Pregnant in Prison – A Recipe for High-Risk

When I learned that women are the fastest growing segment of the prison population, I was troubled. In a 30 year period, I read that the number of imprisoned women had gone from 11,212 to nearly 113,000 women.1, 2 Many of these charges stem from drug related arrests leading one to wonder how effectively we’re helping out our young mothers by jailing them for having a “crack baby.”

It is a known fact that women are far more likely to commit non-violent crimes as opposed to violent ones, which makes them targets for arrest and ultimately detainment. In 2004, Oklahoma prisons held 10 times as many women as Massachusetts or Rhode Island’s jails. 1 Over 70% of incarcerated women have minor children; about half of all inmates with children are single mothers. 2 It is crucial for states with high incarceration rates to consider the impact can have on their systems and prisons in the future if current trends persist – particularly those that may not be fitted out with resources or environment where pregnant moms-to-be can receive adequate care during their stay (as well as deliver).

So why do women account for an increase in the prison population? According to The Rebecca Project, “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.” Compared to men, crime committed by delinquent females is non-violent, often because their criminal activity revolves around drug and property offenses.

The Reality: Pregnancy and Incarceration

Six to ten percent of women entering jail are pregnant. Many inmates fall under the classification of “high-risk” as they have not received adequate medical care prior to their imprisonment. They often suffer from , epilepsy, HIV, hypertension and cardiac and renal diseases in addition to other illnesses related to pregnancy that negatively affect pregnancy outcomes. Alcohol, tobacco and illicit drugs can all have negative effects on a growing fetus, at varying stages and intensities. This is often why women who are pregnant are advised to avoid alcohol or smoking altogether if possible as well as other recreational drugs.

Prematurity: A Difficult and Complex Problem in Obstetrics

There’s a stark racial disparity between people living in the US and those who are incarcerated like only 6 out of 10 inmates in America are white while blacks make up over 67% of that 7. And more than 12% of PTBs affect whites while blacks unfortunately account for 23.1% and hispanics also making up 14.4%. These racial disparities may be related to the increased risks facing black women including greater risk of complications due to preeclampsia and a higher rate of premature births at around 24 weeks. Solving these problems simply isn’t enough; we have to go deeper. And that means looking at the basic root causes of such issues if we really want to build a better world for everyone. While the list below is not complete or necessarily in any specific order, it is important that you pay attention whenever you consider worldwide improvements in areas related specifically when it comes down to issues like improving finances or understanding more about scientific breakthroughs .

The risk factors for early birth, the leading cause of infant morbidity and mortality, are those with:

A history of 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?)

Pregnant inmates can be up to 100 times more likely than the general public to contract diseases or suffer pregnancy-related injuries. Here are some of the issues that might arise if a prison inmate is pregnant.

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 who suddenly experience bleeding should be seen immediately. If available, Nitrazine paper or the Ferning test (which can detect a rupture of a woman’s amniotic membrane) should be applied to the fluid and its pattern observed. Will an appropriately skilled perinatologist leader assist in decision-making about her care? It depends on what type of break is detected. Other management options may include hospitalization, antibiotics and antenatal corticosteroids, or they—PPROM providers—may use others like routine monitoring for infection/contractions. Important: care should be taken to limit (preferably avoid) internal examinations so as not to increase the chances of infection and inflammation!

Preeclampsia

Preeclampsia, also called pregnancy-induced hypertension or gestational hypertension, is a of pregnancy that usually occurs after the 20 th week. It affects 2-7 % of women during their pregnancies and 1% during the first six weeks after childbirth . Women who have had this condition in a previous pregnancy are at high risk for preeclampsia again. Other risk factors include obesity, age over 40 years , having diabetes , chronic high blood pressure , or kidney disease . Prenatal check ups are important for the of both the mother and child because early detection can help protect from serious complications. Although as long as one does their due diligence, like getting regular check up makes it easier for them to maintain a healthy pregnancy by managing possible risks that can arise. There has been some study and research done on ways to decrease preeclampsia, hypertension and intra uterine growth restriction. Compounds such as Aspirin or Magnesium Sulfate are two drugs commonly used to manage some conditions during pregnancy.

