Excerpted From: Amanda Corbett, Ingie Osman, Alexus Roane, Allison D. Crawford, Anne Siegler and Rebecca Shlafer, The Impact of the Covid-19 Pandemic on the Care and Treatment of Pregnant, Birthing, and Postpartum People in Prisons in the United States, 19 University of Saint Thomas Law Journal 587 (Spring, 2023) (150 Footnotes) (Full Document)


PregnantWomenPrisonsIt is a well-known, albeit unfortunate, fact that the United States incarcerates more people than any other country in the world. Although only four percent of the world's women reside in the United States, the United States is responsible for detaining thirty percent of incarcerated women worldwide. The number of women in U.S. state and federal prisons increased by more than 600% between 1980 and 2020. Women from racial and ethnic minority backgrounds are incarcerated at disproportionately higher rates than their White counterparts; in 2020, Latina women were 1.3 times, Black women were 1.7 times, and American Indian and Alaska Native women were 4.3 times more likely to be incarcerated than White women. Most women in the carceral system are of childbearing age (aged eighteen to forty-four) and more than half (fifty-eight percent) in state prison are mothers of minor children. Seventy-seven percent of incarcerated mothers in state prisons reported being the primary caregiver to their minor children prior to incarceration, as opposed to twenty-six percent of incarcerated men.

State and federal prisons and local jails have not historically collected information on pregnancy status at intake, so no consistent data are available. Sufrin and colleagues estimated that approximately 56,400 pregnant people were taken into custody between 2016 and 2017 (1,400 to state and federal prisons and 55,000 to jails). On the basis of these data, it is estimated that approximately three percent of women in federal prisons, four percent of women in state prisons, and four percent of women in local jails were pregnant upon admission, though it is important to recognize these numbers are out-of-date, and rates of incarcerated pregnant people are likely higher, particularly in local jails and state prisons. In 2018, the First Step Act was signed into law, which required the Bureau of Justice Statistics (BJS) to annually report, among other things, the number of individuals who enter federal prison while pregnant. As a result of this requirement, it was determined that slightly more than one percent of women in federal prison were pregnant upon admission in 2019. Correlative data are not available to reflect the rate of pregnancy in local jails and state prisons at this time. It is worth noting that, while the BJS's reported rate of pregnancy has declined since the data reported in 2016-2017, the number of women in the carceral system has increased, thus the number of pregnant women in custody has likely stayed the same, if not increased.

State and federal prisons were designed and continue to operate by gender-neutral, if not male-centric, policies that have negative impacts on women, particularly those who are pregnant or postpartum. Pregnancy introduces unique, time-sensitive healthcare needs that ensure the pregnant person's physical and emotional needs are being met. A small body of international research shows a relationship between incarceration during pregnancy and poor maternal mental health, which increases the risk of poor outcomes in the mother (e.g., significant negative impact on mental health resulting from separation from their infant after birth) as well as the neonate (e.g., premature birth, low birth weight, and greater risk of the newborn needing hospitalization). Lack of access to services in carceral settings (which, when offered, are generally of poor quality) also impacts maternal health (e.g., quality healthcare, childbirth and parenting education, nutrition, emotional support, counseling, and, at times, substance use management). As of 2022, forty-one states and the District of Columbia had passed legislation specifically referring to healthcare provided to incarcerated pregnant people, although the content, comprehensiveness, and oversight of these laws varied considerably between states.

Pregnant individuals in prison must grapple with concerns unrelated to the prison environment but not typically encountered in the general community. Prior to going to prison, incarcerated women are three times more likely to be the head of a single-parent household with minor children (forty-two percent) than to be a co-parent in a two-parent household with minor children (fourteen percent). Once incarcerated, single parents are required to arrange and coordinate childcare from the inside for their children residing in communities often located great distances from the prison, which frequently results in a complicated cobbling together of formal, informal, and state-appointed solutions for care. While difficult for all parents in prison, arranging childcare for an unborn child is one more challenge the pregnant parent must traverse. All in all, pregnancy behind bars is extremely stressful.

