Duke Medical Ethics Journal

confinement often, and at times for punishment for minor violations such as being out of lace or failure to obey an order by a prison guard. These practices are harsh and quite different from those of other leading countries, which have shorter sentences for minor crimes, and often focus on rehabilitation and reintegration into the community during one’s incarceration, rather than violent and strict daily life[3]. Due to this fact, there is often concern for the quality of care and supervision that is provided to pregnant inmates in the US prison system, which are critical factors in the development and outcome of a pregnancy. While this is data that is important and should be vigilantly recorded, the stigma surrounding incarcerated people and the lack of advocacy for their well being has led to a gross lack of data and statistics showing the quality of healthcare provided to pregnant inmates. 

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While at the national level, U.S. prisons are required to provide prenatal care under the Eighth Amendment of the Constitution, there are no federal standards to ensure that pregnant people are receiving this care, and many prisons do not have outlined policies for their specific institutions[4]. There are many accounts suggesting that experiencing pregnancy and birth while in prison can be dangerous and dehumanizing for mothers and may create a higher risk for a non-ideal outcome in the pregnancy[5]. 

Despite the small amount of data available, it is clear that there is a lack of care for the health and well-being of pregnant inmates in the U.S. prison system. The lack of advocacy provided for these people, and their marginalization in the larger US healthcare system is influenced by many factors, including a lack of overall prioritization of the lives and wellbeing of incarcerated populations, the qualities of the prison system, and the stigmatization and marginalization of imprisoned individuals both by the public and by healthcare professionals themselves. 

 

Pregnant people in the US prison system will inevitably increase as the amount of incarcerated women in the US increases, and this figure has been growing for quite some time. In general, there is a lack of available data, and a lack of data currently being taken on the living conditions of pregnant inmates and on the outcomes of pregnancies for patients in prison. The most recent studies indicate that around 4% of women in the prison system are pregnant upon entry[2]. 

 

Incarceration levels are disproportionately higher for people of color in the US: recent data shows that 48 White women are incarcerated for every 100,000 people, while African American women see incarceration rates of 83 for every 100,000 people, and LatinX women have rates of 63 for every 100,000 people[1]. While these figures show a linear decrease in the incarceration rates of Black women to White women (incarceration rates of white women show a 41% increase from 2000 to 2019, and the incarceration rates of African American women saw a 60% decrease in incarceration rates from 2000 to 2019), it is still clear that incarceration rates are significantly higher for women of color in the US. 

 

Similarly, it is documented that these same marginalized groups are at higher risk for pregnancy complications, reduced access to prenatal care, maternal mortality, and general health complications due to pregnancy and/or its termination[1]. Disparities in maternal health care access exist in the general population. In 2015, around 75% of non-Hispanic black women and 76% of Hispanic women received prenatal care in the first trimester of pregnancy in comparison to 89% of non-Hispanic White women[6]. It is important to recognize the disproportionate effect that both the prison and healthcare system has on women of color, specifically non-Hispanic black and Hispanic women, in the United States, and to advocate for their equality and equity when discussing marginalization of groups in medicine. 

 

While it is thought that there may be a correlation between the environment of prisons and potentially higher risks of adverse pregnancy outcomes, there has been little data taken thus far on the percentages of pregnant women in prisons, and even less data taken on pregnancy-related outcomes of women in jail. A paper released examining the lack of data on pregnant women in prison and jails noted that the data from the US Department of Justice, Bureau of Justice Statistics, which estimated that 4% of women in state prisons and 3% of women in federal prisons were pregnant at admission in 2004, has not since updated their statistics when the study was released in 2019.[7]. The same study also notes that more recent, but unupdated and unreleased data from the Association of State Correctional Administrators estimated that 2852 pregnant women were admitted to state and federal prisons over 10 months in 2010, and when surveyed, 4 participating states reported that more than three-quarters of the birth that occurred while the patient was in prison were considered ‘other than normal births’, meaning the mother and/or infant experienced complications during birth.[2]. The study reflects on the fact that this data is extremely outdated, and that as the amount of women incarcerated continues to increase that these percentages are more likely to be incorrect, and that there are probably larger percentages today. Regardless of whether or not the data is accurate or an underestimate of today's figures, the report that over three-quarters of births were classified as other than normal should instill a desire to understand how being incarcerated while pregnant may affect the chances of adverse pregnancy outcomes for women, yet, there is no updated data to allow for further study or potential solutions to these figures. 

