As a mom who was unaware of the issues surrounding these moms-to-be, I was troubled when I read that women are “the fastest growing segment of the prison population.”1 Over a 30 year period, the number of imprisoned women went from 11,212 to nearly 113,000 women.1, 2
Within this population are huge state-to-state and regional disparities. In 2004, more than 10 times more women were imprisoned in Oklahoma than in Massachusetts or Rhode Island.1 Though the reasons for such differences are beyond the scope of this article, those states with high female imprisonment rates need to prepare for the very real issue of pregnant women within their system. More women= more moms-to-be in jail.
So, why the rise in women calling prison their home? According to The Rebecca Project for Human Rights, “Women have borne a disproportionate burden of the war on drugs, resulting in a monumental increase of women who are facing incarceration for the first time, overwhelmingly for non-violent offenses.”3 When compared to men, the crimes of incarcerated women are typically non-violent offenses, and often the result of alcohol, drug, and property offenses.4
The Reality: Pregnancy and Incarceration
Six to ten percent of women entering jail are pregnant.5 The nature of this population means the majority fall within the classification of “high-risk.” Medical problems that negatively affect pregnancy outcomes are common. These include: diabetes, epilepsy, HIV, hypertension, cardiac and renal diseases. Also, many of these women have not received adequate medical care prior to their imprisonment. They are more likely to smoke, be heavy drinkers and use illicit drugs.6 These factors have a significant impact on their requirements for increased (often specialized) prenatal care, as well as their need for education, counseling and substance abuse treatment programs throughout pregnancy and beyond.
Prematurity: A Difficult and Complex Problem in Obstetrics
A racial disparity exists, not only within the prison population where 67% are non-white6, but also in preterm birth (PTB) where Black women have the highest rates (17.5%), followed by Hispanics (12.1%), then Whites (11.1%).7 Research has shown that Black women are three to four times more likely to have their babies very early (between 20 and 24 weeks), in part because of their predisposition to infections.8 Many of the problems discussed mirror the risk factors for PTB (a birth occurring at less than 37 weeks gestation). PTB is a major global issue, where sadly the US ranks worse than most other developed countries. The conditions described in this article all contribute to prematurity.
The risk factors for early birth, the leading cause of infant morbidity and mortality, are those with8:
•A history of pregnancy loss or PTB ( #1 risk factor)
•Womb abnormalities or carrying multiple babies
•A family history of PTB
•Diabetes*
•Periodontal disease*
•Bacterial vaginosis (BV)*, and other genital infections like trichomoniasis, chlamydia, syphilis and gonorrhea.
•High stress*
•A history of cervical surgeries (including multiple D&C/abortions)*
As well as:
•Black women (who have a higher risk if they are underweight or overweight)*
•Obese women with a BMI of 35 or more or those with a low BMI
•Teens
•Heavy smokers*
•Those taking certain antidepressants
•Unemployed women*
•Heavy drinkers, cocaine or heroin users*
* These factors are highly likely in incarcerated pregnant women.
Of Special Concern for Prison Healthcare Personnel8 (Edited excerpts from the book High-Risk Pregnancy- Why Me?)
Based on risk factors of women within the prison system, certain conditions and issues are likely to be encountered in this environment. The following are probable pregnancy issues medical personnel may be faced with when working with this special needs population.
Preterm Premature Rupture of Membranes (PPROM)
Who’s at Risk? Women who:
* Have had a previous PTB
* Are at an economic disadvantage
* Have a low BMI
* Have had a cerclage or biopsy procedures to their cervix
* Are experiencing early contractions
* Have a urinary tract infection or STD
* Are experiencing vaginal bleeding
* Are smokers
Women with suspected early ruptures should immediately be provided specialized care and confirmation using NitrazineTM paper and/or observation of “ferning.” An appropriate management plan under the direction of a perinatologist should be devised depending on the type of rupture (remote from term, near term, etc.). (Women with term ruptures should also be evaluated/monitored immediately.) Other management options will likely include hospitalization throughout the duration of the pregnancy, antibiotics, antenatal corticosteroids and routine monitoring for infection/contractions. Important: care should be taken to limit (preferably avoid) internal examinations to reduce the risk of infection/inflammation. (This is the largest problem faced by providers when managing PPROM, along with preterm contractions.)
