Prenatal care: Incarcerated females

INTRODUCTION — While the same standards of obstetric care apply whether patients are living in correctional facilities or the community, the risk factors associated with incarceration and the operating systems of correctional facilities create specific challenges to the provision of routine obstetric care for residents of these facilities. These challenges include difficulties with communication and transportation, implementation of care plans, follow-up of abnormal tests, and guardianship for newborns. In a systematic review, key patient-reported concerns included mental health challenges, dehumanization of prenatal care and birthing, lack of privacy, stigma, psychological trauma, lack of emotional support, use of shackles, lack of access to female correctional officers, lack of timely medical care and support for breastfeeding, and the devastation of separation from their newborn [1].

This topic will discuss issues encountered in caring for incarcerated pregnant people. Our recommendations are generally consistent with guidance provided by the American College Of Obstetricians and Gynecologists [2] and American College of Physicians [3]. While much of the discussion is based on data and experience from the United States, the general care principles may be applicable to other locations. Topics on general medical care in correctional facilities, routine prenatal care, and the impact of parental incarceration on children are presented separately.

●(See "Clinical care of incarcerated adults".)

●(See "Prenatal care: Initial assessment" and "Prenatal care: Second and third trimesters" and "Prenatal care: Patient education, health promotion, and safety of commonly used drugs".)

●(See "Developmental and behavioral implications for children of incarcerated parents".)

EPIDEMIOLOGY — In the United States, approximately 3 to 4 percent of females in state prisons and jails were pregnant between 2016 and 2017 [4,5]. Data on pregnancy and incarceration are limited because of variable reporting requirements and inconsistent pregnancy testing upon entry to correctional facilities.

The female incarcerated population has increased at a rate double that of males in many countries [6-8]. Although the number of female prisoners in the United States increased by over 700 percent since 1980, the number of females incarcerated in state and federal correctional facilities decreased by 2.6 percent between 2007 and 2017 (from 114,311 in 2007 to 111,360 in 2017) [9].

SPECIAL CONSIDERATIONS

Pregnancy testing — Policies on pregnancy testing upon being admitted to the correctional system vary by institution. The National Commission on Correctional Health Care (NCCHC) and the American College of Obstetricians and Gynecologists advise [10,11]:

●Offer a pregnancy test to all females under age 55 years, and

●Repeat testing two weeks later (in case the first test was performed before the human chorionic gonadotropin level was detectable), and

●Repeat testing as needed for those who remain at risk of pregnancy (eg, because of conjugal visits from spouses, leaves of absence during incarceration)

Pregnancy testing upon entry to the correctional system allows for timely counseling regarding possible emergency contraception, prenatal care, triage of pregnant people with obstetric or medical concerns (eg, vaginal bleeding, possible ectopic pregnancy, opioid withdrawal), and pregnancy termination.

Communication between on- and off-site staff — To ensure that pregnant patients receive the care they need, good communication is essential among the on- and off-site medical staff and the security staff, as well as with the patient. Two major areas that need to be addressed are:

●Establishing a treatment schedule – On-site medical staff tend to establish treatment schedules and ensure feasibility of treatment plans (for both on- and off-site visits). The individual is then given permission per facility protocol (a written document or entry in the incarceration facility's computerized system) that allows them to leave their unit or other duties in the correctional facility to visit the medical unit at specified times for on-site care.

Most facilities request that future off-site appointments are communicated to the on-site health care providers so future transport can be arranged. Incarcerated individuals are typically not told of their future off-site appointment dates for security reasons.

●Advising on-site staff of pregnancy issues – Officers and on-site clinicians who do not regularly provide prenatal care for incarcerated people may need to be advised about pregnancy-related activity restrictions (eg, types of work assignments), safety issues (eg, use of the bottom bunk bed, restrictions on shackling such as no leg restraints), and nutritional requirements and interventions (eg, prenatal vitamin supplementation, continuous access to hydration, small frequent meals, special diets such as for gestational diabetes).

Our approach — While the resources of correctional systems vary, we have found the following approach enables expedient care for the pregnant person and successful communication among health care providers and correctional staff:

●Upon entry into a correctional facility, the health provider enters routine pregnancy restrictions into the incarceration facility's computerized system that can be viewed by correctional officers and other on-site medical staff. The restrictions are active for the duration of pregnancy and for six weeks after the estimated date of delivery. This process occurs within 24 to 72 hours of arrival.

●If on-site prenatal providers are not present when a new patient arrives, orders for routine prenatal care and medications (eg, prenatal vitamins, acetaminophen, anti-emetics) are reviewed by the admissions nurse with the on-call medical provider so patients can receive necessary treatments in a timely fashion. Appropriate pregnant patients may have certain medication orders approved for "keep on person" status, which allows the patient to take a supply of medication with them rather than returning to the medication line every time those drugs are needed.