 

Similar to the lack of data being taken on the percentages of pregnant patients in prisons, there is also a significant lack of available data on the quality of care that is provided to pregnant patients while imprisoned. A 2010 report found that 38 states had no policies requiring that incarcerated pregnant people receive basic prenatal care, and that 41 states did not ensure adequate diets for pregnant incarcerated people [2,8]. This lack of data not only indicates that there are potentially large gaps in today’s figures compared to the times of these studies, but it also creates a lack of accountability for and monitoring of the living and medical conditions of pregnant women in prison. This lack of data being reported shows prisons the lack of care for the medical care of pregnant inmates, and there is thus no incentive to upkeep the living conditions for these women. The lack of data reflects a larger pattern of disregard for the wellbeing of

incarcerated individuals generally in the United States. The stigma surrounding incarcerated individuals and the overgeneralizing assumption that all those imprisoned are dangerous individuals not worthy of attention or empathy means that potential injustices in healthcare are largely ignored. Thus these people become marginalized both within their communities, and within the healthcare system itself. Advocating for the quality of and fundamental right to medical care of incarcerated people is an important and current discourse that is necessary in order to continue to advocate for the medical quality provided to pregnant inmates in the US prison system. 

 

Proper monitoring and care over the course of pregnancy are fundamental steps to promote a positive outcome. Proper prenatal care, consistent monitoring, diet, and limiting intense exercise are all important factors ensuring a good outcome for both the mother and the fetus [7]. As many of these factors are poorly monitored in the prison system, many incarcerated mothers will experience an inherently higher risk of complications. While it is possible to draw broad conclusions, the lack of available data makes it difficult to pinpoint specific issues which may guide targeted intervention. One of the prime areas of concern is that the CDC does not currently include the maternal incarceration status of mothers in the data they collect for their census on the systematic assessment of abnormal births annually in the United States. This means that researchers are currently unable to estimate the adverse effects on pregnancy for incarcerated individuals accurately. As a result, any suggestions for policy correction or attempts to improve outcomes are not fully researched and thus may not be impactful if implemented in the current prison system. The lack of recognition by the CDC and other federal organizations means that there is a lack of proper conduct or enforcement of the few policies that are implemented in prisons. There are a few policies dedicated to maternal health care implemented in prisons, but many of them are privately established and vary from prison to prison, and the lack of accountability from organizations such as the CDC means that there are often holes and a lack of enforcement of the policies that exist in prisons today. 

 

Another way in which pregnant incarcerated people experience medical marginalization is through the lack of counseling provided to them. One of the primary consequences of birth when imprisoned is the separation of mother and child postpartum, almost immediately after birth. This separation of mother and child can have severe effects on the mother’s mental health and overall well-being, yet there is little to no counseling offered for coping with these experiences. When reporting mental health concerns for incarcerated women, the most significant was the traumatic separation of their newborn after birth. The division of mother and child inhibits bonding with the newborn and the initiation of breastfeeding. These women have reported reluctance to initiate breastfeeding because of fear of emotional attachment to the infant or feeling uncomfortable in the presence of officers. When the patients return to the carceral facilities, lactation is further limited and dependent on each institution’s policy [7]. The treatment of these people and the trauma that they experience during this time is often overlooked, and it is also often a source of trauma for these incarcerated women. 

 

Additionally, the fetus may experience distress due to this separation. Skin to skin contact, particularly with the mother, is very important for the bonding of mother and child and for infants to be more responsive to breastfeeding and accepting food. It has also been said to help with the child’s ability to regulate their temperature after birth, as well as stabilizing blood sugar [9]. Forced separation of mother and child may then also impart a negative effect on the infant's ability to thrive [17]

 

Another contributing factor to the trauma of giving birth while in prison is the lack of attention given to the mental health of incarcerated individuals. Mental health in pregnant incarcerated patients can be poor, both due to the separation from their children, but also from the dehumanizing treatment that they experience in the carceral system and their experience in healthcare facilities. The stigma surrounding imprisoned individuals often results in treatment without empathy, and they often feel less than human due to their treatment. This change in treatment can have negative effects on the patient’s mental health. Pregnant patients recounted feeling empty and alone during their process of labor and delivery, and many recounted their experiences being dehumanizing. Many patients compared their treatment to that of animals: “It made me feel like an animal. I think at that point, I understood that I was not seen as a human being.(…) I was seen actually

as a criminal, not just a lady having a baby but some type of criminal monster or something”[10]. Many patients also note experiencing feelings of emptiness after delivering, and when returning to prison after being separated from their child[10,11]. There were also patients that noted feeling guilt regarding complications that occurred during birth, feeling as though the prison environment and stress may have contributed to the complications [10, 12]. There is also sometimes a lack of empathy from prison guards and healthcare workers toward the patients giving birth, alienating the imprisoned mother during an extremely emotional and painful experience [10,13]. 