Recognizing the gaps in existing health services and resultant poor health outcomes in this population, some international standards have been created that support perinatal services for pregnant women in prison; such services include providing perinatal education, birth attendants, and comprehensive perinatal healthcare. Some states in the United States have implemented similar perinatal programming to pregnant and postpartum individuals in prison. Limited information is available on perinatal programming in prisons in the United States, but best estimates suggest that twenty-one states were planning for or had implemented perinatal programming in state prisons prior to the pandemic. Group-based classes, one-on-one support, birth attendants, and lactation support are some of the enhanced services offered to support the unique needs of this population. Evidence suggests birth outcomes are better for incarcerated pregnant individuals who receive enhanced perinatal care than their counterparts who receive little to no perinatal care; reduced likelihood of preterm delivery and less likelihood of recidivism have been reported in individuals who received enhanced services.

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Behind bars, the COVID-19 pandemic has disrupted the continuum of pregnancy-related care and postpartum support, drastically impacting pregnant and postpartum people in prison. Policies related to visiting, programming, and accessing health services have been modified to limit the spread of disease, compromising the provision of care for incarcerated people during and after their pregnancies. Policy changes (or lack thereof), however, do not always match personal accounts of individuals' experiences inside prisons; written policy is only as effective as the level to which it is enforced. The extent to which care and experiences have been affected by the pandemic is difficult to capture.

As the COVID-19 pandemic continues to impact people behind bars, the population of pregnant and postpartum people needs to be prioritized for care and treatment in order to promote positive maternal and child health outcomes. Importantly, this population needs to be prioritized for release. The conditions of carceral facilities put people at greater risk of COVID-19 infection, severe illness, and death; and facilities are not well-equipped to deal with ongoing public health crises. Those who are most vulnerable, such as pregnant individuals, should be prioritized for release. In addition, given their increased risk for adverse outcomes from COVID-19 infection, pregnant and postpartum people are strongly recommended to get vaccinated against COVID-19. To promote uptake of COVID-19 vaccination, and counteract targeted misinformation, tailored messages about vaccination are needed for pregnant and postpartum people who are incarcerated. Messages should be evidence-based, timely, transparent, and tailored to the unique context of incarceration, including acknowledgement of unethical medical experiments conducted on individuals in the criminal legal system. Pregnant and postpartum people in prisons and jails should be provided with frequent opportunities to ask questions about their health and the COVID-19 vaccines from providers they trust.

Given the unpredictable nature of the COVID-19 pandemic and the potential for future public health crises to emerge, policies and practices need to be enacted that are responsive, equity-focused, and evidence-based. Understanding the impact of the COVID-19 pandemic on the care and treatment of pregnant and postpartum people in prisons is paramount to developing policies and practices that address health disparities, center maternal and child health, and promote health equity.

Amanda Corbett, MPH, is the Project Director of Enhanced Perinatal Programs for People in Prison (E4P), a five-year NIH-funded longitudinal study based out of the Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA.

Ingie Osman, MPH, is a Research Project Specialist in the Division of General Pediatrics and Adolescent Health at the University of Minnesota. Her work focuses on health equity, community engagement, and COVID-19 response efforts in prisons and jails.

Alexus Roane is a PhD candidate in Sociology and a third-year MPH student in Health Behavior and Health Education at the University of Michigan. She is a site co-lead in the Enhanced Perinatal Programs for People in Prison (E4P).

Allison D. Crawford, PhD, RN, is an assistant professor at the University of Texas Health at San Antonio's School of Nursing. Her research focus and expertise encompass the health disparities of childbearing communities influenced by incarceration.

Anne Siegler, DrPH, is an epidemiologist and independent public health consultant. Her work focuses on the intersection of public health and criminal justice.

Rebecca Shlafer, PhD, MPH, is an Associate Professor in the Department of Pediatrics at the University of Minnesota Medical School. She is a national expert on pregnancy and parenting in prison and serves as the Research Director for the Minnesota Prison Doula Project.