●Electronic health records allow correctional staff and medical providers to communicate. The correctional staff can view the dates, times, and locations of all of the incarcerated individual's appointments (eg, court dates, medical appointments, mental health appointments or group sessions, childbirth classes [where available], or work assignments).

●For appointments at off-site facilities, the off-site providers place their notes and any follow-up appointment information in a sealed medical documents folder that the correctional officer carries back to the facility. The medical documents folder is then given to the nursing staff or a medical provider who ensures information about future appointments is entered into the incarceration facility's computerized system. If questions arise regarding the ability of the correctional facility to meet the requirements of the treatment plan, the correctional staff contacts the on-site nurse practitioner.

●At times, incarcerated patients will ask the off-site obstetrics provider to authorize or request special privileges such as extra blankets, pillows, or food. We have found that if the off-site providers communicate these requests with on-site medical staff, the latter will review such requests with the correctional staff to make sure those special privileges are considered in the correctional setting to be medically necessary.

HIPAA compliance — Under the Health Insurance Portability and Accountability Act (HIPAA), an incarcerated individual's medical information is deemed protected health information (PHI) [12]. An off-site clinician can share medical information with the correctional facility if the PHI is necessary for the provision of health care or to protect the health and safety of the individual or other incarcerated individuals.

Correctional officers should never be used to communicate between off-site and on-site providers as they are not health care providers nor are they held to HIPAA standards. During prenatal visits, labor, and birth, the clinician may have to request that the correctional officer leave the room for examinations and procedures to ensure the patient's privacy. However, a correctional officer's presence may be necessary in some situations, such as security or escape issues.

Consent for medical procedures — The process of obtaining patient consent for medical treatment or procedures is the same in correctional settings as in community settings. Incarcerated individuals have autonomy: the right to make informed health care decisions, including refusal of medical care if they are deemed to have the capacity to make this decision.

Specific to the correctional setting, incarcerated individuals may be banned from consenting to postpartum sterilization (permanent contraception) because of historic concerns around coercive sterilization. (See 'Contraception and sterilization' below.)

Pregnancy termination — While incarcerated, individuals may retain a legal right to abortion services, but individual experience varies by the state, region, and facility [13,14]. Full access to services, including appointments, transportation, and payment, is not always available. For example, state and federal prisons may be prohibitively distant from an abortion clinic (75 to 383 miles) [15].

Most correctional facilities do not pay for abortion-related services. Therefore, incarcerated pregnant people, who have limited opportunities to save or borrow money while in custody, must rely on private savings or must seek a donor through nonprofit sources [13,16]. Pregnancy termination procedures are considered an outpatient service, and in certain locations the costs are covered either by the health care vendor contracted by the Department of Corrections (DOC) or the DOC itself if there is no vendor. Hospital admissions of greater than 24 hours can be billed to Medicaid. The Hyde Amendment prohibits the use of federal dollars to fund abortions, which affects individuals in the custody of the Federal Bureau of Prisons.

In our practice setting, abortion care is provided through our safety net hospital, and every attempt is made to provide same-day services (eg, counseling and, if desired, an abortion procedure at the same visit) to minimize patient discomfort and potential transportation challenges.

Transportation — Prenatal care of incarcerated individuals is generally shared between on-site and community-based clinicians. Thus, transport to nearby medical facilities is typically needed for portions of routine care (eg, ultrasound for fetal anatomic survey) or to manage high-risk or complicated pregnancies. Transportation to and from an outside medical facility can be stressful, and some individuals decline outside medical care for this reason. Potential stressors include long wait times to pass through security systems, embarrassment about being seen in public in correctional facility uniforms and restraints, and the need to be strip searched on return to the correctional facility. Transportation to appointments can also be complicated by unanticipated lockdowns that halt movement of incarcerated individuals through and out of the facility.

When caring for incarcerated patients with high-risk pregnancies, the amount of time required for the entire transport process needs to be factored into management plans. With the onset of a medical problem or emergency, the patient generally needs to contact a correctional officer, who will then contact a nurse, who will contact a clinician or other health care professional with obstetric experience before the decision is made to evaluate or transfer the patient. Additional time is required for passage through the security systems. These events occur before the patient is on their way to the outside medical facility, which could be a significant distance from the correctional facility where they are housed.

Follow-up care after release — While an estimated 1400 incarcerated individuals per year give birth while incarcerated in the United States [10], most pregnant incarcerated individuals will be released prior to giving birth. Upon leaving a correctional facility, obstacles to continuity of care include lack of stable housing, lack of transportation, and financial challenges (eg, lack of income, savings, or support from friends or family to pay for food and shelter).

