 2015; Sufrin, 2017).

Although 3.8% of women enter prisons pregnant, qualitative scholarly attention to the lived experiences of these women has been somewhat limited (Sufrin et al., 2019). Research often focuses on perinatal outcomes, maternal mental health, prenatal care, nutritional needs, opioid use, and prison nurseries (Bard et al., 2016; Carlson, 1998, 2001, 2009; Ferszt & Clarke, 2012; Hotelling, 2008; Lorenzen & Bracy, 2011; Mertens, 2000; Mukherjee et al., 2014; Shlafer et al., 2017; Tanner, 2010; Williams & Schulte-Day, 2006). This scholarship demonstrates that pregnant women come to prison with increased risks for perinatal and postnatal morbidity and mortality due to histories of abuse, inadequate prenatal care, poor nutrition, substance and tobacco use, mental health issues, socioeconomic status, racism, stress of incarceration, and lack of social support. Bard et al. (2016) found that incarcerated, pregnant women often have improved perinatal outcomes. However, this reflects the dearth of adequate health care for marginalized communities pre- and postincarceration (Baker, 2019). Finally, there is also attention to the human rights violations and negative health effects of shackling pregnant women during labor, transports, and birth (Committee on Health Care, 2011; Doetzer, 2008; National Commission on Correctional Health Care, 2020; National Women's Law Center, 2010; Van Gundy & Baumann-Grau, 2013).

A few scholars explore the interactions of pregnant, incarcerated women with health care providers (Abbott, 2015; Sufrin, 2017). Many women feel guilty and embarrassed that they are pregnant and incarcerated. Judgment from providers can exacerbate feelings of stigma. Sufrin (2017) describes how some health care providers embrace cultural tropes about race, poverty, and motherhood, which affects beliefs about who is deserving of care. While some providers maintain professionalism in front of the women, others express contempt. At the same time, some of these providers also show compassion and connection to the women. Sufrin (2017) speaks to the inherent ambiguities of providing health care in penal institutions.

Scant research has looked at the interactions between pregnant women and prison officers (see Abbott, 2015 and Sufrin, 2017 as exceptions). There is, however, more general research about relationship dynamics between prison officers and incarcerated people. Prison is an “emotional arena” for officers as they must manage their emotions with incarcerated people (Crawley, 2004). Officers must negotiate appropriate distance in light of the inherent intimacy of a total institution (Sufrin, 2017). Prison officers employ discretion and interpretations of rules to navigate this tension (Liebling, 2000). Scholars detail that there are cooperative relationships with officers as incarcerated women are dependent on them due to an “intersection of interests” (Owen, 1998, p. 160) and that “the negotiation process…is the heart of social order in any prison” (Britton, 2003, p. 95). Cooperation can yield information, some security, routine, resources for women, and more work stability for officers. However, relationships are also characterized by inherent conflict due to the nature of the carceral system, power differentials, training, and workplace cultures that construct incarcerated people as the enemy (Britton, 2003; Kauffman, 1988; Owen, 1998). Much of the officers' training does not recognize the role of gender, thus leaving officers less prepared for working in a women's prison especially with regard to pregnancy, labor, and delivery (Abbott, 2015; Britton, 2003; Sufrin, 2017).

This qualitative research in a maximum-security state prison in the United States contributes to the literature on pregnant, incarcerated women by focusing on their lived experiences, an area needing attention (Sufrin et al., 2019). The findings explore the interactions with prison officers from the women's perspectives throughout their pregnancies, labor, and births. Officers can be gatekeepers and advocates for medical care and simultaneously engage in dehumanizing behavior. Yet, many also display compassion and empathy. Officers' interactions with pregnant women reflect the influence of prison rules and norms, how setting affects interactions, general inconsistency, and use of discretion. The implications of this research bring attention to how prisons can incorporate trauma-informed care and to (re)consider the benefits of prison doula programs.

Method

Approval for this research was granted by the Institutional Review Board of DePauw University. The state department of corrections Internal Review Board approved this research. A Certificate of Confidentiality was obtained via the National Institutes of Health to further protect participants.

