Maternal Health Equity and Justice for Pregnant Women Who Experience Incarceration

Pregnant people who experience incarceration are among the most marginalized and overlooked individuals, yet they have significant health care and other needs that affect their and their children’s long-term well-being. Of the nearly 36 000 women admitted to Canadian provincial and federal prisons, most are of childbearing age; therefore, some of them will experience pregnancy during or after their confinement.¹ In Canada, as in the US, structural racism and the legacies of colonialism manifest in the disproportionate incarceration of women of color. Understanding the effect of incarceration on maternal health and pregnancy outcomes is a matter of health equity and justice. However, there is a paucity of data on how many incarcerated people are pregnant and what happens to pregnancies behind bars, signaling another way through which pregnant people experiencing incarceration are elided.

The limited existing research on pregnancies among people who experience incarceration shows variable findings, with an integrative review² finding that some studies suggest improved and others suggest worse maternal and neonatal outcomes. Research also documents that incarcerated women in general have higher rates of chronic illness, mental health diagnoses, and substance use disorders; these health conditions intersect with an array of adverse social and structural determinants of health, from poverty to homelessness to systemic racism, among others. Together, these conditions are associated with compounded increased risk of negative maternal and infant health outcomes among pregnant people who experience incarceration, which then has a ripple effect for families and communities more broadly.

One way to contextualize and potentially mitigate the effects of imprisonment on pregnancy outcomes is to understand what kind of antenatal care pregnant people who spend time in prison receive. Inadequate systems for monitoring and reporting make it difficult to know when pregnant women enter and exit jail and prison systems, much less whether they receive guideline-consistent antenatal care during incarceration and after they return to the community.

Carter Ramirez and colleagues³ seek to address that gap by examining indicators of antenatal care quality provided to women in Ontario, Canada, who were incarcerated in a provincial prison during their pregnancies. Leveraging the unique data linkages that are possible with a public system of health care provision, they identified all the pregnancies within the province from 2005 to 2015 and categorized them by prison exposure using a cohort of women released from the provincial prison in 2010. Although this linkage method may miss some incarceration episodes among women who were not released in 2010, it resulted in a substantial number of prison-exposed pregnancies (n = 626), nonexposed pregnancies to mothers with histories of incarceration (n = 2327), and nonexposed pregnancies to mothers who were not incarcerated (n = 1 308 879) for comparison. They then compared antenatal care quality indicators among these 3 groups, finding that women who experienced incarceration during pregnancy had decreased odds of having the recommended number of antenatal visits and sonograms compared with women who were incarcerated outside pregnancy and that both these groups had decreased odds of guideline-consistent antenatal care visit numbers, sonograms, or other ambulatory care compared with women who were never incarcerated.

The authors ascertained antenatal care for people when they were in and out of prison during a particular pregnancy. This is a notable strength of the study because it tells us something about challenges to accessing community antenatal care even when someone is released from prison. Because more than half of people in the prison pregnancy group were in custody for less than 30 days, they spent most their pregnancy time in the community, where their care nonetheless met fewer antenatal care quality indicators. This finding raises important concerns about continuity of care after release from prison.

Study findings contrast with prior work² that suggests improved pregnancy outcomes when women are incarcerated during pregnancy. That reporting on quality measures rather than maternal or neonatal outcomes produced disparate results but led to additional important conclusions. Their results are consistent with an Australian study⁴ that examined the receipt of guideline-consistent antenatal care, which found that women with prison-exposed pregnancies were more likely to establish care later than 20 weeks’ gestational age than women with nonexposed pregnancies who otherwise had histories of incarceration. Measuring quality indicators, such as sonograms, opioid withdrawal, and shackling, Kelsey et al⁵ painted a bleak picture of antenatal care access in jails across the US. Using other measures of antenatal care quality (eg, nutrition needs and childbirth education), Ferszt and Clarke⁶ also described inadequate antenatal care in US prisons. Although increasing quantity and quality of antenatal care during incarceration have been associated with improved outcomes, the effect of incarceration itself has been mixed.² That, in some contexts, women and their infants experience improved outcomes after incarceration despite inadequate antenatal care may be more strongly associated with the condition of the social safety net outside jails and prisons for women with low socioeconomic status, women of color, and women who use illicit substances than with the medical care they receive inside prison.

Carter Ramirez and colleagues³ used a particular metric of quality that is quantitative and largely based on number of visits with physicians. However, this is only part of the picture in understanding the actual quality of care people receive. This study highlights the need for different and more comprehensive quality metrics, such as adherence to infection and gestational diabetes screening guidelines, substance use disorder treatment, trauma-informed care, and access to nonphysician health care practitioners, such as midwives, and how these differ according to race/ethnicity and other key demographic characteristics. First Nations Canadians have higher pregnancy and infant mortality rates and are more likely to be incarcerated. Likewise, a push to measure other prison-specific conditions that adversely affect pregnancies, such as shackling pregnant people or placing them in solitary confinement, could influence policy changes that could substantially improve outcomes and promote dignity in care of pregnant people who experience incarceration.

Furthermore, quality must be understood in the relational context of how practitioners interact with patients who are incarcerated; qualitative research suggests that patients who are incarcerated experience more discrimination and derogatory care.⁷ Discrimination and systemic racism have been associated with disproportionately higher rates of maternal mortality among black Americans, independent of markers of socioeconomic status, suggesting that even the adequate number of antenatal care visits and sonograms may be necessary but not sufficient to improve outcomes for pregnant people who are imprisoned. Quality, too, must be understood on a longer-term time horizon in the life course context of social and economic structures that do not adequately support the resources needed for healthy, safe parenting.

Antenatal care cannot easily address the stigma, concentrated disadvantage, and other structural inequities experienced by women who are incarcerated during pregnancy. There is nonetheless a need to improve care for pregnant people who are incarcerated. These needs include ensuring delivery of community-standard prenatal care, adequate nutrition, and mental health and addiction treatment; never placing pregnant people in solitary confinement; not shackling pregnant, birthing, or postpartum people; respectful, safe childbirth; enabling breastfeeding and maternal-infant bonding; and investing in alternatives to incarceration. We also need mandatory standardization and accountability of health care quality in prison, which currently does not exist. As the study by Carter Ramirez and colleagues³ suggests, exposure to prison during pregnancy is likely a marker for layers of inadequacies in structural supports of which antenatal care is just one. Their work should push us to measure and improve care that will mitigate and disrupt these persistent inequities.

Published: August 6, 2020. doi:10.1001/jamanetworkopen.2020.13096

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Knittel A et al. JAMA Network Open.

Corresponding Author: Carolyn Sufrin, MD, PhD, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, 4940 Eastern Ave, Room A121, Baltimore, MD 21224 (csufrin@jhmi.edu).

Conflict of Interest Disclosures: Dr Sufrin reported receiving grant funding from the National Institutes of Health and the Society for Family Planning and royalties from the University of California Press for Jailcare: Finding the Safety Net for Women Behind Bars. No other disclosures were reported.