To help ensure that time-sensitive imaging or laboratory tests (eg, fetal anatomic survey, aneuploidy and diabetes screening, assessment of fetal growth) or treatments (eg, anti-D immune globulin) occur on schedule, we take the following approach:

●Provide intensive assistance to help reactivate a patient's health insurance prior to release.

●When possible, share all follow-up appointment dates with the incarcerated individual immediately prior to release and explain the purpose, and importance, of each. This transfer of information may not be possible if an individual is released directly from court.

●Where possible, schedule follow-up care with the same provider or health care facility that managed the individual's care during incarceration. For individuals who cannot follow up with the prior care provider, we make every attempt to transfer their care and records prior to their release to the individual's preferred prenatal provider.

●Encourage correctional facilities to provide incarcerated individuals with medication in hand to bridge the individual to their next appointment. If medication cannot be released, the on-site medical staff can fax or call in prescriptions to outside pharmacies to be filled. In our experience, prescriptions are best written by the on-site medical staff as they have the most accurate information as to when the individual may be released from the facility (the individual often does not have this information). Institutional policies vary regarding provision of medication upon release [17].

●For individuals receiving methadone or buprenorphine, we contact an accessible treatment clinic or approved provider prior to the patient's release from the correctional facility. Methadone clinics typically require very specific documentation from the medical providers in the correctional facility, including a letter documenting the patient's last methadone dose.

PROVISION OF ROUTINE PRENATAL CARE — Incarcerated individuals are entitled to health care under the Eighth Amendment of the United States Constitution [18]. Policies regarding pregnancy-related health care for female incarcerated individuals vary among states [19] and countries [6,20-23]. Several organizations, including the Federal Bureau of Prisons, the National Commission on Correctional Health Care, and the American College of Obstetricians and Gynecologists, have proposed minimal standards for pregnancy-related health care in correctional settings.

●Genetic counseling and testing – Obstetric standards for genetic counseling, genetic screening, and diagnostic testing are the same for incarcerated individuals and those in the community.

However, abnormal test results create additional challenges for incarcerated individuals because they have decreased or no contact with family and friends, and therefore limited psychosocial support. The father of the fetus may not be available for genetic testing, which is sometimes important when the maternal result is abnormal. In addition, incarcerated individuals have reduced access to information on the test/disease as correctional facilities typically have limited library resources and no internet access for them. For these reasons, clinicians are advised to discuss abnormal test results, provide counseling services, and offer diagnostic testing during the same visit, if possible, or as expediently as possible.

●Ultrasound examination – Ultrasound examination for confirming or revising the estimated date of delivery, screening for congenital anomalies and short cervical length, and fetal surveillance (growth, well-being) follows the same guidelines as for nonincarcerated patients. Given the challenges of scheduling and transportation, efforts should be made to provide immediate counseling and support for abnormal test results.

●RhD status – All pregnant incarcerated individuals undergo an early maternal blood type with antibody screen as a part of their routine prenatal care. Intravenous use of nonprescribed drugs, particularly the practice of needle sharing, is a risk factor for alloimmunization to RhD and non-RhD red blood cell antigens. RhD-negative pregnant people without RhD alloantibodies receive anti-D immune globulin for routine indications (eg, bleeding during pregnancy) and as prophylaxis at 28 weeks of gestation. (See "RhD alloimmunization: Prevention in pregnant and postpartum patients".)

Consultation with a maternal-fetal medicine specialist is desirable for pregnancies complicated by alloimmunization. (See "RhD alloimmunization in pregnancy: Management" and "Management of non-RhD red blood cell alloantibodies during pregnancy".)

●Childbirth education and support – Education about and preparation for labor and delivery is especially important for individuals who will give birth while incarcerated because they typically must labor or undergo cesarean birth without the presence of family, friends, or a partner for support.

Childbirth education in the correctional facility can help reduce anxiety about the birth process and prepare the individual for returning to the correctional facility without their child. Models of childbirth education include facilitated group discussions [24] and doula visits to the correctional facility [25].

The authors' institution offers every patient who will give birth while still in custody a doula (at no cost) who speaks their language and provides support during labor or cesarean birth.

SPECIFIC MEDICAL CONCERNS

High-risk pregnancies — We advise appointing a medical liaison to oversee medical/obstetric conditions that are primarily managed by off-site practitioner(s) to facilitate the communication of critical or complex care plans for high-risk pregnancies and help overcome obstacles to care. The medical liaison can communicate changes in the care plan with the facility clinicians, answer questions for the incarcerated individual or correctional staff, and help resolve system challenges or failures. In our practice, our liaison is a team composed of a nurse practitioner who is based entirely in the correctional facility, as well as an obstetrician-gynecologist who primarily works at the off-site hospital where incarcerated patients will deliver and comes to the correctional facility on a weekly basis to provide care.

