The Problem: Mass incarceration is hurting pregnant people and their infants.

Mass incarceration is devastating communities in the United States and has taken a uniquely harmful toll on people of color and on women. According to the most recent available data, 2.3 million people are confined in a U.S. correctional facility,* 231,000 of which are women. Of these, roughly 109,000 are women of color, who are overrepresented in the incarcerated population. Among incarcerated women, three out of four are of childbearing age, more than half are mothers of minor children, and up to one in 10 were pregnant when they entered incarceration.

Being incarcerated during pregnancy or childbirth exposes pregnant and birthing people** to heightened risks to their and their infants’ health and well-being, including extremely high levels of stress, exposure to violence and abuse, and substandard health care. Decisionmakers must take action to mitigate these harms, particularly given the ongoing maternal and infant health crisis among Black, American Indian, and other communities of color.

The United States has created a serious mass incarceration problem, especially when it comes to women. The nation is home to 4 percent of the world’s female population, but 30 percent of all incarcerated women. There are, of course, racial disparities, with Black and Latina women much more likely to be imprisoned than white women: One in 18 African American and one in 45 Latina women will likely experience incarceration in their lifetime, as compared to one in 111 white women. In addition, three out of four incarcerated women are of childbearing age (18–44 years old), and 6 to 10 percent of women are pregnant when they become incarcerated. Between 1991 and 2007, the number of mothers in prison increased by 122 percent and by 2017, 58 percent of all incarcerated women reported being mothers to minor children.

Amid the backdrop of a broader national health care crisis, difficulties accessing care are amplified in correctional settings. While correctional facilities are constitutionally required to provide health care, and states and federal agencies may have their own standards for doing so, there are no universal minimum requirements related to standards of care, data reporting, or mandatory oversight. As a result, there is great variability in pregnancy care for incarcerated and detained people. For instance, 24 states have failed to codify any policies related to planning for incarcerated pregnant women to give birth (for example, plans for hospital transfer or coordination of care). Moreover, pregnancy care in correctional facilities is not uniformly safe or health-promoting. Some practices can be immoral and physically and emotionally harmful to both birthing people and their infants – such as shackling and separating mothers from their newborns. Health care must be improved in correctional settings to prevent unjust harm and provide necessary care to incarcerated pregnant people and their infants.

Incarceration risks the health of pregnant people and their infants

Systematic reviews (rigorous reviews that collect, assess, and synthesize the best available evidence from existing studies) have found:

• Women in prison are a high-risk maternal health group. This is because incarcerated women are, among other factors, more likely to have a medical problem (such as diabetes, hypertension, epilepsy, or cardiac disease) that could negatively impact their pregnancy outcome, yet they are less likely to receive antenatal care.
• Substance use disorders and mental health conditions that negatively impact pregnancy outcomes occur at high rates in incarcerated populations, increasing the need for effective interventions.
• Tobacco use among pregnant incarcerated people exceeds 50 percent, and has been recorded as high as 84 percent, compared to 17 percent among non-incarcerated adult women.
• Alcohol use is common among pregnant incarcerated people, and 36 percent of incarcerated people report using illegal substances while pregnant.
• Four out of five pregnant inmates reported having depression and anxiety.
• When prison perinatal care is enhanced, there can be positive outcomes. For instance, interventions that included not only enhanced care in prisons and co-residence with children after birth, but also coordination of community care on release, demonstrated reduced likelihood of future involvement with the justice system over the 10 years following release when compared to women in the same facilities that did not receive the intervention.

Other individual studies have found that:

• Only 37.7 percent of prison facilities test all women for pregnancy upon entry, and 46 percent of pregnant women in prisons reported receiving no prenatal care.
• Out of 16 general categories of national guidelines for healthy pregnancy recommendations (such as providing prenatal vitamins and adequate nutrition, or prenatal and postpartum mental health care), the U.S. Marshals Service (the entity responsible for individuals awaiting federal trial or sentencing) only provides incarcerated women three, and the Board of Prisons (the entity responsible for federally sentenced individuals) only provides eight.
• About 45 percent of prison facilities put pregnant women with opioid use disorders through withdrawal protocols without symptom alleviators, despite medication-assisted treatment being the standard therapy for this population, because it protects the fetus from repeated withdrawal episodes, thereby reducing the risk of obstetrical and fetal complications, in utero growth restriction, and newborn morbidity and mortality.
• Exposure to incarceration either personally or vicariously through a partner increased the rate of low birth weight and preterm births.
• Shackling is the use of a mechanical device (e.g., ankle cuffs, belly chains, soft restraint, hard metal handcuffs) to limit a person’s movement, and is supposedly necessary to prevent escape. However, a 2011 report found that there was not a single reported case of escape by any incarcerated woman who was not restrained during labor.
• Approximately 56 percent of prison facilities use restraints on women within hours after birth, and 83 percent of perinatal nurses for incarcerated women reported that shackles were used on their patients sometimes or all the time in the hospital.
• Another report found that, of 19 responding prison facilities, six of them cuffed a woman’s ankle or hand when labor began, one kept handcuffs on during labor, and four used ankle shackles during labor.
• Shackling can delay prompt assessment for vaginal bleeding, increases the likelihood of falls and the inability to break a fall, restricts mobility during labor, limits maternal contact with newborns, and may also interfere with the safe handling of newborns.
• Most incarcerated mothers are only allowed 24 hours with their newborns in the hospital after birth. This practice of separating mothers and newborns can be psychologically traumatizing for both the parent and infant. In addition, early separation from a primary caregiver can disrupt an infant’s early biological rhythms, dyadic regulatory processes, and efforts to explore and develop an autonomous sense of self. These disruptions can manifest in infants in inconsolable crying, tantrum behavior, eating and sleeping difficulties, clinging behavior, withdrawal, irritability, aggression, and/or physical symptoms and diagnoses that may require intervention.

