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Pregnancy and Prenatal Care in U.S. Prisons
Pregnancy among inmates is a unique challenge. According to a 2008 report from the Bureau of Justice Statistics on female prisoners, 4% of state and 3 % of federal inmates said they were pregnant at the time they began their incarceration. However, it is difficult to accurately assess the recurrence due to a lack of reporting requirements and irregular pregnancy testing at admission. The needs of mothers during pregnancy and childbirth often conflict with the demands of the prison system.

In the United States, the prison system was designed to accommodate male inmates. The rising rate of female incarceration poses challenges on a variety of levels, including health care. It is estimated that 9% of women in prisons give birth while completing their sentence. In spite of a Supreme Court ruling Estelle v. Gamble, 1976, which declared entitlement to basic health care for all people who are incarcerated, provision of adequate prenatal care in U.S. prisons has been inconsistent at best.

Prenatal Care
Women who are in jail or prison often have very high-risk pregnancies due to a higher prevalence of risk factors, which can negatively influence both pregnancy and delivery. Among these are the mother’s own medical history and exposure to sexually transmitted infections, her level of education, mental health, substance use/abuse patterns, poor nutrition, inadequate prenatal care, socioeconomic status, and environmental factors, such as violence and toxins. .

Prenatal care in prisons is inconsistent. The Federal Bureau of Prisons, the National Commission on Correctional Health Care, the American Public Health Association, the American Congress of Obstetricians and Gynecologists, and the American Bar Association have all outlined minimal standards for pregnancy-related health care in correctional settings, and 34 states have established policies for provision of adequate prenatal care. However, the services can vary widely, and there is not a reliable reporting measure to ensure services are delivered.

Prenatal care for incarcerated women is a shared responsibility between medical staff in the prison and community providers, but specific delineation of care is determined locally, depending on available resources and expertise. Women must often be transported for prenatal care and delivery, which can cause stress for the mother. In addition, some states continue to use shackles for security during transportation, labor, delivery, and postpartum care. The use of shackles is highly controversial, reported as both dangerous and inhumane.

Shackles
Shackles are typically used for inmates, who demonstrate risk of elopement, harm to self, or harm to others. Historically, they have also been used with women attending prenatal care appointments, as well as during labor and delivery. When used during transit, the use of shackles on the ankles and wrists puts a mother at risk of falling, in which case she would be unable to reach out to soften the fall. In turn, this could put both the mother and the fetus at risk of injury. Shackles can also interfere with labor and delivery, prohibiting positions and range of motion for the mother, doctors, and nurses. Following delivery, shackles interfere with a mother’s ability to hold and nurse her infant child. In addition, women feel ashamed and discriminated against when they are shackled in a community hospital. Eighteen states in the U.S. currently have laws either prohibiting or restricting shackling pregnant prisoners, and only ten states prohibit use of shackles by law. As a result, it is still common practice in some places.

Care After Childbirth
The structure of U.S. justice systems makes development of maternal attachment nearly impossible. After the births of their child, many women are returned to the jail or prison, and their infant immediately enters foster or kinship care. However, within many state policies, relatives are given less financial support, which can leave foster care to be more viable than kinship placement. “For 50% of all incarcerated mothers, this separation becomes a lifelong sentence of permanent separation between mothers and their children”.

Some prisons have nurseries for the mother and child. Women are only eligible to participate in a prison nursery if they are convicted of non-violent crimes and do not have a history of child abuse or neglect. Prison nurseries vary widely, but they provide an opportunity to breastfeed during a sensitive stage in development. They also provide time for a maternal attachment to be formed. Rates of recidivism are less for women who participated in prison nursery programs.

An improvement from the alternative, prison nurseries still leave many gaps in care. “Reports from mothers with children in prison nurseries indicate that their babies’ close proximity allows prison staff to coerce and manipulate a mother by threatening to deny her access to her baby”. Some advocacy groups argue for alternative sentencing, such as family-based treatment centers, where mothers convicted of non-violent crimes can learn parenting skills while receiving services and support to foster positive child development and build a foundation to re-enter society following her term with decreased risk for future incarceration.