Preeclampsia
This condition only affects women and their unborn babies during pregnancy, typically after 20 weeks, or during the six-week period after birth. Preeclampsia is present in about 5-8% of pregnancies. Since imprisoned women are more likely to suffer from hypertension, it is extremely important to monitor these women for this condition. (The #1 risk factor is having had this before, followed by women with a high BMI, a history of chronic hypertension, diabetes, or a kidney disorder, as well as those over 40 or under 18.) Regular prenatal visits are mandatory to track and manage the possible onset. If detected, specialized care must be sought to develop an appropriate monitoring program for the health and safety of mom and baby. (Note: Acetylsalicylic acid (aspirin) has been shown to provide a significant reduction in the incidence of severe preeclampsia, hypertension and IUGR. Magnesium sulfate is another common drug used.)
Warning signs all providers working with pregnant women should be aware of:
* Hypertension of 140/90 or greater, observed twice within a six-hour period. A rise in the diastolic of 15 degrees or more or a rise in the systolic of 30 degrees or more is cause for concern, especially with other symptoms.
* Edema, especially in the hands and face.
* Protein in the urine. A 1+ or higher could mean the start of preeclampsia, even if blood pressure is below the threshold. A 2+ is a major red flag.
* Sudden weight gain of more than two pounds in a week or six pounds in a month (though, this isn’t the most reliable detection method).
* Migraine-like headaches that don’t go away, even when treated.
* Nausea and/or vomiting in the second or third trimester (not to be confused with a stomach bug or food poisoning).
* Changes in vision, such as temporary loss of vision, a sensation of flashing lights, heightened sensitivity to light, blurred vision, or spots before the eyes. This is a very serious symptom and should be checked out immediately.
* Stomach pain beneath the ribs on the right side of the body and/or right shoulder pain. This can be mistaken for heartburn, indigestion or kicking.
* Sudden and specific lower back pain, different from the normal aching in the lower back. This is a possible sign of HELLP or other liver problems, especially if patient is displaying other symptoms of preeclampsia.
* Hyperreflexia.
Placental Abruption
This occurs when the placenta separates from the uterus due to internal bleeding, sometime between the twentieth week and when the baby is born. A hematoma further separates the placenta from the uterine wall, causing compression and compromise of the blood supply to the baby. Though quite rare, only occurring in 1% of pregnancies, it is included here since women with hypertension (the most common cause, occurring in 44% of all cases), diabetics, heavy smokers and/or drinkers, or a history of cocaine use are at a higher risk.
Tests to determine this condition include: abdominal ultrasound, complete blood counts, pelvic exams, fibrinogen levels, partial thromboplastin time and prothrombin time. Placental abruption should be suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The top of the uterus (fundus) may have to be monitored, as a rising fundus can indicate bleeding. Early recognition and proper management are key.
Symptoms of Placental Abruption
* 80% have vaginal bleeding.
* 70% have abdominal or back pain and uterine tenderness.
* 60% of the babies show fetal distress.
* 35% have abnormal uterine contractions.
* 25% experience premature labor.
Intrauterine Growth Restriction (IUGR)
Newborns are considered to have had restricted growth when their birth weight and/or length is below the 10th percentile for their gestational age and they have an abdominal circumference below the 2.5th percentile.
This is a complex issue with multiple etiologies. There are, however, several well-known risk factors including: alcohol abuse, drug addiction, poor nutrition and smoking. Ultrasounds for diagnosis and delivery of the baby at the right time, not too early and not too late, are necessary for the effective treatment in pregnancies affected. (Fundal height monitoring can also help to detect growth restricted babies, but ultrasounds are more accurate/ideal.) If IUGR is identified, monitoring should then include vessel analysis and biophysical testing every week or two, depending on the situation.
Short Cervical Length, Preterm Labor, Incompetent Cervix (IC), Infection
These are complex topics within the Obstetrical arena with thousands of studies and just as many opinions. They are either directly or indirectly related to each other, so due to space constraints, I bundled them together. Below is a brief summary of the recent research, treatments and strategies.
Risk Factors for Short Cervix (and IC) and the Chance of a Premature Baby
* Previous cervical surgery, including laser cone biopsy, cold-knife conization, or Loop Electrosurgical Excision Procedure (LEEP)
* Damage from a previous traumatic birth
* A malformed cervix or uterus
* Previous trauma on the cervix from D&C, multiple abortions
* Deficiencies in cervical collagen and elastin
* Genetic susceptibility/environmental factors (infection, inflammation, uterine activity)
A preventative cerclage, a piece of “string” which is looped in and around the cervix to reinforce it, should be considered for all women with a history of spontaneous second trimester losses, those who’ve had large portions of their cervix removed, etc. Prison medical providers should seek the guidance of a specialist in these cases.