Incarcerated individuals tend to have complicated and/or high-risk pregnancies. Contributing factors include low socioeconomic status, late or no previous prenatal care, current or prior trauma (physical, sexual, psychological), illicit drug and/or excessive alcohol use, smoking, mental health disorders, chronic illness, and acute or chronic infectious diseases [26-31]. As in any pregnancy, each patient is assessed for risk factors for adverse pregnancy outcome and monitored and treated as appropriate for the clinical situation.

Medical complications of pregnancy that require special treatment plans are particularly challenging for incarcerated individuals because they have limited access to medical facilities and difficulties with transportation. As an example, incarcerated individuals are typically required to go to a medical unit every time a glucose level needs to be checked because medical equipment such as lancets can pose a security risk. The timing and frequency of access to the medical unit for procedures, such as glucose or blood pressure monitoring, can be restricted by the need for a nurse or correctional officer to call and escort the individual to the medical unit.

Infectious disease

●Sexually transmitted infections – Tests for the following sexually transmitted infections are performed routinely at the first prenatal visit and then repeated in the third trimester for individuals who are at high risk: syphilis, hepatitis B antigen, hepatitis C antibody, HIV, chlamydia, and Neisseria gonorrhoeae. Incarcerated females also benefit from routine Trichomonas vaginalis testing. In a cross-sectional analysis of data from 205 females entering a correctional facility in Rhode Island who were at risk for an unplanned pregnancy, one-third tested positive for gonorrhea, chlamydia, or trichomonas [32]. As these individuals are also at increased risk of human papilloma virus (HPV) infection, cervical cytology and HPV testing is performed if not up-to-date. (See "Prenatal care: Initial assessment", section on 'Laboratory tests'.)

●HIV – HIV testing is routinely performed in pregnancy unless the patient declines (opt-out) [33]. Repeat testing is recommended for incarcerated and other high-risk individuals in the third trimester, preferably before 36 weeks.

According to the Bureau of Justice, there were 1220 female incarcerated individuals with HIV or acquired immunodeficiency syndrome (AIDS) in state and federal prisons in 2015 [34]. Approximately one-third were admitted in states that conducted mandatory HIV testing, and an additional 31 percent were admitted in states with opt-out HIV testing during intake. (See "Screening and diagnostic testing for HIV infection" and "Clinical care of incarcerated adults", section on 'Testing for HIV'.)

●Vaccination – In addition to testing for infections, routine antepartum vaccinations (eg, influenza and Tdap) are particularly important for incarcerated individuals as they have little to no control over their exposure to others with respiratory illness. Postpartum, other vaccinations (eg, human papillomavirus; measles, mumps, and rubella [MMR]; varicella) should be given, as appropriate. Up to date COVID-19 vaccination is recommended and without regard to gestational age. (See "Immunizations during pregnancy", section on 'Routine prenatal immunizations' and "Immunizations during pregnancy", section on 'Postpartum immunization'.)

Mental health

●Prevalence and consequences – Approximately two-thirds of incarcerated females report a history of mental health problems, and 20 percent meet the threshold for recent serious psychological distress [35]. Symptoms can be exacerbated by the stress of being incarcerated, pregnant, or both [36-38].

Among the consequences of mental health disorders, incarcerated individuals who reported a mental health problem were twice as likely as those without to have been injured in a fight during incarceration in one study (20 versus 10 percent) [39]. The impact of violence among incarcerated individuals is compounded when the individual is pregnant since abdominal trauma can cause abruption.

Suicide rates are markedly lower among pregnant incarcerated individuals; the rate is estimated to be half of that observed for nonpregnant female incarcerated individuals [40]. Although pregnancy appears to reduce the rate of suicide, the protective effect may be diminished if the pregnancy is undesired or if the pregnancy ends in miscarriage or stillbirth [41]. (See "Clinical care of incarcerated adults", section on 'Prevention of suicide and self-harm'.)

●Screening – As in the community, pregnant incarcerated individuals should be screened for depression and anxiety at the initial prenatal visit, later in pregnancy, and at postpartum visits using a standardized, validated tool (table 1 and figure 1A-B) [10,42]. Systems should be in place to ensure timely access to assessment and diagnosis, effective treatment, and appropriate monitoring and follow-up based on severity.

Before initiating pharmacotherapy for depression, screening for bipolar disorder (table 2) should be performed because misdiagnosis can lead to inappropriate choice of depression treatment, which may precipitate mania, mixed states, rapid cycling, or psychosis. (See "Unipolar major depression in adults: Choosing initial treatment" and "Severe antenatal unipolar major depression: Choosing treatment" and "Severe postpartum unipolar major depression: Choosing treatment" and "Mild to moderate episodes of antenatal unipolar major depression: Choosing treatment" and "Generalized anxiety disorder in adults: Management" and "Bipolar disorder in women: Preconception and prenatal maintenance pharmacotherapy" and "Bipolar disorder in women: Indications for preconception and prenatal maintenance pharmacotherapy".)