 

Another dehumanizing effect and potentially medically dangerous phenomenon experienced by pregnant patients in prisons is the procedure for restraints and shackles while pregnant. The lack of mobility and potential fall risk poses a medical risk for pregnant inmates in general, and the use of shackles for pregnant patients has been argues against by many major medical organizations, such as the American Medical Association, the American Congress of Obstetricians and Gynecologists, the American College of Nurse-Midwives, the American Public Health Association, and the American Civil Liberties Union, among others [2]. These medical risks are clear, and while there has been official condemnation of the use of shackles in pregnancy on medical and ethical grounds [7], specifically during the late stages and especially during labor and delivery, in many states and in many prisons the practice continues. Although as of July 2022, 40 states and federal government contain legislation restricting the use of shackles in labor and pregnancies in some respect, the scope of the laws vary greatly, and due to the lack of attention and accountability in prisons from officials, the practice can continue with little to no consequence [7]. This is a grave issue that must be addressed, and can be addressed through more advocacy for the medical quality and rights of incarcerated individuals. 

 

Living conditions in prisons are also not conducive to the health standards that should be provided to patients during the time of pregnancy. Maintaining a proper diet and reducing high-impact activities are highly recommended by physicians to create optimal conditions for the fetus during pregnancy [7], and give the best chances for normal development and progression through the pregnancy. Diet in prison is regulated, and while many prisons give adjustments for pregnant patients, the choice of food and times at which the inmates eat are fixed, meaning that eating habits of pregnant patients are disregarded. They are also most likely not receiving proper nutritional value from the meals provided by prisons [14]. 

 

Another especially prevalent issue in the medical rights of pregnant incarcerated patients is abortion. In the past, while federal supreme court cases protected the right to abortion for Americans, including incarcerated individuals, states that were hostile to the right to choose often has policies making it extremely difficult for abortion to be accessible to pregnant patients in prisons. This included not giving proper counseling for patients on their rights and abilities to choose while incarcerated, and charging a co-pay that most inmates would not be able to provide for the procedure[15]. Most medical insurance is voided while incarcerated, and thus procedures that would have been covered by insurance( i.e. Medicare or Medicaid) are no longer provided, leaving the patients unable to pay for the procedure and thus leaving them with no option but to continue with the pregnancy. With the reversal of Roe vs Wade and Casey vs Planned Parenthood, the fate of all pregnant individuals’ right to choose is now uncertain, but this reversal may disproportionately affect those experiencing pregnancy while incarcerated. 

 

In addition to evidence supporting pregnant patients as a marginalized group, there is a growing body of literature evidencing bias from healthcare professionals directly. In a self-reported study, multiple physicians and other healthcare professionals documented that their levels of respect and empathy often changed when treating incarcerated patients when they found out the details of their crimes, even when their discovery of the information was unintentional [16]. This data shows that while healthcare professionals generally do not seek out the details of their patient’s crimes (which would be arguably unethical as it is not pertinent to the patient’s health and can create the very biases and potential for reduction of quality of care that may be present in these studies), it can affect their perception of the patient, and potentially, change the quality or type of care that the patient receives. This shows that there needs to be further advocacy for the respect for incarcerated patients in the healthcare system, and netter education on the empathy that should be provided to all patients. The change in care and perception of the patient can have negative effects on the patient's mental health, and further dehumanizes the patient, a feeling that has no place in healthcare. 

 

These effects linger even after a patient’s release from prison. Released individuals often experience alienation and isolation when trying to reintegrate into their respective communities. Some patients recount that when they return to their community clinics they feel as though their past still defines the way they are treated by their healthcare professionals [7,10]. 

 

Overall, pregnant incarcerated patients in the US face stigmatization in the healthcare field and in society as a whole. Marginalization as patents stems from this stigmatization. The lack of data on the conditions of pregnant patients in prison is the main issue at hand, as a lack of current data makes it difficult to begin to understand how the conditions in prisons may negatively affect pregnancy outcomes, and to understand the extent to which the current prison policies may be dangerous to pregnant patients, as is recounted in the few outdated statistics that are available to the public. Recognition of these concerns by federal and national organizations would force prisons to have more accountability in upholding policies, such as access to prenatal care and reduced shackling, that would ensure the health and safety of pregnant patients. Recent data indicate that pregnant patients in prison deal with improper diet, potentially aggressive and dangerous shackling, severe mental health tolls, and invasion of privacy by correctional officers. Improving the quality of conditions for pregnant patients is vital in improving the outcomes of pregnancies in prison, and the numbers of other-than-normal births raise concern for the effects of pregnancy outcomes in prison. Advocacy for more insight into the conditions of life in prison and healthcare in prison and allowance for more data would allow for paths to reform the quality of life and healthcare for pregnant patients and hopefully reform the state and quality of healthcare overall in the U.S., by aiming to give focus to marginalized patients in the healthcare industry, and to create a more equal and equitable healthcare system in the United States.