Dignity in Jails and Prisons

No Shackling While Pregnant

Why is this important?

• The use of restraints can interfere with maternal and fetal health care during pregnancy, labor, delivery, and maternal and newborn health care during the post-partum period.[1]
• The use of restraints can pose health risks for pregnant women or girls and their fetuses/ newborns, not only by limiting movement that is necessary for balance, circulation, and safety, but also by potentially interfering with urgent medical examinations and procedures.[2]
• Trauma-based symptoms of pregnant and post-partum women and girls in custody may be exacerbated by the use of restraints, leading to significant maternal and fetal/infant stress.[3]
• Women and girls are particularly vulnerable to behavioral health conditions such as depression and post-traumatic stress disorder (among other psychiatric diagnoses) during pregnancy and the post-partum period; these conditions are also disproportionately prevalent in the corrections population. Use of restraints during and immediately following pregnancy can lead to these conditions, or exacerbate them where they already exist.[4]
• Restraints can inhibit physical contact between the post-partum woman or girl and her newborn and limit her ability to safely handle and quickly respond to her newborn’s needs, which can be detrimental to the health and well-being of the infant.[5]
• After delivery, a healthy baby should remain with the mother to facilitate mother–child bonding. Shackles may prevent or inhibit this bonding and interfere with the mother’s safe handling of her infant.[6] 
• As the infant grows, mothers should be part of the child’s care (i.e. take the baby to child wellness visits and immunizations) to enhance their bond. Shackling while attending to the child’s health care needs may interfere with her ability to be involved in these activities.[7]

Examples of the Health Effects of Restraints 

• Nausea and vomiting are common symptoms of early pregnancy. Adding the discomfort of shackles to a woman already suffering is cruel and inhumane.[8] 
• It is important for women to have the ability to break their falls. Shackling increases the risk of falls and decreases the woman’s ability to protect herself and the fetus if she does fall.[9]
• If a woman has abdominal pain during pregnancy, a number of tests to evaluate for conditions such as appendicitis, preterm labor, or kidney infection may not be performed while a woman is shackled.[10]
• Prompt and uninhibited assessment for vaginal bleeding during pregnancy is important. Shackling can delay diagnosis, which may pose a threat to the health of the woman or the fetus.[11] 
• Hypertensive disease occurs in approximately 12–22% of pregnancies and is directly responsible for 17.6% of maternal deaths in the United States. Preeclampsia can result in seizures, which may not be safely treated in a shackled patient.[12] 
• Women are at increased risk of venous thrombosis during pregnancy and the postpartum period. Limited mobility caused by shackling may increase this risk and may compromise the health of the woman and fetus.[13] 
• Shackling interferes with normal labor and delivery: the ability to ambulate during labor increases the likelihood for adequate pain management, successful cervical dilation, and a successful vaginal delivery. Women need to be able to move or be moved in preparation for emergencies of labor and delivery, including shoulder dystocia, hemorrhage, or abnormalities of the fetal heart rate requiring intervention, including urgent cesarean delivery.[14] 