●Treatment – Those with a known diagnosis or who screen positive should be evaluated by a mental health specialist. Referral for mental health evaluation can be initiated by both medical and correctional staff. The request for evaluation is then triaged based on urgency. In the facility in which we provide health care, incarcerated individuals who do not require urgent care are seen within two weeks of the request. Drug treatment of mental health disorders must balance the risks and benefits of medication compared with no treatment for both the mother and the fetus (or breastfeeding infant). (See "Antenatal depression: Pregnancy and neonatal outcomes" and "Unipolar major depression in pregnant women: Prevention and general principles of treatment" and "Teratogenicity, pregnancy complications, and postnatal risks of antipsychotics, benzodiazepines, lithium, and electroconvulsive therapy" and "Bipolar disorder in pregnant women: Screening, diagnosis, and choosing treatment for mania and hypomania".)

Physical and sexual trauma — A history of physical and/or sexual trauma, and especially complex or repeated trauma, is common amongst incarcerated individuals, particularly females [37]. We advise a trauma-informed approach to care of all female incarcerated individuals to promote autonomy and reduce retraumatization. (See "Human trafficking: Identification and evaluation in the health care setting", section on 'Trauma-informed care'.)

To prevent sexual violence, the United States has federal laws (Prison Rape Elimination Act of 2003 [PREA]) to prevent, detect, and respond to sexual abuse in correctional facilities [43]. (See "Clinical care of incarcerated adults", section on 'Sexual violence'.)

Substance use and treatment

●Tobacco use – A study of two United States urban prisons reported daily smoking rates of 42 and 91 percent for incarcerated females [44]. To improve overall health, United States correctional facilities are increasingly becoming smoke-free. Smoking cessation should be encouraged and cessation programs should be offered to all incarcerated individuals who wish to stop smoking. (See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment options".)

●Drug and alcohol use disorders – In a sample of prisons and jails in the United States participating in the Pregnancy in Prison Statistics (PIPS) study, 26 percent of pregnant individuals admitted to prisons and 14 percent of those admitted to jails had opioid use disorder [45]. In a National Inmate Survey, approximately 70 percent of incarcerated females met criteria for drug (including alcohol) dependence or abuse, but pregnancy status was not identified [46]. The high rates of drug and alcohol use, and the potential life-threatening complications from withdrawal, highlight the need for screening (table 3) and treatment of substance use disorders. (See "Substance use during pregnancy: Screening and prenatal care", section on 'Screening for substance use' and "Alcohol intake and pregnancy".)

●Treatment of opioid use disorder – Approximately one-quarter of incarcerated individuals take part in some kind of drug treatment program, including self-help and peer counseling programs [46]. While incarcerated pregnant people and their developing fetuses benefit from the reduction in access to addictive substances [47], acute opioid withdrawal during pregnancy may have adverse fetal effects; therefore, pregnant individuals with an opioid use disorder should be transitioned to medication-assisted treatment with methadone or buprenorphine, as available in their setting. Treatment may require daily transport of the individual to an off-site clinic. (See "Opioid use disorder: Overview of treatment during pregnancy" and "Opioid use disorder: Pharmacotherapy with methadone and buprenorphine during pregnancy".)

Treatment programs may also reduce relapse, and therefore recidivism, upon release. Once discharged from a correctional facility, individuals on maintenance therapy require prompt follow-up at an outpatient treatment center. Formerly incarcerated individuals with a history of opioid use disorder are at an increased risk of death from an overdose compared with the general population [6,48]. Specific education about access to and use of naloxone is essential for incarcerated individuals who are being released. (See "Clinical care of incarcerated adults", section on 'Opioid use disorder' and "Prevention of lethal opioid overdose in the community".)

Although pharmacotherapy with either methadone or buprenorphine is the recommended treatment for opioid use disorder during pregnancy, in the sample of prisons and jails in the United States participating in the PIPS study mentioned above, nearly one-third of pregnant incarcerated individuals were managed by withdrawal, usually when the individual was not already on pharmacotherapy prior to incarceration [45]. Two-thirds of the prisons and three-quarters of the jails providing pharmacotherapy for opioid use disorder in pregnancy discontinued it postpartum, although continuation reduces relapse and its consequences among those who will be getting released. (See "Opioid use disorder: Overview of treatment during pregnancy".)

Diet and nutrition — Many states do not require correctional facilities to provide appropriate nutrition for pregnant incarcerated individuals [49]. Some specific issues include:

●Food safety – Correctional facilities housing pregnant individuals should have appropriate meal options [50], which exclude cold cuts, unpasteurized foods, and raw or undercooked meat due to risk of Listeria and toxoplasmosis. (See "Nutrition in pregnancy: Assessment and counseling", section on 'Food safety'.)

