Mass incarceration is a public health crisis in the United States, and, within the directly affected population, incarcerated pregnant women are uniquely vulnerable. We imprison more women than any other country in the world,1 and most (74.7%) imprisoned women are of childbearing age.2 National pregnancy in prisons data, which have never been sufficient, were conspicuously absent for more than a decade. During this time, communities across the United States chose to continue criminalizing young women of color, women in poverty, and women with substance use disorders, while rendering invisible the pregnant women among them.
In this issue of AJPH, Sufrin et al. (p. 799) provide a year (2016–2017) of much-needed data on pregnancy and birth outcomes in 22 US state prison systems and the Federal Bureau of Prisons. The overall percentage (approximately 4%) of women who were pregnant on admission is similar to 2004 data from the Bureau of Justice Statistics,3 but the article includes important, and previously unreported, intrastate variability. For example, 16.7% of women admitted to prison in Maryland over one month were pregnant compared with no admissions of pregnant women in Maine. Texas, unsurprisingly, had the largest number of pregnant women and of births, but a lower than average pregnancy prevalence. States with high pregnancy prevalence, such as Rhode Island and Massachusetts, had few or no live births, suggesting that women were released before birth. Notably, most participating institutions were not tracking pregnancy or birth data before this study. In the context of our decentralized criminal legal system and apathy toward this population, the study represents a huge accomplishment and proof that ongoing pregnancy surveillance is feasible.
DATA FOR ACCOUNTABILITY AND EQUITY
The isolated nature of US detention environments and their histories of inhumane treatment demand our ongoing research attention. With data, we can more easily hold the criminal legal system accountable to our communities and promote health equity for incarcerated people. We agree with Sufrin et al. regarding the urgent need for information on pregnancy in jails. Participating states with unified jail and prison systems had the highest pregnancy prevalence, more women pass through jails each year than prisons, and the last pregnancy in jail statistics were from 2002.4 Pregnancy in prison statistics are also needed in the 28 states that did not participate in this study, 18 of which have higher than average women’s incarceration rates or state prison censuses.5
To insure regularly updated information from all US detention facilities, we support federal legislation requiring inclusion of standardized pregnancy-related data in the National Prisoner Statistics program, the Annual Survey of Jails, and the Census of Juveniles in Residential Placement, all of which track deaths but not births in custody. Data collection must include the following: pregnancy prevalence; pregnancy and birth outcomes; pre- and perinatal health care and services provided, including availability of and census in residential nurseries; and the use of shackles and isolated confinement. Data should be reported at the state level to account for high variability and include demographics to allow assessment of disproportionate racial impact. Immigration and Customs Enforcement should also be mandated to publicly release nonidentified data obtained under their pregnancy monitoring directive.
We know even less about the babies born to incarcerated women than we know about their mothers. The vast majority of these babies will be separated from their mothers within days of birth, even in states with nurseries.6 Data are needed regarding how custody decisions are made, who cares for babies born during a mother’s incarceration, and patterns of contact and maternal–child reunification.
While we welcome the new insights these results provide, we join the authors in advising against drawing conclusions about the effects of imprisonment on any of the reported pregnancy outcomes. In particular, we are concerned about favorable comparisons between preterm birth rates of children born to incarcerated and nonincarcerated women. Further research must account for the diversity of this population and the extreme variability in case processing and conditions of confinement across jurisdictions. Use of existing research to support maintaining or expanding the criminal legal response to pregnant women, especially those who use substances, fails to acknowledge limitations in the existing evidence and our lack of more humane responses at scale.
We must also move from surveillance to action by evaluating interventions for pregnant women who are incarcerated or at risk for incarceration. Research efforts should focus on more than public health augmentation of criminal legal responses, which creates the false appearance that we have no other options. In particular, there is great need to build the evidence base for nonpunitive, community alternatives that support the mother–child relationship while addressing the intersecting root causes of women’s justice contact, namely mental illness, trauma, substance use, and poverty. To do this, we can better leverage the existing evidence base on family supportive housing and substance use treatment of pregnant and parenting women.
ACTING NOW WITH HUMAN RIGHTS AS A GUIDE
Even with so little evidence, we can act now using human rights as a guide.7 Incarcerated pregnant women comprise a relatively small group in institutions overflowing with people in need, but they are one of the groups whose health and dignity criminal legal systems are least able to protect. For example, empirically documenting the harms of shackling is unnecessary to advocate for protective laws in states that do not have them and to monitor implementation in those that do.
A human rights approach demands that public health maintain a strong presence in the fight to end mass incarceration. As it relates to pregnant women, we can ensure that their unique needs are included and uplift the voices of directly affected women within the conversation. Ending mass incarceration will require a significant challenge to the status quo about who must be incarcerated. A substantial proportion (approximately one quarter) of incarcerated women have been accused or convicted of violence, and excluding them from alternatives to incarceration, and even parenting programs, has been widely accepted. We can no longer sustain this practice without thoughtful assessments of women’s capacities to maintain safety and good-faith attempts at restorative justice. For pregnant women whose incarcerations cannot be prevented for public safety reasons, we can demand that health and dignity guide decision-making at all phases of criminal justice contact, from arrest, detention, sentencing, and incarceration, to reentry.
ACKNOWLEDGMENTS
The authors would like to acknowledge the Coalition for Women Prisoners.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
Footnotes
See also Sufrin et al., p. 799.
REFERENCES
- 1.Walmsley R. World female imprisonment list. 4th ed. Institute for Criminal Policy Research. 2017. Available at: http://www.prisonstudies.org/sites/default/files/resources/downloads/world_female_prison_4th_edn_v4_web.pdf. Accessed January 30, 2019.
- 2.Carson EA. Prisoners in 2016. NCJ 251149. Bureau of Justice Statistics. 2018. Available at: https://www.bjs.gov/content/pub/pdf/p16.pdf. Accessed January 30, 2019.
- 3.Maruschak L. Medical problems of prisoners. NCJ 221740. US Department of Justice. 2008. Available at: https://www.bjs.gov/content/pub/pdf/mpp.pdf. Accessed January 30, 2019.
- 4.Maruschak L. Medical problems of jail inmates. NCJ 210696. US Department of Justice. 2006. Available at: https://www.bjs.gov/content/pub/pdf/mpji.pdf. Accessed January 30, 2019.
- 5.Kajstura A. States of women’s incarceration: the global context. Prison Policy Institute. 2018. Available at: https://www.prisonpolicy.org/global/women/2018.html. Accessed February 1, 2019.
- 6.Goshin LS, Arditti JA, Dallaire DH, Shlafer RJ, Hollihan A. An international human rights perspective on maternal criminal justice involvement in the United States. Psychol Public Policy Law. 2017;23(1):53–67. [Google Scholar]
- 7. The Economic and Social Council. United Nations rules for the treatment of women prisoners and non-custodial measures for women offenders (the Bangkok Rules). United Nations. 2010. Available at: http://www.refworld.org/docid/4d92e5392.html. Accessed January 30, 2019.