Author(s): Beth D. Williams-Breault
Incarcerated women’s healthcare has traditionally been neglected due to a lack of standards, inadequate funding, transportation barriers, and lack of advocacy. In the United States, no federal government body has established national standards for medical care in prisons. However, various nongovernmental organizations offer voluntary healthcare standards including the American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC). Accreditation from these organizations suggests a constitutionally acceptable level of care for inmates and leads to improved health status, fewer grievances and lawsuits, and reduced health risks to the community.
The general health care disparities among incarcerated women are vast, although when women are imprisoned, they gain a constitutional right to health care that doesn’t exist outside of prison. The 1976 Supreme Court decision Estelle v. Gamble established that “deliberate indifference to [an incarcerated person’s] serious medical needs” violates the Eighth Amendment’s prohibition on cruel and unusual treatment [1]. The Constitution prohibits correctional officials and staff from “intentionally denying or delaying access to medical care or intentionally interfering with treatment once prescribed” [2]. However, no federal government body has established national standards for medical care in prisons. Various nongovernmental organizations do offer voluntary standards, including the American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC), which accredit jails and prisons [3]. Standards published by ACA include a section on health care, although it is not as detailed as the standards published by the NCCHC. In order to uphold the highest standards for incarcerated women’s health, it is recommended that health commissions throughout the United States work with community partners to gain NCCHC accreditation for all county and state correctional facilities.
Women represent 9-14% of the incarcerated population in the U.S. and 6-10% of incarcerated women are pregnant at some point in their sentence. This means there are approximately 12,000 pregnant women incarcerated in the U.S. at any point in time and these women are not receiving adequate prenatal or postnatal care. A significant portion suffer from addiction and mental illness, have STIs, have experienced physical or sexual trauma, experience stress related to parting with baby after delivery, and are experiencing unintended pregnancies. Incarcerated women’s healthcare has traditionally been neglected due to a lack of mandatory standards of care, inadequate funding and equipment, complicated transportation barriers, and lack of advocacy. Correctional officers are not always available to accompany an inmate to a medical appointment. Furthermore, being shackled and wearing a uniform is a major deterrent for women choosing to seek care in public. Studies show that being in prison while pregnant is actually a protective factor for some birth outcomes when it is compared to women who have been incarcerated but were pregnant at a time other than their incarceration. Each day spent pregnant in prison increases birth weight by 1.49 grams compared to women who have been incarcerated and have given birth but were not pregnant while incarcerated [4]. This is likely due to having reliable meals and housing, and possibly a greater access to the healthcare system than before incarceration. Additionally, suicide rates of incarcerated pregnant women are half that of non-pregnant incarcerated women. Incarceration has the potential to greatly affect pregnancy outcomes and policy that improves healthcare for incarcerated women would improve birth outcomes.
In Massachusetts, the Massachusetts Correctional Institution (MCI) Framingham is the only institution for female-only offenders. Women are sentenced to this state prison (maximum and medium security). Also, women who are waiting to go on trial or serving a sentence for a misdemeanor in Essex, Middlesex, Norfolk and Plymouth Counties are housed there. MCI Framingham has a daily average of 568 inmates [5].
At MCI Framingham, every woman under the age of 55 is given a urine pregnancy test upon entry and again two weeks later. These are National Commission on Correctional Healthcare (NCCHC) guidelines. If the urine test is positive, an OB is called to order prenatal vitamins and the woman is given a full exam when the facility is able to transport her to Boston Medical Center (BMC). Dr. Shannon Bell of BMC spends one day per week providing care at MCI Framingham. Bell maintains that pregnant women are given Options Counseling- non-bias counseling and support to determine how desired the pregnancy is. If the patient desires an abortion, she is taken to BMC and it is performed surgically. Surgical abortions are preferred by most incarcerated women because the procedure happens in the privacy of the hospital and there is less visible recovery time. These abortions are provided on the same day as the off-site visit with the OB to minimize transport issues [6].
These women are immediately given the flu vaccine, TB testing, and STI testing. If they have a history of substance abuse, maintenance therapy is allowed. For all future appointments and for delivery, the patient is transported to BMC, unless it is an emergency, then the patient is transported to MetroWest Medical Center in Framingham. All pregnant women at MCI Framingham are granted the privilege of bottom bunk
In 2014, Governor Deval Patrick signed a bill that banned leg and waist shackling among incarcerated women who are pregnant, in labor, or are postpartum in an effort to improve the safety and care of female inmates. Hand shackles are allowed at times other than during labor. This bill also stated that pregnant women must be transported in a vehicle with working seat belts, an MD or nurse can order the removal of restraints at any point in time, and the officer in the care-delivery room must be female and must respect the patient’s privacy. As of 2016, 22 states did not have this law and according to the Prison Birth Project, Massachusetts is not fully compliant of this law [7]. In 2016, Middlesex County, and thus MCI Framingham, violated the anti-shackling law in three areas: did not always ban postpartum restraints in transportation, did not always ban leg and waist restraints, and did not accurately define ‘extraordinary circumstances’ in which these laws may be broken. None of the Massachusetts counties were fully compliant with all aspects of the anti-shackling law.