Setting

The research site is a maximum-security women's prison in a mid-sized city in the Midwest. It houses approximately 600 women, which is approximately 25% of all women incarcerated in the state. Fewer than 200 staff work at the prison, with 125 defined as “custody staff” in 2017. The prison is unique because of its urban location and has some progressive programming such as a prison nursery. Women who are physically or mentally chronically ill, elderly, youthful, high profile, and/or pregnant are sent to this prison because of access to services. Pregnant mothers receive contracted nurse midwifery care on-site and birth in a hospital an hour away. If they have high-risk pregnancies, they see an obstetrician. Shackling is still legal during pregnancy and labor in this state (National Women's Law Center, 2010).

Participants

Eighteen women at the prison were interviewed in 2016 (see Table 1). All participants have been given pseudonyms. Two of the women were pregnant at the time of the interview while the other 16 women were less than three months postpartum. Six of the women participated in the nursery program though two had their babies sent home for illness and violations of nursery rules. Their ages ranged from 20 to 37 years old with an average of 29 years old. Twelve of the women (67%) had been incarcerated before and three had given birth while incarcerated previously. Sentences ranged from six months to 10 years with an average of 58 months.

Table 1.

Demographics of Women (N = 18)

Characteristics		% of sample
Education
Some high school	1	6%
High school	4	22%
GED	4	22%
Some college	9	50%
Family income preincarceration
$0–19,999	8	44%
$20,000–39,999	8	44%
$40,000 and up	2	12%
Race/ethnicity
White	14	78%
African American	3	16%
Latina	1	6%
Sexual identity
Heterosexual	16	88%
Bisexual	2	12%
Relationship status
Married	3	16%
In a relationship	7	39%
Single	7	39%
Divorced	1	6%
Religion
Christianity	14	78%
None	4	22%

Fourteen of the women (78%) were White (see Table 1). Over 80% of incarcerated women in this state are White, thus the participants are reflective of this pattern. The women were predominately poor or working class preincarceration as 88% had a family income below $40,000 a year. Half of the women had taken some college courses. The women were almost all heterosexual and most identified with a Christian faith tradition. The majority (55%) were married or in a relationship at the time of the interview.

Data Collection and Analysis

In-depth interviews were used to assess the lived experience of these women, an approach encouraged for prison research in the 21st century (Reiter, 2014). This methodological approach is most appropriate for understanding their subjective worlds (Charmaz, 2002). Open-ended questions addressed their backgrounds; interactions with health care providers for all pregnancies and births inside and outside the prison; relationship dynamics with family, friends, other incarcerated women and prison staff; decisions about placement for their babies; and coping mechanisms, though this paper is limited to interactions with officers.

All pregnant and postpartum women within three months of giving birth were invited to participate via an invitation sent through prison mail by a prison employee. A response rate is indeterminable due to transfers, releases, and issues with prison mail. All women were told before the start of the interview that the researcher did not work for or report to the DOC and that the data were protected by a NIH certificate of confidentiality. Interviews were conducted in a no-contact room in the visiting area. The author and the participant were allowed to sit together on one side. Interviews lasted on average over two hours with a few taking place over multiple visits. The researcher had been involved in an organization for mothers in the prison, taught a class there, and was known to many of these women, which likely helped establish strong rapport. Nearly all of the women expressed a wide range of emotions including crying, anger, and even joy, dissimilar to research by Williams and Schulte-Day (2006), who reported women as disconnected from their feelings in the open-ended part of their interviews. All interviews were audio recorded and then transcribed.

The data were managed using Excel and Word as a means to structure for analysis (Ose, 2016). This process was inductive due to both limited research on the topic and a feminist methodological commitment to the women's voices. The data were read during the collection process to address new emergent themes in subsequent interviews, which is a standard approach in qualitative research (Strauss & Corbin, 1998). After reaching data saturation, the data were analyzed as a whole and codes were assigned. Codes were continuously collapsed and expanded during the process, which culminated in emergent themes.

Findings

This section details the themes within the mothers' narratives about their interactions with prison officers during their pregnancy, labor, and birth. They described how officers acted as gatekeepers but also as advocates for access to health care at the prison. Some officers did degrade the women, yet many simultaneously exhibited empathy especially while at the hospital. The findings reveal the officers' use of discretion in application of rules, general inconsistency in interactions with the women, and potential for (re)traumatization for a vulnerable population.

Gatekeepers

Pregnant women at this prison have regular prenatal appointments in the infirmary with nurse midwives from the contracted hospital; interim concerns are addressed by infirmary staff and often do not align with bureaucratic procedure for medical care. Thus, officers are often left to determine whether they should allow women to go to the infirmary.