●Folic acid and iron – All pregnant incarcerated individuals should receive folic acid supplements containing 400 to 800 mcg of folic acid for prevention of neural tube defects. Individuals with anemia or iron deficiency should be provided with iron supplementation. Many incarcerated pregnant individuals receive prenatal vitamins, which typically contain folic acid and iron. (See "Nutrition in pregnancy: Dietary requirements and supplements".)

●Management of nausea and vomiting of pregnancy – Incarcerated individuals may have more problems with pregnancy-associated nausea and vomiting because they cannot control the timing of their meals, type of food that is available, and access to fluid. High-protein snacks and bland diets have been reported to be helpful, but incarcerated individuals may only be able to purchase less healthy snacks with commissary (canteen) funds, if available. Therefore, correctional facilities are advised to provide snacks outside of scheduled mealtimes and dietary flexibility (bland diets, high-protein snacks) for individuals experiencing pregnancy-associated nausea. Access to fluid should be available at all times. Ideally, incarcerated individuals should also have access to scheduled antiemetic drugs. (See "Nausea and vomiting of pregnancy: Treatment and outcome".)

INTRAPARTUM RESTRAINTS (SHACKLING) — The use of restraints, or shackles, during pregnancy, labor, birth, and postpartum is an incompletely resolved and controversial matter. Although the United Nations Bangkok Rules [6]; recommendations of government, medical, and legal societies [3,51-54]; and laws [55] state that restraints should only be used on pregnant incarcerated individuals in extreme circumstances and that restraints should never be used on these individuals during labor and delivery [3,6,51,55], the actual experience of pregnant incarcerated individuals may differ. In addition, existing anti-shackling laws often have grey areas with regards to use of restraints on pregnant individuals in transit or while in an off-site facility (including admission to a hospital, visit to an outside clinic, or court appearance) during the antepartum and postpartum periods [56].

Concerns about shackles and handcuffs include that they can increase the risk of a fall, can prevent an individual from breaking a fall with their hands, and generally discourage ambulation. Abdominal trauma incurred during a fall can potentially cause placental abruption, which can lead to preterm labor and other adverse effects. To promote patient health and safety in regions where restraints are used, clinicians should discuss the risks to the mother and fetus with corrections facility administration and advocate for total adherence to existing anti-shackling laws and recommendations.

PREGNANCY OUTCOME — Although a systematic review of pregnant people in high-income countries imprisoned at any point during pregnancy reported that they are at higher risk for preterm birth and having a low birth weight newborn than the general obstetric population [57], when compared with similarly disadvantaged obstetric populations, maternal and fetal outcomes actually improve with increasing lengths of incarceration (eg, less preterm birth and growth restriction, higher birth weight). The improved outcomes may reflect the effects of regular prenatal care, stable housing, provision of meals, better physical security, and a reduction in drug and alcohol use. However, access to and quality of prenatal care from prison to prison are variable, and individual prison systems and pre-incarceration conditions may play a role in pregnancy outcome [8].

On average, for each day spent incarcerated while pregnant, an infant's birth weight increases by 1.49 g compared with infants born to individuals incarcerated at times other than during their pregnancies [58]. In addition, compared with disadvantaged pregnant people living in the community, incarcerated pregnant people had a lower risk of stillbirth (odds ratio [OR] 0.35, 95% CI 0.14-0.84) and low birth weight (OR 0.57, 95% CI 0.35-0.93) [57]. These outcomes appear to be influenced by the timing of incarceration during pregnancy, racial differences, and amount of prenatal care [59-62].

More recent data were reported in a prospective study on pregnancy outcome among 1396 pregnant people in United States state and federal prisons in 2016 to 2017 [8]. Overall outcome was favorable, with live birth in 92 percent (6 percent were preterm), miscarriage in 6 percent, abortion in 1 percent, stillbirth in 0.5 percent, newborn death in 0.5 percent, and no maternal deaths. The gestational age at prison entry was not available, which could bias the findings since gestational age at study entry could be expected to affect the prospective risk of some outcomes. The same group reported similar data for jails in the United States. Of the 224 pregnancies that ended in jail, 64 percent were live births, 18 percent were miscarriages, 15 percent were induced abortions, and 1.8 percent were ectopic pregnancies. The preterm birth rate was 8 percent [5].

POSTPARTUM ISSUES

Maternal-newborn contact — Following the birth, an incarcerated individual will usually spend two days (for a vaginal birth) to four days (for a cesarean birth) in the hospital prior to transport back to the correctional facility. During this time, depending on plans for posthospital discharge separation, maternal-newborn bonding and skin-to-skin contact is encouraged.