Anti-Shackling Principle Recommendations 

• Corrections agencies encompassing adult and juvenile systems, forensic hospital settings, and transport to and from correctional settings should have written policies and procedures on the use of restraints on pregnant, laboring, birthing, and post-partum women and girls.[15]
• Policies and procedures on the use of restraints on pregnant women and girls under correctional custody should be developed collaboratively by correctional leaders and medical staff who have knowledge about the potential health risks to pregnant women or girls and their fetuses/newborns that can result from the use of restraints at any stage of pregnancy, labor, birth, or the post-partum period.[16] 
• Pregnant women and girls under correctional custody (and their fetuses/newborns) have unique healthcare needs that are not addressed by most standard custody management policies. Additionally, women and girls in correctional settings are more likely to have high-risk pregnancies for a variety of reasons that can include lack of obstetric care, lack of adequate nutrition, use of substances (e.g., tobacco, alcohol, prescription medications, illicit drugs), physical and emotional abuse, traumatic experiences, mental health issues, sexually transmitted infections, and other issues requiring careful medical management. Policies and practices specific to the needs of pregnant women and girls are necessary to ensure their health and safety and the health and safety of their fetuses/newborns.[17] 
• Policies and their associated procedures with regard to the use of restraints with pregnant women and girls under correctional custody should clearly reflect the need to balance the safety, health, and well-being of the pregnant woman or girl and her fetus/newborn with that of all other parties involved (including care givers, corrections staff and medical staff), and should be gender responsive.[18]
• The use of restraints on pregnant women and girls under correctional custody should be limited to absolute necessity. The use of restraints is considered absolutely necessary only when there is an imminent risk of escape or harm (to the pregnant woman or girl, her fetus/newborn, or others) and these risks cannot be managed by other reasonable means (e.g., enhanced security measures in the area, increased staffing, etc.).[19]
• One effective way to maximize safety and minimize liability is through consistent and comprehensive training for staff working with women and girls who are or could possibly be pregnant. Clearly written policies and procedures governing evaluation for pregnancy, provision of prenatal care, and modifications of policies and procedures that apply to the general population to better suit the unique needs of pregnant women and girls are essential. Experts in these areas hold knowledge critical to understanding the needs; requirements; and security, health, safety, and behavioral health risks of pregnant women under correctional custody. By working together, these professionals can maximize physical and psychological safety while minimizing risk of harm to the staff, detainees and prisoners, and fetuses/newborns involved.[20]

 
Anti-Shackling Operational Recommendations 

• The following types of restraints and restraint practices are expressly prohibited under all circumstances: 
  • Abdominal restraints, because they pose a danger to the fetus resulting from the risk of physical trauma, dangerous levels of pressure, and restriction of fetal movement.
  • Leg and ankle restraints, which increase the pregnant woman’s or girl’s pre-existing elevated risk of a forward fall. 
  • Wrist restraints behind the back, because they restrict the pregnant woman’s or girl’s ability to protect herself and the fetus in the event of a fall. 
  • Four-point restraints, whether a pregnant woman or girl is placed face down or on her back, because being restrained face down poses a danger to the fetus due to pressure on the pregnant woman’s or girl’s abdomen and because being restrained on her back inhibits blood circulation to both the pregnant woman or girl and her fetus and delivery of oxygen to the fetus.[21]
• Wrist restraints, if used, should be applied in such a way that the pregnant woman or girl may be able to protect herself and her fetus in the event of a forward fall (i.e., in front of her body).[22]
• Restraints should never be used on a woman or girl during labor and delivery because​ they: a) inhibit her ability to be mobile during labor and delivery and b) may interfere with the prompt administration of medical evaluation and treatment during normal and emergency childbirth.[23] 
• The use of restraints should be avoided during the post-partum period; if restraints are deemed absolutely necessary, they should not interfere with the woman’s or girl’s ability to safely handle and promptly respond to the needs of her newborn.[24] 
• When transporting a pregnant woman or girl, restraints should not be used except where absolutely necessary (i.e., when there is a current likely risk of escape or harm to the woman or others, and these risks cannot be managed by other reasonable means).[25]
• Standard operating procedures should outline a clear process and frequency for reassessing the use of restraints when they have been deemed absolutely necessary. If upon reassessment it is determined that the risk of imminent harm has changed, the use of the restraints should be reevaluated.[26] 
• Standard operating procedures should be in place to address emergency and non-emergency decisions around the use of restraints. The Task Force recommends the following procedures at a minimum: 
  • Advance planning among members of the woman’s care team (i.e., health care and corrections professionals) should be conducted before hospital admittance.
  • When reasonably possible, the facility administrator (or the most senior ranking corrections professional in the absence of the administrator) will collaborate with the health authority to determine whether the use of restraints is necessary. 
  • The senior ranking person on site will immediately notify the facility administrator if restraints are deemed necessary and are used.[27]​

Perinatal Care
Why is this important?