The mothers felt they had to prove that they were in labor in order to get sent to the infirmary. Problematically, recognizing the signs of labor is unlikely a part of job training. Women officers often relied on their own experiences with labor to either acknowledge or deny the onset of labor. Melissa showed her wet underwear to prove her water broke. Haley chose to not flush her mucus plug down the toilet: “So I'm like showing the guard…it seems like nobody believes anything around here, so it was like look, you know, witness.” Another mother was chastised for flushing the mucus plug. Susan, in labor with her seventh child, was also reprimanded for flushing.

And I, when I started gushing blood, I had wiped and flushed the toilet before I called the officer, and she was like, you're not supposed to flush the toilet, you're supposed to let me see that you're bleeding all the blood. So I think they thought I was like, faking it. So I'm just sitting there like bleeding all over myself for an hour waiting to go to the hospital.

A smaller but significant example of gatekeeping is allowing pregnant women to use the bathroom during count, which is against the rules. Similarly, different officers allowed women access to their pregnancy night snack after 9 p.m. Numerous women mentioned that some officers would let them while others refused, often leading to write-ups for the women.

Advocates

Despite officers' more frequent role as gatekeepers, mothers described how some were also advocates for them when in labor on the unit. Haley discussed being told she was not in labor by infirmary staff, but the officer knew she was. “She felt so bad for me because I was walking and having contractions. And finally, she just came in my room with a wheelchair. She's like, I called up there (the infirmary), you're in pain.” Another officer had the laboring mother by the desk and timed her contractions and soothed her.

Officers occasionally advocated for mothers in the hospital. One woman had twins that were in the NICU. There was bureaucratic red tape and miscommunication from the prison on when and how long she could go to the NICU. Several officers tirelessly called the prison to clarify. One officer let her go to the NICU frequently and was subsequently reprimanded by her superiors.

Dehumanizing Behavior

Many women described officers as being frequently rude on the unit, during transports, and even in the delivery room. Expressions of disgust arose in response to the corporeal reality of birth and the lack of privacy afforded the women. Mercy had an enema while at the hospital and the officers could hear her in the bathroom, laughed, and made fun of her. Marie recounted how the officer told her to make sure her backside was covered when she went to the bathroom: “I don't want you to see my butt, trust me, I'm covering as soon as I'm shackled to a bed and my shit's like, in the back, so it's like dehumanizing.” After her cesarean section and upon first going to the bathroom, Susan described the following:

I was trying to pull my pants down…and all of a sudden, pee and blood just goes everywhere…and I couldn't get my pants off because the handcuffs. So I pressed the help button, the nurse had to come in there and help me, and then one of the guards had to come in there and get the handcuffs off, and she's saying like, “Oh, this is fucking nasty, this is so gross”…but I was like, I can't help it.

The laboring mothers commonly described a general lack of privacy and acknowledgment that they were giving birth, an emotional event for many especially while birthing alone. Officers were at times nosy or too chatty or conversely ignored the laboring woman who was often in pain. Justice said, “Yeah, she was really rude. She didn't even want to talk to me! Yeah, you know? So I just had my baby and I can't even conversate, you know?” Women described some officers as gossiping with the officer stationed outside the door, complaining about their work, other officers, and the nurses, as if the laboring woman did not exist. During hard labor, Lydia said, “She just complained the whole time about everything. And all I'm thinking to myself is just like, shut up. And I'm mentally trying to prepare, you know?” The mothers also felt like some officers enjoyed the perks of the hospital. Amanda said, “It is like a vacation for them.” Some controlled the channels on the TV, ordered food, and ate in front of the women who were not allowed to eat while in labor. In sum, the women often felt that they were not recognized or given respect for their interactional desires while laboring, shackled, and without family or friends.

Compassion

While many women did experience dehumanization and a general lack of respect and privacy, most also described officers as “different at the hospital.” In fact, the majority of the women described them as “really nice” during their births and that they got “lucky.” Several women said they were nervous as some of the officers were usually “mean” or “strict.” Lydia recounted, “Yeah, she was horrible on the dorms, but she's worked here for 20-some-odd years, she's not gonna’ play with you…(at the hospital). Like she was amazing!” Amanda cynically attributed the difference in behavior as due to fewer duties when at the hospital: “They're happy they don't have to be there. They just get to kick back and watch TV with me, so they don't really care.” Crystal felt the nature of her charge affected her experience with one officer: “Once she found out that I wasn't in on a dope case, it was a burglary charge, she was nice to me.”