Cervical Length – A Preemie Predictor
There’s general consensus, which is backed by the research, that the shorter the cervix, the greater the risk of an early delivery. (A short cervix is commonly defined as ≤2.5 cm prior to 24 weeks gestation.)
Transvaginal sonography (TVU) – has increased the ability to predict and even treat women at risk of a premature baby by measuring cervical length.
Suggested TVU Screening Scenario:
* One check at around 18-22 weeks in low-risk women
* For high-risk women – e.g., those with a prior preterm birth – two checks, one at 14-18 weeks and another at 18-22 weeks
* For extremely high-risk women – i.e., those with a history of a second-trimester loss or very early spontaneous preterm birth – TVUs are recommended every two weeks from 14 until 24 weeks.
Understanding the Numbers:
* A length of less than 2.5 cm is best for predicting an early birth. The earlier a short length is seen, the higher the risk.
* A cerclage should be considered in high-risk women with a cervix shorter than 2.5 cm (prior to 24 weeks). The reduction in preterm birth following a cerclage has been shown to be about 30%.
* Cervical length of greater than 3.0 cm at 24 weeks = low risk of an early delivery.
Provider Options to Managing Early Birth
•In situations of preterm labor, providers need to consider whether there is an underlying problem, such as infection, triggering it. There are many side effects, with the use of tocolytics, to both mom and baby, so experience in this area is required. Research has shown promise in the ability of these medications to extend pregnancy to allow for transfer and steroid administration, as well as stopping a bout of preterm labor (specifically, Nifedipine due it’s overall safety profile and Indomethacin).
•17 Alpha-Hydroxyprogesterone Caproate (aka 17P or progesterone) is a hormone which is shown to reduce PTB by 33% in women with a history of a prior early birth. Every woman with a history of a spontaneous early birth should be prescribed this medication during pregnancy. (Low-risk women with cervical shortening of ≤2.5 cm vaginal progesterone has demonstrated a substantial decrease in delivery before 33 weeks, as well as reduced neonatal morbidity and mortality.9)
•Fetal Fibronectin (FFN) swabbing is a test used to help “predict” the likelihood that the patient will deliver within 7-10 days. A negative equates to a >90% confidence that the woman will not deliver during this period. There is a huge range of variability with positive results, meaning only about 9-46% confidence. When swabbing of the cervix confirms the presence of fetal fibronectin (FFN) after 22 weeks, a link to PTB has been shown to exist. (Combined FFN swabbing and cervical length determination is the ideal approach when determining management plans for symptomatic women.)
•Steroids should be considered for women being treated for preterm labor between 24 and 34 weeks (dexamethasone or betamethasone).They are given as a series of shots in the muscle, two shots 24 hours apart, or 4 shots 12 hours apart. The use of steroids has drastically reduced preemie death rates, respiratory distress syndrome and intraventricular hemorrhage.
Make Adequate Prenatal Care, Nutrition and Education a Priority
Though an extremely complex issue, it’s important to provide these moms-to-be proper care and nutrition throughout imprisonment to meet their additional needs during the antepartum period and to help ensure healthy outcomes for mom and baby. This would ensure they “are not further compromised by poor care during imprisonment.”6 Pregnant women with specific problems, such as diabetes or hypertension, need to have access to specialist care.
It should be noted that studies have shown that there may actually be a beneficial effect for babies when mom is imprisoned, by providing food (leading to higher birth weights), shelter, protection from abusive partners, access to prenatal care, and moderation/elimination of alcohol and drug use.6, 10, 11 Though, there still appears to be much needed improvements within many state systems in order to meet the needs of this specialized population. The Rebecca Project reported that 38 states received a failing grade in prenatal care, which include inadequate policies, prenatal care, nutrition, screening and treatment for women with high-risk pregnancies.3
Providing education, with a combination of written through the library and on-site classes are ideal and should be a priority. Women should be provided the opportunity to educate themselves about pregnancy, what they can expect, body changes, potential risk factors, signs, symptoms or issues they should be aware of (such as the signs and symptoms of PTB, PPROM or preeclampsia), the importance of proper nutrition, etc.
Steps for Medical Personnel to Help Ensure Healthier Pregnancies
•Every incoming female should be tested for pregnancy as soon as possible to identify those who will need antenatal care. An ultrasound should be performed on all pregnant inmates to determine gestation. (Note: First trimester ultrasounds are more accurate for pregnancy dating than later ultrasound testing.)