Newborn placement — Most newborns will be separated from their mothers upon discharge from the hospital. Few correctional facilities offer on-site nursery programs. Child placement options are typically limited to family, friend, foster care, and adoption. For individuals likely to give birth while in custody, parenting and child custody services should be available in the correctional institution to facilitate guardianship planning prior to the birth [63]. When advanced planning is not possible, the patient may have to wait until they have access to hospital social workers at the time of giving birth.

Breastfeeding — Mothers who are eligible for contact with their infant may elect to breastfeed while in the hospital. This may require collaboration among correctional officers, obstetrics staff, newborn nursery/neonatal intensive care unit staff, and social workers to support her efforts. Upon discharge, medical providers in the correctional facility should be prepared to help the individual anticipate and treat engorgement, prevent mastitis using a tight-fitting bra, and identify signs of mastitis if they do occur.

Prolonged breastfeeding is rarely an option given the lack of widespread on-site nurseries that would allow for newborns to remain with their mothers while still in custody. If separation between the mother and infant will be only temporary due to imminent release, a correctional facility may be able to make special arrangements for the mother to pump and discard the milk in order to preserve their milk supply.

Some facilities have successful programs that allow incarcerated mothers to pump breast milk and have it stored until it can be picked up by the infant's guardian [10]. However, most facilities do not have the infrastructure to support prolonged pumping due to: (1) lack of privacy when pumping, given shared cells and the need for correctional officers to maintain visual contact with incarcerated individuals; (2) concern for potential self-harm or creation of weapons with parts of electric breast pumps (but hand pumps are an alternative); and (3) lack of storage protocols for breast milk, considered a potential hazardous bodily fluid.

Contraception and sterilization — Contraceptive options, including immediate postpartum placement of long-acting reversible contraception (LARC), are discussed as part of routine prenatal care. For incarcerated individuals, contraceptive counseling also addresses the planned duration of imprisonment and any state laws that may ban permanent contraception (sterilization) procedures because of historic concerns around coercive sterilization [64,65]. When contraception is offered at no cost while the individual is still incarcerated, they are 15 times more likely to start a method than if it is offered at no cost in the community [66].

Prior to release to the community, incarcerated individuals can be given referral information for their ongoing contraceptive needs. One option is community-based Title X services (United States federally funded services for reproductive health targeting poor and underserved populations). Provision of emergency contraception is another option. In one study, 71 percent of female incarcerated individuals said they would accept an advance supply of emergency contraception upon release from the correctional facility [67]. Another option is creating an infrastructure within the prison for prerelease female health visits that include sending a prescription for the first few months of the pill/patch/ring to a pharmacy close to where the individual will release, administering a depot medroxyprogesterone acetate injection to cover the first three months after discharge, or provision of LARC prior to release, as patient's medical history and contraceptive preferences dictate. (See "Contraception: Counseling and selection".)

Incarcerated individuals who are not offered a contraceptive are at increased risk of an unintended pregnancy. In one study, approximately half of a group of previously incarcerated individuals conceived within 90 days of leaving the correctional facility [68]. In another study, 84 percent of incarcerated individuals who had been pregnant reported having an unintended pregnancy and 85 percent said it was likely that they would have sexual relations with a male within six months after release [69].

CHILDREN OF INCARCERATED MOTHERS — In United States prisons, 62 percent of female incarcerated individuals are mothers of children under age 18 [70]. In the month prior to arrest, approximately half lived with their minor aged children and 75 percent of those living with their children were in single-parent households [26,57,70]. After the mother was incarcerated, 45 percent of children lived with grandparents, 37 percent lived with the other parent, 30 percent lived with other family or friends, and 11 percent were in foster care [70]. Foster care placement can be particularly stressful for mothers and their children because incarcerated mothers risk losing their parental rights if they are unable to meet court-mandated family reunification requirements for contact and visitation with their children [71].

Arrest and incarceration of a parent is a unique stress for affected children. In addition to this stress, poverty, parental substance use and mental illness, domestic violence, and inconsistent or unavailable caregivers put these children at risk for behavioral and developmental problems. (See "Developmental and behavioral implications for children of incarcerated parents".)

The familial disruption and risk to child welfare posed by incarceration has led several advocacy groups to call for alternatives to custodial terms and reduction of unnecessary imprisonment. Until such changes can be achieved, guidelines such as the United Nations Bangkok Rules promote the creation of maximum opportunities for incarcerated mothers to meet with their children as long as "public safety is not compromised" [6]. Family-centered services in correctional facilities can help parents use their sentence to strengthen their parenting skills, foster continued bonds with their children, and access community supports to assist them upon release.

RESOURCES FOR CLINICIANS

●American College of Obstetricians and Gynecologists (ACOG) – ACOG recommended health care for pregnant and postpartum incarcerated females.