Officers cannot and did not offer labor support to the women, although some tried to offer encouraging words. Marie was so happy to see a particular officer walk in during the final stage of labor that she pushed “one more time because she is so awesome.” Chris said, “The one that asked, told me, I wish I could hold your hand, but she wasn't allowed or whatever. She's the one that said, maybe get the epidural.” This exemplifies the tension between wanting to show physical compassion but not breaking rules. Instead, the officer suggested a medical intervention perhaps as a substitute for labor support.

A few officers did help with the babies despite rules prohibiting this. Susan described her postpartum period.

Ah, she's kind of like a grandma, like she's a little old white lady. They had the bassinet beside the bed, and because of my C-section, I couldn't like, put her all the way down in the bassinet because I had to lift her over…she was like, oh yeah, I'll come get her for you.

This same officer was the first to change Susan's baby's diaper. Jamie also described an officer as “like a little grandma” and “just so super sweet” who helped with the baby and picked him up. “When I needed to write down when he ate, when he was changed, if it was just wet or whatever, she was writing that stuff down.” Marie even said most officers would hold the baby if they could. Finally, a few officers would watch the baby and allow the mothers to sleep.

Discussion

These findings show that pregnant, incarcerated women have inconsistent interactions with prison officers throughout their pregnancies, labor, and delivery that lead to confusion for the women in an already fraught experience. This research contributes to the larger literature about women's health concerns in prisons and, more specifically, to discourse to improve the care for these mothers. Exploring the interactions with officers may be one means to enact change that could help mothers and clarify the role of the officers, benefiting all.

The work of prison officers is draining and emotionally taxing (Trounson & Pfeifer, 2017). Prisons are a “domestic” setting. Rachel noted this, “You do kind of live with ‘em because you are here so long.” As with most domestic settings, there is familiarity, bickering, teasing, and camaraderie (Crawley, 2004). Crawley (2004) discusses a variety of techniques officers use to manage their emotions in this setting. They rely on humor, de-personalization, and detachment, though some find this difficult.

These emotion management techniques must also be understood from a structural and cultural perspective. Prisons are a male-dominated organization and female staff have felt the need to adopt masculine presentation of self to prove their worth (Rader, 2005). Britton (2003) reports that male and female officers prefer working in men's prisons as women are too “excessively emotional.” Some female officers explicitly reject any notion of “mothering” incarcerated women (Britton, 2003). This rejection of an essentialized notion of women as inherently nurturing may be further eschewed when dealing with pregnant and birthing incarcerated women.

Officers served as gatekeepers and advocates to access health care with great discretion. Amanda noted, “It's really hard for a lot of things because the only thing that's consistent is inconsistency.” Inconsistency may reflect officers' vacillation between detachment, empathy, and beliefs about whether the women are worthy of care (Crawley, 2004; Sufrin, 2017). Sufrin (2017) found that officers were hypervigilant about pregnant and laboring mothers due to liability issues. In this research, mothers did not perceive officers as hypervigilant. Most women actually felt they had to prove they were in labor to officers who were not health care providers. Some scholars suggest that withholding or delaying medical care can be a way to humiliate inmates (Fearn & Parker, 2005). Officers who demanded visual proof of blood and/or a mucus plug led women to feel embarrassed and disrespected. Officers should not have to perform the role of gatekeeper to health care for pregnant and laboring women as they are not trained to assess “serious medical need” for this population (Fearn & Parker, 2005).

Some officers did exhibit compassion and empathy, especially at the hospital, though limited by prison rules. Showing some empathy may be a technique to acknowledge the laboring and birthing woman yet maintain emotional detachment. Although many officers were described as “nice” at the hospital, they generally did not acknowledge that the mother was in pain, alone, afraid, and grieving that their baby will be taken away if they were not a part of the nursery program. Haley elaborated, “You know, and like, especially not having family or her dad there, just someone to reassure me that it's going to be okay. Because you know, the guard, they just sits back.” In short, officers were not nor should they be a substitute for labor support.