Recommendation Accreditation suggests a constitutionally acceptable level of care for inmates. This leads to improved health status, fewer grievances and lawsuits, and reduced health risk to the community when inmates are released [8]. Although Massachusetts correctional facilities are only guided by the NCCHC standards [9], full accreditation would pave the way for quality improvement and achievement of a nationally accepted standard of care in health services delivery, not just for women, but for the entire incarcerated population. The Standards for Health Services (the basis of NCCHC’s accreditation program for jails, prisons, and juvenile detention and confinement facilities) contain several standards that impact women’s health care, including the following [10]:
• Receiving Screening (E-02) suggests inquiry into current gynecological problems and pregnancy for women and female adolescents. • Initial Health Assessment (E-04) recommends that clinical practice guidelines be followed for pelvic examinations and Pap smears. • Intoxication and Withdrawal (G-07) acknowledges the special management of pregnant inmates with opioid use disorders. • Contraception (G-08) recommends that women be provided with nondirective contraception counseling, access to emergency contraception, and continuation of current contraceptive method while incarcerated.
Counseling and Care of the Pregnant Inmate (G-09) specifies that comprehensive counseling and assistance are given to pregnant inmates in keeping with their express desires in planning for their unborn children, whether they desire abortion, adoptive service, or to keep the child. It also addresses prenatal care and the nonuse of restraints during childbirth.
More specifically, The Prison Birth Project’s report Breaking Promises: Violations of the Massachusetts Pregnancy Standard & Anti-Shackling Law (2016) recommends that if a woman is pregnant, full-scale pregnancy services should be provided which include options for counseling. A trained counselor will speak with the inmate about how desired her pregnancy is. If the pregnancy is undesired, access to abortion will be offered but the desire to have an abortion will not be assumed. If the pregnancy is desired, the patient will be fully supported and will be given quality and timely prenatal care by a qualified healthcare provider either onsite or offsite. This qualified healthcare provider will follow community standards for pregnancy care, focusing on both mom and baby, and will require certain privileges for the patient including having the bottom bunk and unlimited water.
If the patient must be transferred to a hospital for routine care, the correctional facility will be fully compliant with all aspects of the 2014 Anti-Shackling Law including absolutely no leg or waist shackling, requiring working seatbelts in transportation, allowing only a female officer in the care room, obeying a doctor’s or nurse’s order to remove shackles at any time. If the woman receives onsite care, she must receive the same quality as off-site care [11].
The care provider should use a trauma-informed approach and should treat the patients with respect, listening to what they need and being sensitive to their life-experiences. Most women are incarcerated for nonviolent crimes often related to addiction, trauma, or lack of access to medical or mental health care. Providers should engage patients in the process of their health care and pregnancy including the importance of maintaining a healthy lifestyle while under the constraints of incarceration, offering family planning services, and advocating for them to have doulas or other support systems. Providers should keep in mind the continuity of care and how these women can access community services post-release. If the facility does not have adequate equipment, mobile care such as ultrasound vans should be considered and contracted with [12].
It is recommended that all health commissions in the United States work with community partners to gain NCCHC accreditation. Community partners in Massachusetts could include the Massachusetts Department of Public Health, Boston Medical Center, Boston University School of Public Health, and Boston University School of Medicine. This recommendation should be shared with the Massachusetts Department of Correction, as it would apply not only to MCI - Framingham, but to all correctional facilities.
If all state and county correctional facilities seek accreditation, they will be striving towards quality improvement and achievement of a nationally accepted standard of care in health services delivery. The process is challenging, but NCCHC staff members help facilities by providing guidance throughout the process. Compliance is measured by a survey team composed of experts who also share suggestions for improvement during the site visit. Staff from accredited facilities consistently remark on the value of feedback from knowledgeable professionals. Accreditation also signals a constitutionally acceptable level of care for a facility’s inmates, which translates into improved health status, fewer grievances and lawsuits, and reduced health risk to the community when inmates are released [13].