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 (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 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

Placenta previa occurs when the placenta stops growing toward the uterus by 20 weeks of pregnancy, or at any time during birth. This is due to internal bleeding, which separates the placenta from the uterine wall. When this happens, there is compression and compromise of the blood supply to your baby.

Diagnosis of this condition may involve the following: abdominal ultrasound, complete blood count, pelvic exam, fibrinogen levels, partial thromboplastin time, and prothrombin time. Placental abruption should be suspected when a pregnant mother has sudden localized abdominal pain and/or bleeding. The top of her uterus may have to be monitored, as a rising fundus can indicate bleeding. Early recognition and treatment are important keys to a positive outcome.

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 .

Intrauterine Growth Restriction (IUGR)

Babies are considered to have restricted growth when their birth weight and/or length is below the 10th percentile for their gestational age AND if they have an abdominal circumference below the 2.5th percentile. You can use another example in baby clothes or even an infant car seat instead of clothes onesie or a newborn diaper.

The exact cause of IUGR is still not fully understood, but there are many possible factors that may lead to it. Those risk factors include things like alcohol, drug abuse, and poor nutrition. If you experience any of those or others listed in the examples above, it might be smart to seek the advice and help of a specialist so that he or she may take the time to customize a treatment plan for you.

Short Cervical Length, Preterm Labor, Incompetent Cervix (IC), Infection

These are complex topics for a birth practitioner. It’s vital to stay up-to-date with the latest research and strategies, as well as constantly asking mentors and colleagues for advice, in order to provide your patients with the most comprehensive care possible.

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 can be considered for women with a history of problems or who have had either a C-section or spontaneous loss and then gone on to attempt another pregnancy. The cerclage would be likely to sustain the pregnancy through gestation, but it should not be performed unless a specialist in this field deems it necessary during pregnancy.

Cervical Length – A Preemie Predictor

There’s general consensus and research that tells us that when a baby has less room to move around in the uterus there’s still a higher possibility of an earlier birth. (A short cervix is commonly defined as 2.5 cm before twenty-four weeks.)

For women at risk of delivering their baby prematurely, doctors have found that transvaginal sonography offers more accurate results than other non-invasive tests such as the urination test.

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 cases of unexpected preterm labor, surgeons need to be thoroughly aware of potential underlying causes for it. There is a wide range of side effects specific to both the mother and the baby when it comes to tocolytics (these are drugs that are designed to delay premature birth), which is why the right option can involve a great deal of knowledge and experience. Some approaches have shown promise in delaying birth in some instances (such as Nifedipine due its overall safety record and Indomethacin), but further research is needed to confirm their long-term effectiveness.

17 (alpha)-Hydroxyprogesterone caproate (aka 17P or progesterone) is a hormone which has been shown to reduce early delivery by 33% in women with a history of prior early births.9 Every woman who has had a previous spontaneous early birth should be given this medication when she becomes impregnated. If they are not aware of the risk issues, they should ask their doctor or midwife to prescribe it.

Fetal Fibronectin (FFN) testing is a tool used to help predict the likelihood that you’ll deliver by 7-10 days. A negative result indicates that there’s a greater than 90% chance you will not have your baby during this time frame. Positive test results, however, only indicate about 9-46% confidence. When FFN testing of the cervix confirms the presence of fetal fibronectin after 22 weeks, a link to preterm birth has been shown to exist. Because cervical length determination is paramount in making sense of positive test results – combined with FFN swabbing – the ideal approach when determining management plans for symptomatic women is most optimal then, isn’t it?

Steroids such as betamethasone are usually given to women in their third trimester of pregnancy whose fetuses do not respond to the stimulants that were administered earlier. These steroids feed the baby and also block chemicals that can make them stressed out or alert.

Make Adequate Prenatal Care, Nutrition and Education a Priority

Although an extremely complex issue, it’s important to provide detainees with proper care and nutrition throughout their imprisonment. This would ensure that they are not further compromised by poor care during imprisonment.