Despite some displays of compassion, few officers violated rules about shackling. Shackling is the penultimate symbol of dehumanization and penal harm medicine in addition to the myriad negative physical and emotional health consequences (Sufrin, 2017). Shackling is not recommended and denounced by all major health organizations including the National Commission on Correctional Health Care. As these women were shackled during labor and after birth, the additional instances of shaming and verbal abuse heightened women's feelings of humiliation and anger. Dehumanizing comments by officers may help officers detach and depersonalize the birthing woman (Crawley, 2004). The officers may also have a more custodial approach to their work and/or have experienced trauma in their own lives that leads to detachment (Freeman, 2003; Miller & Najavits, 2012).

The consequences of various types of dehumanization during labor and birth can be significant. Incarcerated women have high rates of experiences with various types of trauma including physical, emotional, and sexual abuse as well as mental health issues (Covington, 2007; Kubiak et al., 2017; Miller & Najavits, 2012; Mukherjee et al., 2014). While most pregnant women experience high rates of stress in prison, those with trauma histories are especially at risk for physiological and psychological consequences for their own health and their infants (Abbott, 2015; Benedict, 2014; Marshall, 2010). Some scholars suggest that justice-involved women may be (re)traumatized by lack of privacy and shaming especially during birth (Dirks, 2004; Elson & Bullock, 2012). Future research should evaluate experiences with (re)traumatization among pregnant, incarcerated women as it may affect self-esteem, future parenting, and recidivism rates (Abbott, 2015).

Numerous scholars discuss means to reduce (re)traumatization in correctional settings (Benedict, 2014; Kubiak et al., 2017; Miller & Najavits, 2012). The basis for trauma-informed care is to “offer justice-involved women opportunities to experience safety, trust, choice, collaboration and empowerment” (Benedict, 2014). Research reveals numerous positive outcomes including safety, security, and less conflict for women and staff. There are numerous models for trauma-informed care that may be applicable for pregnant incarcerated women (Benedict, 2014; Kubiak et al., 2017; Miller & Najavits, 2012). Future research should consider how these models may be implemented for pregnant women.

While integrating trauma-informed care at the organizational level is a large undertaking, in the interim, more explicit training about the role of officers during labor and delivery should be considered to address inconsistencies that would alleviate stress for the mothers and officers (Abbott, 2015). As discussed, some officers do break the rules to advocate and give instrumental help especially at the hospital. Dirks (2004) warns against prison staff enacting roles of both “therapist and disciplinarian” (p. 109.) Though Dirks (2004) is referring to mental health therapy, it could be applied to officers negotiating their role as rule enforcer and the sole witness to the mothers' labors and births. Professional labor support could mitigate this.

Women's prisons should (re)consider the incorporation of doula programs. Birthing alone may exacerbate feelings of isolation and trigger previous trauma. Birth doulas provide emotional and physical support to laboring women, improve birth outcomes, and lead to high satisfaction rates for both mothers and prison staff (Marshall, 2010; Schroeder & Bell, 2005). Professional labor support can alleviate some of the dehumanization mentioned by mothers and minimize (re)traumatization. Furthermore, officers can maintain their custodial roles during labor and birth, leading to less inconsistency and stress for all.

Limitations

While this research explores interactions between pregnant and postpartum incarcerated women and prison officers, it does not include the voices of officers. Future research should evaluate how they feel about their interactions with pregnant women during labor and birth as this research suggests it is multifaceted.

Additionally, as the majority of women were White, this research cannot speak to the experiences specifically of women of color, a topic of crucial importance due to disproportionate rates of incarceration of women of color. Maternal and infant mortality rates for African American women are disturbingly higher than for White women (Centers for Disease Control and Prevention, 2020). Thus, future research must address whether the general racialization of pregnancy and birth in the United States exacerbates the experiences of pregnant, African American women who are incarcerated (Bridges, 2011).

Conclusion

Incarcerated women have unique health needs due to high rates of trauma, abuse, substance use disorder, mental health issues, poverty, and racism (Covington, 2007). A number of women arrive to prison pregnant. Incarcerated women are particularly at risk for (re)traumatization during incarceration (Dirks, 2004). This research contributes to the growing literature on pregnant incarcerated women by exploring inconsistent interactions including gatekeeping, advocating, dehumanization, and acts of compassion by prison officers with pregnant, laboring, and birthing women. Implementing trauma-informed care training for prison officers and a birth doula program could minimize possible re(traumatization) for women, clarify the role of officers, and help decrease stress for all.

Author Disclosure Statement

The author disclosed no conflicts of interest with respect to the research, authorship, or publication of this article.

Funding Information

The author received no financial support for the research, authorship, and/or publication of this article.