Structural racism drives the mass incarceration of (and subsequent disproportionate harm to) people of color, including pregnant people and their infants

The consequences of mass incarceration disproportionately impact communities of color. When compounded with the fact that Black women overall are three times more likely than white women to die because they were pregnant, and three times more likely to suffer severe complications like fibroids (benign tumors in the uterus that can cause postpartum hemorrhaging), the added risks for Black pregnant people of being incarcerated during pregnancy are unconscionable.

Furthermore, Black women and other women of color have a painful history of experimentation, eugenics, and forced sterilization in detainment settings. For instance, from 2006 to 2010, 144 women were sterilized in California’s prisons without the state’s approval, and 39 did not consent. Furthermore, in 2020, there were whistleblower allegations of women in Immigration and Customs Enforcement detention that were being sterilized without their consent or knowledge.

In addition, infants and children of color are disproportionately harmed by mass incarceration. Having a parent who is incarcerated is considered an “adverse childhood experience” (ACE). There is a significant body of evidence that shows a strong correlation between the number of ACEs a person had in childhood and the greater likelihood of poor health later in life. Parental incarceration increases the risk of a child living in poverty or experiencing household instability, independent of any other factors present in that child’s life.

• Black women are incarcerated at a rate twice that of white women, and Latinx women are incarcerated at a rate 1.3 times that of white women.
• Black girls are also three times as likely to be incarcerated and American Indian girls are four times as likely to be incarcerated than their white peers.
• Formerly incarcerated Black women’s unemployment levels are 37 percent higher than non-formerly-incarcerated Black women, whereas formerly incarcerated white men’s unemployment levels are only 14 percent higher than non-formerly-incarcerated white men.
• Formerly incarcerated Black women are four times more likely to experience homelessness than formerly incarcerated white men.
• One in 9 Black children and one in 28 Hispanic children have an incarcerated parent, in contrast to one in 57 white children.

Recommendations

1. Congress must pass the Justice for Incarcerated Moms Act (H.R. 948/S. 341), part of the Black Maternal Health Momnibus, which would end shackling, provide funding to improve care for pregnant and postpartum people who are incarcerated, and study the drivers for maternal health inequities among incarcerated people.
2. Congress must pass the Stop Shackling and Detaining Pregnant Women Act (H.R. 3563/S. 648 in the 116th Congress), which would prohibit the Department of Homeland Security from detaining a woman during pregnancy or postpartum recovery, require the immediate release of any detainee found to be pregnant unless they pose a significant risk to public safety, prevent the use of restraints on pregnant detainees, and more.
3. We must interrupt criminalization at its roots by investing in historically marginalized and underserved communities across all sectors, including but not limited to education, housing, transportation, public health, and health care. These investments must not rely on criminal or carceral approaches, but instead must be oriented toward providing communities with the services and support necessary to thrive.
4. Our carceral system must be dismantled. Policing and the criminal justice system harms communities and perpetuates centuries of trauma. It is time to shift investments at the federal, state, and local levels from policing and incarceration to programs that support communities. Congress should introduce and pass the Breathe Act, a bill that divests from brutal and discriminatory policing and invests in a new vision of public safety.
5. Federal and state agencies charged with managing incarceration and detention facilities should enact policies that ensure consistent access to high-quality health care, including prenatal care, comprehensive reproductive health care, mental health care, and treatment for substance use disorders.
6. Federal, state, and local governments should enact and enforce universal bans on shackling during labor and birth, implement long-term programs that keep birthing parents and infants together, and provide coordinated community services on release.
7. Federal and state prisons, detention centers, and local jails should collect more data on the quality of care and health outcomes for pregnant incarcerated people, including disaggregation by race and ethnicity.

*For the purposes of this bulletin, “correctional facilities” is used as an all-encompassing term and refers to prisons, jails, and detention centers. It is important to note the differences in these facilities. Prisons are facilities that hold individuals long-term after sentencing, jails are facilities that hold individuals awaiting trial or sentencing, and detainment facilities are entities that temporarily hold individuals awaiting sentencing or deportation. Further, detainment refers to the “temporary holding of individuals accused of Federal crimes or those awaiting sentencing or deportation”, whereas incarceration refers to the “long-term confinement of convicted and sentenced offenders”. See https://www.justice.gov/archive/ag/annualreports/ar99/Chapter5.pdf

We recognize and respect that pregnant, birthing, postpartum, and parenting people have a range of gender identities, and do not always identify as “women” or “mothers.” In recognition of the diversity of identities, this report prioritizes the use of non-gendered language where possible.

Saving the Lives of Moms & Babies