It was found that babies of incarcerated mothers appear to do better on average than children of incarcerated fathers by showing a largely positive maternal influence on both the baby’s physical and psychological development.6, 10 To this end, a benefit to the baby is that they would receive necessary items such as food (leading to higher birth weights), clothing, protection from abusive partners, and access to prenatal care. However, there are many problems within our correctional facilities in the United States when it comes specifically to adequately meeting the needs for this special population. The Rebecca Project observes that 38 states received an F grade in prenatal care. This can be contributed to a lack of support and inadequate policies. One of the top reasons that many women do not fully participate in prenatal care is because they do not believe it will benefit them or make a difference in their lives, whether they are high-risk patients or not.

If a club or organization has a good library that is maintained with knowledge and helpful information and offers classes which are available to the general public, this will help in educating women about pregnancy and everything else they need to know.

Steps for Medical Personnel to Help Ensure Healthier Pregnancies

Every woman who comes in must be tested for pregnancy twice. A first trimester test needs to be done to determine how far along she is and then an ultrasound should be made after the first trimester and before the second one.

Just like one can’t have a cake without the flour, you can’t have a healthy baby without taking prenatal vitamins. By taking prenatal vitamins you’ve taken the first step to complete health and wellness for both you and your baby. If a woman doesn’t take the correct dosage of folic acid every for at least 3 months before , she will significantly increase her risk of having a baby with serious defects of the brain or spinal cord called neural tube defects.

Programs within the system should include comprehensive smoking cessation programs, as well as comprehensive alcohol and drug rehabilitation. These behaviors are linked to not only high PTB risk, but low birth weight and IUGR risks too.

Obtaining a full and detailed medical history for every pregnant woman is paramount as we look to evaluate whether or not these women are at risk for pregnancy issues and an early birth. As stated in one of the articles above, there has been sparse and inconsistent access to prenatal care within the prison system – a key thing to take note of when addressing this topic.

Women should be screened and treated for sexually transmitted infections , in particular HIV.

When it comes to pregnancy, the nutritional needs of a mother-to-be are very different from those of someone not pregnant. (Proper nutrition can reduce the risk of PTBs, certain birth defects/low birth weight babies)

As was previously mentioned, the most effective way to promote healthy pregnancies is by fostering partnerships amongst pregnant women and specialists.

The Doula Perspective – Birth and the Confined Mom

(As a doula) It’s imperative to mention the issue of prison birth in relation to women who must serve out their sentences.

Thirty-six states have been given a failing grade for their shackling practices of pregnant women.  The driving reason behind this is that there is no evidence to support the violence and escape risk being in any way linked to the pregnancy itself. In other words, shackling could be potentially considered unnecessary and cruel.

Prison programs have proven to help foster the bond between a mother and the baby they just gave birth to while they’re in prison, which can be an important transitional step once these women are released from prison. Unfortunately, 38 states currently do not offer these programs.

Pregnant inmates should have birth plans with their doctors or midwives. It is unacceptable for a woman to deliver her baby in her jail cell.

Some women may feel unprepared for the childbirth process if they don’t know what to expect, and others will be scared about what’s in store for them when it comes time to give birth. These are both circumstances that a doula can help prevent. A doula is someone you may want on your team who specializes or happens to be trained in areas related specifically when it comes down to how one can manage and even stay relaxed during the labor and birth process.

Coping with pregnancy can be tough because women have to worry about many changes in their bodies. As a pregnant woman, you need to make sure your body gets the proper care and support it needs. The most important aspect of any medical plan is the careful monitoring of a pregnant woman’s health from start to finish. A prison has a responsibility to accommodate the special or unique needs of an inmate who is under their watch.

Even Small Changes Matter

Some key issues have plagued the prison and prenatal care industries. Things that might be overlooked, such as seemingly minuscule logistical details like the proper way of handling paperwork which are large for a small percentage can become huge for larger entities. Babies with mothers behind bars tend to fare better in life when there are appropriate support programs in place.

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 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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