•All pregnant women should take prenatal vitamins with folic acid as soon as they arrive in the facility or are identified. Along with preventing neural-tube defects, it has also been shown to reduce PTB. (Education about the benefits to the baby’s development may help with compliance within this population. Explaining to mom that her baby could be severely disabled or die as a result of not taking vitamins may help her to better understand the needs of her developing baby, hence, improve her willingness to participate.)
•Programs within the system should include smoking cessation, as well as comprehensive alcohol and drug programs. These behaviors are linked to not only PTB, but low birth weight, IUGR, PPROM, placenta previa and placental abruption.
•A FULL and DETAILED medical history should be obtained for every pregnant woman by a trained obstetrical provider (including detailed discussions around risk factors). This evaluation should be used to determine the specific needs of each woman and the likelihood of pregnancy issues and early birth. (Sadly, actual access to prenatal care has been shown to be sparse and inconsistent within the prison system, which was designed to meet the needs of males.3)
•Women should be screened and treated for sexually transmitted infections and HIV.
•Programs which meet the specific nutritional needs of pregnant women must be implemented (and followed). (Proper nutrition reduces the risk of PTB, certain birth defects and low birth weight babies.)
•As stated previously, education materials and one-on-one discussions to help women better understand their situation/needs and pregnancy/birth in general should be mandatory.
The Doula Perspective – Birth and the Confined Mom
As a doula (a woman who assists women and families during the birth process, physically and emotionally), I couldn’t let this article go without a mention of labor and delivery for imprisoned moms.
•Thirty-six states received a failing grade for their shackling practices of pregnant women.3 Shackling should ONLY be reserved for the most violent of offenders (so a very small fragment of the female prison population) or those with a previous escape attempt. This practice is not only a health and safety issue, it is inhumane and falls under cruel and unusual punishment. (I couldn’t imagine giving birth while tied up.)
•States should evaluate the use of prison nursery programs which help foster the bond between mom and baby. (Thirty-eight states failed for not offering this to new imprisoned moms.3)
•Pregnant inmates should have a plan for their birth in a hospital or birth center. Under no circumstances should a woman give birth in her jail cell.
•Every mom-to-be should receive education regarding the labor and birth process, help developing a birth plan (her choices for pain relief, etc.) and should be allowed to have someone there for support during her birth (ideally family, significant other, or a doula for non-violent, low-risk offenders). Prison doula programs should be considered to help support and educate incarcerated pregnant women.
•The basic needs of pregnant women should be met, even during imprisonment (adequate beds, pillows and clothing to manage body changes and back pain).
Even Small Changes Matter
The complexity of issues regarding pregnancy and prison must be overwhelming to those who work within and manage the prison system. Even baby steps can lead to great change. Each in turn, will make a positive difference and impact within the population you serve. Providing mothers and babies with a healthy start trickles down to shape a better future for children born to imprisoned women.
References
1. Frost NA, Greene J, Pranis K. HARD HIT: The Growth in the Imprisonment of Women, 1977-2004. Institute on Women & Criminal Justice (The Punitiveness Report) May 2006
2. Guerino P, Harrison PM, Sabol WJ. U.S. Dept. of Justice, Bureau of Justice Statistics, Prisoners in 2010; Dec. 2011, NCJ 236096
3. Saar MS, Bisnott B, Mathon-Mathieu F, et al. The Rebecca Project for Human Rights, National Women’s Law Center, Mothers Behind Bars: A state-by-state report card and analysis of federal policies on conditions of confinement for pregnant and parenting women and the effect on their children. Oct 2010
4. Hotelling BA. Perinatal Needs of Pregnant, Incarcerated Women. J Perinatal Education 2008;17(2):37-44.
5. Clarke JG, Phipps M, Tong I, et al. Timing of conception for pregnant women returning to jail. J Correct Health Care 2010;16(2):133-138.
6. Knight M, Plugge E. Risk factors for adverse perinatal outcomes in imprisoned pregnant women: a systematic review. BMC Public Health 2005;5(111).
7. Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary Data for 2008. National Vital Statistics Reports 2010;58(16).
8. Whitehead, Kelly. High-Risk Pregnancy- Why Me? Understanding and Managing a Potential Preterm Pregnancy. A Medical and Emotional Guide. McAfee, New Jersey. Evolve Publishing, 2012.
9. Romero R, Nicolaides K, Conde-Agudelo A. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data. Am J Obstet Gynecol 2012;206(2):e1-124.
10. Tanner R. Pregnancy outcomes at the Indiana Women’s Prison. J Correct Health Care 2010;16(3):216-219.
11. Knight M, Plugge E. The outcomes of pregnancy among imprisoned women: a systematic review. BJOG 2005;112(11):1467-1474.
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