●National Women's Law Center – A nonprofit organization dedicated to protecting and promoting equality and opportunity for women and families.

●American Civil Liberties Union – A nonprofit organization dedicated to defending and preserving individual rights and liberties guaranteed by the Constitution and laws of the United States.

●National Commission on Correctional Health Care – The National Commission on Correctional Health Care is a nonprofit private association that provides recommendations for the management of a correctional health services system, including care and treatment, health records, administration, personnel and medical-legal issues.

●American Correctional Association – The American Correctional Association is nonprofit private association committed to improving practices in correctional systems by helping agencies provide correctional populations with safe and effective health service delivery.

●The Needs of Incarcerated Pregnant Women: A Systematic Review of the Literature.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General prenatal care" and "Society guideline links: Health care of criminal justice-involved populations".)

SUMMARY AND RECOMMENDATIONS

●Prevalence of pregnancy among incarcerated individuals – In the United States, approximately 3 to 4 percent of incarcerated females are pregnant. (See 'Epidemiology' above.)

●Pregnancy testing – Pregnancy testing upon entry to a correctional setting allows for timely counseling regarding prenatal care, triage of pregnant incarcerated individuals with obstetric or medical concerns (eg, vaginal bleeding, possible ectopic pregnancy, opiate withdrawal), or pregnancy termination. (See 'Pregnancy testing' above.)

●On-site and off-site staff communication – To ensure that pregnant patients receive the care they need, good communication about pregnancy issues and treatment schedules is essential among the on- and off-site medical staff and the security staff, as well as with the patient. (See 'Communication between on- and off-site staff' above.)

●HIPAA – Under the Health Insurance Portability and Accountability Act (HIPAA), an incarcerated individual's medical information is deemed protected health information (PHI). An off-site clinician can share medical information with the correctional facility if the PHI is necessary for the provision of health care or to protect the health and safety of the individual or other incarcerated individuals. Correctional officers should never be used to communicate between off-site and on-site providers as they are not health care providers nor are they held to HIPAA standards. (See 'HIPAA compliance' above.)

●Prenatal care – Obstetric standards for prenatal care, including genetic counseling, genetic screening, diagnostic testing, mental health screening, and ultrasound surveillance, are the same for incarcerated patients and those in the community. Incarcerated individuals are considered high risk for many infectious diseases where retesting in the third trimester is recommended. (See 'Provision of routine prenatal care' above.)

•Transportation to and from the facility – Transport to nearby medical facilities is typically needed for portions of prenatal care and the amount of time required for the entire transport process needs to be factored into management plans. Some incarcerated individuals may decline transport because of associated stress. (See 'Transportation' above.)

•High-risk pregnancies – High-risk pregnancies are common. Contributing factors include low socioeconomic status, no or inadequate prenatal care, current or prior trauma (physical, sexual, and psychological), illicit drug and/or alcohol abuse, mental health disorders, chronic illness, and acute or chronic infectious diseases. As in any pregnancy, each patient is assessed for complicating risk factors and monitored and treated as appropriate for the clinical situation. (See 'High-risk pregnancies' above.)

●Labor and birth – Although multiple legal and medical bodies advise that restraints should only be used on pregnant incarcerated individuals in extreme circumstances and that restraints should never be used during labor and delivery, the actual experience of these individuals may differ. In addition, existing anti-shackling laws often have grey areas with regards to use of restraints on pregnant incarcerated individuals in transit or while in an off-site facility (including admission to a hospital, visit to an outside clinic, or court appearance) during the antepartum and postpartum periods. (See 'Intrapartum restraints (shackling)' above.)

●Postpartum – Education about postpartum issues, including newborn placement, breastfeeding, and contraception, is begun during the prenatal care process. Most newborns will be separated from their mothers upon discharge from the hospital, and prolonged breastfeeding through pumping and storage is rarely an option. Screening for postpartum depression should be performed, as in all postpartum patients. (See 'Postpartum issues' above and 'Mental health' above.)

●Follow-up of pregnant incarcerated individuals released before giving birth – Most incarcerated pregnant individuals will be released prior to giving birth. On leaving a correctional setting, obstacles to continuous care include lack of stable housing and financial challenges. Steps that help ensure continuity of care after release include reestablishing medical insurance, scheduling follow-up appointments, transferring health care records to the outside providers, and providing bridge medication or prescriptions to cover the individual's needs until their next scheduled appointment. For individuals receiving methadone or buprenorphine for opioid use disorder in pregnancy, continuity of care includes ensuring services with an accessible treatment clinic or approved provider prior to the individual's release from the correctional facility. (See 'Follow-up care after release' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jennifer G Clarke, MD, MPH, who contributed to an earlier version of this topic review.