• Pregnant prisoners have health-care needs that are minimally met by prison systems.[28]
• Many of these mothers have high-risk pregnancies due to the economic and social problems that led them to be incarcerated: poverty, lack of education, inadequate health care, and substance abuse.[29]
• Lamaze educators and doulas have the opportunity to replicate model programs that provide these women and their children with support, information, and empowering affirmation that improve parenting outcomes and decrease recidivism.[30]

Perinatal Care Recommendations 

• Intake
  • Assess for pregnancy risk by inquiring about menstrual history, heterosexual activity, and contraceptive use and test for pregnancy as appropriate.[31]
• During Pregnancy
  • Provide pregnancy counseling and abortion services. 
  • Provide perinatal care following guidelines of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. 
  • Assess for substance abuse and initiate treatment; prompt initiation of opioid-assisted therapy with methadone or buprenorphine is critical for pregnant women who are opioid-dependent. 
  • Test for and treat human immunodeficiency virus (HIV) to prevent perinatal HIV transmission. 
  • Screen for depression or mental stress during pregnancy and for postpartum depression after delivery and treat as needed. 
  • Provide dietary supplements to incarcerated pregnant and breastfeeding women
  • Deliver services in a licensed hospital that has facilities for high-risk pregnancies when available. 
  • Provide postpartum contraceptive methods during incarceration. [32]​

Postpartum Care
Why is this important?

• Participation in post-delivery mother-infant residency or nursery programs is associated with lower recidivism rates, reduced risk of babies entering foster care, and improved odds that mothers and their babies will remain together after the mother’s period of incarceration.[33]

No solitary confinement while pregnant
Why is this important?

• Use of restrictive housing and restraints on incarcerated pregnant women is dangerous to the health of mothers, fetuses, and infants.[34]

Feminine hygiene products
Why is this important?

• Access to the proper hygiene products not only helps keep reproductive organs free from potentially harmful bacteria from makeshift pads or tampons, but also prevents women from being humiliated due to menstrual seepage through undergarments and clothes.

Family Visitation Rights
Why is this important?

• Children who grow up with parents in prison are six to seven times more likely to become incarcerated themselves.[35]
• Prisoners who maintain close contact with their family members while incarcerated have better post-release outcomes and lower recidivism rates.[36]
• Children of inmates who are able to visit their imprisoned parents have increased cognitive skills, improved academic self-esteem, greater self-control, and change schools much less often.[37]

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[1] Committee on Health Care for Underserved Women (ACOG), 2011; Committee on Health Care for Underserved Women (ACOG), 2012; Amnesty International, 2011. 
[2] ACOG, 2011; AOCG, 2012; Amnesty International, 2011.
[3] Justice-involved women report higher rates of childhood abuse compared with women in the general population (Harlow, 1999). Women in state prisons also report higher rates of physical abuse compared with men in state prisons; up to nearly 50 percent of women in correctional facilities have experienced physical and/or sexual abuse (Harlow, 1999; Harlow, 1998); Covington, 2000; Johnsen, 2006 
[4] Amnesty International, 1999; ACOG, 2010.
[5] Early maternal-child bonding has critical and long-lasting benefits for mothers and newborns (Bergman, Linley, & Fawcus, 2004; Bystrova, Matthiesen, Widstrom, et al., 2007; Bystrova, Widstrom, Matthiesen, et al., 2007; Christensson, et al., 1992; and others). Separation of mother and infant after birth can cause critical impact to the child (Baldwin & Jones, 2000). 
[6] ACOG Committee on Health Care for Underserved Women, 2019.
[7] ACOG Committee on Health Care for Underserved Women, 2019.
[8] Committee on Health Care for Underserved Women, 2019.
[9] Committee on Health Care for Underserved Women, 2019.
[10] Committee on Health Care for Underserved Women, 2019.
[11] Committee on Health Care for Underserved Women, 2019.
[12] Committee on Health Care for Underserved Women, 2019.
[13] Committee on Health Care for Underserved Women, 2019.
[14] Committee on Health Care for Underserved Women, 2019.
[15] Best Practices in the Use of Restraints with Pregnant Women and Girls Under Correctional Custody, 2014.
[16] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[17] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[18] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[19] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[20] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[21] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[22] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[23] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[24] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[25] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[26] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[27] Best Practices in the Use of Restraints with Pregnant Women..., 2014.
[28] Hotelling, nd.
[29] Hotelling, nd.
[30] Hotelling, nd.
[31] ACOG Committee on Health Care for Underserved Women, 2019.
[32] ACOG Committee on Health Care for Underserved Women, 2019.
[33] ALEC Model Policy, 2018.
[34] ALEC Model Policy, 2018.
[35] ALEC Model Policy, 2018.
[36] ALEC Model Policy, 2018.
[37] ALEC Model Policy, 2018.